Caesarean section (CS) rates continue to rise. Vaginal birth after Caesarean section (VBAC) for a woman needs to be determined on an individual basis. With careful selection, the majority of women (60–80%) will achieve vaginal delivery with minimal risks. There are two randomized controlled trials underway that are likely to have an impact on clinical management of women who have undergone prior Caesarean. The first is the CAESAR study, which will evaluate whether the single or two layers closure of the uterine incision has a significant impact on immediate morbidity and that of future pregnancies. The second is the ACTOBAC trial (A collaborative trial of birth after Caesarean) in which women who have undergone prior Caesarean will be randomized to vaginal versus Caesarean birth. Until data from these studies are available, the evidence to date suggests that for most women who have undergone prior low segment Caesarean a trial of labour should be offered after providing adequate information. The fetal condition and progress of labour should be monitored closely. Prompt resort to emergency CS should be undertaken with signs of fetal compromise or of scar dehiscence.
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder affecting women in their reproductive years. It is frequently associated with reproductive dysfunction, including anovulatory infertility and early pregnancy loss. The underlying pathophysiology of PCOS is not fully understood, although there is considerable evidence to suggest that an excess of ovarian androgen production, either genetically determined or due to hyperinsulinaemia or hypersecretion of luteinising hormone (LH), remains central in the pathogenesis of PCOS. Chronic anovulation seems to be the result of abnormal folliculogenesis characterised by follicular arrest at the small antral phase with escape from atresia. Hypersecretion of LH, hyperandrogenaemia and/or hyperinsulinaemia has been postulated as the possible underlying mechanism of early pregnancy loss in women with PCOS. Anovulatory infertility in PCOS women can be treated with insulin-sensitising measures (such as weight reduction and metformin), clomifene citrate, laparoscopic ovarian diathermy (LOD) and ovarian stimulation with follicle-stimulating hormone. LOD and metformin may help to reduce the risk of miscarriage in women with PCOS, although the effectiveness of these measures remains to be established.
Parturition is a multifactorial, physiological process involving numerous interrelated maternal and fetal pathways, which may be both positive feed-forward and negative feedback. The mechanisms that initiate human parturition are not yet fully understood, despite decades of clinical, physiological and biochemical research by many investigators. However, it has been proposed that there are a number of stages that promote the myometrium to a contractile state, including the upregulation of receptors, prostaglandin production, and increased formation of intracellular contraction-associated proteins. The exact trigger for uterine contractions and which pathway is pre-eminent is yet to become clear. Cervical ripening is independent of the initiation of uterine contractions, although the pathways are not yet fully known, it does involve the release of proinflammatory cytokines, leukocyte infiltration into the cervix, the release and activation of extracellular matrix metalloproteinases, other proteins and glycoproteins. Drugs that act upon the pregnant uterus can be thought of as modifiers of these endogenous physiological pathways controlling normal myometrial contractility and cervical ripening. They may be characterized by their sites of action into agents acting upon prostaglandin pathways, progesterone receptors, β-adrenergic receptors, calcium channels, the oxytocin receptor and via nitric oxide. Drugs may also be functionally classified into agents used for the induction and augmentation of labour, for the termination of pregnancy, to treat postpartum haemorrhage, and to treat threatened preterm labour. This review aims to discuss the therapeutic drugs that act on the pregnant uterus.
The incidence of multifetal pregnancy has increased dramatically with the introduction of artificial reproductive techniques (ART). These pregnancies are at high risk for maternal, perinatal and long-term complications, and embryo reduction (ER) has been used for a number of years in an attempt to improve these outcomes. In high-order multifetal pregnancies ER is associated with a decrease in the background risk of miscarriage and perinatal death, but there are some questions regarding the benefits of reduction in triplet pregnancies. The importance of preventative ethics, by restricting the number of embryos transferred or careful monitoring of ovulation induction agents is generally agreed upon. Regulation of treatment regimes coupled with refinements to ART, have reduced the rate of triplet- and higher-order multifetal pregnancies in the last few years. In this article, the moral status of a fetus is discussed and biomedical ethical principles are examined in the context of ER. In addition, religious considerations and medical guidelines are discussed.
