WO EN'S HEALTH

A CORE CURRICULUM

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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
Cindy Farquhar and Neil Johnson 8
Abnormal bleeding
Counselling before pregnancy 64
Cindy Farquhar and Neil Johnson 12
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
Edited by Lucy Bowyer
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
Edited by Lucy Bowyer
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 by Lucy Bowyer
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
Edited by Lucy Bowyer
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:
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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

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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
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
At the end of this chapter, the student
will be able to:
Premenstrual syndrome
define premenstrual syndrome ond
Indicate Its prevalence
list the common symptoms of
premenstrual syndrome
outline a management plan for a
woman with premenstrual syndrome
Dysmenorrhoea
differentiate between primary and
secondary dysmenorrhoea
list the causes of secondary
dysmenorrhoea
d(scuss the social and economic effects
of dysmenorrhoea
construct a plan for Investigation and
management of dysmenorrhoea
Abnormal vaginal bleeding
define the terms menorrhagia,
dysfunctional uterine bleeding ,
intermenstrual bleeding and postcoital
bleeding
V
recall the physiological changes in the
endometrium during the menstrual
cycle
• describe the Investigations for
menorrhagia In a teenager and a
woman of perimenopausa l y ears
outline the principles of management of
menorrhagia
Delayed puberty
describe the pubertal process and the
development of secondary sexual
characteristics
• list the common causes of delayed
puberty
outline an investigation and
management plan for delayed puberty
Polycystic ovary syndrome
• define polycystic ovary syndrome
describe the clinical manifestations of
polycystic ovary syndrome
summarise the long-term complications
of polycystic ovary syndrome
describe the prinCiples of management
of a woman with polycystic ovary
syndrome
(Continued over)
•

Women 's health: a core curriculum
(leaming objectives continued)
Hyperandrogenlsm
appreciate the wide variation in hair
distribution and density in different ethnic
groupS
describe the normal cycle of hair growth
• list the normal sites of androgen
production
discuss the causes of excess androgen
production and its effects
discuss the social consequences af
hyperandrogenism
outline an Investigation plan that
distinguishes benign from malignant
causes of hyperandrogenism
• explain the cosmetic and drug treatment
options for hyperandrogenlsm
Premature ovarian failure
define premature ovarian failure
list the causes of premature ovarian failure
outline how to investigate and confirm the
diagnosis of premature ovarian failure
discuss the short- and long-term effects of
premature ovarian failure
discuss a management plan for a woman
with premature ovarian failure.
Skills
At the end of this chapter, the student
should learn how to:
• counsel a woman on the evidence-based
treatments and other strategies for
management of premenstrual syndrome
exp lain the nature of primary
dysmenorrhoea
write a prescription for a nonsteroidal anti-
inflammatory drug or oral contraceptive
pill and explain to the patient how she
should take the medication
take a comprehensive history from a
woman with menorrhagia
counsel a woman concerning treatment
options for menorrhagia
• elicit a relevant personal and family
history from a peripubertal girl
take a comprehensive history from a girl
presenting with primary amenorrhoea
• assess the development of secondary
sexual characteristics in a girl
counsel a woman on the benefits of weight
loss and the long-term consequences of
polycystic ovary syndrome
examine a woman for signs of
hyperandrogenism and virilism
counsel a woman with premature ovarian
failure on the use of hormone therapy and
assisted reprod uction .
Attitu des
At the end of this chapter, the student
should reflect upon :
• the effects of premenstrual syndrome on
family and social dynamics
• the broader social and economic impacts
of abnormal vaginal bleeding
• the implications of delayed puberty for
interactions at school and In the family
• obesity as a public health issue
the social consequences of
hyperandrogenism and obesity
psychosocial and health implications of
premature 'ageing' for a woman and her
family.
1 The menstrual cycle and vagi nal bleeding
* Premenstrual syndrome Symptoms and signs
Women with PMS will often feel 'overwhelmed'
Common clinical presentation or 'out of control' and have one or more of a range
For one week out of every four, before her of psychological and physical symptoms. The
menstrual period, a busy professional woman symptoms are not an exacerbation of another psy-
with a young family feels 'out of control', snap- chiatric disorder. Thus PMS is, in part, a diagnosis
of exclusion.
ping at her children, weeping and foiling to
cope at work. She would like you to prescribe Typical psychological symptoms include:
'0 pill to sort out my hormones'.
• affective lability - tearfulness, irritability or
anger
• anxiety or tension
Epidemiology • depression
• loss of interest, difficulty concentrating, lack of
Premensnual syndrome (PMS) is defined as the energy, sleep disturbance, appetite disturbance.
cyclical occurrence JUSt before menses of a range
,. of symptoms that are severe enough to impact on Physical symptoms accompanying PMS may
lifestyle, relationships or work, and that resolve include:
with the onset of menses. A symptom-free week
• breast tenderness
after menses is an essential diagnostic feature.
While 95% of women of reproductive age experi- • fluid retention and weight gain
ence some physiological symptoms premensnu- • headaches
• aching joints.
ally, approximately 50/0 of women are severely
incapacitated by these symptoms. The typical age
at presentation is 30-40 years. PMS presents in all Evidence
ethnic groups, although the reported symptom A substantial placebo response in PMS should not
clusters may vary with ethnicity. discredit the psychosocial aspects of the
doctor-patient encounter. Indeed, the response to
Pathoph ysiology an interested, understanding, empathetic and edu-
cational approach from the doctor is very impor-
Both medical and social models of the pathophys- tant. However, because this placebo response is a
iology and approach to the management of PMS possibility, studies of possible treatments must be
have been proposed. The most plausible hormon- double-blind randomised controlled trials (RCTs)
al explanation is high levels - or, probably more to assess treatment effects rigorously - lower lev-
accurately, rapidly declining levels - of proges- els of evidence are notoriously unreliable.
terone (or the progesterone/oestrogen ratio) in the Attention to lifestyle, relationships and work
luteal phase of the cycle. Other medical patho- interactions may shift the focus of what was
physiological theories include contributing factors assumed to be PMS. Changes that allow women to
such as increased renin-angiotensin-aldosterone exert greater control over their lives are most
activity, changing prostaglandin levels, vitamin
likely to produce a lasting benefit. Relaxation
deficiency, excess prolactin secretion and endoge-
techniques are often helpful. Exercise may allevi-
nous endorphin depletion.
ate symptoms for some women. Homeopathy and
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

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

gical oophorectomy.
Natural history
For some women, dysmenorrhoea improves after
childbirth. Pelvic pain from all causes tends ro
regress after menopause.
Impact/outcomes
Dysmenorrhoea affects not only personal health,
but has a big economic impact through lost work-
ing hours, Clear explanation of the cause and
benign narure of primary dysmenorrhoea, and
reassurance that it docs not affect fertility, are
important. Conversely, the infertiliry somerimes
associated with endometriosis can make a painful
condition more difficult to endure. Some women
with dysmenorrhoea may develop a chronic pain
syndrome that is notoriously difficult to treat.
Health maintenance
It Is important tor a woman to
understand the physiological nature
at primary dysmenorrhoea ,
A 28-year-old woman InSists you reter her lor a
hysterectomy. as she is led up with very heavy
regular menstrual bleeding.
Epidemiology
Menorrhagia is defined as abnormally heavy men-
strual bleeding (HMB). The traditional definition is
a blood loss greater than 80 mL per period. The val-
idated method for measuring menstrual loss, the
alkaline haematin technique, is available only as a
research too!' Other validated techniques, such as
the pictorial blood-loss assessment chart (pBAC),
have been used to obtain an objective measurement
of menstrual loss. Individual perceptions and cul-
rural perceptions may playa role in what is accept-
ed as 'normal'. Thus, in practical terms, a woman's
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-
ing on the management plan, after a full discussion
of available options. The prevalence of HMB
increases with advancing age in the reproductive
years. It accounts for 2-4% of all GP consultations,
but over 15% of GP referrals to specialists. HMB is
the commonest cause of iron-deficiency anaemia in
developed countries. Management of HMB has a
substantial cost implication for any health service.
Dysfunctional uterine bleeding (DUB) encom-
passes both ovulatory DUB presenting as regular
HMB (menorrhagia) and anovulatory DUB pre-
senting as irregular vaginal bleeding. It implies that
anatomical causes have been excluded and that a
subtle benign hormonal dysfunction is the under-
lying cause.
Intermenstrual bleeding (I1vlB) is vaginal bleed-
ing that occurs between expected menstrual
e'"
u.. ,,-~ ~ 20 c
'C
c 20
a
• '~"
:s CJl 500
e
0.
10
b
o
Menstrual
Proliferative
~1 +'-----------I-~---------------4
Receptive 10
implantalion
a
Day at cycle
FIGURE 1.4 The me nstrual cycle showln (0) h
(Based on Rymer et 01 199 7, P 2:'. Fig 36? ormona l chonges ond (b) endometrial changes
periods. If it occurs while the "oman is takin
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.
gIn dIscharge after sexual intercourse. Up to ov ulanon, the endometrium increases in
thickness and endometrial glands proliferate (pro-
Anatomy and pathophysiology liferatIve phase). After ovu lation, under the influ-
ence of progesterone from the corpus luteum
Thhe phrsiology of normal cyclical biological
~h:ges resultIng from the interaction of the hypo-
the endometrium undergoes secretory changes u:
preparation for reception of the implant-
d lIUC-plruItary-ovanan hormonal axis is
Ing embryo. If a pregnancy does not occur, the
emonstrated in Figure 1.4. Physiological events
decreaSIng levels of progesterone from the

ME

Women 's health: a c o re cu rric ulum
degenerating corpus luteum becom~ insufficient
to maintain the endometnal mtegnty, allowmg
spasm of the spiral arterioles in the basal layer of
the endometrium, and synchrorused sheddmg of
the more superficial endometrial layer occurs at
menstruation. Typically, the menstrual period lasts
5 days and the length of the cycle is 28 days,
although these times vary m different women and
from cycle to cycle in the same woman. . • endometrial hyperplasia
Wilen the cervix is exanuned usmg a vagmal
speculum, the squamocolumnar junction can usually
be seen, where the pink squamous epIthelium on the
ectocervix adjoins the more red-coloured columnar
epithelium emerging from the endocemcal canal.
This exposed area of columnar epithelium on the
ectocervix is known as the trarJ.sformatlon zone,
since the columnar cells are replaced, over many
years, by squamous cells in a normal process known
FIGURE 1 5 Multiple fibromyomas. ranging In size from 2 mm to 9 cm In dlamet~r. s~en
during abdominal hysterectomy (Reproduced w ith perm ission from Ma ckay. Belsc er.
Pepperell & Wood 1992. P 385. Fig 27.1)
as squamous metaplasia. An exaggerated appearance
of columnar epithelium on ci;e ectoceIVlX ~ knowr;
as a cervical ectopy or ectropIon (the term erosIOn
is no longer used for this normal appearance).
The following conditions may be the cause of
menorrhagia:
• fibroids
• endometrial or endocervical polyps
• adenomyosis
• hypothyroidism
• coagulopathy
• presence of an intrauterine contraceptive
device (IUD)
• endometrial or endocervical carcinoma
DUB, if pregnancy and the above causes have
been excluded.
Ovulatory DUB may result from an excess of
plasminogen activator, resulting in the breakdown
of fibrin plugs (fibrinolysis) at the open spiral
arterioles of the endometrium (these fibrin plugs
normally minimise the heaviness of menstrual
bleeding). It may also result from an imbalance of
prostaglandin (PG) levels - PGFza brings about
arteriolar vasoconstriction and PGE z vasodilata-
tion in these vessels, and poor constrictive activ-
ity may lead to heavier blood loss. Anovulatory
DUB usually results in irregular bleeding, as the
normal cyclical stimulation of the endometrium
by steroid hormones does not occur. Three com-
mon patterns are recognised:
• in adolescents soon after menarche, owing to
low oestrogen concentrations
• in women with polycystic ovary syndrome
(PCOS), owing to unopposed oestrogen stimu-
lation
• in women in the few years before menopause,
owing to a sharp rise and then fall of oestrogen
concentrations.
An older term for anovulatory PCOS-type
DUB was metropathia haemorrhagica. Women
with PCOS-type DUB will often have infrequent
periods, rhen long periods with heavy bleeding.
They often develop 'Swiss-cheese endometrium'
(cystic hyperplasia).
Intermenstrual bleeding might be purely DUB
(and this is the case for most younger women with
1MB), but it is a warning symptom for endome-
trial pathology. Postcoital bleeding may have a
benign aetiology from a cervical ectopy, but PCB is
a warning symptom for cervical carcinoma, and the
cervix must be inspected carefully to exclude this.
Symptoms and signs
A woman presents not necessarily with heavy peri-
ods, but often with a change to her 0"''Tl typical
cycle. It is important to ascertain the age of men-
arche, the typical bleeding pattern in teenage
years, the typical bleeding pattern if COCP has
been used, the commencement of menstrual cycle
abnormalities, their progression and any relation-
ship to body weight. Women with heavy periods
often describe clots or flooding (causing social
embarrassment) and the need to use towels in
addition to tampons. A menstrual calendar may be
helpful, especially if bleeding is irregular, to ascer-
1 The menstrua l cycle a nd vaginal bleeding
tain the typical bleeding pattern. Menstrual bleed-
ing problems may interfere with a woman 's so-
cial life, sex life and relationship. Paradoxically,
women with 1MB or PCB sometimes delay con-
sulting a doctor because of a fear of cancer. This is
particularly unfortunate, since cancers presenting
with abnormal bleeding (typically endometrial or
cervical cancer) have a high chance of curative
treatment if recognised early. Menorrhagia can
lead to fatigue from anaemia and, if severe, short-
ness of breath.
Important examination signs include pallor and
a pelvi-abdominal mass that may be present with a
fib roid uterus. Vaginal speculum examination may
reveal a vulval, vaginal or cervical lesion, including
cervical ectopy, polyp or malignancy. Bimanual
pelvic examination is the best way to clinically
diagnose a fibroid uterus (irregularly enlarged) and
this may be confirmed by a pelvic ultrasound scan.
Investigati ons
Pregnancy should always be excluded. Women
with irregular bleeding must be investigated to
exclude genital tract pathology. This usually
involves a hystt:roscopy and endometrial biopsy.
Women who present with menorrhagia should
be investigated as follows:
• A full blood count is performed for all women.
• Coagulopathy and thyroid functi on tests are
performed only if other clinical features suggest
these diagnoses. However, teenagers with pro-
found HMB should have a coagulopathy
screen because of the higher incidence of von
Willebrand's disease and idiopathic thrombo-
cytopenia. ""
'9j.,A transva~al pelvic ultrasound scarfShould be
pertorme or women who are at hIgher risk of
endometrial pathology (hyperplasia and carci-
noma): women >45 years of age and those
with weight > 90 kg, nulliparity, a history of
irUertility, a family histoty of endometrial or
colon cancer.
• A transvaginal sonohysterogram (ultrasound
with saline fluid infusion into the uterine cavi-
ty) may provide the contrast needed to distin-
guish endometrial polyps from submucous
fibroids.
• CT and MRI scans are expensive and there is
no evidence of superiority over transvaginal
ultrasound.
ME
Women 's health: a core curricu lum
FIGURE 1.6 The Pipelle endometrial sompling device
(Based on McKay Hart & Norman 2000, p 112)
• Endometrial biopsy is indicated if the endome-
trial thickness is 12 rrun or greater, or if ultra-
sound is not available in the above higher-nsk
scenarios, Pipelle sampling, which can be per-
formed in the clinic during a pelVIC examma-
tion for most women, is a less lIlvaslve method
of endometrial biopsy (Fig 1.6), The Plpelle IS
inserted into the uterine caviry until resIStance
at the fundus is encountered; the plunger .IS
then withdrawn to produce a ~acuum and os-
sue is sucked into the Pipelle as It IS rotated and
slowly withdrawn, It is less common for a
dilatation and curetrage (D&C) to be necessary,
especially as there is no evidence of any thera-
peutic advantage from a D&C. . .
• Hysteroscopy, a fine telescopic exanunaoon of
the endometrium, is the gold-standard diagnos-
tic technique for endometrial pathology diagno-
. (F'Ig 1.7) . This can often be performed
SIS . ( ,on an
outpatient basis with local anaesthesia a para-
cervical block') if a suffiCiently narrow-
calibre hysteroscope and minimal distensIOn
medium (carbon dioxide or salme) are used.
Tre atm ent
For some women, explanation of the concept of
DUB ('no disease') as a cause for HMB IS suffiCient
and no other treatment is reqUired. Anaerrua
should be treated by iron replacement.
Medical
An antifibrinolytic agent, such as tranexamic acid
1 g tablets taken four times dally dunng menstru-
ation, is the most effective oral medical tr~atment
for HMB. NSAlDs, such as mefenamIC aCid
500 mg tablets taken three times daily durmg
menstruation, are also helpful. Cychcal oral
Ht.{~ ~~fI.-'"
progestogens, such as me d roxypro gesterone .d I
acetate or norethisterone, were the most WI ~y
prescribed medication for HMB well lIltO e
1990s but when used only in the luteal phase they
are th~ least effective! Long-course oral progesto-
gen treatment (used for 3 out of every. 4 weeks)
is effective, but long-term use is limited by a
high incidence of side effects, The. OCP reduces
HMB even if fibroids are a conmbutlIlg cause.
Ethamsylate is ineffecnve and no longer used. The
Side effects of rlanazol, gestrlnone and GnRH
analogs prohibit thelf use for HMB. The levo-
norgeStrel mtrautenne system (LNG-IUlb~ tht
most
re~easeseffecnve notlSurgIcal
progestogen hormoneopoon
to att for blrthet
loamyMB.
endometrium.
""'" Bleeding may be expecte d to be Iess
than half as heavy as It was before mseroon (Wlth
around 1 in 5 women becorrung amenorrhoeiC),. at
the cost of an irlSertion procedure (the deVICe
needs to be replaced every 5 years) and Irregular
bleeding for the fust 2-3 months after msernon,
The choice of medical treatment IS often influ-
enced by a woman's other requirements. A woman
needing contraception would choose the OCP or
LNG-IUS ' a woman wishing to conceive or to
have no:Wormonal treatment would choose
tranexamic acid or an NSAlD; the LN G-IUS or an
SAID would be most appropnate for a woman
with dysmenorrhoea. Combinations of tranexarruc
acid and NSAIDs may be used if response to eIther
one alone is insufficient.
Blodder
Uterus
FIGUR E 1. 7 The hysteroscope (Based on
;v1cKay Hort & ~lorman 2000, p 112)
Irregular DUB
An OCP or cyclical oral progestogens are usually
effective.
H a woman presents with continual intractable
heavy vaginal bleeding, which is believed to be DUB,
this can usually be controlled by bed rest, oral
tranexamic acid and high-dose oral progestogen
treatment (such as norethisterone 15 mg three times
daily, reducing after 48 hours to 10 mg three times
daily). In this event, it is wise to control the cycle by
I giving long-course oral progestogen treatment
-1! ofI I. (3 weeks out of 4) for at least 3 months. Rarely,
~~intravenous high-dose oeStrogen or traneXarrllC acid
If
""I_VV'[~might be usefuL Emergency D&C is occasionally
u£fi .
- ·.a m".",,", if medical treatment proves ins oent.
Surgical
Endometrial ablation techniques are designed to
partially or full)' destroy the endometrium. Two
generations of techniques are available. First-
generation techniques are performed under
hysteroscopic guidance and include transcervlcal
resection of the endometrium (TCRE) (Fig 1.8),
rollerball ablation and endometrial laser ablation
(ELA). Second-generation techniques have been
developed for selected cases that require less sur-
FIGURE 1.8 How a TCRE Is performed (Based
On ymon ds & Symonds 1998, p 232, Fig 22.9)
1 Th e m enstrual c y cl e an d vaginal blee ding
~~--"-"QQl~-- Subserous
Submucous
Intramural
FIG URE 1.9 The d istrib ution and types of
flbrolds (Based on Wllcocks & Phillips 1997,
P 227, Fig 14,1)
gical expertise, and evidence suggests that they
prodUCe results comparable to those of first-gener-
ation techniques. They may often be performed
with local anaesthetic or intravenous sedation in
an outpatient setting, and include thermal balloon
ablation and microwave endometrial ablation
(MEA)_ Generally, ablation is successful for four
out of every five women with regular HJ\1B, one
of whom is likely to become amenorrhoeic; ooe in
five ablations are not successful, while the tech-
nique is unsuitable for women with irregular DUB.
Hysterectomy involves major surgery, although
it should be possible to carry Out at least 70% of
hysterectomies by the vaginal route (rather than
abdominal hysterectomy) for DUB.
Fibro id s
The distribution of uterine fibroids and their
nomenclature is shown in Figure 1.9. Submucous
fibroids that distort the endometrium are rypically
associated with Hj\lB. Heavy bleeding may also
occur where the uterus is substantially enlarged by
intramural fibroids, which increase the surface
area of the endometrium, Hysterectomy (via the
abdominal route) has traditionally been the treat-
ment of choice for women with HMB related to
fibroids. There is now increasing evidence con-
cerning other treatments.
There is insufficient evidence to support med-
ical treatment options (other than OCP) . Evidence
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,-.. ,

Women's health: a c or9 c urr iculum
does not support the surgical removal of fibroids
to treat infertility or to prevent a fibrOId from
turning into a malignant leiomyosarcoma (very
rare, fewer than 1 in 1000 cases). Myomectomy
(removal of fibroid) rather than. hysterectomy
should be considered for women Wlth HMB who
wish to retain fertility and for whom there are no
other treatment options. Submucous fibroids
impinging on the uterine cavity may be resected
with a transcervical myomectomy techmque SlIDI-
lar to TCRE.
In women who need to undergo hysterectomy
for fibroids, preoperative medical treatment to
shrink fibroids (for example with GnRH analogs)
may allow a less invasive operation: for example,
a vaginal rather than an abdominal hysterectomy:
Fibroid embolisation (by an intervennonal radi-
ologist) is a new technique that might avoid a hys-
terectomy in some circumstances, although rare
hazards associated with embolisation (such as the
need for emergency hysterectomy soon after-
wards, premature ovarian. failur~ or severe li£e-
threatening sepsis) mean thiS reqUIres further eval-
uation before it can be widely recommended.
Natural history
Most cases of DUB run a benign course, although
abnormal menstrual bleeding may herald malig-
nancy and this should be excluded. The peak inci-
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
unopposed oestrogen stimulation of the endo-
metrium, as can occur in anovulatory PCOS,
where the endometrium is not exposed to the pro-
tective effectS of progesterone. The peak incidence
for cervical carcinoma is currently under 50 years
and continues to fall. Those countries with well-
organised cervical cytology screening programs
have reduced their incidence of cervical cancer,
with appropriate use of colposcopy and conserva-
tive excisional surgery for cervical intraeplthelial
neoplasia (CIN), the premalignant condition . of
the cervix. Very rarely, abnormal vagillal bleeding
may be due to fallopian rube cancer or to a hor-
mone-producing cancer of the ovary (granulosa
cell tumour), which influences endometrial
growth and shedding.
Impact / outcomes
Menorrhagia may affect social activity, relation-
ships and employment. Inadequate treatment.of
menorrhagia may lead to chromc anaerma, ill-
health and psychological upset. The cost of men-
strual hygiene productS may be qwte conSiderable
for women with intractable HMB.
Fertility issues may have an impact on the man-
agement of anovulatory DUB .. Ovulanon mduc-
tion treatments (such as clormphene citrate for
anovulatory PCOS) will often improve cycle con-
trol as ovulation is established.
Fear of a cancer diagnosis is prominent among
women with menstrual bleeding disorders. In
some cases this can delay presentation for medical
advice and compromise the prognosis. Abnormal
menstrual bleeding should be invesngated thor- ,-
oughly, especially in women who. have u:regular
bleeding, 1MB, PCB or other risk factors for
endometrial cancer.
Health maintenanc e
Early presentatio n with symptoms o f
abnormal menstrual bleeding allows
early detection of endometrial
cancer and a good prognosIs.
Cervical screening programs have
been shown to prevent deaths from
cervical cancer.
* Dela yed puberty
Common clinical presentations
A child is taken to see her GP because she has
become self-conscious In the school changing
rooms about the fact that she has not devel-
oped breasts or pubic hair like her classmates.
A mother takes her daughter to see the GP
because all her daughter'S peers seem to have
commenced their menses, but her daughte f
has not.
Normal puberty
Puberty is the time at v.'hich, under the influence
of sex hormones, a ch ild becomes an adult
1 The m enstrua l cycle and vag inal b lee ding
5G)
>-
E
.B Height
II
'"
C
G)
E
~
0
.s
:E
C>
a;
:J:
8 9 10 11 12 13 14 15 16 17 18
Age (years)
FIGURE 1. 10 The sequence of pubertal events (Based on Llewellyn -Jones 1999, p 9, Fig 2.1)
physically, s~xually and psychologically. The onset development of the breast, known as thelarche, is
generally varies between 9 and 14 years. the first sign of oestrogenisation and usually occurs
The physical e"cnts of puberty tend to follow around 10-11 years of age (Fig 1.11). The growth
an ordered sequence in time (Fig 1.10) . Although of sexual hair is controlled by adrenal androgens
the most obvious changes are within the reproduc- and is termed adrenarche.
tive system, the first sign is generally a pubertal Depositio]] of subcutaneous fat occurs and gives
growth spurt. Girls tend to go through puberty both the more rounded female contour and the
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
by the early development of secondary sexual colW1U1ar and becomes secretory. The vagma length-
characteristics. Menarche, the first menstruation,
ens, thickens and begins to sectete mucus_ The pelvis
occurs between 11 and 14 years. Finally, secondary
acquires the female configuration. All these changes
sexual development is completed and is accompa-
occur under the influence of oestrogen.
nied by a further growth spurt. Menstruation usually first occurs at around
13 years of age (11-14 years) arid this links to
Seconda ry sexual characteristics
approximately Tanner stage 4-5 of breast develop-
Secondary se 'ual characteristics comprise five ment. In 95% of girls it has occurred by age 13.
ch~ges: the development of breasts, pubic and Bleeding can be erratic and sometimes heavy
axillary hair, the growth spurt and the onset of because many initial 'menstruations' represent the
menstruation (menarche). shedding of the uterine cavity endometrium when
The first physical sign of puberty is generally oestrogen-stimulated growth outgrows blood sup-
breast development, followed by growth of sexual ply, rather than the culmination of an ovulatory
hair in the pubic area and then the axillae. The hormonal cycle.
 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
absent sense of smell are key findings. Anatomical
defects of the miillerian ducts must be sought,
especially when a disparity between normal puber-
ty and absent menses is encountered.
Investigations
These include X-rays for bone age, brain imaging,
gonadotrophin and prolactin concentrations,
adrenal and gonadal steroid measurements, and
assessment of thyroid function. Patients with ele-
vated gonadotrophins require a karyotype, pelvic
ultrasound and, very occasionally, a diagnostic
laparoscopy.
Treatment of delayed puberty
In physiologic delay, reassurance that the antici-
pated development will occur is the only manage-
ment needed. Removal or correction of the
primary aetiology when possible is imporrant, as
in the treatment of hypothyroidism. In hypo-
gonadism, hormone therapy will initiate and sus-
tain maturation and function of secondary se,,:ual
characteristics and promote achievement of height
potential. Long-term treatment is important to
prevent osteoporosis.
Treatment can be initiated with very small
doses of ethinyl oestradiol 1 !-,g daily for approxi-
mately 6 months, increasing to 2, 5, 10 and 20 fLg
at 6-monthly intervals. Low-dose ethinyl oestrad-
iol is not widely available, and arrangements may
need to be made with specialist uni ts. The low-
dose 171' oestradiol patch can be used as an alter-
native.
Traditionally, the cacp has been the drug of
choice for long-term treatment. With the advent of
a large variety of hortDone therapy (HT) prepara-
tions, a greater choice is available.
Regimes with HT are superior because the type
of oestrogen it contains and the dose are not asso-
ciated with an increased incidence of hypertension
or unfavourable changes in lipid profiles. The
overall oestrogen intake over a long period of time
is also increased, as there is no hormone-free
week, and this is beneficial in women with
Turner's syndrome who have no endogenous
oestrogen production. Girls on long-term oestro-
gen supplementation should have their bone min-
eral density checked at regular intervals .
Specific conditions associated
with eugonadism .
An imperforate hymen can lead to obstruction of
the flow of me nstrual blood (cryptomenorrhoea),
whereby girls with a functioning uterus present
with cyclical lower abdominal pain. In the
advanced stages, a palpable abdominal swelling
will be present and separation of the labia will
reveal the classic blue-coloured membrane.
Treatment is by incision and excision of the mem-
brane, leading to the release of large amounts of
tarty chocolate-coloured fluid.
Vaginal agenesis in the absence of a uterus can
be managed by nonsurgical and surgical methods.
The nonsurgical method involves reaching rhe gIrl
to apply a vaginal dilator to the central dimple in
the area of the introitus so that a functional vagina
can be produced. Surgical methods include creat-
ing a pouch or using a split skin graft to create a
neovagina. When the girl is sexually acnve, ha~mg
intercourse will increase the length of the vagma.
Indeed, fonnation of a neovagina is only under-
taken when the girl is approaching sexual activity.
Girls with comp lete androgen insensitiviry syn-
drome have a nortnal 46 XY karyotype but are
phenotypically female. T he testes are normal and
may be found anywhere along the line of testicu-
lar 'descent from the abdomen to the labia. The
risk of malignancy in these gonads is around 5%
and hence thev should be removed after the com-
pletion of pub·eny. This diagnosis can be devastat-
ing, and extensive counselling of the mdivldual
and family is often required.
Health maintenance
Reassurance Is the basis af manage-
ment at physialagically delayed
puberty.
* PolYcystic ovary
syndrome
Common clinical presenlaflons
A 35-year-old wom~n cannot predict when her
next period will be. Her cycles of 6- J 2 weeks
are aSSOCiated with increasingly heavy and
prolonged bleeding.
A 36-year-old woman and her partner seek
help because of her inability to conceive. She
has irregular cycles and can sometimes go
without a period for up to 3 months. On exami-
nation, she Is overweight with a 8MI of 38. She
has mild faCial hirsutism and ocne.
A 28-year-Old Woman with painful periods has
a pelvic ultrasound showing large-volume
polycystic ovaries.
Definition and diagnosis
The polycystic ovary syndrome (PCaS) is the
commonest endocrine disturbance affecting
women. It may be characterised by the ultrasound
appearance of polycystic ovaries and the associa-
tion of one or more of the follOwing clinical symp-
toms or biochemical fe atures: oligomenorrhoea,
amenorrhoea, clinical or biochemical hyperandro-
genism, obesity, or elevated serum LH concentra-
tion. The accepted ultrasound criteria for defining
polycystic ovaries are at least 10 follicles (usualJy
8-10 mm in diameter) arranged peripherally
around a dense core of ovarian stroma or scattered
'
throughout an increased amount of stroma. In
North America, the syndrome is described by the
combination of hyperandrogenism and chronic
anovulation, where other secondary causes (e.g.
adult-onset congenital adrenal hyperplasia) have
been excluded. In the N orth American context,
there IS no. need to identify the presence of poly-
cysnc OVarIes by ultrasonography. ather causes of
hyperandrogenaemia are discussed in the next sec-
non of this chapter.
Epidemiology
Using the ultrasound criteria outlined above sev-
eral studies have sh own that approxim'ately
20-25% of women have polycystic ovaries. Using
1 The m e nst ru al c yc le ond vagina l b lee d ing
the European definition of pcas, about 80% of
women with ultrasound evidence of polycystic
ovaries have peas . The more stringent US cri-
teria, which do not utilise ovarian morphology,
show a 4.5-11.2% prevalence of pcas. Women
with pcas have an increased incidence of diabetes
mellitus, dyslipidaemia and possibly hypertension.
All of these place the woman with pcas at a
higher risk of cardiovascular disease.
Pathogenesis - ~ .e..wl..:,~
c~ ~ -71' V\l~
The pathogenesis of polycystic ovaries and pcas
is unknown. Insulin resistance is thought to be a
key metabolic consequence of a complex genetic
trait disorder. The resulting hyperinsulinaemia
causes an overproduction of ovarian androgens
and a decrease in serum sex-honnone-binding
globulin (SHBG), leading to elevated serum-free
testosterone. The high androgen concentrations
interfere with follicular growth and ovulation,
thereby causing menstrual disturbances and infer-
tility. Insulin may have direct hypothalamic effeCts,
such as stimulating appetite and gonadotrophin
secretion. Women with pca s are pron e to eating
disorders, perhaps because of a link with leptin,
which affects the hypothalamic pulsatility of
gonadotrophin-releasing honnone, with impor-
cant effeCts on reproduction. -1- ~'L c.>Js, J-..t
Clinical manife stations -- t ri.,>U \)t-\ .
The clinical signs and symptoms of pcas include
menstrual cycle disturbances ranging from amenor-
rhoea to irregular menstruation (typically those of
unopposed oestrogen effeCts), obesity, infertility and
Signs of androgen excess (hirsutism, alopecia, acne).
Biochemical abnormalities include elevated serum
concentrations of LH, testosterone, androstene-
dione, dehydroepiandrosterone sulfate (DHEAS)
and insulin. There is considerable heterogeneity of
the symptoms and signs amongst women with
pcas, and for an individual these may change over
orne. Polycystic ovaries can exi>t without clinical
signs of the syndrome, which may find expression
over time. Weight gain and loss are associated with
increasing and decreasing symptoms respectively.
PsychOSOCial stressors also affect how the individual
woman copes and manages her condition. The
hyperandrogenic effeCts of hirsutism and acne can
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 reduc- tion/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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women's health: a core curric ulum
pcos, above). The diagnosis of PCOS, however,
does not rule out other causes, since there may be
dual pathology. . oestrogen (30 mg ethinyl oestradiol) to control the
The HAIRAN syndrome conSISts of hyperan-
drogenism, insulin resistance, and acanthosIs
nigricans. Acanthosis?igricans IS a velvety,
hyperpigmented change In the crease areasof the
skin, It is a disorder charactensed byseveremsulm
resistance and enlarged hyperthecotIc ovaries.
21_hydroxylase-deficient nonclasslc adrenal
hyperplasia is a homozygous r~cesslve disorder
that leads to excessive accumulano n of the precur-
sor of the enzyme, namely 17u-hydroxyproges-
terone and an increase in adrenal androgen
producion. Excluding all other causes leads to the
diagnosis of idiopathic hirsunsm.
Signs and symptoms
Hirsutism
Hirsutism is an excessive hair growth in androgen-
sensitive areas of the skin in women. It marufests
as an excessive or inappropriate development and
growth of the pilosebaceous unit. A ,summary of
the anaroIDY and physiology of harr growth IS
found in Gray's textbook of anatomy (WIlliams
et al 1995). Androgens cause transformation of
the vellus (fine and soft) hair inro termmal. haIr.
The variability in sensitivity of the pilos.cba-
ceo us unit affects the extent to w hich an mdivId-
ual is affected by androgen excess. The hair cycle
varies in different parts of the body: It ranges from
3 ro 6 months on the face to 5 or more years on
the scalp, Familial and ethnic differences will also
cause a wide variation.
Rapid development of hirsutism should alert
the clinician to the possibility of an adrenal or
ovarian neoplasm.
Acne
Acne is commorrly present in female adolescents,
and persistence into the 20s is a feature of
hyperandrogenism. A:; with hirsutism, there IS no
correlation berween the degree of acne and fre e
testOsterone concentrations.
AndrogeniC alopecia
This may be the sole sign of hyperandrogenism.
Typically it occurs initially at the vertex but even- be sought.
tually becomes a diffuse pattern of hair loss.
However, alopecia may be due to other. causes
such as weight loss, thyroid dysfunCtIon or
anaemia. Certain drugs, like danazol, may also
cause hair loss.
Virilisation
Virilisation is characterised by clitoromegaly,
deepening of the voice, androgenic muscle devel-
opment, breast atrophy, severe hirsutism and male
pattern baldness, and is assOCIated. WIth severe
hyperandrogenism. Androgen-secrenng rumours
should be suspected if androgeruc symptOms are
sudden or severe.
Ovulatory dysfunction
This is expressed as an abnormality of mensrrua-
tion that varies between amenorrhoea and Irregu-
1ar bleeding. The high androgen concentrations
interfere with follicular bi ology. TyplCally, the
abnormal bleeding is associated with unopposed
oestrogen activity.
Obesity
Obesity also contributes to a worsening o.f the
effects of hyperandrogenism, espeaally those of
ovulatory and menStrUal dysfunctIOn. The meta-
bolic risks including irnparred glucose tolerance,
hypertenst'on and dyslipidaemias, are more com-
mon in the obese.
Psychological effects
The symptoms of hyperandrogenismcan be severe
and distressing for women, espeCially younger
women. Similarly, the association WIth obeSity will
have further negative effects, with social reJecoon
and isolation being common.
Assessment and investigation
History
This should include information about the age of
onset and its relationship to thelarche and men-
arche. The rates of development of all the fearures
of androgen excess, mensrruaJ history, weIght
changes, family histoty, diet and lifesryle should all
PhYSical examination
Examination should include body mass index and
general signs of cardiovascular health. The degree
of hirsutism is assessed by the well-known
Ferrirnan-Gallwey score (Ferriman & Gallwey
1961). Vtrilising fearures should be actively sought.
Investigations
Pelvic ultrasound to assess for PCOS is the most use-
ful investigation. Serum FSH, LH and prolactin will
aid the diagnosis of PCOS or the uncommon hyper-
prolactinaemia, which causes hyperandrogenism.
Measurement of circulating androgen concentra-
tions (e.g. tOtal testosterone) has limited diagnostic
utility, except in the minimally hirsute or nonhirsute
woman ..,vith a mensrrual cycle disorder. Androgen
levels do not necessarily reflect androgen produc-
tion rate. Androgen-secreting rumours are suspected
by histoty and physical examination. An elevated
17a-hydroxyprogesterone (17u-OHP) suggests an
adrenal cause (21-0H-deficiem nonclassic adrenal
hyperplasia), The 17u-OHP should be an early-
morning specimen taken in the first 2 weeks of the
mensrrual cycle. If abnormal, stimulation with
adrenocorticotropic hormone (ACTH) is performed
to investigate for nonclassic adult-onset congenital
adrenal hyperplasia (CAH). Suppression tests (e.g.
dexamethasone) will help distinguish ovarian causes
from adrenal abnormalities like Cushing's
disease/syndrome or adrenal cancer. Cushing's and
acromegaly should be investigated if there is clinical
suspicion.
Treatme nt
General measures are as described under pcas (see
above). These include measures to control associ-
ated ovulatoty dysfunction, infertiliry and obesity.
Psychological and social disability will require close
emotional support, and counselling should always
be at the forefront of a management plan. The sur-
gical measures used for PCOS \\~U not help hir- .
sutism or acne.
Specific phannacological m~a:;ures can be used
to reduce the effects of excess androgen. The COCP
decreases ovarian androgen production but is not
useful for women who already express fearures of
more than mild hyperandrogenism. Use of contra-
ceptive brands containing the antiandrogen cypro-
terone acetate will be required to reduce unwanted
hair, Cyproterone acetate is a strong progestogen
1 The m e nstrual cyc le and va g in a l b leed in g
and acts by androgen receptor blockade. In severe
cases, cyproterone acetate may be prescribed in a
larger dose (50-100 mg per day) and combined with
mensrrual cycle,
Spironolactone also acts as an androgen recep-
tor blocker. It is an aldosterone antagonist, a mild
diuretic and an antihypertensive agent (see PCOS).
Side effects include dizziness, diuresis, nausea,
fatigue and headaches. Six months' treatment with
spironolactone is associated with significant subjec-
tive improvements in hirsutism, but its value for
arne in clinical practice is difficult to assess from
currently available research. It is best combined
with the COCP.
The effects of either cyproterone or spironolac-
tone may take 6 months to achieve. These drugs
will not reverse the terrninalisation of veHus hairs
already transformed, but will stop new terminal
hairs from growing. A:; patients age, they may
experience a reduction in hair growth, associated
with a loss of hair follicles and a decrease in andro-
gens. Insulin-sensitising agents (e.g. metformin)
will improve ovulatoty function, but their role in
hirsutism is not clear.
Glucocorticoids are commonly used for sup-
pressing adrenal androgen production in patients
with late-onset CAH.
Long-term consequences
The metabolic sequelae for hyperandrogenism result
from the associated hyperinsulinaemia and insulin
resistance, and the dyslipidaemias. These patients
are potentially at long-term risk of diabetes and car-
diovascular disease but the precise extent and natu-
ral histoty of these risks are not known. In the
absence of other clear clinical guidelines, the practis-
ing clinician ought to have a high degree of aware-
ness of long-term effects, and should promote good
healthcare strategies of weight control, exercise,
stopping smoking and psychosocial stress relief.
.Screening for diabetes mellitus, by a fasting blood '
sugar test, should be an annual event.
Health maintenance
Women suffering from hyperandro-
genism, whether problematic or not,
should be advised on lifestyle
changes that may modify long-term
health consequences.
Wi

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
changes are also common, such as mood swings,
anxiety, insomnia, loss of libido and depresslOn.
Common clinical presentation
32-year-old nulliparous woman has Just
A Pathophysiology
returned from overseas and has not had her
period for a year. She Is also having problems
with intercourse and complains of vaginal dry-
ness and lack of libido.
Physiology
Menopause occurs with permanent cessation . of
menstruation following the loss of ovanan acnvny.
On average, menopause occurs at 50 years of age
(range 48-55 years). When it occurs before 40 years
of age (affecting 1% of women), it IS defined as pre-
mature ovarian failure. In 10-30% of such cases, It
occurs in the context of primary amenorrhoea.
In the embryo, germ cells develop from the
gonadal ridge and migrate to the primitive ovary.
They multiply to form approximately 7 million
oocytes. H owever, fewer than 500 eggs are re-
quired duriog the reproducti e life span. Before
birth, rwo-thirds of the eggs are destroyed, and
berween birth arid 40 years of age they are gradu-
ally reduced from 1 million to 10,000 in each
ovary. Beyond 40 years of age, the destructive
process is accelerated. After menopause, there are
no remaining ovarian follicles. Currently, It. IS
thought that acceleration of the oocytedesrruCtlon
process is the cause of premature ovarian failure.
During the normal menstrual cycle, FSH surnu-
lates the ovary to enable the follicle to marure. With
advancing age, and particularly after the age of 40,
the number of primordial follicles, which secrete
inhibin decreases and more FSH is required to
marure'the follicle. As the FSH level requirements
increase, anovulatory cycles become more frequent
and the menstrual cycle lengrh increases. This usu-
ally happens 2-8 years before menopause.
In the posrrnenopausal state, when no follicles
remain in the ovary, oestradiol levels decrease and
FSH levels increase. With the decrease in oestrad-
iol, clinical features develop. Vasomotor symptoms
occur in up to 50-800/0 of ·: :omen. Hot flushes last
berween 1 and 4 minutes and are associated with a
rise in temperarure, peripheral vasodilatation and a
Premature ovarian failure is due to a reduction in
the number, or to the absence, of oocytes within
the ovaries. Women with raised FSH, amenor-
rhoea and ovarian follicles in the ovaries have a
rare condition called resistant ovary syndrome,
which is believed to be due to either the absence of
gonadotrophin receptors on the follicles.or a
posrreceptor signalling defect. In the maJonty of
women, the cause of premarure ovarian failure is
unknown. Identif}'ing a cause can help WIth the .~
psychological trauma of an early menopause and
its consequences.
The causes largely fall into twO main groups:
genetic and autoimmune.
Genetic causes
Two intact X chromosomes are needed for normal
ovarian function. The most common genetic cause
of premarure ovarian failure is Turner'ssyndrome,
where there is one X chromosome rrussmg, 45 XO.
Generally women with Turner's syndrome are of
short stature and present with primary amenor-
rhoea. The very early development of the ovary
appears to be normal but there is an accelerated
loss of germ cells prior to birth. Turner's syndrome
mosaics (45XJ46XX) or deletions in either arm of
the X chromosome can also cause premature ovar-
ian failure. There is evidence that a specific parr of
the X chromosome is required for normal ovarian
function.
Premarure ovarian failure can occur where no
identifiable genetic defect can be found, and yet
several members of the family are affected. It
seems that familial premarure ovarian failure has
several modes of inheritance. Other inherited dis-
orders associated with premarure ovarian failure
include galactosaemia, fragile X syndrome and
blepharophimosis.
Autoimmune causes
Premature ovarian failure due to an autoimmune
cause is usually associated with abnormal thyroid
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-
ease, type 1 diabetes, hypoparathyroidism and per-
nicious anaemia.
There is some evidence that viral infections can
cause premature ovarian failure, the most common
being mumps.
Iatrogenic causes
Iatrogenic causes include any pelvic surgery, par-
ticularly ovarian cystectomy or hysterectomy
where there may be damage to the ovary or the
ovarian blood supply. Pelvic radiotherapy and sys-
temic chemotherapy can also cause premarure
ovarian failure. The effea depends on the dose
given and the age at the starr of therapy. Before
commencing these therapies, the option of ovarian
cryopreservation can be offered in the hope that
techn ology to produce marure eggs from ovarian
tissue may be developed in the furure.
Assessment and investigations
A full history and examination are required as
other causes of secondary amenorrhoea need ro be
considered, including PCOS, pregnancy, hyper-
prolacnnaenua, stress, anxiery and weight disor-
ders, cervical stenosis and Asherman syndrome.
The diagnosis of premature ovarian failure is
confinned by measuring FSH and oestradiol con-
centrations. The FSH concenrration needs ro
be measured on two separate occasions. Concen- References and further reading
trations greater than 20 IUIL are rarely associated
with a successful pregnancy, and a level greater ACOG Practice Bulletin 2002 Clinical maoagement
than 40 IUIL is diagnostic of ovarian failure.
Oestrogen concentrations are low. Investigations
should also include karyotyping, particularly with Adams J, Polson DW, Franks 5 1986 Prevalence of
premarure ovarian failure and primary amenor-
rhoea. Thyroid function tests and a general auro-
anobody screen are performed, together with a
beta-human chorionic gonadotrophin (~-HCG) Azziz R 2003 The evaluation and management of hirsutism.
level to exclude pregnancy. Ulrrasound is useful to
look at ovarian volume and evidence of remaining
follicles.
Once the diagnosis of premature ovarian fail-
ure 1S made, referral ro a specialist is indicated and Carpentet SEK, Rock JA 2000 Paediatric and adolescent
the prognosis, implications for fertility, and long-
term oestrogen deficiency need to be discussed.
1 The menstrual cycle an d vaginal bleeding
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-
tility and subsequent natural pregnancy is around
5-15% for women with a normal karyotype.
There is no evidence that any treatment can
enhance this rate, and egg donation with IVF or
adoption remain options.
Long-term consequences
Women with premarure ovarian failure experience
symptoms of oestrogen deficiency, have an increased
age-related mortality rate and are at increased risk of
osteoporosis. Long-term hormone therapy that does
not prevent conception is indicated until the age of
natural menopause is reached. Women should also
be informed of the need for adequate calcium intake
and physical activiry. Long-term follow-up is neces-
sary to check for the development of associated
autoimmune endocrine disease.
Health maintenance
Smoking Is assocJated with the onset
of menopause at on earller age .
Adequate physical activity and
calcium intake min imise bone loss In
women. Up-la-date Information about
the risks and benefits of hormone
replacement Is Important.
guidelines for obstetrician·gynecologists. Obstetrics and
Gynecology 100(6):1389-1402.
polycystic ovaries in women with anovulation and
idiopathic hirsutism. British M~dical Journal (Clinical
R<search edo) 293:355-359.
Obstetrics and Gynecology 101:995-1007.
Balen A, Michelmore K 2002 What is polycystic ovary
syndrome? H wn.m Reproduction 17(9):2219-2227.
gynecology, 2nd ecln. Lippincott Williams & WUkins
Baltimore, pp 181-204. '
Wi
Women's health: a co re c urriculum
Clark M ..I, Thornley B, Tomlinson L et al 1998 Weight loss
in obese infertile women results in improYC!rnem in
reproductive outcome for all forms of fertility
treatment. Human Reproduaion 13:1502-1505.
Conway SG 2000 Premarure ovarian failure. British
Medical Bulletin 56(3):643-649.
Edmonds DK 1993 Primary amenorrhoea. Progress in
Obstetrics and Gynaecology 10:281-295 .
Farquhar C, Anoll B, Ekeroma A et al 2001
An evidence-based guideline for the management of
urerine fibroids. Australian and New Zealand Journal
of Obstetrics and Gynaecology 41 :125-140 .
Farquhar CM, Williamson K, Gudex G et al 2002 . 2.
A randomized controlled trial of laparoscoplc ovanan
diathermy versus gonadotroph.in therapy for women
with clomiphene-resistant polycystic ovary syndrome.
Fertility and Sterility 78 :404-411.
Farquhar CM, Lee 0, Toomath R et al 2003 Spironolactone
versus placebo or in combination with steroids for
hirsutism andlor acne. In: Cochrane Database of
Syste matic Reviews ([he Cochrane Library) . Online.
Available: hnp:!/www.update-software.com!cochrane.
Fcrriman D, Gallwey JD 1961 Clinical assessment of body
hair growth in women. Journal of Clinical
Endocrinology and Metabolism 21 :1440-1445.
Garden SA 1998 Problems with menstruation. In: Garden
SA (ed) Paediatric and adolescent gynaecology. Arnold,
London, pp 127-154.
Hacker NF, Moore]G 1998 Essentials of obstetrics and
gynaecology, 3rd edn. Saunders, Philadelphia.
Jacobs HS, Conway GS 1999 Le ptin, polycystic ovaries and
polycystic ovary syndrome. Human Reptoducnon
Update 5:166-171.
Kalantaridou SN, Nelson LM 2000 Premarure ovarian
failure is not premature menopause. Annals of the New
York Academy of Sciences 900:393-402.
Llewellyn-Jones D 1999 Fundamentals of obstetrics and
gynaecology, 7th edn. Mosby, London.
1 The m enstrual c ycle and vaginal bleeding
Marshall WA, Tanner jM 1969 Variations in pattern of
pubertal changes in girls. Archives of Disease in
Questions 5. Which of the following scenarios would
Childhood 44:291.
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?
Illustrated textbook of gynaecology. WB Saunders! diagnosing endometriosis?
BaiII~re Tindall, Sydney. a. Height of 150 cm
a. Pelvic MRI
McKay Hart D, Norman J 2000 Gynaecology ,Uusrrated, b. Hysteroscopy b. Breasts which are smaller than those
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
edo. Churchill livingstone, Edinburgh.
e. A thorough history of the nature of d . Widespread pubertal hair extending
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
Which of the followin g is supported by
when swimming
Speroff I., Glass RH, Kase NG 2001 Abnormal puberty and the strongest evidence of effectiveness
growth problems. In: Speroff L, Glass RH, Kase NG for treatment of premenstrual e . Absence of menses, but with hair
syndrome?
(eds) Clinical gynecologic endocrinology and infertility, .0' and breast secondary sexual
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
with her mother because she has not
Clinical gynecologic endocrinology and infertiliry, 6th c. Pyridoxine (vitamin 96 ) yet had a period. On examination, she
edo. Lippincott Williams & WLlkins, Baltimore,
d. Progestogens Is short in stature and there is no
pp 431-448.
~ condary sexual development.What
Symonds ElVl, Symonds 1M 1998 Essential obstetrics and
e. Spironolactone Is the most likely diagnosis i
gynaecology, 3rd edo. Churchill L vingstone, a . Prolactlnama
Edinburgh.
3. Which of the following Is the most
effecflve nonsurgical option for b . Congenital adrenal hyperplaSia
Wilcocks j , Phillips K 1997 Obstetrics and gynaecology. ovulatory dysfunctional uterine
bleed in g? c. Imperforate hymen
Churchill Livingstone, New York.
a. NSAIOs @ rurner 's syndrome ..,.
Wtld RA 2002 Long-term health consequences of PCOS.
Human Reproduaion Update 8:213-241. b. Tranexamic acid e . Mosaic 46XY I 45XO
c. Short-course pragestogens
WLlli.ms PI., Bannister LH, Berty MM er 01 (eds) 1995 7. A 30-year-old woman presents with a
Gray's anatomy: the anatomical basis of medicine and ~ Levonorgestrel intrauterine system 6-month history of amenorrhoea and a
surgery, 38th edo. Churchill Livingstone, London,
e. Transcervical resection of the vague history of hot flushes. Which of
pp 400-405 . endometrium the following statements is incorrect?
Working Party for Guidelines for the Management of a . ~-HCG Is useful to exclude
4. Which of the following is a
Heavy Menstrual Bleeding 1999 An evidence-based pregnancy
characteristic feature of Turner's
guideline for the management of heavy menstrual syndrome?
bleeding. New Zealand Medical ]oumal112:1 74-1 77. b . FSH is useful to diagnose ovarian
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
I. vague history of hot flushes. Which of
the following statements Is incorrect?
I a. Ovarian resistance syndrome is a
possible diagnosis.
b. A prolaclinoma should be excluded.
c. Thyroid disease should be excluded
if ovarian failure is diagnosed.
d . Long-term oestrogen/progesterone
substitution is contraindicated in
case of ovarian failure.
e. Pregnancy is the most common
cause of amenorrhoea In this age
group.
9. The ultrasound diagnosis of polycystic
ovaries is based upon which of the
following parameters?
a. An ovarian volume greater than
12 cc
b. Any ovarian abnormality that
contains more than one follicle
larger than 15 mm in diameter
c. Ten follicles (usually 8- 10 mm in
diameter) arranged peripherally
around a dense core of ovarian
stroma
d. Multiple ovarian follicles in an
enlarged ovary
e. Follicles larger than 20 mm in
diameter that persist longer than
3 months
10. A 25-year-old woman menstruating
every 3-4 months has noticed
increasing acne and hirsutism over the
previous year. Her serum testosterone Is
elevated, as is a measurefl1ent of 17a-
Vaginal discharge
hydroxyprogesterone . What Is the usual
next management option? Leo R Leader
a. Prescribe a COCP containing
cyproterone acetate. Edited by Lucy Bowyer
b . Perform an adrenal stimulation test.
c. Reassure her that the diagnosis of
PCOS does not necessarily need
treatment. /
d. Prescribe an aldosterone
anatagonist.
e. Use depilatory agents to control
hirsutism .
11 . Which of the following is the single
. Learning objectives
most useful investigation in a woman
presenting with hirsutism and
oligomenorrhoea?
Knowledge Skills
a. Serum-free testosterone
At th e end of thi s chapter, the student At th e en d of this c hapte r, the studen t
b. Total testosterone wIll be able to : sh o uld learn how to:
c. SHBG
discuss the role of oestrogen in the distinguish between a normal and a
d . Ovarian Ultrasound d evelopment and maintenance of pathological vaginal discharge
/'
e.DHEAS vaginal epithelium throughout a
woman's life develop a professional and articulate
approach to an embarrassing problem.
12. Cyproterone acetate is effecli e in • list th e causes of vaginal discharge
reducing hirsutism because it Is which th roughout a w oman 's life
of the following?
Iden tify common infections of the lower
a. A strong progestogen and acts b y genital tract Attitu des
androgen receptor blockude
construct an appropriate diagnostic At the e nd o f th is c ha p te r, the student
b. An oestrogen and suppreises and management plan for each
ovarian function sho ul d reflect upo n:
diagnosis considered
c. An Insulln-sensitising agent ..".-r • outline the management of recurrent the Importance of a woman 's
d. An aldosterone anatagonist candidal infection. understanding of normal physiology.
e. A depilatory agent
Wi
 Women 's health: a c Ole urric ulum
Common clinical presentations
A 21-year-old woman taking the oral
contraceptive pili (OCP) presents with
excessive vaginal discharge.
A 70-year-old woman consults for a vaginal
discharge and soreness.
Normal vaginal discharge
In women of reproductive age the vagina is moist,
due to secretions from vaginal transudate and cer-
vical mucus, and, to a lesser extent, to uterine, fal-
lopian tube and Bartholin's gland secretions. The
volume of secretion that is accepted as normal by
individual women varies greatly, Excessive normal
secretion (leukorrhoea) usually produces staining
of underclothes and vaginal odour due to the heat
denaturation of the proteins in the secretions.
Secretions are clear to white and range in consis-
tency from thick mucUS before menstrUation to a
thin, watery, more profuse secrenon at ovulanon,
Leukorrhoea is associated with:
• increased production of the ovarian steroids
(oestroge ns in particular), which occurs at the
time of ovulation; with the use of oestrogemc
hormonal preparations (e.g. oral contraceptives
or hormone therapy); in pregnancy
• cervical ectropion (also incorrectly called a cer-
vical erosion), caused by hyperrrophy of the
endocervical columnar glands and their exten-
sion from the cervical canal onto the ectocervix
• increased vaginal transudate, which occurs with
sexual excitement and vaginal irritation (such as
chemical irritation from vaginal douches, per-
fumed producrs, vaginal applications or even use
of spermicides)
• increased uterine secretions: before menstrua-
tion, secretory changes in the endocervical and
endometrial glands may produce a premenstrual
increase in vaginal discharge; following men-
struation, the last days of menstrual flow may be
prolonged; irritation from an intrauterine con-
traceptive device (IUD)
• granuloma (arising in the suture line at the vagi-
nal vault following a hysterectomy), which can
give rise to a profuse di charge that is besr treat-
ed by cautery, either chemically or by diathenny.
7
Management of leukorrhoea
Take a history and make specific enquiries about:
the timing of discharge - midcycle or premen-
strual exacerbation; oral contraception - espe-
cially oestrogen concentration; use of douches,
additions to bath water or deodorising sprays;
recent medications - especially vaginal applica-
tions, spermicides, antibiotics; and recent preg-
nancy (Leader et al 1996). . symptom. The discharge is classically thick, white
On examination, assess the amount of diS-
charge and check whether there is any redness of
the vulval, vaginal or perianal skin. Exclude pel vIC
or vaginal infection : if there is any doubt, take a
high vaginal swab and an endocervical swab for
culture and sensitivity. The diagnostic feature of
leukorrhoea is that there are no pus cells visible on
microscopy in a wet saline preparation.
Explain the physiology of the normal cycle.
Strong reassurance that the discharge is not due to
an infection or any abnormality may be all that is
required. Eliminate any aggravating cause such as
a high-dose oestrogenic pill, nylon underwear or
inappropriate vaginal applications (Reed. & E~ler
1993). Give general advice regarding hYgIene, lim-
iting local heat to the genital area, avoiding
deodorising sprays, and wearing conan under-
clothes that absorb some of the secretions.
Ablative therapy (cryocautery, diathermy, laser) to
the cervix is used in a minority of persisrent cases
to reduce the number of endocervical glands,
However, if the original precipitating factor is still
present (e.g. oral contraception), relief will be
short-lived.
Pathological discharges
These usually present with other symptoms, such
as vaginal/vulval pruritus, dyspareunia or pelvic
pain. J\ilany of the infective causes of vagInal
discharge produce a classical vaginal reacoon;
however, more frequently there is a nonspecific
discharge and a nonspecific vaginal reaction.
It is important to realise that organisms that
may cause a pathological discharge can be present
in the vaginas of many women, without producing
any symptoms (Sobel 2000) . In studies of well
women who have been attending family planning
clinics, 15-30% of women have been found to
have Monilia or GardnereLla vaginalis, 10-15%
Trichomonas and 10-20% Chlamydia trachomatis.
Candida' vaginitis (thrush)
Candidal (or monilial) vaginitis is caused by
Candida albicans, a yeast-like fungus that appears
[JUcroscoPlcalJy as long filaments (mycelia) or as
spores.
It can be found in the vaginas of 15-30% of
asymptomatic women and is usually treated only
when It IS symptomatic. Itching is the predominant
and cheesy, and tends to stick to the walls of the
vagina, leaving a reddened area when removed.
The vagina may be extremely sore, making exam-
ination painful.
The organism thrives in the presence of carbo-
hydrate, and is therefore more common during
pregnancy or the second half of the menstrual
cycle, in diabetes and following broad-spectrum
FIGURE 2.1 Speculum examination of lateral
va Inal wall affected by candldol vaginitis
shOWing w hite ' cottage cheese' -like
app earance of adherent discharge (From
P kin et al 2003, p '03 , Fig 2)
2 Vaginal discharge
antibi otics, which destroy the normal vaginal
flora.
First-line treatment is often topical: imidazole
drugs are very effective: for example, clotrima-
zole. in cream or pessaries for 3 to 6 days. Vaginal
applicaoons may be supplemented with local cream
for vulvitis. Many patients prefer to use oral treat-
ments, such as ketoconazole or fluoconazole, as such
treatments are not messy like vaginal applications,
but oral treatment should not be used during preg-
nancy.
Recurrent infection occurs as local intravaginal
spores gernunate or WIth reinfection from a sexu-
al parmer. Spores are not affected by either local
or oral treatment. Relapse is more likely to occur
at the time of the menses, probably as a result of
changes in the pH in the vagina. Precipitating
causes, such as antibiotic use, diabetes or even
Hrv, should be sought.
Treatment of recurrent thrush is usually oral
therapy for 5 days, which can be repeated in sub-
sequent menstrual cycles. This pulse therapy will
kill any spores thar start to germinate as conditions
become more favourable premenstrUally. The part-
ner should be treated either with local imidazole
cream applied twice daily for 7-10 days or oral
ketaconazole.
Gardnerella vag initis
This can be found in the vaginas of 10-30% of
asymptomatic women and is caused by a small,
non-monle, gram-variable coccobacillus (Gar-
dnerella vaginalis).
The typical clinical presentation includes a vari-
able amount of thin discharge that has a fishy or
unpleasant odour, ofren more pronounced after
intercourse and caustng local irritation but not
pruritus. Microscopic examination of a wet prepa-
ranon mounted on a slide will show large numbers
of coccobacilli fl oating between and attached to
vaginal epithelial cells in a stippled manner ('clu e
cells').
Treatment is with tinidazole or metronidazole.
Alcohol sho uld be avoided, as these drugs are
metabolised in the liver and can cause nausea and
vomiting.
Ten per cent of men will be asymptomatic
carriers of this bacterium and so should be treated
initially or if there is recurrence,
-E
Women's health: a core curriculum
Trichomonal vaginitis
This is caused by a flagellate unicellular organism.
It is harboured, usually asymptomatically, in
2-10% of males and can be transmitted sexually. It
can also be found in the vaginas of 10--15% of
asymptomatic women. The discharge is classically
frothy and yellow-green in colour, variable in
amount and has a typical fishy odour. It is often
associated with dysuria and prurirus. The vaginal
walls and cervix may have an inflamed appear-
ance, with punctate 'strawberry' spots. The diag-
nosis can be made microscopically. Tinidazole or
metronidazole are again used for eradication; the
male parmer should also be treated.
Sexually transmitted infections
See Chapter 3 for chlamydia, gonorrhoea and
other sexually transmitted infections.
Atrophic vag initis
Lack of oestrogen in posnnenopausal women
results in a very thin vaginal epitheJium, which is
easily injured or infected. The responsible organ-
isms are usually nonspecific (producing a mixed
growth on culture) and of low virulence.
The discharge is thin, purulent and often
blood-stained, and the vagina may appear red and
ha':e many tiny bleeding points. Vaginal, vulval
and perineal soreness are frequently present and
may make an adequate examination of the patient
difficult.
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.
2 Vagina l disc harge
Childhood vaginitis
This is uncommon and may be associated with a Questions
wide range of organisms, which are usually of low 2. Candida infection :
virulence. Select the correct answer to complete the a . is also known as Gardnerella
Whenever a child presents with a vaginal dis- statement.
vaginitis
charge, always suspect a foreign body. However,
1. White vaginal discharge :
Neisseria gonorrhoeae and Trichomonas vaginalis b. is also known as moniliasis /
do occur in children, and the possibility of abuse a . is called diarrhoea
c. is caused by a bacterium
should be considered. b. is always abnormal
d . is less common in women with
c. is commonly caused by syphilis diabetes
Health maintenance
d . must always be examined with a
Most vaginal discharges are physio- va ginal swab for culture e. can be treated with antibiotics.
logical. Wearing undergarments
made of natural fibres and avo iding e. may occur with Candida infection .
the use of perfumed products In the
genital area will help to min im ise
vaginal Irritation and leukorrhoea. /
References
Leader LR, Bennen M], Wong F 1996 Handbook of
obstetrics and gynaecology. Chapman Hall, London.
Pitkin J, Beattie All, Magowan BA 2003 Obstetrics and
gynaecology - an illustrated text. Chutchill
Livingstone, Edinburgh.
Reed BD, Eyler A 1993 Vaginal infections: diagnosis and
management. American Family Physician
47: 1805- 1818.
Sobel JD 2000 Bacterial vagiuosis. Annual Review of
Medicine 51:349-356.
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
At the end of this chapter, the student
wi ll be able to:
Sexually transmitted Infectlans (ST/S) -
general principles
describe high-risk behaviour for the
development of STis
• discuss the educational initiatives to
Inform people about STis
summarise the public health impli -
cations of notifiable diseases and
contact tracing
Genital herpes
indicate the prevalence of genital
herpes
describe the clinical findings and
laboratory diagnostic tests
• outline a management plan for primary
and recurrent infection
Genital warts
indicate the prevalence of HPV Infection
and Its significance with respect to
development of genital warts and
genital neoplasia
• describe the clinical appearance and
distribution of genital warts
• list the treatment options for removal of
genital warts
Syphilis
describe the symptoms, signs and time
frames of the primary, secondary and
tertiary stages of syphilis
evaluate the diagnostic and screen
tests for syphilis
outline a management plan for the
treatment of syphilis
Gonorrhoea
Indicate the prevalence of gonorrhoea
Infection
• describe the symptoms of gonorrhoea
infection
list the long-term consequences of
untreated gonorrhoea infection
• outline a plan for the diagnosis and
management of gonorrhoea
Chlamydia
describe the worldwide distribution of
ChlamydIa infection
outline the short- and long-term
consequences of pelvic infection with
Chlamydia
• describe the laboratory investigations In
the diagnosis of ChlamydIa infection
(Continued over)

