(Core Clinical Cases) Gupta, Janesh Kumar - Mires, Gary - Khan, Khalid Saeed - Core Clinical Cases in Obstetrics and Gynaecology (2011, Hodder Arnold)

Core
Clinical
Cases in
Obstetrics and
Gynaecology
Third edition
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Core
Clinical
Cases in
Obstetrics and
Gynaecology
Third edition
Gary Mires MBChB MD FRCOG FHEA

Professor of Obstetrics and Undergraduate Teaching
Dean, School of Medicine, Ninewells Hospital and
Medical School, University of Dundee, Dundee, UK
Khalid S. Khan MRCOG MSc MMEd

Professor of Women’s Health and Clinical Epidemiology,
Institute of Health Sciences Education, Bart’s and The
London School of Medicine and Dentistry, London, UK
Janesh K. Gupta MSc MD FRCOG

Professor in Obstetrics and Gynaecology, University
of Birmingham, Birmingham Women’s Hospital,
Birmingham, UK
Core Clinical Cases series edited by
Janesh K. Gupta MSc MD FRCOG

Professor in Obstetrics and Gynaecology, University
of Birmingham, Birmingham Women’s Hospital,
Birmingham, UK
First published in Great Britain in 2001 by Arnold,
Second edition published in 2005 by Hodder Arnold
This third edition published in 2011 by Hodder Arnold, an imprint of Hodder
Education, a division of Hachette UK, 338 Euston Road, London NW1 3BH
http://www.hodderarnold.com
© 2011 Gary Mires, Khalid S. Khan and Janesh K. Gupta
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only be reproduced, stored or transmitted, in any form, or by any means with prior permission in
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Contents
Series preface vi
Preface vii
Abbreviations used for investigations ix
OBSTETRICS
Chapter 1 Early pregnancy problems 1
Chapter 2 Pregnancy dating and fetal growth 13
Chapter 3 Late pregnancy problems 31
Chapter 4 Labour 43
Chapter 5 Medical disorders of pregnancy 57
Chapter 6 Puerperium 67
GYNAECOLOGY
Chapter 7 Abnormal uterine bleeding 77
Chapter 8 Amenorrhoea and menopause 89
Chapter 9 Incontinence and prolapse 101
Chapter 10 Neoplasia 113
Chapter 11 Discharge and pain 123
Chapter 12 Infertility 135
Chapter 13 Fertility control 147
Index 161
Series preface
‘A history lesson’
Between about 1916 and 1927 a puzzling illness appeared and swept around the world. Dr von
Economo first described encephalitis lethargica (EL), which simply meant ‘inflammation of the brain
that makes you tired’. Younger people, especially women, seemed to be more vulnerable but the
disease affected people of all ages. People with EL developed a ‘sleep disorder’, fever, headache and
weakness, which led to a prolonged state of unconsciousness. The EL epidemic occurred during the
same time period as the 1918 influenza pandemic, and the two outbreaks have been linked ever since
in the medical literature. Some confused it with the epidemic of Spanish flu at that time whereas
others blamed weapons used in World War I.
Encephalitis lethargica was dramatized by the film Awakenings (book written by Oliver Sacks, an
eminent neurologist from New York), starring Robin Williams and Robert De Niro. Professor Sacks
treated his patients with L-dopa, which temporarily awoke his patients, giving rise to the belief that the
condition was related to Parkinson’s disease.
Since the 1916–27 epidemic, only sporadic cases have been described. Pathological studies have
revealed encephalitis of the midbrain and basal ganglia, with lymphocyte (predominantly plasma cell)
infiltration. Recent examination of archived EL brain material has failed to demonstrate influenza RNA,
adding to the evidence that EL was not invasive influenza encephalitis. Further investigations found
no evidence of viral encephalitis or other recognized causes of rapid-onset parkinsonism. Magnetic
resonance imaging of the brain was normal in 60 per cent but showed inflammatory changes localized
to the deep grey matter in 40 per cent of patients.
As late as the end of twentieth century, it seemed that the possible answers lay in the clinical
presentation of the patients in the 1916–27 epidemic. It had been noted by the clinicians, at that
time, that the central nervous system (CNS) disorder had presented with pharyngitis. This led to the
possibility of a post-infectious autoimmune CNS disorder similar to Sydenham’s chorea, in which group
A ß-haemolytic streptococcal antibodies cross-react with the basal ganglia and result in abnormal
behaviour and involuntary movements. Anti-streptolysin-O titres have subsequently been found to be
elevated in most of these patients. It seemed possible that autoimmune antibodies may cause remitting
parkinsonian signs subsequent to streptococcal tonsillitis as part of the spectrum of post-streptococcal
CNS disease.
Could it be that the 80-year mystery of EL has been solved relying on the patient’s clinical history of
presentation, rather than focusing on expensive investigations? More research in this area will give us
the definitive answer. This scenario is not dissimilar to the controversy about the idea that streptococcal
infections were aetiologically related to rheumatic fever.
With this example of a truly fascinating history lesson, we hope that you will endeavour to use the
patient’s clinical history as your most powerful diagnostic tool to make the correct diagnosis. If you
do you are likely to be right between 80 and 90 per cent of the time. This is the basis of all the Core
Clinical Cases series, which make you systematically explore clinical problems through the clinical history
of presentation, followed by examination and then performing appropriate investigations. Never break
those rules!
Janesh Gupta
2006
Preface
Why core clinical cases?
In undergraduate medical education there is a trend towards the development of ‘core’ curricula.
The aim is to facilitate the teaching of essential and relevant knowledge, skills and attitudes.
This is in sharp contrast to traditional curricula, where there was an emphasis on detailed factual
information, often without any practical clinical relevance. Currently, students’ learning is being
more commonly examined using objective structured clinical examinations which assess the practical
use of knowledge, rather than the regurgitation of small-print information that was commonly
emphasized in traditional examination methods. This book has defined the ‘core’ material for
obstetrics and gynaecology by considering the common core clinical problems which may be
encountered in primary and secondary care, and it provides a learning strategy to master this ‘core’
material for examinations.
Why a problem-solving approach?

In practice, patients present with clinical problems, which are explored through history, examination and
investigation, progressively leading from a differential to a definitive diagnosis. Unfortunately, standard
textbooks tend to present the subject matter according to a pathophysiological classification that does
not help to prepare students to confront clinical scenarios. We have therefore based this book on a
problem-solving approach. This inculcates the capacity for critical thinking and helps students to analyse
the basis of clinical problems. The deep understanding of learning issues acquired in this way means that
knowledge can be more easily retrieved both to solve real patients’ problems in the future and to answer
confidently clinical questions encountered in examinations.
How will this book inspire problem-solving traits?

The short case scenarios presented in this book are based on common core clinical cases which
students are likely to encounter in an undergraduate obstetrics and gynaecology module. We have
grouped these cases according to areas of patients’ complaints. There are seven groups in the
gynaecology category and six groups in obstetrics. Each group includes five or six cases, which begin
with a statement of the patient’s complaint followed by a short description of the patient’s problem.
For each case, using a question and short answer format, the student is taken through a problem-
solving exercise. There are two types of problem-solving cases in this book. One type deals with the
development of a diagnostic and therapeutic strategy, and the other deals with the development of
a counselling strategy. The sequence of the cases and questions in each patient’s problem group is a
logical one, taking the student from basics to the advanced aspects of clinical care. ‘Core’ information
about the subject matter relevant to the patient’s problem is also summarized, as this information is
helpful for answering the questions. The format of the book enables the cases to be used for learning
as well as for self-assessment.
In the cases that deal with diagnostic and therapeutic strategies, the student is questioned about
the interpretation of all the relevant clinical features presented, in order to compile an array of likely
differential diagnoses. They are then asked to identify specific pieces of information in the history and to
select an appropriate clinical examination which will narrow down the differential list to the most likely
diagnosis. This emphasis is important because, in clinical practice, history and examination alone result
in a correct diagnosis in 80–90 per cent of patients. Following this, students are asked to suggest the
investigations which would be required to confirm or refute the diagnosis. Once the diagnosis has been
reached, students will develop a treatment plan. In general, this plan should first consider conservative
non-invasive options (e.g. doing nothing), followed by medical and finally surgical options.
viii Preface
The therapeutic strategy will also have to be conveyed to the patient in a manner that he or she
can understand. Therefore in each group, patient problems that will challenge students to develop a
counselling strategy have been included. These counselling cases will help students to communicate
confidently with patients (one counselling case has been included in the last chapter which gives an
idea of the marking system that may be used in an examination situation). This generic learning strategy
is followed throughout the book with the aim of reinforcing the skills required to master the problem-
solving approach.
G. Mires
K. S. Khan
J. K. Gupta
Abbreviations used
for investigations
✓ investigation required
± optional investigation
✗ investigation not required
ßhCG ß human chorionic gonadotrophin
AFI amniotic fluid index
AFP a-fetoprotein
ARM artificial rupture of the membranes
BP blood pressure
BPD biparietal diameter
CHD coronary heart disease
CIN cervical intraepithelial neoplasia
COC combined oral contraceptive pill
CRP C-reactive protein
CT computed tomography
CTG cardiotocograph
D&C dilatation and curettage
DIC disseminated intravascular coagulation
DUB dysfunctional uterine bleeding
DVT deep vein thrombosis
EDD estimated date of delivery
FAC fetal abdominal circumference
FBC full blood count
FHR fetal heart rate
FSH follicle-stimulating hormone
GnRH gonadotrophin-releasing hormone
HELLP haemolysis, elevated liver enzymes and low platelets
HPV human papillomavirus
HRT hormone replacement therapy
HSV herpes simplex virus
HVS high vaginal swab
x Abbreviations
ICSI intracytoplasmic sperm injection

Ig immunoglobulin
ITP idiopathic thrombocytopenic purpura
IUCD intrauterine contraceptive device
IUGR intrauterine growth restriction
IVF in vitro fertilization
IVF-ET in vitro fertilization and embryo transfer
LBC liquid-based cytology
LFD large for dates
LFT liver function test
LH luteinizing hormone
LLETZ large loop excision of the transformation zone
LMP last menstrual period
MCH mean cell haemoglobin
MCV mean cell volume
MRI magnetic resonance imaging
MSU midstream specimen of urine
NSAID non-steroidal anti-inflammatory drug
PCOS polycystic ovarian syndrome
PID pelvic inflammatory disease
PMB postmenopausal bleeding
PMS premenstrual syndrome
POP progesterone-only pill
SGA small for gestational age
SSRI selective serotonin reuptake inhibitor
STI sexually transmitted infection
TENS transcutaneous electrical nerve stimulation
TFT thyroid function test
TSH thyroid-stimulating hormone
TTN tachypnoea of the newborn
UA umbilical artery
U&Es urea and electrolytes
USS ultrasound scan
UTI urinary tract infection
WCC white cell count
1 Early pregnancy problems
Questions
Clinical cases 2
OSCE counselling cases 3
Key concepts 4
Answers
Clinical cases 5
Revision panel 12
Questions
Clinical cases
For each of the case scenarios given, consider the following:
Q1: What is the likely differential diagnosis?

Q2: What issues in the given history support the diagnosis?
Q3: What additional features in the history would you seek to support a particular
diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 1.1 – My period is 2 weeks late and I am bleeding.

A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea. She has not been using any
contraception. She normally has a regular menstrual cycle every 28 days. A pregnancy home test is
positive. She has noticed slight vaginal spotting.
CASE 1.2 – I am 8 weeks pregnant and have pain and bleeding.

A 34-year-old woman presents with a history of 6 weeks of amenorrhoea, abdominal pain and slight
vaginal bleeding. She stopped the oral contraceptive pill 2 years ago in order to conceive, and she
recently booked an appointment to see her doctor because she was concerned that she was infertile.
She has previously had an appendectomy and pelvic inflammatory disease (PID). Recently she has been
feeling dizzy. A home pregnancy test is positive.
CASE 1.3 – I am pregnant and cannot keep anything down.