Obesity complicating pregnancy continues to be a major clinical problem for the obstetrician and the obstetric anaesthetist. Studies suggest that the physiological changes of pregnancy, designed to increase maternal energetic efficiency and liberate fetal substrates, may contribute to a worsening of obesity in susceptible subjects. Adverse outcomes of pregnancy that are significantly more common in the obese include maternal death, thromboembolism, preeclampsia, gestational diabetes, emergency caesarean section, neonatal death and fetal overgrowth. Outside pregnancy, obesity in the mother and the newborn contribute to later disease patterns that can shorten life expectancy.
Female urinary incontinence is a common but underreported condition. Initial investigation and treatment can in most cases be undertaken without urodynamic or other detailed tests. History by the use of validated symptom and quality of life questionnaires is key to the initial investigation. Initial treatment includes pelvic floor muscle training (PFMT) regardless of the type of incontinence; lifestyle interventions and bladder retraining, anticholinergics and serotonin/noradrenaline reuptake inhibitors (e.g. duloxetine) are also included depending on the type of symptoms. In mixed incontinence the predominant symptom should be treated first. When this initial treatment is ineffective, further investigation should be offered prior to specialised treatment. Urodynamics should be considered for all patients prior to surgery. Imaging and cystoscopy to exclude pathology, for example in elderly patients with an overactive bladder, are also necessary. Newer surgical interventions should be offered after careful consideration of the risk:benefit ratio for each individual woman and the amount of evidence that is currently available to support their use.
Clinical and epidemiological studies have begun to change the way in which we think about foetal growth restriction. Research worldwide has established that people who were small at birth and had poor infant growth have an increased risk of adult cardiovascular disease and type 2 diabetes, particularly if their restricted early growth is followed by increased childhood weight gain. These relations extend across the normal range of infant size in a graded manner. The observations have led to the ‘developmental origins of health and disease hypothesis’, which proposes that cardiovascular disease and type 2 diabetes originate through developmental plastic responses made by the foetus and infant; these responses increase the risk of adult disease if the environment in childhood and adult life differs from that predicted during early development. Evolutionary considerations and experimental findings in animals strongly support the existence of major developmental effects on health and disease in adulthood.
Clinical negligence claims have been steadily increasing worldwide and these can pose a serious threat to the financial viability of healthcare organizations, threatening their very existence. They may also encourage ‘defensive’ practice, lack of transparency, avoidance of provision of ‘high risk’ services such as obstetrics and orthopaedics, to avoid potential clinical negligence claims. In the U.K., costs of clinical negligence claims have been steadily increasing. Hence, the NHS Litigation Authority (NHSLA) was established in 1995 as a Special Health Authority to administer an ‘insurance policy’ (called Clinical Negligence Scheme for Trusts or CNST) to participating trusts. The aim is to provide a scheme for NHS organizations to fund the cost of clinical negligence claims. Although the participation in this scheme is voluntary, currently all the trusts in England are enrolled in this scheme. As at 31 March 2008, the NHSLA estimates that it has potential liabilities of £12.1 billion, of which £11.9 billion relate to clinical negligence claims.
The past few years have seen rapid advances in the understanding and management of fetal disease. The development of high-resolution and 3D/4D ultrasound and the ability to analyse fetal DNA in the maternal blood have proved to be exciting innovations. In utero fetal therapy is, however, still limited by the complications of preterm labour and premature rupture of membranes, and the further development of endoscopic procedures is dependent on improvements in the management of these complications. In this article, we look at some of the recent advances in fetal medicine and speculate on the possible directions that future developments may take.
Postpartum collapse signifies an acute event involving the brain, heart or lungs and may ultimately result in death. Every effort should be made to prevent this possible catastrophic outcome. This can be achieved by understanding the causes of maternal collapse and by prompt appropriate resuscitation. Implementing guidelines and ensuring a multidisciplinary input will improve the chances of a good outcome. In addition, it is essential that high-risk women are identified in the antenatal period to allow care to be optimized to prevent postpartum collapse.
In the recent white paper ‘Choosing Health: making healthy choices easier’, the UK Government outlined the actions required to prioritise sexual health care in the NHS. This is in response to an unprecedented rise in sexually transmitted infections (STIs) in recent years. There has been an increase in high-risk sexual activity, ignorance regarding consequences and higher incidence of infection resulting from migration from developing countries. Acquisition abroad via so-called ‘sex tourism’ is also a factor in prevalence, as is the development of drug-resistant infections.