Women's health: a c ore curriculum
(Learning objectives continued)
• design a plan for the diagnosis an.d
management of Chlamydia Infection
HiV/AIOS
describe the epidemiology at HIV
Infection
summarise the pathophysiology of HIV
infection
list the Investigations performed to
diagnose HIV infection and monitor host
response
• identify particular health issues of
relevance to HIV-positive women
Srts and pregnancy
• describe the consequences of
antenatal infection with hepatitis B. ..
Chlamydia. gonorrhoea. herpes. syphilis
and HIV.
Skills
At the end of this c hapte r. the student
sh ould learn how to:
counsel regarding safe sexual
behaviour
* Genita l herpes
Common clinical presentations
A woman attends the emergency department
because she has such severe genital pain that
she is unable to urinate.
Having recently had casual sexual intercourse,
a 20.year-old woman no~ces some blistering
around her labia.
Epidemiology
Seroprevalence studies show that 220/0 of adults
have herpes simplex type 2 vlms (HSV-2). Most
women with HSV-2 infection are not aware that
they have genital herpes, as their symptoms are
'.
• take a history and perform an
examination for an STI with sensitivity
and respect in a non-judgmental
manner
• explain the diagnosis t.o a woman with
a sexually transmitted Infection and
counsel her
explain to the patient the importance of
adequate treatment for an infection
and follow-uP of contacts
provide pre-test counselling for a woman
about to undergo an HIV screen.
Attitudes
At the end of this chapter. the studen t
should reflect upon:
• the need for community education on
responsible sexual behaviour
• the requirement of informed consent for
testing for STis. in particular HIV
confidentiality
the effect of a diagnosis of pelvic
infection upon personal relationships.
body image and self-esteem.
mild. However, they can pass on the infection to
sexual partners and newborns.
Pathophysiology
Genital herpes is an infection with herpes simplex
vims type 1 or type 2. About .10% of gemw
lesions are caused by HSV-2 acqUIred from symp-
tomatic or asymptomatic sexual partners, and
from genital, oral and sexual contact-
Signs and symptoms
Classically, there is blistering and ulceration of the
directly infected region(s), which i l l ,,":omen are
usually on the labia majora, labia nunora and
around the clitoris and urethra. The leSIOns are
frequently multifocal, bilateral and at different
stages of development and resolution. They can be
acutely painful and precipitate dysuria and reten-
tion of urine. Herpetic lesions can cause anorectal
spasm, discharge from the vagina and/or urethral
discharge and local lymphadenopathy. Systemic
manifestations include fever, myalgia and, rarely,
autonomic neuropathy and even meningitis.
Natural history
The primary episode may be atypical and asymp-
tomatic; occasionally, it is associated with very
severe, painful manifestations that last for 4 weeks
or more. Prolonged severe infection should raise
the suspicion of immunosuppression, e.g. HIV
infection.
Recurrence may be precipitated by sexual con-
tact, fever, stress and general illness. The recurrent
lesions may involve the genitals, anus and perianal
area, buttocks, legs and perineum. Neuralgic pain
in the lower back, perineum and inner or back of
thighs represents nerve root irritation. Grouped
localised lesions along sacral dermatomes may
occur unilaterally. Rarely, meningoencephalitis
may occur. There is an increased risk of HIV ttans-
mission and acquisition of opportunistic infections
in immunocompromised individuals.
Diagnosis
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
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,
during transportation to the laboratory. The virus
culture is more than 90% sensitive, with sensitivi-
ty decreasing if the swab was taken later than
36 hours afrer the active episode. However, this
method is expensive, labour-intensive and slow.
False-negative tests for HSV are not uncommon if
taken more than 48 hours after the onset of an
attack or afrer medication has been applied.
Management
Drug treatment varies according to whether the
infection is primary or recurrenL For a primary
infection, acyclovir 200 mg is given five times daily
or 400 mg 8-hourly for 5-10 days. Alternatively,
3 Sexually Ironsmltted Infectio ns
valaciclovir 500 mg can be given 12-hourly for
5-10 days. Side effects of the above medica-
tions include headache and nausea. Symp-
tomatic management with analgesia and topical
lignocaine 2% jelly is offered to those with
pain. Treatment of secondary infections with
antibiotics and antifungals ma y be required. In
severe cases, admission to hospital and the
insertion of an indwelling urinary catheter may
be required.
Recurrent herpes infections are managed with
suppressive regimens of acyclovir 200 mg 8-hourly
or 400 mg 12-hourly, valaciclovir 500 mg dally or
farnciclovir 250 mg bd for 3-4 months. This treat-
ment should then be discontinued intermittently
to assess the need for further courses. Episodic
therapy should be initiated by the patient at the
first sign of prodromal symptoms or very early
lesions .
Health maintenance
Community education about at-risk
behaviour and STis Is Important and
particularly relevant to individuals
under 25 years of age.
* Female genital warts
( CO ndylomata
acuminata)
Common clinical presentations
A woman describes new lumps around her
genitalia and anus.
A woman has noticed that her partner has a
penile wart. .
Epidemiology
Anogenital warts are caused by the human papil-
lomavims (HPV). Over 50% of sexually active
adults have been infected with HPY, but most of
these in fection s are subclinical, benign and
unrecognised. Clinical manifestation of H.PV in
the form of genital warts is common.
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

Women's health : a c o re curr icul um
* Gonorrhoea
Common clinical presentations
A 25-year-old woman presents with Infertility
and tubal blockage.
An asymptomatic woman presents with her
partner. He Is complaining of urethritis.
A woman presents with a mucopurulent
vaginal discharge.
Epidemiology
Gonorrhoea is the second most commonly re-
ported notifiable STI in Australia. The prevalence
is influenced by the spread from asymptomanc
people and others with at-risk behaVIOur.
Pathophysiology
Gonorrhoea is caused by the gram-negative diplo-
coccus N eisseria gonorrhoeae. It is contagrous and
spread mainlv by coitus. . Chlamydia Infection was also found as part of
It affects 'mucosal and glandular strUCtures m
the genital tract, reCtum, oropharynx and conJunc-
tivae. The incubation penod IS usually 2-7 days
but can be longer.
Signs and symptoms
In more than 60% of women, the condition is
asymptomatic: hence contact .tracmg 15 lIDpOrtant.
The most common symptom IS cervlcms and a dis-
coloured vaginal discharge. .. . choma is endemic and child-to-child trans.truSSlon
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,
dysuria and a yellow urethral discharge, while
25% of males are asymptomanc.
Diagnosis and management
Diagnosis is confirmed by demonstrating the organ-
ism in culture. Appropriate swabs are taken from
the endocervix, urethra, anus, throat or abscess.
A presumptive diagnosis can be made by finding
gram-negative intracellular diplococa m smears.
Most gonorrhoea infections are sensmve to
penicillin. Spectinomycin, ceftnaxone or orclpro-
floxacin can be used in cases of penicillinase-
resistant Neisseria gonorrhoeae. Follow-up IS
recommended 1 week afrer eompletmg a treat-
ment regimen to ensure cultures are negatJve.
Outcome
In 60-80% of cases, pelvic infection in women
under the age of 25 years is caused by gonorrhoea
or Chlamydia. This can lead to infertility, chrOille
pelvic abscess and pelvic pain. . sion and by vertical transmission in childbirth or
Without treatment, gonorrhoea m men causes
prostatitis, vesiculitis and epididymitis. In the new-
born, ophthalmia neonatorum (conJunCtlVltIS
within 21 days of birth) is a notifiable disease.
*
C hlamydia
Common clinical presentation
A 19-year-old woman presents for colposcoPY
because of an abnormal cervical smear test.
a routine screen.
Epidemiology
In industrialised western society, virtually all
Chlamydia trcu:.hom atis infections are sexually
transmitted. Chlam ydia is the most common STI
in Australia. In many deveiopmg. countnes? a- :r
is common.
Pathophysiology
Chlamydia trachomatis is an obligate intracellular
parasite. If symptoms occur, these usually appear
1-3 weeks afrer exposure.
Signs and symptoms
In 70-90% of wo men, the infection is asymptO-
matic. Whete there are symptoms, they are likely
to be mucopurulent discharge and/or cervlCltl~
postcoital bleeding and lower abdommal pam.
10-150/0 of cases, there may be pelVIC mflamm a-
to ty disease (PID).
Diagnosis
Samples should be taken from the endocervix, ure-
thra and urine. Chlamydial tests include culture,
immunofluorescence and detection of antigen or
nucleic acid. First-catch urine tests by polymerase
chain reaction (peR) or ligase chain reaction
(LCR) are alternatives to swab tests. N on-culture
tests may give false-positive results and should be
interpreted with caution.
Management
1. Check for other STIs as Chlamydia may occur
concurrendy with gonorrhoea.
2. For local infections, give azithromycin 1 g orally
as a single dose (category B1 in pregnancy), or
doxycycline 100 mg twice a day for 10 days
(category D in pregnancy), or erythromycin
800 mg twice a day for 10 days (cate-
gory A in pregnancy).
3. Where there is PID, azithromycin and metron-
idazole are recommended, followed by doxy-
cycline.
Outcome s
In women, upper genital, peritoneal, joint and
ocular manifestations can occur, and Chlamydia
infections are associated with tubal blockage and in-
fertility. In men, Chlamydia may cause epididymitis.
Health maintenance
Scree ning for other STis is important.
as several may co-exist .
* HIV/AIDS
woman whose partner Is an
~.I I...I,nv,.... ,'''. drug user has a postlve test to HIV
attar presenting for routine STI screening.
Epidemiology
Women represent 6% of adult cases of human
immunodeficiency virus (HIV) in Australia. In the
developed world, the epidemiology of HIV has
3 Sexua lly transm itted infections
had three phases: men having sex with men, intta-
venous drug users and heterosexual transmission.
Pathophysiology
The humatl immunodeficiency virus is a retrovirus
which can be found in the blood, vaginal fluids or
semen of infected people. The virus can be trans-
mitted to others during sex, by sharing needles and
syringes, through a contaminated blood tratlsfu-
during breastfeeding.
Signs and symptoms
The initial illness usually occurs within 2 weeks of
infection and has symptoms similar to those of
glandular fever: headaches, fever, swollen glands
and body rash. After a dormant phase, the sympto-
matic carrier state occurs once the immune system
is affected. There are a wide range of clinical mani-
festations including fatigue, fever, weight loss,
diarrhoea and glandular swelling. Autoimmune
deficiency syndrome (AIDS) has severe effects on
the immune system, causing the body to be over-
whelmed by infections and cancers. The most com-
mon of these are pneumonia, Kaposi's sarcoma
(rare .in women) and lymphoma.
Diagnosis and ma nagement
Antibodies to HIV appear approximately 3 months
afrer infection and remain throughout life.
After the primary infection, the viral load stabi-
lises at a 'set point'. The disease is monitOred with
HIV/viral load and CD4/CD8 lymphocyte counts.
Rising viral load and falling lymphocyte count
indicate the need for antiretroviral therapy.
Treatment
Antiretroviral therapy is consrandy changing. It is
common to use a combination treatment with
three drugs. Specialist assisrance should be sought
to investigate and plan management.
Specific considerations
1. Fifty per cent of HIV-positive women have a
high risk of HPV and therefore are at an
increased risk for cen·i. cal cancer.
WE

Women's health : a core cur riculum
d her partner and other children
During vaginal intercourse, women a,re at high- ch ec ke d , an . d . d 'f
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
and several other STIs, probably mcluding
is at delivety. The combination of liTIIDunoglobulm
HSV-2 infection, gonorrhoea and Chlamydia. and immediate postparrum vaccmatlon prevents
3. Reproductive issues: pregnancy outcome ma~
the majority of perinatal transmiSSIOns.
be affected by an HIV diagnosIS, whether It IS
made before or during pregnancy. Chlamydia
Mother-to-fetus infection can occ~ at the time of
Counselling and testing for HIV birth by direct transmission. The mfant may de-
It is essential that the patient give informed con- velop conjunctivitis or pneumonltls: the nsks are
sent before any testing and after explanaoo n about thought to be up to 250/0 and 15% respeenvely. If
the possible results. Explam a mother tests positive for Chlamydra dunng preg-
th e implications of th'
that there is a 3-mon WID . d ow' fr om exposure to nancy the risk to the neonate IS reduced by a
antibody development, and therefore a repeat test cours~ of antibiotics. Erythromycin is the first drug
will be necessary before a negaave test can be con- of choice. Azithromycin or alilOluCillin are mdicat-
firmed. Confidentiality issues are. Important. ed if erythromycin is not tolerated.
A positive result may have. imphcanons for life
insurance and immigranon, In addinon to ralsmg Bacterial vaginosis (BV)
serious social and psychologlcallssues. Although not a sexually transrrutted infecti.on, BV
-. . -.
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
involved in the counselling process. increase in Gardnerella spp, Mycoplasma spp and
anaerobic bacteria. Epidemiol.ogl cal srudles sug-
gest an increased risk of rruscarnage, preterm
* delivery and low-birth-welght mfa~ts amo ng
women with BY. However, the mecharusms are not
Sexually transmitted completely underst.ood and inter:enti.on studies
infections and have not been sh.own to be effecnve m reduang
preterm delivery. There is insuffiClent eVidence to
pregnancy recommend routine screenmg 10 average-nsk
pregnant women.
Common clinical presentations 'Herpes
A pregnant woman seeks advice afte' recently
Vertical transmission and perinatal infection w ith
having casual unprotected Intercourse. HSV are most likely to occur \\~th vagmal dehvery
A pregnant woman's antenatal screen test is at the timE of primary or active maternallnfecnon.
The risk of neonatal infection is about 41%. 10
positive for syphilis.
babies born to women who acqUIre infeenon
At 39 weeks' gestation, a woman notices for the first time near the onset.of labour, and
painful vulval blisters.
bo ut 30/0 in women with
aCaesarean
established Infecnon.
section may be m . d'leate d'm pr.oven
active primary HSV maternal infection. About
Consideration should be given to the effect of the 15% of neonatal infeCtlon results from posmatal
infection on the mother, the ferus and the neonate. traIlSmission from oral lesions.
Genital warts
Hepatitis B
These can increase in pregnancy: Excision can some-
The woman who is hepatitis B surface antigen pos- times cause scarring. Podophyllin, podophyllotoXlD
itive (HBsAg+ve) should have her liver enzymes
and imiquimod should not be used during preg-
nancy. The baby can acquire the genital wart virus
from the vagina during childbirth; rarely, this can
cause neonatal laryngeal warts. Genital warts are
not considered to be an indication for performing
a caesarean section.
Syphilis
All pregnant women should be screened for
syphilis because it is easily treated, whereas
untreated syphilis in pregnancy causes potentially
severe disease in both the mother and the fetus. As
a general rule, tetracyclines should not be used in
pregnancy. If the nonspecific screening test is p.osi-
tive, exposure to syphilis should be confirmed
with a positive T. pallidum haemagglutination
assay (TPHA). There is a high incidence of syphilis
alilong Aboriginal women, and a number .of babies
with congenital syphilis have been born in recent
years. These women should be rescreened in the
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-
lowed up in the posmatal period. Maternally
acquired antibodies will be detectable in non-
infected infants for some months afrer delivery.
Advice from the pathologist, paediatrician, obste-
trician or sexual health service can be obtained if
there is doubt about interpreting neonatal syphilis
serology. Penicillin is the drug of choice for treat-
ment of the pregnant woman.
Gonorrhoea
A baby passing through a birth canal infecred with
gonorrhoea may develop conjunctivitis or a pha-
tyngeal infection. Gonorrhoea should also be sus-
pected with a 'sticky eye' in the neonate.
Ophthalmia neonatorum (conjunctivitis within
21 days of birth) is a notifiable disease.
Chlamydia
Conjunctivitis can occur in 30-50% of neonates and
pneumonia in 10-20% of neonates born through an
infected birth canal to a mother with Chlamydia.
HIV
Universal screening may be cost-effective in some
countries, aIld testing .of pooled antenatal sera
3 Sexually transmitted intec llon>
would be valuable in monitoring any increase in
cases in other countries with a lower prevalence.
Screening should be offered to pregnant women
after appropriate counselling is given about the
limitations of the testing and the implications of
the results. HIV transmission to the fetus can be
markedly reduced by the use of antiviral medica-
tions during the pregnancy and a caesarean section
delivery; in developed countries, breastfeeding the
infant should also be avoided.
Health maintenance
Antenatal screening may consider-
ably reduce the risk of vertical trans-
mission of Infection to the fetus and
neonate.
Further reading
Bowde n FJ, Tabrizi SN, Garland SM et al 2002 Infectious
dise ..... 6: Sexually transmitred lniections: new
di agnostic ap proaches and treatments. Medical Journal
of Australia 176 (11):551-557.
Brown ZA, Selke SA, Zeh j et al199 7 Acquisition of herpes
si mplex virus during pregnancy. New England journal
of Medicine 337:507-515.
Crum Cp, BerkowitZ R5 2002 H uman papilloma viruses:
Applications, caveats and prevention . Journal of
Reproductive Medici ne 47 (7):519-528; discussion
528-529.
Sexual health: at hrtp :liwww.health.qld .go.l.au1scxhealth
Sisk EA, Robertson ES 2002 Clinical implications of hwnan
papilloma virus infection . Frontiers in Bioscience
7:77-84.
Stanberry LR, Rosenthal SL 2002 Genital herpes simplex
virus infection in the adol escent: special consideration
for management. Paediatric Drugs 4 (5):291-297.
Whitely Rj, Kimberlin S\V, Roizman B 1998 Herpes
simplex viruses. Clinical Infectious Diseases
26:541-553.
Zur Hausen H 20Q2 Papilloma viruses and cancer: from
basic studies to clinical application. Nature R~t'Ws.
Cancer 2 (5):342-350.
ME
Women's health: a core curriculum
Questions
1. Which of the following statements Is
incorrect?
a. An Increase In vaginal discharge
indicates the presence of an STI.
b. An increase in vaginal discharge
may be related to the use of
hormone therapy.
c . An increase in vaginal discharge
could suggest cervical cancer.
d . A positive culture for Gardnerella
vaglnalls does not Indicate a
sexually transmiHed Infection.
e. There may be an Increase in vaginal
discharge during pregnancy.
2. Which of the following statements is
not true of '~ic ky eye' In the neonate?
a. It can be caused by a herpes
infection .
It Is always due to gonorrhoea.
c . It may be caused by a Chlamydia
infection,
d. It should be treated with saline eye
drops.
e. The mother should be tested for
vaginal infections.
3 . Which statement is incorrect?
( f0P.. n ulcer of the vulva can be caused
/ V by use of steroid cream.
b. An ulcer of the vulva is painless if
caused by syphilis.
c. An ulcer of the vulva could be a
vulval malignancy.
d. An ulcer of the vulva is painful if
caused by the herpes virus.
e . Delivery by caesarean section
should be considered for primary
herpetic infection of the lower
genital tract close to term.
Lower abdominal pain
Edited by Vivienne O'Connor
Pelvic pain Ian Jones
Endometriosis Vivienne O'Connor
Pelvic Inflammatory disease Vivienne O'Connor
Learning objectives
....,. Knowledge Skills
A~ the end of this chapter, the student At the end of this chapter, the student
will be able to: should learn how to:
Pelvic pain • explain the concept of endometriosis in
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

Common clinical presentation
Lower abdominal pain (LAP) is a common
gynaecological and obstetric problem ,
Associated symptoms may Include nausea,
vomiting, vaginal discharge, vaginal bleeding,
painful menstruation, dyspareunia : abdominal
bloating, and urinary and bowel symptoms,
Pathophysiology
LAP may originate from the genital tract organs,
the bowel or the urinary bladder. It may also be
• 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-
tions, and most often the problem is treated and
• retrograde menstruation • character, site, intensity, duration, periodicity,
• primary dysmenorrhoea resolved. In the chronic situation, management
radiation, onset also depends on the underlying cause and is more
• trauma to the upper genital tract following • aggravaring and relieving features
likely to be long-term.
instrumentation. • effeCts of micturition, defecation, vomiting,
The non-gynaecological causes of acute LAP coughing on the LAP
• 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
• relationship to last menstrual period (LMP),
development of chronic pelvic pain ,
• acute appendicitis
the menses, micturition, defaecation, move-
• 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-
sue is suggested as the gold standard. Recently it
has been suggested that the degree of pain is more
likely to be associated with the depth of invasion
into the tissues.
Health maintenance
cervIX. There may be vaginal discharge, abnormal
Use of the oral contraceptive pill bleedUlg or dyspareunia. However there is not
minimises the risk of developing good evidence to relate these non~pecific symp-
endometriosis. toms to PID.
Natural history
Abbott J, Hawe J, Shaltoot N et al 2002 Pelvic pain scores
in women without pelvic pathology. Journal of the
American Associarion of Gynecologic LJparoscopisrs
9(4):414-417.
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.~
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 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

Women's health: a core cu rri culum
A wide range of contraceptive options is available
for couples. Different methods . may be used. by
couples at different stages of the1l" lives. Providing
information, education and advice for couples on
all aspectS of contraception is an important role
for the health professional.
There are twO methods of reporting contracep-
tive efficacy:
1. The Pearl inde-x gives the number of failures
per 100 woman-years of exposure (usually
based on 1 year of exposure).
2. The life table analysis calculates a failure rate
for each month of use, with comparison of con-
rraceptive methods by cumulative failure rates
for any specific length of exposure.
*Reversible contraceptive
methods
Common clinical presentation
A 25-year-<lld woman requests 0 reversible
method of contraception ond would like to
know her options.
Combined oral co ntraceptive pill
(COCP)
This is a daily oral pill containing oesrrogen (E) -
ethinyl oesrradiol (EE) - and a progestOgen (P).
ProgestOgens used in COCPs include:
first generation: norethisterone and its deriva-
tives
o second generation: norgestrel group - levo-
norgesrrel, the most androgenic of the available
progestOgens . whom oestrogen is contraindicated (e.g. past histo-
third generation: desogestrel, norgesnrnate and
o o
gestOdene. These have beneficial effectS on
lipids and reduced effects on carbohydrate
metabolism
o fourth generation: cyproterone acetate, dros-
perinone. These are amiandrogens and benefit
women with mild hirsutism and acne.
Drosperinone is also a mild diuretic, and min-
imises bloating and breast tenderness.
ttl'
1. Highly eNectlve contraception In motlvoted
women (annual failure rate 0.1%)
2. Reduced risk of:
• Iron-deficiency anaemia • EndometriosiS
• Dysmenorrhoea • Fibroids
• Endometrial cancer
• Menorrhagia
• Functional/simple • Ovarian cancer
• Bacterial 51ls
ovarian cysts
• Premenstrual syndrome
BOX 5,1 Benefits of the COCP
The following types of preparations are available:
o low-dose (<50 ,t.g EE) or high-dose (;;<50 ft.g EE)
monophasic (same daily dose of E and P)
o biphasic (two-step P dose)
triphasic (two-step E dose, three-step P dose).
The mechanisms of action of COCPs are:
o suppression of follicular selection and ovula-
tion at h'·pothalamus/pituitary (E and P)
o endometrial atrophy, thickening of cervical
mucus, and reduced tubal motility (P).
The benefitS of COCPs are given in Box 5.1.
Side effects/risks
o There is an increased risk of venous throm-
boembolism. The incidence is 3-4 in 10,000
women using the COCp, compared with 1 in
10000 women who don't use it. In pregnancy
th~ risk of venous thromboembolism increases
30 times. There may be a greater risk with a
COCP using a third-generation progestogen,
o If the woman is over 35 years old and IS a
smoker, there is also an increased risk of car-
diovascular disease (lower with third-genera-
tion Pl·
o There is a dose-dependent increase in cere-
brovascular disease if EE ",50 mg/day.
If the woman has wei !-controlled hypertension,
the COCP is not contraindicated.
For the woman with well-controlled diabetes
o
mellirus, the COCP is not contraindicated, but
some preparations may cause reduced glucose
tolerance.
The COCP may accelerate gallbladder disease.
o The COCP may increase the risk of cervical
cancer.
o There may be a slightly increased risk of breast
cancer, but only of localised disease, and this may
be due to acceleration of the onset of existing
cancers. Some studies show no increased risk.
Pill administration
The woman should be advised that she must take
seven active pills before the COCP will be effective
(efficacy is immediate if she starts active pills on
day 1 of her cycle). This contraceptive method
may fail to be effective if a pill is missed by > 12
hours (particularly if this increases the pill-free
interval), if the woman has vomiting and/or diar-
rhoea, or if there is a drug interaction. Drugs that
may interfere with the COCP include antibiotics,
anti epileptic medications, antituberculous drugs
and antifungals.
If there is risk of failure, an additional contra-
ceptive method should be used until seven active
pills have been taken after the risk ceased.
Health maintenance
Women on the combined oral
contraceptive pill should ovoid
smoking to minimise the risk of venous
thromboembolism.
Progestogen-only p ill (POP) /
minipill
This is an oral pill with no oestrogen and a small
dose of progestogen (e.g. 30 ~g levonorgestrel,
350 ft.g norethisterone). It actS by changing the
nature of the cervical mucus and the endomet-
rium, which prevents implantatio n; 40 % of
women on the POP continue to ovulate.
It is mainly indicated for women who are breasr-
feeding because, unlike the COCp, it has no effect
on breast milk. It should also be used by women for
ty of deep vein thrombosis - DVT).
Si de 'effectsj p ro b Iems
o There may be irregular vaginal bleeding (this
causes 20% of users to cease).
o The POP has an increased risk of pregnancy
compared with the COCP (shorter half-life of
19 hours, and must be taken at the same time
5 Con traception
Facfs
• COCP does NOT cause weight gain.
• Prolonged COCP use does NOT cause infertility.
• 'Pill holidays' are NOT required to reduce risk of
endometrial/uterine carcinoma.
Contraindicotions
• History of thromboembolism
• Suspected breast cancer
• Smokers :>35 years old
• Markedly impaired liver function tests/jaundice
• Cerebrovascular/cardiovosculor disease
• Acuie/chronic/cholestallc liver disease
Relative contraindications
• Migraines
• Uncontrolled hypertension
• Epilepsy (need 50 ~g EE/day)
• Sickle cell disease
• Active gallbladder disease
BOX 5.2 Facts abo u t lhe COCP and its
contralndications
- or within 3 hours - every day); with obesi-
ty, there is an even greater risk of failure (2 pills
a day should be taken) .
o Other potential problems include follicular
CYStS (20%, usually asymptomatic) and an
increased risk of ectopic pregnancy (relative,
due to effect on tubal motility).
Inje ctable progestogens
Depo-Provera (depot medroxyprogesterone acetate,
DMPA) is a highly effective contraceptive, admin-
istered as a 3-monthly injection. It works in the
same way as the COCP and is commonly used for
women who have difficulty complying with an
OCp, or for women for whom oestrogen is con-
traindicated:
The main problems with this drug are the
short- and long-term side effectS, as follows:
o irregular vaginal bleeding. Of the women using
this drug, 20% have prolonged regular or irreg-
ular bleeding episodes, 40% amenorrhoea and
40% scant regular periods. This is the most
common reason for ceasing the drug. This
irregularity can be treared by giving low· dose E.
o weight gain (6 kg after 4 years of use) due to
increased appetite
o delayed return to fertility - up to 1 year after
cessation (20% of users)
81
Women's health: a core c urriculu m
• possible osteoporosis with long-term use (sup-
plemental E may be required if use is long-term
or from a young age).
Health maintenance
Hormonal contraception has definite
health benefits, especially reducing
the Incidence of heavy painful
menses, endometriosis, and endo-
metrial and ovarian cancer.
Implantable progestogens
Implanon (desogestrel) is a single-rod implant and
is effective for 3 vears. The indications are the
s~e as for DlItrPA. It is highly effective, with
irregular bleeding as a major side effect. Fertiliry
rerurns immediately upon removal and there is no
adverse effect on bone density.
Intrauterine device (IUD)
There are three types of intrauterine devices:
inert IUDs; e.g. Lippes loop (plastic), stainless
steel IUDs (mainly in China/SE Asia)
copper IUDs (CuT380A is effective for 10
years and multiload Cu375 for 5 years)
hormone-releasing IUDs (Mirena, with levo-
norgestrel coating, lasts for 5 years) . Mirena
IUDs are also an effe ctive treatment for menor-
rhagia (9 7% reduction of menstrual blood loss
at 1 year).
Mechanism of action
The sterile inflammatory response interferes with
sperm motiliry and therefore prevents fertilisation.
The IUD also prevents implantation.
Side effects/problems
• Menorrhagia/dysmenorrhoea may occur (15%)
with copper and inert IUDs.
• There is a slightly incre ased but not long-term
risk of intrauterine infection after insertion
(IUDs are not protective like OCP'progesto-
gens or barrier methods). The)' are contraindi-
cated in women who are at ris!·: of bacterial
endocarditis. Actinomycosis is an infection
5 Contraception
that is more common in users of inert IUDs
(less likely with Cu IUDs) : if it occurs, remove
the IUD and treat with penicillin G 500 mg qid
for a month.
• There is a 30% miscarriage risk if pregnancy
occurs. Remove IUD immediately.
• The absolute risk of ectopic pregnancy is not
increased by IUDs, only the relative risk.
Contraindications
An IUD should not be used in the foUowing con-
ditions:
• risk of endocarditis
• surgery (contraindicated)
• copper allergy and Wilson's disease (if intend-
ing to use copper IUD)
• immunosuppression (relative)
• pregnancy.
Post-insertion
Check strings in siru with a speculum examination
after the next period. The woman should check
the stri ngs after each period.
Barrier methods
These include both male and female condoms and
the diaphragm. Condoms have the added benefits
of protecting from STls and pelvic inflammatory
disease (PID) and reducing the incidence of cervi-
cal cancer.
Diaphragms need to be properl y fitted over the
cervix to be effective. Insert up to 6 hours before
intercourse, and remove at least 6 hours after-
wards. There is an increased risk of vaginal irrita-
tion and urinary tract infections. Spermicides
inactivate sperm in the vagina, work for up to
8 hours and can protect against STIs (including
H1V), but can cause allergic reactions. Condoms
(male and female) protect from STls as well as
providing a contraceptive effect, but can reduce
sensit:iviry in intercourse.
FIGURE 5 . 1 Common methods of contraception:
Natural family planning
: - mo~oPhasic oCP; B - triph asic OCP; C - POP (minipill); D - postcoi tal contraception '
Narural methods of contraception involve avoid- in - ma e condom; F - female condom; G - diaphragm; H - IUD s; I - Implanon rod and'
ing intercourse during the fertile parr of the men- sertlon trocar. (Pho to co urtesy Peter Fa rk os/Ro yal Darwin Hos pital)
strual cycle (i.e. peri ovulation) .
The rhythm/calendar method entails absti-
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
Barrier contraceptive methods protect
against sexually transmitted infection.
Consider investigation for STI in a
woman who requests emergency
contraception,
contraception
Common clinical presentation
A couple with three children have decided that
their family is complete, They would like advice
about methods of sterilisation.
Cheng L et .1 1999 Interventions for emergency contracepnon. Lippincott Williams & Wilkins
contracepoon. In: The Cochrane Database of Baltimore. '
Systematic Reviews (The Cochrane Library 3). Online.
Ava,lable : hrrp:llwww.update-sorware.comlcochr<lue Yusuf F, Siedlecky S 1999 Contraceptive use in AustralW.:
eVidence fro m the 1995 National Health Survey
Glasier AF 2003 Ferrility control. In: Shaw RW Sourrer WP. Australian and New Zealand Journal of Obstetri'cs and
Stanton SL (eds) Gynaecology, 3rd edn. Churchill ' Gynaecology 39:58.
LlYIngstone, Edinburgh.

* E m erg~ncy
contracepti on
Common clinical presentation
• A 26-year-old woman hod unprotected
intercourse 24 hours ago. She asks your advice
about the use of emergency contraception
and her opNons.
Methods
There are four emergency contraception methods.
1. Yuzpe method: 100 p.g EE and 0.5 mg levo-
norgestrel are given 12 h apart with an anti-
emetic. The failure rate is 2-3% if given within
72 h. Nausea is a common side effect related
to E.
2. Progestogen-only emergency contraception
(POEC): twO doses of 0.75 mg lcvonorgestrel
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
72 h) and better tolerated. It can also be given
as a single 1.5 mg dose with the same efficacy.
3. Copper IUD insertion prevents implantation if
inserted within 5 days of the most likely day of
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
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
b . 1,5 mg levonorgestrel .
toma, infection, sperm granulo mas, epidi- b. Well-controlled hypertenSion
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 /
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
has a 50% success rate if done within 10 years. of all P-only contraceptives? 5. Which of the following women may
a. Weight gain request reversal of a tubal ligation at a
later date?
Tubal ligation (TL) b. Irregular bleeding
Tubal ligation is highly effective (1 in 200 lifetime c. Mood disturbance a . A woman in a stable relationship
failure rate) and involves blocking the fallopian d.Headaches b. A womon who had the procedure at
tubes by diathermy, clips, rings or transection (all e.Acne 40 years of age . - /
can be pedormed laparoscopically as day proce-
dures) . An increased risk of ectopic pregnancy is 3. Which of the following contraceptive
c A woman who had her last child ~
5 years ago
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
unstable relationship, if TL is performed im-
mediately postpartum or at caesarean section, c. Depo-Provera e . A woman who had her last child
d. Condoms 3 years ago
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
At the end of this chapter, the student
will be able to:
Counselling before pregnancy: general
discuss the prevention of anaemia,
rubella infection and neural tube
defects in pregnancy
Identify women w ith lifesty le issues that
have an impact on pregnancy
identity preexisting medical conditions
that have an impact on pregnancy or
may be affected by pregnancy
• list appropriate pre-pregnancy
investigations
Women with genetic concerns
indicate the prevalence, mode of
inheritance and populations at risk for
Down syndrome , thalassaemia and
cystic fibrosis
• identify the underlying genetic or
biochemical abnormality leading to
each of these disorders
• describe briefly the clinical
manifestations of each disorder
critically appraise the screening and
diagnostic tests for Down syndrome
outtine the screening and diagnostic
tests for thalassaemia and cystic fibrosis .
Sk ills
At the end of this chapter, the student
should learn how to :
outline to a woman the requirements of
a normal, balanced d iet and how It
should be modified in pregnancy
counsel a woman about the prevention
of neural tube defects with folic acid
supplementation
counsel a woman about the risks of
smoking in pregnancy and encourage
her to quit
explain to a patient the difference
between a screening and a diagnostic
test
• explain to a woman the principles of
screening for Down syndrome
• counsel a woman who has a positive
antenatal screen test for Down syndrome
interpret a family pedigree with
conventional symbols.
A ttitudes
At the end of this chapter, the stUdent
should reflect upon:
different cultural and personal belief
systems Influencing patient preferences
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
Common clinical presentations
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

Women's health: a core cu rri culum
Down syndrome is caused by the presence of
an extra, partial or whole chromosome 21. The
majority of cases (950/0) are conce1ved by non-
dysjunction of maternal chromosomes dunng
meiosis, the minority by unbalanced translocaoon
or mosaicism.
Down syndrome is usually identified soon after
birth by a characteristic pattern of dysmorphic fea-
tures, including a flat fac1al profile, hypotorua,
slanted palpebral fissures and loose skin on the
back of the neck. It is associated Wlth a w1de spec-
trum of phenotypic marUfestations. Affected mdi-
viduals have mild to severe mental retardaoon,
with IQ scores ranging from 25 to 75. In the
absence of severe congenital heart dlsease, life
expectancy of Down syndrome individuals 1S
good, with over 50% living longer than 50 years,
but morbidity is high.
Prenatal scree ning te sts
Although the risk of having a child with Down
syndrome increases considerably afrer the age of
35 most babies with Down syndrome are born to
w;meo under 35 years of age, since more women
under 35 have babies. Screening is performed dur-
ing the firSt and second trimesters. .
The first trimester screerung IS performed
berween the 11th and 14th weeks of gestation,
using a nuchal translucency scan (NTS; Fig 6.3\
with or without biochemical screenmg of maternal
serum (~HCG and pregnancy associated plasma
FIGUR E 6.3 Ultrasaund Image af fetus tn
sagittal section, with nuchal translucenc y
measu rement marKed by calipers .
FIGURE 6.4 Image o f a mniocentesis needle
In situ
protein A, PAPP-A). Increased nuchal translucency
thickness low PAPP-A and high ~HCG serum level
are all ~ssociated with the fetus having an
increased risk of DO\>.1l syndrome. The combina-
tion of NfS and serum markers detects over 80%
of Down syndrome cases (compared :mth 70%
detection rate if NTS is used alone), WIth a false -
positive rate of 5%.
The second trimester maternal serum (MSS)
screening for Down syndrome is performed
berween 15 and 20 weeks' gestation, and measures
serum alpha-fetoprotein (AFP), unconjugated oest-
rio~ 0 and ~ HCG. Down syndrome is associated
with high ()HCG and low levels of AFP and uncon-
jugated oestrioL The test can detect 70% ~f affected
pregnancies with a false-posmve rate of 5 Vo.
Pren a t a l d iagnos is
Definitive prenatal diagnosis of Down syndrome
requires culture of fetallplacental cells and karyo-
typing of fetal chromosomes. Karyotypmg IS rou-
tinely offered to all women who are 35 years or
older, and to those with risk factors such as a
known translocation.
Amniocentesis (Fig 6.4) is usually performed
berween 15 and 18 weeks' gestation. The risk of
miscarriage associated with amniocentesis is
approximately 1 in 200. CVS can be performed m
the first trimester, usually around 11 weeks' gesta-
tion. The risk of miscarriage associated with CVS
is approximately 1%.
Counselli ng
Consultation with a genetic counsellor is advisable
before any prenatal diagnostic test. If diagnostic
tesong reveals a fetal abnormaliry, the parents
should be given assistance to address any concerns
and help them make a decision whether to termi-
nate or continue the pregnancy.
Tha iassaemia
Thalassaemias are autosomal recessive inherited
disorders characterised by a reduction in the syn-
thesis of globin chains (0 or ~; Table 6.3) . This
results in reduced haemoglobin synthesis and a
hypochromic microcytic anaemia. Of the total
Australian population, 1% are estimated to be car-
riers of the thalassaemia trait. Alpha(o)-thalas-
saemia is most common among patients from
China and Southeast Asia. Adults normally have
four copies of a globin genes. Absence of all four
ct globin genes is lethal and results in hydrops
fetalls. Beta(~)-thalassaem ia is the result of
reduced or absent ~ globin chain synthesis. It is
most co mmon in patients from the Inruan subcon-
tinent and Mediterranean countries (Italian, Greek
and Lebanese).
Children who inherit beta-thalassaemia major
are normal at birth, but at 6 months of age, when
Hb synthesis switches from Hb F to Hb A, they
develop severe transfusion-dependent anaemia.
Numerous clinical problems ensue, including
growth failure and bony deformities. The clinical
course is modified by transfusion therapy, but
transfusional iron overload (haemosiderosis) often
results. Death usually occurs berween 20 and 30
years from cardiac failure. Patients with beta-
~ globin Hb A Hb A, Hb F
genes (%) (%) (% )
Normal 97-99 1-3
Thala ssaemia major ~o~o o 4-10 90-96
~.~. 0- to 4- 10 90-96
Thala ssaemia minor ~~. 80-95 4-8 1-5
80- 95 4-8 1- 5
W Fa m ily ped ig ree
~o = absent ~ glpbin chain synthesis
~. = .educed synthesis
Hb A = a,~,; Hb A, = a,5,
Hb F (fetal Hb) = =1'
TAB LE 6 .3 Haemoglobin and beta·tholassoemio
6 He alth ed ucation b efore a nd during pregnancy
thalassaemia minor generally have clinically
insignificant microcytic anaemia.
Carrie r sc reeni ng and
prenatal d ia g nos is
In the mother, thalassaemia is diagnosed by mean
corpuscular haemoglobin concentration (MCHC)
and haemoglobin electrophoresis. Prenatal diagnosis
mvolves DNA analys1s of fetal cells from either first-
trimester CVS or second-trimester amniocentesis.
Cystic fibrosis (CF)
CF is the most common potentially fatal cause of
severe chronic lung disease in Caucasian young
adults. With an incidence of 1 in 2500 live births
in Australia, the carrier frequency is 1 in 25 and
transmission is autosomal recessive. The most
common gene mutation is 6F508, which is respon-
SIble for 75-88% of cystic fibrosis cases in north-
ern-hemisphere populations.
Abnormalities in the epithelial cell membrane
result in altered chloride transport and water flux
across the cell. Viscous mucous secretions predis-
pose to glandular obstruction and tissue damage.
Paoents With CF suffer from chronic lung disease,
gastrojmcstinal and nunitional abnormalities and
infertility. The median lifespan increased from
1 year in 1950 to 31.1 years in 1996. The chief
determinant of morbidi~ ' and mortality is the rate
of progression of lung diSease.
Prena ta l diagnosi s
Population carrier screening is usually applied to
high-nsk populations by performing common
mutation DNA analysis. Newborns are screened as
part of the Guthrie test, when the baby is 3 days
old. Those with a positive result are then referred
for diagnostic genetic testing. Prenatal diagnosis is
performed by D A analysis of fetal cells, usually
obtamed by CV5 at 10-12 weeks' gestation. For
conclusive genetic testing, definitive knowledge of
the type of both parental mutations is required.
A family pedigree summarises a complex family
history LOto a sunple and concise format (Mueller
& Young 1998). The construction of an accurate
family pedigree is a fundamental component of
clinical genetic services and of human genetic
'#
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
~~ Carriers
JZ10 Deceased individuals
58 Stillbirth (write below the symbol)
p Pregnancy (write Inside the symbol)
~.~. Proband: an affected Individual
coming to med ical attention
Independent of other family
m embers
~D~O Consultand: an individual
seeking genetiC counseling/testing
~ Spontaneous abortion (SAB) (If
ectopic. write ECT below symbol)
.......
..
Allected SAB (write gender below
Mo le/f"emofe the symbol)
L;A Termination of pregnancy (TOP)
Affected TOP (write gender below
Mole/ Female the symbol )
TABLE 6.4 Common pedigree symbols and def-
initions (From Mueller & Young 1998)
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
c . reduces the Incidence of /
References anencephaly In pregnancy b . require constant b lood transfus ions
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
Gynaecology 94:387-402.
e. helps women with diabetes have d . have more than 50% norma l adult ..,.
Hanrctty KP 2003 Obsterrics illustrated, 6th eeln . Churchill better glucose control . haemoglobin
Livingstone, Edinburgh.
2. Smoking : e . are at risk of an affected pregnan cy
Hercberg S, Preziosi P, Galan P 2001 Iron deficiency in if their partner does not carry the
Europe. Public Health -urritioo 4(2B):537-545. a . reduces the chance of conception gene.
Jensen TK, Hjolland NHI, Henriksen TB er al 1998 Does b . reduces the chance of miscarriage
5. Cystic fibros is:
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
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 /
Council Vitamin Srudy. Lancer 338(8760):131-137 .
c. occurs as a result of extra
M ueller RF. Young ID 1998 Emery's elements of medical 3 . Nuchal translucency ultrasound : chromosomes
genetics, 10th edn. Churchill uvingstone, Edinb urgh. a . is a d iagnostic test
d. creates neurologic a l abnormalit ies
Newberger DS 2000 Down syndrome: prenaraJ risk b . is m ore accurate tha n
assessment and diagnosis. American Famil y Physician amniocentes is e. is usually diagnos ed in the fetus by
62 :825-832. a blood test.
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
At the end of this chapter, the student
w ill be able to:
• discuss lifestyle Issues in pregnancy
F~ trimester
summarise early embryonic and
placental development
• discuss the minor complications of early
pregnancy and their management
• describe the clinical and laboratory
diagnoses of pregnancy
oulline the role of first-trimester
ultrasound
describe the antenatal screening tests
performed at the first antenatal visit
list the models of antenatal care
E, c pregnancy
• discuss the epidemiology of ectopic
pregnancy
• list the sites of ectopic pregnancy
discuss the pathophysiology of tubal
damage in ectopic pregnancy
discuss the investigations commonly
utilised to diagnose ectopic pregnancy
• oulline the emergency treatment for
ectopic pregnancy
• discuss the effect of ectopic pregnancy
on future fertility
Mfs~ ge
define miscarriage and the types of
miscarriage
indicate the prevalence of miscarriage
list the common causes of miscarriage
describe the Invesllgatlons for first-
trimester vaginal bleeding and oulline
management options
Se~d trimester
outline the management of second-
trimester minor complications
describe the maternal and fetal
screening tests performed in the second
trimester
outline the clinical evaluation of the
pregnant woman at each antenatal visit
Third trimester
describe briefly the physiological
changes in the uterus before labour
outline the management of minor
complications of late pregnancy
summarise the health education
Information to be given in preparation
for birth, breastfeeding and parenting
(Continued over)
•
 7 An te na ta l c are
Women's health : a core curricul um

