ABSTRACT Key Content Lichen sclerosus (LS) is a common dermatosis that specifically affects the anogenital skin in women. LS is mostly seen in the postmenopausal age group, but it can develop during childhood or in the reproductive years. It is important for obstetricians and women's healthcare providers to be able to advise on genetic counselling, pregnancy, mode of birth, post‐partum treatment and breastfeeding as part of comprehensive care for women with LS. This review summarises the available literature on these topics, including clinical features and evidence‐based management; disease course and management of LS during pregnancy; and differential diagnosis of post‐partum vulval symptoms and their management. Learning Objectives To recognise the clinical features of lichen sclerosus. To understand that pregnant women can continue topical corticosteroids throughout pregnancy and the post‐partum phase. To understand that the mode of birth can be planned according to standard obstetric indications. To recognise that there may be a requirement for increased application of topical corticosteroid during the post‐partum period. To understand that low‐dose intravaginal estradiol may help to improve the atrophic symptoms experienced in the post‐partum period.
ABSTRACT Key Content Unexplained infertility accounts for up to 30% of cases of infertility. Potential causes for unexplained infertility have been proposed including reduced oocyte quality, poor endometrial receptivity, ovulatory PCOS, subclinical endometriosis and low semen quality. Investigations for the diagnosis of infertility include assessment of ovulation, tubal patency, semen quality and uterine structure. Predictive models such as the Hunault model can predict the likelihood of natural conception in those with unexplained infertility and can help guide management options which include expectant management, intrauterine insemination (IUI) (with or without ovarian stimulation) or in vitro fertilisation (IVF). Current NICE guidance advises that couples with unexplained infertility are referred for IVF after 2 years of trying to conceive naturally. The recent ESHRE guidance supports IUI as a first‐line treatment for those with unexplained infertility. There is some evidence that both IUI and IVF confer a benefit in those with a poor prognosis to natural conception; however, further good‐quality research is required. Learning Objectives To review current definitions and potential hypotheses for the causes of unexplained infertility. To summarise the best practice for the investigation of the subfertile couple. To summarise and review recent evidence on the treatment of unexplained infertility.
ABSTRACT Key Content Submucosal fibroids have the most impact on fertility, while subserosal fibroids do not generally affect fertility. The effect of intramural fibroids on fertility is uncertain. For clinicians caring for women with infertility, the decision for if, and when, to intervene to treat fibroids can be complicated, especially for intramural fibroids. Treatment decisions depend on the type, location and size of the fibroid(s), as well as the age of the woman, cause of infertility and reproductive history. The main treatment options are hysteroscopic, laparoscopic and open myomectomy. The impact of fibroids on fertility has long been debated. In some women, fibroids may contribute to infertility, reduce the success rates of assisted reproductive techniques and lead to pregnancy complications. Black women have a higher prevalence of fibroids and face worse outcomes from fertility treatment. Addressing these disparities through earlier referrals is crucial. Learning Objectives To determine a safe framework for the management of fibroids in women of reproductive age. To review the management of fibroids in the context of infertility. To discuss how improving the management of fibroids may help to reduce racial inequality in access to, and success of, assisted reproductive techniques.
ABSTRACT Key Content Neurovascular conditions in pregnancy are rare but are associated with poor maternal and fetal outcomes. This review covers the prevalence, clinical presentation, diagnosis and management of neurovascular disorders in pregnancy. The approach to clinical assessment and investigation of pregnant women with acute or changing chronic neurovascular conditions differs from standard practice. In acute presentations where maternal prognosis is poor, standard clinical care of the underlying condition should be followed regardless of fetal compromise. Learning Objectives To understand the clinical presentation and aetiology of acute neurovascular disorders in pregnancy, and encourage early identification. To be aware of current recommendations for investigation and treatment of chronic neurovascular conditions during pregnancy. To recognise the importance of multidisciplinary care for women with acute or chronic neurovascular disorders in pregnancy. To understand the implications on future pregnancy, reproductive health and pre‐conceptual counselling. Ethical Issues Optimal management of these cases is limited by the lack of evidence. Decision making needs to balance maternal morbidity with fetal prematurity and its implications, resulting in gestational age being central to counselling women. Pre‐pregnancy counselling for chronic neurovascular conditions is complex and controversial due to a paucity of evidence.
Elevated human chorionic gonadotrophin (hCG) levels can originate from various conditions outside of pregnancy. Phantom hCG cases represent false‐positive results. Elevated pituitary‐hCG levels are a normal physiological response in women with reduced ovarian reserve. Elevated hCG levels can be present in malignancies from trophoblastic diseases, germ cell and other extra‐ovarian tumours. To highlight the different conditions that raise hCG levels outside of pregnancy. To clarify when to suspect physiological conditions versus malignancy. To guide clinicians on management and patient follow‐up. Should perimenopausal women receive routine hCG testing? How can an incorrect diagnosis of elevated hCG impact patients, particularly patients with subfertility or misdiagnosed malignancies? How does centralised management of gestational trophoblastic diseases affect patients' experience and the local centres?