A 26-year-old primigravida presents at 8 weeks’ gestation with a history of nausea and vomiting for the
last 2 weeks. However, over the past 48 h, she indicates that she has been unable to keep any food or
drink down.
Questions 3
OSCE counselling cases
OSCE COUNSELLING CASE 1.1 – I am upset that my first pregnancy has

ended in a miscarriage.
A 23-year-old woman has had an evacuation of the uterus following an incomplete miscarriage at
10 weeks’ gestation in her first pregnancy. She is ready for discharge home and very upset.
Q1: What counselling would you give her about miscarriage and about postoperative recovery
before discharge?
OSCE COUNSELLING CASE 1.2 – This is my third miscarriage. What can

be done about it?
A patient has just undergone an evacuation of the uterus for her third consecutive spontaneous
miscarriage. She has had no pregnancies beyond 10 weeks’ gestation.
Q1: What investigations should be undertaken?
Q2: In the absence of any identifiable cause, what are her chances of achieving an ongoing
pregnancy on the next occasion?
Key concepts
In order to work through the core clinical cases in this chapter, you will need to understand the following
key concepts.
BLEEDING IN EARLY PREGNANCY

Bleeding in early pregnancy is very common.
20 per cent of pregnancies undergo spontaneous miscarriage.
Ectopic pregnancy should be considered in the differential diagnosis in all women of reproductive age
presenting with abdominal pain and vaginal bleeding.
Answers 5
Answers
Clinical cases
CASE 1.1 – My period is 2 weeks late and I am bleeding.

A1: What is the likely differential diagnosis?
Miscarriage
threatened miscarriage;
inevitable miscarriage;
incomplete miscarriage;
complete miscarriage;
missed miscarriage.
Ectopic pregnancy (see Case 1.2).
Molar pregnancy.
A2: What issues in the given history support the diagnosis?

Six weeks of amenorrhoea and a positive pregnancy test, after regular menstrual cycles, indicate an early
pregnancy. The small amount of bleeding is a sign that the patient is threatening to have a miscarriage.
However, a firm diagnosis can be established only after further investigations.
A3: What additional features in the history would you seek to support a
particular diagnosis?
The degree of bleeding, associated pain and passage of products of conception would indicate the type
of miscarriage (Table 1.1).
A4: What clinical examination would you perform and why?

Assess the patient’s haemodynamic status, including blood pressure (hypotension in hypovolaemic
shock), pulse (tachycardia in hypovolaemic shock) and degree of bleeding. The temperature should be
taken to exclude infection in septic miscarriage. An abdominal examination is essential to elicit signs of
rebound tenderness and acute abdomen (ectopic pregnancy).
Speculum examination should be performed to visualize the cervical os and determine whether
fetal tissue is present in the os or the vagina. The nature of the cervical os (open/closed) on digital
examination will help to distinguish between the different types of miscarriage (see Table 1.1). Uterine
size should be assessed during bimanual examination. Uterine tenderness is unlikely unless there is septic
miscarriage. Vaginal examination may elicit cervical excitation (pelvic tenderness on moving the cervix)
and adnexal tenderness in ectopic pregnancy.
A5: What investigations would be most helpful and why?

Urine ßhCG ✓ To confirm pregnancy. Home pregnancy tests
may be unreliable.
FBC ✓ To assess blood loss and measure white cell
count (WCC) and differential as a marker of
infection.
Table 1.1 Summary of key features in the history, examination, investigations and outcome for the various types of miscarriage and ectopic pregnancy
History Examination Investigation Management/outcome
Type of Pain Bleeding Cervical os Uterine size in Uterus on

miscarriage relation to ultrasound
gestational age scan
Threatened Slight/none Slight to Closed Consistent Fetus with Approx. 25 per cent
moderate heart beat will miscarry
Inevitable Moderate Moderate/ Open Small or Fetus may be alive Miscarriage is inevitable
heavy consistent
Incomplete Moderate Heavy, some Open Small Some fetal tissue Will need evacuation of
fetal tissue uterus by medical/surgical
parts may have means
been passed
Complete Slight at presentation, Slight to Initially open, Small Empty No treatment required
but moderate moderate after then closed after
earlier on heavier loss miscarriage
Missed Absent None/slight Closed Consistent or Fetus with no Will need evacuation of uterus
small heart beat by medical/surgical means
Septic Moderate Moderate/ Open Consistent or Empty or fetal Antibiotics and evacuation of
offensive small tissue retained products of conception
Molar Slight/none Slight to Closed Consistent or Classic Will need surgical

moderate large ‘snowstorm’ evacuation of
appearance uterus and follow-up
of vesicles
Ectopic Variable: none to None/slight Closed/cervical Small Empty uterus See Case 1.2
moderate/severe excitation
Answers 7
CRP ✓ If temperature is elevated or there are other

signs of infection, e.g. offensive vaginal loss.
Blood group ± To check rhesus status and administer anti-D if
indicated (see Revision panel, p.12).
Group and save, cross-match ✓ In cases of shock.
USS ✓ To determine whether the fetus is intrauterine

and if it is viable. It will also detect retained fetal
tissue (products of conception). The absence of
intrauterine fetal tissue (i.e. empty uterus) should
suggest the possibility of an ectopic pregnancy.
Serum ßhCG ✓ There is a doubling of levels within 48 h in a
viable intrauterine pregnancy.
Histology ✓ Any tissue expelled from the uterus should be
sent for histology to exclude molar pregnancy.
Sometimes the tissue is an endometrial cast
without any trophoblast, indicating an ectopic
pregnancy.
A6: What treatment options are appropriate?

CONSERVATIVE
Bedrest does not prevent miscarriage. Admission to hospital in cases of threatened miscarriage is not
always necessary.
MEDICAL
Intramuscular ergometrine may be required to reduce heavy bleeding in cases of incomplete, inevitable
or complete miscarriage. In patients with mild bleeding, it may be possible to avoid surgical evacuation
in incomplete miscarriage by using mifepristone and prostaglandins to induce evacuation of the uterus.
The patient should be warned of prolonged irregular bleeding.
SURGICAL
Removal of fetal tissue from the os can stop uncontrollable bleeding. In incomplete or missed
miscarriage, evacuation of retained products of conception under general anaesthetic is used to
prevent continued bleeding and risk of infection.
Antibiotics are required if there is evidence of suspected or confirmed infection.
CASE 1.2 – I am 8 weeks pregnant and have pain and bleeding.

Ectopic pregnancy.
Miscarriage (see Case 1.1).

Diagnosis of ectopic pregnancy can be difficult. A period of amenorrhoea, abdominal/pelvic pain and
slight bleeding is classically associated with ectopic pregnancy. Syncopal episodes (fainting/dizziness)
are associated with fallopian tube distension and stimulation of the autonomic nervous system.
Previous surgery (e.g. appendectomy), PID and conception after infertility are all risk factors for ectopic
pregnancy.
Any factors that may damage the fallopian tubes are risk factors for ectopic pregnancy, including PID
secondary to a sexually transmitted infection (STI) or an intrauterine contraceptive device (IUCD). Tubal
surgery, such as reversal of sterilization and salpingostomy for hydrosalpinges, and assisted conception
(e.g. in vitro fertilization or IVF) are additional risk factors. Other symptoms include shoulder-tip pain
resulting from irritation of the diaphragm by blood leaking from the ectopic.

Assessment of the patient’s haemodynamic status by checking blood pressure (to detect hypotension)
and pulse (to detect tachycardia) will indicate the degree of blood loss. An abdominal examination
should be performed to elicit tenderness to palpation, rebound tenderness, guarding or rigidity, as well
as gentle vaginal examination to detect cervical excitation (pelvic tenderness on moving the cervix) and
the possibility of palpating a tender adnexal mass. Care should be taken not to convert an unruptured
stable ectopic to an emergency situation by compressing and rupturing an ectopic mass during bimanual
vaginal examination. This examination should therefore not be undertaken in a community setting.

Urine ßhCG ✓ This should always be tested in women of
reproductive age, who present with pain and
bleeding, to confirm pregnancy.
FBC ✓ To assess the systemic effect of bleeding and
measure WCC and differential as a marker of
infection.
CRP ✓ If temperature elevated or other signs of
infection, e.g. offensive vaginal loss.
Blood group ✓ To check the patient’s rhesus status and administer
anti-D if indicated (see Revision panel, p. 12).
Group and save, cross-match ✓ In cases of shock.
Serum ßhCG ✓ Normally, a doubling of levels in 48 h is

associated with intrauterine pregnancy. This
test should be undertaken if conservative
management is planned in a stable patient.
USS (preferably transvaginal) ✓ This can indicate an intrauterine pregnancy as
early as 6 weeks’ amenorrhoea. An empty
uterus, fluid in the pouch of Douglas and an
adnexal mass on USS would give a high index of
suspicion of ectopic pregnancy.
Diagnostic laparoscopy ✓ This is the gold standard for confirming the
diagnosis. Very early ectopics can still be missed
at laparoscopy. The false-negative rate is about
5 per cent.

CONSERVATIVE
There is no place for conservative management in ectopic pregnancy if the patient is symptomatic,
because this is a life-threatening condition. The patient should be admitted to hospital and definitive
treatment administered.
Answers 9
A conservative approach would be appropriate only if the patient was asymptomatic and, after
investigations, there was uncertainty about the diagnosis. A very early intrauterine pregnancy may
not be visible on a scan, but serum ßhCG repeated after 48 h would show a doubling of levels if the
pregnancy was viable. If the pregnancy is not viable, ßhCG levels will fall and will eventually become
undetectable.
MEDICAL
Unruptured ectopics less than 3–4 cm in size can be treated with methotrexate systemically or by
administering it into the ectopic sac under USS or laparoscopic guidance. Follow-up with ßhCG is
essential because the risk of persistent ectopic pregnancy is high. This method may allow the tube to
function in the future, because 60 per cent of women will subsequently have a successful pregnancy.
There is a 15 per cent risk of recurrent ectopic pregnancy.
SURGICAL
This may involve laparoscopy or laparotomy.
Milking of the ectopic or salpingotomy can be used for removal of an ectopic pregnancy without
removing the tube. Both of these procedures salvage the tube, but follow-up with ßhCG is essential
to exclude a persistent ectopic pregnancy.
Salpingectomy involves removal of the ectopic with the tube. Follow-up with ßhCG is not necessary
in this case.
CASE 1.3 – I am pregnant and cannot keep anything down.

Hyperemesis gravidarum.
Urinary tract infection (UTI).
Appendicitis.
Gastrointestinal infection.
Rarer problems (e.g. bowel obstruction, hepatic disorders or cerebral tumours).

Pregnancy and vomiting of all food and drink support the diagnosis of hyperemesis, particularly in the
first trimester.
Acute onset of the problem would support a diagnosis such as gastroenteritis or appendicitis. A longer
duration of the symptoms with pre-existing nausea/vomiting would support a diagnosis of hyperemesis.
Associated symptoms (e.g. diarrhoea, urinary symptoms, abdominal pain), other members of the
family with the same problem or symptoms of thyrotoxicosis would support a diagnosis other than
hyperemesis.

Look for evidence of dehydration (e.g. dry mouth, tachycardia or postural hypotension). Abdominal signs
of tenderness and guarding would support a diagnosis of appendicitis. A large-for-dates uterus may
suggest multiple pregnancy as a cause of hyperemesis.

FBC ✓ Haemoglobin for haemoconcentration and
WCC for infection.
U&Es ✓ To check for dehydration.
Urinalysis ✓ The presence of ketones supports a history of

excessive vomiting. The presence of leucocytes
and/or protein supports a diagnosis of urinary
tract infection (UTI).
MSU ✓ To exclude UTI.
USS ✓ To exclude molar and multiple pregnancy.

Hyperemesis is more common in these cases.
Trisomy 18, features and/or markers for which
can be seen on ultrasound, can cause prolonged
severe vomiting extending into the late second
trimester.
LFT ± For liver disorders.
TSH ± To exclude thyrotoxicosis. Note that thyroid-

stimulating hormone (TSH) can be suppressed in
hyperemesis.
Stool sample ± If diarrhoea is present for more than 48 h.