• perform and interpret a urinalysis
(Learning objectives continued)
• perform a clinical o~stetr!c examination
of a woman in the third trimester.
• describe the principle of the birth
plan
Attitudes
list the signs of commencement of
At the end of this chapter, the student
labour.
should reflect upon :
Skills
pregnancy and birth as a physiological
At the end of this chapter, the student process
should learn how to: • the role of the health professional to
provide support and education
perform a pregnancy test
• the role of medical screening in
explain to a woman the physiologic~1
antenatal care
basiS of minor pregnancy complications
and suggest management options • the opportunity afforded by pregnancy
to encourage women to Improve
use the correct technique to measure general health and lifestyle.
arterial blood pressure
unpaid leave, is usually of 12 months' duration. At
the completion of maternity leave, the employee is
entitled to resume employment at the same level of
seniority within the organisation concerned. In the
private sector, maternity leave entitlement varies
considerably and the o rganisation's human
resources officer should be approached for
detailed information.
Additional entitlements for many parents
include the maternity allowance, family payments
and the baby bonus payment. Parental leave may
also be available for parents to enable them to care
for a newborn or adopted child. Paternity leave
(paid or unpaid) of 1 week may be available for
fathers at about the time of the birth of their child.
. Exposure to toxic chemicals and radiation in the
Seatbelts
It is a legal requirement that all motor vehicle driv-
ers and passengers, including pregnant women,
wear seatbelts. During pregnancy, the lap belt
should be worn low under the enlarging abdomen
and over both anterior and superior iliac spines
and the symphysis pubis. If a shoulder harness is
used, the straps should be placed so that they pass
to inferior vena caval occlusion. Contact sports
and recreational activity with an increased risk of
falling should be avoided. Exercise may contribute
to the management of gestational diabetes by
increasing glucose utilisation.
Occupational work
Evidence suggests that physically demanding work
and prolonged standing are associated with preterm
birth and reduced birth weight (Berkowitz &
Papiernik 1993). Shift and night work, and high
cumulative work fatigue scores may also be associ-
ated with preterm birth. However, long working
hours and preterm birth are not associated.
work environment is best avoided during pregnancy.
Sexual activity
Variable changes in sexual feelings are normal in
pregnancy, ranging from a significant increase to a
decrease in desire. While sexual intercourse is not
contraindicated at any time during normal preg-
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
Women's health: a core curriculum

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

Women's health : a c ore cu rr ic u lum
is taken and physical examination performed. The
principle of care is to identify a baseline so as to
monitor the impact the pregnancy may have on
maternal wellbeing. It must be remembered that
the majority of pregnant women are healthy. The
purpose of antenatal care is to promote health and
manage complications. Blood tests that are rou-
tinely ordered include full blood count (FBC),
blood group (ABO and Rhesus), red. blood cell
antibody screen and serology for syphihs, hepaDtls
B (and, for women at risk, hepatitis C), human
immunodeficiency virus (HIV) and rubella. If
these tests identify a problem, they enable treat-
ment to be given to improve outcome. For ex-
ample, if red blood cell antibodies are detected in
the mother's blood during pregnancy, further
investigation and appropriate treatment can
reduce the effects of Rhesus isoimmunisation.
A sterile mid-stream urine (MSU) sample is also
collected and sent for culture and sensitivity, as
asymptomatic urinary tract infection is more cOm-
mon in pregnancy and may lead to pye\onephritls
if untreated.
First-trimester ultra sound
Fetal imaging with ultrasound in the first trimester
is performed to establish gestational age, to illves-
tigate vaginal bleeding or to screen for Down syn-
drome. High-resolution ultrasound, parucularly
with a high-frequency transvaginal imaging probe,
is able to date the pregnancy accurately (±5 days)
and identify the presence of a fetal heartbeat from
6-7 weeks amenorrhoea. This demonstrates a live
fetus, whether the pregnancy is intrauterine or
ectopic, and shows whether the pregnancy is sin-
gleton or multiple.
Ultrasound can also be used routinely as a
screening test for chromosomal abnormality such
as Down syndrome (trisomy 21) by measuring
fetal nuchal translucency, ideally together with
first-trimester biochemical assay of the two hor-
mones: free j3HCG and pregnancy associated
plasma protein A (pArP-A). Such a test has an
85-90% detection rate for trisomy 21 (and also
for some of the other major chromosomal disor-
ders) and can be used as a population-screening
test for women who have been counselled and
choose to have this test (Spencer et al 2003).
i:'
Diagnostic tests
Chorionic villus sampling at 10--13 weeks involves
raking a transvaginal or transabdominal SamPle,
under ultrasound guidance, of chonomc villi for
genetic testing to identify chromosomal abnormal-
ities and some hereditary conditions. Amniocentesis
is most commonly performed in the second
trimester and is described under second-trimester
care in this chapter.
Models of antenatal care
and education
Women in Australia are able to choose different
models of care for their pregnancy and birth: home
birth with a midwife or doctor, birth centre
attached to a hospital, shared care with family .
practitioner at a public or private hospital, team
midwifery care or private obstetric consultant care.
The role of the health professional is to present the
options and discuss with the woman and her part-
ner those that best suit her individual needs.
Individual needs
Australia is a comple.x, multifaceted society. There
are groups of women within our society who, for a
variety of reasons, will reqwre speaal conslderanon
when they present for antenatal care. They may be
indigenous or from a non-English-speaking back-
ground. They may be very young, depressed, vic-
tims of domestic violence or soaally disadvantaged.
The history taken at the first antenatal visit should
identify any factors that need consideration when
providing care for the individual woman so as to
enhance her care and her e."'qJerience of pregnancy.
Early presentation for antenatal care
allows accurate establishment of
gestational age, baseline health
assessment and timely lifestyle
modifications to optimise maternal
and fetal outcome.
* Ectopic pregnancy
A 26-year-old woman presents with amenor-
rhoea and pelvic poln.
A young woman presents with bleeding In
early pregnancy.
A pelvic ultrasound scan is performed at
6 weeks' gestation and no Intrauterine gesta-
tion sac is seen.
A 35-year-old woman uncertain ot her last nor-
mal menstrual period complains of severe
abdominal pain and collapses.
Epidemiology
Ectopic pregnancy remains a major health concern
for women of reproductive age and a common
cause of pregnancy-related deaths. In developed
counm es, the mCldence of ectopic pregnancy has
increased six-fold over the last 20 years, although
ill recent years there is some evidence of reduction .
The incidence of ectopic pregnancy in the general
populanon IS 1 m 200; in a high-risk population it
can be as high as 1 m 30. With IVF, there is a risk
of ectopic pregnancy in 5% of pregnant cycles and
of heterotopIc pregnancy (co-existing intrauterine
and ectopic pregnancies) in up to 3% of pregnant
cycles (Lemus 2000).
Sites
The fallopian tube is the most common site for
ectopic pregnancy (97%): 810/0 ampulla, 12% in
the lSthmuS, 5% fimbrial end, 2% interstitial seg-
ment (cornual). Other sites include the ovary,
cervL"<, broad ligament and peritoneal cavity.
Pathophysiology of tubal damage
Ectopic pregnancy is believed to be due to
endothelial tubal damage secondary to salpingitis,
disturbed mbal oocyte transport or proliferation of
refluxed endometrial tissue arrested within the fal-
lopian tube. History of salpingitis often cannot be
obtalned, . but deciliatlon is frequently found or
there IS histologic evidence of previous salpingitis
(Speroff et al 1999, Guyton & '-fall 2000).
7 Antenatal ca re
Consequently, . risk factors include sexually
transrmtted mfectlOns, pnor ectopic pregnancy,
prIor tubal surgery, hormonal factors such as
diethylstilbestrol exposure and progestogens, con-
rraceptlve faLlures . (e.g. intrauterine devices),
mcreasmg age and cigarette smoking. Proliferation
of refluxed endometrial tissue arrested within a
tube could provide the epithelial characteristics of
a uterine environment, and this is the pathophysio-
logical explanation involving endometriosis
(Hunter 2002). There is also an increased risk with
assisted reproduction techniques (NF). .
Extensive investigation has been conducted at
the cellular level to study decidualisation and
Implantation in ectopic pregnancy (Lemus 2000).
Diagnosis
Ectopic pregnancy is frequently misdiagnosed at
the mmal visit. At present, we rarely see patients
who present m shock because of ruptured ectopic
pregnancy. The main symptoms are delayed per-
IOd, abnormal bleeding or pelvic pain, initially uni-
lateral but It may become more generalised.
On examination, the patient should be assessed
for signs .of shock, such as pallor, tachycardia and
hypotenSIOn. O n abdominal examination there
might be unilateral or generalised guar~g and
pentorusm. On vaginal. examination, there may be
bleedmg, a closed ce rvIX, a small uterus for gesta-
nonal age, an adnexal mass (with or without ten-
derness) and cervical excitation.
Currently, transvaginal ultrasound scan (TVS)
and senal j3HCG determinations remain the two
most important diagnostic tools. The absell ce of an
mtrauterine gestation sac on TVS when ~HC G is
above 1500 IU/mL is strongly associated with
ectopic pregnancy.
Clinical findings are associated with a higher
probabIlity of ectopic pregnancy, even when
j3HCG and TVS are below algorithm threshold. In
these situations, findings of free fluid in the pouch
of Douglas (POD) and adnexal mass on TVS are
useful. A f)HCG rise of at least 60% over 48 hours
and progesterone values over 25 nglmL are pre-
dictors of VIable pregnancy, but do not determine
the site of pregnancy.
Emergency trea tme nt
W hen a patient has haemorrhagic shock, she must
be operated on as soon as possible by the most

Women's health: a core c urriculu m
FIGURE 7.1 Unruptured tubal p regnancy (Reproduced wi th permission from
Belscher et 011997, P 172. plate 5)
expedient method. Open laparotomy is often
preferable, after securing IV access and blood for
blood group, crossmatch, FBC and ~HCG, even
before blood and fluid have been replaced.
Management and implications
A:; diagnosis becomes possible at increasingly
earlier gestation, it is possible to observe the
ectopic pregnancy when indicated and await natu-
ral resolution. The success rate of expectant man-
agement is up to 700/0 in selected cases with low
~HCG, no haemoperitoneum and a tubal mass
less than 2 cm. Rupture of ectopic pregnancy can
still happen and expectant management has a poor
efficacy. Follow-up requires measurement of
(lHCG until it disappears, which might take up to
50 days. Operation is indicated as soon as there is
deterioration in clinical symptoms/signs.
Today's surgical approach is by laparoscopy.
Laparoscopy is associated with less blood loss,
7 Anlenatal core
Suspected ectopiC pregnancy
Patient haemodynamically unstable
Deteriorating clinical Signs/unstable -
~HCG levels
failing/patient stable .
observe
shorter hospital stay, lower analgesic requirements
and quicker postoperative recovery compared
with laparotomy. Laparoscopic salpingectomy or
salpingostomy can be performed. There is no dif-
ference in the intrauterine pregnancy (IUP) rate
following these twO procedures if the contralater-
al tube is healthy. Failure to completely remove
trophoblast and recurrent ectopic pregnancy is
higher after salpingostomy (RCOG 2002).
In selected cases - e.g. asymptomatic patient, FIGURE 7. 2 Management of suspected e c topiC p regnancy
no free fluid in POD and small tubal ectopic on
TVS, and low (lHCG - it is possible to give
methotrexate, an antimetabolite that prevents the
growth of rapidly dividing cells by interfering with complex.. With the aid of methotrexate, a more Fertility outcomes
DNA synthesis. It can be administered systemic- conservanve approach has recently evolved. Other
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
IUP followmg an ectopic is 85%, with 7.5% recur-
scopic guidance and has a 7+-84 0.0 success rate
emb.ohsation, Foley catheter tamponade and rence and 7.5% infertility. Future fertility is unre-
(Buster & Heard 2000, Sowter et al 2001). These
SUction curettage (Tulandi & Sarnmour 2000). All lated to size of ectopiC, haemoperitoneum or tubal
patients require (lHCG follow-up.
Non-tubal ectopiC pregnancies are rare, and non-senslOsed Rh-negative women should receive ruptur,e. It is significantly affected by the presence
standardisation in diagnosis and management is 250 IU (50 !-!g) of anti-D IgG. of penadnexal adhesions.
 7 Antenata l ca re

Women's heolth: a c ore curriculum

The patient should be involved in the selection
of the most appropriate treatment. She should be
reviewed in a follow-up clinic and have appropri-
ate counselling regarding future fertility. Support
for the grieving process related to pregnancy loss
should be provided if necessary.
embryo/placenta to develop normally. This is fol-
lowed by haemorrhage into the decidua basalis,
which causes necrotic changes at the site of pla-
centation. At the same time, there is a fall in
oestrogen and progesterone concentrations, caus-
ing decidual sloughing. All these changes result in
vaginal bleeding and uterine irritability, leading to
uterine contractions and expulsion of the products
On vaginal examination, the internal os of the
cervix is open and often products of conception
are present in the canal.
Septic miscarriage presents with fever, bleeding
and srgruficant tenderness in the lower abdomen
and uterus.
. in complete miscarriage, products of concep-
oon are passed and on pelvic examination the
cervix is closed. An ultrasound scan reveals an
Expectant management may be a solution for
WOmen in the first trimester. In a randomised con-
trolled trial, up to 80% of patients were managed
expectantly,. but they needed regular follow-up,
and some soli needed surgrcal evacuanon. Medical
evacuation is an accepted alternative using miso-
prostol (RCOG 2003).
Women with recurrent miscarriages should be
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

Women's health: a core c urri c ulu m
* Anten atal care -
second trimester
Common clinical presentations
A woman at 26 weeks' gestahon In her first
pregnancy Is referred to the antenatal clinic by
her general practitioner for apparent slowing
of fetal growth .
A 37-year-old woman at 16 weeks' gestation
asks if her age poses any risk to her
pregnancy.
A 22-year-old woman at 24 weeks' gestation
presents to the antenatal clinic with a history of
a previous intrauterine death .
A pregnant woman who has a long-term
history of essential hypertension presents to the
antenatal clinic at 25 weeks' gestation.
Follow-up antenatal care
Antenatal care in the second trimester is based on
monitoring maternal health and feral wellbemg,
and providing education and support to the
woman and her parmer. Care also alms to prevent,
identify and manage any obstetnc and/or medical
problems that arise, including SOClOeconomlC and
psychological issues. . cus at 20 weeks. Thereafter SFH rises by 3-4 cm
In the second trimester of pregnancy, until
28 weeks ' gestation, a woman will have regular
monthly antenatal check-ups with her pregnancy
carer. Randomised controlled tnals m developed
countries have shown that a decrease m antena.tal
visit frequency is not associated with any neganve
maternal and perinatal outcomes. However, some
women feel less satisfied and their expectanons of
care are not fulfilled (Villar et al 2003).. ..
A comprehensive history taken at the first VISit
will alert the carer to any problems. At each sub-
sequent visit, the woman is asked about her gen-
eral wellbeing and fetal acnvlty.
Screening/investigations
If no first-trimester nuchal fold translucency risk
assessment for Down syndrome has been conduct-
ed, the woman should be offered maternal serum
screening (for ~HCG, AFP and oestriol), which if
7 Ante nata l c are
• 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
and otten. She is asked to report sudden changes
' ..
in the fetal achlty. In the third trimester, she will tee I ---·::·h:·· .. ·
the baby roll over and kick several times a day. ~ "'"
'y
• symphysis-fundal height (SFH) Is measured (gener-
ally, fundal height In cm ±3 = weekS of gestation).
Fetal size, lie, presentation and descent.of the pre-
senting port ore assessed . Fetal growth IS evaluated
by comparison with previous SFH measurements.
The fetal heart rate is checked with a Pinard stetho-
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
• 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
and preeclampsia. 2003. pp 59, 75)
• 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
transition and her need tor social support IS ,
70% pick-up rate for Down syndrome, with a 5% formal glucose tolerance assessment.
assessed .
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
Amniocentesis is the removal of a sample of weeks, ultrasound is unreliable in confirming ges-
amniotic fluid under ultrasound guidance. It is usu- tational age of the pregnancy. Ultrasound is also
ally performed between 14 and 18 weeks. It is used to assess fetal wellbeing if there is any evi-
1. Inspection - abdominal contour, operation offered to any woman at increased risk of chromo- dence of delayed fetal growth or other indicators
scars, striae, pigmentation, tetal movements somal abnormality, e. g. over 35 years of age. This of maternal/fctal compromise (see Chapter 8).
2. Palpation procedure carries a 0.5-1 % risk of miscarriage. In some centres, women will have a FBC at
• 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
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.
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~
the abdomen longitudinally, determine the lie o f
the long axis of the fetus in the uterus.
• Presentation. Using ooth hands, determine the
presenNng fetal part and assess descent Into the
pelviS. The one-hand Pawlic's grip is more
uncomfortable for the woman.
• Auscultation. Usten to the fetal heart over the
area of the fetal shoulder. This area is deter-
mined by Identltying the posit1on of the fetal
back and limbs. The back Is telt as a smooth,
firm elevation . Fetal limbs are felt by gilding the
hands over the surface of the abdomen, seek-
ing the mobile Irregularit1es. The fetal heart Is
heard directly using a Pinard stethoscope or
Indirectly using Doppler ultrasound. The normal
fetal Mort rate is 110-150 bpm.
FIGURE 7.4 A bdomi nal palpation (Based on Hanretty 2003, p 76)
BOX 7.2 ObstetriC abdominal examination
'*

Women's health : a co re curricul'Jm
• Nausea and vomiting (usually resolving by early In
the second trimester, but may con~ nue) .
• Con~ p~on due to Increased progesterone
(smooth muscle relaxes in gastrointesMal tract).
Relief measures Include Increasing Huld and ~bre
intake, exercise. mild laxatives or stool softeners.
• Varicosities due to progesterone-mediated smooth
muscle relaxation of the veins, Increased blood vo~
ume, stasis ond Increased pelvic pressure. Relief
measures include frequent posl~on changes, ele-
vation of legs , exercise , avoid ing lengthy periods of
standing, and support stockings .
• Headaches, often worse In those women who have
a pre-pregnancy history of migraine. Consider
anaemia, hypoglycaemia. Relief measures Include
rest, hydr~on, simple analgesia and cold packs.
BOX 7 .3 Minor complications o f pregnancy In the
second trlmester
Education
The second trimester of pregnancy is often a time
when the woman is feeling well. :Morning sickness
has passed and she starts to fee l the baby move
and experience the growth. of . the uterus, but
without the later physicallimltanons of the heavy
gravid uterus. It is during the second mmester
that the woman co=ences parent educauon
classes. She is usually starting to explore what It
will be like to be a new mother. She may relate
stories she has been told by family and friends
about birth and parenting. This can be a frighten-
ing as well as joyous time. Each woman's expen-
ence will be unique. Her background, culture and
social supportS strongly influence how she per-
ceives her parenting role.
* Antenatal care
third trimester
Common clinical presentations
• A 25-year-old woman at 34 weeks' gestation In
her first pregnancy wishes to discuss how she
will manage pain during labour and birth .
A 3D-year-old woman at 32 weeks' gestation In
her second pregnancy wishes to talk about
having her baby naturally this time, as the
previous birth was by elective caesarean
section because the baby was very small.
A 37-year-old woman at 41 weeks' gestation In
her firsl pregnancy presents to Ihe cliniC. She Is ..
now 7 days beyond her expected dale of
delivery.
The third trimester of pregnancy is a time of
increasing anticipation about the. birth of the baby.
It is important that those carmg for pregnant
women allow adequate space and time for. the
woman and her partner to voice all their quesoons
in preparation fo r birch. The principles of man-
agement remain to:
• monitor the progress of pregnancy . Preparation for birth
• provide advice, reassurance and educanon about
pregnancy, labour and planning for a parennng
role, including factors influencmg the overall
health and wellbeing of women and thelf families
• identify women ar risk of maternal and fetal
complications during pregnancy .
• manage any obstetric and/or medical problems
arising during pregnancy, mcluding soaoeco-
nomic and psychological factors.
In the third trimester, antenatal visits will be
formightly from 28 to 36 weeks, and ~en weekly
to 41 weeks. At each visit, the woman will have the
systematic assessment outlined in Box 7.1. Blood
pressure is of greater slgruficance m the third
trimester because this IS when preeclampSia IS
most lik~ly to occur (Brown & Whirworth19 99).
The focus of education moves to preparaoon for
labour. One area receiving increasing attention IS
the prevention and management of major perineal
The enlarging uterus can produce the following
symptoms:
• gastro-oesophageal renux due to reloxatlon of the
sphincter. The woman should be advised to eot
frequent, small meals, to ovoid caffeine ond spicy
food and to toke antacids If severe
• Increasing difficulty w~h breathing due to enlarge-
ment or the uterus. This can be especially evident
at night. Sleeping in a supported lateral position
con help
• oedema ond potenHol median nerve compres-
sion, leading to cor pol tunnel syndrome . Lower
limb oedema Is reloted to water retentlon ,
increased blood volu me and prolonged standing.
Reller measures Include wearing support hose and
regular exercise. Median nerve compression In the
carpal tunnel by oedema may require physiother-
apy rererral and wrist splints
• supine hypotension due to aortocovol compres-
sion
• postural hypotension due to obstructed venous
return from the lower limbs
• urinary frequency due to pressure on the bladder.
• loin pain secondary to varying degrees of ureteric
obstruction
• back and pelvic pain from the descent of the
feta l head and fhe relax oMan of pelvic ligaments.
ReUef measures Include sleeping In the lateral
position, massage, heat pocks and peM c rock
exerc ise.
BOX 7.4 Minor complications of pregnancy In the
third trimester
trauma. Pelvic fl oor exercises antenarallv are
believed to reduce longer-term problems with anal
incontine nce, stress incuntinence and geni ral
prolapse (Tindall 1991). There is also greater
emphasis on assessment of antenatal depression or
posmatal depression.
Investigations
Many health centres will perform an FBC at
28 weeks' gestation and an antibody screen at
36 weeks if the woman is Rh negative. There is
no good evidence to supporr the use of a routine
third-trimester ultrasound scan, which should
be done only if fe tal growth problems are sus-
pected fr om the history or examination (Larsen
et al 1992, US Preventative Services Task Force
1996).
1 Ante n atal care
Physiology
Further breast enlargement occurs during the third
trimester and colostrum production commences.
The uterus contracts irregularly throughout preg-
nancy, but in the third trimester it contracts more
frequently in preparation for the labour.
Contractions commence as painless tightenings
but become more painful closer to the onset of
labour. The cervix undergoes a process of ripen-
ing. This involves breakdown of collagen so that
with the pressure of the amniotic sac and the pre-
senting parr, the cervix assumes a more anterior
position in the vagina, becomes shorter (effaces)
and dilates. As a result of this, women will notice
an increasing amount of discharge or the loss of a
discrete mucous plug.
The precise trigger for rhe onset of labour is
nor known but the following are important events
leading up to it. Oesrrogen promotes the develop-
menr of gap junctions between myometrial cells,
thus facilitatin coordinated contractions in
labour. estrogen r motes t e pro uction
of prostaglandins from the membranes. Another
placental hormone, corticotrophin-releasing hor-
mone (CRH), is produced in increasing amounts.
The action of progesterone is removed, possibly
through a change in receptor subtypes. Fetal mat-
uration also seems to contribute to the onset of
labour (Challis 2001).
All women will have many questions about the
signs of labour, the length of labour, what con-
tractions feel like, pain llJanagement options, who
will care fo r them, or otller1toncems about labour
based on their own pa~t experiences or those of
others. Every woman f.;hould be encouraged and
supported to explore fhe changes occurring in her
body and her life during pregnancy, and to prepare
for birth and parenthood. A birch plan facilirates
the documenration of how the woman would Like
her labour and birth care to be conducted. Writing
these thoughts encourages her to think about her
expectations and makes them explicit for the mid-
wives and doctors caring for her. A birth plan is
usually written at around 36-37 weeks. It may
document simple requests such as her preference
for analgesia or the presence of support persons,
or it may make exp licit her wishes about medical
lit

Women's health: a core curriculum
intervention, Once documented, this plan can be
discussed with the doctors and midwives cating
for her.
A woman should be advised to stay at home until
the contractions ate regulat and becoming more fre-
quent, for example once every 7-10 minutes, She
should contact her health service when the mem-
branes ruprure, or if she is bleeding, experiencing
reduced fetal movements or is feeling distressed.
Antenatal education prepares the
couple for childbirth, breastfeeding
and parenting .
References
Beischer NA, Mackay EV, Colditz P 1997 Obstetrics
and the newborn; an illustrated textbook, 3rd edn.
WB Saunders, Sydney.
Berkowitz GS, Papieroik E 1993 Epidemiology of pretenn
birth. Epidemiologic Review. 15:414-443.
Brandt EN 1987 Smoking and «productive health.
PSG Publishing, Littleton (MA).
Brown MAo Whitworth JA 1999 Management of
hypertension in pregnancy. Clinical and Experimental
Hypertension 21:907-916.
Brown MA, Hague WM, Higgins J et al 2000
The detection, investigation and management of
hypertension in pregnancy: full consensus statement
(Australasian Society for the Study of Hypertension in
Pregnancy). Australian and New Zealand Journal of
Obstetrics and Gynaecology 40(2);139-155.
Buster J, H eard M 2000 Current issues in medical
management of ectopic pregnancy. Current Opinion in
Obstetrics and Gynecology 12:525-527.
Challis JRG 2001 Characteristics of parturition. 10; 'Creasy
and Resnick, Maternal fetal medicine - principles and
practice. WB Saunders, Philadel phia.
Cunningham FG, MacDonald PC, Gant NF et al 1997
Wtlliams' obstetriCS, 20th edn. Appleton & Lange,
Stamford, Connecticut, pp 959-960.
Dolan-Mullen P, Ramirez G, Groff JY 1994 Obstetrics: a
meta-analysis of randomised trials of prenatal smoking
cessation interventions. American] ournal of Obstetrics
and Gynecology 171: 1328-1334.
Enkin M, Keirsc MJNC, Neilson J et al 2000 A guide to
effective care in pregnancy and childbirth, 3rd edn.
Chapter 6, Dietary modification in pregnancy. Oxford
Rosevear S 2002 Handbook of gynaecology management.
University Press, Oxford, pp 38-39.
Farquhar C, Jamieson M 1997 IntrOduction to obstetrics
and gynaecology. Department of Obstettics and
Salir G, Younis J, Hoffman R er al 2002 Trombophilia is
Gynaecology, Univorsiry of Auckland/National
Women's Hospital, Auckland.
Haorerty KP 2003 Obstetrics illustrated, 6th edn.
Sharpe PT 1999 Homeobox genes and determination of
Churchill Livingstooe, Edinburgh.
Hunter RH 2002 Tubal ectopic pregnancy: a patho-
physiological explanation involving endometriosis
(review). Human Reproduction 17(7): 1688-1691.
Sowter M, Farquar C, Petrie K 2001 A randomised trial
Kitzman H, Olds DL, Henderson CR Jr et al1997 Effect
of prenatal and infancy borne visitation by nurses on
pregnancy outcomes, childhood injuries, and repeated
childbearing: a randomised clinical trial. Journal of the
American Medical Associatioo 278;644-652.
Spencer K, Spencer CE, Power M, Dawson C, Nicolaides
Kurreh W 2001 Recurrent pregnancy loss: an update.
Current Opinion in Obstetrics and Gynecology
11:435-439.
Larsen T, Larsen JF et al 1992. Detection of small-for-
gestational-age fetuses by ultrasound screening in a
high-risk population ; a randomised conrrolled srudy.
British Journal of Obstetrics aod Gynaecology
99(6):469-474.
QuestIon s
Lemus J 2000 Ectopic pregnancy: an update . Current
Opinion in Obstetrics and Gynecology 12:369-375.
1.
Lipson T 1994 From conception to birth - our most
important journey. Millennium Books, Sydney.
Nardo L, Rai R, Backos M etal 2002 High serum
luteinizing hormone and testosterone concentrations
do not predict pregnancy outcome in w omen with
recurrent miscarriage. Ferrility and Srerility
77(2):348-351.
Offenbacher S, KatZ V, Ferrik G et al 1996 Periodontal
infection as a possible risk factor for preteon low birth
weight. Journal of Periodontology 67:1103-1113.
Ouellette E.M, Rosen HL, Rosman NP, Weiner L 1977
Adverse effectS on offspring of maternal alcohol abuse
during pregnancy. New England Journal of Medicine
297:528-530.
RCOG (Royal Conege of Obstetricians and Gynaecologists,
UK) 2002 Clinical green top guidelines: tubal
pregnancies - management. Online. Available:
http://Www.rcog.org.ukJguidelines.
RCOG (Royal College of Obstetricians and Gynaecologists,
UK) 2003 Clinical green top guidelines: early
pregnancy loss - management. Online. Available:
http://www.rcog. org. ukJguidelines.
Blackwell Science, Oxford.
common in women with idiop~thic pregnancy loss and
is associated with late pregnancy wastage. Fertility and
Sterility 77(2):342-347.
embtyonic body plan. 10; Rodeck C, Whitrle M (cds)
Fetal medicine - basic science and clinical practice.
Churchill Livingstone, London.
comparing single dose systemic methotrexate and
laparoscopic surgery for the treatment of unruprurcd
tubal pregnancy. British Journal of Obstetrics and
Gynaecology 108:192-203.
KH 2003 Scree.ning for chromosomal abnormalities in
the first trimester using ultrasound and maternal serum
biochemistry in a one~stop clinic: a review of three
Which of the following statements Is
correct?
a . Behavioural strategies to stop
smoking during pregnancy are
unsuccessful.
b. Social support during pregnancy
prevents preterm labour.
c . Air travel during pregnancy is
contraindicated after 28 weeks'
gestation.
d . Government organisations provide /
12 months' maternity leave.
e. Treatment of periodontal disease
shOUld be delayed until after
parturition.
Which of the following blood tests is
not routinely performed at the first
antenatal visit for all women?
a. Full bload count
7 An tenatal care
years prospe 've experience_ BJOG: an international
journal of obst ' d .ecology 110(3):281-286.
Speroff L, Glass R, Kase N 1999 Clinical gynecology,
endocrmology and infertility, 6th edn. Lippincotr,
Williams & Wilkins, Baltimore,
Tindall V 1991 Gynaecology - illustrated textbook.
Gower, London.
Tulandi T, Sarnmour A 2000 Evidence-based management
of ectopiC pregnancy. Current Opinjon in Obstetrics
and Gynecology 12:289-292.
US Preventative Services Task Fotce 1996. Guidelines for
clinical prevention.
Villar J, Carta Ii G, Khan-Neelofur D et al 2003 Panerns of
routine antenatal care for low-risk pregnancy. 10: The
Cochrane Database of Systematic Reviews (The
Cochrane Library). Online. Available:
http: //,,".\"W. update-sofrware.comlcochrane.
Zib M, Lim 1., Walters WAW 1999 Symptoms during
normal pregnancy: a prospective controlled stUdy.
Australian and New Zealand Journal of Obstetrics and
Gynaecololgy 39(4):401-410.
b. Hepatitis B serology
c . HIV serology
d. Thyroid function tests (TFTs)
e. Rubella serology '/
3. Which of the following statements is true?
a . All fetuses with Down syndrome look
abnormal on a scan at 18 weeks'
gestation.
b. All cases of spina bifida will have an
elevated maternal serum alpho-
fetoprotein (MSAFP) blood test result .
c. Most cases of Down syndrome are
detectable by first-trimester /
screening with nuchal translucency
ultrasound.
d. A scan at 18 weeks should be done
only on women who are at high risk
of fetal malformations.
e. Amniocentesis can detect the vast
majority of fetal malformations.
'*
•
Women's health : a co re curricu lum
4, Which is the most like ly diagnosis in a
woman with a quantitative flHCG of
3000 IU/mL, an empty uterus on
transvaginal ultrasound scan and light
vaginal bleeding?
a, A live intrauterine fetus
b, An incomplete miscarriage
c , A pseUdo-pregnancy
d , An ectopic pregnancy
e, A delayed (missed) miscarriage
5, A 40-year-old woman who has had a
tubal ligation presents with a posit ive
pregnancy test and 7 weeks '
amenorrhoea , Which of the following
statements is correct?
a , This is a folse-positive test and the
patient should be reassured,
b, The woman should have a
transvaginal ultrasound scan and
quantitative BHCG,
c , The woman should be advised to
terminate the pregnancy,
/ fundal height is not a screening test.
d, The woman should be advised to
return in 2 w eeks for a repeat test
and evaluation ,
e , The woman is probably extremely
pleased to be pregnant.
6, Which of the following statements
about spontaneous miscarriage Is
true?
a , It is commonly due to an inherited
chromosomal abnormality,
b . It occurs aHer fetal viability, I. e .
24 weeks' gestation.
c. There is decreased risk if the woman
is ove r 40 years of age ,
d , It is most commonly due to sporadic
chromosomal abnorma lity.
e, It is frequently recurrent,
7, Which of the following statements
about antenatal care In the second
trimester is correct?
7 Anten atal care
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
wellbeing , parturition? d . Gamma-amlnobutyric acid
b . Psychosocial issues have little a. Corticotrophin-releasing hormone e , Oxytocin
bearing on the provision and
outcome of management In the b , Prostaglandin
second trimester of pregnancy.
c, Antenatal care in the second /
trimester aims to identity and
manage any obstetric or medical 1\+ D\I\...u..k- o~ ~ :
problems that develop during this
ti me. ~ -e.J-t"nI 'Y"" fo.. 'l ~ roJ-f,.?
d . Ul trasound aHer 20 weeks is very
reliable In the calculation of the
gestational age of the fetus , CD rY\'l4~~~
e, A maternal blood pressure of
150/95 mmHg is normal.
~ Ce.k
8, With respect to screening tests in the
second trimester, which of the
following statements [s correct?
a , Measurement of the symphysis-
b , Screening for gestational diabetes Is
not carried out In the second
trimester.
c. An Rh-nega tive woman in whom no
anti-D was detected in the first
trimester does not need to be tested / '
for anti-D at 28 weeks ,
d , Materna[ serum screening may be
oHered to assess the risk of Down
syndrome .
e , Umbll[ca[ artery Doppler evaluation
is a useful screening tool for
intrauterine growth restriction.
Wh ich of the following is an essential
and routine port of the assessment
during an antenatal visit in the third
trimester of pregnancy?
a , Dipstick testing of urine
b. Weight measurement ../
c. Blood pressure measurement
d . Che ck ing the amount of oedema in
the lower limbs
e, Assessment of amniotic fluid volume
WI
 J
The fetus
Martha Finn
Learning objectives
Knowledge
At the end of this chapter, the student
will be able to:
Fetal growth
discuss the importance of accurately
dating a pregnancy
describe the physiology of amniotic
flu id and the causes ot reduced or
excessive fluid volume
• list the causes of a small-for-dates and a
large-far-dates tetus
list th e maternal and fetal causes of
In trauterine growth restriction
evaluate th e ro les o f palpation and
ultrasound in Identifying the small-fo r-
dates fetus
discuss the perinatal mortality and
mo rbidi ty associated with intrauterine
growth ,estrlctlon
discuss the importance of timing and
location of delivery
evaluate the Impact of intrauterine
growth restriction on the newborn, th e
child and later adult years
• describe the risks associated with
accelerated fetal growth
Assessment of fetal wellbeing
indicate the rates of stillbirth, cerebral
palsy and b irth anomalies
• summarise fetal adaptations to acute
and chronic hypoxia
• c riticall y appraise the methods tor
assessment of fetal wellbeing in n ormal
and complicated pregnancies
• critique the view that one can ha ve a
perfect baby every time
outline the merits of a day-assessment
service versus hospital admission
expla in the rele vance of ·t he cerebral
palsy statement.
Skills
At the end o f this chapter, the student
should learn how t o :
establish gestational age using
menstrual and ultrasound data
ta ke a n antenatal histo ry a nd p erform
an antenatal exami nation with
particular reference to reco rd ing and
interpreting symphys is-fundal height
measurements
listen to the fetal heart using a Pinard
stethoscope or handheld Doppler
explain to a woman the significance of
a fetus that appears small for dates .
Attitudes
At the end of this chapter, the stUdent
should reflect upon :
the value of prenatal education and a
healthy IifeSfyle in pregnancy
• the Impact of intense fetal monitoring
on the wellbeing of the pregnant
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 :,...-
.
/

subsequently did well.
If one snapshot in time shows the fetus to be
truly small for dates but the fetus is surrounded by
normal amniotic fluid, is active, morphologically
normal, and has normal umbilical arrery resist-
ance, the mother may be reassured that the fetus
appears healthy. A repeat ultrasound to assess
growth may be performed a minimum of 2 weeks
later. The liquor volume may be evaluated more
frequently, as fluid changes are more dynamic and
may demonstrate a compromised fetus earlier. The
mother should be assessed for risk factors and her
blood pressure monitored weekly.
Growth restriction is one manifestation of
preeclampsia. Figure 8.4 shows the case of a small
42
40
38
36
:ll22 ./
ment. The mother showed evidence of severe /
/' ./
preeclampsia. A caesarean section was performed. 20
The baby weighed 1600 g, was hypogiycaemic at 18
V
birth but required minimal oxygen supplement- .. 16
~
r-
ation, fed well and rapidly gained weight. 14 I
A decision to deliver a growth-restricted fetus
~a~VD~~~RDM~38~3838~~U
must balance the risks of prematurity and con-
Weeks
tinued fetal compromise in utero. While severe
JUGR poses a significant risk for the fetus, peri- FIGURE 8.4 Fetal growth restriction In a woman with severe preeclampsia
natal monality and morbidity is dominated by
gestational age at diagnosis and delivery. When
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-
must be given to the timing, mode and location 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
compromise dictates the urgency of the delivery.
Deliverr of a pre term compromised baby lead to separation of mother and baby, and diffi-
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~
sterOIds to promote pulmonary maturity. may rncur significant exp~nses either travelling
~
~

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
monitoring as a tool for assessing feral wellbeing,
except in [Wo circumstances. A ferus with a base-
line hearr rate within the normal range (110-150
bpm), moderate baseline fetal hearr rate variability
(6-25 bpm) and no decelerations is not at risk of
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
persistent late or variable decelerations has evi-
dence of potentially damaging acidaernia.
The majority of the above tests of fetal well-
being may be performed in a day-assessment set-
ting. This allows close surveillance of the pregnan-
cy, while causing least disturbance to the woman's
family life. Maternal causes of compromised
FIGURE 8.7 Normal ontenotal cardiotocograph pattern (Courtesy of Peter Farkas /Ro yal Dar win
Hospital)
8 The fotu.
uteroplacental function, e.g. hypertension or dia- The International Cerebral Palsy Task Force
betes mellitus, may also be thus monitored. ing difficulties - may reflect physiological irnma-
(MacLennan 1999) considered three essential cri-
tunty. Nevertheless, the document gives valuable
teria to be necessary to amibute the cause to Intra-gwdance to expert opinion when counselling in
Cerebral palsy pa~ hypoxia:
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
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-
been associated with intrapartum adverse events. • earl agrng Intrapartum hypoxia, which has been the
Recently, however, it has been recognised that .~~~~~~~~~~ mam emphasis to date.
about 90% of cases can be amibuted to intrauter-
ine events preceding labour, e.g. IUGR, fetal coag-
ulation disorders, multiple pregnancy, anteparrurn Health maintenance
haemorrhage, chromosomal and metabolic abnor- A healthy lifestyle involving diet and
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
c. A single ultrasound examination can b . fetal talipes equinovarus-
determine fetal growth.
-~ £)n aternal preeclampsia
,/
"·k

Women's health: a core c Uiri culu m
d. reduced fetal umbilical artery
resistance
e. all of the above.
3. A 35-year-old woman with diobetes
mellitus is at risk of having:
a . a macrosomic baby
b . a growth-restricted baby
c. a traumatic delivery associated with
shoulder dystocia
d. a baby that succumbs to
intrauterine asphyxia
e. all of the above.
/ b. About 10% of cases of cerebral
4. Which of the following is correct in the
assessment of fetal wellbeing?
a. Amniotic fluid volume reflects
uterine perfusion and the processes
of fetal swallowing, fetal cardiac
function and renal function .
b. Isolated abnormal fetal umbilical
artery Doppler resistance reliably
predicts a hypoxaemlc fetus .
to
c. A fetus with a normal cardio- .
tocograph is likely to be aCidotiC.
d. The use of fetal scalp sampling for
acid-base status in labour has been
associated with an increase In
caesarean section rates.
e. All of the above.
5. Which of the following statements
about cerebral palsy are correct?
a. Cerebral palsy occurs In less than 5
per 1000 births.
palsy may be attributed to
intrapartum hYPOXia.
c Severe metabolic acidosis In labour
. should be an essential criterion to
diagnose an Intrapartum event as
causal to cerebral palsy.
d. Intrauterine growth restriction may
imply a cause of cerebral palsy
other than acute intrapartum
hypoxia.
e. All of the above.
*9
Medical disorders in
pregnancy
Edited by Martha Finn
Hyperemesis gravidarum Regina Wulf
Anoemia Petra Porter
Isoimmunisation Louise Komman and Helen Savoia
Abnormal glucose tolerance Helen Lammi
Hypertension Mark Brown
Thromboembolic disease Petra Porter
Learning objectives
Knowledge
At the end of this chapter, the student
will be able to:
Hyperemesis gravidarum
indicate the prevalence of morning
sickness and hyperemesis gravidarum
• discuss the differential diagnosis of
hyperemesis gravida rum
describe the Investigations required to
assess the severity of hyperemesis
gravidarum
outline a management plan for severe
hyperemesis gravida rum
Anaemia
define anaemia in pregnancy
indicate the pregnancy demands for
iron and identify dietary sources of iron,
folate and vitamin BI2
describe the pathophysiology of
anaemia in pregnancy
describe the common causes of
anaemia, their prevalence and
management
• outline the diagnostic tests performed
to Identity the cause of anaemia
discuss the value of routine versus
selective iron supplementation
outline a plan for the diagnosis and
management of a microcytic anaemia
in pregnancy
Isolmmunisat/on
identity the common antigens that ma y
cause haemolytiC disease of the
newborn
describe the pathophysiology of fetal
anaemia and cardiac failure in
Isoimmunisation
describe the pathophysiology of
neonatal anaemia and jaundice
• outline the Investigations and
management prinCiples of
isoimmunisation
• discuss prevention strategies, the value
of screening and effectiveness of anti-D
immunoglobulin
Abnormal glucose tolerance
describe the physiology of glucose
homeostasis in pregnancy
define gestational diabetes mellitus
describe the population at risk for
gestational diabetes
• discuss the implications of abnormal
glucose tolerance for the mother, the
fetus and the neonate
outline the principles of management of
gestational diabetes
(Continued over)
II.F

women's health : a core curr icu!u rn
(learning objectives continued)
• discuss the Importance of maintaining
normal pre-pregnancy blood glucose
levels in women with established diabetes
Hypertens ion
• define the subtypes of hypertension In
pregnancy and discuss the clinical
implications of each
• list the maternal risk factors for develop-
ment of preec lam psia
describe the pathophysio logy of
preeclampsia
outline the investigations performed to
assess maternal and fetal wellbeing in a
hypertensive pregnancy
discuss the statement that hypertension in
pregnancy, in particular preeclam~sia , is a
common cause of maternal mortality and
af perinatal morbidity and mortality
• outline a management plan for a patient
admitted with preeclampsia
Thromboembolic disease
• discuss the significance of thrombo-
emboliC disease in pregnancy
• identify the common symptoms and signs
of deep vein thrombosis and pulmonary
embolism
• outline the investigations used to Identify
DVT and PE In pregnancy
describe the management of deep vein
thrombosis and pulmonary embolism in
pregnancy
identify women who may need prophylaxis
for thromboembo lic d ise ase in pregnancy
or the puerperium.
Ski lis
At the end of this chapter, the student
should learn how to:
clinically assess the degree of dehydration
in a woman with hyperemesis gravidarum
perform and interpret a ward urine dipstick
examination
interpret blood biochem istry of a woman
with severe prolonged vomiting
counsel a woman regarding the
significance of hyperemesis gravldarum
take a nutritional history from a pregnant
woman and offer appropriate advice.
about iron and vi tamin supplementallon
explain the role of postpartum passive
immunisation to the Rh-negative mother
who has no ant ibodies detected in
pregnancy
explain to the Rh-negative mother the
implications of a posllive anlibody screen
test in pregnancy
explain to a woman the value of a glucose
screening test in pregnancy
counsel a woman with gestational
diabetes mellitus about her long-term
health risks
clinically assess the woman who presents
with hypertension in pregnancy
counsel a woman about appropriate
therapy for deep vein thrombosis and
pulmonary embolism in pregnancy.
Attitudes
At the end of this chapter, the student
should reflect upon:
the value of indivldualisation of care for
each woman In pregnancy
the maternal anxiety engendered by the
label of 'high-risk pregnancy '
the maternal guilt of having a condition
that may adversely affect the fetus.
* Hyperemesis
gravidarum
A 30-year-old woman at 8 weeks' gestation Is
unable to eat or drink owing to severe nausea
and vomiting. She fells dizzy and weak, passes
only small amounts of dark urine twice dolly
and is unable to look after her other child or to
do any housework. She also experienced
nausea and vomiting In her previous
pregnancy.
Morning sickness
Nausea and vomiting are cornmon in early preg-
nancy and are referred to as morning sickness, but
symptoms are restricted to the morning in only
2% of women. Up to 85% of pregnant woman are
affecied, and symptoms are commocly expen-
ence from the 4th to the 12th week of Ereg-
n~. Although the symptoms may be traulITe-
some, they rarely require investigation or dru&
~eraa In general, first-trimester nausea has no
a verse effect on the roWer or ferns.
Hyperemesis gravida ru m
Hyperemesis gravidarum (HG) is excWiye pq:g-
nancy-related nau(;f and /gr vomiting that
prevents ad uate fo and fluid intake and is asso-
oate with ei t oss a mare t an 5% of body
mass. It occurs in ess than 3% 0 pregnancies.
Symptoms usually begin at 4-6 weeks' gestation and
peak between 9 and 13 weeks. In 10-20% of cases~
symptoms may last the entire pregnancy. The inabil-
ity to retain food and fluids leads to de!tndration,
nutritional deficiency and metaboGc lIDb ceo
Aetiology
The cause of HG is not well understood. Human
chorionic gonadotrophin (HCGl. which rises to a
peak at 12 weeks' gestation and falls thereafter,
bas been held responsible. The HCG level is ex-
tremely high in women with molar pregnancies
and twin pregnancies, conditions associated with
HG. High levels of HCG are also associated with
9 Medical d isord e rs in p regn a ncy
increased thyroid-stimulating activity and elevated
serum thyroxine levels have been reported in more
than 70% of patients with HG. Hyperthyroidism
usually resolves early in the second trimester, sub-
siding along with the hyperemesis. PSjCchosocjal
stress is not a cause of hyperemesis but can
affiavate It and should be taken into consideration
in e overall management of the woman with HG.
Women who have experienced HG in a previ-
ous pregnancy or who have experienced nausea
while taking oral contraceptives are more likely to
suffer from HG.
Physiology
The pyloric glands of the stomach produce gasrric
secretions high in potassium (15 mEq/L) and with
significant sodium content. The secretion from the
parietal cells is isotonic but contains chiefly
hydrochloric acid. It also has a significant potas-
sium content (5-8 mEq/L). In the formation of
hydrochloric acid, sodium bicarbonate is rernmed
to the extracellular fluid (ECF). C.!(!!,tinued vomit-
ing thus leads to aemia, hYE.0natraemia,
~oraemlc alka losis an a decreass in FeE
v Alkalosis shiftS more potaSSium into the
cells. In adclition, the concentration of body fluids
increases because of insensible water loss with no
replacement. In some patients who have been
vomiting for a long period of time, the pyloric
sphincter rela;'(es and large quantities of alkaline
duodenal contents are lost. These patients will
usually have bile in the vomirns.
Urine output is reduced. This occurs by hyper-
osmolar stimulation of antidiuretic hormone
secretion and reduced glomerular filtration, asso-
ciated with reduced ECF volume. Urine specific
gavity is incregsed. Initially the urinepH IS atka
~6ecause the kidneys excrete bicarbonate in an
attempt to correct the alkalosis. As the condition
p!:o~esses, however, the jlQtaSSium defiaens
causes an ina ro riate acidifica .on of the urfue
and the urine comes more acidic.
Clinical picture
The reduced ECF volume and hypokalaemia cause
thirst, malaise, dizziness when tanding and ~
~ ~ati0!1 is associated With postural
hRr0tensJOn and fever. Hyponarraemi!, may cause
~s, convUl5iOm and reSplIatory arre t.
-
Iltt
Women's health : a core curriculum
Diagnosis
Investigations
e oss 0
tic! ta oscur
bo y a our ue to rapid fat oss and ketosis may
be noted. Excessive salivation (ptyalism) with con-
srant spitting is found in many women. The urine
is usually dark, and urinary frequency is reduced
to two to three times daily, as the body tries to
retain as much water as possible.
Symptoms of hyperthyroidism are similar to
those of normal pregnancy (heat intolerance, pal-
pitations, tiredness), but the presence of goitre,
tremor and signs of eyelid lag or exophthalmos
should alerr to the possibility of associated hyper-
thyroidism.
Symptoms and signs of a urinary tract infection
\ 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,
protein and urine acidity, as severe dehydration is
associated with high specific gravity and the produc-
tion of ketones. The haematocrit is increased as a
result of a concentrated blood volume. T here are
blood eleCtrolyte changes, e.g. decreased sodium,
p~ chloride and ~ esium are common, as
well as elevared'1iver, enwmes such as asparrate
transaminase (AS 1j, alarune transaminase (ALT)
or bilirubin. Overr jaundice is rare. Thyroid function
teStS should be checked in women with clinical signs
of hyperthyroidism, in which an increased T4 con-
centration and reduced thyroid-stimulating hor-
mone (fSH) may be found. An ultrasound should be
performed to identify a rwin or molar pregnancy. _.
Tre a tment
In the eighteenth century, it was believed that HG
was caused by a 'fullness of the vessels of the uterus'
and it was treated by venesection. Today, once the
diagnosis is made, trea . 0 .
care with correction a both flu ' 01
irn c deficienCies.
Hospitalisation is necessary in severe es.
Adequate fluid, eleCtrolyte and vitamin adminis-
tration will prevent life-threatening complications.
First-line management includes intravenous rehy-
m anon WIth normal saline or H artmann'S solution
WIth potasSlUm chlOride su pplementarion. It is
irnporrant not to correct severe hyponatraemia toO
rapidly, as this may also precipitate central pontine
myelinolysis. Fluid and electrolyte regimens
should be re-evaluated daily, based on serum urea
and eleCtrolyte concentrations. A woman who has
been unable to eat sufficiently for weeks is at risk
of significant malnutrition. V~it~";!;
m~in~ s~~,IOiOj~
tion, es eciall of the water-s e vitamins su
as amm I, IS lIDporrant to Rrevent evelop-
ment of werrucke's encephaloE!athy.
Oral lIwd and food should be withheld for
48 hQurs and then a bland carbohydiate diet cOm-
menced WIth small and frequent meals. Antiemetics
are tndlared tor S~ptoIllS that are inr:;:;lctable
despite adequate hidranon. t hey shoUld be iJruL
witl£:caunon, especiaIIy dUring the first 10 weeks of
n
pregnancy. necessary, melowest effecnve dose IS
administered. Metoclop rarnide, phenothiazines
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
AI " es suc as pow er (1 g
dally) and Vltamtn B. (30 mg pyridoxine daily) • A 32-year-old nulliparous woman presents at
have also proved to be effective and can be tried 14 weeks ' gestation to receive the results of her
where oral therapy is possible. S stemic steroids Initial antenatal screentng blood tests. Her
(hydrocortisone, prednisolone) have e e haemoglobin is 90 gIl.
fully H.sed in patients f Of whom annemegc therapy
A 24-year-old woman presents at 29 weeks'
has failed. Parenteral therapy haS a role to play in gestaHon with tiredness. She is a vegan and
severe HG.
has two young children at home.
It is imporrant to remember that a woman who
has been hospitalised for a prolonged period with
HG, who is dehydrated and confined to bed, is at
increased risk of venous thromboembolic disease, The majority of hereditary haemolytic anaemias
and tlJ.£Qmboprophyl~s (lffilZ-Wo!eCJJ lar-weit t and homozygous haemoglobinopathies are identi-
heoiif and compressIOn stockings) shoUld e fied before pregnancy. At the . t antenatal visit,
co~ensa: the most common cause of anaemia IS nutrltto .
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
come for the fetus. In sev . ed
aplasia or leukaemia are identified. The ~
maternal naus v ttn and we
of nutritional anaemias are due to iron deficiency.
erus IS at ris of &9wth restriction, whieh may
lead to preterm delivery and its complications. ft is rare today, with food forrification and vitamin
supplemenration for prevention of neural tube
Summary defeers, to see folic acid deficiency or the haema-
tological manifestations of vitamin Bu deficiency_
Screening beyond the first trimester is directed at
identifying iron deficiency anaemia.
Physiology
Plasma volume begins to increase by the sixth
week of gesration, peaJdJ]g at around 30 weeks,
With a total of 1.2-1.3 litres extra by term. The
erythrocyte mass mcreases more slowly and' pro-
pomonately less than the plasma volume, resulting
As psVchological factors may influ- in a net dilutional effect. This is referred to as the
ence the severity of hyperemesis
gravidorum . early adaptation to the phYsiological anaemia of premqnQ'. The lowest
pregnancy and a pos itive outlook pregnancy haemoglobin (Hb) occurs at 25-26
should be encouraged. weeks' gestation. A haemoglobin less than 110 gil
in the first trimester or less than 100 gIL in late
second and third trimesters should be considered
as anaemia and investigated furrher.
Mild agaemia, although a marker for poor
nutritional status, rarelfuhas untoward effects dur-
;f ~egnancy. When e haemoglobtn IS 60 70
, ~e mother is at risk for high-ournut cardiac
failure and extreme tati~T'" At these levels the
1'eWs'is at the lower limit ~ adequate o"lgen;tion_