Amniotic fluid volume (AFV) is a vital measurement in the determination of fetal well‐being by means of ultrasound. There are many factors that determine AFV and, in many cases, complications affecting the fetus may manifest through change in its value. Isolated abnormal amniotic fluid index antenatally is relatively common, but its management remains contentious. The prevalence in the United Kingdom for isolated oligohydramnios is up to 5% of pregnancies, and isolated polyhydramnios complicates up to 2% of pregnancies. This article reviews and discusses the maternal and fetal implications of isolated oligohydramnios and polyhydramnios in the antenatal period, intrapartum and neonatal period. Overview of oligohydramnios and polyhydramnios and their aetiologies. Review threshold for timing of delivery and management of isolated oligohydramnios and polyhydramnios. Review of fetal and neonatal complications of oligohydramnios and polyhydramnios and their management.
Chronic pain is of increasing relevance in clinical practice and may affect a significant proportion of pregnant women. Effective management demands a balance between adequate pain control and minimisation of risks to the fetus. Chronic pain medicines have varying safety profiles with regard to teratogenicity, pregnancy outcomes and neonatal development. Management is not limited to pharmacological therapies, and it is important to be aware of non‐pharmacological options available as alternatives or adjuncts to drugs. While the management of chronic pain is multidisciplinary, obstetricians are central to management decisions in pregnancy, and they must be familiar with current evidence to provide safe care. Existing guidelines on chronic pain do not include pregnancy‐specific considerations. We present the current evidence on perinatal use of pain medicines and discuss how non‐pharmacological interventions may benefit pregnant women with chronic pain conditions. To be familiar with the pharmacological and non‐pharmacological approaches to chronic pain management and their use in pregnancy. To understand the available evidence on the safety of chronic pain medicines in the perinatal period. To understand non‐pharmacological interventions for chronic pain and how these may benefit pregnant women with chronic pain.
Resident doctors in obstetrics and gynaecology have limited exposure to, and confidence with, urogynaecology, especially conservative management of pelvic floor dysfunction. Despite this, general gynaecologists and trainees will often be referred to for troubleshooting difficult fittings in advanced pelvic organ prolapse (POP) and managing related complications.This learning objectives and key content for this education article are as follows: evidence for using pessaries to manage POP; instruction on assessing POP with a validated system (POP-Q) and assessing suitability for pessary fitting; types of pessaries, including their relevant applications, merits and drawbacks, and under-used types; selection of suitable pessaries; their sizing and fitting; follow-up required for safe maintenance of pessaries, including self-management; common complications arising from pessary use (increased discharge, bleeding, erosions, fistulae) and their management; and national guidelines and current research studies relevant to pessaries.These objectives will be discussed in the context of high-quality consensus guidelines from the UK Continence Society and the International Urogynecology Consultation, the latter published recently (2025). This education article adds to existing literature by summarising best available evidence from the UK and internationally to generate a practical, useful resource, covering additionally challenging 'craft' topics, like pessary fitting, in some detail.
ABSTRACT Key Content Work‐up of azoospermic men includes a detailed history, physical examination and investigations to find the underlying cause. Causes and management of azoospermia (pre‐testicular, testicular and post‐testicular) with case presentations. Importance of multidisciplinary team input including fertility specialists, healthcare scientists, urologists, endocrinologists and geneticists. Impact of genomics and novel biomarkers in diagnosis and prognosis of retrieving sperm surgically. Learning Objectives To understand how to take a detailed history, perform a physical examination and interpret the results of investigations of the azoospermic male. To recognise the link between azoospermia and certain medical conditions and poor general health. To know the surgical sperm retrieval techniques, the alternative options and understand patient selection. To familiarise with the process of spermatogenesis induction in hypogonadotropic hypogonadism. Ethical Considerations Azoospermia is a distressing diagnosis. Insufficient understanding of the condition and its implications can be a missed opportunity to improve these patients' health and wellbeing. Increased risk of birth defects or transmission of genetic abnormalities with intracytoplasmic sperm injection (ICSI) using surgically retrieved sperm is still under debate.
Twin pregnancies are at an increased risk of fetal growth restriction and require tailored growth surveillance strategies. Fetal growth in twin pregnancies is strongly influenced by chorionicity. In dichorionic twins, fetal growth restriction typically arises from uteroplacental insufficiency affecting one or both fetuses. In monochorionic twins, unequal sharing of the single placenta with its intertwin vascular anastomoses is the key determinant of fetal growth. Intertwin discordance and selective fetal growth restriction are key concepts in twin growth assessment. Singletons and twins follow different growth trajectories; hence, using singleton growth standards for twin growth surveillance may overestimate growth restriction in twins, leading to unnecessary interventions. Twin‐specific growth charts have the potential to improve diagnostic accuracy and clinical decision‐making in antenatal care of twin pregnancies. To understand the physiological differences in fetal growth between twin and singleton pregnancies. To evaluate the role of twin‐specific growth charts and emerging evidence surrounding their use in clinical practice. To review the current key recommendations in the antenatal growth surveillance of twin pregnancies. Potential overtreatment of healthy twins due to misclassification using singleton charts.