Conditions other than hyperemesis require treatment specific to the problem (e.g. evacuate molar
pregnancy with appropriate follow-up (urinary and serum ßhCG and avoiding pregnancy with
adequate contraception until normal ßhCG has been obtained; appendectomy for appendicitis;
antibiotics for UTI).
HYPEREMESIS
Supportive:
admit the patient to hospital;
reassure her that this problem is likely to resolve spontaneously at 12–14 weeks;
offer psychological support (many women have additional social and emotional problems).
Medical:
intravenous fluids – 24/48 h to clear ketones and rehydrate;
antiemetics (prochlorperazine, intramuscular or suppository; intramuscular metoclopramide;
intravenous ondansetron; oral when vomiting settled);
introduce foods as appropriate in small amounts – avoid fatty foods;
steroids may be given in severe cases;
vitamin supplementation (vitamin B6, if prolonged vomiting occurs);
may occasionally require parenteral nutrition.
Surgical:
in severe cases, termination of pregnancy may need to be considered.
Answers 11
OSCE COUNSELLING CASE 1.1 – I am upset that my first pregnancy has

ended in a miscarriage.
A1: What counselling would you give her about miscarriage and about
postoperative recovery before discharge?
MISCARRIAGE
Miscarriage is very common, with approximately one in five pregnancies ending in miscarriage.
Most are unexplained.
There is nothing that the patient could have done that would have caused the miscarriage.
There is nothing that she could have done to prevent the miscarriage.
Her risk of miscarriage in the next pregnancy is not increased.
POSTOPERATIVE RECOVERY
The patient can expect some continued vaginal blood loss for a few days. It should not be heavy or
offensive, and should gradually tail off. If the loss becomes heavy and fresh or offensive, she should
seek medical help.
There is no medical reason why she needs to delay further attempts at pregnancy, but she must feel
psychologically ready. You might suggest waiting for one normal period.
If she needs additional support, offer her contact telephone numbers and information about early
pregnancy loss support groups within the local area. In addition, you might offer a follow-up
appointment if she would find this helpful.
If she is rhesus negative, and she meets the requirements for administration, ensure that she has had
anti-D before discharge and explain the reasons for this.
OSCE COUNSELLING CASE 1.2 – This is my third miscarriage. What can

be done about it?
A1: What investigations should be undertaken?
Three consecutive miscarriages are defined as recurrent miscarriage. This is more often associated
with an identifiable cause than are isolated cases of miscarriage.
Investigations would include the following:
chromosomal analysis of the products of conception;
chromosomal analysis of both parents – a chromosomal abnormality (e.g. balanced translocation) will
be diagnosed in one of the partners in 3–5 per cent of cases of recurrent miscarriage;
maternal blood for anticardiolipin antibodies and lupus anticoagulant to exclude antiphospholipid
syndrome present in 15 per cent of cases of recurrent miscarriage;
a pelvic ultrasound to assess uterine anatomy and morphology.
A2: In the absence of any identifiable cause, what are her chances of
achieving an ongoing pregnancy on the next occasion?
There is a 60–70 per cent likelihood of successful pregnancy if no cause is found for recurrent
miscarriage.
REVISION PANEL
Rhesus prophylaxis following early pregnancy loss:
Not all RhD negative women require anti-D immunoglobulin following early pregnancy loss.
The following is taken from Royal College of Obstetricians and Gynaecologists Greentop Guideline 22.
The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis and gives a guide to those who do.
Ectopic pregnancy: Anti-D Ig should be given to all non-sensitized RhD negative women who have
an ectopic pregnancy.
Spontaneous miscarriage: Anti-D Ig should be given to all non-sensitized RhD negative women who
have a spontaneous complete or incomplete abortion after 12 weeks of pregnancy. Anti-D Ig
should be given to such women prior to 12 weeks when there has been an intervention to evacuate
the uterus.
Threatened miscarriage: Anti-D Ig should be given to all non-sensitized RhD negative women with a
threatened miscarriage after 12 weeks of pregnancy. Where bleeding continues intermittently after
12 weeks’ gestation, anti-D Ig should be given at 6-weekly intervals. Routine administration of
anti-D Ig in threatened miscarriage before 12 weeks is not recommended. However it may be prudent
to administer anti-D Ig where bleeding is heavy or repeated or where there is associated abdominal
pain, particularly if these events occur as gestation approaches 12 weeks.
2 Pregnancy dating
and fetal growth
Questions
Clinical cases 14
Key concepts 16
Answers
Clinical cases 22
Revision panel 29
14 Pregnancy dating and fetal growth
Questions
Clinical cases

diagnosis?
CASE 2.1 – I think I am pregnant, but I cannot remember the date

of my last menstrual period.
A 23-year-old woman has a positive pregnancy test but is uncertain about the exact stage of her
pregnancy. She thinks that her last period was 4 months ago. She has had irregular and infrequent
periods in the past. She has presented for her first antenatal visit, in her first pregnancy.
CASE 2.2 – The midwife says my baby is small.

A 28-year-old in her second pregnancy attends the midwife antenatal clinic at 32 weeks’ gestation.
There are adequate fetal movements, but the midwife is concerned that the uterus feels small for dates.
The symphysiofundal height is 27 cm. The patient admits to smoking 20 cigarettes per day. Her antenatal
care to date has been uneventful.
CASE 2.3 – The midwife says my baby is big.

A 32-year-old woman in her third pregnancy attends the midwife antenatal clinic at 34 weeks’ gestation.
The midwife is concerned that the uterus feels large for dates. A booking scan had shown a singleton
pregnancy consistent with menstrual dates. The symphysiofundal height measures 40 cm. There were
no anomalies noted on her 20-week scan. The patient has experienced increasing abdominal discomfort
during the last 2 weeks, and she is having irregular uterine activity. In addition, she has noticed an
increase in shortness of breath.
Questions 15
OSCE COUNSELLING CASE 2.1 – I have been told that my baby is small.
How am I going to be monitored?
A woman in her first pregnancy attends the antenatal clinic at 34 weeks. On examination, the uterus
feels small for dates, and an ultrasound scan (USS) confirms that the abdominal circumference is below
the fifth centile for gestation. The liquor volume is reported to be within normal limits, and the umbilical
Doppler ultrasound is normal. The woman reports that the baby is active.
Q1: Counsel this patient about the findings and how you propose to monitor fetal well-being.
OSCE COUNSELLING CASE 2.2 – I want to have screening for Down’s

syndrome. What is involved?
A 24-year-old primigravida at 10 weeks’ gestation attends the antenatal clinic. She has read about
testing for Down’s syndrome in a magazine and wishes to discuss this with you.
Q1: Counsel her about screening for Down’s syndrome.
Key concepts
key concepts.
SMALL FOR GESTATIONAL AGE (SGA)

Term used to describe a fetus with a birthweight <10th centile corrected for gestation, sex of baby,
maternal height and weight, ethnic origin and birth order. This may reflect:
A fetus that has grown normally but is constitutionally small
or
Chronic compromise resulting from ‘placental insufficiency’, leading to intrauterine growth restriction
(IUGR).
400
350
300
FAC (mm)
250
200
150
Figure 2.1 Fetal abdominal circumference (FAC) in
100
a small-for-gestational-age (SGA) fetus with normal
50 growth (constitutionally small). The FAC is increasing with
12 16 20 24 28 32 36 40 gestation at an appropriate rate, i.e. parallel to the centile
Gestational age (weeks) line but < 5th centile.
INTRAUTERINE GROWTH RESTRICTION

The fetus is failing to achieve its growth potential (e.g. if a fetus is genetically determined to be 3.8 kg
but only achieves 2.8 kg).
400
350
300
FAC (mm)
250
200
150 Figure 2.2 Fetal abdominal circumference (FAC) in a

small-for-gestational-age (SGA) fetus with abnormal
100
growth (intrauterine growth restriction or IUGR). The FAC
50 crosses the centile line with increasing gestation, i.e. at
12 16 20 24 28 32 36 40 28 weeks above the 5th centile line but at 34 weeks well
Gestational age (weeks) below the 5th centile line.
Questions 17
VIABILITY
Taken to be after 24 completed weeks in the UK.
LARGE FOR DATES

Term used to describe a fetus with a corrected birthweight >95th centile for gestational age.
MACROSOMIA
Birthweight >4.5 kg.
POLYHYDRAMNIOS
Excess amniotic fluid (>8 cm average liquor pocket depth or an amniotic fluid index (AFI: sum of pocket
depths of liquor in four uterine quadrants) >25 on ultrasound, but is dependent on gestational age).
OLIGOHYDRAMNIOS
Reduced amniotic fluid (<2 cm average liquor pocket depth or an AFI <5 on ultrasound).
TERM
Pregnancy between 37 and 42 completed gestational weeks.
PRE-TERM
Pregnancy before 37 completed gestational weeks.
POST-TERM
Pregnancy beyond 42 completed gestational weeks.
GRAVIDA
Number of pregnancies, including current pregnancy.
PARITY
Two values are given. The first is the number of pregnancies beyond 24 weeks plus those ending before
24 weeks in which there were signs of life, and the second is the number of pregnancies ending before
24 weeks without signs of life.
Box 2.1 Cardiotocography

Components of a cardiotocograph (CTG)
A CTG is a combined pictorial representation of the continuous recording made up of two
components:
‘Cardio’ component: fetal heart trace measured by external ultrasound Sonicaid, or by an electrode
attached to the fetal scalp (or fetal buttock) during labour.
‘Toco’ component: measurement of uterine contraction activity assessed by external strain gauge
transducer.
The normal recommended paper speed should be set at 1 cm/min to allow for correct
interpretation.
Reasons why a CTG is performed
During the antenatal period, a ‘non-stress test’ (when no contractions are expected) by a CTG is a
method of assessing fetal well-being.
During the intrapartum period, continuous recording is used to detect ‘fetal distress’, with the aim
of detecting fetal hypoxia.
Features of a normal CTG (Fig. 2.3)

The baseline rate can range from 110 to 160 beats/min for a term fetus.
The ‘beat-to-beat’ baseline variability should be >5 beats/min.
There are no decelerations.
There are at least two accelerations (>15 beats/min for 15 s) in a 20-min trace often in response to
fetal movements. This indicates a healthy ‘reactive’ trace.
Acceleration Normal baseline with normal variability
200
180
160
FHR (bpm)
140
120
100
80
60
100
Uterine activity
75
50
25
0
Figure 2.3 Features of a normal cardiotocograph.
Types of abnormalities that a CTG can detect

Early deceleration: deceleration beginning with the onset of the contraction, returning to the
baseline rate by the end of the contraction. Usually caused by head compression as the cervix dilates
over the wide anterior fontanelle, but can result from cord compression or early hypoxia (Fig. 2.4).
200
180
160
FHR (bpm)
140
120
100
80
60
Early deceleration
100
Uterine activity
75
50
25
0
Figure 2.4 Abnormal cardiotocograph: early decelerations.
Questions 19
Variable deceleration: deceleration appearing at a variable time during the contraction, of irregular
shape, >15 beats/min and lasting for at least 15 s but <2 min. They are often caused by cord
compression.
Late deceleration: deceleration trough is the lowest point, which is past the peak of the
contraction (the lag time). Late decelerations are associated with fetal hypoxia. The most
worrying CTG is one that has a combination of loss of beat-to-beat variability, fetal tachycardia
and late decelerations. This appearance is strongly associated with fetal hypoxia (about 60 per
cent of cases) (Fig. 2.5).
Baseline tachycardia
Lag time and reduced variability
200
180
160
FHR (bpm)
140
120
100
80
60
Late
deceleration
100
Uterine activity
75
50
25
0
Figure 2.5 Abnormal cardiotocograph: late decelerations/tachycardia/reduced variability.
CTGs are usually classified as reassuring, non-reassuring or abnormal. The criteria for classification are
given in Table 2.1.
Table 2.1 Classification of CTGs
Feature Baseline (bpm) Variability (bpm) Decelerations Accelerations
Reassuring 110–60 >