women's health: a core curr ic ulu m
Screening for anaemia
A full blood examination (FBE) estimates haemo-
globin concentration, platelet and white blood cell
counts. In addition, the red cell size (mean corpus-
cular volume, MCV) and the red cell Hb concen-
tration (mean corpuscular Hb concentration,
MCHC, and mean corpuscular Hb, MCH) are
calculated. . performed at 26 weeks' gestation showed a
Microcytic anaemia (MCV <80 femtolitre s
(fL)) is commonly found in Iron defiCiency
anaemia and thalassaemia. Provided the platelet
and white blood cell count are normal, the first
investigation of microcytic, hypochrorruc (low
MCHC) anaemia is directed at Identifymg \ron
deficiency, by estimati pg sepJI~ ferpryn concentra-
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
low, with a riilldly depressed MCV), haemo obm
electrophoresis is performed to Iden carner
statesof haemoglobinopathies. . of Asian or Australian Aboriginal origin. Rh(D)-
A macrocytic anaemia (MCV > 100 fl.) ~s asso-
ciated with folic acid and vitamin B12 dettclenCies.
Anaemia associated with macrocytic red blood
cells (RBCs) and hypersegmented polymorphs
should be investigated to detennme erythrocyte
folate levels. Serum B12 levels are difficult to mter-
pret in pregnancy and are commonly phYSIOlogi-
cally low in the second half of gestatlon.
Iro n -deficiency a naemia
Women are prone to iron deficiency, which is
aggravated by menstrual loss and short intervals
between pregnancies. In the non-~regn.ant state,
approximately 1-2 mg elemental . \ron IS needed
each day. An additional 2-3 mg \ron per day 1S
needed in pregnancy (apgror4 atelv 900 mg m
total per pregpanf)' The ad tionaJ \ron IS used
both to increase e maternal red blood cell mass
(400-500 mg) and liver stores (250-300 mg) and
for fetal haematopoiesis.
Oral iron is absorbed in the stomach and duo-
denum, in a mildly acidic medium. Thus enteric-
coated or sustained-release iron preparatlons are
inefficient. Iron absorption is inhibited by antaCids
and enhanced by ascorbic acid, and therefore Iron
is beg ral ~en °0 20 empty stomach . The iron ~varr:
;J;fe for absorption is termed th e elemental \ron.
Thalassaemia
Alpha-chain haemoglobin production is under the
control of four genes and beta-chain produ~on
under the control of only twO genes, one inhented
from each parent. Thus thalassaemia may have
major and minor forms. The major fonns are
usually identified before pregnancy as severe trans-
fusion-dependent anaerrua. The common .
. efe resul ' e unde d The most common cause of anaemia in pregnancy
.either alpba or beta sbaLJli.. Un . .
uses an uru:natched excess of the other leadin
mem(lU)e e an mcrease e e ~ -
ity and reS111ring.JO a c orne emo ~c anaenua. ~
T he populanons most affected Y beta-& ilas
saemia minor are from the Mediterranean regIOn,
where the carrier rate may be as high as 1 m 7 llldi-
viduals . Alpha-thalassaemia minor is more com-
mon in sub-Saharan Africa and Southeast Asia- ~
women with bo th the alpha and beta tram, ee g-
n1.hf:
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 -
g 0 Ul concentration an aem
trophoreslS. s is Im portant because twO peop e
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
morbidity and mortality. Parents should be given
the option of prenatal diagnosis.
Sickle cell syndrome
It is important to screen all high-risk ~oup s, such
as black people of A1ncan Orlgtn, , ans, Saudi.
ArabIans artdivfediterranean eo Ie, or sickle cell
traIt. SICkle ce . soluble
-
Summary
is nutritional deficiency. With changing migration
patterns throughout the world, it is important to
screen for haemoglobinopathies.
A healthy diet generally meets the
physiological demand for Increased
iron in pregnancy. Oral supplement-
ation may be considered to maintain
maternal iron stores .
1-
9 Modlcal disorders In preg nancy
* Iso im munisa ti on
Common clinical presentations
A woman presents with an Inevitable miscar-
riage at 10 weeks' gestation. Her blood group
Is Rh(D)-negatlve.
A woman presents to the antenatal clinic at
27 weeks' gestation. The routine antibody test
titre of 1 In 128 of antl-Rh(D) antibodies.
Further questioning reveals that atter a previ-
ous ectopiC pregnancy she had not received
Rh(D) Immunoglobulin. There Is no record of
an earlier antibody titre in this pregnancy, as
she was travelling overseas In the earlier
weeks of her pregnancy.
Approximately 170.0 of Caucasians are negative for
the Rh(D) arttigen and are termed Rhesus negative
(Rh(D) negative). This blood type is rare in people
positive individuals may be heteroz)'gous or.~
homozygous for the D antigen. A heterozygous, ( f ,
father has a 500.0 chance of passing on the D anti- f (I
gen. If a w oman is Rh(D) negative and her partner 'l
is heterozygous, each fents bas a 50 % chan ce of ,CfJ·
being Rh(D) positive or Rh ipl peg3 ~. ••
M ore than 40 dillerent red cell antigens have
been reported to cause haemolytic disease of the
ferus/newborn (HDN) . However, o.!llx 3gri-R h (Q.),
anti-Rh(c) and 3nrj- Ke l! cause seriolIS feral prob-
lems. Other antibodies (Rh E, C, e), Duffy (Fya),
tGcId aka) and Lutheran (Lua) are common but
usually cause only mild to moderate HDN .
Pathophysiology
During pregnancy, fetal cells may cross the placenta
and enter the maternal circulation, exposing the
mother to 'foreign' red cell antigens that the ferus
has inherited from the father. This fetomaternal
haemorrhage (FMH) is most likely to occur at deliv-
ery (60% of pregnancies) but may also occur spon-
taneously during pregnancy and in association with
threatened or complete miscarriage, after trauma
and after invasive procedures such as amniocentesis,
chorionic villus sampling (CVS), external cephalic
version (ECV) or abruptio placentae .
'0
 Women's health: a core curriculum
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
maternal age, a previous magosgmjc infiJlt or
Wlexplained fetal demise. Some ethnic groups (e.g.
indigenous Australians, Pc:!:::an and Indian
women) are at pamCularly ~sk of developing
GDM.
Pathophysiology
Normal pregnancy is characterised by hyperplasia
of pancreatic beta cells, increased insulin secretion
and insulin sensitivity in early pregnancy, followed
by a progressive increase in insulin resistance.
Placental diabetog~c bormones, such as growth
hOnnone, progesterone and corticotrophin, lead
to changes in maternal carbohydrate metabolism
during pregnancy. These hormones rise linearly
during the second and third trimesters ill orCJef..u,
sup~owing ferus consrandy with sufficiwt
n~ - glucose and am;;o ac~. The mot.Mr
~ from carbobydiaL tg _ w!:!abfjIWTI,
utilisinr. free fatty acids, triglycerides and ketones
fanue . .
~rmal pregnancies, blood glucose levels fall
by 10-20% owing to ' increased storage of tissue
glycogen, increased peripheral glucose utilisation,
decreased hepatic glucose production and fetal
glucose consumption.
In estational diabetes, there is gr-eater insul '
resi rure m sec e
p~ Hyper ycaemia is associated with an
. increase in maternal and fetal complications. The
maternal same!.e of gestational diabetes include
an mcrease risk of pregnancy-mdu ed hyperten-
sion and preeclampsia, premature delivery and
caesarean seenon.
Women wuh pre-pregnan~ diabetes have an
increased risk of fe@ congen! abnormatities, in
particular cardiac detects and neuraJ rube deteers.
Later UiItuences on me tHus depend on the degree
of maternal hyperglycaemia.
FetalJlyperglycaemia stimulates hyperinsulin-
aemia, which leads to stora e of excess energy and
aces erate gro . S IS maru es S as mago-
somla, With resuTting increased rates of shoulder
dystoCla. and birth trauma.
Polyhydramnios IS caused by hyperosIDplar
fetal 01 ria and may precipitate reterm labour.
e mcrease c rate an 0 en
requirementS may partly :=rlain e !perease risk
or llltrauterme asphYXla:tiey also lead to tlie
develo ~ment of raised baemnocri r wd neopalil'
hi'Perb'irubinaemja.
Admissions to neonatal intensive care WlitS
occur more ofren and perinatal mortality is
increased. Neonatal complications include hypo-,
glycaemia and hypocatcaemla, the latter bemg
attributed to reduced parathyroid hormone syn-
thesis. Compared with infantS of similar gesta-
tional age, infantS of mothers with diabetes have
less surf~ctant production and are at increased risk
of respiratory distress syndrome.
Signs and sy mptoms
A woman with gestational diabetes is usually
asymptomatic and diagnosed after screening for
the condition. Alternatively, she may have symp- '
toms of hyperglycaemia (polyuria, polydipsia) or a
large-for-gestational-age ferus.
Screening
There is controversy regarding which women
should be screened and how to screen for gesta-
tional diabetes. Some guidelines recommend uni-
versal screening of pregnant women, and others
suggest testing only high-risk groups. Approx-
imately one-third of women with gestational dia-
betes will be missed if risk factors alone are used to
guide screening.
The optimum time for screenin is 24-2
weeks' estanon, w en insulin resistance increases.
t e present orne, ere is a ac of high-qu ty
evidence regarding important health outcome
measures related to screening for gestational dia-
betes. The Australasian Society for Diabetes in
Pregnancy (Hoffman et al1998) recommends uni-
versal screening.
An oral glucose challenge test performed at
24-28 weeks' gestation is used to screen for gesta-
tional diabetes. Two variations are described with
positive resultS:
• a serum glucose level greater than 7.8 mrnoVL
1 hour after a morning nonfasting 50 g glucose
load
• a serum glucose level greater than §Jl. mrnoVL
1 hour after a morning nonfasting 75 g glucose
load.
Diagnosis
If a screen test is positive, a confirmatory test is
reqUired. Common diagnostic testS include either:
• ~ 75 g glucose tolerance test that yields a fast-
Ing glucose greater than 5.5 mmol/L or a
2-hour result of greater than J.-;nmollL
(Hoffm~ et al1998). A 2-hour cut-off level of
9 mmo'!~ IS used in New Zealand.
• A 3-hour 100 g glucose tolerance test, taken
after .overnight fasting and carbohydrate load-
mg, IS more commonly used in the United
States.
Therapy
section
Fetal monitoring
An ul
9 Medic al diso rders In p regn a ncy
_ nn a!jties in babies of WOmen wi th pre-
pregnancy diabetes. In all women with abnor-
mal glucose tolerance in pregnancy, fetal growth
should be assessed clinically and by regular
ultrasound to Identify growth restriction or
accelerated growth. Fr eks onwards,
cardlo" c a h , be er
,as
t ere IS an Increased rlS 0 sudden intrauterine
fetal death. However, the cJinical effectiveness
of thIS approach is not weJl established.
Induction of labour rna be c ' red after 38
wee s gestation In women with 0 0
tro e " , VI ence that peri-
natal mortiih1y IS Increased in the presence of
weJJ-controJled gestational diabetes.
Good glycaemic control is important in labour.
Lower insulin requirements are common in
labour, and hypoglycaemia should be avoided.
Elecrroruc fetal monitoring is advisable.
Close neonatal fo Uow-u is iill artant arti-
e a: or e eteenon 0 emia and
:.:,splratory stress syn orne. Breastfeeding IS
acdvely eHEolliaged.
Prog nOSis
Most women become euglycaemic after delivery
,
as somatomamrnotrophic hormone produced b; ..
the placenta has a short half-l ife.
Women with abnormal glucose tolerance
have a 30-70% increased risk of recurrent gesta-
tional diabetes, ,the higher rate being reported in
the non-CaucasIan population . Higher pre-preg-
nancy weIght and a, hIstory of a large infant are
assocIated, Ith an Increase d risk of recurrence.
The nsk of developing type 2 diabetes meJlirus is
up to 50% over the following 5 years. There is
emergrng eVidence thar the incidence of obeSity,
insulin reSIStance and diabetes is increased in the
offsprmg.
The
W~)[Denla
2r~~, ~~~endati~~ f screen
~: f VEt; : pbetes -at
6 weeks postpamun and ths! rg cgntinue to
screen tor diabetes at least every two years
(Hoffman et aI 1998). Women who have had ges-
tational dIabetes should maintain ideal body
weIght and exercise regularly to decrease the risk
of future diabetes , There is no strong evidence that
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

Contraceptive advice should be given in the
puerperium, and women should be advised to
plan future pregnancies with careful attennon to
good pre-conception blood glucose controL
Health maintenance
In women with diabetes mellitus, nor-
malisation of blood glucose levels
before pregnancy reduces the risk of
fetal congenital abnormalities and
facilitates optimal control during
pregnancy. Identification of abnormal
glucose tolerance in pregnancy ~as
lifelong implications for a woman s
general health.
Type of Characteristics
hypertension
De !l~VO trt~2ttitl§I~!l arlsln~
1. Preeclampsia
Offer 20 weeks' gestatlo n,
rmorl'Hng Fo normal within 3
monmspoi!Od@tD
and ane or more or:
p~a - ~3()() mg/dafr
spat urine albumln:creOflnn e
ratio (ACR ) ~30 mg/ mmol or
d ipstick proteinuria persistenHy
~3 gIL
Rena/Insufficiency - pl~
creanmi'ie ~1;I!l ~ mollL
Uvw distiase - AST >50 IU/L
and/or severe epigastric/right
upper quadrant pain
Neurol0fl.'cal Qr51~b2~i-
convulsions (eclampsia);
hyperrenexla with clonus;
accompanying evidence o f maternal cerebral,
renal, hepatic or clotting abnormalities, or fetal
growth r estriction.
In developing countries, preeclampsia remains
one of the most common causes of maternal death
and a common cause of death in young women.
Death may occur from acute hypertensive crisis,
mkam£Ti' acute pUiIDOnary~edema, acute
ure, 'ver failure, haemorrhage or co::.:a~,."
o _ __
Ii'i1Iie developed workI; maternal mo .ty is now
uncommon, although occasional cases still occur
despite the best possible management. Perinatal
mortality is of the order of 20-35 per 1000 cases.
-
but once preeclampsia has begun it runs a pro-
gressive course until delivery.
Clinical assessment
Preeclampsia is detected initially in most cases by
the presence of hypertension arising after the
20th week of pregnancy. It does nor occur before
the 20th week, except in the rare case of hyda-
tidiform mole. S~s are not always present,
but may comprise severe headaches, convulsions.
s~e, re eated visual scotoma (all manifesta-
tions of cere r lnvo vemenc), severe epjga§qjc
or right upper quadrant pain (reflecting hepatic
ischaemia With pOSSi ble subcapsular haematoma
of the liver or even li ver rupture), ~ (due
to acute renal failure) , bleeding ~use d by dis-
se minated intravascular coagu \:tion (DIC::) ,
lower abdominal ~ain ca used by abruptio-pTa-
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
ultrasound, and fetal wellbeing by a combination
oTCaraTotocography and ultrasound assessment of
bio~:fiKal profile and utenne mea resIStance. It
slio be stre sed that none of the assessments of
fetal wellbeing provide any long-term certainty
about fetal outcome.
Eclampsia
HELlP syndrome
HEllP syndrome (haemolysls, elevated liver
enzymes and low platelets) IS a subcategory of
preeclampsia. Although sometimes regardedas a
separate entity, HELLP simply refers to a severe
form of preeclampsia in which the hepatic and
platelet abnormalities dominate. Clinicians should
continue to look for all the other potential
complications of preeclampsia in such women.
Prevention
Unfortunately no set of tests has reliably predicted
the development of preeclampsia. Low-dose
aspirin reduces the risk of developin~reeclamp­
~ but apprOlamately 100 women ne thiS treat-
ment to prevent one case (Knight et al 2000). It is
best reserved for women considered at highest
risk; such as those who have expenenced a tures to resolve, and a few patients will have
~ious fetal loss due to preeclampSIa or who
have prevlOus0 re;i1llred very earty de!ivery
because gf t hiS g]wrWr - systems such as hepatic or portal veins) as well as
Treatment
• progressive evidence of maternal gcva n dys-
fu~ worserung renat or hepatic function,
worsening thrombocytopenia, development of
neurological symptoms or signs
• inability to control blood pressure
inadequate letal grgwth.
AntihYJ1ertensive m edications are usual ly
given if e systolic blood pressure IS persIs-
tently ~ao mmHg a1lti
Oi diaseotOmSl!re
~o mm g, aIthough t~ choice 0 the exact
blood pressure level at which treatment . is
required remains controversial. For such chronic
treatment, several agents may be used,
including methyldft};a, o~re nolol, labetalol and
clonidine as hrst- e agents. ~ hen addltlonal
treatment IS reqUIred, hydralazine, nifedipine or
prazosin may be added. Angiotensin-converting
enzyme (ACE) inhibitors, angiotensin II (~
receptor antagonists and ~ are ~y
a~ the first two groups cause a fetal
hypotension syndrome and diuretics reduce an .-
already impaired maternal blood volume.
Blood pressure ~170/110 mmH re uires acute
treatment er to revent mate oke
an~r e ampsla. IS setting, in~s
hy r azme or mtravenous labetalol are most com-
mo@y used. o@ IiiJedipme 15 al 0 usefUl.
MagnesIum sulfate is the dru~hoice for
co nvulSion prophylaxis. It is a stered to
those \~omen who have already bad a conYUl-
sion an IS otherwise reserved for women who
have severe ttIfi'ptomatic preeclampsia, hyper-
~Ia or 0 er diIIj@ evidence of cereOraJ
involvement.
Postpartum m anagement
Recovery should be anticipiued over 5-7 days fol-
lowing - delivery in most women. OccasIonally,
panents may take up to 3 months for all the fea-
proteinuria that takes up to a year to disappear
completely.
As~s~~~~~~~~~~~~
months os artum i ato . ressure
sh ave returned to normal within 3 months.
If it oss not, t s s ou prompt a seare or
underlying essential or secondary hypertension.
Urinalysis and urine mjcroscooy should be nor-
mal, certainly by 12 months postpartum, if not
n
before. this is not the case, a pnmary underly-
ing renal disease should be sought.
As a general rule, preeclamosia or gestational
hypertension will recur in about 15% of women
in a subsequent r.re~ancy. Women who have
presented at or beor?S weeks of gestation may
have a highet risk of recurrence.
. The traditional view has been that preeclamp-
sIa IS not assOCIated WIth long-term health risks for
the mother, although gestational hypertension _
particularly when recurrent - prediCts a greater
likehhood of later essential hypertension.
However, it is now thought that long-term cardio-
vascular and cerebrovascular risks are increased in
women with preeclampsia or geStational hyper-
tensIOn.
Gestational hypertension
Chronic hypertensio n
In most cases, this is due to essential hypertension
a.nd, unlike preeclampsia or gestational hyperten-
~I~n, It IS apparent in the first half of pregnancy. It
IS unp ortant to exclude 'white-coat' hypertension
with 24~hour ambulatory home blood pressure
morutormg before making a certain diagnosis of
essential hypertension.
The main risks of chronic hypertension in
pregnancy are :
fetal growth resrriction
• accelerated maternal hypertension
• superimposed preeclampsia (in about 25% of
cases).
Wire ;! rnriljr;r, and bVi mdE are major
contributors to maternal morbidity. Pregnancy,
DVT and PE are closely linked, as pregpancy is a
[Jon actors, eVI ence 0
gen activation, and impairment of yenous retur. p
9 Medical dis o rders in pregn ancy
Health maintenance
Early presentation for antenatal care
facilitates identification of chronic
hypertens ion and risk factors for
development of preeclampsia .
Regular antenatal care allows early
detection and management of the
often asymptomatic hypertensive
disorders of pregnancy.
* Thromboembolic
d isease
Common clinical presentations
A 33-year-old woman presents at 34 weeks'
gestation In her third pregnancy for routine
antena tal review. During the consultaHon she
complains of a swollen . sore left leg. .
One week after an emergency caesarean
section under general anaesthetic for fetal '
distress. a 25-year-old woman presents to the
emergency department with breathlessness.
A 34-year-old woman presents to her general
pracHtroner for advice about her next preg-
nancy. During her third pregnancy, she was
d iagnosed with deep vein thrombosis and
treated with low-molecular-weight heparin unNI
6 weeks postpartum . .
Thromboembolic disease encompasses thrombot-
IC events (deep vein thrombosis - DVT
generally of the lower limbs, superficial throm~
bophlebitis and thrombosis of other venous
embolic phenomena, both venous and arterial
(pulmonary embolus - PE, cerebral and other
end-artery systems). This chapter discusses only
DVT and PE and their relationship to pregnancy.
P~on= embolism is a mabor cause of
rothrom botlc state WIth an increase in coa 1-
0 asmino-
..-
Women's health : a core curriculum
in the lower limbs. Pregnancy may be associated
with other risk factors, imrnobilisation (hospitali-
sation) and surgery (caesarean section).
Deep vein thrombosis
The prevalence of DVT is less than 3 per 1000 preg-
nancies. Thrombosis often startS in the calf but only
thrombosis above the knee produces dots large
enough to create a significant risk of pulmonary
embolism. Alone, superficial thrombophlebitis in
the leg or thigh is unlikely to generate aPE.
DVT occurs with e uaI Ere uen in each
. ester but
DVTs occur in the e eg or ater y. is sug-
gested by signs and symptoms that include pain,
swelling, oedema, heat and redness. As swelling is a
common symptom in late pregnancy, it has poor
sensitivity as a sole symptom. Unilateral or early-
trimester bilateral swelling should be taken seriously.
In re an there should I w res old
for eJ<! u n . iagnostic investigations are the
same as for non-pregnant panents except for the
value ot the D-difiler test: the D-diriier IS usuany
elevated In pregnancy and especially postparnun.
Ultrasound - usuaJIy compreSSlOn Ultrasound - is
e Low-molecular-weight heparip is becgmipg tb e
Pulmonary embolism after consultation with a haematologist. Patients
Without a c10ttrng tendency usually have postpar-
tum prophyl3.XJ.s but not necessarily antenatal
prophylaxis.
Prophylaxis without DVT
TbromboEfog,hv w with heparin in £!3!gpaocy
mQ be o$r;;C;; ummen WIthOut a hiStory of
DVT/PE who have a thrombophilia or possibly a
strong farruly hiStory. Some obstetric units offer
prophylaxis post-caesarean section for all patients
whereas others offer this intervention only wher~
other rIsk factors coexist.
Ri,tJ$..factors may h.e considered in two grQ'1PS:
~le and a~le. The former include
maternal age over 35 years, high Parity, ~:
persona:t or £3illlly hiStory of throm1Josls,
bophilia syndrome or malor surgery. Av~e
nsk factors that demand arrenoon indu~­
~n, Immobility, pree~lampsia and r;:,a~ok
Intercurrent liifecoon or Illness. Multiple ns
factors fiiitlier Ihtrease an individual's risk of
thromboembolism, and prophylaxis should be
cOrISidered. .
Heparin
stanfod anticoa@l4iit used during pregnancy
~a In the noo-pregnant state. It is..wgrs expell-
slve 9ut regtllres little monitorin~and is assocj<u:-
ed .lYlth a reduction in the side eeets comwpolJl
seen~th untracoonated he~.e. o§.t eoporo-
~ om60cytog;rua and be . Symonds EM, Symonds 1M 2004 Essential obstetrics and
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 .
...
9 Medical disorders In pregn a n cy
References and further reading
Cousins L 1987 Pregnancy complications among diabetic
women: revieW 1965-1985. Obstetrical and
Gynaecological Survey 42(3):140-148.
Divakaran TG, Waugh J, Clark TJ et aI 2001 Noninvasi ve
techniq ues to detect fetal anemia due to .red blood cdJ
alloinununizarion: a systematic review. Obstetrics and
Gynecology 98:509-517.
Hod M, Orvieto R, Kaplan B 1994 Hyperemesis
gravidarum: a review. Journal of Reproductive
Medicine 39:605 .
Hoffman 1., Nolan C, Wuson JD et aI 1998 Gestational
diabetes mellirus - management guidelines [consensus
statement], the Australasian Diabetes in Pregnancy
SocJ<ry. Medical Journal of Australia 169:93-97.
_
Knight M, Duley 1., Henderson-Smarr D], King JF 2000
Ann·platelet agents for preventing and treating
preeclampsia. In: The Cochrane Database of
Systematic Reviews (rhe Cochrane Libtary), issue 2:
CD000492. Online. Available: http://www.update.
somvare.comlcochrane.
Langer 0, Conway D, Berkus M et aI 2000
A comparison of glyburide and insu/in in women with
gestational diabetes mellirus. New England Jourrul of
Medicine 343 (16): 1134-1138.
NHMRC 1999 Guidelines on the prophylactic use of Rh D
immunoglobulin (anti·D) in obstetrics. Online.
Available: http ://www.health.gov.au/n/unrc.
Queenan J 1999 Management of Rh-immunized
pregnancies. Prenatal Diagnosis 19:852-855.
gynaecology, 4th edn. Churchill Livingstone New
~~ ,
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
At the end of this chapter, the student
will be able to:
• discuss the time sequence of fetal
organ development In relation to
possible teratogenic Influences
Rubella
describe the consequences of maternal
rubella Infection in pregnancy
discuss the Importance of pre-
pregnancy counselling, antenatal
screening and primary prevention by
vaccination
Hepatllts B
list the modes of transmission of
hepatitis B
• describe the consequences of maternal
hepatitis B Infection
• describe the serological tests for
hepatitis B
• outline a management plan for an
infant at risk of hepatitis B
Urinary tract Infection
• state the significance of urinary tract
infection (UTI) and asymptomatic
bacteriuria in pregnancy
explain the predisposition to UTI in
pregnancy
describe the clinical and
microbiological diagnosis of UTI
outline the management of UTI in
pregnancy
• list appropriate antibiotics used for
treatment of UTI in pregnancy
\ NV\
Other infections
summarise the eHects of other common
infections on the mother and fetus/
neonate
• outline the diagnostic procedures for
each infection in pregnancy
describe available tests to confirm fetal
Infection
outline management options for each
Intection
Chorioamnionitls
oulline the aetiology of preterm
prelabour rupture of membranes and
preterm labour
list the common causative organisms tor
chorioamnionitis,
Skills
At the end of this chapter, the student
should learn how to:
• explain to a pregnant woman the results
of rubella and hepatitis B antibody
screening tests
instruct a woman how to collect a
midstream specimen of urine.
Attitudes
At the end of this chapter, the student
should reflect upon:
the maternal anxiety engendered by an
uncertain prognosis, particularly when
tetal or neonatal infection may not be
evident for several weeks after maternal
exposure,
'tf
 10 Infecl lons In pregna nc y
Women's health: a core curriculu m

* Rubella
Common clinical presentations
Impact/outcomes
If a woman believes that she may have been
A pregnant woman Is concerned because a
child at her doughter's preschool has a rash .
A woman discovers that she Is pregnant shortly
after being vaccinated against rubella.
Epidemiology
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~ looking for a ch3llge in rubella IgM and IgG Rme of greatest susc epHbllity Susceptibil ity stgrts with ayes and brain , then movin
antibodies (lgM rises 7-10 days after primary infec- ac1 ; Ss own peak o f towards lower limbs g
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 '
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
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.
Women's health : a core curriculum
Diagnosis
Management
Treannent of any pregnant woman with UTI should
include advice about ~ fluid intake .and ~
Ce~ (250 mg or y 6-hourly), ~­
toin (50 mg orally 6-hourly; best tolerated rn the
~olide form) or amoxicillinJ~otasSlUm clavu-
l~te.J.2501125. mgoratiy 8-houry) are the most
app ro~riate anoblOocs, and should oe contmue~
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. .
PregIlant women presentin~ with a seve(e febrile
. ess and ossible sepocaerrua sha uldlJe treated
m rn a
Impact/outcomes
Subsequent to the sue
in
shoul
e
esta
a ro am of re
e
eatment of UTI dur-
recurrence .
"'OC'CaSi'onally, recurren! infectjQn~ make propby-
laxis a~ODriate Wlth rutrofurantorn (50-100 mg
oraJIy ~ynor dle remamder of tln!-pregnancy.
Health maintenance
The association between urinary tract
infection and preterm labour is
sufficient to warrant mlcroblolo~ical
examination of a midstream urine
specimen in the event of any urinary
sympfomatology. Asy,!,pton;atrc
bacteriuria should be Identrfled of fhe
first antenatal visit.
* Varicella zoster virus
A pregnant woman who Is not Immune to
varicella zoster virus has Significant contact
with a child who develops the rash of chicken-
pox 1 day late I.
Pathophysiology
The varicella zoster virus (VZV),. which causes
chickenpox and herpes zoster (shingles), ~
risks for both the mother and the feros if infeCtlon
occurs dUTIn¥ pregnan~ The usual rncubauon
penod IS 10- 4 days, Wl infecoVIty lasont.from.
1 to 2 days before the rash appears un@ an esions
-
are crusted.
Im pact/outcomes
Management
A varicella-seronegative pregnant wOII,lan \1{ho
has a sl .{icant e osure to VZV mEe
s ou e oHered zoster unmune J? 0a (ZIG)
within 72 hours of exposure. Varlce a~se~oneg­
atIve pregnant women who have a slgmflcant
exposure to VZV and do not receive ZIG, or
who have risk factors for severe adult dlsease,
should be considered fur prophylactic Ora ', ac:y-
c~ Pre gnant women ;to ,develop yap cella
pneumonia Qt.p,her compcatlo ns of VZV (e.g.
ha1iTIorrhagic rash, neurolOgical SignS) s~
ge offered intravenous a9,c1ovlI, as sh,?uld preg-
nant wo men receIvmg systerruc comcosterOid
therapy who develop otherwise uncomphcated
VZV infection. Babies born to women WIth
10 Infections in pregnancy
VZV =q~~ in the Seriparrum period sho!!ld
begixen
eriCOUraged.
va
and reastfeeding should be * Cytomega lovirus
Common clinical presentatio n
*
A pregnont chlldcare worker asks about the
Pa rvovirus 8 19 consequences of contact with a child Who Is
known to Chronically excrete cytomegalovirus
In her urine.
• A fetal death, secondary to the development
of hydrops fetalis, occurs after a minor mater-
nal febrile illness. Pathophysiology
Cytomegalovirus (CMV) is a member of the her-
pes virus group and is the virus most freQuemly
Pathophysiology transmitted to a feI!!S. Illf.;,crious CMv max.,be
Infection with parvovirus BI9 causes a cornmon fo~nd in wine" s~~ blood, := sem,!!1 and
childhood febrile illness known as fift breast mill<, and rh s eddiiiiOf ~rus may rake
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
lasts 1-3 weeks wjth a cbamgerjsdc rcd ra§h l1fi
the cheeks and a lace-like rash on the trunk au
d
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,
the most impoltan use or COD enital viral infec-
No treatment or vaccine is available. .' . 4 ecnOlL ~
Outcome /impact
risk 0 e
infectiog maY lea to a gene
rh~ wirh an SAM nsk 0 compllcat1ru16
'7
infecoon in
within the first few years of life, Indu~ h~g
~ISlOn = M!tm@' and vatyJ,ng degre_ of=---
tal retardation. Alternatively, rhe infant may be
~ with no symptoms at birth, and subse-
quently may deVelop hearing and mental or coordi-
nation problems. There appears to. be little risk of
CMV-related complications for women who have
been infected at least 6 months before conception.
Management
In rhe event of a CMV-specific antibody rise in a
pregnant woman, amniotic fluid viral culture and
fetal blood antibody testing have been used to
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-

Common clinical presentation
A pregnanl velerlnary nurse quesllons Ihe
safety of conlacl wilh cols.
Pathophysiology
Ma nagement
Treatment of the carrier State is not successful
in eradicating the organism. The incidence of neQ-
Impact/outc ome ?x
natal disease is sigpificantly reduced iprr3P?,!,J?"
anti blogCi : intravenous Gasta"we pe pJCdhn
2 x 106 u, followed by 1 x 106 U 4-houdy until
dslli:;ry; or clinctamycm 906 mg 8-hourly or e:rytli-
Symptoms and signs
These may include maternal fev" and/or
~ fetal tachycardia, uterine pain and ten _
:jJt:
~~ Pf'~ labour and ~ or puruJem
amn10_ -- . ----
DiagnOSis
Full blood examination reveals a leuk~osis with a
neutroph jlia, and a cervical swab reve .targe num-
bers of le~~es and pathogenic pacteQ!!, with an
absence? Ctobacilli. Occasionally, microscopy
and culture ot ammotic fluid obtained by amnio-
centesis may be needed to confirm the diagnosis.
Impact/outc ome
ered: vagill IS e, as caesarean sec-
nonin ese CIrCUmStances may lead to serious
intraperitoneal sepsis.
Health maintenance
Women known to be at risk of giving
birth to a baby with GBS colon isation
shOUld be treated with intravenous
antibiotics In labour; potentially this
means thai 20-30% of labouring
women will be exposed to antibiotics,
with the ~Isk that this Will lead to on
increase in the incidence of antibiotic-
reSislant bacteria .
Further reading
Freij B], South MA, Sever]L 1988 Maternal rubella and
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

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

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

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

a . termination of pregnanc/y e . should be given acyclovir during

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

Common clinical presentation
A 25-year-old woman presents at 28 weeks'
gestation with irregular uterine contractions .
Her previous baby was born at 24 weeks'
gestation and died a few hours after birth.
Postmortem examination was not performed .
Risk factors
Preterm labour is preceded by spontaneous rupture
of the membranes in one-third of cases. It is thera-
peuticall, induced in the maternal or fetal interest
in another third (e.g. in the presence of hyperten-
sive disorder or fetal growth restriction). The cause
of up to one-third of pre term labours is unknown.
cervical incompetence.
Consequences of preterm birth
The ma jor risks of pre term birth include ~
death due to eXtreme illlffiaturtty, and rejpiaatoD'
distress syndrome, as the lungs are un er evel-
oped and surfactant is deficient. The developing
fetal organs, particularly the brain and bowel
mucosal are susceptible to hypOXIa. III the late sec-
Ond trimester and early thlrd trimester, the
vascular subependymal plate below the cerebral
ventricles is particularly sensitive to changes in
oxygen tension, and these fragile vessels may bleed
into the ventricles, causing ventricular dilatation
and scarring. Developmental arrest of the rapidly
growing bowel mucosa leads to necrotising entero-
colitis.
The preterm baby has relatively low stores of
fat and without this insulation is prone to
~E.2:$S!l!;~' In the pre term infant, the tmmature
stores, leading to ~
I" Suppression of labour IS con IT
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
trregular utenne contractions and lUldilated or
effacing cervix --:- prediction of labour is impor-
should be administered with caution to women WIth
tant. One predicove test is based on detection of diiibetes mdlitus, as thIS may prec!pltate sliiIiificant
fibronectin, a glycoprotein produced by the chori- hrer!ycaemla.
orne cells and released when the interface between ~ use of prophylactic antibiotics for prema-
ture labour without ruptured membranes has been
the chorion and decidua is interrupted, either
investigated in a large multicentre ITial, the ORA-
mechanIcally or owing to infection. Detection of
CLE II srudy (Kenyon et a! 2001). Although there
fibronectin has a poor positive predictive value for
was a reduction in maternal infection, it failed to
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
neonatal outcome.
may be useful in determining the need to transfer oco! 'c ents su
the woman to a tertiary referral centre. cated or tene
on. ey are e to success e
Management
"CeniiCar dilatation' Or if preterrn
Unfortunately, therapeutic agents designed to sup- I our occurs early in the second trimester. They
press labour have not been effective in prevention of may act by beta S)'ID"bathetic agonist activiry (salbu -
preterm bmh (delivery before 37 weeks' gestation). taIIiol or ntoanne), y reducrng myometrial inrra-
The management of threatened pretenn labour is cellular calcium levels (calciwn channel blockers
therefo~e auned at prolongmg the pregnanCY to such as nifeclipine), by smooth mUScle relaxation
allow mne for adiIllnistration of corncosteroids (glyceryl trinirrate) or i.illiibition of prostai:landjc
to The mother. 10 treat [lJe undeclymg cause and to producuon (mdomeiIi'acin). Despite being predomi-
ow tr the mo er 0 e a cenITe. ~ta 2 agonises, the sympathetic agonises are
e owever assoaated WIth the severe maternal side effeces of
where continuation of pregnancy may prove dele: tachycardia, pulmonary oedema and myocardia!
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

women who have an increased risk of cervical
incompetence, transvaginal ultrasound may be use-
ful ra measure cervical length and predict preterm
birth. A shortening cervix may prompt the insertion
of a cervical cerclage.
Prognosis
An accurate assessment of gestational age, taking
menstrual and ultrasound data inra consideration, is
essential. This will determine the likelihood of via-
bility, and hence suitability for resuscitation, and the
prognosis for the infant if born at an early gestaTIon.
The paediatric and obstetric team should deade if
delivety at the current hospital is safe or if transfer
ra another centre is more appropriate. This will
depend on the progress of labour, the availability of
neonatal intensive care support, and expernse 1Il the
management of very preterm babies. Preterm labour
is a highly stressful event for most parents.
Counselling about the possible neonatal outcome of
the fetus and the discussion of management options
is very important.
preterm births
Aetiology
Spontaneous rupture of the membranes at term is
usuauy caused by a narurat weaJ<erung ot the mem-
branes or by the force of contractions. In ~
p@M; an iriHatdiMEOt i piUe~ weakens the
c.l:iorioamnion. Bacteria and macropllages prOduce
protease, phospholipase, elastase, cytokines and
eicosanoids, which lead ra uterine irritability, cervi-
cal ripening with membrane weakness and rupture.
A previous histOry of pretenn PROM is the mOst
common risk factor for reterm PROM.
CervtcovaguuTIS ue to s transDll c-
, a e w c
ococcus is strongly associated with
P . Uf1Ilary tract ection may to
c orioamnionitis if the woman becomes septi-
caemic. Cc;rvical incompetence, polyhydramnios
and mul1l.le PlIfanClesaISo preref'se to weak-
preterm PROM, as the reduction in amniotic fl uid The interpretation of an elevated leukocyte
restricts lilllb aria Chest movements. count and C-reactive protein can be difficult in
pregnancy, as they are physiologically elevated.
Diagnosis Fetal hean rate monitoring may identify fetal
compromise due to cord compression or infection.
The diagnosis of preterm PROM is based on the
Cardiorocographic recording is unfortunately less
history, physical examination and identification of
reliable in very preterm pregnancies, as the central
amniotic fluid. In 90% of cases, the patient's his- nervous system is still immature. The relatively
tory alone is correct, but urine leakage and later physiological development of the parasympa-
increased vaginal discharge may be mistaken for thetic system results in a greater sympathetic sys·
preterm PROM. tem influence with higher fetal hean rate and less
To confirm the diagnosis a steri le sllcmlum variability in the preterm infant.
examination IS performed. Digital examination
If expectant ;;;rcgemem is chosen, the w~
Should be avoided, as this increases the risk of is nospltaJiSed ancorticosteroids and anrik .
infection. ~ol of liquor cannot be identifie ~ a . erO! ave teD sho':Y!Uo
a IS from the osterior forrux an improve fetal outcome by reduang the mCldepce
smeared on a s e. is owe to and then
Ofli y:wt me:rrafie S!ease mtraventIicular
examined under a light microscope for the appear- Memo age an necrotlSrng enterocolitis in the
ance of feming, which is characteristic of amni- event of preterm labour. Steroids have not been
otic fluid. Another method employs nitrazine, an shown to increase the risk of fetal or maternal
altint that c'tinges colour from renow to blue at a infection. The effectiveness of steroids has not
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
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
A 35-year-old woman presents at 29 weeks'
gestation with a history of waking up In a pool
of Muid. She hod two previous preterm deliver-
Ies at 36 and 34 weeks' gestation.
A 22-year-old woman presents at 32 weeks' ges-
tation In her first pregnancy feeling generally
unwell. She describes a constant malodorous
wetness far 5 ·days. The baby Is less active than
usual. On examination. her blood pressure Is
110/65, temperature 38.4·C and her abdomen
soft but mildly tender. Speculum examination
reveals a closed cervix and a pool of liquor In
the vagina. The liquor has an offensive odour.
The baseline fetal heart rate is 180 beats per
minute.
Prelabour rupture of the fetal membranes (pROM)
is defined as ru turf of membranes that oc
reterm pre our ruo-
or preterm PROM) is
reflects the presence of one or more of the above Ultrasound examination can be helpful to
support the diagnosis in the presence of oligo-
risk factors.
hydramnios and to confirm the fetal presenta-
tion. A finding of normal liquor volume, how-
Sequelae of preterm PROM
ever, does not exclude a diagnosis of ruptured
of preterm PROM is
membranes.
Management
Management will depend on w tational .ffiie, the
presence of iIlfection, and fetal and maternal welJ-
b3. At 34-36 weeks' gestaTIon, de4yerv may J?e
apnriate as a balance between fetal maturity
an e nsk of infection.
At less than 34 weeks' gestatign agd in the
absence of SignS of maternal or fetal infection or
cord com ression directed
Prognosis
Ax less than 24 weeks' gestatio ~ the outcome is
usually poor. Pulmonary hypopasia as a conse-
quence of madequate alveolar growth and in utero
chest compression in chronic oligohydramnios
leads to poor oxygenation. In survivors ener-
alised develo mental dela , dela ed motor
ogment, cere ~riit p y and chIomc lung dise.ase
rnafn0ccur as oog-term problems.
cases where preterm PROM occurs very
early in the second trimester and is likely to be
associated with in utero fetal death or chronic
oligohydramnios, termination of pregnancy may
be considered and the parents need in-depth coun-
selling.
Overall, the risk of expectant management
must not be underestimated and close observation
can make the difference between a healthy moth-
er and fetus or high maternal and fetal morbidity.
Parents should be involved in decision making
after counselling by a senior obstetIician and a

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.
Health maintenance
Attention to oral hygiene and avoid-
ance of STis minimises the risk of
chorioamnionitis and preterm labour.
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
Kenyon SL, Taylor DJ, Tarnow-Mordi W 2002 Antibiotics
for pretc:rm prelabour rupture of the membranes: Edited b y Lucy Bowyer
short-term and long-term outcomes (ORACLE
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

At the end of this chapter, the student At the end of this chapter, the student
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
At the end of this chapter, the student
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
Common clinical presentations
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

Ilred jspgses t 9 cardiac fai lure jn the }¥gw an w jth
underlying cardiac disease. The development of
anaemfa in pregnancy further increases the work-
load 0 the heart.
"toag\ilauon factor production is increased in
Rre
puerpenum. e me an! pressure 0 e uterus
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
then remaining sta!ile for the remamder of the
pregnancy. G IL!;!u;co~s!.!ie~~l5i.lo.il~Uu.ll.lo!;;.I.I.:~.w.~1lS
pregnancy, WI relative resistance to insulin.
LevS[ or adrenocomcOtroPIC hormone (ACrB)
and unbound cortisol are increased. Thus preg-
nancy IS a prodiJhefiC State.
M ental state
Health maintena nce
Antenatal patients must be assessed
carefully and women with high-risk preg-
nancies (e.g. those with heart disease,
diabetes, renal disease or pregnancy-
induced hypertension) referred to
specialist units. Adequate facilities for .
delivery and the care of mothers should
be provided according to their risk.
Careful postpartum observation and
early ambulation are important in all
women, with prompt intervention to man-
age abnormalities such as postpartum
haemorrhage, deep vein thrombosis,
puerperal depression ond psychosis.
A woman at 32 weeks' gestation reports that
she has not felt fetal movements for 3 days.
An ultrasound at 28 weeks' gestoNan reveals an
abnormal fetal heart and evidence of fetal
hydrops.
A newborn baby becomes cyanotic with
feeding .
neonates from 400 g birtb weight, or of at leaSt 20 rates, with the neonatal deatb rate decrease being
weeks' gestation wben birtb weigbt is unavailable the more marked. Figure 12.2 grve the main causes
as well as neonates up to 28 days after birth. ' of permatal mortality in WeStern AuStralia. The
three main causes are similar in all States, but a
Rates and prevention in Austra lia nanonal report using the more recently introduced
Tbe AuStralian perinatal mortality rate decreased AUStralian and New Zealand Antecedent Classi-
from 22.6 per 1000 births in 1973 to 8.5 per 1000 ficanon of Perinatal Mortality is not yet available.
births ill 1999 (FIg 12.1), This fall can be attributed Tbe development of neonatal intensive care
to a combination of lower fetal and neonatal death , services bas been largely responsible for the
25r-----------------------------=========
20
~~73~--~19~7;6--~1~97~9~~~;---~~--~~~--L-----L-----1-~
1994 1997
Year
. _. - - Fetol deaths -0- Neonatal deaths Perinatal deaths
FIG URE 12.1 Fetal neonatal and . t I
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)

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" ~) -
Women's health: a core curriculum

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
(Leornlng objectives continued)
establish the date of delivery using
menstrual and ultrasound data
• counsel a woman about the risks of a
pregnancy that Is more than 42 weeks'
gestation
• describe the methods of induction and
discuss the associated risks to the mother
and fetus.
* Normal labour
Common clin ical presentations
At an antenatal clinic,nulliparous woman
0 b~
asks how long her labour will be.
A womon hovlng her first boby telephones
to soy that she Is hovlng controctlons every
3 minutes ond osks if she is In labour.
~ A multlparo arrives In strong lobour and wonts
to know If she con hove on epldurol.
Definiti on
res e antiCI-
pate outcome 0 norm a our is e vaginal
birth of a full-term, live, healthy infant to a healthy
mother. Giving birth is a most significant event 10
a woman's life. As health professionals, we must
respect the significance of labour and birth for the
woman and her partner.
When labour begins the woman will report
uterine activity that progressively increases in fre-
quency, duration and intensity until she JS havmg
regular, rhythmic contractions every 3-4 mmutes,
each lasting 60--90 seconds. This mayor may not
be accompanied by spontaneous rupture of the
membranes.
Clinical history, abdominal e~%:9~ arul..
vaginat exalIti:na4if1etermige Whecll1't lab\l!!r
haS co=enced: 1 e progress of labour is moni-
tored by the fTequency and duration of contrac-
tions the descent of the fetal head mto the pelVIS
and ilie dilatation of the cervix. Each hospital or
Attitudes
At the end of this chapter, the student
should reflect upon :
the range of women's attitudes towards birth
different women's responses to medical
intervention in labour.
care facility will have a policy that must be fol-
lowed when monitoring progress and maternal
and fetal vital signs in labour.
Ti ming
The vast majority of women will be delivered by
7 days beyond the due date, although in some
instances this will be as a result of medical mter-
venti on in the pregnancy. Approximately 7% of
babies are born be fore 3 7 weeks, and less than 2%
are born later than 41 weeks.
Mechanisms
Process
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
~daby
3. stage: delivery of the p lacenta and mem-
In the nulliparous woman, cervical shQqe~g,
known as effacem ent, is followed by dilatanon,
whereas they commonly occur together in the
multiparous w oman.
The first stage of labour can be divided into
two phases:
1. ~ phase - a gradual process of efface-
m~pd dihtatWD
2. ~ phase - from dilatation of 3 em, the
,~ ~~ ~
\/'0/
FIGURE 13.1 Cervical effocement and
di latotion in the nullipara (Based on Farquha r
& Jamieson 1997. p 55. Fig 6.10)
13 Lobo ur a nd d e livery
progress of the labour accelerates to a minimum
of 1 em dilatadOn pH Hour III the nullipara.
. The sece d stage of labour cap alsg be d~ed
mto two p es:
1.
Duration
Surprisingly the 'normal' duration of labour
remains poorly defined and hotly debated.
Difficulties arise with the definition of the onset of
labour and appreciation that the lengths of both
the first and second stages of labour do not have a
normal (Gaussian) distribution. Thus median and
interquartile ranges more appropriately describe
the distribution than parametric methods (mean
and standard deviation). The latent phase 13§\s
!found 8 hgurs on ayern ge, and adequate progress
in the active phase for the normal labour is con-
sidered to be 1 em per hour in the nullipara and
1.5 cm per hour in the multipara. The activUrlih,ase
of labour lasts on avc.raf 8 hours for tile n para
E
an:!! hours for [he wnJjparp
I e duranon of labour can be demonstrated
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-
junction with cervical dilatation and station of the
presenting part. The partogram can be used as an
aid to evaluating the progress of labour.
The duration of the second stage is influepced
by the clioice of anak esla. 1he woman with a
gooa e iduraJ bJoCk;;TI be unaw
moment ea reaches
floor and thus
lafi ~ urge to push. It is advisable to allow eXtra
timetor the head to descend (first stage) before
encouraging the woman to push. The mean d!.l.t.a-
tion of th econd sta e of labour for - .
min tan e (median 45 mins
I range 27- 7 6 mins) and 100 minutes withB.
epidural (median 82 IQ range 45-134 mins), and
fo rihe'" multipara 20 minutes without an epidural
(median 13 mins IQ range 8-22 mins) and nearly
60 minutes (median 33 mins IQ range 17-70
mins) with an epidural (Paterson et al 1992,
Saunders et al 1992).
"t
Women's health : a core curriculum
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

Management
rncrease.
. If there are correctible factors, a prolonged
lab our may progress to a vaginal delivery, or
labour may become arrested with or without fea-
tures of obstructed labour. An arrest of labour
occurs when there is no further cervical dilara-
non des ite aChievm adequate uterme acnvity
WIt oxytocin stimu an on. , of cervical dilatation (at least 1 cm dilatation).
there IS arrest of descent of the ead, progressive
caput and iii pp idlilg, and pOSSIbly me appearance
of materna! feller, tachyc~rdla and haematuria.
LaOcili"r arrest :md obstrucnon require delivery by
-
caesarean secnon.
* Acti ve manageme nt
of labour
A 26-year-old woman expecting her first baby
presents In labour at 4 em dilatation. Two hours
later, there has been no progress . . ,
Active management of labour is a concep t origi-
nally described by O'Driscoll in 1969 at the
National Maternity Hospital in Dublin. It was
designed to prevent prolonged labour and applies
principally to nulliparous women in spontaneous
labour with a singleton fetus and cephalic presen-
tation. Over time, the definition of prolonged "
labour has changed from more than 36 hours in
1963 to more than 12 hours in 1972. On aver-
age, maternal morale in labour deteriorates after
6 hours and rapidly declines after 12 hours. The
reduced caesarean and instrumental delivery
rates that resulted from this management
approach in Dublin have been a fortuitous by·
product which has prompted other institutions to
adopt active management of labour in part or
whole.
The key components of active management of
l~are :
• antenatal education
definition of the onset of labour
• one-to-one l(ersonaJ care 10 labour
routine amruotomy and early use of oxytocin
for slow progress (less chan 1 cm per hour
increase in cervical dilatation).
Antenatal education prepares the woman for
labour. In a nulliparous woman, onset of labour
is defined by full effacement and commencement
The use of a partogram to monitor progress of
labour prOVides a Visual ald for both the woman
~her care-wets. It I!n~~~ ete~tl'IO/l of clille
otaelivery as well as aertlOg sow progress.
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
escri es pro~ ess in the second stage.
re~ar vagm examrnanon is essentiaL
13 l a b o ur o nd de livery
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
(1992), have shown a significant increase in rounne amruotowy sh0rteps labgur by 1 2 hgurs
neonatal resuscitation if this line is crossed. (Fraser et al 2002). Another Cochrane review
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
lab£.ur I er 10 t ese two groups an e m ter· 5 mlOUteS an ess ostnata at
ventIon of oxYtoCin IS less sate rn a multiparous 6~ 0 nett .
\voman a due t6 lHtfeasSd riSk or titeHHe rupture. . Acnve management of labour has been prac-
In a nulliparous woman, the likely causes of tised around the world with varying success.
abnormal labour are, 10 order of GesuenS)': Some question an approach that identifies 45%
1. inefficient uterine action of nulliparous labours as abnormal, requiring
augmentation with oxytocin. While the majority
2. persistent oCCIp ito-posterior positioQ o£ the
fetus of studies of active management of labour have
3. cephalopelvic disproportion. demonstrated a shortened length of labour (circa
2 hours) and reduced rate of women delivered
Conversely, in a parous woman the ljkely after 12 hours «5%), reports of secondary Out-
ca ~e: come of caesarean section rare have been variable
1. obstructed lab o l1f
(Tabowei et al 2003, Sadler et al 2000). In South
Africa, a randornised trial showed significantly
2. ?crsi~ent occipiro-posterior position
fewer caesarean sections in those managed with
3. rnefficlenr uterlOe acnon (r~ in a multipara).
selected principles of active management of
ocin au ents inefficient contractions labour than in those who were managed expec-
and encoura es = 0 0 e eta ea , so that tantly (pattinson et al 2003). This flOding is par-
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-
para overcomes two of the most likely causes of branes was deliberately avoided to minimise the
~bnortnal bbour, but must be used with caution risk of vertical transmission of HIY.
in the multipara and gnly wbeg obstDlcred labour
has been excluded. If this measure fails, delive[Y
Summary
IS by caesarean section. The retrospective diagno- The total package as practised in Dublin achieves
SIS IS that of cephatopelvic disproportion in this the aim of avoiding prolonged labour in nulli-
labour. parous women, with the advantage of compara-
At the National Maternity Hospital (NMH) in tivel y low caesarean section rates. The application
Dublin, 63% of nulliparae were delivered in of acnve management of labour varies from place
6 hours with 93% delivered by 10 hours to place, as different centres implement selected
(O'Driscoll et al 1993). By comparison, 50% of components according to their own philosophy of
muloparae were delivered in 2 hours and 90% by labour and staffing resources.
6 hours. In 1993, the rates of caesarean sections
and instrumental deliveries at the NMH were 50/0
and 10% respectively, with 45% requiring aug-
mentation with oxytocin . More recently a
prospecnve observational study in Dublin re-
evaluated active management of labour and
found similar outcomes of a low incidence of
If;
Women's health: a core curri culum
* Operative vag ina l
delivery
Common clinical presentations
A nullipara has been fully dilated and push'ing
for 2 hours and is now too tired to continue.
A multipara has been pushing for 15 minutes.
The head Is not In view yet and the fetal heart
falls to 60 bpm and falls to recover.
• A nullipara with severe preeclampsia Is fully
dilated, the head is 3 cm below the ischial
spines (+3) and the maternal blood pressure Is
180/110. You wish to expedite delivery without
maternal effort.
Defini tio n
An oPerative delivery is an gbstGvje ipteryepry on
in the second stage o f Jahg llr t9 aSsist WJtb the bIrth
a e bab b the u f the force s or vacuum ex-
tracto r (ventoug ) whep there i§ Asru O[ & telltial
compromise to the health of the mother or e fetus.
Inc idenc e
The operative delivery rate varies significantly
depending upon the instirution, the operator and
~i
'''00 [
Sho nk [
Lock [
Shoulder [
Handle [
FIGURE 13.4 Forceps parts and some commonly used forceps (Based on Symonds & Symonds
2004, p 192, Fig 13 .16)
Maternal
• Maternal exhaustion/Inability to push because
01 dense motor blockade
• Prolo nged second stg ae
• Coexisting medical c onditions that
con fTdlndicore signihcont maternal effort,
e.g. severe preeclampsia, maternal
cardiopulmonary or neurological disease
Fetal
• Non-reassuring fetal stgWs (e.g. abnormal
cardiofocogra ph , a b ruptio placentae, cord
prolapse, acidaemla Identified on fetal scalp
sampling)
• Assistance with the birth of the second twin
BOX 13.1 Indications for an operative vaginal
delivery
,.
the patient population. Recent Australian data
for low-risk primiparae demonstrated a forceps
d elivery rate of 10.50/0 and a vacuum dehvery
rate of 6.8%.
Instrument design
The three main types of forceps used in Australia
are the Neville-Barnes, Kielland and Wrigley for-
ceps. They all have a pelvic curve and a cephalic
curve, and are designed WIth a handle, a shank
and a blade with fenestrations. The Neville-Barnes
KleUand's forceps
l. 1=:1 I
i'J e'.lille-8ornes fo rceps
13 Labou r and d elivery
• The mother-to-be has been Informed of the
procedure.
• The woman has been posltloped sultgbly
(e.g. stirrups or footplates, with the end of the
bed removed).
• Full dilatation of the cervix is confirmed,
• Ens o sem ent of the (etg' heSl,d has occurred (the
maximum diometer of the skull has passed the
pelvic inlet) .
• The membranes are ruptured .
• The b ladder Is e m pty - catheterise If necessary.
• Ania l~isla needs have been considered -
sp no epidural/pudendal block: especigllY fpr
fo~s.
• CogsjdergtjgD has b eeg glyen to episigtgmy _
m are likely with forceps than with ventouse.
BOX 13 .2 PrereqUisites for an operative
vaginal delive ry
FIGURE 13.5 Ve ntouse cups for anterior and
posterior p ositions of the occiput, trac tion cord
forceps may be J.Wid for ditea OA deJiyeWS from and tractio n handle (Reproduced with permisslo
the mid-cavity, the Wri e force s suit an outlet fro m Beischer et 01 1997, P ~ 7B, Fig 47 .10A)
deJi:£wr and the Kielland are or r eps
deliveries (Fig 13.4).
There are a significant number of different ven-
rouse cups available: metal, soft silicon, rigid plastic,
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
both OA and rotational deliveries (e.g. Kiwi cups)
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
the rubing to prevent compression against the
maternal tissues and lass of suction (Fig 13 .5).
Indi c ations and p re requisites
The indications and prerequisites for an operative
vaginal delivery are given in Boxes 13.1 and 13.2. Contrai ndicatio ns
Some contrainrucations apply for both instru-
Types of Instrumenta l delive ry ments, others for one or the o ther.
• M~ - the fetal head is engaged and the
station is less than 2 cm below the ischial Both
spines.
• Fetal Station abOye the ischia ' spines
• L~ ty - the station is at least 2 em below • Any expectation of significant cephalopelvic
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

tIl Lw.,t .
Forceps The choice of instrument depends upon the
individual circumstances of the patient, and the
Indication to avoid an episiotomy, e.g. ~
experience and preference of the operator.
anticoagulatipn
Ventouse
Non-vettex preseruations, e.g. breech/face Antenatal education should prepare
Sigii!Iicant prematurity <34 ws;e~ women for the experience of labour
and birth and inform them obout the
Complicati ons available' choices, including options
for analgesia .
The complications of force ps and ventouse deliv-
ery are outlined in Table 13. l.
Compa ri son of fo rceps
and vento use
* Prolonged pre gnancy
• The forceps have a lower failure rate.
A woman who has reached 42 weeks'
The vento use IS less likdy to cause significant
gestation, confirmed by early ultrasound,
wishes to await spontaneous onset of labour
and hove a natural birth.
A pregnant woman at a gestation of 40 weeks
and 2 days presents to the antenatal clinic. She
is very anxious being stili undelivered and
wishes to be Induced.
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
anencepJlaJJc ferus typically may not labour spon-
complications m me current pregnang': for exam-
ple, preeciame;:la, diabetes mellitus, chronic renal
taneously until 43 weeks' gestation.
disease, recurrent pyelonephritis, antepartum
The 0 er main cause of increased erinatal hae morrhage or illtrauterine growth restrlctIon.
mottali ro ongeC! Inaucnon of lebour tg betore 41 weekS; gestation
in a healthy pregnanCY confers no advantage to
mortier or terus.
.~\J.
Management options at 41 weeks:' \ ,,\t.S\
If clinical assessment at 41 weeks is ngrm a! tb~ VtJN
induCtIon of labour betore 42 weeks should be "":'in . .1A.
ol1ered to die mother. Compared to conservative ~..... ..
management with close fetal surveillance, a policy
of induction reduces the risk of perinatal death in
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
compared to nine deaths among a similar number
in the conservative group. Five hundred induc-
tions were needed to prevent one death associated
wjth prolonged pregnancy. This policy also result-
ed in a small, but statistically significant, reduction
in the caesarean section rare and a decrease in the
incidence of meconium-stained liquor.
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.
of cervix lcm or more
Farquhar C, Jamieson M 1997 Introduction to obstetrics
Length of 3 em 1-2 em Less than and gynaecology, 2nd edn. Department of Obstetrics
cervix or more lcm and Gynaecology, University of AuckJandlNarional
( effacement) Women's Hospital, Auckland.