Vaginal discharge is a common symptom in women of reproductive age. The causes can be divided into those that are infective or non-infective, the most common being the infective agents. Initial assessment of a patient with vaginal discharge requires a thorough history, including sexual history, examination, and testing for these common infections.
Cervical cerclage is a procedure in which sutures are inserted around the cervix in women suspected to have cervical weakness. This is thought to prevent cervical dilatation and membrane exposure, thus helping the uterus to retain the pregnancy in women who are prone to miscarrying, mostly in the mid-trimester. It was first described over 50 years ago by Shirodkar, followed by McDonald. It has been widely practised in different parts of the world with variable results. This procedure can be performed as either a planned or an emergency operation depending on the clinical situation. Based on the indication, the approach could be vaginal or abdominal. Despite having been practised widely, uncertainty still exists with regard to its indications, patient selection, effectiveness and adverse effects. Counselling patients of the possible outcome of the procedure in terms of success needs to be individualised. In this article, we revisit the basics of this condition, along with the available evidence for its practice.
Good preoperative preparation of patients, both physically and psychologically, is essential to provide optimum intra-operative conditions and to lay the basis for a smooth postoperative recovery. A well planned postoperative care regime leads to a reduction in morbidity, shorter hospital stay and greater patient satisfaction.
Intrauterine growth restriction (IUGR) is a common clinical diagnosis in obstetrics, although it is frequently not diagnosed until after delivery. There are many causes, and our understanding of the pathophysiology is limited. Individuals with a low birthweight have an increased risk of adult disease such as ischaemic heart disease, and the fetus and neonate have an increased risk of mortality and morbidity. Severe early-onset IUGR is uncommon and presents difficult management decisions. Delivery is the only practical treatment option, and the timing of delivery must be aimed to maximise gestation while minimising the risks of continued intrauterine life. The investigation of the fetal circulation using Doppler ultrasonography has become more sophisticated, with greater attention being played to the venous circulation, particularly that unique to the fetus: the umbilical vein and ductus venosus.
The physiological changes of pregnancy and the presence of the second patient, the fetus, mean that the management of thyroid disease in pregnancy is not the same as outside pregnancy. These adaptations and differences in management will be discussed.
Venous thromboembolism (VTE) is one of the leading causes of maternal mortality worldwide and is also the cause of significant maternal morbidity. This article discusses the risk factors for VTE in pregnancy, the management of the pregnant woman at risk both antenatally and postpartum and the acute management of VTE when it occurs during pregnancy.
Polycystic ovarian syndrome (PCOS) is one of the most common hormonal disorders affecting women, although the true incidence and pathophysiology have yet to be determined. A diagnosis of PCOS is likely to be associated with an increased long-term risk of developing cardiovascular disease and type 2 diabetes, especially in obese women. The evidence base for a causal relationship between cancer risk and PCOS is weak. Lifestyle changes leading to weight loss is the most effective treatment in these patients. There is insufficient evidence for the use of metformin or surgical interventions such as ovarian drilling in preventing the long-term effects of PCOS.
Sadly, intrauterine fetal death is a common occurrence and one that all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect of investigation and labour ward teams require a clear understanding of the legal aspects of this. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of this care.
Every gynaecologist should study the law applicable to his or her practice. This involves a knowledge of civil law, especially the tort of negligence, and criminal law, as well as the related acts. The application of legal principles has become a part of everyday practice, ranging from the signing of consent forms to risk management and incident reporting. There is a considerable overlap with medical ethics. This article gives an overview of the various aspects of law in gynaecological practice, ranging from the reasons for getting into trouble, statutory law and authority, new trends in consent, the provision of information, risk management, clinical incident reporting and complaints, the concept of safe practice, the legal position of guidelines, and professional and personal conduct. Forensic gynaecology also involves extensive legal and clinical knowledge. Specific problem areas such as abortion, female sterilisation, colposcopy, hysteroscopy, laparoscopy, hysterectomy, urogynaecology and assisted conception are discussed. The article concludes with some suggestions for training and education.