_5 None Present
Non-reassuring 100–9 <5 for Typical variable The absence of

40–90 min decelerations with accelerations
over 50 per cent with otherwise
of contractions, normal trace is
occurring for over of uncertain
90 min significance
161–80 Single prolonged

deceleration for
up to 3 min
Abnormal <100 <5 for Either atypical

>90 min variable
decelerations
with over
50 per cent of
contractions or
late decelerations,
both for over
30 min
>180 Sinusoidal Single prolonged

pattern deceleration for
>
_ 10 min more than
3 min
National Institute of Health and Clinical Excellence. Intrapartum care: care of healthy women and their
babies during childbirth. Clinical guideline 55. London: NICE, 2007.
Another approach to assessing fetal well-being is the biophysical profile. This is a 30-min USS which
considers amniotic fluid (liquor) volume, fetal tone, fetal breathing movements and fetal movements
in addition to a CTG. The scoring criteria are shown in Table 2.2.
Questions 21
Table 2.2 Biophysical profiles: scoring criteria
Biophysical variable Normal (score 2) Abnormal (score 0)
Fetal breathing movements >1 episode for 30 s in 30 min Absent/<30 s in 30 min
Gross body movements >3 body/limb movements <3 body/limb movements in

in 30 min 30 min
Fetal tone >1 episode body/limb Slow, or absent

extension followed by return extension–flexion
of body or limbs to
flexion, open–close
cycle of fetal hand
Reactive fetal heart rate >2 accelerations with fetal <2 accelerations, or 1+
movements in 30 min deceleration in 30 min
Qualitative amniotic fluid >1 pool of fluid, at least Either no measurable
1 cm × 1 cm pool, or a pool <1 cm × 1 cm
A score of 8 or 10 suggests that the fetus is in good condition, a fetus scoring 6 may be ‘sleeping’ and a
repeat biophysical profile later the same day should be performed, and a score of 0, 2 or 4 suggests that
fetal compromise and delivery should be considered.
Answers
Clinical cases
CASE 2.1 – I think I am pregnant, but I cannot remember the date of

my last menstrual period.
Uncertain dates – pregnancy dating is crucial in this patient’s further management because prenatal
biochemical screening for Down’s syndrome is dependent on gestational age. Furthermore, decisions
about the type and frequency of antenatal care, as well as decisions about delivery, particularly post-term
delivery, are also dependent on pregnancy dating.

The irregular infrequent periods support the dating uncertainty. The first day of the last menstrual period
(LMP) is usually used to calculate the estimated date of delivery (EDD) (e.g. by the obstetric ‘wheel’). This
is only accurate if there is a regular 28-day cycle, assuming that ovulation occurs 14 days before the next
menstrual period. A longer cycle would require an upward adjustment of the EDD by the number of days
that the cycle is longer than 28 days (e.g. adding 7 days if the cycle length is 35 days). This, along with
uncertainty of LMP, makes an attempt at dating the pregnancy by this method inaccurate.
A detailed menstrual history should be obtained, as well as a history of contraceptive use (e.g. recent use
of the combined pill or Depo-Provera, which may make ovulation timing unpredictable after cessation of
contraception).

General health and nutritional status (gestational diabetes is more common in overweight women).
Height (dystocia is more common in short [<150 cm] women).
Baseline blood pressure.
Chest examination (to identify previously undiagnosed heart murmurs).
Breast examination (to detect incidental breast disease).
The patient’s abdomen should be palpated in order to determine the pregnancy size. The uterus
is usually palpable abdominally at 12–14 weeks’ gestation. The fundus reaches the umbilicus at
20 weeks’ gestation. Thereafter, each additional gestational week is measured as a 1-cm increase
in the symphysiofundal height (Fig. 2.6).
Answers 23
36 weeks
28 weeks
20 weeks
16 weeks
12 weeks
Figure 2.6 Uterine size in pregnancy.

Urinalysis ✓ To exclude proteinuria, which may indicate an
asymptomatic urinary tract infection (UTI). Also
glycosuria which may indicate gestational or
undiagnosed type 2 diabetes.
Urine culture ✓ Asymptomatic bacteriuria can lead to
pyelonephritis.
FBC ✓ To exclude anaemia.
Rhesus and antibody screen ✓ If rhesus negative will need to be offered

antenatal anti-D prophylaxis at 28 and
34 weeks.
Timed plasma glucose ✓ To exclude gestational or undiagnosed type 2
diabetes, the incidence of which is increasing.
Note that gestational diabetes in early gestation
is rare and most cases diagnosed at this stage
will be type 2. However, by definition any
diagnosis of diabetes in pregnancy is
gestational.
Serology for syphilis ✓
Rubella IgG ✓ If not immune will be offered immunization in

the postnatal period.
USS ✓ A USS is mandatory in this case, and would be
the most accurate way of dating this pregnancy.
The fetal crown–rump length is an accurate
measurement up to 12 weeks’ gestation.
The biparietal diameter (BPD) is used between

14 and 20 weeks. After 20 weeks, growth
patterns differ between fetuses, and there is no
accurate measurement that reflects gestational
age. Other advantages of ultrasound are
exclusion of multiple pregnancies, maternal
reassurance and detection of fetal structural
abnormalities.
Consider:
Down’s syndrome screening.
HIV and hepatitis B and C screening.
Haemoglobin electrophoresis for at-risk individuals (e.g. those from the Mediterranean region and
Asia).

Subsequent antenatal care should be provided as for a normal pregnancy.
CASE 2.2 – The midwife says my baby is small.

Small for gestational age: normally growing but constitutionally small fetus.
Intrauterine growth restriction.
Wrong dates and the fetus is an appropriate size for the correct gestation.

The uterus measurement being small for dates supports SGA or IUGR. Heavy smoking is associated
with IUGR.
Checking the certainty of the patient’s dates is essential (i.e. accuracy of menstrual data, and findings
on USSs in the first and early second [up to 20 weeks] trimester). This is because, if the pregnancy is not
as advanced as is believed, this could explain the discrepancy between the symphysiofundal height and
gestational age. Additional risk factors for IUGR are a previous small-for-dates baby, maternal illness (e.g.
hypertension), maternal infection in pregnancy (e.g. rubella, cytomegalovirus), and history of antepartum
haemorrhage.

Examination would include blood pressure measurement to exclude hypertension and pre-eclampsia,
which are both associated with IUGR. A clinical assessment of liquor volume should be made because
IUGR can be associated with reduced liquor volume. The fetal heart should be auscultated and a CTG
performed because fetal compromise and intrauterine death are associated with IUGR.

Urinalysis ✓ Proteinuria indicates pre-eclampsia if blood
pressure is high.
Cardiotocography ✓ To identify evidence of fetal compromise.
Answers 25
USS ✓ This should be performed (1) to measure

abdominal circumference and BPD in order to
confirm SGA, (2) to assess liquor volume, (3) to
perform umbilical arterial (UA), middle cerebral
artery (MCA) and ductus venosus (DV) Doppler
assessment if SGA confirmed and (4) to perform
a biophysical profile. Ultrasound may also
indicate features of congenital infection (brain
calcification) or structural anomaly (cardiac
defect). UA Doppler is an indicator of placental
resistance and hence indirectly placental
function. Abnormal MCA and DV Doppler is an
indicator that redistribution of the fetal
circulation has occurred and hence hypoxia is
likely, i.e. in hypoxia the fetus redistributes blood
to the brain.
Amniocentesis or chorionic ± This may be considered if there are features on
villus sample the USS that support a chromosomal
anomaly or if severe early onset IUGR
is identified. This can be associated with a
chromosomal anomaly.
Fetal blood sample (cordocentesis) ± This is performed only in fetal medicine centres.
It may be useful if congenital infection is
suspected.

The mainstay of management is to deliver a fetus as mature and in as good a condition as possible.
Serial ultrasound examination should be performed to monitor the velocity of fetal growth in order
to distinguish between a constitutionally small fetus and an IUGR fetus. The fetus that is growing and
not showing evidence of compromise does not require any intervention.
Umbilical Doppler waveform patterns in association with middle cerebral artery and ductus venosus
Doppler, which if abnormal suggest redistribution of fetal blood supply and biophysical assessment,
including cardiotocography, are required to identify evidence of fetal compromise.
Specific aetiological conditions need appropriate management (e.g. hypertension).
Steroids to promote surfactant production and reduce the risk or severity of respiratory distress
syndrome in the case of pre-term delivery.
Box 2.2 Risks of intrauterine growth restriction and small for gestational age
Antepartum:
hypoxia;
intrauterine death.
Peripartum:
hypoxia;
intrauterine death;
meconium aspiration.
Postpartum:
neonatal hypoglycaemia;
hypocalcaemia;
hypothermia;
polycythaemia;
hypoxic–ischaemic encephalopathy;
hypoxia during the antenatal and intrapartum period can result in developmental delay and cerebral
palsy.
CASE 2.3 – The midwife says my baby is big.

Constitutionally large for dates (LFD).
Macrosomia (e.g. secondary to diabetes).
Wrong dates.
Polyhydramnios.
Multiple pregnancy.
Hydrops.

The uterus is clinically LFD based on symphysiofundal height. The increased discomfort, irritable uterus
and shortness of breath suggest polyhydramnios. The previous dating and second-trimester USSs have
excluded multiple pregnancy and fetal anomaly which might be associated with polyhydramnios (e.g.
duodenal atresia).
A family history (e.g. first-degree relative with diabetes) or maternal obesity increases the risk of
gestational diabetes and macrosomia.
Previous high birthweights would support a fetus that is constitutionally LFD. Rhesus factor and
antibody checks are needed to exclude rhesus isoimmunization, which may be associated with fetal hydrops.

Abdominal palpation is necessary to assess liquor volume. A tense uterus, difficulty in feeling fetal parts
and fluid thrill all support an increased liquor volume.

Glucose tolerance test (GTT) ✓ Fasting level >5.1 mmol/L and 2 h level
>8.5 mmol/L would support a diagnosis of
gestational diabetes.
USS ✓ To:
confirm LFD (BPD, abdominal circumference);
measure liquor volume;
exclude multiple pregnancy;
exclude fetal anomaly that may have been
missed on earlier scans (fetal micturition
and swallowing mechanisms are essential
to maintain normal liquor volume; gut
Answers 27
atresia and neurological abnormalities

such as anencephaly are associated with
polyhydramnios because liquor cannot be
swallowed);
identify evidence of hydrops (e.g. fetal
oedema/pleural effusions and/or ascites).
If present look at fetal heart to exclude
congenital cardiac defect.
Rhesus status and antibodies ✓ To exclude rhesus isoimmunization.
Erythrovirus B19 serology ± If evidence of hydrops.