Consistency Firm Average Soft Fraser WO, Turcot L, Krauss I, Brisson·Carrol G 2002
of cervix Amniotomy foe shortening spontaneous labour.
In: The Cochrane Darabase of Systematic Reviews
Position Posterior Central Anterior rrhe Cochrane Librar},). Online.
of cervical os Early confirmation of gestational age Available: http ://www.update-sofrware.com!cochrane.
allows accurate determination of the
Station of - 3 em -2 em Oor+ expected date of delivery. Th is Hodnett ED 2002 Continuous suppOrt for women dUring
presenting or higher or-l em minimises the risks associated with childbirth. In : The Cochrane Database of Systemaric
part prOlonged pregnancy and avoid s Reviews (n,e Cochrane Library). Online.
unnecessary induction of labour. Available : http://www.update-sofrware.com!cochranc.
TABLE 13,2 Modified Bishop score
Labour and delivery
Jo hanso n RB, M enon V 2003 Vacuwn extraction versus
forceps for assisted vaginal delivery. In: The Cochrane
the risk of perinatal death in prolonged pregnancy. References Database of Systematic Reviews rrh e Cochrane
Lib rary). Online. Available :
When managed conservatively. about SOotn of
http ://www.update·so ftware.comlcochrane.
woW deliver 4-5 days Wr 42 wee~s. Beischer N A, M acka:: EY, Colditz PB 1997 Obstetrics and
the newborn, 3rd edn. WS Sau nders, London.
au ru ie nrnulatioo for 3 ho urs b the Kilpatrick SJ, Laros RK 1989 Characteristics of normal
parmer an e sm ill 0 me em- Bo hr. U, Donnelly ], O'Connell MP er al 2003 Acti ve labor. Obstetrics and Gynecology 74:85-1!7.
bfaiieS swee the management of labour revisited : th e fi rst 1000
pri.miparous labours in 2000. Joumal of Obstetrics Leighton BL, Halpern SH 2002 The effects of epidural
and Gynaecology 23 (2) : 1 18-120. analgesia on Jabor. maternal and neonatal outcomes: a
systematic review. American Journal of Obstetrics and
Carroll D, Tramer M, Mcquay H, Nye S, Moore A 1997 Gynecology 186:569-77.
Transcutaneous electrica l nerve stimulation in labour
Induction of la bour pain: a systematic review. British Journal of Llewellyn·Jones D 1999 Fundamentals of obstetrics and
Obstetri cs an d Gynaecology 104:163-168. gynaecology, 6th edn. M osby, London.

Prenatal education
The rerurrence rate of pl:longed pregpaucv
30% after one and 40% er two previou '
looKe pr . . 15 tmpOrtant or these
women to k~ep an accurate record of their menses.
If a woman has irregular menstrual cycles, she
should be made aware of the value of early ulrra-
sound to allow more accurate estimate of the ges-
tational age and expected date of delivery.
Summary
The more accurate the estimate of the geStational
age, the lower the LPo dence 01 prolonged preg-
nancy and thus unnece l nEion Of Illad-
ve ent preterm .e ·very. It is important to rea
Chelmow D, Kilpatrick 5J, Laros RK 1993 Ma ternal and
n eon.1t~ outcomes after prolonged latent phase.
Obstetrics and Gynecology 81 :486-491.
Crowley P 1995 Elective induction of labour at 4 1 +
weeks gestation. In: Kerise M]NC, Renfrew MJ,
Neilson JP, Crowther C (eds) Pregnancy and
childbirth module. The Cochrane Pregnancy and
Childbirth Database, the Cochrane Database of
Systematic Reviews rrhe Cochrane Library). Online .
Available: http://www.upda<e-sofrware.com!cochrane.
Derbam RI, Crowhurst I, Crowther C 2003 The second
stage of labour: durational di lemmas. Australian and
New Zealand Journal of Obstetri cs and Gynaecology
31(1): 31 -36.
Dujardin S, De Schamphcleire I, Sehe H, Ndyiaye F 1992
Value of the aleC{ an d action lines on the panogram.
Lancet 339: 1336-1338 .
Lowe NK 2002 The nature of labor pain. American Journal
of Obstetrics and Gynecology 186:516-24.
Mayberry LJ, Clemmons D, De A 2002 Epidural analgesia
side effectS, co-interventions, and care of women
during chiJdbirth: a sysrcmatic review. American
Journal o f Obstetrics and Gynecology 186:581-93.
Norwitz ER, Robinson ]N, Challis JRG 1999 The control
of labor. The New England Journal of Medicine
341 :660-666.
O'Dri.scoll D, Meagher K, Boylan P 1993 The active
management of labour: the Dublin experience, 3rd
cdn. Mosby, St Louis.
Paterson CM, Saunders N St G, Wadsworth J 1992 The
characteristics of the second stag. of labour in 25,069
singleton deliveries in the North West Thames Health
Region, 1988. Journal of Obstetrics and Gynaecology
99:3:-7- 380.
·.
Women 's health : a c ore curriculum
Patti nson RC, Howanll GR, Mdluli W et al 2003
Aggressive or expectant manage men t of labour:
a randomised clinical trial. BJOG: an
International Journal of Obstetrics and
Gynaecology 11 0:457-461.
Peisner DP, Rosen MG 1985 Latent phase of labor in
normal patients: a reassessmeoc. Obstetri cs and
Gynecology 66:644-648.
Riley M, Halliday J 2001. 2003 Births in Victoria
1999-2000. Perinatal Data Collection Unit, Victorian
Government Departmem of Human Services,
Melbourne.
Robern CL, Tracy 5, Peat B 2000 Rates for obstetric
in tc rvt: lltio n ~Ill ong priva te and public patients in
Australia: population-based descriptive srudy. British
Medic,l Journal 321:137-141.
Rosen MA 2002 itrous oxide for re lief of labor pain: a
systematic review. American Journal of Obstetrics and
Gynecology 186:5110-226.
Sadler LC, Davison T, McCowan WE 2000
A r. ndomised controUed trial and mero-analysis of
active management of ;"bour. BJOG 107: 909-915.
Saunders N Sr G, Parerson CM, W.dswonh J 1992
eomra! and maternal morbictiry in relation
to the length of the second scage of labour.
Questions
1. Normal active labour is associated
with wh ich of the following maternal
physiological changes?
a. Heart rate increases, respiratory
rate Increases and peripheral
vascular resistance falls.
b . Heart rate , respiratory rate and
o cardiac output are unchanged .
Cardiac output , blood pressure and
catecholamine secretion all rise. \/'"
d . Cardiac output and catecholamine
secretion increase, blood pressure
foils.
e. Oliguria.
Journal of Obstetrics and Gynaecology
99 :381-385.
Simkin p, O'Hara M 2002 Nonpharmacologic relid of pain
during labor: syStematic reviews of five methods.
American Journal of Obstetrics and Gynecology
18 6:513 1- 159.
Smith CA, Cyna A./VI, Crowther CA 2003 CompLementary
and alternative t herapi~ fu r pain managem ent in
labour. In : The Cochrane Database of Systematic
Reviews (The Cochrane library)_ Online.
Avai Lable: http://www.upda te-softw.re.com/cochrane.
Symonds EM, Symonds 1M 2004 Essential obstetrics and
gynaecology, 4th edn. Churchill Livingstone,
Edinburgh.
Tabowei TO, Obora VO 2003 Active management of
labour in a district hospira! setting. Jo urnal of
Obstetrics and Gynaecology 23(1):9-12.
Vacca A 1992 Handbook of vacuum extraction in obstetric
practice . Hodder and Stoughton, Lo ndon.
Wucocks ], Philips K 1997 Obstetrics and gynaecology.
Churchill Livingstone, New York.
Wo rld Health Organization 1994 Maternal health and safe
motherhood programme. World Health Organ ization
partograph in management of labor. Lancet
343:1399-1404.
2. Which one of these statements about
analgesia in labour is correct?
0 EPIdurai analgesia may be
associated with a 10w-grad V
maternal pyrexia .
,.t5. Nitrous oxide reduces uterine activity.
c. Epidura l analgesia does not affect
the rate o.f instrumental delivery.
iT." Non-pharmacolog ical methods of
pain re lle.f such as baths , massage
and continuous maternal support
have not been shown to have any
effect upon maternal pain scores .
L One-to-one care in labour is
associated with an Increase in
analgesia reqUirements .
3. Which one of these statements about
normal labour is correct?
r In efficient uterine action .
p. The average duration of the latent
phase of labour Is 2 hours.
tt.'For the primigravida, adequate
pregress In the active phase of
labour is cervical dilatation of
2 cm/h .
/ - The average duration of the active
phase of labour for the multigravida
Is 10 hours.
@ he average duration of second . /
stage of labour for the null ipara '"
without an epidural is 60 minutes.
e. The purpose of the parto ra h is to.
record uterine contractio~s . p~
4. Which one of these statements about L.
prolonged labour is correct? .,
6:"w
~, he action line on the partogram
prOVides a visual cue for abnormal""'V
~
rogress of labour. \/
An abnermal pelvis shape is the
m ost likel y reason tor prolonged
labour in the nul lip ara .
c . Fa ilure of descent w ith p rogressively
Increasing caput and moulding is a
feature of normal labour.
d. The. use of o xytocin a ugmentation is
Similar for the nullipara and the
multipara .
~ The most common cause of slow
p rogress in a nullipara is InefficlenW
uterine action . V be performed .
Which of the following statements
about active management of labour
are correct?
@
a . The principle aim is to reduce the
caesarean delivery rate .
EarI Y amniotomy allows visualisation
of the liquor and augments labour./
c. The. action line on t he partogram
Indicates a cervical dilatation rate
of 2 cm per hour.
13 Labour a nd d el/very
G
/
The most likely reason for slow
progress in a nulliparous labour Is
b ' <ne-te-one care in labour has been
~own to reduce the duration of
labour. ;.
6. Which one of these statements obout
operative delivery is correct?
a . Five per cent of low-risk nulliparae
require an Instrumental deli very.
b . Wrigley forceps can be used for a
rotationa l delivery.
C)M ed ical conditions affecting the
mother's abi lity to push are an ~
indication for a forceps delivery.
d . In a low-risk nullipara, an
Instrumental delivery should be
conducted atter 30 minutes of
pushing.
e . The use of the ventouse Is
contraindicated for rotational
delivery.
7. Whic h one of these statements about
operative delivery is correct?
a. A forceps delivery can be
conducted appropr iately withou t
any ana lgesia .
b . A forceps delivery is safe when the
fetal head Is above the iSChial
spines .
0,:he membranes must be ruptured
before an instrumental dellver:'''~
l,J'"'"
d . A vente use is the instrument of
cho ice to. deliver a fetus of less than
34 weeks' gestation .
e . The vento use is associated with
more maternal trauma than the
forceps .
8. Which one of these statements about
operative delivery is correct?
a. Forceps and ventouse have the
same maternal and feta l
complications.
Women's health: a cO'a c urr ic u lu m
(9The vento use requires less analgesi q /
at delivery and is associated with /
less pain postpartum.
c. The ventouse may be used for
delivery with a face presentation .
d. There is no limit to the number of
traction efforts that can be
attempted with a ventouse delivery.
e. Episiotomy 15 unnecessary with
9.
forceps delivery.
A 28-year-old woman with uncertain
menstrual dates presents at 41 weeks'
gestation, as determined by ultrasound
assessment at 20 weeks. Her
pregnancy appears to be progressing
normally. Which of the following
statements are correcn
I'6'\The pregnancy couJP be at 42
\.7 w eeks' gestatio V
6)rhe pregnancy may not be post-date.
c. Urgent induction of labour 15
advisable.
tdl The risks of prolonged pregnancy
\./ a nd induction of labour should b eJ
discussed with the woman.
~ Conservative management may be
considered, with close surveillancV
until spontaneous onset of labour.
10. Which of the following statements
about inducing labour are correct?
td:\Cervical ripening with prostaglandin
V may be required for a c e;.VIX with a
Bishop score of 3. V after 42 weeks' gestation.
b. Prostaglandin-ripening of the cervix
is safe in grandmultiparae.
0 · mniotomy is an effecti~ method
Vof inducing labour. V Edited b y lucy Bowyer
0 .terine rupture is a risk assocjpted
with induction of labour. ../
G Electronic fetal monitoring is
recommended for women on
(\1.,&
'
'I oxytocin infusion
11 . tephanie's LMP was 01.02.2004. The
first trimester ultrasound m e asurement
of fetal crown rump length (CRL)
suggested a fetal gestational age of
8 weeks and 6 days and a D e stimated
date o f delivery (FOP) Of 12 11 04. A p-
later morphology scan su r ested a
gestational a~e of j 8 wee s a nd 6
days and anbb of 16.iT .04. Wh ich
of the ,o iiOWlilg Sldi Ql ii t§nts are
c orrect?
~ aegele's rule gives on expected V
~date of delivery of 08.11 .04.
I ® :he second ultrasound Is more
accurate than the first for 'f-
estimating gestational age.
( 9he first ultrasound examination
supports Stephanie's menstrual dotes.
@ Stephanie should be offered urgent
Induction of labour if undelivered
on the 10.11.04.
& here is Increased perinatal ._. . /
mortality if Stephanie is undelive ~
"i-
01 ~ /l \ ,
l2. (\I ... V
* 14
Specific obstetric emergencies
Nadia Badawi, Michele Batey, Jonathon Morris, Michael Nicholl
Learning objectives
Knowledge
At the end of this chapter, the student
will be able to:
Antepartum haemorrhage
discuss the aetiology and differential
diagnosis of antepartum haemorrhage
describe the assessment and
management of a woman presenting
with antepartum haemorrhage
outline the emergency management of
a patient presenting w ith life-
threatening antepa rtum haemorrhage
Primary postpartum haemorrhage (PPH)
define primary postpartum
haemorrhage and indicate Its
incidence
summarise the physiological
adaptations of normal pregnancy in
anticipation of PPH
critically appraise active and
physiological management of the third
stage of labour
list the risk factors for PPH
describe the emergency management
of severe PPH
Umbilical cord prolapse
• list the conditions predisposing to cord
prolapse
describe the signs that may indicate a
cord prolapse
describe the effect of cord prolapse on
the fetus
outline a management plan for the
patient who presents with cord prolapse
Fetal malpresentations
describe the possible fetal
malpresentations in labour
discuss the complications of fetal
malpresentation
discuss the management of each
malpresentation
Shoulder dystocia
describe the clinical presentation of
shoulder dystocia
list the risk factors for shoulder dystocia
• describe the complications associated
with shoulder dystocia
outline the appropriate management of
a woman with shoulder dystocia.
S kills
At the end of this chapter, the student
should learn how to:
take a relevant medical history from a
patient presenting with antepartum
haemorrhage
(Continued over)
It¥
 Women's health: a cor e curri CU!l..!m
(Learning obiectives continued)
describe the general condition of a post-
partum woman and accurately record
postpartum blood loss , blood pressure and
pulse rate
palpate a postpartum woman's abdomen,
and accurately record size and tone of the
uterus and any deviation from the midline
• perform emergency resuscitation measures
In a simulated major antepartum
haemorrhage.
*
Antepartum
haemorrhage
Common clinical presentations
A patient presents In the third trimester of preg-
nancy with a small amount of vaginal bleed-
Ing ofter sexual Intercourse.
A patient is brought In by ambulance at
36 weeks' gestation, having hod a massive
painless vaginal bleed at home. She Is
. hypotensive and tachycardic.
A known hypertensive patient presents at
32 weeks ' gestation with abdominal pain and
rigidity, and vaginal bleeding,
A patient has recurrent moderate vaginal
bleeding throughout the third trimester of
'. pregnancy.
The placenta! site is where the conceprus
isp1ants [nCO the endometrium. ImptaTIta60n
Attitudes
At the end of this chapter, the student
should refiect upon:
the need to appreCiate maternal risk factors
for obstetric emergencies and to prepare a
plan of management before labour
the need to call for immediate assistance
in obstetric emergencies
• the impact of primary postpartum haemorrhage
on the mother-infant relationship.
usually in the upper two-thirds of the uterus, more .'
often posteriorly. At 20 weeks' . n the
centa is low-l in in a rm(lmatel 5
b Y term slruanon as resolved in 90%
o~ (Comeau et at 1983) . this apparent pla-
cental migration is due to the differentia! growth
of the lower uterine segment compared with
the remainder of the myometrium. The blood flow
through the placenta is enormous, reaching
500 mUmin at term. Following delivery of the
baby, the uterus contracts and rapidly decreases in
size, leading to separation of the placenta.
Placenta praevia
Placenta praeyia is implantation of the placenta in
thelower segment of the uterus. I he wadence IS
Un 100 blctfjii. Rli[ fiicwp; lIlclude previous cae·
sa~an seaioo, in vitro fertilisation, mUinpancy,
maternal age oyer b years, and t~ an? ~e
USe The most important of these IS prevIOus cae-
~an section. After one caesarean section, the risk
is reported to be 1-40/0, while after four or more
caesarean sections it is 10% (Clark et a! 1985).
Four types of placenta praevia are described
(Fig 14.1):
• 11.ES.I (marginal) : placenta encroaches on
JOWei e t t rea e mte
• ty~ (minor): pia
os;out does not coyer it
• ~ (major): placenta partially coveye
in~os
~ (major): placenta completely covers the
15
----
internal os.
14 Specific obste tric emerce ncies
corticosteroids at less tbag 34 weeks' gestation] in
case-premawre deJiyeqr js reTlired .
If bleeding settles with expectant management,
the patient should be observed in hospital for at
least 48 hours. Approximately 60% of patients wjl!
have wgher bleedio8 after the initial episode.
Traditionally patienrs were observed in hospital for
the remainder of the pregnancy, but more recently
studies have shown no difference berween inpatient
and outpatient management in terms of materna! or
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
Presentation cl I ve a e one and the
- mean 0 rerum to the hospital imme
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
cte"1t9
bJee '
yrsifue contractjORs or]jpiihdlty. the
usually stops spontaneou y
re omes out the cy.
Bleeding is thou r to e assoaated with the
deve/opment and thinning of the lower uterine
segment, which results in disruption of the placen-
tal attachment.
Diagnosis
If the materna! and feta! conditions are stable,
ultrasound should be performed. Transabdominal
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
praeVla greatly depends on the gestation at which
the ultrasound is performed. Digital va .
ina ' uld .
prae;ia has een excluded by ultrasound.
Management
cen u eru .
e
Th~ost common presentation of abruptio,>is
s
mild wana! bleediog, with or without ptenQr
a! contractiorIS and a normal fetal heart rate, which
occurs WIth partial abruptiQIl. Major placental
aDrupnon may aJsOi£{ese~t with DIe. In such cases
.;;=?i....."lr4r:;,.:;...;~;.:;::;:;::;:,7I'~d, even to the em nt the sigrIS are va iilleeding. bleeding from
':.:::~.w!;UI.~~~~Wi1~ in early gestations. vpnep uncture sites and brujsing. Fulminant DIe can
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;

women's health: a co re cu rriculum
FIGURE 14.4 Cord prola pse (Ba se d on Pi tkin et
al 2003, p 62. Fig 2)
soon as they are detected by fetal hean auscultation should remove his/her examining hand from the
or electronic fetal hean monitoring.
There are a number of ide tifia
for umbilical cord pro apse. These include preterm mortalitffIOom cord prolapse may
prelabour rupture of the membranes, malpJ'benta- 30%.
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
ptacenta. these coiidinons predispose to cor pro-
lapse, since the presenting pan is not closely
applied to the cervLx. When the membranes rup-
ture the umbilical cord can slip past the presenting
part of the fetus and present at the cervix, or actu-
ally prolapse into the vagina. It is estimared to
occur in approximately 1 in 800 deliveries.
Management
gen ca ere IS no e ective
reglOn anaesthesIa, a rapid general anaesthetic is
necessary. Senior neonatal personnel skilled in
resuscitation should be in attendance. The person
responsible for preventing cord compression
vagina only after the baby has been delivered.
Even with prompt obstetric manal?~~: ~e
bUi ljiPh ;s
* Malpresentations
Expecting her third baby, a mother complains
ot excessive tetal mobility. Upon examination,
the tetus Is in a transverse lie.
When examining a woman In labour. a mldwlte
is concerned that she does not palpate the
tetal head as the presenting part.
~resentation of the ferus (Fig 14.5) ~
~ed as any tetal presentanOp gther tban vertex.
The mOSt common malpresentation is the breech
presentation. However, other abnormal presenta-
tions include transverse lie, shoulder presentation,
fac e presentation, compound presentation and
brow presentation.
Malprsrenratip ps put the fetus at increased risk
of inumber of com lications. These include ~
panum e ess, perinar death and umbiltcal
cor pro pse. The moilier who has a ferus in m.al-
presentation is more til<e\Yto be subject to operanve
NO/mal Molposillon COP)
Me'presentation (8res:::h) ~Q/pr e.sen to r1on
fIGURE 14. 5 M alpresentotio n and malpositio n
(B ased on Pitk in et 01 2003, P 53 , Fig 4)
Breech presenta tion
Breec~ presentation happens in approxi mme ly 3%
of delivenes at term, but is more common in
prcterm than in term labour. It oc~ wbeg the
fetal buttockS present III the birth canal, and may
be further classified as:
• frank (extended) breech: the fetus has flexed
hips and extended knees
• complete (flexed) breech: the ferus has flexed
hips and flexed knees
• footling breech: the fetus has one or both hips
and knees extended so thar the feet of the fetus
are presenting.
14 Spec iti c o bstetric eme rgencies
pressure on e via a en.
T s proce ure should be performed in hospital
with the addition of uterine tocolysis. External
cephalic version successfully rotates a breech to a
cephalic presentatlon in 40% of nulliparou s
~ and 80% of multiparous women. It should
be performed III a cen tre that bas the resourcesro;
Immediate caesarean section ill case ot fetal dis-
(StIoufdlH)
tress dun ng [he procedure. 1he morbidIty associ-
ated With thiS procedure Is low.
. SometilDes vagmit breech delivery occurs
eIther because of maternit preference or the diag-
nosIs of breech presentation is not made in suffi-
cient time to perform a caesarean section. In these
instances, vaginal breech delivery should be per-
formed by senior obsretric staff, with paediatric
staff ill attendance. An3Pisiotorny is ysually per-
formed. The legs, bUttocks and abdomen are
allowed to deliver spontaneously. The shoulders
and arms of the fetus may be delivered by rotation
of the fetal trunk. Following the delivery of the
shoulders, the fetal head should be delivered by
fleXlon ill a controlled fashion either with the use
of forceps or manually.
Transv e rse lie
A transverse lie occurs when the long axis of the
fetus is perpendicular to that of the mother. W~
the ferus IS !P a rragsyerse~~ ~ ':,n~ ~~~
viiiiillly. If labour isaUow,;a ;n:;;;m; ;;h a
ferus in a transverse lie after rupture o~ ~e mem
branes, either te umbilical cord may prolapse Qr
me fetal shoUl er may become firmly impacted in
the maternat pelVIS. 1£ attempts to perform a
versIon of ilie ferns to a ton@tudiriat lie WIth a
cepfullic presentation are not successtul, a caesar-
ean section IS necessary 10 order to deliver the ferus.
1'4
Women's health: a core curricu lu m
a. Menta-anterior - delivery possible
FIGURE 14.6 Face presentation (Based an Pitkin et 01 2003 , P 53 , Fig 5)
Face/brow presentation
A face presentation occurs when the fetal head is
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
the feral face presents, the chin, mouth and eyes
are palpable. Fetuses with a face resentati.
b del ivered va u back into the birth canal. The chi n does not
s~,
1 n a brow cresentation (Fig 14.7), the fetal
head remams between full extension and full flex-
ion so that the biggest diameter (the mento-vertex)
presents. A brow presentation is usually diagnosed
by vaginal examination only when labour is well
established, Under most circumstances, a v~al
FIGURE 14 .7 Brow presentation (Based on
Pitkin et 01 2003, P 53, Fig 6)
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
b. Menta-posterior - delivery Impassible fdiE-rrom the symphysis pubis. Gentle down-
ward traction should be applied [0 the fetal
head together with these manoeuvres .
2. Should these measures Dot result ig deHyw:- of
the baby, the accoucheur should reach t te
delivery of a persistent brow oresentation is not the 0 e erus in an
po~,b1s. and a caesarean section is requjred. -
.~~~~~~~~~~w-
* Shou ld er dystocia
3. of
After d elivery of the fetal head, the shoulders 4.
do not descend and the fetal head is retracted Yic
clear the perineum.
If Done of the above manoeuvres bays i'ccPIfl-
pHshed delive~ an attem~t can be made to ~­
Ma nagement erately fiam Jr ~be d a",c1 gt tIle fetuS by o r =g
DiagnosiS the anterior clavicle a~t the maternal sym-
Shoulder dystocia is an ob tetric emergen8', It has phYSIS pubis. OccasIOn y, wnere noneOf the
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
placenta previa and deli very outcome. Obstetrics and
• shoulder dystocia with a previous birth Gynecology 61.577-580.
"# I
Women's health: a core curriculum
Farquhar C, Jamieson M (eds) 1997 lnrroduction to
obstetrics and gynaecology, 2nd .dn. Department of
Obsterrics and Gynaecology, University of
AucklandlNationa! Women's Hospital, Auckland.
HoErneyr GJ, Hannah ME 2003 Planned caesarean section
for term breech delivery. In: The Cochrane Database of
Systematic Reviews 3 (The Cochrane Library),
CDOOOI66. Online. Available: http ://www.update-
software.com/cochrane.
NSW Health Department 2002 Framework for prevention,
early recognition and management of postparrum
haemorrhage (pPH). Circular 2002199, 7 November.
Sydney.
Questions
1. Which of the following is most
characteristic of placenta praevia?
a. severe abdominal pain
b. disseminated intravascular
coagulopathy
c. Intrauterine fetal death
0 painless vaginal bleed
e. small bleed at the time of rupture of
membranes.
2. Which of the following should not be
part of the initial assessment of a
patient with antepartum
haemorrhage?
a. abdominal palpation
~ Vaginal examination
c. ultrasound
d. coagulation stUdies
e. cardiotocograph.
3. Which of the following is true of
primary postpartum haemorrhage?
a. Blood loss postpartum is usually
overestimated .
b. Primary PPH Is a rare obstetric event.
~ imary PPH is sti ll a major cause of
U aternal mortality.
14 Speci fic obstetric 6' m ergencle~
Pitkin J, Beattie AB, Magowan BA 2003 Obstetrics and
~undal pressure helps to deliver the
gyn.tecology - an illusrrated text. Churchill e. is not considered an obstetric
Livingstone, Edinburgh. emergency.
~ abY.
Prendiville WJ, Elboume D, McDonald S 2002 Acrive
6. Which of the following is true of
versus expectant managemem in the third stag!:: of
shoulder dystocia? 7. Which of the following Is true of a
labour. In: The Cochrane Database of Systematic malpresentation?
Reviews 1 (The Cochrane Ubrary). Online. Available : a. From the time of delivery of the fetal
http://www.update-software.com/cochrane. a. It decreases the chance of
head to delivery of the fetal body caesarean section.
15 minutes can elapse before the'
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.
trial of inpatieot vs o utpatient expectant managem ent. b . houlder dystocia Is more common
American J ouma! of Obstetrics and Gynecology In mothers with diabetes mellitus. c. A breech presentation means the
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.
d. Primary PPH does not occur with
caesarean section.
e . Primary PPH can occur anytime in
the first 6 weeks postpartum.
4 . Which of the following is true of
primary postpartum haemorrhage?
~rimary PPH cannot be prevente o!.
b. Primary PPH is most ef/ectively \"
prevented by the expectant
management of the third stage of
labour.
~ ISk reduction can be achieved by
the routine use of prophylactic
oxytocic agents.
d . Primary PPH Is always characterised
by hypotension and tachycardia.
e. Primary PPH does not occur as long
as the uterus is well contracted.
5. The management of established
primary postpartum haemorrhage:
a . always involves blood transfusion
and the use of other blood products
b . ideally Involves colloid solutions for
the correction of hypovolaemla
c . does not involve inspection of the
lower genital tract
rd't: onslsts of initial assessment and
'-.)reatment followed by more dire cted
in terventions
*15
The newborn
Paul Craven and Nadia Badawi
Edited by Lucy Bowyer
Learning objectives
Knowledge
At the end of this chapter, the student
w ill be able to:
describe the cardiorespiratory changes
that occur in the transition from fetal to
neonatal life
describe the care of the newborn in the
first 48 hours
discuss the problems of the premature
baby
describe the features of Down syndrome
outline the immunisation schedule
planned for the first year
describe the neonatal screening tests
discuss the impact of the newborn on
the family and community.
Skills
At the end of this chapter, the student
sh ould learn how to:
• assess a newborn baby 's Apgar score
• perform an examination of the newborn
accurately weigh and measure the
newborn
discuss Immunisation schedules and the
use of growth charts v,. ith parents
• perform neonatal resuscitation and
examination on a mannequin.
Attitudes
At the end of this chapter, the student
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
Common clinical presentations
You ore osked to perform 0 routine
doy 3 check on 0 neonote before dlschorge.
A term boby born by emergency coesorean
section hos 0 resplrotory rote of 80 breoths per
minute at 1 hour of oge.
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.
Definitions and problems
Of around 245,000 babies born in Australia each
year, the majority are born at term (37-42 weeks'
gestation). Approximately 7% are born prema-
turely at less than 37 weeks' gestation and 1.5% at
less than 32 weeks' gestation. A baby born at more
than 42 weeks' gestation is described as post-term.
The average term bab wei 3500 is 5
Ion and
Changes to the
cardiorespiratory system
15 The n ewb orn
Head 33-35.5 em In
circumference. Moy be length 51 cm
covered with lanugo (fetal Weight 3.5 kg
hair) which will c ome out.
+--____ Eyes dry. The newborn boby
seldom weeps.
Sclero Is otten blue o f birth.
Pulse (apex beat)
120-140/mlnute
Feeding Stump of umbilical cord fled
or clamped. It should
Early establishment of feeding after delivery is obliterate In 3-4 days, and
desirable, and breastfeedin& is most successful if separate in er-9 days.
mother-infant suCktID~ be~ W1ctUn an hour of" In the moles, testes should
bIrth. Breascteeding s oule gm III the delivery have descended into the
swre and then be continued and supported when scrotum by term .
the mother is moved to the posmatal ward.
limbs are worm and well
Although breastfeeding is optimal for both mother rounded. The whole skln
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
generate heat. Wants lose heat from evaporation,
condUCTIon, convection and radiation. ~
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
CH t..f/... '\
Apgar scores
Ductus arteriosus 0 mentation of features is essential for accurate
Colour White Blue
Heart rate Absent <100
left lung
Respiratory None Irregular
effort
Tone None Reduced
Reflex Irritability None Reduced
TABLE 15.1 Apgar scores fo r neonates
Pulmonary trunk
+-----Heart
-1'--- - - - - Aorta
Examination of the neonate
~: i dney All newborn infants admitted to either the neona-
tal nursery or the postnatal ward require a thor-
ough postnatal examftnon. ThiS 15 r~
performed on day 3 ~ life and aims to Identify
cornmon patholOgies 10 the newborn period. Of
major concern are ductal dependent ~a rdiac
2 ns ,. dysplastic hips, SPLnaJ anomalies and
anogerutal anomalies. There are a multimde of
other common anomalies that should be identified
and managed appropriately. To identify anomalies
accurately, a thorough systematic approach to
newborn examination should be taken. This
includes:
Internal Iliac arteries
• 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
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
• palpation gf the hard aDd 59 ft ra'aIe
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
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
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
and resuscitation. cO,me a e III ant an cal
(Fig 15.4)
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~_
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
uated 1 minute after birth and the Apgar score currently a strategy to develop a program of
the infant on an afpropnate cenrile chan.
recorded in the notes (Table 15.1). The rFtuation mandatory ttaming for those involved in the care
. If a number 0 anomanes are Identified in the
is~peated every 5 mmutes until e IIlfant of the newborn.
mfant, this raises concern over a syndromic or
15 Th a n e w born
genetic cause of the dysmorphism. Thorough docu-
Pink
diagnosis and effective communication with genetic
specialists.
>100
Regular Down syndrome
Normal
Normal Reno. t presents WI lOcreasmg equency as
maternal ;t:e mcreases. An IIlfant born with
Down synome may be recognisable by certain
characteristic fearures. These should be identified
by the day 3 ch«ck. Such fearures inclUde ~_
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
for making a diagnosis and for further investiga-
nons of the aSSOCiated morbiditie of Down syn -
dr~e, which mdude:
• hearing deficits - 60-80%
• co!!S,eruta! hean disease - 40-50%
• intesonat abnormalities (especially duodenal
atresIa) 30-34%
• cataracts - 3%
• hFyroidism - 15-20%
at antoaxJal instability - 15%.
Other COrnmon syndromes identified in the
neulborn period include Edwards' syndrome (tri-
somy 18), Patau's syndrome (trisomy 13), and
velocardiofacial syndrome (a micro deletion of
chromosome 22).
Newborn screening
The newborn screenm test is desi
for tr ata e etabolic d '
New om screening tests are free ut not compul-
sory. Each year the Newborn Screening Program
detects about 90 who need urgent assessmem and
treatlnenr.
Common conditions that are screened for are
pbdJJIketonun~
rol m and ~snc
J!ky), con~enital hxoothy-
rOSIS. PKU IS a rare condition.
If it is detecte by newborn screening and the baby
IS given a diet low m phenylalanine normal growth
and development will Occur. Untteated PI<! I can>
es severe neurolOgical impairment. Co~
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
W g'
OCQ1TS in 20%of infant:; horn at less than
10 weeks' gestarjon (Disability Online 2004) and
can have devastatin neurolo· cal conse u ces,
their severity eing equ to t e seventy a j)i
all infants born at less than 30 weeks' gestation,
ru:ZO% Will have cerebral ¥ilf, up to 5.Q1!uyill
have a flnecific learnwm diffi ty, 1% will 6eregis-
-
tered b· d and 5% . be deaf.
Taki ng the baby home
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
guide, parents of preterm infants are told to expect
their baby's discbarge to coincide roughly with the
initial due date. Te . annal! remain in hos-
pital between 6 hours and 1 we
e amv a any t in the home is onc of
the most profound changes to lifestyle that a family
will ever experience. Problems the parents may have
to cope with include sleep deprivation, breastfeed-
ing dilemmas and society's attitudes to this, financial
consrraints as one partner often ceases working,
posmatal depression and sexual diffirulties.
Suppou for t h e faqlily once they have been dis-
charged from hospital is supplied by a nlWlber of
services. Community midwjxe5, co=unirv health
c~ and gegeral practitioners provide excellent
support and pnmary care tadlities for these families.
After cfucha[ge, jt is recQmmended that the bahy be
reviewed at the early childhood cenerd; whicb will
often orgaruse a home visit WIthin e fust
wee a owmg e om OSplt . The gen-
er praCtItioner proVl es primary health care for
both the mother and the baby. .All newly discbatged
Qu e sti ons
Complete each statement w ith the correct
answer.
1. A neonate :
a . is premature if born at 37 weeks'
gestation.
15 The newborn
.~ ve
~£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:
~o/mln.
a normal respiratory rate of
noted in the parent-held health record, Subsequent a. will mostly surVive at 24 weeks'
consultations, health checks and vaccination sched- gestation.
G are susceptible to hypothermia.
ules are also recorded in the parent-held record. b. are unlikely to develop
intraventricular haemorrhage.
./
c. develop jaundice secondary to
Parents should be advised against phototherapy.
smoking in the home to minimise the
risk of neonatal lung problems and
sudden infant death syndrome.
References
Apga r V 1953. A proposal for a new merhod of eV:1l u.a tio n
of the newborn infant. Current Researches in
Anesthesia and Analgesia 32:261-267.
Disability Online 2004 Premature babies.
Available: http://www.disability.vic.gov.a ui
dsonlineidsartid es.nsflpageslPremature_babies.
H anretty KP 2003 Obstetrics illustrated, 6th edn. Ch urchil.l
Livingstone, Edin burgh.
Llewellyn-Jones 1999 Fundamentals of obstetrics and
gynaecology, 7th edn. Mosby, London.
NHMRC 2002 The Australian Standard Vaccination
Schedule 2000-200l. In: T he Australian Immunisation
Handbook, 7th edn. National Heal th and Medical
Research Council.
NS W Department of Health 200 1 New South Wales
mothers and babies 200 0. NSW Departmen.t of Health
(public H ealth Division), Sydney.
Pitkin JP, Pe.artie AB, Magowan BA 2003 Obstetrics and
gynaecology. Churchill Livingstone, Edinburgh.
b. is macrosomic If the baby weighs
2500 9 at term.
k ' ls premature If born at 32 weeks'
V gestation .
d. w ill only feed several hours atte v
birth.
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

At the end of this chapter, the student
will be able to:
Normal p uerpe rium
• describ e the physiological changes of
the puerperium
• discuss the establishment of successful
breasHeeding
describe the assessment of the mother
before discharge
oulline the role of the 6-week
postpartum health check
Care after caesarean delivery
list the common complications of
caesarean section
• describe prophylactic interventions to
minimi se these complications
discuss the management of pregnancy
follow ing caesarean section
Prob lems of th e puerperium
• define puerperal p yrexia
list the risk factors for development of
pu e rperal sepsis
• list common sites of infection and
oulline management of each infection
( PPH)
define secondary postpartum
haemorrhage and indicate its
prevalence
list the common causes of secondary
PPH
oulline the management options for the
c ommon causes of secondary PPH
Gen ital tract trauma
• list the causes of gen ital tract in jury
describe the d ifferent types and
degrees of episiotomy
discuss the ro le of episiotomy In
childbirth ,
Skills
At the end of this chapter, the student
should learn how to :
• assess the amount of vaginal blood loss
and a woman 's haem adynamic statu s
counsel a mother before discharge
about her own health and caring for
the baby
palpate the postpartum uterus and
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
longer palpable abdominally. By 6 weekS the
(Learning objectives continued)
uterus has returned to close to "itS pre-premant
s.s. The term uteru we ighs approxImately
Attitudes moo g, but involutes to 50-60 g by 6 weeks post-
At the end of this chapter, the student delivery. Uterine contractions under the influence...
should reflect upon: of oxytocin are ohen paiIlfui 6Jterpains) and may
rt: q ~e aiia1g§@.
the sociocultural Influences on childbirth The mtemar 0 of the cervix is closed b the
and breastfeeding
sec e vagJna, gaments a e uterus,
the impact of puerperal Illness on the muscles of the pelvic floor and separated rectus
experience of childbirth muscles return to close to their pre-pregnant state
the gravity of serious postpartum with time and exercise. The decidua is shed aDd
haemorrhage. appears as lochia (postpartum blood flow). Lochia
consists of blood; leUI<o es and dwaual "Fa;-
m_ . . y ng t oehia rubra) for 3 or 4
days, changmg over the next 10-12 days to pale
brown (lochia serosa) and finally to yellowish
their family doctor. Pelvic floor exercises assist in
the healing and reduction of pain.
Cardiovascular system
In the first 24 hours, the mother's baseline pulse
rate drops b,' about 10-15 bpm and her tempera-
ture may be slightly elevated. This is investigated if
it persists or becomes significantly elevated. Blood
volume decreases and viscosity increases to pre-
pregnant levels. Smooth muscle tone of vessel
walls improves and cardiac output reduces. There
is an increase in the leukocyte count during labour
and in the first 24 hours postpamun. Evaluation of
the haemoglobin concentration is important if
there has been significant postpartum blood loss.
The physiological, hyp ercoa~ble state of preg-
nancy persiSts u to 6 wee 0 artum and

* 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

A woman has delivered her first baby. She
enquires about the physica l changes she
can expect to experience over the next
6 weeks.
The puerperium refers to the 6 weeks durin
w ' aw siolo .call retu
pregnant state. These c t es are a result of the
withdrawal of pre~CY OnTIones. The puer-
perium connnues t eslgnihcant tranSIUOn that
pregnancy has begun. For many couples, it is n~t
until these early days and weeks after theIr baby s
birth that they begin to fully understand their new
role as parents. . '
The midwife is the primary care-gJver durmg
the early puerperium, and the family medical prac-
titioner supports later puerperium care. For
women who have had a homebirth, a IDldwife will
visit them each day for about 10 days. If a woman
has delivered in hospital or in a birth centre, the
length of stay will range from 6 hours to 5 days,
with the majority o£ wo wen gging hgrne 3 days
after birth. -
~
itor the rocesses £ o re ric ioyo pn rnlli-
main aims of pos~artum ~ ~ r~ tp
establi;h
breas etsg an assist the development 0 Qar-
ennng s s and abiIines.
2 weeks, but it may take up to 6 weeks at the for-
mer site of the placenta. In general! postpartum
blood flow ceases by 4-sn weekS po~artum
(medJaO 30 days). I fie totat volume IS about 250
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
infeC1'lon Or retamed proJucrs of conception.
Ovarian func tion
Ovarian function returns after about 10 weeks to
die non-lactating woman but may return as earlY
as W weekS p&EpaHum. In lactating women, 1 Breastteedlng
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
~--", 2 4 weekS postpartum as~lst e esta ent 0 reas ee ng. ~
________ . , milk meets aU the infant's nutrWlllliLll"&.,ds in the
----14
_ _ _+6
_ _-+8
Perinea l tra uma hist 6 monthS of tJe and rem];;; ; ; ...
fom! ror a fUrther 6 months. Breast#pwr;..s
!:;
I
T~ including second-degree tears or episiot- agamst irifecnollS thrOUgh specific and nonspecific
tOffile5, heals within 2- 3 WSeks Women need to immune factors 10 milk and has !:~g-tM mgse-
keep the penneum clean and dry. It is important to quences for metabolism, deyerm;!!!.!:~und ~
aVOId constig:!!;ion and report increasing pain, ~- latei'" w file. For the mo eastfeedin aids
nal ctJ¥C!lai"ge or malodour, as these may be signs of involunon, reduce risk of e I eI
mfeCtlon. ~ cancer and e a . icy
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
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

!"
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

caesarea n delivery
Common clinical presentations
A 35-year-old nulliparous woman has a caE>-
sarean section for breech presentation.
Four days otter a caesarean delivery. a woman
has a temperature of 38°C and on InHamed
wound site.
In the antenatal clinic. a 32-year-old woman
requests an elective cae sa rean delivery for the
.birth of her second child. Her Hrst baby was
barn via emergency caesarean section
because of failure to progress In labour and
fetal d istress.
Common com plications of
caesarean section
associated with injury to the uterine vasculature.
Damage to the bladder is possible, especially in the
presence of scarring from one or more previous cae-
sarean sections. Such an injury does not usually have
long-term sequelae if promptly recognised and
appropriately repaired. Continuous bladder drain-
age is instituted for several days postoperanvely.
Most complications occurrin in the u eri-
um ar te WI ever. ll:~~e......_ .....= ""
ours, the source 0 a eve ' .
tract 1Il eetlon, mtrauterine sepsili. or se~
lung coIIapse. Par31yoc ileus is unusual1Ollo\ving
caesarean section .
Fexer associated with a wound infection" IS
obvious after 3-4 cia and IS assOCIated V.'1th
increasing lower abdo " an !£l: ,.
thema surrounding the wound. Full-thickness
wound disruption is rare . Wouud.infection is mpre
likely in women who are obese~ when the caesa!-
ean seetlon occurs after obsrn'd'lH;I gF IOltQ-
I Uf, or were there is difficulry in estab-
operation of choice, as this scar is less likely to
rupture in subsequent pregnancies than the longi-
augment labour. Obstetricians are, however
tudinal incision in the body of the uterus (as
increasingly advising women to attempt vaginal
birth in these circumstances.
performed in the classic caesarean section). There
If th ta develo s on the anterior lower
is little evidence that different operative tech-
niques, such as single- versus double-layer closure
of the uterus, alrer the risk of postoperative wound
complications (Enkin & Wilkinson 2003
WIlkinson & Enkin 2003). '
Deep vein thrombosis can be migim~by
.karefuIS handling of the woman's legs during and
afrer the operation to minimise endothelial injurY,
and .by attention to . good hyclTaoon and early
mobilisauon. There IS evidence that graduated
compression Stockings are useful in minimising the Health maintenance
incidence of deep vein thrombosis in hospitalised
Good hydroll'jln , egWi nwbil!SQ~n
patients and that this prophylactic procedure is anOpjJYsio!bergpy minim ise toe
more effective when used in association with other postopergliye complications Qf
prophylactic techniques, such as intermittent calf vef'l"ous throm boembolism and chest
compression devices and/or low-dose heparin in ~ .
(Aroaragiri & Lees 2003) . This evidence is not spe-
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
rate from sepsis rise to one woman in four or five
of those giving birth (Loudon 1986).
In the late 1800s, streptococcal organisms were
demonstrated in pus from wound infections. In
1879, Louis Pasteur identified the haemolytic
Streptococcus in the blood of a woman with puer-
peral sepsis (Adriaanse 2000). When Joseph Lister,
learning of Pasteur's work and the germ theory,
began to apply antiseptic principles to the practice
of surgery, there was a dramatic fall in postopera-
tive deaths from infection (Lister 1870). It took
nearly 30 years for 'Listerism' to be universally
accepted by medical practitioners. By the end of
the nineteenth century, the need for obstetric asep-
sis was well appreciated.
Today, in AuStralia, deaths from puerperal sepsis
are extraordinarily rare (the overall maternal mor-
taliry rate is currently about 0.1 per 1000 births;
Donnay 2000), but infection and fe er are not rare,
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
mo~ry.
Risk factors
Risk factors for puerperal sepsis include:
prolonged rupture of membranes resulting in
an asceriztiHg irikEtloH
fre~uent use of urin ~ cathetS]
p rO onged labour, WI lllc;!.ased interveIlli.on
and more vagmat examinan o;!i
assisted birth (vacuum or forceps delivery with
epIsiotomy) - -
vaPi!£al lacerations
postpartum haemorrhage
• caesarean secnon.
The most common causative organisms are
Groul< B Streptococci, Staphylococci, Gonococci,
coTtforms and other Dowel flo ra (Lewis 1984,
McCormick 1947).
The clinical diagnosis is based on a history of
labour and delivery, and presenting symptoms that
usually reflect the site of infection. A full examina-
tion of the woman is required.
Genital tract infection
The woman presents with fever and malaise,
offensive lochia that may be purulent or bloody,
16 Routine manog emen l at the p uerp e rium
subsequently be transferred to the infant
(although there are wide variations). The in..fuut Clinical signs and symptoms
suffers adverse effects sllfb as diarrhgea and COD- Postpartum haemorrhage most typically Occurs in
snpa~n, due to the acnon of antibiotics on the the second week post-delivery (40% of all cases)
neonatal gastrointestinal tract. In the early puer- when the placenta! site scar is being shed and is
penum.' acomprehenslve assessmenr is required to uncommon after the ftrst 4 weeks postpartum (5%
ascertam if It IS safe for a mother who is breast- of cases) (Dewhurst 1966). On occaSions, the firSt
feeding to take a specific medication (Hale 2002). menstrual penod after delivery may be misinter-
preted as a secondary PPH, as this menstruation is
Wound infection ofren anovulatory. The volume of blood loss is not
usually severe but is associated with haemodyna-
Infection is more commonly seen in caesarean ser-
mlc compromise in 10% of cases.
tion wounds around day 4 or 5 post-delivery but Bef?~ discharge the woman s~ld
be informed abollt tb e signs Qf Subinvolution or abnormalities of involution
may also occur at clle site of epIsIOtomy ano per-
puerperal iI:lLilction to allow early are clinically recognised by a large sofr uterus and
ineal tears. The woman complains of fever, red-
recognition and prompt
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
~ed and there may be assOCiated offensive ' the SignS of endometritis is importanr. Clinical
Weep~ows of secondary PPH are fresh vnm;;r
lo~ A swab and smear of clle wound should be
Ii eeding of greater than 100 rnL and crampin~
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""
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
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
presents With dVSwla, fever and doudr' malodorous a woman presents with an abrupt Increase In ~'Organised blood dots may reseDible placen-
~.s:. A midStream oT9jtbsrsr 5pegme~e vaginal bleeding associated with lower ta! nssue sODographically, and in 10--15% of C§eS
S ould be coTIeged. Antibiotic theWlY SJ;11tlhe abdom inal pain . On physical examination. she u}tr:=und .will Incorrectly report retained placen-
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
and tresh blood clots issuing tram on open f se-neganve rate lot ultrasound in this setting,
Thromboembolism cervix.
however, IS very low. An atonic uterus, without
Ten days after a normal voginol delivery at retamed placental tissue, usually has an enlarged
term. a woman is transferred to the emergency endometrial cavity on ultrasound (>2.5 em antero-
room via ambulance with severe vaginal posterior di~meter). Ultrasound may ide ntify
bleeding. ute nne rOlds or arteriovenous fistulae which
may be associate Wl
• Excessive bleeding after shedding of th e placen-
ta~r _
Transmission of drugs in breast milk • Idiopathic subinvolution
It is generally agreed that medications penetrate • Retained placental tissue and/or membranes
• Endometritis
milk more during the first four weeks than in
• Coagulopathy
marure milk, although there are exceptions. In
·Tra~
the breastfed newborn, the infant must me tab-
olise and eliminate the drug. In the case of many • Uterine nbrolds (rare)
antibiotics! the oral bioavailablliry is such that • Cervical ca~ (rare)
generally es t an 1% of t.h e maternal die
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
Management
There are three basic strategies in the management
of secondary PPH:
• ascenain the aetiology of the bleeding
• insogate a medlc31 or surgical management
plan to treat the bleeding
reSUscitate m cases of excessive blood loss.
It is imponant to take the whole clinical picture
into account to avoid overdiagnosis of retamed
tissue as a cause of secondary PPH and thus to
minimise urmecessary surgery. Infeenon Witham
retained placental tissue is optimally managed
medically with antibiotics. If delivery was by
A full gynaecological history and examination Is
required. On examination, the follawlng may be
faund :
General and abdominal
• Uterine enlargement and/or tenderness
• Fever, tachycardia
• Occasionally haemodynamic compromise
Speculum examination
• Bload and/ar necratlc placenta In the cervical
canal
• Cervical dilatatian
• Purulent or affenslve vag inal discharge
BOX 16.2 Clinical examination signs In
secondary PPH
• Intravenous line insertian (Iarge·bore cannula)
• Volume replacement wijh crystalloid/colloid
• Blood transtuslon If haemoglobin <80 g/dL -
fresh frozen plasma, cryoprecipitate and platelet
Intusion may be required
• Intravenous oxytocin (10 IU), followed by an Intu-
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
bleeding
• Intravenous broad spectrum antib iotics
• Operative exploration of the uterine cavity and
lower genital tract under anaestheSia , once sta-
bilised
BOX 16.3 Management of se v ere secondary
postpartum haemorrhage
'.
• Uterine perforation (3%)
• Hysterectomy (1%)
• Asherman syndrome (rare)
BOX 16.4 Complications of surgical
postpartum evacuation of the uterus
Preventative strategies
Breastfe edjn" has long-term health
be ne/lfs for both mother and baby. It
m ini mises costpartum haemorrhage
an d p romo tes uterih e IiI Obluflet't,--
Infant immu y and es s ment o f
th e on e ee n mo er an y.
* Genita l tract trauma
A pregnant woman enquires about how she
may avoid episiotomy or perineal trauma dur-
Ing birth.
• Two hours after delivery, a woman complains
of excruciating vulval pain. On Inspection, one
labium maJorum is grossly swollen and dis-
coloured.
One week postpartum, a woman states that
her p erineum Is red, swollen, painful, and there
is d ischarge from the gaping wound .
Anatomy of the genital tract
The bulbocavernosus (alternatively bulbospongio-
sus) muscles form a thin, flat loop partially encir-
cling the vaginal orifice before passing forwards to
the clitoris. The superficial transverse perineal
muscles pass from the ischial tuberosities to the
centre of the perineum. This is the point of arrach-
ment of many other muscles in the pelvic floor and
16 Routin e m anageme nt of th e p uerpe rium
farms the central perineal body. The ischiocaver-
nosus muscles cover the crura of the clitoris and
traverse in part along the medial margin of the
ischiopubic ramus. The triangulated ligament is a
two layered fibrous sheath situated between the
symphysis pubis and the superficial transverse
perineal muscle. Laterally it extends to the ischial
tuberosities. The deep transverse perineal muscle
is a thin sheath of mixed muscle fibres lying
between the superior and inferior fascial layers of
the urogenital diaphragm (Fig 16.3).
The levator ani muscles form a sling to suppon
the pelvic organs. They originate from the symphy-
sis pubis, laterally from the ischial spine and pos-
teriorly from the coccyx. Fibres cross over in the
midline, encircling the vagina and blending with
the reCtum. The levator ani is divided into ileo-
coccygeus, pubococcygeus and puborectalis pans.
Portions of tbe levaror an i that maY be directJy
affected in deep secopd-deu ce laceratiOns alld
episiotomy include- aq
• the pu~s, which comprises the most
medial and inferior portion. It attaches to the
central perineal body and the external anal
sphincter to fonn a sling around the anal canal.
• the pu bococCXi:!'us, which is continuous with
the puborectalis, but slightly more lateral and
superior to it. It forms a sling between the sym-
physis pubis and the coccyx.
The uterus can be divided into:
• the upper uterine segment
• the lower uterine segment
• the cervix.
BOX 16.5 The uterus
Three layers of muscles in the pelVic Hoor support
the pelvic organs:
• superficial muscles
• triangular ligament
• deep muscles.
BOX 16.6 The pelvic floor
'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 lacerations
Perineal lacerations are classified according to the
srructures involved. They are commonly disun-
guished by four degrees:
1. F~t d~grbn-laceration of the yaginal mucosa,
penne s ' or fourchette only, but not of the
unJerlymg muscles of the perineal body. .
2. Second degree - laceration of the vaglA~
eEi?ie!iIr;' perineal skin and muscle of the
penne ody, whiCh may be slight or severe but
does not include the external anal sphincter.
The muscles involved are the superficlal
Urogenital
dIaphragm
Inferlor ramus
perineal body, and posten or margin 9£ th~p
transverse Illuscle and""uro enita! dia hragrn. A
dee second-d . the
pu ore s and pubococcygeus muscles.
3. ~ degree - the te~extent .~~u~ me
who e of the perineal bgdy a n _ LVQ v_ any
PaUgt the eXTernal anal sphincter..
4. Fourth degree - the tear extends mto the anal
or rectal mucosa.
Episiotomy
This is the surgical incision made to enlarge the
vaginal outlet durmg childbirth. It IOvolves:
• perineal skin.and subcutaneous tissue
• postenor va . al wall
• b ocavernosus muscle
superfiCIal ttan verse ;ferineal muscle
puoococcygeus mJ'sd~
The : cision may be made in one of two main
Vagina
ischiocavernosus
muscle
the labium majorurn. The bl.o_,; o;;..
dl~o.::;ssrr-";""'''
1. The mediolateral eEisiotomy is the most com- haematoma ma be considera
mon. The incision starts at the midpoint of the hypovolaemia, s oc an severe anae~a. If the
fourchette and is directed laterally at a 45° haematoma IS extensive or continues to extend, it
angle to the right or left of the midline of the will require evacuation under general anaesmesia
perineum. Mediolateral incisions are per. or regional analgeSia.
formed in a vascular area.
2. The median episiotomy is a vertical midline Rupture of the uterus
incision in a vascular watershed area. It maybe
This mostly occurs during labour and may be
associated with less bleeding but carries the ~ attributed to:
of extension into~.
• rupture of a previoys classic or lower uterine
Vaginal lacerations caesarean section scar. A dehiscence may cause
little bleeding.
These are tears of vaginal mucosa and underlying
tissue. They may occur on the posterior vaginal • Spontaneous ruf ure follO Wing obstructed
laBour DY cephal nelyje di§prgponi on or .QJAk
wall or along one (unilateral) or both (bilateral)
sides of the vagina. presentation. The rulIDJre is accompanied by
P, 3 bleediIlg, haematuria and collapse.
Vulval trauma r;auma (latJogeruc r - - -
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
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
clearly demonstrate that episiotomy does not
Cervical trauma achieve this protection. A systematic rcviPw

--
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

Women's health: a core curric ulum
blood loss. These problems may interfere with
the mother's ability to care for her baby. L~_
term complications include chromc permeal am
. .' an ~
wi consequ n composition of human milk fat. Advances in
incontinence (faecal and flams) With ItS atten . t
psyctJ{;logical effects. Relationship difficulties
due to dyspareunia have been reported to lead to
marital breakdown.
Health maintenance
AnteQQtgl p erineal m assage may
mTriim ise genital Irac! trauma In
labOUr. Attention to good wound
hy g~e promotes nealing an't! ovoids
lQ'i'ig:Term complications.
References
Adria.nsc AH, Pel M, Bieker OP 2000 Semmelweis, the
comb.t against puerperal fever. European Journal o f
Obstetrics, G)'necology and ReproductJ vc B,ology
90:153-158.
Ale.xandcr J, Thomas P, Sanghera J 2002 Treatments for
secondary posrpa rtUm hae morrhage. Cochrane
Pregnancy and Childbirth Group. In: The Cochrane
Database of Systematic Revie,",'S (The Cochrane
Library), issu~ 4. Online. Available : hrrp :/lwww.update-
software.com/cochrane.
Am aragiri Sv, Lees TA 2003 Elastic compression stockings
for prevention of deep veIn thrombosIS. In : The
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Enkin MW, Wukinson C 2003 Single versus two layer
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Hanretry KP 2003 Obstetrics illustrared, 6th edo. Ch urchill .
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G ynaecology 108 :927-930.
H um phrey M 1999 The obstetrics manual (revised edn).
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M edical History, Aust L85-107.
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Loudon I 1986. Deaths in childbed from the eighteenth
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Lydon-Rochelle M, Holt VI.., Easterling TR, Martin DP
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Scotr JA, Binns CW 1999 Factors associated with the
initiation and duration of breasrfeeding: a review of
Quest ions
Which of the following influences the
initiation of lactation?
a. Increased levels of prolactin and
progesterone post-delivery
b. The length of labour
flC\lncreased levels of prolactin and
V w ithdrawal of progesterone post- /
delivery
d. The desire of the mother to
breastfeed her baby
e. Return of progesterone and
oestrogen to pre-delivery levels
2. The process of involution is usually
monitored by which of the following?
a. The return of ovulation and
menstruation, signifying the process
is complete
b . Ensuring the woman is able to pass
urine post-delivery
16 Rou ti ne management o f the puerperium
the literarure. Breasrfecding Review 7(1):5-16.
Smaill F, Hoimeyr GJ 2003 Antibiotic prophylaxis for
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Systematic Reviews (The Cochrane Library), issue 1.
Online. Available, http / iwww.update-
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Stone C, Halliday J, Lumley J, Brennecke S 2000 . Vaginal
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Wilkinson CS, Enkin MW 2003 Perireneal non-closure at
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Systematic Reviews (Th e Cochrane Library), issue 1-
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software.corn/cochrane.
Recommended reading
Perineal Repair. Clinical 'green rep' guidelines. Online.
Avai lable: hrrp :iiw"'""'.rcog.org.uk.
c. The transition of lochia rubra to
lochia serosa
d. The closing of the internal cervical
os
~alpation of the descent of the
uterine fundus /"
3. Which of the following is good
advice for a woman who has had a
caesarean section for breech
presentation?
k ]':"\n a subsequent pregnancy, it is /'
'--1mportant for the woman to attend " ,
early antenatal care and discuss
the proposed mode of delivery
with the obstetrician.
b. It is important to avoid intercourse
for 3-4 months after caesarean
section.
c . A repeat caesarean section is
necessary in a subsequent
pregnancy.
(Continued over)
'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 ~""
aesarean delivery. ~ ~ ~ ~ d. Ultrasound examination of the
caes~ean
d. ower uterine segment
sect ion is practised to reduce "f
complications in subsequent
pregnancies . 9. Which of the followi ng may speculum
e . Caesarean delivery is associated
with on Increased risk of venous
thromboembolism when compared
to vaginal delivery.
5. Which are the most common clinical
signs of endometritis?
a. Secondary PPH
b. Uterine tenderness and vaginal
bleeding
~~terine
tenderne5- pu rulent lochia
V~nd fever ./
d. Subinvolution and secondary PPH
e. Lower abdominal pain and dysuria
6. Which of the following does not
Increase the risk of puerpera l sepsis?
a. Prolonged rupture of membranes
b . Frequent use of urinary catheters
c . Assisted birth - vacuum or forceps
@ pr imiParit y / there is any pain, increaS~ng :;;our
e. Caesarean section
c. Vaginal cultures
~ Knowledge
uterine cavity
I9.\AII of the above /
-.;:;,r.
examination of a woman with a
moderate secandary postpartum
haemorrhage show?
a. Blood clots In the cervical can al
b. Cervical dilatation
c. Clinical signs of severe endometritis
d. Bleeding from a vaginal tear
~" of the above ./
10. Advice for a woman with a second-
degree perineal tear should include
which of the following?
a. Avoidance of Interco urse for
3 months
b . Reassurance that the wound will be
healed in 6 weeks
c. Avoidance of constipation, as the
tear has involved the rectal
sphincter
d. Delay in starting pelvic floor
exercises until 2 months postpartum
.t.\EncoUragemen t to keep the area
r.::::J clean and repo rt to the doctor if
or discharge from the site/
At the end of this chapter, the student
will be able to :
Psychological experIence
• discuss women's emotional changes
during pregnancy
indicate the prevalence of depression
and anxiety in pregnancy
discuss the social and cultural issues
affecting the transition to parenthood
outline the antenatal assessm ent of a
woman's risk of depression
Psychological/ps ychiatric dIsorders
describe the common psychiatric
disorders of pregnancy
• discuss the effects of antipsychotic
medication on the fetus
• outline the management of
psychological/psychiatric cond itions in
pregnancy
Postnatal mental health issues
indicate the prevalence of mental
health problems In the puerperium
describe the common mental health
problems of the puerperium
outline the management options for
each of these mental health problems
• d iscuss the public health Im plications of
postnatal mental health problems .
Sk ill s
At the end Of this chapter, the student
should learn how to:
help a woman recognise normal
anxiety during pregnancy and when to
seek further counselling
use a screening tool for depression
during and after pregnancy.
Attitudes
At the end of this chapter, the student
should reflect upon :
the multiple factors Influencing a
woman's experience of pregnancy
• the impact of a psychiatric disorder on
a woman and her family
the influence of psychosocial stressors
on the development and exacerbation
of psychiatric disorders .
Women's health: a core curri c ulum
* The psychological
experience
Common clinical presentation
During her antenatal visit at 34 weeks'
gestation, a woman appears quiet and offers
no Information about her adjustment to
pregnancy. She tells you that she wishes her
mother were stili alive.
Depression and anxiety
during pregnancy
Contrary to common myth, pregnancy does not
provide a 'protective umbrella' against depressive
and anxiety disorders. There is a significant rise in
the incidence of depressive disorders in the post-
natal period and new evidence that they occur
even more frequently during pregnancy. It has
been found that the incidence of depression is
50% higher at 32 weeks' gestation than at 8 weeks
postpartum (Evans et al 2001).
Depression in pregnancy is sometimes missed
because the symptoms may be attributed to the
physiological changes of pregnancy. Women may
also choose not to volunteer symptoms of mood
disturbance at a time when they are expected to be
'blooming', and clinicians may fail to probe suffi-
ciently for symptoms.
Emotional changes of pregnancy
As well as being a time of great joy, pregnancy is
often a time of worry and uncertainty. A woman
may have concerns about the baby's wellbeing,
possible abnormalities, her capacity to cope with
and enjoy motherhood, and the potential and
probable changes that it will bring to her life, such
as her perception of self, her relationship with her
partner, and the change in her employment and
financial status, including becoming financially
dependent on her partner. A woman may be
exposed to the extremes of prediction: an ideal-
ised concept of the wonder of motherhood - or a
series of 'disaster stories'. Clinicians must offer
prospective mothers a balanced and integrated
view of the changes that occur in pregnancy and in
the puerperium.
While some women welcome the physical
changes of pregnancy in terms of its symbolism
and sense of womanhood, for many the changes in
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
appropriate reassurance and validation.
If a woman has had negative experiences in her
childhood, her fears about her capacity to be a
good mother may manifest indirectly during preg-
nancy or the posmatal period.
Social, emotional and
cultural issues
Immigration and multiculturalism in Australia has
had an unprecedented influence on the manage-'
ment of pregnancy and the postpartum period. It
would be difficult for any clinician to have a func·
tional awareness of all the culrural issues.
However, the consistent themes mentioned by
patients of different cultural backgrounds include
the desire to be understood, to be respected as
individuals and to have access to good communi-
cation channels (often through interpreter ser-
vices). Professional interpreters will often explain
the background to a relevant cultural issue if they
are requested to do so.
The family
A Woman having her first baby may not have fully
grasped the dynamics of changing from a couple to
a family, and negative consequences may emerge
in unexpecred relationship issues in the postnatal
period. Despite the number of books available on
pregnancy and motherhood, many couples reach
parenthood without adequate preparation.
Up to 30% of pregnancies are unplanned. The
reality of pregnancy and adjustments to pregnancy
and parenthood can have unsertling effects (Niven
1992). Some women's ambivalence may even lead
them to consider termination of pregnancy. An
unplanned pregnancy can be quite poignant post-
panum, when the mother absorbs the wonder and
innocence of her newborn.
A 'conventional' couple consists of three enti-
ties: the woman, the man and their relationship.
The arrival of the frrst child brings many layers of
complexity to this. The prominent themes of the
17 The psychological experience of pregnancy
Mother Father Mother Father
the response of the woman and partner to the preg-
nancy. This can be supplemented by encouraging the
?--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
antenatal education and exercise classes may facili-
Baby tate the woman's exploration of her feelings in
respons~ to the changes of pregnancy. It is also the
FIGURE 17.1 The mother-baby-father dinioan s role to encourage the woman to reflect on
relationship
suppOrt mechanisms during pregnancy and assist
WIth suggesnons of how to develop these networks.
mother-baby-father relationship shown in Figure DepreSSIOn IS more likely if a woman has a past
17.1 are the relationship between the mother and or family .history of depression, an unsatisfactory
her baby, the relationship between the father and relanonship With her own mother, a perception of
the mother-baby dyad, and the perception of lack of personal support - especially from her
many men that they are 'triangulated out' by the partner, diffimlty conceiving and holding preg-
mother-baby relatIOnship. These relationships can nanoes, medical problems, ongoing social stresses
be proacnvely dIscussed with the couple during or a range of unfinished personal and psychologi-
the pregnancy. cal busmess. The diagnostic features and criteria
, Selma Fraiberg introduced the concept of for. depreSSIOn and aIL'(iety are the same in the
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
Ity of the mother, the baby, the Cot and the blan- com~ound the joys, wonder and expectation in
kets. The 'ghosts' are the encoded memories of the the first trImesrer. Distress and concern may be
woman's own mothering, her relationship with secondary to blOlogJcal, psychological and/or
her,mother and father, her projections of her part- SOCial factors such as changes in role, lifestyle and
ner S p atte~ of relanonship with her new baby, mdependence. These processes of adjustment
hermemones of her parents' relationship and the need to be carefully distinguished from clinical
proJecnon of her fears and/or hopes for her own anxIety disorders or depressive disorders.
relanonship. AU of us have an 'instincti,re' per- Pregnane/ 'loss is not a rare event. Some
specnve on parentmg, which in most cases is based wo~en .vlew early miscarriage as sad and regret-
on a combination of genetic encoding and our table Without experiencing much additional dis-
own memones of being parented. tress, but it may have a profound PSYcholOgical
For many women, these memories are valuable Impact on other women. It is important for the eli-
and positive, and enhance the relationships with maan to understand the woman's loss and to
therr baby and their partner. For other women, demonStrate empathy.
there IS a range of consaous and unconscious con- . Fet:ti bonding is often quite prominent .in the
cerns, fears and even dreads linked to these ghosts first trImester. It tends to become stronger around
ill the nursery. Many of these issues surface during 18 weeks, WIth the detection of fetal movements
the posmatal penod. Irunal explanation, reassur- and visu~isation of the baby on ultrasound. For
ance and, ill some mstances, referral to a specialist the baby s father, bonding with the ferus usually
may be indicated. occurs later than for the mother.
It is important to have heightened awareness of
mental illness m the third trimester, as for 50% of
~anagement of Psychological Women With posmatal depression there is evi-
ISsues in pregnancy dence that the illness started in pregnancy.
An' . . The use of medicanon in pregnancy is complex.
unportant first step IS to take a comprehensive
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
Women's health: a core curriculum

pregnancy and during breastfeeding. Data continue
to emerge, and expert advice should be sought to
help the couple make an informed decision about
the use of medication during pregnancy and breast-
feeding.
Health maintenance
Women should be encouraged to
share their experiences of pregnancy
at each antenatal visit and at
antenatal education classes.
Depression
Depression is more common in pregnancy than in
the postnatal period. In man) women, the first
symptoms of clinical depression emerge. ill the
third trimester. The clinical symptoms mclude
anxiety, tearfulness, perceived inability to cope,
depressive ideation, slowing of psychomotor func-
tion, sleep disturbance and early mOrnillg waking.
Some symptoms of depression, such as sleepless-
ness, loss of appetite and libido, can be masked by
the physiological changes of pregnancy and the
adjustment to the posmatal penod. . In the second and third trimesters, all psychoactive
A valid., reliable screening tool- the Edinburgh
Posmatal Depression Scale - is available for both
lamotrigine is used in the management of bipolar
mood disorder and, so far, appears to have a lower
rate of congenital abnormalities thah the rwo pre-
vious agents. If a woman needs to remain on these
anti epileptic drugs through the first trimester of
pregnancy, it is recommended that she use high-
dose folic acid supplementation before conception
and in the first trimester. This may help to reduce
the incidence of spina bifida.
Effects of medication on the fetus
medications cross the placenta. The concentration
of antidepressants in the fetal circulation is esti-
Denial in both women and clinicians may cause
unnecessary distress and psychopathology.
It is bener to screen for psychological and/or
psychiatric disorders during the pregnancy rather
in the postnatal period. Screening is achieved by
clinical interview and administering tools such as
the Edinburgh Posmatal Depression Scale. This
allows for open discussion to enable exploration
of emotional wellbeing or distress.
Depression in pregnancy and the posmatal
period has its roots in biological, psychological
and social factors. Effective intervention involves
an approach involving all three of these areas.

* 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
some women have been depressed during preg-
nancy and this becomes more apparent postpar-
tum. A further 120/0 of women suffer symptoms of
subsyndromal depression that is not classified as
depression by standard mternatlonal crltena but
may have ongoing damagmg effects on the mdi-
vidual her family and other relatlonshlps.
Th~ symptoms of posmatal depression include
anxiety, tearfulness, perceived inability to c.ope and
poor mothering skills (although the baby IS usual-
ly well cared for), depressive ideation, slowmg of
psychomotor function, sleep disturbance and early
morning waking. Risk factors for developmg
depression include obstetric complicatlons, a past
history of depression or arunety disorders, and
poor social support from a woman's parmer
and/or her own mother.
Early diagnosis and management is important.
Screening in the antenatal and early posmatal
period is achieved with tools such as the
Edinburgh Posmatal DepreSSIOn Scale (Box 17.1;
Cox et al1987). Midwives and child health nurses
are most likely to detect the early signs. The fam-
ily doctor will often detect postpamun depreSSIOn
through a careful empathetic enqUIry mto the
woman's emotional state and mood at the 6-week
The Edinburgh Postnatal Depression Scale
In the past 7 days:
1. I have been able to laugh and see the funny
side of things .
2. I have looked forward with enjoyment to things.
3. I have blamed myself unnecessarily when
things went wrong .
4. t have been anxious or worried for no reason .
5. I have felt scared or panicky for no good
reason.
6. Things have been getting on top of me.
7. I have been so unhappy that I have had
difficulty sleeping.
8. I have felt sad or miserable.
9. I have been so unhappy that I have been crying .
10. The thought of harming myself has occurred to
me.
The answers Include a choice of: yes, most of the time; yes,
some of the time; not very often; no, nevef. Response
categories are scored 0, 1. 2 and 3 according to the
increased severity of depressive symptoms .
BOX 17 . 1 The Edinburgh Postnatal DepreSSio n
Scale (Adapted from Cox et 01 1987)
posmatal visit. Postpartum. depression may be
treated by counselling, cogrunve therapy or med-
ication (Evans et aI 2001).
Postpartum psychosis
Postpartum psychosis occurs in about 1 in 100.0
women (Kendall et al 1987). Posmatal marna
emerges in the first few days postpartum and IS
often rapid in its evolution and flond ill Its presen-
tation. Active and efficient intervention is impor-
tant for the safety and wellbeing of both the
mother and the baby. Ideally the woman is man-
aged in a specialist mother-and-baby unit staffed .by
a multidisciplinary team, including a psychiatrIst,
mental health nurses, midwives, mothercr~ nurses,
psychologists and social workers. Separatlon of the
mother and the baby is inadvisable. The treatment
includes initial sedation and a range of psychoac-
tive agents, which should be used with due caution
while a mother is breastfeeding. Tncyclic annde-
pressants appear safe in full doses and pheno-
thiazines safe in moderate dosages, WIth morutonng
of the effects on mother and baby. Drug therapy
should be suspended if the baby becomes too
drowsy or does not feed well. Lithium IS con-
traindicated while breastfeeding.
Public health implications
If 14% of women develop pastpamun depression.
and a further 12% of women have significant dis-
tress in the first year after delivery, the effects of
this depression and distress will potentially affect
the dynamics of many families. Wide~reachmg
psychological intervention and support 15 of SIg-
nificant value. For some women, this begms WIth
creating a forum for ventilation and debriefing of
their birth experience. Regrettably, some women
have a traumatic obstetric history or an expenence
quite different from their birth plan. For many
women, having a baby may cause a range of emo-
tions and conflicts to surface. SOCIal support, sup-
port of parmers and practical help during the
extremely busy and tiring posmatal penod are
important.
Proactive anticipation and management of
emotional, psychological and psychiatric disorders
in pregnancy and the posmatal period are of great
value to women and their families in the short
term. In the long term, there is clear evidence that
this proactive management has significantly better
outcomes for children in terms of emotional
and/or behavioural consequences (Niven 1992).
Health maintenance
Women with a history of psychiatric
disorder are well advised to discuss
the benefits and risks of continuing to
take Psychotropic medications in the
antenatal period or While they ore
breastteeding.
References
Altshuler LL, Cohen L, Szuba MP et al1996 Pharmacologic
managemem of psychiatric illness during pregnancy:
dilemmas and guidelines. American J oumal of
Psychiatry 158:592~06 .
Cohen LS, Altshuler LL 1997 Pharmacologic managemem
of psychiatric illness during pregnancy and postpartum
period. Annals of Drug Thcrap;; Psychiatric Clinics of
North America 4 : 21~0.
COX J, Holden], Sagovsky R 1987 Detection of postnatal
depression: developmem of the ten item Edinburgh
Posmatal Depression Seale. British Journal of
Psychiatry 150:782-786.
Questions
1. Which of the following statements is
correct?
a. DepreSSion in pregnancy is not
common because of the protective
umbrella of pregnancy.
b The incidence of depression is 50%
. higher in the third trimester than in
the early postpartum period.
c. DepreSSion in pregnancy is not
related to the emotional changes
and needs of women in
pregnancy.
d. DepreSSion in pregnancy should be
actively managed with medication
and hospitalisation .
17 The p sych oi ogical E.·Q eri&nce of pr egna ncy
David S, Crawford AM, Breier A 1998 Prolactin levels in
olaozapine versus typical and atypical anti psychotics.
Schizophrenia Research 29 (1-2): 153.
Evans J, Heron]. Francomb H, Oke S 2001 Cohon srudy
01 depressed mood during pregnancy and after
childbirth. British Medical Journal 323:257-260.
Fraiberg S 1975 Ghosts in the nursery: a psychoanalytic
approach to the problems of impaired infant-mother
relationships. Journal of the American Academy of
Child Psychiatry 14(3):387-421.
Kendall RE, Chalmers L, Platz C 1987 The epidemiology of
puerperal psychosis. British Journal of Psychiatry
150:662~73.
Kulin N, Pasruszak A, Sage S er al 1998 Pregnancy Outcome
follOWing maternal USc: of new selective seroronin
reupnkc inhibitors: a prospective conrroUed multi-
centte . rudy. JAMA: Journal of the American Medical
Association 279:609~1O.
Niven CA 1992 Psychological eare for families: before,
during and after birth. Butterworth-Heinemann,
Oxford.
Nulman I, Laslo D, Fried S et aJ 2001 Neurodevelopmenr
of chilc:lrtn exposed in utero to treatment of maternal
malignancy. British Journal of Cancer
85(11): 1611-1618.
e. Less than 5% or women develop
postpartum depreSSion.
2. Management of the Psychological
experience of pregnancy Includes
which of the following?
a. A comprehensive social history at
the first antenatal visit
b. Encouraging the woman to share
her experiences of pregnancy at
each antenatal visit
c. Early administration of the Edinburgh
Postnatal Depression Scale to screen
for risk of depression
d. Encouraging the woman to reflect
on and develop Support
mechanisms during pregnancy
e. All of the above
Women 's health: a core curri c ulum
3, Which of the following are risk factors
for postpartum depression?
0 , A past history of depressive
disorder
b . A family history of depressive
disorder
c . Lock of support
d . Obstetric complication
e. All of the above
4. Which of the following statements Is
true of the Edinburgh Postnatal
Depression Scale?
a. It can be used in the antenatal
period as well as the postnatal
period
b , It has not been widely validated
c . It Is difficult to administer
d , It is a diagnostic tool
e, All of the above
jltl
5. Whi c h of the follow ing symptoms
Inferti Iity
would alert you to a possible
diagnosis of major depression? Michael G Chapman and Una Conway
0, Pervasive feeling of low mood and
loss of quality of enjoyment of the Edited by Lucy Bowyer
day
b . Difficulty going bock to sleep In the
middle of the night
c, Undue tearfulness
d . Unexplained changes In appetite
e, All of the above
6. Which medications have been shown to
be safe to use with caution and informed
consent in the antenatal period? Learning objectives
0, Selective serotonin reuptake
inhibitors
Knowledge Attitudes
b . Benzodiazepines
At the end of this chapter. the student At the end of this chapter. the student
c , lithium will be able to : should reflect upon :
d , Mood stab ilisers
indicate the prevalence of infertility the impact of inferti lity on a couple
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
should learn how to:
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.
'4'

Women's health : a co re curriculum
Common clinical presentations
A young couple has been trying to conceive
for 12 months with no success.
A 32-year-old woman and her 34-year-old
partn'er have had extensive fertility
Investigations. A diagnosis of 'unexplained
infertility' has been made.
*
Epidemiology
Infertility is defined re to conceive after
a e ' d 1 ths 0 un . e.
Ithin this time frame, the natural rate of ~oncep­
tiQn in a woman under the age of 35 years IS more
th~
During the second year of attempted concep-
tion, some 50% of couples will conceive sponta-
neously. In each subsequent year, the. chance of
success declines. Treatments for miertility produce
success rates greater than these background rates
of conception. . .
Infertility is divided into pnmary (no prevIous
pregnancy) and secondary (previous pregnancies).
There are different causes In these two groups:
e.g. male factor infertility is less likely in secondary
infertility.
* Pathophysiology
Other causes include: in~e i.tm;!9-
tence retrogr~on and anti-sperm anti-
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
unexplained infertility.
* History and
examination
A detailed history from both parmers can reveal
potential problems. Infertility is a stressful Sit-
uation and so a ful~ mcluding occu-
pation f~es and the im£.i!ct of the failu~e
t~ceive is worthwhile. Frequency of sexual
intercourse, timing and other problems involving
interCourse should be explored with both parmers.
In the male, specific features in the history
shoufcf"beSOught including sexu"ilY .transmltted
di~~ and mll;!!lPs as an adult; opeIanons such as
repair of in~al hermas and o~hldope?cy; drugs
such as an~ents, b~ta blockers . and
exce~1i()l. Examination ~rura1la
sho~ld be performed to assess the size and consis-
tency of the testicles, as well as the presence of the
vasa deferentia and/or varicocele.
In the female, normal fearures of ovulation
include a re lar menstrUal cle, midcycle pam,
chan es in vagig isc arge, premenstrUal sLmp-
toms art pnmary dysmen~ea. The past re ro-
~ve his!QD' should be documented.. ere may
be predisposing factors for pelvIc infeenon, such as
sexu~ rransmined infections the use of an
intraurerine device or previous pelvIC surgery.
Symptoms suggestive of endometriosis shoUld a.tso
be explored, such as secondary dysmenoIrhoea
and dyspareunia. Examjnation should Identify sec-
ondaryJl'x]1?1 delleIQ~nt, eVIdence .of. pe1vlC
inflamma~ory disease (PID) or en_dometnosls.
* Investigations
Male
Semen should be analysed afrer 3 days' abstinence
from ejaculation. The sample must be brought
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
be repeated after 4-6 weeks before a final assess-
ment of quality is made. For abnormal speClmens,
serum follicle-stimulating hormone (FSH) and
testosterone levels should be tested. Severe unpalC-
ment of sperm quality is predominantly due to
18 Infertility
Normal
Volume
2-5 mL
Concentration
>20 mlllion/mL
Motility
>50%
Normal torms
>30%
Azoospermia No spe rmatozoa seen
Oligospermia
Mild 10-20 mllllon/mL
Moderate <5-10 mllllon/mL
Severe <5 million/mL
Asthenospermio Decreased
Teratospermia Decreased
TABLE 18.1 Normal and abnormal qualities of semen
spermatogenic failure of unknown cause. Recently Tubal patency
genetic causes related to deletions in the Y chromo- Tubal patency needs to be established.
some have been documented. H ysterosalpingography involves the introduc-
The postcoital test involves aspiration of a
tion of radiopaque material through the cervix
sample of cervical mucus around the time of ovu- into the uterus and the fallopian rubes.
lation, within 6 hours of intercourse. The test is Intrauterine anatomy and rubal patency can be
somewhat controversial, as many factors other documented. Hysterosalpingography has the
than mucus hostility can influence a negative advantage of being an outpatient procedure,
result (lack of sperm motility) , e.g. infection or although it is poorly tolerated because of pain- It
incorrect timing. provides no information about problems occur-
ring elsewhere in the pelvis, i.e. adhesions or
Female endomerriosis. There is a small risk of introducing
Ovulation or reactivating pelvic inflammatory disease.
Laparoscopy with dye instillation is performed
It should be established that ovulation is occurring under general anaesthesia. A laparoscope is intro-
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
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
B~ bodY.1l:wperarure cbarts can reflect ovu- together with hysteroscopy, which may show
lation by documenting t~ 0 SOC rise in tempera- intrauterine pathology such as adhesions, polyps
ture between the follicular phase and the ImeaL or fibroids .
p~e. Tiley are useful in defining cycle length and
gmng an indication of the days in which ovulation
may have occurred.
Serial monitoring of luteinising hormone levels
* Treatment
identifies the preovulatory surge of this hormone. Male
Ultrasound can be used to monitor follicular The major change in the management in infertil-
growth and formation of the corpus luteum. ity in the last decade has occurred in the ability to
Laparoscopy allows direct visualisation of the cor- deal with men with poor sperm quality and even
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

FIGURE 18.1 Intr acytopla smic sperm injection.
The egg is held by a suction pipette (left) and
the sperm In/ected Into the cytoplasm . (From
Pitkin et 01 2003. p 133. Fig 5)
underwear, variS2£ele obljtaation and hormonal
strategIes have been shown to be of nQ...significant
bet. The development of intracytoplasmic
sper~niecrj Qn (ICSn (Fig 18.1) in :;action
WIth In n tro fertilisanon (IVF) has-eaa. SJlZ;-
cessliiI treatment in severe cases of male faeror
pr.Ql:ilaiis. Intrauterine insemmagon may help
mild oligospermia
fertilisation. Reversal of clip sterilisa~;::~ai~
the one area jn iYtl lt5 bJ b a! SlJrgery isCwhile.
rQ'F has now been used for more than 20 years
and results in pr-!Uancy rates hi~er than 25-35%
pe~ accor g to panent se eenon. The pro-
cedure was primarily developed to bypass tubal
disease. However, its application has broadened
substantially with the evolution of ICSI and its use
in unexplained infertility. IVF involves induction
of multiple follicles with subcutaneous FSH injec-
tions and the collection of multiple oocytes under
ultrasound control. Fertilisation with the partner's
sperm then occurs in the laboratory. One or [WO
embryos are replaced transcervically into the uter-
ine cavity after 48-72 hours. The major complica-
tion of IVF is srtfCcant ovarian hJ(pecstimuiation
syndrome, whic occurs ~ < 1% of cases.
Cfomiphene bas been shown tObe helpful in
unexplained infertility, but intrauterine insemina-
tion (IUI) is now the treaanent of choice. IUI suc-
Questions
cess rates are in the order of 15-20% per cycle in
women under the age of 35 years. If IUI has failed,
1. What chance do a healthy 29-year-old
IVF can be offered. Cervical factor and anti-sperm
antibody infertility is poorly understood and diffi-
cult to treat. Spontaneous pregnancies do occur
and assisted conception may be useful.
The tr~nd has ~een to legislate more definitively to
aVOid extreme c:ases: In all slruations, one gener-
ally agreed pnnclple 15 to protect the furure inter-
est of the child.
Heolth maintenance
When planning a family, women
should be aware of the influence of
ageing on fertility.
Chlamydia - a sexually transmitted
disease affecting fertil ity - can be
prevented by the use of condoms.
woman and her 35-year-old partner
have of conceiving In the next 12
months? . b. Sperm denSity; 21 mil li on per mL
a.50%
Reference
Pitkin J, Pearue AB, Magowan BA 2003 Obstetrics aod
!lYIl.aecology: an illustrated colour text. Churchill
LIVlDgstOne, Edinburgh.
Further reading
For information on the management of the infertile
couple, see the website of the Royal College of
ObstetriCians and Gynaecologists in the UK at
http:// www.rcog.org.uk.
3. Which of the following semen
parameters is considered abnormal?
a . Volume; 3 mL
0 0tllity: 40% L )SD 'I.)

Female
In women with polycystic ovarian syndrome or
hYRothalamic ameDorrh~a, mductioD of ov\!!g.-
tion improves the chance of conceptIOn to
alIjlQst normal rates, provided the couJ1le~
fo r 6-1 2 m ~nths. Clomiphene citrate is used in
p'olycystic ovarian synorome at a dose of 50 mg
for 5 days in the eady follicula r phase of the
me ~ t[l!al qrc ~ ClomiEhene increases FSH
pr~ by acting as an anti-oestrogen at the
pituitary level. Response to treatment sbould be
measured by midIUteaI serum progesterone to
confirm ovulation. Other ovulanon mductloD
agents sUitable fo r hypothalamic problems
include gonadotrophins and gonadotrophin-
releasing hormone (G'n RID. They should be
prescribed only in specialist units. Compli-
cations of ovulation induction include multiple
pregnancy and ovarian hyperstimulauon .
Tubal surgery ii now rarely undertaken, since
its success rates of only 20-30% compare
unfiivourably with the success rates of in vitro
* Medicolegal and
ethi ca l issues
b.60%
c . 70%
~ 80%
d . Morphology: 32% normal forms
e. Sperm antibodies in seminal fluid :
negative
/
e . 90% / 4. Which of the follOWing are possible
As reproductive medicine adopts the latest techno- complications of IVF treatment?
logical advances in cell biology and molecular 2. What is the major reason for a decline a . Multiple pregnoocies
genetics, the potential for treaanent with manipu- /n fert ility with maternal age? b . Ovarian hyperstimulatlon
lation of gametes and their genetic make-up opens a. Reduced frequency of intercourse syndrome - - - -
a Pandora's box of ethical and medicolegal dilem-
mas. Conservatism clashes with progressive exper- b. DecreaSing semen quality c. Psychological trauma
imentation. A number of achievable treaanents are @ Reduced oocyte quality d . Low-blrth-weight babies /.
banned to varying degrees by different jurisdic-
tions, both in Australia and internationally. Tbese
d . Impaired hormonal environment I e l of the above
include the use of donor gametes in single women e . Ageing of the uterus
with 'social' infertility, and pregnancies in women
over the age of 50 years. The use of a surrogate to
carry the child of a woman who has lost her uterus
or is medically unable to carry a pregnancy is a
minefield for the lawyers : it is banned by some
governments, legalised by others and unclear in
the remainder.
Many of these issues pose personal questions,
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
appraise the complex issues influencing
the wide variation In termination rates
• describe the principles of counselling
for a woman who requests termination
of pregnancy
describe the surgical and medical
options for termination of pregnancy
and the possible complications of these
procedures.
Attitude s
At the end of this chapter, the student
should reflect upon:
the effect of unwanted pregnancy on
different aspects of women's lives
the Impact of termination of a
trisomy 21 pregnancy on the parents.

Skills

At the end of this chapter, the student

should learn how to:

• 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
Women's health : a core curriculum

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
Common clinical presentations
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 pro- state 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
termination solely on the grounds of a serious fetal
anomaly up to 28 weeks' gestation. Practitioners
mUSt know the law that applies in their own region.
New Zealand
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-
tificate. The New Zealand law states that abortion
is legal in a case of a pregnancy of not more than 20
weeks' gestation where the obstetrician believes that
the continuance of the pregnancy would result in
serious danger to the life or to the physical and
mental health of the woman or girl, or that there is
a substantial risk that the child, if born, would be so
physically or mentally abnormal as to be seriously
handicapped. Very rarely, a termination is done
beyond 20 weeks when it is believed that it is nec-
essary to save the life of the woman or to prevent
serious permanent injury to her physical or mental
health. COWlSelling, though often practised, is not a
legal requirement in New Zealand.
Ethics of abortion
Moral and religious issues are a maner for indi-
vidual conscience. Medical practitioners in
Australia are not legally required to perform abor-
tions or to refer women for abortion.
* Septic abortion
Serious infective complications may occur with a
termination of pregnancy (legal or illegal). Gas
gangrene causing multiple organ failure is a signif-
icant cause of death from this condition.
Maternal deaths from septic abortion at the
Royal Women's Hospital, Melbourne, declined
from 188 deaths berween 1939 and 1947 to
12 deaths berween 1951 and 1959, 2 deaths
berween 1960 and 1969 and 1 death berween 1970
and 1979 (Ranen et al 1985). It is incorrect to
assume that this decline in serious sepsis in Australia
is mainly due to liberalising of abortion laws, which
did not occur in Victoria until 1969. Presumably,
general improvementS made in women's health,
improved antibiotic therapy and safe surgical evac-
uation of infected intrauterine tissue were the main
responsible factors. There is no Australasian data on
which to judge the effect of liberalising abortion
laws on non-fatal sepsis.
Unfortunately, in the developing world septic
illegal abortion is a major cause of maternal mor-
tality to the present day.
* Pregnancy termination
Access
Access to termination services varies throughout
Australia and New Zealand. Larger urban centres
have specialised clinics with dedicated staff.
Women may self-refer directly to these clinics.
Women in rural and small urban communities do
not have access to specialised clinics in their own
community. Confidentiality is important to all
women seeking termination of pregnancy, and this
can be a problem in small communities, where the
woman may know hospital or clinic staff. Some
women choose to be managed in a major centre
for this reason.
The majority of terminations in New South
Wales are performed in the private sector (includ-
ing holders of healthcare cards, predominantly
low-income women), reflecting access difficulties
in the public sector in that state. In contrast, in
South Auscralia most terminations are performed
in the public sector. Recent data shows that hun-
dreds of Auscralian women crave! interstate each
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.
First-trimester termination
Regardless of the reasons for the request, this is an
extremely distressing situation for the woman.
History-taking and examination must be per-
formed sensitively and non-judgmentally.
Determine clearly the reasons for the woman's
request. In most jurisdictions, medical grounds are
necessary for the request to be granted. Very occa-
sionally, the request is based on a mistaken
assumption of teratogenic risk, which could be
managed by reassurance (e.g. that exposure to a
substance perceived to be unsafe is in fact harm-
less). Seek advice if there is any question that the
pregnancy could be the result of a sexual assault.
Enquire what contraception, if any, was used and
19 Unp la nned p reg n a ncy an d termlllOlioll
try to ascertain why this failed. Is the woman
centa praevia, and delivery. of a low-birth-weight
aware that postcoital contraception is available?
baby. The nsk of pre term birth lIlcreases with th
What future contraceptive options would be best
number.of terminations of pregnancy (or SPontan~
for her? Be alert to the possibility that the woman
eous nuscarnages) a woman undergoes. Most
could be acting under duress (usually pressure
women who decide to terminate a pregnancy do
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
about her opoons, conSIder referral to a social The antigro/iesq;roQ& wilipristop.e..(RU486) has
worker. Accurate pregnancy dating is important been widely employed in Europe for medical ter-
and is best done by ultrasound scan. Arrange for a mination .o f pregnancy and wote best in comb i-
second medical opinion if required. nat;!,on .WIth a pmsraSI2J;tdin. (e.g. rrusoprostiJ).
ApprOXImately 80% of first-trimester pregnancies
Suction curettage or
will be successfully terminated this way. This
dilatation and curettage
:nethod IS effecnve before 6 weeks' gestation by
lIlduClJ1g a nuscarnage. Mifeprisrone is not cur-
Surgical termination of pregnancy by suction curet-
rently available in Australia.
tage or dilatation and curenage are the only reli-
able methods available in Australia. Suction curet-
tage is the preferred method, as it is considered to Second-trimester termination
b~ easier and have a lower complication rate than Dilatation and evacuation
dilataoon and curettage. This is a day procedure
and can~e done under local, regional or general Suction termination is not safe or effective beyond
anaesthesIa. Ultrasound scanning to guide the pas- a?out 13 weeks, although surgical termination by
sage of the suction catheter and to confirm com- dilatation and evacuati &E u to about 18
plete evacuation of the uterus may be performed. wee gesta sate an e ecnve 1Il s
Prostaglandins (e.g. misoprostiL) can be employed handS and with appropriate instrumentS.
preoperanvely to make cervical dilatation easier The cervix needs to be widely dilated for D&E.
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.
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
pr"gnancy. EndQroen:itis (with or without retained hospitals offer medical termination, as skilled sur-
produCtS) is relatively cOllliPon and usually pres- geons available to perform D&E are scarce.
ents WIth exce .' in and . P~
phylacnc ann IOnCS ven re or durin the Medical termination
proce e may re uce the rate of endometritis.
Senous consequences from endometritis are rare. Medical termination using pr~ (e.g.
In some cases, return to theatre to evacuate mlsoprostil, dinoprostone) induces' on in
retained produCtS is required. Uterine perforation 60-80% of cases at firSt anempt, but it can be a
IS an uncommon but potentially serious complica- slow process, sometimes taking several days. Rates
non, as small- or large-bowd injuty or injury to of retamed placenta requiring manual removal are
major pelVIC vessels can occur. Failure to terminate high (over 40%). A second anempt after a few
IS more likely to occur if the procedure is done days wIll usually follow a failed first anempt. If the
before 6 weeks' gestation. Rarely, termination fails second anempt fails, alternative methods include
because It IS . not realised that the pregnancy is intra-amniotic installation of hypertonic saline,
ectopIc. MedIUm to long-term complications are urea, or prostaglandm F transcervical infusion
2cv
uncommon and may include depression, early of oxytocin or PGF through a Foley catheter,
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
are done on mental health grounds. Laws are dif-
ferent between and within countries and access to
termination of pregnancy is not uniform in the
same country. Termination rates to Australia and
New Zealand are slmilar to those in other Western
countries. Serious hazards from termination of
pregnancy are rare except in countries where ter-
mination of pregnancy is illegal.
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
teratogeniC substances in the first
trimester min imise the risk of congen-
ital malformations.
Q uestions
1. Termination of pregnancy in Australia
and New Zealand is mainly requested
for which of the following reasons?
a. Genetic anomalies in the fetus or
embryo
b. Pregnancy resulting from rape
. c. Teenage pregnancies
d. Pregnancies in women over 40 years
old
e . Mental health reasons
2. Which of the fallowing is correct
regarding surgical termination of
pregnancy in the first trimeste r?
a . Legal abortion is required for
ectopic pregnancy.
b. A termination procedure must be
done by a specialist gynaecologist.
**4
References
Cico N 1999 Abortion law in Australia 1998-99. Research
paper I, Law and Bills Digest Group, Department of
Genital prolapse
the Parliamentary Library, Parliament of AUstralia
Canberra. ' Paul Duggan
Henshaw 5K, Singh 5, Haas T 1999 Tbe incidence of
abortion worldwide. International Family Planning Edited b y M artha Finn
Perspectives 2S (Supplement):S30-S38.
Ratten GJ 1985 Changes in obstetric practice in our time.
Australian and New Zealand Journal of Obstetrics and
Gynaecology 25(4):241-244.
,
Knowledge
Attitudes
A~ltl hbe end of this chapter the student
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
c . Failure to terminate pregnancy is
Impossible . Aht the end of this chapter, the student
s ould learn h ow to :
d. Perforation of the uterus during
suction curettage is a trivial
perform a Sims' speculum examination
complication .
perform a bimanual pelvic examination
e. Most women bleed for at least a
week following termination . Counsel a woman with uterovaginal
pro!apse regarding her treatment
options.
3. Which of the following is correct
regarding termination of pregnancy In
the second trimester?
a. Termination for a serious fetal
anomaly is common.
b. Suction curettage is the safest
method of termination o·v allable.
c . Prostaglandins are commonly
employed to induce termination.
d. Reta ined placenta is rare.
e . Prostaglandin termination takes as
long as D&E .
tji

Women's health: a core c u rriculu m
A 48-year·<lId woman presents with an
uncomfortable 'dragging' sensation In her
vagina.
Uterovaginal prolapse refers to abnormal descent
of the uterus and~. The mostCommon grad-
ing system defines grade 1 uterine prolapse as
descent of the cervix at rest to above the level of
the introitus, grade 2 as descent to .the lntrOltus
and grade 3 as descent beyond the mtroltus (FIg
2.0, I). There is, however, a poor relattonship
between prolapse grading and symptoms. The
terms cystocele, rectocele and ente rocTJe~e
prolapse of the ant.erior vagi nal w;J14 pnsrenor
va~al wall and vagmal vault respecuvely.
* Prevalence and
incidence
A Scandinavian survey of randomly selected women
aged 40-6.0 years reponed symptoms of pelVIC
heaviness in 15%, the. presence of a genual bulge In
4% and use of fingers in the vagina or on the pen-
neu~ to assist defecation in 120/0 (Eva et al 2.0.03).
An Australian survey found that 9% of womel! ~5D
years of age had had at least one prolapse repalr and
9% had current symptoms of prolapse. Over 1.0%
reponed difficulties with defecation and 5% vagrnal
laxity (MacLeI1llan et al 2.0.0.0).
o . Grade I : descent of the cervix 0 1 b. Grade 2: descent to the i n~
rest to above f e level of the Introitus
FIGURE 20 .1 Uterine pralapse (Based an Mackay 1990, p 347, Fig 23.14)
* Applied anatomy and
physiology
The uterus and vagina are mobile and distensible
with connective tissue suppons predoffilnantly
comprised of smooth muscle and collagenous
matrix. DefectS in connecuve ttssue followmg
pregnancy, surgery or from inherited connecuve
tissue disorders may all result 10 vagInal prolapse.
The cord-like round ligament, the relanvely
dense infundibulopelvic ligament and the thin
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
attachments comprise peritoneal folds, connecuve
tissue, nerves, lymphatics and blood vessels. The
uterosacral and infundibulopelvlc ligaments may
be surgically attached to the vaginal vault to ald
in the suppon of the upper vagrna followmg a
hysterectomy. .
The levator ani striated muscle group prOVides
* Clinica l eva luation
the principal suppon of the pelvic floor .and IS an
important suppon of the lower vagIna. T he
pudendal nerve supplies motor fibres to the leva-
tor ani and is at risk of lnJury from pregnancy and
childbinh, as are the bony attachments and muscle
fibres of the levator ani. Strengrherung of the leva-
tor ani muscles by specific exercises has been
shown to improve symptoms of prolapse and
incontinence.
c. Grade 3: descent beyond the
Introitus - the vagina is c omple tely
ev~a cystocele , rectocele and
enterocele are also prese nt
FIGURE 20.2 Vagi nal wall pralapse (cystocele)
presenting at the Int ro itus (Photo courtesy Paul
Duggon)
/
20 Genital prolapse
Hydronephrosis resulting from ureteric kink.
ing may Occur in more severe forms of uterovagi. the appearance of a lump or bulge at the vaginal
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
the bladder base below the urethra may also occur.
urinary and faecal incontinence. Rectal prolapse
Rectal prolapse,-naemorrhoids and faecal inconti-
or haemorrhoids may also be present. Men-
nence are sometimes seen in association with
struating women may report difficulties with
uterovaginal prolapse. Not infrequently, a multi-
insenion of tampons. Many women report low
disciplinary approach involving gynaecologists,
back pain, which may be due to other causes.
physiotherapists, continence nurse advisers, urolo-
Prolapse may affect a woman's desire to have sex-
gists and colorectal or general surgeons may be
ual relations. Ulceration of prolapsed epithelium
required to optimally manage complex cases.
may occur and result. in discharge or bleeding.
* 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.
reported as independent risk factors for prolapse. Uterovaginal prolapse is best identified using a
The incidence increases with age, postmenopausal Sims' speculum, while examining the woman in
status, smoking, chronic lung disease and obesity. the left lateral decubirus position.
* M anagement
The typical sympto ms of prolapse include a drag- Management options are tailored to the individual
ging or bearing down sensation in the vagina and woman. These options include strengthening
exercises for the pelvic floor, intravaginal oestro-
gen supplementation, vaginal packing, vaginal pes-
saries or corrective surgery. It is appropriate to
give reassurance in all cases, as prolapse is not a
life-threatening condition,
Potentially reversible risk factors should be
identified and managed (obesity, constipation,
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
pelvic floor exercises or has related bladder or
bowel problems.
Vaginal packing
Chafing and ulceration of externalised epithelium
occurs in neglected cases and may be managed by
i*t

Women's health : a core curricU lUm
vaginal packing with cotton gauze liberally
smeared with oestrogen cream. The prolapse is
reduced by the pack, which should be replaced
daily. Ulceration managed in this way will respond
in 2- 3 weeks, when definitive treatment (pessary
or surgery) may then be undertaken. Prophylaxis
for venouS thromboembolism must be considered,
as these women are usually elderly and frequently
immobile.
vaginal pessaries
An appropriately selected and fitted pessary (Fig
20.3) should reduce the prolapse and not affect
either partner's en joyment of intercourse.
Pessaries need to be removed, washed and re-
inserted periodically to minimise ulceration of
vaginal epithelium and prevent incarceration
(every 3-6 months is sufficient fo r ring pessaries
but may be insufficient for pessaries that have a
large surface area in contact with vaginal epithel-
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.
Surgery
The principles of surgery for uterovaginal prolapse
are to correct the anatomical defect, to maintain
sexual function and to treat associated urinary and
bowel dysfunction. Traditional surgical repair
involv~ va&i£al hvsteregamy, midline suturing of
v~ fasaa and excision of redundant vaginal
epithelium - an operation that has changed little in
the last 100 years. Many newer operations have
been described that utilise vaginal, abdominal or
laparoscopic techniques. Long-term randomised
data are required to properly evaluate these tech-
niques. In some instances, the woman's own tissue
is inadequate for a satisfactory repair, so synthetic
mesh and/or slings are utilised. Non-absorbable syn-
thetic materials could potentially provide a more
durable repair but are associated with complica-
tions, including chronic infection or rejection in
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
be performed relatively quickly under local anaes-
thesia and may be appropriate in selected cases.
FIGURE 20.3 vaginal pessories: A -
pessory; B - medium ring pessary; C - shelf
p essary (Photo courtesy Peter Far kas/ROya l
Darwi n Hospital)
r;:.ea~t. Other contributors to sexual dysfunc-
~~n, mcluding lo.~o, relatiOlWP problems
10 . arnmat~-a: conditions of the vulva and vagin~
ana pSY,.chO gi91 influences, must be considered.
*
Summary
Uterovaginal prolapse is a common condition that
mcre~es In preyalegce with age Pregnanc;y and
childbirth are lIDPOnant risk factors. Magagerneac
IS tailored to the individual woman. It should
Include reassurance and may include ~r
e~~t, oestrogen supplementation, v~l
p~, pessarles or s~. A multidisciplinary
approach IS usuaIly worthWhile.
. Health maintenance
Pelvic floor exercises help maintain
pelvic floor function . Avoidance of
obeSity, constipation, chronic cough
and heavy liftin g minimises pelvi c floor
dysfunclion.
Questions
1. Which of the following is correct in a
55-year-old woman with prolapse of
the anter ior vaginal wall presenting at
the vaginal entrance?
a . The woman has almost certainly
had a hysterectomy.
b. The woman will almost certainly
have urinary stress Incontinence .
c. Sexual Interco urse is not advisable .
d . Th is problem will respond best to
vaginal oestrogen replacement ther-
r apy.
~, e . vaginal pessary may satisfactorily
([;;\ treat thiS problem .
~~ Which of the following is correct In a fit
I 70-year-old woman prese nting with com-
plete prOCidentia. a deficient perineal
b o dy and absent retropubic shelf?
large ring
a . The woman is too old for surgery.
b. Pelvic floor exercises will c orrect the
prolapse .
20 Gen ital p rolapse
References
Boyles SH, Webe r A;"I, Meyn L 2003 Procedures fo I ·
organ prolapse in the United States, 1979- 199;. pe VIC
AmeCican Journal of Obstetrics and Gynecology
188(1):108-11 5.
Eva UF, Gun W, Preben K 2003 Ptevalence of urinary and
fecal mcon tlnence and symptOms of genital prolapse .
women. Acta Obstetcicia et Gynecologica Sandi " in
82(3):280-286. o>\!ca
Mackay EV, Beischer Nt\, Pepperell RJ, Wood C 1990
IUusrrated textbook of gyriaecolos)', 2nd edn. WB
SaundersfBailliere T Uldall, Sydney.
MacLennan AH, Taylor AW, Wilson DH, Wilson D 2000
The .prev:il.ience of pelvic fl oor diso rders and their
relanonshtp to gender, age, parity and mode of
deli very. BJOG : an [ntemanonal Journal of Obsretrics
and G yuaecology 107(12) :1460-1470.
O lsen AL, Smith VJ. Bergstrom JO, Colling JC, Clark AL
1997 EpidemIOlogy of surgically m.maged pelvic organ
prolapse and urmary incontinence. Obstetrics and
Gynecology 89(4):501-506.
c. A pessary Is unlikely to manage this
problem satisfactorily.
d. This pro blem will respond best to
vaginal oestrogen re placement the r-
apy.
e . The Le Fort operation (vaginal oblit-
eraHon) is the first procedure of
chOice .
3. Wh ich of the following is correct?
a: There Is a d irect relationsh ip
between the severity o f prolapse
and the severity of sym ptoms.
b . Prolapse does not occur in young
nulliparous women . .
. c. Prolapse causes stress incontinence.
~o men with posterior vaginal wall
prolapse may have to place a
finger In the vagina to assist with ~~')t...'.
bowel evacuation. ,"\0 ~ (~':,
e. Sexual enjoyment is likely to Improve
su bstantially following prolapse
t ~~
\'
treatment. 11 .." .
7
*f'
 V
Incontinence
Paul Duggan
Edited by Martha Finn