If constitutionally LFD no action is required. This is not an indication for induction of labour or caesarean
section.
If gestational diabetes is diagnosed, it should be managed in a multidisciplinary clinic with dietary
control and oral hypoglycaemic agent/insulin if blood sugars not controlled with an appropriate diet
(preprandial less than 7 mmol/L).
Polyhydramnios without symptoms and evidence of fetal anomaly does not require any treatment. In
cases near term where there is maternal discomfort, induction of labour should be considered.
In cases where the fetus is premature and maternal discomfort is a problem, serial amniocentesis
may be considered. However, there is a risk of pre-term labour and infection, and the fluid rapidly
reaccumulates;
Indometacin can reduce liquor volume, but the risk to the fetus is premature closure of the ductus
arteriosus and reduced cerebral perfusion;
As pre-term delivery is a risk, two doses of steroids (betamethasone 12 mg), 12 h apart, should
be given to the mother to promote lung maturity and reduce the risk of respiratory distress
syndrome.
OSCE COUNSELLING CASE 2.1 – I have been told that my baby is small.
How am I going to be monitored?
A1: Counsel this patient about the findings and how you propose to monitor
fetal well-being.
Counselling would involve the following points:
The scan suggests that the baby is small.
The scan is otherwise normal (normal blood flow measurements and amount of fluid around the
baby), and the baby is active.
It could therefore be that the baby is small and healthy, but it is important to monitor the baby in
case the placenta is not working as well as it should and the baby becomes distressed.
This monitoring will include assessment of the baby’s heart beat by external cardiotocography (i.e. a
belt attached around her abdomen, which will monitor the heart over a 20-min period). This will be
performed every day, but could be done as an outpatient.
A repeat USS will be performed in 1 week to measure blood flow through the umbilical cord
(umbilical arterial Doppler), and in 2 weeks to measure how much the baby has grown and to check
growth velocity and again to measure blood flow through the umbilical cord
and the amount of fluid around the baby.
She should monitor the movements of the baby and notify the hospital if there is any change in
pattern, particularly a reduction in movements.
If any concern arises about the condition of the baby while this monitoring is being undertaken
(e.g. signs of fetal distress or inadequate growth), early delivery may be required.
She will be given a course of steroids to help mature the baby’s lungs in case early delivery is
indicated.
OSCE COUNSELLING CASE 2.2 – I want to have screening for Down’s

syndrome. What is involved?
A1: Counsel her about screening for Down’s syndrome.
As she is only 10 weeks she can be offered first trimester screening. Details of the tests should include
the following:
What is involved (a USS and a venous blood sample).
When it is performed (between 11 and 14 weeks).
The USS confirms gestational age and a measurement of the nuchal thickness (NT: skin behind fetal
neck) is taken.
The blood measures two hormones, PAPP-A and free ßhCG and data on levels of these hormones
and the NT combined with the mother’s age will give a measure of her personal risk of having a
Down’s syndrome baby. The risk is classified as high (>1:250) or low (<1:250).
General points applicable to ultrasound and biochemical screening:
How long the results will take to be returned.
How the patient will receive the results.
Answers 29
The tests do not diagnose Down’s syndrome and, if the patient is in the high-risk category, she will
require further investigation (i.e. amniocentesis or chorionic villus sampling – CVS). Both of these tests
are associated with excess fetal loss (1 per cent for amniocentesis and 2–3 per cent for CVS).
If the patient is in the low-risk category, she may still have a baby with Down’s syndrome.
A detailed anomaly scan at 18–20 weeks may identify associated anomalies (e.g. cardiac
abnormalities or other ‘markers’ for Down’s syndrome).
If the patient had a Down’s syndrome fetus, would she consider termination of pregnancy? This may
affect her decision as to whether to participate in the screening programme but is not a prerequisite.
Box 2.3 Risks of polyhydramnios

Pre-term labour.
Pre-term rupture of membranes.
Cord prolapse.
Unstable lie.
Malpresentation.
Abruptio placentae.
Postpartum haemorrhage.
REVISION PANEL
The uterus is usually palpable abdominally at 12–14 weeks' gestation. The uterine fundus reaches
the umbilicus at 20 weeks' gestation.
Dating a pregnancy to confirm gestation with ultrasound is only accurate before 20 weeks'
gestation.
The mainstay of management of intrauterine growth restriction is to deliver a fetus as mature and
in as good a condition as possible. A fetus suspected of being growth restricted requires regular
assessment of growth and well-being.
Large for dates pregnancy is not an indication for early delivery or elective caesarean section in its
own right i.e. in the absence of additional fetal or maternal concerns.
Biochemical and ultrasound screening for Down's syndrome only gives a maternal risk.
Amniocentesis or CVS is required to confirm a diagnosis.
3 Late pregnancy problems
Questions
Clinical cases 32
Answers
Clinical cases 34
Revision panel 41
Questions
Clinical cases

diagnosis?
CASE 3.1 – I am 38 weeks pregnant and bleeding vaginally.

A 24-year-old woman attends the midwife at 38 weeks’ gestation. She has had two previous
uncomplicated deliveries, and she is concerned that over the past few days she has been having a
small amount of fresh vaginal bleeding intermittently. She has no abdominal pain and the baby is active.
CASE 3.2 – I have not felt my baby move since yesterday.

A 30-year-old parous woman at 36 weeks’ gestation has not felt any fetal movements on the day when
she presents to the doctor. Fetal movements had been becoming less frequent over the last few days,
but she had not been recording them. She previously had two normal deliveries at term of babies of
normal weight. In this pregnancy her scans showed a singleton fetus consistent with menstrual dates at
12 weeks and with no fetal anomaly at 20 weeks. Her screening for Down’s syndrome was reported as
low risk. She has been managed as a low-risk patient, because her pregnancy has progressed without
any problems.
CASE 3.3 – I am 32 weeks’ pregnant and am having abdominal pain

and contractions.
A 25-year-old nulliparous woman at 32 weeks’ gestation presents with abdominal pain associated with
uterine contractions. Fetal movements are satisfactory. Her booking ultrasound scan (USS) showed
singleton pregnancy consistent with menstrual dates and her anomaly scan at 20 weeks’ gestation
was normal. Her screening for Down’s syndrome was reported as low risk. She had been a smoker
but stopped in mid-trimester. She had an appendectomy as a child. She was assessed to be a low-risk
pregnancy at booking.
Questions 33
OSCE COUNSELLING CASE 3.1 – I have experienced bleeding in

pregnancy. How will I be managed?
An 18-year-old woman has had one episode of unprovoked fresh vaginal bleeding at 28 weeks’
gestation. A USS shows a normally growing fetus with a placenta sited in the lower segment as a minor
(grade I) placenta praevia. The patient has no abdominal tenderness. Her cardiotocograph (CTG) is
normal, her haemoglobin 12.0 g/dL and her blood group rhesus negative. She has been in the hospital
for a few days and the bleeding has not recurred.
Q1: What information is required for counselling this patient about how she will be managed
during the rest of her pregnancy?
OSCE COUNSELLING CASE 3.2 – How should I record fetal movements?

A 29-year-old woman presents with reduced fetal movements at 35 weeks’ gestation. Investigations
show a normal CTG.
Q1: What information is required for counselling this patient about monitoring her fetal
movements over the next few weeks?
Answers
Clinical cases
CASE 3.1 – I am 38 weeks pregnant and bleeding vaginally.

Placenta praevia (Fig. 3.1).
Placental abruption.
Cervical lesion (e.g. erosion, polyp, cancer).
Marginal placenta praevia Major placenta praevia

(previously grades I, II) (previously grades III, IV )
Upper
segment
Grade I
Grade III partially

Lower covers os
Grade II segment
Grade IV covers
os centrally
Cervical os
Figure 3.1 Grades of placenta praevia.

Answers 35

The history of painless small bleeds supports the diagnosis of placenta praevia.
The patient’s smear history should be obtained. The reports of any previous USSs in this pregnancy
should be checked in order to identify the location of the placenta.

The pulse and blood pressure should be recorded.
Examination would include abdominal palpation, with a soft non-tender uterus, high presenting part
and an abnormal lie supporting a diagnosis of placenta praevia, and a tense tender uterus supporting
a diagnosis of placental abruption.
The fetal heart should be auscultated to exclude fetal distress, which is more commonly associated
with placental abruption.
If it is confirmed that the placenta is not low (by USS), a speculum examination to visualize the cervix
and look for local causes, e.g. erosion/cancer would be indicated. Under no circumstances should a
digital examination be performed, because torrential bleeding can be provoked if a placenta praevia
has falsely been excluded as a cause.

FBC ✓ To identify the presence of anaemia.
Blood group and cross-match/ ✓ In case bleeding increases and a transfusion is

Kleihauer test if rhesus negative required. The patient should be given anti-D
if her blood group is rhesus negative to prevent
isoimmunization.
USS ✓ To localize the placenta and determine whether
it is low lying, as well as to assess fetal growth
and well-being.
CTG ✓ To identify fetal compromise.

Management would be to admit the patient to an obstetric unit. At term gestation with a history of
antepartum haemorrhage, delivery is indicated to ensure the safe delivery of a mature fetus.
Caesarean section should be performed in cases of major placenta praevia.
Consider examination without anaesthesia and artificial rupture of membranes in cases with minor
degrees of placenta praevia. This procedure should be performed in an operating theatre with a
senior anaesthetist present and ready to administer a general anaesthetic to expedite delivery if
bleeding is provoked on vaginal examination. In addition, cross-matched blood should be available in
the operating theatre and scrub nurses should be ready to perform an immediate caesarean section
(i.e. scrubbed with instrument tray open).
If a diagnosis of placental abruption is suspected (based on the absence of a low lying placenta
on scan, normal appearance of the cervix on speculum examination) and there is no evidence of
fetal compromise, an artificial rupture of the membranes should be performed and an oxytocin
(Syntocinon) infusion commenced with continuous monitoring of the fetal heart because of the
increased risk of fetal hypoxia. If fetal compromise is suspected a caesarean section should be
performed.
Box 3.1 Risks of antepartum haemorrhage

Haemorrhage and shock with placenta praevia and placental abruption.
Renal failure due to hypovolaemic shock.
Disseminated intravascular coagulation (DIC) in placental abruption or in cases of major blood loss
in placenta praevia.
Fetal hypoxia.
Intrauterine death.
CASE 3.2 – I have not felt my baby move since yesterday.

Prolonged periods of fetal sleep without any compromise.
Fetal compromise.
Fetal death.

In most cases with the given history, there is no particular obstetric problem. In this case, the pregnancy
had been uncomplicated. Reduced movements had been reported over several days, which would
warrant further investigation in order to exclude fetal compromise or death.
The history should explore whether there are any reasons (e.g. hypertension, diabetes, fetal growth
retardation and haemorrhage) for concern about fetal compromise.

A general examination, including pulse, temperature (sepsis associated with intrauterine fetal death) and
blood pressure (associated pre-eclampsia), is required. The abdomen should be examined to determine
the symphysiofundal height, and clinical assessment of liquor volume should be made (fetal compromise
is associated with growth restriction and reduced liquor volume). Try to stimulate fetal movements by
gently moving the fetus around at the time of abdominal palpation. Listen to the fetal heart to exclude
fetal death. If no fetal heart is heard a USS is required.
Answers 37

Urinalysis ✓ To exclude proteinuria to detect pre-eclampsia.
CTG ✓ To assess fetal well-being, looking for variability,

accelerations and a lack of decelerations.
USS ± Required only if there is concern about fetal
growth or well-being, to (1) check fetal heart
rate and (2) assess fetal well-being by assessing
liquor volume, fetal movements (which may not
be perceived by the patient), fetal tone, fetal
respiration and umbilical Doppler (absent or
reversed diastolic flow) biophysical profile.

Confirm fetal well-being, and, if this is satisfactory, the patient can be discharged home with advice
to record daily fetal movements (using a kick chart). If there are fewer than 10 movements over a
12-h period, the patient will need to return for a CTG.
If there is fetal growth restriction, investigations will be performed to identify fetal compromise.
As the pregnancy is approaching term, delivery may be contemplated.
If fetal death is confirmed, medical induction of pregnancy should be conducted using
antiprogestogens and prostaglandins together with appropriate investigations (fetal postmortem
examination, chromosome analysis of fetus and parents, anticardiolipin antibodies, lupus and
infection screen) and bereavement counselling.
CASE 3.3 – I am 32 weeks’ pregnant and am having abdominal pain

and contractions.
Obstetric causes:
pre-term labour;
chorioamnionitis;
concealed abruptio placentae;
fibroid degeneration (usually at mid-trimester).
Non-obstetric causes:
urinary tract infection, pyelonephritis (can precipitate preterm labour);
irritable bowel syndrome, constipation;
ovarian cyst (haemorrhage, torsion).

The history seems to suggest preterm labour. There are many causes of preterm labour including
infection, placental abruption, idiopathic and multiple pregnancy. Smoking is a risk factor for abruptio
placentae, which may lead to preterm labour.
The history should first establish whether the uterine activity is regular or irregular and whether or not it
is painful. Irregular uterine action is not usually associated with labour and is likely to be Braxton Hicks
contractions, particularly if not associated with pain. Regular, painful contractions that progressively
become longer, more painful and more frequent are typically labour pains. Lack of pain-free intervals
would suggest abruptio placentae. Vaginal bleeding is often (but not always, as in concealed abruption)
associated with abruptio placentae. A history of ruptured membranes supports the diagnosis of
chorioamnionitis. A history of urinary symptoms (dysuria, loin pain, etc.) and bowel symptoms (vomiting,
diarrhoea, etc.) might suggest a non-obstetric cause of the problem. However, these conditions can
sometimes precipitate preterm labour. Ureteric colic can mimic labour pains. A history
of fibroids on scan might suggest red degeneration, especially if the pain is localized.