Learning objectives

Knowledge • Instruct the patient how to perform

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

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

Women 's health : a cora curriculum
Common clinical presentations
A pregnant woman at 32 weeks' geslation
enquires how she may prevent urine and slool
loss problems after delivery.
Eight weeks after delivering her fourth baby a
woman enquires when she may expect to slop
wetling and soiling herself.
A general health enquiry reveals that your
patient Is experiencing Incontinence episodes .
A patient states that she is having trouble
making it to tl1e toilet when nature calls .
(I
* Urinary incontine nce
Urinary incontinence is the . u:::!ntentional loss of
urine. Urinary incontinence 15 reported m approx-
imately 130/0 of women aged 18-23 years, mcreas-
ing to more than 35% in women over ~ .
Incontinence is a common reason for arumsslOn of
elderly people to residential care facilines. Rates In
men are much lower. Urinary inconnnence IS often
ass;.red Witb:~::~~rte:dSY::;rt~lms;f:
mC.2!llJD.'ll-ce, ut~ ______ ; - . p .
There are many mechamsms mvolved m conn-
nence and thus many rypes of mconnnence.
Evidence supporting current invesnganon and
treatment modalities is often lacking. anagemenr
generally requires a multidisciplinary approach.
structure and function
of the lower urinary tract
A derailed description of the embryology, structure
and function of the urinary tract can be found m
many classic anatomy and physiology textS (Gray
2000, Ganong 2003).
For the normal adult female :
• the bladder should comfortably retain 400-500
mL of urine
:~:~v~=:~=~;:::~d
twice if over 60 is n~rmal
voidiIig IS usWilly a Quick "?~ efficient pws;ess
_ there should be no strauung, and the blad-
der should be almost completely empno;d
« 25 mL residual volume)
• urine is sterile but often contaminated with
vaginal flora - an infected ample should have
a pure growth of a pathogen (> 105 colony
counts) and ~ 10 white blood celli per hW1
-
power field.
Causes of urinary incontinence
Urinary incontinence may occur as a result of
injury to or dysfunction of the central or penph-
eral nervouS system, striated muscles, conneCtlve
tissue and ligaments of the pelVIC floor, or the
smooth muscle and mucosa of the bladder and
urethra. Direct injury to these strUctures usually
results from pregnancy and delivery. Pudendal
neuropathy may result from increased pressure
during pregnancy. Trauma, lschaerrua or malIg-
nancy may injure the spmal cord or central nerv-
ous system. Pelvic radiotherapy may damage blood
supply to soft tissue and nerves. Many drugs .and
medical conditions may affect unnary funcnon .
e.g. alpha blockers or anticholinergiC medlCanons,
Sjogren's syndrome, diabetes , mellirus, multiple
sclerosis, myotomas or lvlarfan s syndrome.
Types of urinary incontinence
Urinary incontinence may be defined by subjective
symptoms or objective diagnoses. More than one
type of incontinence may be present. Some com-
mon types are as follows:
Stress incontinence: a loss of urine associated
with activities that cause an increase in pressure
within the abdominal cavity - coughing,
sneezing, lifting or exercise. . '
Urodynamic stresS incontlDence: streSs mconn-
nence observed during a urodynanuc study m
the absence of a detrusor contracnon. . Exercising the levator ani group is not intuitive.
• Urge incontinence: loss of urine associated With
an uncontrollable desire to void . . It is usually
associated with detrusor instablhry, I.e. an
observed detrusor contraction associated With
the desire to void in a person who IS trymg to
inhibit micturition. ..'
Overflow incontinence or obstructlve mCODU-
nence: loss of urine due to a reflex contraCOO n
of an overdistended detrusor. .
• Vesicovaginal fistula : an abnormal conneCOo n
between the epithelium of the bladder and the
vagina, which may result from trauma, malig-
nancy, infection or radlOtherapy.
The effect of incontinence
on women
Surprisingly, many women regard incontinence as
a normal burden to endure and treatment is not
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-
sonal health, or because of embarrassment.
Incontinence may affect the quality of life and self-
esteem in many ways. Women may become social-
ly isolated due to the fear of embarrassing leakage
in public, urgency and frequency that is difficult to
control, and the fear of a urine smell. Stress incon-
tinence may affecr participation in SpOrt and exer-
cise. Leakage during intercourse may affect sexual
relationships. Significant leakage may also result in
frequent changes of clothes and bed linen, requir-
ing frequent laundering. Painful symptoms of cys-
titis and nocturia may affect sleep, leading to
chronic fatigue and depression.
Can urinary incontinence
be prevented?
Elective caesarean section is probably nor effective
in preventing further problems in parous women
who have abnormal bladder and bowel symptoms,
except where there is some anal sphincter disrup-
tion. Antenatal and postnatal pelvic floor exer-
cises have been shown to give short· term benefit
but long-term data are lacking.
History
Key features in the history include the woman's
age, the nature of the problem, the effect that the
problem is having on her life, the type and out-
comes of treatments that have been tried (if any),
in addition to medical, drug, Sutgical and social
history. Look for contributing factors (chronic
cough, neurological dysfunction, obesity, reduced
mobility or pelvic floor injury associated with
pregnancy or previous surgery) and the patient-
specific risks of possible treatments. Note antibiot-
ic allergies, as urinary tract infection may require
treatment.
You should establish what a woman means
by 'her problem', and specifically inquire about
other abnormal urinary or bowel symptoms,
symptoms of prolapse, sexual d ysfunction,
21 Incontine nce
oestrogen deficiency, emotional and psychiatric
symptoms.
Examination and investigation
Perform an abdominal, vaginal and pelvic exami·
nation to assess oestrogenisation, perineal excori-
ation, prolapse, pelvic masses and strength of
pelvic floor muscles. Ask the woman to cough and
record whether or not leakage was observed. A
urine sample should be tested to exclude infection.
Some expertS advise asking the woman to keep
a bladder diary, usually a record of times and vol-
umes voided, fluid intake and leakage episodes for
2 consecutive days or longer. Excessive and
reduced fluid intake can be assessed this way and
excessive use of bladder stimulants and substances
with diuretic properties (mainly drinks containing
caffeine) can also be assessed. This type of record
gives additional insight into the patient's bladder
function and habits and the diary can be com-
pared with a new record after treatment. The
bladder diary also gives an indication of the
woman's motivation.
Ma nagement
An othenvise healthy woman with stress inconti-
nence, no previous treatment and no urinary
infection should be instrUcted in pelvic floor exer-
cises. Pelvic floor exercises should be done regu-
larly: 10 separate, sustained contractions of the
levator ani group of muscles performed twice
daily are sufficient. After 6 months, about 50% of
women are happy with the results. Pelvic floor
exercises will also assist women experiencing uri-
nary frequen'CY, urgency and faecal incontinence.
Results may be better if an appropriately trained
physiotherapist, continence nurse adviser or medi-
cal practitioner with a special interest gives the
instruction. These professionals can provide edu-
cation, assess adequacy of technique and provide
additional motivation to the woman, and can offer
alternative methods such as the use of vaginal
cones, urethral plugs and biofeedback techniques
to wom en who are experiencing difficulry.
Although there is no data on the long-term out-
come of pelvic floor exercises, these exercises
should probably be performed lifelong.
tt'
Women's health : a core curriculum
Oestrogen supplementation, often given intra-
vaginally, is used as an adjunctive therapy in
postmenopausal women. To date no clinical
benefit for stress incontinence has been observed
in randornised controlled trials comparing oestro-
gen with placebo.
If surgery is being considered to treat stress
incontinence, urodynamic investigations are rec-
ommended, because cure rates for genuine stress
incontinence are reduced when detrusor instabil-
ity is also present. Detrusor instability is usually
diagnosed by cystometry and can also be observed
fluoroscopically.
In the beSt hands, surgery will subjectively cure
genuine stress incontinence in over 90% of cases.
Hundreds of operations have been described.
Complications include short-term or long-term uri-
nary retention, urinary, wound and cheSt infections,
haemorrhage, bladder perforation, very occasion-
ally ureteric injury, de novo detrusor inStability,
deep venous thrombosis and, rarely, bowel perfor-
ation. Surgery is expensive, requiring 1-7 days in
hospital and 2-12 weeks off normal activities,
depending on the operation, the patient and the
surgeon. The Burch colposuspension and the trans-
vaginal tape (TVIJ procedures are the moSt com-
monly performed operations at the present time.
Stress incontinence comprises 50% of cases of
incontinence. In the others, urinary incontinence
is due primarily to detrusor instability. If there is
an identified neurological cause, the diagnosis is
detrusor hyperreflexia. Spinal cord injuries,
stroke, diabetes and demyelinating disorders may
result in this diagnosis. Usually, there is no expla-
nation for the condition, and it is assumed that
there is a breakdown in the neurological pathways
that inhibit the detrusor muscle. This problem is
usually managed in a multidisciplinary way, with
pelvic floor exercises and bladder drill performed
under the supervision of a continence nurse ad-
viser or appropriately trained physiotherapist,
with anticholinergic and antispasmodic medica-
tions and oestrogen replacement in appropriate
cases. In all cases, attention is paid to fluid intake
and good bowel habit (especially avoiding consti-
pation). Bladder drill requires a conscious effort to
delay voiding. Experts recommend that women
drink at least l.5 L daily and minimise the use of
drinks containing caffeine and alcohol. About
600/0 of women report improvement in symptoms
with this type of approach. Operations devised for
stress incontinence or prolapse are inappropriate
when detrusor instability is the cause of the
woman's incontinence.
Obstructive incontinence means that the blad-
der emptying is abnormal, typically slow and
incomplete. Symptoms may be the same as for
detrusor inStability, and recurrent bladder infec-
tions may also occur with this condition. All oper-
ations for stress incontinence cause a degree of
obstruction to the outflow of urine. Outflow
obstruction in women that is not the result of sur-
gety is mainly due to detrusor failure. The reason
for the detrusor failure is seldom identified.
Intermittent clean self-catheterisation is the first-
line treatment for these cases.
Immobility can be an important contributor to
urge incontinence, simply as a result of the
woman's inability to get to the toilet in time.
Assistance may be required with household aids
and appliances, in addition to other therapy.
Often, a multidisciplinary approach is required
under these circumstances.
There are a wide variety of continence aids,
including various pads, nappies and permanent
catheters. Pads come in a variety of sizes, are
expensive and may caus.e chafing and contribute to
excoriation. Permanent catheters are the laSt resort
(due to discomfort and ever-present risk of infec-
tion) but will improve quality of life in women
with severe incontinence, when other therapies
have failed or are unsuitable.
* Faecal incontinence
Faecal incontinence can lead to social isolation
and reduced quality of life. Up to 7% of healthy
people over 65 years and up to a quarter of the
women attending urogynaecological clinics report
faecal incontinence.
Structure and function
of the lower gastrOintestinal tract
A detailed description of the embryology, structUre
and function of the lower gastrointestinal tract can
be found .in many classic anatomy and physiology
textS (Gray 2000, Ganong 2003) .
21 Incon tin ence
Causes of faecal incontinence
operative treatment, are unfit for surgery d
The causes of faecal incontinence are numerous not respond to surgery may, in conjunctiono
r
'rb
but obstetric trauma is one of the most common pelVIC floor exercises, try dietary malU·pul WI
factors Identified. Here the causes appear to be h f .. anon
t e use 0 Constipating agents (loperamide'
pudendal nerve damage and/or direct trauma codeme phosphate) or biofeedback. Manage '
to the anal sphincter complex. Trauma to the IS usually multidisciplinary. ment
sphincter complex is associated with forceps deliv-
ery,. high birth. weight, median epiSiotomies and
OCClPltO-pOSterIor fetal positions. Health maintenance
Preconception counselling and ante-
Investigation and management natal classes should Inform women
about incontinence and encourage
External sphincter defeers may be obvious at deliv-
the practice of pe lvic floor exercises.
ery. Third and foUrth degree tears (involving the
external anal. sphincter and anal mucosa respec- Pelvic floor exercises should be a reg-
ular port at a woman's life.
nvely) occur ill 0.5-1.0% of vaginal deliveries and
are highly asSOCIated with midline episiotomies.
. Sphincter trauma is more often occult and,
With anal endosonography, up to 35% of primi-
parous women can be shown to have evidence of References
sphmcter complex disruption. The mainstay of Ganong WF 2003 Review of medical physiology 21st edn
treatment IS pelv~c floor exercises. For obstetrical McGraw-Hill, ew York. , .
traumanc disrupnon of the sphincter complex, the
treatment IS usually surgical, using an overlapping Gray 2000 Gray 's anatomy of the human body, 20th edn.
external. sp~l?cter repair technique. Patients with Ba.rt!eby Com, New York.
lesser disability from incontinence who decline
Questions
2. For a 50-year-Old Australian woman
complaining of urinary incontinence.
1. Which of the follOWing is the most
whrch of the following Is true?
characteristiC of urinary stress
A ontinence?
~ OCcurs with a sudden increase in
a. She Is most likely to have a
vesicovaginal fistula .
rntra-abdominal pressure . b . She shOUld have an anterior repair
as the first step of management.
b . Considerable quantities of urine are
lost.
c. She is likely to have ureteric reflux.
c. Bed wetting OCcurs at night. 0 he should have urodynamic stUdies
d. There is a deSire to empty the
Q~erformed .
bladder again immediately after e. She is most likely to have had more
mlctuntlon. than three children.
e. It is most commonly found in
teenagers.
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

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

Skills

At the end of this chapter, the student

should learn how to :

• design a tailored plan for the

management of the menopause in an
individual woman

fIE
 Women's health: a core curriculum
22 The menopause a nd b
eyand

* The menopause arotllld late perirnenopause and early posrrnenopause.

Common clinical presentation
A 49-year-o ld married woman attends her Gp,
complaining of severe hot Hushes, night sweats,
sleeplessness, tiredness, recent Irritability, loss of
libido, Joint pains and urinary frequency. Her
periods have become heavy and Irregular.
There is a fam ily history of cardiovascular
disease, bowel Cancer and osteoporosis. She
smokes, drinks two glasses of alcohol per day
and has no time to exercise because she Is
busy with her part-time job, husband,
adolescent children and her elderly parents.
She asks for help, wants to 'go through
menopause naturally' and is hesitant about
taking hormones.
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-
idly increasing longevity, most women will now
live 30-40 years beyond the menopause. This has
brought women a new way of life and a new way
of death, with age-related diseases that were previ-
0usly uncommon - such as osteoporosis, heart
disease, dementia and cancer.
Premature menopause is usually defined as
ocaming under the age of 40 years and is experi-
enced by about 2q.-6 of women either naturally or
o\ving to oophorectomy for conditions such as
endometriosis, pelvic inflammatory disease or
malignancy. Those women born \vith gonadal dys-
genesis (e.g. Turner's syndrome) are particularly at
risk of the long-te= consequences of oestrogen
deficiency.
The climacteric consists of:
• the perimenopause, which is a phase of menstrual
cycle irregularity and fluctuating menopausal
symptoms for up to 4 years before the last men-
srrual period and for 1 year after the final sponta-
neous period
• the posrmenopause, which includes all the symp-
toms and sequelae of ovarian senescence and
which rnay be lifelong in some women.
Menopausal symptoms can be exp~ rienced at any
time during the climacteric but are more common
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
Psychological symptoms such as anxiety
Potential symptoms around depreSSion and unloved feelings ' •
the menopause Lo?omotor symptoms such as Joint Pa ins, muscle
pains and backache
Up to 80% of women around the menopause will
eventually experience some menopausal or oestro- • Urogenital symptoms such as dry vagina
gen-deficiency-related symptoms (Box 22.1). uncomforta ble intercourse ond urinary fr~qUency
Other putative menopausal symptoms are
muddled thinking and loss of memory. Loss of BOX 22.1 Oestrogen-deficiency symptoms
libido is not closely associated with the menopause
transition and is more associated with ageing,
Oestrogen_ Before 3 months 6 months
general health and psychosocial issues. deficiency
therapy after
A menopausal symptom score (Table 22.1) is a symptoms after
starting starting
useful way of detecting the onset of the peri-
menopause, monitoring the severity of the symp- Hot flushes
toms and the response to therapy. Women without Light-headed
menopausal symptoms or who are being ade- feelings
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
DepreSSion
Osteoporosis
I Unloved feelings
Loss of bone density occurs rapidly in the first few AnXiety
years around menopause with about a 15% loss in
the first 5 years. Bone loss continues at a slower Mood changes
rate thereafter with the risk of an osteoporotic Sleeplessness
fracture graduclly increasing. By age 65 years, one UnUsual Hredness
in four women has experienced an osteoporotic
Backache
fracture, by age 75 years one in three women has
had such fracrure, and by 85 years one in two. Joint pains
Some women are at particular risk of developing Muscle pains
osteoporosis (Box 22.2).
New facial hair
Osteoporosis is best diagnosed by bone den-
sitomerry at sites such as hip, spine and wrist (Fig Dry skin
22.1). The World Health Organization defines CraWling feelings
osteoporosis as bone densities more than 2.5 under skin
standard deviation units below the young normal
Less sexual feelings
mean (T score <2.5).
Preventative measures should be considered in Dry vagina
younger postmenopausal women with T scores Uncom fortable
between 1.5 and 2.5. Treatment should be intercou rse
recommended for all women who have a bone
Urinary frequency
mineral density (BMD) below 2.5 standard
TOTAL SCORE
deviations and in women who have had an osteo-
porotic fracrure. Seor
seve~ei~Pt"""" a s tallows Ni (0). MIld (I ). Moderate (2) and
TABLE 22.1 Menopause symptom score
-
Premature menopause
Family history of osteoporosis
• Previous low trauma fracture
• Low calcium Intake
Low bOdy mass Index «20)
EatIng disorders aSSOCiated with decreased
weight
• Immabllisation
• Lifestyle factors InCluding smoking, alCohOlism
lack of exercise or excessive exercise '
• Medical conditions that include prolonged
glucocorticoid therapy
BOX 22.2 Clinical ri sk fac tors for osteo porosis
*menopause
Management of the
There ~e many nonho=onal influences On a
woman s quallty- of-life around the age of
menopause (Fig 22.2). Psychological, social and
sexual ISSues need to be addressed. Lifestyle factors
are particularly impOrtant. Women should be
encouraged to maIntaIn their optimal weight
through diet and exercise (30 minutes of weight-
bearmg exercise each day), avoid excessive caf-
feme and alcohol (less than rwo standard drinks
per day) and stop smoking. Smoking has been
associated With earlier menopause and more
severe symptoms.
Nonhormonal therapies
Vasomotor symptoms may reduce with venlafax-
me, gabapennn or c1onidine. Psychological symp-
toms can be treated with antidepressants or
anxlOlytlcs and locomotor symptoms with anal-
gesICS or nonsteroidal anti-inflammatory agents
Lubncants may help a dry vagina and uncomfon~
a bje mtercourse and antispasmodic agents may
h e p unnary urgency and frequency.
lhJ:oesrrogens are present in foods such as soy
an 0ha er vegetables. In large quantities, these foods
rnay ve a modest effect on the amelioration of
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
Region
Neck
Words
Troch
Shott
Total
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
from menopause, The white square re p resen ts this patient's bone density . (Courtesy Alastai r
Maclennan/Department of Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital)
oestrogens such as isoflavones have not been shown
to have an effect greater than a placebo.
The ~ffect of a placebo on hot flushes Over sev-
eral months is usually around 50% and this should
be remembered when assessing the many commer-
cial claims of unregistered over-the-counter prod-
ucts for the menopause. Currently there are no
effective alternative (complementary) thetapies for
the menopause and irs sequelae. Most have no
long-term safety data.
Hormonal therapies
Postmenopausal hormone therapy (HT) differs
from the stronger synthetic oestrogens used in oral
contraception, in that HT usually contains the
human oestrogens, oestradiol or oestrone, or con-
jugated equine oestrogens which mostly
metabolise to oestradiol and oestrone. The average
~ ~
30 40 50 60 70 80 90 100
Age (years) changing
family role changing
BMD Young-Adult Age-Matched bOdy image
(g/cm 2) T-Scare Z-Score diffiCulty re-entering
workforce
0.893 -D,7 -D. 1
0.729 -1.4 -1.3
0.592 -1.8 -1.3 FIGURE 22,2 PSYChologica l, social and sexual Influences around menopause
0.970
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-
paInS appearing around m enopause may manon m healthy arreries. However, secondary
reduce with HT. cardioprevennon studies (i.e. in women wirh estab-
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
dose of oesrrogens used in HT is very much weaker of an osteoporotic fraCture . Irs advantages are detrnnental by destabilising the plaque ani in-
in potency than the synthetic hormones used in low COSt, high therapy compliance added cr~asJng adverse cardiovascular Outcomes by about
oral contraception. Thus, perimenopausal HT symptom concrol, low numbers-ne~ded-to­ 1o, o~jJer year (WHI 2002).
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
tive. In non-smokers, combined oral contracep- unscreened population. sought to determine whether HT had long-term
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
symptom control, menstrual control and comra-
the use of HT There is mixed evidence that HT symptoms or other indications for HT. The pri-
ception. Later, when menopausal symptoms are
Improves some aspects of cognitive function (e g mary outcomes were cardiovascular disease and
experienced during the pill-free week, a HT regi-
verbal memory and menopausal depressio~): breast cancer. Women were enrolled between the
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.
dIOvascular risk factors.
Indications for hormone therapy The combined HT arm (premarin and medroxy-
Hormone therapy and progesterone acetate) of the WHI trial was
1. Relief of menopausal symptoms. Systematic re- cardiovascular disease stopped <:fter 5 years, when it was deemed that a
views of randomised controlled trials show that decrease III cardIOvascular evenrs was unlikely to
Animal studies, laboratory studies and epidemio-
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-
vasomotor and urogenital symptoms (urinary cers had Just reached a predetermined conserva-
the age of menopause suggest that HT may playa
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
when indicated but are not merited routinely.
Mammography is recommended every 2 years or
yearly when there is a strong farruly history. of
breast cancer. It need not be more frequent dunng
Hr. A bone density scan (e.g. dual energy X-ray
absorbtiometry - DEXA - of hip and spme) IS
appropriate when this influences management. A
thrombophilia screen may be considered where
there has been a history of thromboembolism.
Pill, patches . paste , puff,
pessary or pellet?
Oral therapy is generally the firSt route of choice.
However, poor absorption or excessive metabo-
lism of oestrogen can occur ill the case of malab-
sorption disorders, irritable bowel syndrome or
the concurrent ingestion of H2 antagomsts for gas-
tric refllLx. If oral oestrogen is ineffecnve, then It IS
reaso nable to try rransdermal routes. Some
women prefer oestrogen and progestogen patches,
but when there are skin allergies or the patches do
not stick, an oestrogen gel may be preferred. An
intranasal oestrogen spray is another optIOn, giV-
ing less risk of breast tenderness. Skin sprays are
currently under trial. Local vagJOal oestrogens can
be given as pessaries or creams for vagJOai symp-
toms with minimal systermc absorption or effect
elsewhere. Implants are another way of debvermg
hormones, but over time there is a risk of tachy-
phylaxis.
Hormone therapy regimens
Oestrogen therapy should be continuous, and
doses can usualJy be given that ameliorate oestro-
gen-deficiency symptoms without glvmg symp-
toms of oestrogen excess, such as breast tender-
ness. Progestogen therapy, in combmanon With the
continuous oestrogen regimen selected, needs to
be given cyclically around the perimenopause to fit
in with the endogenous ovarian cycle and to aVOid
breakthrough bleeding. The progestogen IS usuaJly
given for 10-14 days per month. A predictable
period or withdrawal bleed usually occurs afrer the
cessation of progestogen therapy and often the
irregularity and heaviness of the penmenopausal
periods are improved.
After 4 years of cyclical progestogen therapy, or
if HT is commenced more than 1-2 years after
menopause, a postmenopausal regimen can be
continuous
Perimen opou se
L -_ _----:-' oestrogen
D~D~D~
cyc ~ cal
progestogen
progestogen wlthdrowal bleeds
conffnuous
Postmenopouse oestrogen
continuous
progestogen
contInuous
Affer hysterectomy L '_ _ __ _ _ ~ oestrogen
alone
FIGURE 22.6 Hormone t heropy reg imens
prescribed where the progestogen is given contin-
uously, usually at half the dose of the pen-
menopausal regimen. Ir is Important to counsel
that most women will have mmalmegular bleed-
ing and then sporting over the first 3-9 months of
a continuous progestogen and oestrogen regJrnen
before endometrial proliferation ceases and a
stable atrophic endometrium is established. There
is usually no need to investigate dirmOlshing ltreg-
war bleeding in the first 12 months after the IillO-
ation of combined continuous hormone therapy
regimen.
A woman who has had a hysterectomy usually
does not require progestogens and receives unop-
posed oestrogen therapy (Fig 22.6).
Testosterone therapy
There is insufficient data to clarify the optimal use
or long-term safety of testosterone. In some
women, it may help libido and anecdotally a fe~
may expe rience improvement 10 energy an
mood. Some may also expenence mcreased. fe~l­
ings of aggression and in excess it can have vmlis-
ing side effectS. There are currently no regIstered
preparations in Australia for women, although
low-dose injections and implants are often used,
especially in younger women who have had a pre-
mature menopause. A registered compound called
tibolone can have a mild androgenic effect m post-
menopausal women and can be used as an 'all-m-
. occupies
. and
one' postmenopausal therapy, as It
stimulates the oestrogen, progestogen and testo-
sterone receptors.
Options tor the management
ot osteoporOSis
In an older woman with cardiovascular risk fac-
tors and a recent low-trauma fracture but few
menopausal symptoms, a bisphosphonate (alen-
drcnate, risedronate or etidronate) may be an
appropriate option. In a woman who has had an
osteoporotic fracture and has breast cancer con-
cerns or fear of uterine bleeding, a selective
oestrogen receptor modulator such as raloxifene
should be considered. In younger women with
symptoms and low bone densiry, HT could
be considered. Parathyroid hormone and Stron-
tium ranaleate may be other therapeutic options.
Calcium, vitamin D, hip protectors and weight-
bearing exercise are adj uncts to the above evi-
dence-based therapies.
Length of therapy
Women can be treated for as long as they perceive
an improved qUality of life from the alleviation of
menopausal symptoms. This time varies greatly
from woman to woman and can be from months to
many years. It is reasonable for Women to have a
trial period off HT after 4 to 5 years of therapy. To
avoid rebound vasomotor symptoms, the dose can
be reduced over 1-2 months before cessation. Up CO
approximately 40% of Women may experience a
return of debilitating symptoms, warranting the
option of a further course of therapy after
counselling about the risks of longer-term therapy.
Often a lower dose can be recommenced with
effect.
Tailoring therapy
High continuance rates can be achieved with ade-
quate initial counselJing, early follow-up and tailor-
ing of the regimen to minimise start-up side effectS
and give effective relief of symptoms. After a satis-
factory regimen is established, yearly review is
appropriate. About 15% of women are sensitive to
progestogens and may experience premenstrual
feelings. They may require lower progestogen
dosages or an intrauterine progestogen delivery sys-
tem can be fitted that gives local endometrial
protection fo r 5 years without adverse systemic
effect.
22 Tho menopause and beYond
Long-term goals tor
healthy ageing
Increasing longevity has brought with it an
increased number of disability years. Disability
years are defined as those when an individual is in
the care of ochers for assistance with day-to-day
livmg. Women now have an average of 9 disabil-
ity years before death. The most common reasons
for disability are cardiovascular disease, locomOtor
disorders such as arthritis and osteoporosis, incon-
tinence and dementia. The men opause and its sub-
sequent management may influence all these.
There isa needJor more research into improving
the quality of bfe afrer menopause and reducing
the disability years.
* bPostm
enopa usal
leed ing
Common clinical presentati on
A 54-yea r-old WOman presents With vaginal
bleed ing 3 years after her lost menstrual
period .
Postmenopausal bleeding is a symptom, not a diag-
nosis. It refers to bleeding that occurs 12 months
or more after the last natural menstrual period.
The true incidence of postmenopausal bleeding is
unknown. There were over 46,000 hospital
admissions for diseases of the pelvic organs and
genital tract in Australia in 2000-2001 in women
over 50 years of age. }dany of these admissions
would have been for evaluation of post-
menopausal bleeding. Figure 22.7 shows the age-
adjusted rate of cancers of the endometrium and
cervix in Australian women. It can be deduced thar
most instances of postmenopausal bleeding are
due to benign causes.
Clinical evaluation
An appropriate history, examination and investi-
gations are required. Proper steps must be taken to
exclude gynaecological cancer, including referral
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
OJ
-0:
0 Ldl.J
,
20-24
J
30-34
1 1
40-44
~~~~~~e~2;~o~9:~~~~~~~~~~;~St~fo~~~~~r~f ~~~
not be found, will greatly reduce the woman's
anxiery. I . I
Identified risk factors for gynaeco oglca can-
cer may influence clinical declslOn making,
particularly when there is doubt regarding the
significance of the presentation (e.g. blee?mg
within 12 months of the 'last' penod). Tnese
risk factors include:
• past or current use of unopposed oestrogen
therapy d/ ' dr
• polycystic ovarian syndrome an . or syn orne
X' (obesiry, hyperrenslOn, Insulin reSIstance),
linked to endometrial cancer, pOSSibly as a
result of chronic unopposed oestrogen expo-
sure from ovarian and adipose sources
• nullipariry. . fusion, vaginal packing or emergency radiologI-
arypical endometrial hyperplaSIa
• abnormal Papanicolaou (pap) smear
previous gynaecological malIgnancy
• family cancer history .
tamoxifen therapy for breast cancer or ItS pre-
vention d b
• increased endometrial thickness measure y malignancy, but is more likely to miss benign
ultrasound.
Recent cessation or current use of hormones
may be a simple explanation for the bleeding.
Unscheduled bleeding in the fmt year of contInU-
ous oestrogen and progestogen hormone replace-
ment therapy does not need invesnganon but
• Cerlix
50- 54 60-64 70-74 80-84
Age
endome trium and cervix in Australian women
Heolth website)
endometrial biopsy and hysteroscopy could be
considered after this time. . initiate the presentation and may be confused
Speculum examination of the vagina and
cervix, a Papanicolau (Pap) smear, a bunanual
examinati.on of the pelvic organs and an abdonunal
examination must be performed. If hysterectomy
and/or oophorectomy have been performed, .the
histology and details of pOSSIble remammg ovarIan,
uterine or cervical tissue must be estabhsh~d ..
Blood loss is usually not heavy but. will influ-
ence decisions regarding management, Includmg:
urgency of referral to a specialist for evaluation
prescription of continuous oral progestogens
to manage bleeding . never have had a Pap smear. Cervical cancer may
• emergency transfer to hospItal for blood tranS-
cal or surgical intervention (all rarely reqUIred).
Benign causes of
postmenopausal bleeding
Hormone therapy (HTl is a very common cause o~
bleeding in postmenopausal women. In. thorough!)
evaluated younger postmenopausal women not tak-
ing HT, usually no cause is identified and It IS
assumed that the bleeding IS a result of narural
. ally'. b ' endo-
honnonal flucruation. OccasIOn emgn 6-
me trial polyps or subendometnallelOmyomata ~
broids) are identified and can be hysteroscopic Y
dyscrasias may be a cause of postmenopausal
bleeding. Vaginal infections hardly ever cause any
bleeding.
Non-gynaecological causes of
postmenopausal bleeding
It is very unusual for women to mistake rectal or
urethral bleeding for vaginal bleeding, but bleed-
ing from these sites should be considered and
evaluated. Prolapse or eversion of distal urethral
mucosa is common in elderly women and may
present with bleeding. Carers of these women may
regarding the site of bleeding.
En dometrial hyperplasia
Simple hyperplasia is not a premalignant condi-
tion. Atypical endometrial hyperplasia will pro-
gress to adenocarcinoma in up to 40% of cases,
may respond to progestogen therapy and is defin-
itively managed by simple hysterectomy (Lethaby
et aI 2003) .
Endometrial cancer
Endometrial cancer (usually adenocarcinoma) is
primarily a disease of older women (Fig 22.7). The
diagnosis is based on histology, with tissue obtained
by hysteroscopy and directed endometrial biopsy
or by dilatation and curettage.
Dilatation and curettage, although a blind sur-
gical procedure, is probably as effective as hys-
teroscopy and directed biopsy in diagnosing
tumours. Outpatient endometrial sampling is a
cheaper alternative but is probably less diagnosti-
cally reliable than hysteroscopy or dilatation and
curettage. However, if outpatient sampling makes
a positive diagnosis of malignancy, it is not neces-
sary to undertake hysteroscopy or dilatation and
curettage. Transvaginal ultrasound measurement
icaIly thin endometrium increase uncertainry as to
the place of this investigation.
Endometrial cancer spreads locally (lower
uterus, cervix and occasionally ovaries) and to the
pelvic lymph nodes. The preferred management is
tOtal abdominal hysterectomy, bilateral salpingo-
oophorectomy and pelvic node sampling.
Postoperative radiotherapy is offered to prevent
local vaginal cuff recurrence in appropriate cases.
If the disease is too advanced for surgery or the
patient unfit for surgery, pelvic radiotherapy may
be employed as primary management. Local
recurrence may be managed SUrgically, with radio-
therapy or chemotherapy. Ill! selected cases,
gonadotrophin-releasing hormone (GnRH) ana-
logues or high-dose progestogen therapy may be
utilised. Overall, 20-year survival is estimated to
be about 80% for Women diagnosed with
endometrial canc.er, but survival is poorer in older
postmenopausal women (Brenner 2002).
CervIcal cancer
Cervical cancer appears to have a bi-modal age
distribution (Fig 22.7). Women presenting in the
postmenopausal period with cervical cancer may
be suspected from a Pap smear, but the diagnosis
is histological, requiring a tissue biopsy for con-
firmation. Most cervical cancer is of the squa-
mous cell rype, but adenocarcinoma is be-com-
ing increasingly impOrtant_ Unfortunately, a Pap
smear does not as readily detect adenocarcin-
oma of the cervix.
Cervical cancer spreads locally (lower uterus,
cervix, vagina and adjacent Structures) and to the
pelvic lymph nodes. The preferred management
is an extended total abdominal hysterectomy
and pelvic node sampling or pelvic radiotherapy,
depending on available expertise. Sometimes, the
tumour is shruuk by radiotherapy before surgery.
In appropriate cases, postoperative radiotherapy is
offered to prevent local recurrence. If the disease

'IF
Women's health: a core curriculum
is too advanced for surgery or the patient unfit for
surgery, pelvic radiotherapy is offered. Local
recurrence may be managed surgically, with radio-
therapy or chemotherapy. Overall, 20-year sur-
vival is estimated to be about 60% for women
who are diagnosed with cervical cancer, with
poorer survival in older postmenopausal women
(Brenner 2002).
Other primary
gynaecological malignancies
The rare primary uterine malignancies (leiomyosar-
coma and other sarcomas), ovarian granulosa cell
tumours (which secrete oestrogen) or vaginal or
vulval cancers may present with postmenopausal
bleeding.
Su mmary
Most posrrnenopausal bleeding is unexplained or
due to hormone therapy, atrophic genital epithelium
or benign uterine tumours. Ho'.vever, a thorough
evaluation is required to exclude the uncommon but
important malignant causes.
Health maintenance
Lifestyle factors , psychological, social
and sexual issues, health education
and evidence-based management
options all influence the quality of life
in the peri- and postmenopausal
years.
References
Brenner H 2002 Long-term survival rates of cancer patients
achieved by the end of the 20th century: " pe ri od
analysis. Lancet 360 (9340) : 1131-1135 .
Lcthaby A, Farquhar C, Sarkis A et al 2003 Honnone
n.:placemenr therapy in posnnenopausaJ women:
endometrial hyperplasia and irregular bleeding. In:
The Cochrane Database of Systematic Reviews Questions
(The Cochrane Library), issue 2. O nline. Available,
htrp: IIWW'N.update-software.comlccchrane.
1. Which Is the most appropriate
hormonal regimen for a 56-year-old
MacLennan AH 2003 Horm one replacement therapy: postmenopausal woman with a uterus
where to now? Australian Prescriber 26 :8-10.
who has many menopausal
symptoms?
Maclennan AH, Lester S, Moore V 2001 Oral ocstrog"n
a. Comb ined cyclical oestrogen and
replacement therap y versus placebo for hot flushes.
In: The Cochrane Database of Systematic Reviews
cyclical progestogen
(The Cochrane Library), issue 1. Online. Available: b. Combined continuous oestrogen
htrp J /www.update-software.comlcochrane . and cyclical progestogen
WHI 2002 (Writi ng Group for the Women's Health c. Combined cyclical oestrogen and
continuous progestogen
Initiati ve Investigators) Risks and benefits of estrogen
plus progestin in healthy postmenopausal women. . Combined continuous oestrogen
Principal results from the Wom en's Health Initiative and continuous progestogen
Randomised Conrrolled Trial. Journal of the Ame rican
e . Cyclical or continuous oestrogen
M edical Association 288 ,321-333.
alone, depending on her wish for
periods
WHI 2004 (Women's Health Initiative Sreering
Committee) Effects of conjugated estroge n in
2. What Is the most common start-up side
posr.ffit:nopausa l women with hysterectomy. The
eH~ct of hormone therapy about
Women's Health Initiati ve Randomized Controlled
which a postmenopausal woman
Trial. Journal of th e American Medical Association
should be warned , along with less
291:1701-1712. common risks?
Zandi Pp, Carlson M C , Plassman BL et al 2002 (for the ~ lrregUlar bleeding
Cache C ou nty Memory Srudy Investigators) Hormone b . Breast tenderness
therapy and incidence of Alzheimer's disease in older
WOmen : the Cache County Study. Journal of the c. Breast cancer
American M edical Associarion 288 :2123 . d. Weight gain
6. Which of the following is correct?
e. Bloating
Recommended reading and 3. Which one of the following therapies is
useful websites not on eVidence-based therapy for the
reduction of osteoporotic fractures?
The Australian Institute of Health and Welf.re website a. Raloxifene
htrp:llwww.aihw.gov.aul
b. Bisphosphonates
The Australasian M enopause Society \\'cbsite, c. Vitamin D
htrp:llwww.me nopause. org.au. with links to tbe
Inte rnational M enopause Society, the North AmeriCln
Q Phytoestrogens
M enopause Society and the J ean Hailes Foundation. e. Hormone therapy
4. A well 55-year-old woman Whose lost
menstrual period was 4 ye ars ago and
who has never used HT presents with
vaginal bleeding . Which of the
follOWing is correct?
22 rhe meno POuse and b
eyond
a . Evaluation is not required if h
hod a hysterectomy. s e has
b . This is likely to be endomet · I
cancer. na
c. This is likely to be cervical cancer.
(3)The woman should be referred to
speclOllst for evaluation. a
e. An ultrasound scan to measure
endometrial thickness is mandatory.
5. A 70-year-old woman with osteoporOSiS
presents With light vaginal bleedln
She has recently stopped using or~I'
combined HT because of adverse
publiCity from the WHI study. Which of
the fOllOWing Is correct?
a. The bleeding is likely to be due to
,-() cervical cancer.
\::I The bleeding is likely to be due to
vaginal atrophic changes.
c . The bleeding Is likely to be due to
endometrial cancer.
d. The bleeding is likely to be due to a
Candida alblcans infection .
e . The bl.eeding Is likely to be due to
stoPPing HT.
a . Postmen opausal bleeding is
expected In women Who are taking
warfarin .
b. There Is never a role for oestrogen
supplementation for women with
postmenopausal bleeding.
c. A Pop smear is not necessary if a
woman is over 65 years of age.
. Hysteroscopy and endometrial
sampling are probably the best
diagnostic tests for postmenopausal
bleeding.
e. There Is no chance of endometrial
cancer If a woman presenting with
postmenopausal bleeding has a
normal transvaginal ultrasound
scan.
'tf b
*23
Principles of operative
gynaecology
Phil Watters and Clement Chan

Edited by Lucy Bowyer

Learning objectives

Knowledge write postoperative orders for

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

Skills

At the end of this chapter, the student

should learn how to:

toke informed consent for various

gynaecological procedures
assess a patient's suitability for major
surgery

'Ii

women's health: a co re curriculum
* Gynaecological * Psychologica l re sponse
to surgery
procedures
Gynaecological surgety involves organs of special
significance to body image and femlntnlty, and the
res onses to the need for surgery vary greatly
d ili
A 45-year-<>ld woman presents with
be;:'een individuals. PsycholOgical respons
menorrhagia that is poorly controlled by
affected by the premorbid personality an
medical therapy. nature of the surgery, whether It IS elecnve, emer-
gency life-threatening or With a grave prognosIs (e.g.
b,
adv~ced cancer surgery). Anxiety~. depresslO
Gynaeco Ioglca. I procedures can be described in an er and occasionally frank hosnlity may . e
several ways: en~ountered. It is helpful for the surgeobn to 'den~
. aI vulval vaoinal cervical, uterine, those who may face psycholOgical pro lems m t e
1. Anatonuc - ''''' . f th postoperative period and to ensure the panent IS
tubal or ovarian, or any combinauon 0 ese.
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
*
nary incontinence surgery). if
• Interruption of fertility (e.g. tubal ster lsa- Minor procedure s
tion) or menstruation (e.g. endometnal resec-
tion or ablation). h Minor procedures that are often performed alas out-
Su .cal - describing the route of approac . dau surgery with or Without loc anaes-
panent or J , . _.1 al skin andlor
3. (e.ivaginal, abdominal, endoscopic or a com- thesia, include surgery on the vwv
bination of these approach es). the cervix by cold knife (scalpel), electrosurgery or
laser procedures. . al
* Physiological response
Some minor procedures reqUire gener . or
regional anaesthesia. These include 'marsuplallsa-
tion' (forming a pouch of the cysrJabscess caVity
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
curenage' is also performed for incomp ete or
missed miscarriage or therapeunc abornon.
*
Intermediate and major
procedures
. . d rformed in hos-
These are more mvaSlve an are pe th . Most
pital under general or regional anaes eS' I
intermediate operations are performed as ay s~~d
gery but some intermediate and all major surgl .
ope;ations require hospitalisation. A laparoscop'c
on
or hysteroscopic procedure is the most comm ry
. .
minimally invaslve or nurum
. aI a
ccess surge
(MIS) performed in this category.
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
tissue dissection, the more likely the procedure will
be considered major. There are many advantages to
MIS: overnight hospitalisation is usually not
required or is significantly reduced; magnification
e using fibre optic insrruments enables significantly
improved close-up views of the structures and tis-
e
sues; convalescence is shorter; there are fewer
wound complications (e.g. pain or infection) with a
faster return to nonnal activities. However, there is
a long learning curve to achieve the required
expertise and in some cases the effectiveness and
the complication rates do not match those of the
equivalent conventional procedures. There are also
increased cOSts owing to the use of disposable
instruments. The time--<:ost-effectiveness balance
for each type of operation has to be evaluated and
will vary between different operatOrs.
Major operations involve removal of organs
(e.g. the uterus, with or without fallopian tubes
and ovaries) and generally require extensive tissue
dissection for both benign (e.g. severe endometri-
osis with serious anatomical and tissue distOrtion)
and malignant pathology. Extensive reconstructive
surgery, such as in the treatment of prolapse or
urinary dysfunction, is also considered to be major
surgery. These operations can be performed
vaginally, abdominally or laparoscopicaUy (or with
a combined approach).
* Preoperative plann ing
and consent
Preoperative preparation depends on the type of
procedure being undertaken, the age of patients
and whether they have any preexisting medical
disorders. It includes consideration of choice ,!Jf
an~ appropriate mood tests (e.g. full
blood count, urea and electrolytes, grouping and
cross-match of blood, as necessary) and inf~d
co~
Implied consent is usually accepted when a
doctor examines a patient. For operative proce-
dures, however, formal written consent is
required. This includes informing the patient
about the nature of the operation, the anticipated
duration of surgery and convalescence, and the
23 PrinCiples 0 1 operalive g yna ec olo gy
potential for intraoperative complications such as
haemorrhage requiring blood transfusion, bowel
and urinary tract injuries, and pOstoperative com-
plications including sepsis, thromboembolism,
severe adhesion formation and chronic pain. In
raday's litigious society and defensive medical
practice, more time than ever needs to be spent
ensuring that the patient is aware of the potential
risk. In a recent judgment, it was stated that a
material risk r.:~ anvrisk to which, once made
aware of It t anent would attaCh suiliificance
(United M edical Publications 2004). Deciding in
each case what is or would be 'significant' to each
individual is a part of professional responsibility
and can be the most challenging aspect of the pre-
operative phase.
* Pre-surgical interventions
The use of pre-anaesthetic analgesia and sedation
depends on the type and length of procedure.
Opioids such as morphine or pethidine, or seda-
tives such as benzodiazepines, are most often used
for major surgery, especially fo r radical surgery or
protracted operating times.
PrO~~Zlactic.nt~;: ! re fre~e~~~ recom-
mende f ryai' I nd for ro itita'nd
extensive abdominal Sllcgcry with an increased
ri~ction. Anticoa~s are given rourine-
ly to those with nsk factors, mcluding pr.::!.2nged
operating; ti[lle, Rostoperative immobility and a
previous history <iI thTomboembohsm.
Health maintenance
Preoperative preparation, in
particular informed consent and
assessment of a pati ent's surgical
risks , minim ises adverse outcomes.
* Postope rative ca re
The first44 hours afrerJWt!CFY is the period~en
thJLQaticnt is most ..YUlnerable to complications.
For illICW)ediarl MIll- m2 jQ~ry, parenteral
analgesia, intravenous fluids an monit!7I:'tn!(:Uf
temper'lifure, ~, blood pressure, r~iration
and UrInary output are reqUlred.In the 0 OWIng
---.....
'+, 7
Women's health : a core cu rri c ulum
days, attendants monitor the resumption of nor-
mal bowel peristalsis after abdominal surgery,
return to normal diet and early ambulation.
Physiotherapy may be required to minimise the
risk of postoperative lung atelectasis.
* Recovery from surgery
The impact of hospitalisation depends upon the
patient's family situation, occupation and social
support network. Physical recovery varies accord-
ing to the type and length of procedure; whether
abdominal or vaginal surgery was performed; if
the surgery was reconsrructive and if there were
Questions
1, Which of the following are mandatory
before gynaecological surgery is
performed?
~
naesthetlC assessment
urgical risk assessment
. formed consent
. Group and cross~match of blood
e, Prescription of prophylactic
antibiotics
concurrent medical disorders. Conditions where
the convalescent period is likely to be longer
include major surgery, laparotomy, reconsrructive
surgery for incontinence and surgery in the elderly,
with or without medical disorders.
Health m aintenance
Early postoperative mobilisation
reduces the risk of thromboembolism .
Reference
Unjted Medical Publications 2004 Risk Management. UMP,
Sydney.
2. Postoperative care for major
gynaecological operations includes
which of the following?
a. Observation of temperature, blood
pressure , pulse , respiration, urinary
input and output chart In the
Immediate postoperative period
b . Prescription of analgesia
c, Monitoring of bowel activity
d. Early ambulation
e, Abdominal wound care
O il of the above
Screenin g far bregst cancer
V
Principles of oncology
Edited b V Martha Finn
Screening for cancer of the cervix Jennifer Cook
Cervical carcinoma Jennifer Cook
Screening for breast cancer Phillip Carson
Endometrial cancer Bruce Ward
Gestational trophoblastic disease Marc JNC Kelrse
Cancer of the ovary Marc JNC Keirse
Learning objectives
Knowledge
At the end of this chapter, the student
Will be able to:
Cer vical carclnoa;1O
briefly describe the normal histology
and cytology of the cervix
descrlb~ the national recommendations
for cerVical screening and the national
reporting system for cervical cytology
write a flow chart to summarise the
mana~ement of an abnormal smear
and hlstolo~ical diagnosis of cervical
Intraeplthellal neoplasia (CIN)
summarise the pathophysiology of
metaplasia/oncogenesis with special
regard to HPV (human papilloma virus)
recogn.ise the public health implications
of cerVical carcinoma and Its
prevention
outline the management principles for a
patient With Invasive cancer of the
cervIx
identify the risk factors for breast cancer
describe the anatomy of the breast and
the variation in breast architecture
dunng the menstrual cycle and with
IncreaSing age
define the appropriate age group for
mammography
list other causes of an abnormal
mammogram
• outline the management of a patient
With a symptomatic or an asympto-
matic breast lump
describe the follow-up of an abnormal
mammogram
Endometrial c gaeer
indicate the prevalence of and list the
risk factors for carcinoma of the
endometrium
describe the postmenopausal changes
Inthe genital tract
out/ine the metabOlism of oestrogen and
list sources of unopposed oestrogen
describe endometrial hyperplasia and
Its relationship to carcinoma of Ihe
endometrium
list the causes of postmenopausal
bleeding (PMB)
• describe the investigations for PMB
• outline management principles for
cancer or.the endometrium
Ge..:!,atlonol trophoblastic disease
• understand Plocentatio-;:)and the early
formation of the placenta
Identify the chromosomal abnormalities
associated with hydatidiform mole
(Continued over)
'+1
 Women's health : a c<ore cunir;UhJm
(Learning objecNves continued)
discuss the difference between hydatidiform
mole, invasive mole and choriocarcinoma
describe the imaging techniques useful in
diagnosis and management of
trophoblastic disease
describe the role of HCG In the diagn?sis
and management of trophoblastic disease
outline the principles of management of
trophoblastic disease.
Cancer of the OvQlY
• Indicate the prevalence of cancer of the
ovary
• list the risk factors for development of
cancer of the ovary
describe the age distributions of the
various types of cancer of the ovary
relate the various types of ovarian cancer
to the structures from which they originate
provide a differential diagnosis for an
ovarian mass
discuss the investigation of a woman with
an ovarian mass
discuss the management principles of
ovarian cancer
* Screening for cancer
of th e cervix
Common Clinical presentations
A 30-year-old woman presenh; for a routine
Papanicolaou (Pop) smear.
A patient presents with the fol lowing Pop smear
report: 'There are scattered groups of atyp ical
squa mous cells with enlarged nuclei and
irregular nuclear margins. They show a. high
nuclear:cyfoplasmic ratio consistent With a
high-grade epithelial abnormality:
Cervical screening aims to prevent cervical cancer
by detection of precancerous leSions. Countries
that have adopted a national screenmg program
Skills
At the end of this chapter, the student
should learn how to :
perform a Papanicolaou (Pap) smear
advise a woman about an abnormal
smear and its management
inform a woman about the implications of
an abnormal mammogram and the
required follow-up
• outline a management plan for a woman
with an enlarged ovary
• advise a woman about the in v~stigotions
needed when ovarian cancer IS suspected
• counsel a woman about the type of
surgery that is likely to be necessary when
cancer of the ovary IS diagnosed
antici ate what may be necessary in the care
of a t~rminallY ill patient with ovarian cancer
explain to a patient the meaning of
trophoblastic disease.
A ttitudes
At the end of this chapter, the stUdent
should reflect upon :
the impact of a diagnosis of cancer on a
woman's body image and self-esteem .
the sense of loss and grief associated With
surgery for gynaecological cancer.
have seen a reduction in mortality from cervical
cancer of about 30%. Since the mtroclucnon of the
National Cervical Screening Program m the 1960s,
the incidence of and mortality from cervical can-
cer in Australia have dramatically declmcd.
Histology of the normal cervix
The ectocervix and vagina are normally covered by
stratified glycogen-containing squamous eplthelt~
(F 24 1) A prominent smgle-Iayered basal row
ce;~ de~~rcates the epitheliwn from the undcr~mg
stroma. The parabasal cells form the next !e~~
With further maruration, the Intermediate .
show less basophilic cytoplasrrt and decreasm~
nuclear to cytoplasmic ratio. The clearer (more aa
dophilic) cytoplasm contains abundant glycogen.
A slender layer of £lartened cells covers the sur~ce.
ormal squamous epithelium IS non-keranruse .
24 PrinCip les of OnCO logy
Cells
~~
~<!:>.c::::::!.:: ~ Superficial
<:::2~~
!::>~ ~
~<QS~ (ffjjJP
~~CS
Intermediate
8~0
~0 ffi0
0
-0-ffi
Porabasal
Cervical cytology
8888- Th e cytological fearures of squamous cells
removed from the surface of the normal cervix
G888GG[ 8 Basal reflecr the ltisrological appearance. Mature squa-
mous cells desquamated from the superficial layers
FIGURE 24.1 Cell layers In the stratified squamous are relatively large with acidopltilic (Pink Staining)
epithelium of the cervix and vagina (Based On cytoplasm. The nuclei are small and dense.
Symonds & Symonds 2004. p 347, Fig 24.9) Cytological abnormalities that suggest CIN
include: Increased nuclear to cytoplasmjc ratio,
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 .
ese
tion between the stratified squamous epithelium of changes re ect increased nuclear activity and
the ectocervix and me columnar epithelium of the poorer cell maturation and differentiation. The
endocervLx is the transformation zone. Here, a pro- increasing number and severity of these cyto-
cess of squamous metaplasia occurs, where the logical abnormalities correlate with increasing
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
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%
nancy. Conversely, during the postmenopausal have been reported in the literarure. They may
years, the transformation zone is often located result from either sampling errors or laboratory
within the endocervical canal. As the rransforma- errors. Although these are ltigh false-negati ve
tion zone is constantly changing, it is the site rates, they must be seen in the Context of the rela-
where cervical intraepithelial neoplasia (CrN) is tively long premalignant period of cervical neopla-
most likely to occur.
sia and the policy or taking smears at 2- or 3-year
intervals. A 3 ~earl~ screening program willEre-
Cervical intraepithelial neoplasia vent rna arc~o of cases of cervical c;U;cer.
Cervical ;:aepithelial neoplasia fC~ i~: ~sro­
The alse-posIOve rate IS a out .
logical diCos!s ilgraded With pCsi sver- The false-negative rate of cervical cytology in
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
dysplasia and severe dysplasia/carcinoma in siru. In may not shed abnormal epithelial cells.
Clli.l.(Fig 24.2), cellular rnaruration is presew d , The -dHW h,clIllt used to perform a smear
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,

FIGURE 24.3 Histological appearance of CIN 2,
Although there is some surface differentiation
of cells, the deeper la ye rs show marked
nuclear Irregula dty. (Photo courtesy EriC
Hu / Royal Darwin Hospital)
There is lack of differentiation, With Ihe
disordered cellu lar pattern Involving the full
thickness of the epithelium , The basemen t
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
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
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
inconclusive for high-grade epithelial abnormality
shows some, if not all, cytological characteristics
of a high-grade epithelial abnormality. A smear may
be unsatisfactoty if obscured by blood or exudate.
Management of the abnormal smear
Ten per cent of smears will be reported as abnor-
mal. Of these, 900/0 will be squamous abnormalities
and less than 1 % will be endocervical (glandular)
abnormalities. Women can generally be reassured,
as the vast majgrirY will not hays cancer.
An JlPsatisfactory smear should be repeated
6-12 weeks later, Care should be taken to avoid
tc:,sdng in the presence of blood or infection. P;;;y
infection should be a ro nate! treated befOre
,~~~~~~~~~~~~~~~~~~o r­
m resu t er51sts ew hould be referred
for co poscopic examination of her cervIX. All
women with smears of high-grade abnounaJUY
shoUld be promptly referre<Hor cOlposcopy.
My woman who presents wuh symptoms sus-
picious of cervical cancer (e.g. postcoital bleeding
or purulent bloodstained discharge) or clinical
signs of cancer (e.g. contact bleeding or the
appearance of an exophytic, crumbly rumour or
an irregular ulcer on the cervix) should immedi-
ately be referred for colposcopy, irrespective of
cervical cytology.
Colposcopic examination
of the cervix
Colposcopy allows a visual examination of the
cervix to check for the presence of CIN. The col-
poscope is a magnifyin instrument with a ii't
attac e. e rans ormatIon zone must e VISU-
alised to establish the examination as satisfactory.
After initial ins ec 'on f the cervix Lu ol's
iodine IS a e . Both low- and . - a e eslOns
s ow eVldeD' of f cogen degletion. The
cervIX IS then painted wi d ilute acetIc aCiO. This
is taken up by abnormal cells, w hiCh rum white.
Suchaceto-white lesions are associated with CIN
because osmotic dehydration accenruates the high
comem of optically dense chromatin. The gr.591
24 PrinCipl
as ot On Co log y
* Cervical carcinoma
Common clinical presentation
A 50-year-old woman presents with a 2-month
history of Postcolral bleeding . She has never
hod a smear test. On speculum examlnatlo
icant aceto-w .te areas.
friable sort moss is seen on the cervix, WhIC;' a
bleeds on contoct.
Adenocarcinoma-in-situ
Adenocarcinoma-in-siru (ACIS) comprises 0.5-20/0
of in siru carcinomas of the cervix. Most col po-
Jervical ~ancer is the second most common cancer
scopists would agree that ACIS has no specific col-
la nose m women after breast cancer
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
Management of CIN IieatCh Issue. IC
or postmen0J'a sal bleeding. Patients '-;\:6
. dis"""
(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
Recta bleedmg iO'cates spread to th - I'
speamen for analysis and can be performed under ~ e recta
local anaesthesia. The arE. of SlISpecred eIN is
removed to a depth of about 10 mm using a semj-
• Human papilloma virus
arCUIai shaped diathermy wire. Complications
indude na~ge, 1% mcidence of cervical • Smoking - double risk
stenosis an cervical inco m pe[egc;~. • Early age at coitarche (double risk It less th
~ernative methods include laser ablation, in 16 years) on
which an intense, highly focused beam of light can
be used to cut or bum the abnormal tissue, and
• ~~~~~~~dsexual partners (> 10 partners results In
Increased risk)
cryterapy, which destroys abnormal cervical tissue • Age 35-39 years and 60-64 yea rs
by eezing it. Neither method, hOwevf'5 provides
tissue for pathological examination. iathermy, • A portner with cancer at the penis - relative risk 8
cryosurgery and laser have comparable success rates • A portner whose previous partner(s) had
of the cervix cancer
for treating CIN 1 (95 %) , and CIN 2 and
• Herpes vi rus may be a co-factor in HPY
3 185-90%).
transformation of cells
A coviap,,!, is performed if there is~
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
~ 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
oral contraceptive pill may Increase the risk e
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
C s associate with this procedure ~es s of atypical cells with squamous tronscrlptlon
include infection, haemorrhage, cervical stenosis lrferlenHtiation. (Photo court esy Eric Hu/Roya l
Darw n os pita I)
and cervical incompetence. sox 24.1 Risk factors for cervicol cancer
'+1
Women's health: Cl cora curriculum
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~
(fable 24.1). An exarruriartOfi of die patient under
be a tender pelvic mass in advanced disease. A
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
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
consl ered a component of extended clmlCa
of disease to the rectovaginal septum and para-
Staging.
Treatment
External mac nodes ----11--1--1_ V
Internal Iliac nodes
PorometrfaJ node
~~~:k"o
\
Superficial femolel node
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
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)
sac ra l. ob turator and superficial femora no es ..
24 PrinCIPles 01 OnC Olo gy
0
Stage Extent of cancer
Concer-in-situ
* Screening for breast
cancer
I
Cancer connned to cervix
II Cancer has extended beyond the cervix
but not to the side wall
• • ..... - . .
A 48-year-<>ld mother at three teenagers Is
III Extension to side wall (no cancer-free
space on combined vaginal and rectal
worried about dying from breast cancer otter
discovering that her mother has just been
examination). Includes extension to
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
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
dysfunction denervation). Surgery is associated and life c ycle
W It 1% morta ity.
The rudimentary breast develops under the influ-
PrognOSis ence of oestrogen at puberty. The primary func-
Five-year survival for patients wjtb stage mmA. tional structures are 15-20 heterogeneous lobes,
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
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,
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
luteal phase of each menstrual cycle, induce meta-
bolic and structural changes in the epithelial and
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
involution of radiologically dense glandular tissue
and replacement by radiolucent fat. Involution is
slowed by oestrogen replacement therapy.
Benign conditions
Benign conditions of the breast follow an
age-related pattern. They may give symptoms in
their own right but mainly provide a differen-
rial diagnosis for cancer. Fibroadenomas are
benign, firm, smooth round mobile neoplasms
that occur in the 20-35 -year age group .
Fibroadenosis (fibrocystic disease) presents as a
lumpy, sometimes tender area of breast tissue in
older premenopausal women (35-50 years).
Cyst formation, fibrosis, epitheliosis and adeno-
sis occur in various combinations. This condi-
tion is so common that it is probably a variant
of normal ageing. The two conditions of
fibroadenomas and fibroadenosis account for
the majoriry of symptomatic presentations in
younger women. Mammary duct ectasia
(periductal mastitis) may present as sponta-
neous nippl e discharge in 40-SS:year-
old women. It tends to %j0di:C ~f.rc~ or
brown dl~rarge fr0r m_tl P __ d_!:r. _he r
thanthe fdody disc arge from a sjni\le puct
that can be IDdicative of an Intraduct papilloma
or ~arC1noma
Concepts of pathogenesis
of b reast cancer
The epithelium of the breast ductS may undergo
progressive change from hyperplasia, arypical
hyperplasia and carcinoma in-siru to invasive can-
cer capable of metastasising. The initiating stimuli
and the sequential genetic changes accompanying
these morphological changes are not fully cate-
gorised. The rate of growth varies, bur most inva-
sive cancers are likely to have been present for
more than 3 years before they become palpable at
1 cm in diameter. The ability to metastasise in-
creases with time and size of rumour but can occur
early. This imposes a limit on the benefit gained
by early diagnosis of invasive cancer, which relies
on the detection of a solid mass.
Ductal carcinoma in-siru (DCIS) tends to shed
necrotic cells into the duct lumen, which can subse-
quently calcify and display characteristic mammo-
graphic patterns (Fig 24.10). The natUral history of
DCIS is incompletely understood, bur it is likely that
most DCIS will in time progress to invasive cancer.
Risk factors
After gender and age, family history is the most
important factor in predicting the risk of breast
cancer. However, less than 50/0 of breast cancers
occur in women wj t6 a significant family history.
Women with a fi rst-degree relative diagnosed with
breast cancer before the age of 50, or cwo firSt- or
second-degree relatives on the same side of the
family, have a moderately increased risk (1 in 8 to
1 in 4 lifetime risk). High-risk women 1 in 4 to
in 2 lifetime risk) wi . able autosomal do '-
nan pattern 0 inherirance account fo r less tban
1%-;;f all breast cancers.
'OIlier nsk factors for developing breast cancer
relate to the hormonal environment of the breast.
They include lo!:, 'j1a:i=ity, late first pregnancy, shon
period of breaStfe~ding, earry menarche and~
menopause, exogenous oestrogen and possibly
o~d excess alcohol consumption. These
have a minor influence on the individual nsk bur in
a population setting may account for most of the
international and historical variation in incidence.
FIGURE 24. 10 A magnified mammogrom of
resected breast tissue that demonstrates the
linear. bronching pattern of calcification
associoted with ductal carcinoma In·sltu
(DC IS). The calcification occurs within nec rotic
cells shed In the lumen of breast ducts. The
staples seen centrally are used to orienta te
the spec imen . (P hoto co urtesy Peter
Farkas/Royal Dorwin Hospita l)
Screening modalities
Mammography is the primary breast imaging
modality In women over 35 years and is the only
modality that has been shown to decrease breast
cancer mOrtalIty in Whole-population screening
(FJg 24.11). Mammography becomes more sensi-
nve and specific in the postmenopausal age group.
Ultrasound IS a commonly used breast imaging
modality that is particularly helpful in dense
younger breasts or in. funher characteriSing mam~
mographic abnormalines (Fig 24.12). It can be
FIGURE 24. 11 A typical mammogrophlc
appearance of a small invasive carcinomo
presenting as a Splculoted. distorting moss '
leSIon (arrow). This c on cer also has some
central calcification. More subtle a symmetric
densities or architectural dIsturbances may
also be diagnostic of cancers. (Photo courtesy
Peter FarkOS/Royal Darwin Hospital )
24 Pr inCip les of oncology
.FIGURE 24.12 An ultrasound image of on
Invasi ve cancer, which is seen as on Irregulor
mass (solid arrow) with posterior acoustic
Shadow ing (o pe n arrow) . (Photo courtesy
Peter Farkas/ Royal Darwin Hospital)
used as a screening tool in young or high-risk
women but has not been subject to rigorous pop-
ulaaon screerung trials. Magnetic resonance imag-
Ing . (MRI) IS a hIghly senSlUve modality, which
may have a place ill screening very high-risk
Women. Regular breast self examination and regu-
lar exarmnanon by a doctor have not influenced
breast cancer mortality in population screening
srudles. However, breast awareness and early
reporting of changes is likely to account for
unproved case monality between high- and low-
illcldence populations.
Population-based breast cancer
screening programs
The ideal screening modality is sensitive, specific,
cheap, harmless, acceptable and accessible to the
target population. The OUtcome of the disease
must be able to be influenced by early diagnosis.
There IS no Ideal screeni ng rest for breast cancer
by the above definition, but mammography is the
best available Opnon. The best estimates suggest
that, if a woman undergoes 2-yearly, cwo-projec-
non mammography from the age of 50 years, she
WIll decrease. her nsk of dying from breast cancer
by 35%. This effect is diluted in a population-
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
mortality in screened populations of around 20%.
The maximum effect is seen in the S0-70-year age
group. Breast Screen Australia therefore targets
asymptomatic women SO-70 years old, with 2-
yearly biplanar mammography, but women aged
40-49 years and over 70 years are also eligible to
attend. Women in the moderately increased risk
group are screened yearly, while those in the high-
est risk group are best screened by multiple modal-
ities outside of the national program.
Opportunistic screening and
evaluating symptomatic women
Mammography can be normal in up to lS% of
breasts containing diagnosable cancer. In addition,
screening mammograms are interpreted in the
absence of a history and clinical findings, and there-
fore cannot target symptomatic areas for special
attention. It is therefore most important that women
with clinically worrying breast symptoms or a pal-
pable abnormality are not falsely reassured by a clear
report from a screening mammogram. Evaluation of
a breast lump by the triple test is highly specific in
excluding malignancy and avoids open biopsy in the
majority of cases. The triple test combines the clini-
cal examination findings with appropriate imaging
(marnmography or ultrasound) and percutaneous
biopsy (either fine-needle aspiration biopsy, FNAB,
or core biopsy). A more invasive biopsy is recom-
mended if one or more of the components of the
triple test arouse suspicion of malignancy.
* End ometri a l ca ncer
Common clinical presentation
An obese 62-year-<lld woman presents with
postmenopausal bleeding.
Adenocarcinoma of the endometrium is a disease
of affluence. There is a rwenty-fold difference in
incidence throughOut the world, with the highest
rates in the developed countries and lowest in the
third world, even when controlled for life
expectancy by age standardisation.
In Australia, there has been a S% increase in
the incidence of endometrial cancer and a 10%
decrease in mortality in the decade before 2000.
Endometrial cancer is the commonest gynaecolog-
iear iIiahgnang In Australia, With more than 1400
neW'"Cases and more than 2S0 deaths occurring
each year.
Epidemiology and relationship
with oestrogen
or exogenous oestro en
unopgQse y profestogens are lID~o rtant.
DUrIng norma menstrua:! eyc es, oestrogen
action is counterbalanced by progesterone pro-
duced after each ovulation, and endometrial proli-
feration is thereby controlled. In anovulation or
oli o-ovulation, ro esterone release is r hyperpl~la and malignancy.
a sent or infre uent, an uncontrolled
ri pro 1 eranon can occur. normally high
levels of oestrogen can be seen in women with
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.
Polycystic ovarian syndrome combines the factors
of obesity, insulin resistance and oligo-ovulation
with consequent unopposed oestrogen. In women
receiving unopposed oestrogen as hormone
therapy, a practice common in the United
States in the 1960s and 1970s, abnormally high
oestrogen levels were generated. In these situa-
tions, abnormal endometrial proliferation was
observed, with patterns of simple hyperplasia,
atypical hyperplasia and endometrial carcinoma.
Si~ficant protection is afforded b~ use of
the orat contraceptive pill dunng tlKW l:Qd.tlciY.e
penoo; and by parter. POSCSSW'W' 1M I n;;;&!:{ll;
24 Pri rl c ip les of On Cology
bi~strogen/progestogen hormone therapy
dence that screening procedures su ch
r~ or a sequennaI oeStrogen/progestogen reg-
Imen, where the progestogen is given for more than sound or endometrial sampling are h~s ~ltr~­
asymptomanc hlgh-nsk women e g b p m
10 days per cycle, confers a decrease in risk. survivors on tamoxifen. ' . . reast cancer
WI . family history of endometrial
bre~st or ovarian cancer are at mcrease ns ' Pathology
whde 60% of women aHected by the heredltar;
nonpolyposis colon cancer (HNPCC) syndrome Precursor lesions to endometrial cancer ar
. 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
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
a
of [lsk treated With adjuvant tamoxifen.
th lik lih d
e e 00 of progression related to the degr
of cellular atypia found within the hyperplasi~
Presentation Slffiple or CYStiC hyperplasia carnes a risk of malig-
The majority of diagnoses are made in response to nant development of less than 1%, while atypical
abn~a! yaglD a ! bleeding - postmeno a al hyperplaSia carnes a nsk of concomitant cancer of
ble~ heavy or abnormal menstruaT I(}ssY~r lS% With a 50% risk of subsequent development
Interm~t:cJ.al..lt)ss. Soble Ovdlian ldIfiours may of carCinoma if untreated. Progestogen treatment
secrete oestrogen and predispose to endometrial has the capacity to reverse the morphological fea-
cancer. OccasIOnally, [he diagnosis is made by tures of endometnal hyperplasia, but not the
findmg endometrial cancer cells on a cervical malignant potential.
smear, these celis being exfoliated and discharged The most common malignancy of the endo-
through the cervIX. The finding of normal metrIum . IS a carcinoma that reflects the
endomettlal celis On ceryical smear is of no clini- endometnold lIneage, with or without associat-
cal SlgrIiflcance in the premenopausal woman but ed squamous differentiation (Fig 24.13). Rarer
should prompt endometrial sampling in the ;ost- histologIcal types (generally representing a more
n:enopausal woman because of the 10-15% asso- aggressive natural hiStory) include clear-cell
Ciation b~rwecn such findings and endomerrial hIgh-grade. squamous, mixed mesodermal 0;
serous paplilary carcinomas. Sero us papillary
The diagnosis may be suggested by the finding
of an abnormally thick endometrium seen on
ultrasound examination for another gynaecologi-
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-
ca use m the premenopausal woman because of
the Wide range of thicknesses seen throughOut the
menstrual cycle.
Diagnosis
FIGURE 2 4. 13 Endometrial Carcinoma:
endometrl o ld carCinoma with Irregular
glandula r structures . (Phato Cou rtesy
Enc Hu/Rayal Dorwin Hospltol)
II;
•
Women's health : a core curriculum
carcinomas are particularly aggressive with poor
prognosis seen even in well-staged, surgIcally
confirmed, localIsed dIsease. EndometrIal stro-
mal sarcomas are rare, often of low-grade malIg-
nancy, and have a propensity for local recur-
rence rather than metastatic spread.
Tumour grade (G1 - well di£ferentiat~d, G2 :-
moderately differentiated, G3 - poorly dlfferenn-
ated or anaplastic) is a strong indicator of blOlogl-
cal aggressiveness and the probabIlity of meta-
stacie spread.
Investigation, staging
and treatment
While the clinical staging of endometrial cancer is
surgical (Table 24.2), a preoperative chest X-ray IS
important to prevent unnecessary radical surgery
in those with disseminated disease.
At surgery, peritoneal washings are taken as an
initial step, followed by total hysterectomy and bilat-
eral salpingo-oophorectomy. While the tumour
grade may be known preoperatively from the
endometrial biopsy, an illrraOperatlve assessment
Stage Extent of cancer
Confined to the uterine body
A no myometrial invasion
B invasion of <50% myometrium
C Invasion of >50% myometrium
Extending to cervix
A no cervical stromal invasion
B cervical stromol invasion
III Outside the uterus
A extension through uterine serosa or
positive peritoneal cytology
involvement of adnexal structures
C Involvement of pelvic or para-aortlc
lymph glands
IV At distant site
A invasion of bladder or bowel mucosa
distant metastases or involvement of
inguinal nodes
TABLE 24.2 Staging of endometrial carc inoma
needs to be made of myometrial in6.ltration by
tumour. This can be done with the naked eye or by
frozen section. The object of this assessment is to
categorise the risk of nodal metastases to triage those
cases needing node dissection. Pelvic and para-aomc
lymph glands drain the uterus and these need w be
removed in cases where the risk of nodal disease
exceeds 5% (G1 and G2 cases with myometrial
invasion greater than 50%, all G3 cases, all clear-cell
or serous papillary cases). ..
Racliotherapy is offered to women WIth disease
that has spread beyond the uterus. It has not been
shown to reduce mortality but may allow better
disease control in the irradiated area. Women with
clisseminated or recurrent disease should be man-
aged on an individual basis, with surgery, racliation,
chemotherapy and hormonal treatment all having a
role. High-dose proge.>l:ogen therapy will produce
a clinical response in about 30% of wome~ WIth
few side effects. Responses are most likely ill the
more highly clifferentiated tumours, which more
often express oestrogen and progesterone recep-
tors. Chemotherapy may also be offered to women
with symptomatic clisseminated or recurrent diS-
ease with reported response rates of up to 80% and
50%, respectively. The most cffecnve agents are
carboplatin, Taxol and Adriarnycin.
Prognosis
Because more than 800/0 of women '.'.'i.th endomet-
rial cancer present with localised disease, the ~ut­
look is ge~erally favourable, with 5 -year SU[YIval
in women with accurately staged localised clisease
in excess of 90%. Prognosis becomes poorer with
the finding of metastatic nodal disease. Surglcal
removal of involved lymph glands results ill a sIg-
nificant improvement in survival . .
Prognosis in poorly staged clisease drops off
through the effect of unknown metastatic disease.
Adequate disease-staging also plays an tmportant
role in preventing treatment-related SIde effects
and complications, most of which relate to adJU-
vant radiation treatment. The use of intraoperanve
assessment of risk and appropriate triage of
women to radiation has substantially decreased the
numbers of women having radiation, with no loss
of efficacy of treatment.
The 10% i'11provement in overall survival for
women with endometrial cancer that has been
recorded in AUStralia over the last decade is most
likely due to a combination of earlier detection
more effective treatment and lower treatment:
related mortality.
* Gestationa l
trophoblastic disease
A primigravida presents at 12 weeks' gestation
with minor vaginal bleeding and an enlarged
uterus. Ultrasound reports the presence at an
ovarian cyst. likely to be a luteal cyst. ond
multiple vesicular structures In the uterus.
o They occur in association with a pregnan1R"
ranging from early pregnancy loss up to a fU-
term normal pregnancy.
o Their DNA alwar: cliffer from that of the
patient's own UN_
o Human chorionic gonadotrophin (~~
produced b~ the trQphoblast is an e~
tumour mar er, allowing reliable cliagnosis and
management.
o They are ~ sensitive to chemotherapy as to
permit a nearly 100% cure rate, often wu hout
loss of reproducnve fUncnon. __
Benign molar gestation
hydatidiform mole
In a molar pregnancy, the products of conception
consist largely of numerous clear vesicles that vary
24 PrinciPles a t OnCology
FIGURE 24.14 Complete mole : enlarged
chorioniC villi with cystic swelling and
trop hoblast prOliferatio n . (Photo courtesy
Eric Hu/Roy al Darwin Hospital)
in size from a few millimetres to more than 1 cm
and resemble a bunch of grapes. Microscopically,
they resemble chorionic trophoblast, further char-
acterised by oedema in the stroma, loss of capil-
laries and profound trophoblast proliferation at
the surface (Fig 24.14).
There are two main forms: the classic complete
mole and the partial mole. The differences
between the two are summarised in Table 24.3.
In early pregnancy there are no distinguishing
features between a molar and a normal pregnancy,
except for a greater likelibood of hyperemesis
and - more rarely - early development of pre-
edampsia Or hyperthyroidism. Later, the uterus is
unusually large for dates and feels very soft. Ultra-
sound provides a classical picture caused by
the many vesicular structures present (Fig 24.15).
Except with a partial mole, fetal Structures and
fetal heart action are absent. Ultrasound may also
inclicate the presence of ovarian cysts (luteal cysts
resulting from the high HCG levels). Vaginal
blood loss, sometimes containing a few of the
characteristic vesicular Structures, may be the fjr~1:
sign (it usually occurs later in pregnancy than the
blood loss associated with threatened miscarriage
or ectopic pregnancy).
With a partial mole, embryonic death usually
occurs first, followed later by miscarriage, ofren
after the end of the first trimester (13-16 weeks),
or a 'missed abortion'. It is often recognised only
by histological exam ination of evacuated products
"
Women's health : a core curriculum
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
treatment-resistant persistent trophoblast ill the
uterus can usually be cured by·· multidrug
chemotherapy without losing subsequent repro-
ductive function. Surgical excision of localised
metastatic lesions that are relatively resistant to
chemotherapy (e.g. in the lung or an easily acces-
sible part of the brain) may be warranted to reduce
rumour load.
In the absence of metastases outside the pelvis,
99% of patients with persistent trophoblastic dis-
ease can be cured, with 95% maintaining repro-
ductive function if they so desire. However, 5 -year
survival rates are markedly reduced when brain or
liver metasrases are present and dismal when both
are present.
Recurrence
Molar pregnancies carry a risk of recurrence in a
subsequent pregnancy from 1-1.5% after a single
molar pregnancy to 20% after [WO or more molar
pregnancies. Therefore, ultrasound (at 10-12
weeks) is recommended for early diagnosIs ill sub-
sequent pregnancies.
degree relatives with ovarian cancer have almost a
40% chance of developing the disease. There is
also a relationship with the number of ovulations,
in that long periods of anovulation (for example,
during pregnancy and oral contraception) offer
some protection.
Origin of ovarian cancers
The ovary contains surface epithelium, primordial
follicles and ovarian stroma. It thus gives rise to
epithelial rumours, primordial cell (germ cell)
rumours and stromal rumours (Box 24.3), all of
which can be benign, malignant or borderline (also
referred to as 'low malignant potential'). In addi-
tion, the ovary may harbour malignancies that
arise elsewhere in the body (e.g. Krukenberg's
rumour, originating from the gastrointestinal
tract). Overall, roughly 70% of ovarian rumours
are benign, 200/0 are malignant, and 10% are bor-
derline malignant.
Epithelial cancers
Ninery per cent of ovarian cancers are epithe-
lial rumours. The ovarian epithelium - like the
endometrium, the lining of the cervix and the fal-
lopian tubes - originates from the coelomic epitheli-
um of the miillerian duct. Through meraplasia, the
serous Ovanan epithelium can evolve towards the
other epithelia from the miillerian duct, and this
determmes the histological characteristics of epithe-
lial rumours (Box 24.3). Most frequently, they main-
tam the serous ovarian characteristics. Next, in
decteasmg order of frequency, is change towards the
endometnum (endometrioid tumours, which should
not be confused with endometriosis) or towards
endocervical epithelium (mucinous tumours). Clear-
cell tumours (related to endometrioid rumours) and
Brenner rumours (related to fallopian tissue) are less
co rrun on . The histological type has some prognostic
Significance, as endometrioid tumours are more
likely to be malignant than serous rumours and the
latter are more likely to be malignant than mucinous
tumours. However, all of these rumours can be
benign, malignant or of borderline malignancy (low
malignant potential).
Clinical presentation
In its early stages, ovarian cancer is asymptomatic
and IS discovered fortUitously during examinations
Haematogenous spread is rare and Usually occurs
only late m the process.
Investigations
In young women, ovarian enlargement up to 6 cm
In diameter may be caused by simple cysts, which
WIll resolve Spontaneously. Persistence or greater
enlargement should be thoroughly investigated, as
should any ovanan enlargement in post-
menopausal women. Investigations include: a full
general examination; breast, pelvic and rectal
examination; full blood COUnt; serum urea and
electrolytes; liver function tests; and tumour
markers, such as CA-125, HCG and alfa-fetopro-
teln (elevated with germ cell tumours). AbdOminal
or pelvic ultrasound will delineate the mass and
may show features suggestive of malignancy (Fig
24.16). A chest X-ray is necessary to detect meras-
tases. An intravenous pyelogram and barium
enema may be required if there are urinary or
bowel symptoms. A CT scan of the pelvis will usu-
ally be necessary, but staging of the disease still
depends :lil surgical exploration with histological
examlllanon of suspect findings.

* Cancer of the ovary Epithelial tumours

Common clin ic al presentation
A 62-year-<)ld woman presents with slight
vaginal bleeding. Further history reveals loss at
appetite. constipation and a 'heavy' lower
abdomen for the last few weeks.
Ovarian cancer accounts for only one-third of
gynaecological cancers, but its death rate ex~eeds
that of endometrial and cervical cancer combmed.
It follows breast cancer, colorectal cancer and lung
cancer as a major cause of cancer mortaliry in
women. Ovarian cancer is known as a 'silent
ladykiller' because symptoms are usuall y nonspe-
cific and late. In general, it is a disease of POSt-
menopausal women, with a peak frequency
around 60 years of age and an incidence of 10--15
per 100,000 women per year. . cancer, Showing a large cystic structure
The aetiology is unknown, but there IS a strong
familial tendency. Women with [W O or more flrst-
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
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
Involved: colic, vomiting and constipation related
Brenner tumours young WOman who has disease limited to one
to bowel obstruction, loin pain and hydronephro-
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
Endodermal sinus (yolk sac) tumour lead to their discovm.
Sex cord or stromal tumours Spread of ovarian cancer
Granulosa cell tumours
The ovary lies relatively free in the peritoneal cav-
Theca cell tumours Iry. Malignant cells from its surface exfoliate into
Sertoli and Leydig cell tumours, androblastoma
the peritoneal .fluid or gain attachment to nearby
Fibrosarcoma (extremely rare) structures, such as the uterus, fallopian tubes,
Metastasis from a primary tumour elsewhere broad ligaments and omentum. Malignant cells in
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
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.
(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
Stage Extent
limited to the ovaries
I-A One ovary
1-8 Two ovaries
Spread beyond the ovaries but contained
within the pelvic cavity
III Spread outside the pelvic cavity but
within the abdominal cavity
IV Spread outside the abdominal cavity or
with liver involvement
TABLE 24.4 International classification of
ovarian cancer
ovary (stage lA) and wishes to preserve her fertil-
ity, surgery is extensive, with total hysterectomy,
bilateral salpingo-oophorectomy, appendicectomy
and omentectomy. The omentum is often the
source of further spread and debilitating ascites.
Depending on the clinical and histological staging
and the degree of tumour differentiation, addi-
tional combination chemotherapy is warranted_
Even advanced stages are primarily treated with
surgery to alleviate symptoms and to reduce the
tumour mass (debulking), which is subsequently
controlled by combination chemotherapy.
Borderline epith elial tumours
Approximately 10--15% of epithelial tumours have
separate histological features and a less aggressive
behaviour that classify them as borderline tumours
with 'low malignant potential'. Spread outside
the ovaries occurs in approximately 350/0 of the
serous and in about 10% of the mucinous types.
Treatment for borderline tumours is entirely surgi-
cal, and it is unclear whether adjuvant chemother-
apy contributes to a better prognosis. Fortunately,
about 70 0AJ of borderline tumours are detected in
stage I and only 10-15% in stage III or rv.
Prognosis
The 5-year survival rate in stage I depends on the
degree of differentiation of the tumour: 90-100%
with well differentiated and 60--80% with poorly
differentiated rumours. About 80% of the more
advanced stage tumours respond to combination
chemotherapy, and about half of the women (40%
overall) may go into remission. The 5-year survival
rate is about 35% for all women and 600/0 for
those who showed complete remission. Because of
late recurrences, 5-year survival does not necessar-
ily mean a definitive cure, and follow-up with
tumour markers (CA-125) is necessary to detect
recurrences, which generally respond well to fur-
ther treatment.
Terminal care for women with ovarian cancer
can be a major challenge. While the disease is often
limited to the abdominal cavity, the patient may
become cachetic around a distended abdomen.
Intestinal obstruction, with pain and vomiting, and
ascites, which require repeated paracentesis, are
common. Adequate pain relief is crucial.
Germ cell tumours
Germ cell rumours are the second largest group of
ovarian neoplasms. They occur at younger ages
(averaging around 20 years of age), and the aim of
treatment usually is to achieve a cure with conser-
vation of ovarian function and fertility.
Dysgerminomas constirute 50% of germ cell
rumours. About 15% are bilateral and they are
sensitive to radiotherapy and specific chemothera-
peutic regimens. The latter off"r the advantage
that, after removal of the affected ovary, the
remaining ovary can maintain its reproductive
function. The prognosis is relatively good and
recurrences are extremely rare.
Endodermal sinus (yolk sac) tumours are
aggressively growing tumours, which produce
alfa-fetoprotein (a useful tumour marker) and
require surgical treatment, complemented with
combination chemotherapy. They account for
approximately 20% of germ cell tumours.
Solid teratomas account for another 20% of
germ cell tumours. Teratomas are the most com-
mon ovarian rumours in young women. Most are
cystic (dermoid cyst) and less than 5% are solid.
The latter are usually benign but can be highly
malignant if they contain embryonic tissue.
Choriocarcinoma is the rarest of the germ cell
tumours. It can be a metastasis of gestational trO-
phoblastic disease or can arise primarily from
2.
germ cells. It contains trophoblast and secretes
human chorionic gonadotrophin (HCG).
Stromal tumours
The ovarian stromal cells are derived from the
embryonic sex cord mesenchyme and retain the
24 PrinCiples of oncology
potential to evolve into any of the cells that derive References
from that .mesenchyme: granulosa, theca, Leydig
and Senoli cells. These tumours occur at all ages Llewellyn Jones D 1999 Fundamentals f .
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
E.M., Symonds IM 2004 Es .]
gens from the Sertoli-Leydig cell types. Symptoms Symonds gynaecology, 'Ith cdn. Churchill~:~a obstetrics and
may reflect this hormone production. For exam- Edinburgh. ngstone,
ple,. granulosa cell tumours are a rare cause of pre-
COCIOUS puberty, a cause of menstrual irregularity Further reading
and anovulauon dunng reproductive life and a Khoo S-H 2003 Clini",,] aspects of gestational cr .
cause of postmenopausal bleeding in older dISease; a revi ew based partly 0 25 ophob]asnc
a statewide: registry. Australian a:d ;lee;r{;J:~nce of
women. The tumours are usually of low-grade
malignancy and surgIcal removal is usually suffi- Journal of Obstecrics and Gynaecology 43;280-289.
~~tnt treatment, although metastases of granulosa
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
Cen~e 15 a Commonwealth-sponsored jnformation
d~ng house for breast cancer- Its numerous
Health maintenance eVIdence-based publications on all aspectS of breast
Cancer can be accessed online.
Regular cerVical screening reduces
mortality from cervical cancer by
30%.
QUestions
c. The sampling technique Is
1. Which of the following statements unsatisfactory.
about cervical screen ing is correct? d. Sampling is confined to the
a. It is more effective in detecting ectocervix.
cancerous leSIons than in detecting
precancerous lesions . e. Condoms are the only form of
contraception used.
b . It Is effective In the early detection
of endometrial carcinoma . 3. Which statement about cervical
cancer Is correct?
@ It needs to be repeated within 3 ..,.
months If endocervical cells are not
present. a. It does not OCcur In women who
are more than 10 years
G).egUlor cervical screening reduces postmenopause.
mortality from cervical cancer by 30%.
b . It Is clearly associated with
e. All of the above .
nuiliparity.
I~ Which situation is a Pop smear more
c. It can be excluded If a cervical
likely to result in on abnormal finding?
smear report does not Show
abnormalities.
@ A woman has hod three
pregnanCies from three different
partners. It
d. does not Occur In women under
the age of 25 years .
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
4. Which of the following is reasonably
well established?
a. Cervicol cancer responds better to
chemotherapy fhan to radiotherapy.
b. Cervical cancer generally has a
better prognosis than endometrial
cancer.
c. Cervical cancer can usually be
treated effectively by vagina l
hysterectomy.
I1rI Regular screening programs can
W' eradicate cervical cancer more
effectively than any other cancer of
the female reproductive tract.
"'E>-Iequally
I of thevalid.
above statements are
5. Which statement is true of most women
living in Western countries who
develop breast cancer?
a. They have a first-degree relative
who had breast cancer before she
was 50 years old .
b. They are between 40 and 50 years
old.
~They are nulliparous.
d. They do not have recogn ised risk
factors .
~ They will have a premature death
owing to breast cancer.
6. Which of the following is true of
screening for breast cancer by
mammography?
@ It has been shown to reduce
mortality from breast cancer in
screened populations by around
20% .
@b. It is recommended at 2-yearly
intervals for women with moderately
increased ris k.
c. It is able to detect invasive breast
cancer soon atter it develops .
d . It saves most lives in the 40-50 age
group.
e. It reliably excludes cancer if the
mammogram is totally normal.
7. For which of the following women are
investigations required to exclude
endometrial cancer as a cause of
abnormal vaginal bleeding?
a . Obese women
b . Premenopausal women
@ AII women over 40 years of age and
others selectively according to risk
factors
d. Women with diabetes mellitus
@ AII of the above
8. How is endometrial cancer
diagnosed?
-l
r
a . Only by curettage and hysteroscopy
{;;) Only by endometrial biopsy
~BY
any effective cytological or "-
histological test
d. By ultrasound
e . By clinical examination
9. Which of the following is correct for a
woman with endometrial cancer?
@ She must be treatedby a
gynaecological oncologist .
b . She must have lymph node
4- dissections as part of her staging.-l,
Q related
She will have decreased disease-
morbidity by selective
treatment based on individual
findings at staging .
d . Five-year survival with accurate ly
staged localised disease is very poor.
e . Tumour grade does not influence
probab ility of metastatic spread .
0./.
10 . When is a molar pregnancy most like ly
to be present? In a woman who:
1d:\had a molar pregnancy previously
v. reports a sudden cessation of /'
pregnancy-assoc iated symptoms
c. conceived by intracytoplasmic
sperm injection (ICSI) and in vitro
fertilisation (IVF)
d. has a doubling of i3-HCG levels
every 3 days
e . conceived within 3 months atter a
prev ious pregnancy.
11 . Which Of the fOllowing is true of
choriocarCinoma?
It is a disease that cannot be
present in a virgin .
b. It Is always preceded by a molar
pregnancy.
c . It is preferably treated by
radiotherapy.
~t can Occur atter normal childbirth .
e. It could virtually be eliminated by
careful inspection of all products of
conception.
12. In the second trimester of pregnancy,
a molar pregnancy can be excluded
with reasonable certainty in Which of
the following Circumstances?
a. i3-HCG levels are within the normal
range .
b. The uterine size is normal for the
~ uration of pregnancy.
p h e uterine size is smaller than
expected.
@)J bstetric ultraSOUnd shows a normal
0
fetus and placenta .
AII of the above.
13. Which statement is true of ovarian
Cancer?
a . It is the most common
gynaecological cancer.
2<1 Prlnclp l e~ o f On cology
@t Occurs predominantly during
reproduct ive life .
@ It frequently occurs in both
ovaries.
d. It spreads predominantly through
the ovarian veins .
...,. e . It usually produces steroid
hormones.
14. Where does metastasis of ovarian
cancer most frequently OCcur?
a . Brain
b . Kidneys
c. liver
d . Lungs
@ omentum
/
15. Which of fhe following statements
about ovarian tumours is correct?
a . Most solid teratomas are malignant.
/..
b. Granulosa cell tumours predominantly
produce progesterone.
c. Endometrio id tumours arise from
ovar ian endometriosis.
(3 the
Few malignant tumours arise from
ovarian stro ma.
e . The ovarian surface epithel ium is
inactive and unllk;Jy to undergo
metaplasia . ",/
'if
*25
Women and society
Edited by Lucy Bowyer
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
At the end of this chapter, the student
will be able to:
Teenage pregnancy
indicate the prevalence of teenage
pregnancy in Australia
discuss the interaction between
psychological, cultural and
socioeconomic factors In determining
the prevalence and outcome of
teenage pregnancies
discuss the medicolegal issues
associated with teenagers and health
care
• discuss the importance of social
supports for pregnant teenagers and
the need for continuing education
discuss strategies for prevention of
teenage pregnancy
discuss the value of specific adolescent
reproductive health services
VIolence agaInst remales
describe the epidemiology of common
forms of violence against women and
girls
describe the possible presentations of
victimised women and girls in a wide
range of medical settings
• explain the doctor's role In the
assessment and management of
violence against women and girls
Loss and grief In women's lives
describe the different stages of the grief
process
• discuss factors that impair the resolution
of the grief process
• outline the role of the health
professional in a woman 's grief process,
Skills
At the end of this chapter, the student
should learn how to:
take a history from a pregnant teenager
including a detailed psychosocial
history
counsel a teenager about contraception
ask directly and appropriately about
violence In a supportive, non-
judgmental way
listen with sensitivity and empathy to a
grieving woman ,
(Continued over)
'If
 WOmen's health: a c o re curriculum
(Learning obiectives continued)
Attitudes
At the end of this chapter, the student
should reflect upon:
society's responsibility to break the vicious
cycle of teenage pregnancy
* Teenage pregna ncy
Common clinical p resentations
A 15-year-old high-school student asks for confi-
dential advice about termination of pregnancy.
A 16-year-old Intravenous drug user presents with
abdominal pain and is found to be 28 weeks
pregnant.
Prevalence of teenage pregnancy
In Australia, rates of teenage birth vary in different
states. In New South Wales in i001 , there were
3797 births to women under 20 years of age (19 of
whom were under 15) (NSW Department of
Health 2002) . This represents 4.5 % of all births,
whereas in the Northern Territory the ~ate was
15.60/0 of all births (AIHW 2003) .. The lDcldence IS
lower among mothers born rn non-Enghsh-
speaking countries than among mothe~ born m
English-speaking countries, and higher rn Abong-
. al and Torres Strait Islander mothers, of whom
~~out 1 in 5 are teenagers. The fertiliry rate of
Australian teenagets peaked at 55.5 babies per
1000 women in 1971, falling to 17.4 babies per
1000 women in 2000 (AIHW 2002).
In 1999, more than half of all teenage preg-
nancies in South Australia were ternunated (Chan
et al 1999). Based on these annual figures, about
1 in 25 teenagers will become pregnant at some
stage between the ages of 15 and 19 years, and
1 in 50 will give birth.
Female sexual maturation
N mal pubertal development begins between
th~r;ges of 8 and 13 years and proceeds until the
the impact of unacknowledged violence
against women in society
• the nature of the doctor-patient
relationship.
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
sexual maturations are almost lDvanabl y reached
before full psychological and SOCial development.
Sexually transmitted diseases
In addition to routine serological screening for
SYEYiliSI. hepatitis B and...£...and HIv, pregnant
ado escents sHould have a vag~ swab w -
formed at the 6;0£ aptenat al visit. teenagers ha~ e
a higb incidence (around 25%) of chlamydlal
infecuon wJllCTi may lead to neonatal m tectlon_
cer;rcal 'smear abnorma[mes are also common,
making it essential to perform a smear on any
pregnant teenager who has not been screened
within the last 2 years, With appropnate colpo-
scopic follow-up for suspected crN leSIOns.
Smoking, alcohol and drug abuse
The use of both leg<!.l. and JIIegal dru~ is common
in pregnant teenagers, with nearly h of the grrls
being smokers and 1.in 5 drinking alcohol to excess.
MariilJ3na is "sed by 2Q%, .and o.ne-third .of these
girls also use other drugs, mcluding herom, LSD,
amphetamines and solvents (Quinlivan 2002). The
use of illegal drugs is assoaated Wlth othernsk fac-
tors, including social isola non, psychiatric prob-
lems domestic violence and homelessness, making
it clifficult to study the effects of drug ~se alone on
these pregnancies. Antenatal interventions need to
be aimed at improYlDg these other factors, as well
as reducing drug-taking behaviour.
Socioeconomic status
and social support
Pregnant teenagers are more likely to be single,
and the father of the child is less likely to have a
25 Women an d SOCie ty
continuing relationship with the child. They are
more likely to come from low-income or disrupted Medical practitioners and other healthcare
families and may be estranged from their parents workers need to be aWare of lOcal requirements for
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
the necessary social supports to cope with the stress Children and Young Persons Protection Act 1998 to
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
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.
Continuing education
Pregnant teenagers frequently drop Out of school
owing to financial pressures, the pressures of par-
enthood and unwelcoming schools. With their edu-
cation CUt shalt, they lack job skills and are more
likely to live in poverty and depend on social secu-
rity. This economic disadvantage can be sustained
for years. Programs such as that at Plumpton High
School in Sydney have been specifically devised to
keep pregnant pupils and new mothers in school
(ABC 2003). Pupils are given suppOrt and encour-
agement from the school principal as well as a ded-
icated social worker to help arrange transport,
accommodation and childcare.
Prevention o f teenage pregnancy
Parents can help to prevent teenage pr·egnancy by
providing guidance to their children about sexuality
and the risks and responsibilities of relationships and
pregnancy. School classes in family life and sexual
education, as well as clinics providing reproductive
information and contraception to young people, can
Medicolegal issues also prevent pregnancy for some adolescents. At a
broader policy level, prolonging education for girls
Adolescents, like all patients, have a right to pro- and improving social supports for families will
fessional confidentiality. The legaL:ge of consent reduce the number of teenagers with unintended
for medical procedures is 18 years, althoUgh pregnancies.
between the ages of 16 and 18 the patiem herself
can ve COClSenr to contrace non r termination Fathers of teenage pregnancy
of re a roval
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-
between states and counm es, but medicaHy per-
ception and few reported using condoms. The
formed termination of pregnancy is legally
fathers were aged 17 to 29 years and the majority
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
only one-third were resident fathers (i.e. living
with their infants) followmg the birth. In fact, con-
tact with and suppOrt for their infant usually
decreased as time elapsed (McVeigh 2003).
Health maintenance
Information on reproductive h~allh
including sexuality, contraception and
STls should be provided In the
education system, the home and the
commun ity. Programs aimed at
reducing drug use, promoting .
mothercraft skills and encouraging
return to education should be
incorporated into health services
provided to pregnant teenagers.
* Violence against
women and girls
Common clinical presentations
A young woman requests the emergency
contraceptive pili. She has vague memories ot
the party the night betore. She awoke this
morning in a triend's apportment with vaginal
pain and bleeding. She thinks she was raped .
A 7-year-<>ld girl presents w~h her mother. The girl
hos vulval pain and discharge. Her mother Is con-
cerned about increasing behavioural problems .
A woman presents to the emergency
department w~ a black eye and bruising to her
right forearm . She says she fell against a door.
The prevalence of violence
against women and girls
Violence against women and girls is worldwide.
The mO$ com mop foWlS in mdusrnalised counrnes
are childhood sexual abuse, domesnc VIOlence, ~
u~and r~ Childhood sexuaJ abuse ranges
from inappropnate fondling to penetranon, most
often by a male family member. Domesnc VIOlence
is the leading cause of injury among women .of
reproductive age and the single most common rng-
ger for female suicide (Stark et al1991). At the most
extreme end of tJie violence commuum, up to
60% of woman who are murdered die as a result
of a domestic dispute (cqs 1988). In Australia,
homicide was the most frequent principal cause of
incidental maternal deaths (6 out of 34) in 1994-96
(AlHW 2001). Women who suffered domestic vio-
lence in pregnancy were shown tohave more fre-
quent hospital admissions, to utilise the soaal
services more often, to smoke more Clgarettes and
take more prescription drugs, to have a high.er inci-
dence of miscarriage, pregnancy terrrunatlon
and neonatal death than women who were not
abused during pregnancy (Webster et al 1996).
The violence encompasses many forms of coercive
and intimidating behaviour by an intimate partner
or family member, but most often includes phYSical
and/or sexual abuse and is frequently accomparued
by emotional abuse or harassment. Sexual assault is
penegation of either vulva or anus by a pems or
another ~cr. Violence IS under-reported and
therefore cult to measure.
National population surveys in Australia
(Australian Bureau of Statistics 1996) and New
Zealand (Morris 1998) indicate that one lD four or
five adult women has ex erienced h Sl@ a
ual use most a en om a rn e parmer) at some
time lD their lives, w'hile 2.6% of currently part-
nered Australian women report violence in the
previous 12 months. Women are particularly at
risk of Parmer abuse dunn~ preRey. Asurvey of
710 women randomly se ecte rom Australian
federal electoral rolls reported a 200/0 prevalence
of childhood sexual abuse (CSA), the abuse involv-
ing vaginal or anal interco~ in 10% of the vic-
tims. The mean age at the fmt episode of CSA was
10 years, and only 109-b of such experiences were
ever reported to the police, a doctor or a support
agency (Fleming 1997). While much sexual assa.nlt
is under-reported, up to 11.3% of Australian
women are estimated to have been Vl ctLInS ot rape
(Australian Bureau of Statisncs 1998).
Identification and management
Victims of violence may present days, months or
even years after the abuse. Even then, they may be
reluctant to disclose it. It is important always to
consider the possibility of violence and be pre-
pared to ask non-judgmentally about it.
Domestic violence
The identification of domestic violence is a chal-
lenge to all doctors in clinical practice . Women
PsychOlogical Physical
Insomnia Obvious injuries,
Depression espeCially to the head
and neck or multip le
SuiCidal Ideation
areas
Anxiety symptoms
Bruises In various stages
Panic attacks of healing
Somatitorm disorder Sexual assault
Post-traumatic stress Sexually transmitted
d isorder d iseases
Eating disord ers Chronic pelvic or
abdominal pa in
Drug and alcohol
abuse Chronic headaches or
back pain
Lethargy
TABLE 25.1 Potentlol presenta ti ons a t women
experiencing partne r abuse or past his tor y of
child abuse
who are more at risk include those who are sep-
arated or divorced, have a past history of child
abuse, an overattentive accompanying partner,
multiple presentations for minor issues or are
non-compliant with treatment. Women may pres-
ent with a range of psychological or physical
symptoms, as outlined in Table 25.1.
Women may choose not to disclose violence
for many reasons, including a feeling that they
will not be believed or that doctors will not be
able to help, fear, isolation, emotional bonds ro
parmer or family, hope for change and nor wish-
ing to upset or uproOt children. Having a back-
ground of abuse may lead the women ro accept
violence as normal.
A physician's responsibility is to inquire in a
non-judgmental way, to maintain confidentiality
and to assist the victim to achieve safety. Doctors
require up-to-date knowledge of relevant special-
ist agencies and the law. Confidentiality is essential
unless there is severe or life-threatening abuse,
when involvement of the police or another agency
may be required ro ensure safety. When dealing
with parmer abuse, ir is important ro assess a
woman's risk (levels of fear, degree of violence
and threat of weapons). If the violence is ongoing,
the woman may need a safety plan, with impor-
tant documents and money ready for a quick Rape and sexual abuse
escape to a refuge with friends or family, or ro
emergency accommodation. This should be Non-judgmental affirmation, privacy, confidential-
ity and suppOrt for a woman's decision about
25 Wom en and SOCiety
arranged in consultation with a specialist family
VIOlence suppOrt agency. and with access to coun-
sellmg and legal adVice. Women rna d
• C • d 'd d Y nee
rnlormaOon an gul e referrals to take out ro-
teenon orders. p
It is inappropriate to offer a couple counselling
at the time of acute violence, but once an individ-
ual has been identified as being at risk, she should
be made aware of the options available.
Documentation of the consultation, including full
description of any injuries, is imPOrtant for ongo-
rng patient care and pOSSIble future litigation.
Children are at rncreased nsk when there is vio-
lence in a family, and asking about the impact on
them can be a catalYSt for women and men to
make beneficial changes.
In Australia, there is increasing awareness of
domestic and family violence, and screening pro-
grams have been established in many emergency
departments and antenatal clinics. It is impOrtant
to emphasise that the screening is voluntary and
strictly confidential. The individual is interviewed
on her own, in a non-threatening environment.
Help may be offered in the form of relevant con-
tact telephone numbers (refuge shelters, coun-
selling service, sexual assault referral centre, police
domestic violence unit or legal aid), written infor-
mation on domestic or family violence, referral ro
a hospital or community-based domestic violence
service or to the police. Domestic violence orders
(non-violence ordet, non-contact when drunk
order or fuJI non-contact order) may allow the
relationship to continue but with the security of
legal restraint. A typical screening tool is the ques-
tionnaire shown in Box 25.1. Such screening for
domestic violence in maternity settings is accept-
able to women, when it is conducted in a safe,
confidential and non -judgmental environment
(Bacchus et al 2002).
Some physicians, in particular general practi-
tioners, will also have the abusing male partner as
a patient. If a Woman wishes to stay with her part-
ner, men's behaviour change groups are widely
available to assist a perpetrator who is ready to
take responsibility for change.

Women's health: a core curri Cul um
past history are particularly prone to chronic
1. Are you ever afraid of your partner or someone
pelvic pain, sexual problems and the psychological
in your family?
symproms listed in Table 25.1.
2 In the last year, has your partner or anyone in
· your family hit, kicked, punched or hurt you?
3 In the lost year, has your partner or anyone In
· your family often put you down, made you feel
ashamed or tried to control what you do?
<I In the last year, has your partner or anyone in?
· your family threatened to hurt you In any way.
5 In the last year, has your partner or anyone In ,
· your family made you have sex when you dldn t
want to?
Continue to question 6 only It domestic/family
violence has been identifIed In any of the
above .
* women's
6. Would you like help with any 01 this now?
BOX 25.1 Screening tor domestic/family
violence (Adapted from Women's Health
Strategy Unit 2003)
' g are also necessary . after a.
disclosure of
rep oron ' ries of the loss. Grief is painful and the pain is less-
sexual assault. A comprehensive history,. examma-
tion and, if possible, forensic tesnng, With careful
documentation, are reqUlred. This may be used as
evidence if a formal complaint is lodged With the
police. Most population centres have doctors spe-
cially trained in sexual abuse care. Invesnganon
and possible treatment for sexually trarlSmltted
infections and prescription of emergency contra-
ception should be considered. Follow-up care and
counselling referral should also be arranged, along
with follow-up pregnancy and testing for sexually
transmitted infections if required.
Childhood sexual abuse
If an underage girl presents with unexplained vag-
inal discharge, or mood or behaVloural disorders,
child sexual abuse may be the cause.
Identification, affirmation and support of an
abused child is particularly important, as ~hildren
are dependants and are usually unable to Identify
or seek out assistance for their own health needs.
Girls may be subject to threats and mtlmldatlon or
self-blame, so careful, non-judgmental attitudes
and questioning is required. Doctors are expected
ro report child abuse to child protection services.
Adult survivors of childhood sexual abuse are
common in clinical practice. Women With such a
Health maintenance
Health promotion at every level
should inform men , women and
children that violence, particulcHly ,
violence against women and girls, IS
a significant health I?sue and a
violation of human rights.
Loss and grief in
lives
Common clinical presentahons
A couple in their 30s have Just experienced a
third consecutive miscarriage,
A new mother grieves over the loss of her full-
term stillborn baby boy.
A <lO-vear<>ld woman has been trying to
conceive for 3 years, with several unsuccessful
attempts at in vitro fertilisation .
Sooner or later everyone experiences a significant
loss in his or her life. Chro.nie illness can allow
more time to prepare for this and antlClpatory
grief can be beneficial to a family urut. Sudden
unexpected loss leaves no time for preparauon.
During their lifespan, women expenence mare
biological changes than men. In the past, loss of
children was a common event. Both stillbirths and
infant mortality were cornman. In many develop-
ing partS of the world, this is still the case. Modem
expectations of a perfect, healthy mfant, con-
ceived and born without difficulty, do not always
match reality. . 1
Relationship breakdown is readdy acknow -
edged in modern culture, but there IS httle mfor-
mation available for the general pubhc about
grief. Grief can be experienced not only after
the loss of loved ones, but also as a consequenci
of surgery, infertility and miscarriage. A sense ~
guilt often accompames gnef: women m y
blame themselves or look for reasons why they
experienced a particular loss. They need reas-
surance that nothing they did caused the event
to happen.
Management
Acute grief is a time of heightened awareness.
Specifically, the woman will recall everything that
was said, how and when it was said, and under
what circumstances. The aim of the healthcare
professional is to minimise or prevent the pro-
longed effectS of grief. This can be achieved by
good communication and sUppOrt, but also by
resolving uncertainty. In the case of infertility,
assessment and the efficient provision of effective
therapies in a predictable time frame can reduce
grief. Allowing the woman time to grieve in a
supportive environment, in a manner appropriate
to her beliefs and culture, can prevent long-term
adverse consequences. Communicating clearly
and honestly will make information easier to
assimilate. Sharing the sadness reduces an indi-
vidual's sense of isolation: some women may
interpret crying and appropriate touching as
evidence tbat a health professional cares. A sup-
portive silence and attentive listening to the in-
dividual's story can facilitate grief. Ensuring
suppOrt networks exist and function will carry the
ongoing care into the community. Helping to
assemble memories (e.g. photos and footprints of
a dead baby, a favourite toy) may help make th.e
loss real (Kohner 2001). Rituals such as funerals,
memorial services and memorial books can assist
the grieving process.
The grieving process
The normal grieving process is influenced by
culture, religious beliefs and personality, as well
as by past experiences of loss, which mayor may
not have been resolved. The typical early reac-
tion (Table 25.2) to loss is the shock of disbelief,
slowed and disorganised thinking, numbness ,
and a feeling of unreality, associated with weep-
ing. There may be hyperactivity and lack of
awareness of surroundings. This initial phase
may be followed by protest, despair and preoc-
cupation with the loss. Impaired memory, lack
of concentration and worry may all be experi-
enced. There will also be feelings of anger, fear,
25 Wo m en a nd so cie t y
Early phase Middle phase lIesolution
Shack Anger Lessened pain
Disbelief Guilt Reflection
Disorganised Despair Adaptation
thinking
Obsession Assimilation
Numbness
Lack of
Dissociation concenlration
Sadness
TABLE 25 .2 Phases of grief
sadness and guilt. During this middle phase,
there may be withdrawal, avoidance of people
or proneness to accidents, accompanied by
somatic symptoms such as nausea, chest pain,
weakness, sleep disturbance and dreaming about
the loss.
Resolution allows a return to normal activities,
renewed social relationships and realistic memo-
ened and resolved by allowing all aspectS of the
loss to be reflected upon, thus facilitating adapta-
tion and assimilation of the new situation. Factors
that may complicate grief include perceived stig-
mata such as HIY, infertility, suicide and impo-
tence. These circumstances may inhibit the appro-
priate sharing of grief with others, and hidden
grief may have serious long-term outcomes. Prior
depressive tendencies and dependent attachments,
whereby an individual defines herself by a panner
or offspring, may complicate the resolu tion
process. General health may suffer from depres-
sion, impaired immunity and post-traumatic stress
disorder.
Counselling and support
Allowing adequate time for listening, explaining
events and absorbing information will help the
grieving process. Counselling should always be
considered and offered. Good information and
suppOrt groups exist, such as the Stillbirth and
Neonatal Death Society (Si\NDS 1991), miscar-
riage associations, infertility support groups and
cancer support groups. Different groups have dif-
ferent cultural and religious ways of acknowledg-
ing and supporting afflicted women. Respect
fj:F

Women's health: a core curriculum
for these differences is essential, and tactful ques-
tioning will determine the best option for individ-
ual women. Assistance with funerals and cremato-
rium arrangements is always appreciated, and
interpreters should be available for minority
groups who have language difficulties.
Health maintenance
It is important to have Information
available about groups that facilitate
grief, such as miscarriage, cancer
and stillbirth support groups.
References
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AlHW 2002 Australia's health. Australian [nstitute of
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AlHW 2003 Australia's mothers and babies 2000. Permatal
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\
25 Wo men and sociei '.'
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QUestions
2. Which of the follOWing statements
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Q
Women. r
20 years. .
Fleming JM 1997 Prevalence of childhood sexual abuse in a b They are more likely to be smoke
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f;;)hey are more likely to come from
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
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e. They should be taken out of school.
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Morris A 1998 Victims of crime: the women's safety survey. of age.
New Zealand Law Journal (February):46-48.
e. Teenage birth represents
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mothers and babies 2001. NSW Department of Health,
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Quinlivan JA., Evans SF 2002 The impact of continuing
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prospective cohort stUdy. SJOG: an International
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SANDS 1991 Guidelines for professionals on miscarriage,
sril!birth and neonatal death. Stillbirth and Neonatal
Death Societ)" London.
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Finley A (eds) Violence m America: a public health
approach. Univergiry Press, ew Yotk.
Webster J, Chandler J, Battistutta D 1996 Pregnancy
outcomes and health care use: effects of abuse.
Ameticm Journal oi Obstetrics and Gynecology
174:760-767.
Women's Health Strategy Unit 2003 Identifying and
responding to domestic and family violence: a resource
kit for health professionals. Department of H ealth and
Community Services, Northern Territory Gov(!rnment,
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
Women's health : a core curriculum

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