A general examination, including pulse, temperature and blood pressure, is required. The abdomen
should be examined to determine uterine irritability and contractility, and the duration of contractions
should be determined and the loins examined for tenderness. Symphysiofundal height should be
measured and liquor volume should be clinically assessed. Fetal presentation and lie should be
examined (this influences the mode of delivery). Uterine tenderness may be associated with abruptio
placentae or chorioamnionitis. Listen to the fetal heart because abruption (heart rate decelerations)
or chorioamnionitis (tachycardia) is associated with fetal compromise. Vaginal examination should be
performed under aseptic conditions to establish the diagnosis of labour. Labour is more likely if the
cervical os is dilating, the cervix is effaced (short in length) and the membranes have ruptured.

FBC ✓ For anaemia and/or neutrophilia with the latter
being an indication of infection.
CRP ✓ To exclude infection.
Urinalysis and culture ✓ To exclude urinary tract infection.
CTG ✓ To assess fetal well-being. Recording of

contractions on antenatal CTG provides
information only about their frequency, and
not about their intensity.
USS ✓ USS to check fetal well-being and assess liquor

volume (which may be reduced if membranes
are ruptured).
Coagulation screen ✓ If abruptio placentae is suspected.
Blood group and cross-match ✓ If abruptio placentae is suspected.
Kleihauer test ± If abruptio placentae is suspected and patient

is rhesus negative.
HVS ✓ For infection, e.g. group B streptococcus,
particularly if there is vaginal discharge or
ruptured membranes.

In preterm labour, management aims to suppress uterine activity and prolong pregnancy
(if the maternal and fetal conditions allow this) in order to administer steroids, which reduce the
incidence and severity of respiratory distress syndrome. This can be achieved by tocolysis using the
oxytocin receptor antagonist atosiban, the ß-agonist ritodrine, the calcium antagonist nifedipine
Answers 39
or the prostaglandin synthase inhibitor indometacin. The most commonly used agent is atosiban.
Indometacin and ritodrine have adverse side effect profiles. Indometacin can result in transient
impairment of fetal renal function and premature closure of the ductus arteriosus. Ritodrine can cause
side effects in the mother, including tachycardia, pulmonary oedema and arrhythmias. Nifedipine is
not licensed for this use. Tocolytics should be given for 24–48 h only to allow the administration of
steroids.
If abruptio placentae is suspected, it should be managed according to maternal and fetal well-being.
If there is no maternal shock or concern regarding fetal well-being, a conservative approach can
be adopted. Administer steroids, but do not attempt to suppress labour. If immediate delivery is
indicated, decide on the mode of delivery, bearing in mind maternal and fetal condition, progress of
labour, and fetal presentation and lie.
If there is suspected infection, give antibiotics and augment labour if there is clinical evidence of
chorioamnionitis.
In utero transfer will be required if there are no neonatal intensive care facilities on site.
OSCE COUNSELLING CASE 3.1 – I have experienced bleeding in

pregnancy. How will I be managed?
A1: What information is required for counselling this patient about how she
will be managed during the rest of her pregnancy?
This patient has minor placenta praevia (grades I and II), which is likely to be the cause of her
antepartum haemorrhage. Steroids should be administered for fetal lung maturity as there is a risk of
need for preterm delivery. Tocolysis is generally contraindicated in antepartum haemorrhage. There
is no need for long-term hospitalization, which would be necessary only for major placenta praevia
(grades III and IV).
There is no cause for concern because the bleeding has stopped. However, there is a risk of
recurrence and potential need for preterm delivery.
If there is no further bleeding, placental site and fetal growth should be checked by USS at 34 weeks’
gestation.
If there is further bleeding after the patient has been discharged home, she should return to hospital
immediately.
If the placenta is no longer low lying at the 34-week scan, the remainder of the pregnancy will be
treated as low risk.
If the placenta remains low lying at 34 weeks, serial 2-weekly scans should be performed for
placental site. If subsequent scans show the placenta not to be low lying, the remainder of the
pregnancy will be treated as low risk.
If the placenta remains low lying at term the approach to delivery needs to be considered
(see Case 3.1).
Advise against intercourse.
A Kleihauer test should be performed and an appropriate dose of anti-D given.
OSCE COUNSELLING CASE 3.2 – How should I record fetal movements?

A1: What information is required for counselling this patient about
monitoring her fetal movements over the next few weeks?
A kick chart is the established method for monitoring fetal movement.
This chart reassures the patient that all is well, and allows her to identify potential problems in an
objective way.
Specific instructions on how to use the chart include the following:
begin at 09:00;
count every separate movement and record it on the chart with a tick;
if the baby has not moved at least 10 times by 18:00, the patient should attend the labour suite;
in the labour suite the patient will undergo cardiotocography and other investigations if required;
further management will depend on the findings of these tests, and they might warrant
expediting delivery (see Case 3.2).
Smoking, dehydration and poor food intake can reduce fetal movements.
Warn the patient that, with increasing gestation, the time taken to detect the full 10 movements will
become longer. This is normal as long as the 10 movements occur before 18:00.
Answers 41
REVISION PANEL
In cases of antepartum haemorrhage a speculum examination should not be undertaken until a
placenta praevia has been excluded on ultrasound scan.
Anti-D should be administered to unsensitised Rhesus negative women with antepartum
haemorrhage to prevent Rhesus isoimmunisation.
In cases of placental abruption concealed haemorrhage can be underestimated resulting in
inadequate resuscitation and hence increased risk of complications of hypovolaemia.
In cases of threatened pre-term labour maternal steroids should be administered to reduce the risk
and severity of respiratory distress syndrome in the baby if delivery ensues.
4 Labour
Questions
Clinical cases 44
Key concepts 48
Answers
Clinical cases 50
Revision panel 56
44 Labour
Questions
Clinical cases

diagnosis?
CASE 4.1 – My baby is due and I am having contractions.

A 22-year-old primigravida with a singleton pregnancy at term has had an uncomplicated pregnancy.
She starts to have regular uterine contractions and telephones the labour suite. On the advice of a
midwife, she makes her way to the hospital.
CASE 4.2 – I am in labour and the midwife says my baby is getting

tired.
A 20-year-old, unemployed, single mother has had labour induced at 38 weeks’ gestation because the
baby was considered to be growth restricted. This is her first pregnancy and she smokes 20 cigarettes per
day. The cervix is dilated 4 cm, and the midwife is concerned about the cardiotocograph (CTG) (Fig. 4.1).
200
180
160
FHR (bpm)
140
120
100
80
60
100
Uterine activity
75
50
25
0
Figure 4.1 CTG for Case 4.2.
Questions 45
CASE 4.3 – The midwife says my labour is not progressing.

A 26-year-old primigravida at term is in spontaneous labour. Her height is 172 cm. Her pregnancy has
been uncomplicated. She has a singleton pregnancy with a cephalic presentation and the vertex is
engaged. She has not required analgesia. Her partogram is shown in Fig. 4.2.
Fetal pH
Liquor C C C
Moulding
10
9
8
7
Cervix 6 -2
(cm) 5 -1 Descent
() 4 0 (cm)
3
+1 ( )
2
1 +2
0 +3
5
Contractions 4
per 10 min 3
2
1
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
Time
Weak incoordinate contractions

Strong contractions
C Clear
Figure 4.2 Partogram for Case 4.3.

A 26-year-old primigravida at term is in spontaneous labour. She has a singleton pregnancy with
a longitudinal lie and a cephalic presentation. Her previous pregnancy ended at 34 weeks with
a spontaneous vaginal delivery of a 2.0 kg baby. Her height is 150 cm. Her pregnancy has been
uncomplicated, but the midwife has often said that ‘the baby feels big’. She has been in labour
all day and her partogram is shown in Fig. 4.3. She has been given oxytocin (Syntocinon) for the
last 4 h.
46 Labour
Fetal pH
Liquor C C C C
Moulding
10
9
8
7
Cervix 6
(cm) 5 -2
() 4 -1 Descent
3 0
(cm)
2 +1
1 +2 ( )
0 +3
5
Contractions 4
3
per 10 min
2
1
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
Time
Strong contractions
C Clear
Figure 4.3 Partogram for Case 4.4.
Questions 47
OSCE COUNSELLING CASE 4.1 – What pain relief should I have in

labour?
A primigravida, who is attending her first antenatal clinic, wishes to know more about the pain relief
that will be available to her during labour.
Q1: What are the options for pain relief during labour?
OSCE COUNSELLING CASE 4.2 – I have passed my due date and I am not
in labour yet.
A primigravida attends her antenatal clinic at 42 weeks. The pregnancy was dated by ultrasound scan
(USS) in the second trimester and she has had a normal antenatal course. The fetus is well grown and
lying longitudinally with cephalic presentation. The mother wishes to have labour induced. Apart from
some irregular uterine contractions, she has not gone into labour spontaneously.
Q1: What information will be required for counselling her about induction of labour for
post-term pregnancy?
48 Labour
Key concepts
key concepts.
STAGES OF LABOUR
First stage: from the onset of regular painful contractions until full dilatation of the cervix.
Second stage: from full dilatation of the cervix until delivery of the baby.
Third stage: from delivery of the baby until delivery of the placenta.
FETAL LIE
The relationship of the long axis of the fetus with that of the mother (e.g. longitudinal/transverse).
PRESENTATION
The part of the fetus that occupies the lower segment of the uterus (e.g. cephalic when the head
occupies the lower segment).
PRESENTING PART
The lowest part of the fetus that is palpable on vaginal examination.
POSITION
The position of the fetal presenting part in the maternal pelvis in relation to the ‘denominator’:
the occiput in a vertex presentation and the sacrum in a breech presentation (e.g. occipitoanterior,
sacroposterior).
VERTEX
The area of the fetal skull that is bordered by the anterior fontanelle, the posterior fontanelle and the
parietal eminences.
ENGAGEMENT
The state when the widest diameter of the fetal presenting part enters the maternal pelvis.
STATION
Descent of the presenting part measured in centimetres above or below the level of the ischial spines.
ATTITUDE
The degree of flexion of the fetal head (e.g. vertex, brow or face).
MOULDING
The reduction in the diameters of the fetal head caused by the coming together, or overlapping, of the
sutures in the fetal skull as the head is compressed by the maternal pelvis.
CAPUT
Localized swelling of the fetal scalp secondary to pressure during labour.
POSTPARTUM HAEMORRHAGE
Primary: the loss of >500 mL of blood within 24 h of delivery.
Secondary: the loss of >500 mL of blood after 24 h and within 6 weeks of delivery.
Questions 49
CERVICAL EFFACEMENT
The length of cervix that shortens to indicate that labour has started. In primiparous women, the cervix is
tubular and gets ‘drawn up’ into the lower segment until it is flat.
BISHOP SCORE
A measure of the ‘favourability’ of the cervix for induction of labour (Table 4.1). The lower the score, the
more unfavourable the cervix.
Table 4.1 Bishop score
Points 0 1 2 3 Score
Dilatation (cm) 0 1–2 3–4 5–6
Cervical canal length (cm) 2 1–2 0.5–1 <0.5
Station –3 –2 –1/0 +1/+2
Consistency Firm Medium Soft
Position Posterior Mid Anterior
Total
50 Labour
Answers
Clinical cases
CASE 4.1 – My baby is due and I am having contractions.

Labour.
Braxton Hicks contractions.
‘False labour’.

Regular uterine contractions at term usually indicate the start of spontaneous labour.
Increasing regularity and duration of contractions would support a diagnosis of the onset of
spontaneous labour. A ‘show’ (mucus plug from the cervix) and/or rupture of the membranes
may accompany the onset of labour. A brief history of the current pregnancy should be taken.

A general assessment of maternal condition is made, including measurement of pulse, blood pressure
and temperature. Abdominal palpation is performed to feel for uterine contractions, confirm the lie
and presentation, check for engagement of the presenting part and listen to the fetal heart. A vaginal
examination is performed to check for cervical effacement and dilatation, station and position of the
presenting part, and the colour of any liquor draining. Labour would be confirmed if regular uterine
contractions were present in association with an effacing and dilating cervix and descent of the
presenting part.

Urinalysis ✓ Proteinuria is evidence of pre-eclampsia if
associated with raised blood pressure and can
arise for the first time in labour. Ketonuria is
evidence of dehydration.

Maternal well-being should be assessed by regular measurement of the patient’s temperature, pulse
and blood pressure, which should all be recorded on a partogram. Dehydration should be avoided,
with the patient being encouraged to drink water. As a result of the delayed gastric emptying time
and the risk of aspiration, food should be avoided during labour. The mother should be encouraged
to micturate frequently in labour to enable measurement of urine output and to avoid urinary
retention. On each occasion the urine can also be tested for protein and ketones.
Answers 51
Fetal well-being should be assessed by observing the colour of the liquor. The presence of meconium
might indicate fetal hypoxia. The fetal heart should be auscultated every 15 min during and for
1 min after a contraction. If an abnormality is detected, or if another indication arises (e.g. epidural
analgesia is used), continuous fetal heart rate monitoring should be commenced.
Progress of labour should be assessed by performing regular (4-hourly) vaginal examinations. The
dilatation of the cervix is estimated in centimetres, the descent of the head is measured by its
relationship to the ischial spines as centimetres above or below an imaginary line drawn between the
spines, and these measurements are recorded on a partogram (see Figs. 4.2 and 4.3).
Adequate pain relief should be provided. Transcutaneous electrical nerve stimulation (TENS), Entonox,
opiates (e.g. pethidine, diamorphine) and an epidural block are commonly used options. The choice
will depend on maternal preference in association with factors such as the stage of labour, the
availability of an anaesthetist if an epidural is chosen and other obstetric factors (e.g. hypertension, in
which case an epidural may be more appropriate).
CASE 4.2 – I am in labour and the midwife says my baby is getting

tired.
Suspected fetal distress in labour.

Fetal growth restriction is a risk factor for fetal hypoxia. The CTG in this case is abnormal, with reduced
beat-to-beat variation, no accelerations and variable decelerations.
Additional risk factors for intrauterine growth restriction in which hypoxia is more common include
smoking, elevated blood pressure, antepartum haemorrhage and chronic maternal disease (e.g. renal
disease). Reduced fetal movements may have been noted before the induction of labour. Meconium-
stained liquor during labour may be associated with fetal hypoxia.
Box 4.1 Meconium staining of liquor

Meconium staining is present in 15 per cent of all deliveries at term and in 40 per cent of deliveries
post-term.
Meconium staining of liquor is associated with, but not always a sign of, fetal hypoxia.
Gross meconium staining is likely to be significant and, together with CTG abnormalities, should
never be ignored.
Meconium aspiration by the baby may cause pneumonitis, which can be fatal. Aspirating the upper
airway at the time of delivery to clear meconium can reduce the risk of this occurring.

Examination would include abdominal palpation, where the fetal size as assessed by the
symphysiofundal measurement may be less than expected for gestational age. This finding would
support fetal growth restriction with fetal hypoxia.
52 Labour

Fetal blood sampling ✓ The reduced beat-to-beat variation and variable
decelerations would give cause for concern
(Box 4.2).
Box 4.2 What should be done when irregularities of the CTG occur?
A significant proportion of babies who are thought to have ‘fetal distress’ as determined by
abnormalities on the CTG and who are subsequently delivered by forceps or caesarean section are
not hypoxic. A normal CTG, however, is very reassuring and indicates good fetal well-being.
In cases where CTG monitoring shows signs that raise the possibility of fetal hypoxia (e.g.
tachycardia, decelerations), this should be confirmed by fetal scalp blood sampling to measure fetal
pH and base excess.

Management would be according to the analysis of fetal blood sampling (Box 4.3).
Box 4.3 Obstetric management after fetal blood sample

pH <7.20
Deliver the baby by forceps/ventouse if the cervix is fully dilated and the fetal head is engaged, or by
caesarean section if this is not the case.
pH >7.20 but <7.25
Repeat fetal blood sampling after 30 min, unless there is a deterioration in CTG before this time.
pH >7.25
Normal result: repeat fetal blood sampling if CTG deteriorates.

Failure to progress in labour may result from:
Inadequate uterine activity.
Absolute or relative cephalopelvic disproportion, i.e. baby too big/pelvis too small or fetal head in
malposition.

Her height (no evidence of short stature) and the fact that the vertex is engaged do not support
cephalopelvic disproportion. The lack of requirement for analgesia would support inadequate uterine
contractions.
Answers 53
The frequency and duration of contractions should be recorded. Risk factors for cephalopelvic
disproportion (e.g. macrosomia, diabetes) should be sought.

Examination would include an abdominal palpation to assess the clinical size of the baby, to assess
the amount of head that is palpable in order to determine whether the head is engaged, and also to
assess the frequency and strength of uterine contractions. Four-hourly vaginal examinations should
be performed to assess the progress of labour, and the findings should be plotted on a partogram
(as shown in Fig. 4.2). Assessment of fetal position should be made as a malposition (e.g. persistent
occipitoposterior) would create a relative cephalopelvic disproportion because of the increased diameters
presented. An assessment of the presence and degree of moulding (overlapping skull bones) and caput
(scalp oedema) is required and would support cephalopelvic disproportion, if present. An assessment of
liquor colour should be made, with the presence of meconium indicating the possibility of fetal hypoxia.
Maternal well-being (pulse, blood pressure, temperature, urine output) should be assessed and adequate
analgesia provided.

CTG ✓ To look for evidence of associated fetal distress.
FBC ✓ To check for anaemia in case caesarean section

is required.
Group and save blood ✓ In case caesarean section is required and a
transfusion becomes necessary as a result.

In this case the diagnosis is incoordinate/infrequent uterine contractions. There is no caput or moulding
to suggest cephalopelvic disproportion. Commence oxytocin (Syntocinon) and reassess in 4 h if there is
still no concern about fetal condition. Oxytocin makes the contractions more regular, stronger and more
frequent, resulting in effective uterine contractions that will lead to cervical dilatation and fetal head
descent.

Failure to progress in labour may result from:
Cephalopelvic disproportion.
Poor uterine contractility.

Her height (short stature) and the fact that her baby is clinically large (macrosomic) point towards
cephalopelvic disproportion. Her uterine contractions are adequate as recorded on the partogram.
54 Labour
Consider predisposing factors for macrosomia (e.g. gestational diabetes).

Examination would include an abdominal palpation to assess the clinical size of the baby and to
assess the amount of fetal head that is palpable in order to determine whether the head is engaged.
The frequency and strength of uterine contractions also need to be assessed. Four-hourly vaginal
examinations would be performed to assess the progress of labour, and the findings should be plotted
on a partogram. At vaginal examination, assessment of the position of the vertex would be required as a
malposition (e.g. persistent occipitoposterior) could create a relative cephalopelvic disproportion because
of the increased fetal diameters presented to the maternal pelvis. An assessment should be made of the
degree of moulding (overlapping skull bones) and caput (scalp oedema), the presence of which would
support cephalopelvic disproportion. The colour of the liquor should be noted, with the presence of
meconium indicating the possibility of fetal hypoxia. Assessment should also be made of maternal well-
being and adequate pain relief should be provided.

CTG ✓ To look for evidence of associated fetal distress.
FBC ✓ To check for anaemia in case caesarean section

is required.
Group and save blood ✓ In case caesarean section is required and a
transfusion becomes necessary as a result.

In this case the diagnosis is cephalopelvic disproportion. Caesarean section under spinal or epidural
anaesthesia is required because, according to the partogram, the cervix has not dilated for 4 h, the fetal
head has not descended in the maternal pelvis and labour has not progressed despite 4 h of uterine
stimulation with oxytocin.
Answers 55
OSCE COUNSELLING CASE 4.1 – What pain relief should I have

in labour?
A1: What are the options for pain relief during labour?
Antenatal preparation and a calm labour environment are important. The presence of a partner or
birth attendant who can rub and/or massage the woman’s back and provide reassurance and support
can help during labour. Attendance at parent-craft classes will help the woman to prepare for labour.
Choices of analgesia in labour include the following:
transcutaneous electrical nerve stimulation can be of benefit in early labour;
Entonox inhalation has a rapid onset with mild analgesic effects. It is most effective in early
labour. It is best to start inhaling before the onset of a contraction and to continue until the end
of the contraction. It can cause light-headedness and nausea;
opiates such as pethidine and diamorphine can be given as an intramuscular injection every
4–6 h. Pethidine has central sedative effects rather than providing effective analgesia. Patients
can therefore become confused and feel ‘out of control’. It also causes nausea, so there is often
a need for antiemetics. It can cause a sleep pattern in the fetus, so the fetal heart rate may show
some abnormality. At birth, respiratory depression can also occur in the neonate. Diamorphine
given in a similar fashion has a stronger analgesic effect;
epidural analgesia with or without opiates is a very effective form of analgesia that can be either
given intermittently or infused continuously via a pump. It completely blocks sensation (except
pressure) and induces partial motor blockade, making the legs feel heavy and ‘dead’, so mobility
is restricted. It is useful if surgical delivery is required.
Maternal choice and input in decision making is important. Other factors, e.g. parity, stage of labour,
or other complications, such as hypertension, should be taken into account as they will influence the
best option for pain relief.
OSCE COUNSELLING CASE 4.2 – I have passed my due date and I am not
in labour yet.
A1: What information will be required for counselling her about induction of
labour for post-term pregnancy?
Post-term pregnancy occurs in about 10 per cent of pregnant women.
One approach to management of this condition is to monitor fetal well-being while awaiting
spontaneous labour, but it is reasonable to induce labour as an alternative. It is recommended that
induction of labour should be offered at term +7–14 days, in the interest of the fetus, with perinatal
deaths being more common after this period.
On admission to hospital, fetal well-being should be assessed with a CTG.
The state of the cervix will be examined in order to determine its length, dilatation, consistency and
position (a score can be calculated in combination with the station of the fetal head – see Table 4.1
for Bishop score). If the cervix is favourable for induction (Bishop score >6), the fetal membranes can
be ruptured artificially (artificial rupture of membranes or ARM), which would result in a significant
proportion of women going into labour a short time afterwards.
56 Labour
If the cervix is not favourable for induction (Bishop score <6), prostaglandin is administered in the
form of vaginal pessaries. The prostaglandin usually softens and effaces the cervix. Sometimes it can
initiate labour, but its main role in this situation is to ripen the cervix before ARM.
If ARM does not initiate labour, the latter may be induced or augmented with oxytocin (Syntocinon)
infusion.
If induction of labour fails completely, a caesarean delivery may be performed.
Labour after successful induction is managed in the usual manner with regard to pain relief,
assessment of maternal well-being, and progress of labour. However, continuous fetal heart rate
monitoring should be performed.
Box 4.4 Post-dates pregnancy

Perinatal mortality increases by twofold after 42 weeks.
The caesarean section rate increases by twofold after 42 weeks.
Meconium staining occurs in 40 per cent of pregnancies beyond 42 weeks.
Caesarean section rates increase in association with induction of labour in post-dates pregnancy,
together with an unripe cervix.
REVISION PANEL
The Bishop score is a measure of the 'favourability' of the cervix for induction of labour. The
lower the score, the more unfavourable the cervix. An unfavourable cervix should be primed with
prostaglandins if there is no contraindication prior to attempt at induction of labour.
The partogram is a tool to record the progress of labour and assist in decision-making regarding the
management of labour. It should be completed prospectively for all labours.
Meconium staining is present in 15 per cent of all deliveries at term and in 40 per cent of deliveries
post-term. It is associated with but not diagnostic of hypoxia.
Failure to progress in labour is associated with problems with one or more of the three 'P's – powers
(contractions, i.e. inadequate), passenger (baby, i.e. too large or malposition), passages (pelvis, i.e.
too small).
Post-term pregnancy occurs in about 10 per cent of pregnant women. Perinatal mortality increases
by twofold after 42 weeks.
5 Medical disorders
of pregnancy
Questions
Clinical cases 58
Answers
Clinical cases 60
Revision panel 66
58 Medical disorders of pregnancy
Questions
Clinical cases

diagnosis?
CASE 5.1 – I am pregnant and the midwife says my blood pressure

is high.
A 20-year-old primigravida attends the antenatal clinic at 34 weeks’ gestation and is noted to have
a blood pressure of 150/95 mmHg. Urinalysis is negative. Her blood pressure (BP) had previously
been recorded in the range 130–150 to 70–80 mmHg in the mid-trimester. Her booking BP was
120/70 mmHg. The fetus was clinically an appropriate size for dates. Three days later, her blood
pressure is 160/100 mmHg and she has developed ‘++’ proteinuria on dipstick testing.
CASE 5.2 – I am 28 weeks pregnant and have sugar in my urine.

A 38-year-old woman with two previous normal deliveries is at 28 weeks’ gestation. Her weight is
102 kg. Her pregnancy has been progressing well. She attends the antenatal clinic for a routine visit
and on urinalysis is noted to have ‘+++’ glucose in her urine.
CASE 5.3 – I am pregnant and also anaemic.

A 28-year-old vegetarian woman attended the antenatal booking clinic at 12 weeks’ gestation. Her five
children are aged between 6 months and 8 years. Her haemoglobin level was noted to be 8.5 g/dL.
Questions 59
OSCE COUNSELLING CASE 5.1 – I have diabetes and want to become

pregnant.
A 23-year-old woman with type 1 diabetes is taking the combined oral contraceptive (COC) pill. She
wants to come off the pill to try for a pregnancy.
Q1: What pre-pregnancy counselling would you provide for this woman?
OSCE COUNSELLING CASE 5.2 – I have epilepsy and I want to become

pregnant.
A 26-year-old woman who has epilepsy controlled by treatment is planning to get married. She is
concerned about pregnancy and her epileptic medication. She has been seizure-free for 6 years on
two antiepileptic drugs. She has not recently been reviewed by a neurologist.
Q1: What pre-pregnancy care and counselling would you give this woman?
Answers
Clinical cases
CASE 5.1 – I am pregnant and the midwife says my blood pressure is

high.
Pre-eclampsia (pregnancy-induced proteinuric hypertension).
Essential hypertension.
Hypertension secondary to another medical condition (e.g. renal disease or diabetes).

Pre-eclampsia: based on the fact that the woman’s blood pressure is >140/90 mmHg with significant
proteinuria. She is a primigravida and pre-eclampsia is more common among such women. Her booking
BP was normal.
Any related symptoms (e.g. headache, visual disturbances, epigastric pain) that indicate worsening
disease.
Past history of medical disorders that might cause hypertension (e.g. renal disease or diabetes).
Previous blood pressure recording to rule out pre-existing essential hypertension, e.g. at her GP, if
taking the oral contraceptive.

Examination would include fundoscopy to identify hypertensive retinopathy. The reflexes should
be examined to identify hyperreflexia and ankle clonus, which would indicate severe pre-eclampsia
or impending eclampsia. An abdominal examination may identify right hypochondrial or epigastric
tenderness. Ankles and sacral area can be examined for dependent oedema.

U&Es ✓ To identify renal compromise.
Urate ✓ Rising plasma urate levels indicate worsening

disease.
FBC ✓ A fall in platelet count indicates worsening
disease.
LFT ± If clinically indicated (i.e. worsening blood
pressure or increased proteinuria), investigation
may include LFTs to identify the presence of
HELLP (haemolysis, elevated liver enzymes and
low platelets) syndrome, an indication of
worsening disease and imminent eclampsia.
Answers 61
Urinalysis ✓ Twice daily urinalysis for proteinuria; 24-h

urinary protein may also be measured. Levels of
>300 mg/24 h are abnormal.
USS ✓ To assess growth and well-being. Hypertensive
disorders of pregnancy are associated with
intrauterine restricted growth (IUGR).
CTG ✓ To assess fetal well-being.

Pre-eclampsia is usually a progressive condition. Treatment lies in delivery. In the meantime, the aim
is to monitor and control blood pressure and to plan delivery as close to fetal maturity as possible.
Delivery is indicated if there is concern for maternal condition (e.g. as assessed by increasing blood
pressure, deterioration in renal/liver function) or fetal condition (e.g. IUGR, fetal distress). The woman
should be admitted to the antenatal ward and monitored to assess progression of the condition.
Biochemical (renal and liver function) and haematological (to look for evidence of falling platelets or
HELLP syndrome) assessment should be performed as described above. Regular (at least 4-hourly)
blood pressure assessments should be made in order to identify worsening condition. A fluid balance
chart should be commenced to identify oliguria, which again is associated with worsening of the
condition. Twice daily urinalysis should be performed to assess increasing proteinuria. Assessment
of fetal condition, including ultrasound biometry, umbilical Doppler and cardiotocography should
be undertaken. Maternal steroids should be administered in case early delivery is indicated.
Antihypertensive therapy should be commenced if the systolic blood pressure is >170 mmHg and the
diastolic pressure is >110 mmHg. This controls blood pressure and reduces the risk of complications
such as cerebrovascular accidents but does not alter the progression of pre-eclampsia. Labetalol and
nifedipine are appropriate antihypertensive agents for this purpose. If there is hyperreflexia/clonus and/
or HELLP syndrome, delivery is indicated. In this instance, magnesium sulphate as an anticonvulsant
agent should be commenced to reduce the risk of eclampsia.
Box 5.1 Risks of pre-eclampsia

Maternal complications:
Eclampsia.
Cerebrovascular accident.
HELLP syndrome.
Disseminated intravascular coagulation.
Liver failure.
Renal failure.
Pulmonary oedema.
Maternal death.
Fetal complications:
Intrauterine growth restriction.
Placental abruption.
Fetal death.
CASE 5.2 – I am 28 weeks pregnant and have sugar in my urine.

Reduced renal threshold for glucose during pregnancy.
Gestational diabetes.

The woman’s age and her weight increase her risk of gestational diabetes.
Multiple pregnancy, a family history of diabetes in a first-degree relative, a previous history of gestational
diabetes, a previous unexplained intrauterine death, polyhydramnios and a previous ‘large-for-dates’
(LFD) baby are all risk factors for gestational diabetes.

Examination should include fundoscopy for diabetic retinopathy and abdominal palpation for evidence
of a LFD fetus or polyhydramnios.

Glucose tolerance test ✓ A fasting blood glucose concentration
>5.1 mmol/L and/or a 2-h blood glucose
concentration >8.5 mmol/L using a 75 g
carbohydrate test would confirm the diagnosis
of gestational diabetes.
Glycated haemoglobin ✓ To identify long-term hyperglycaemia.

MANAGEMENT OF GESTATIONAL DIABETES
Review of the woman’s diet to include high levels of complex carbohydrate, soluble fibre and reduced
saturated fats. An energy prescription of 30–35 kcal/kg pre-pregnant optimum body weight is ideal,
with at least 50 per cent of energy being derived from carbohydrates.
Pre-prandial blood glucose monitoring (i.e. four times daily) should be commenced. If blood glucose
levels are consistently >6.0–7.0 mmol/L despite adherence to diet, either an oral hypoglycaemic agent,
e.g. metformin, or insulin should be commenced. A regimen of pre-prandial short-acting insulin or
analogue and overnight longer-acting insulin or analogue should be used. Insulin requirements will
increase during pregnancy and should be adjusted accordingly.
Measurement of glycated haemoglobin every 4–6 weeks is common practice, but has not been
shown to improve outcome.
A retinal examination should be performed every 4–6 weeks.
ANTENATAL CARE
Ultrasound examination should be performed fortnightly in the third trimester to measure abdominal
circumference as an assessment of fetal growth, to assess liquor volume and to perform umbilical
arterial Doppler.
More frequent visits will be necessary to allow optimal management of diabetic control and to screen
for complications of pregnancy, which are more common (e.g. proteinuric hypertension).
Answers 63
A multiprofessional team in a dedicated, well-organized, combined, diabetes antenatal clinic should

assume responsibility for care. The team should include an obstetrician with an interest in diabetes in
pregnancy, a diabetes physician, a midwife, a diabetes nurse and a dietitian.
TIMING AND MODE OF DELIVERY

With good diabetic control and in the absence of obstetric complications, delivery at 38–9 weeks by
the vaginal route should be the aim.
Women with gestational diabetes who are on insulin require an insulin and dextrose infusion, aiming
to keep blood sugar levels between 4.0 and 6.0 mmol/L. Blood glucose levels should be checked
hourly. Women who are controlled by diet do not need to monitor blood glucose levels during labour.
Effective pain relief is important and an epidural should be considered.
Continual fetal heart rate monitoring should be used because of the increased risk of fetal distress.
It is important to be aware of the increased risk of shoulder dystocia and to take appropriate
precautions at delivery (i.e. maternal position [consider lithotomy] and episiotomy, particularly if the
scans suggest that the fetus is LFD).
POSTNATAL CARE
For women who are on metformin or insulin, this should be stopped after delivery of the placenta.
Breast-feeding should be encouraged.
All women with gestational diabetes should be seen at 6 weeks for a postnatal check and glucose
tolerance test. In most women, this will be normal, but they remain at risk of developing diabetes in
the future. This risk can be reduced by weight control and exercise. They should all therefore be given
general advice about weight and diet, and should have annual fasting blood glucose tests for early
detection of diabetes.
Box 5.2 Risks of gestational diabetes

Risks of gestational diabetes for the mother include:
Macrosomia and a difficult delivery (shoulder dystocia or the need for caesarean section for
cephalopelvic disproportion).
Polyhydramnios.
Risk of the mother developing diabetes in the future.
Risks of gestational diabetes for the baby include:
Hypoglycaemia.
Hypocalcaemia.
Palsies.
Fractures resulting from difficult delivery.
CASE 5.3 – I am pregnant and also anaemic.

Iron-deficiency anaemia.
Sickle-cell disease.
Thalassaemia.
B12 or folate deficiency.

Iron-deficiency anaemia is supported by the woman’s high parity and narrow spacing between children.
This is the most common type of anaemia in pregnancy, affecting about 10 per cent of women. Her
vegetarian diet would predispose to reduced iron intake.
An additional history would include symptoms (e.g. tiredness, breathlessness, ‘light-headedness’ or
‘dizziness’), evidence of chronic blood loss (e.g. menorrhagia), a previous history of anaemia, the use
of iron supplements and the patient’s country of origin. Symptoms of anaemia are usually absent unless
the haemoglobin concentration is <8 g/dL. Around 10 per cent of African Caribbean individuals in the
UK are heterozygous for sickle-cell disease, and thalassaemia is most prevalent in individuals from the
Mediterranean region and south-east Asia.

Examination would include a search for evidence of pallor (generally the sclera and palms) and
abdominal examination for hepatosplenomegaly.

Blood film ✓ Microcytosis and hypochromia can be seen on
blood film in iron-deficiency anaemia.
Hypersegmented neutrophils are seen in folate
deficiency.
FBC ✓ Both mean cell volume (MCV) and mean cell
haemoglobin (MCH) are reduced in iron-
deficiency anaemia. MCV is usually increased in
folate deficiency. Haemoglobin estimation in
pregnancy should not be the only parameter to
be assessed as a sign of anaemia because it can
be lowered as a result of haemodilution. If the
MCV is in the normal range, this would signify
haemodilution; if microcytosis is present, an iron
deficiency or haemoglobinopathy is likely.
B12 and folate levels ✓ If blood film is macrocytic.
Transferrin, iron and total iron ✓ If microcytosis is present.

binding capacity
Answers 65
Ferritin levels ✓ Ferritin levels should be measured if microcytosis

is present. Levels are reduced in iron-deficiency
anaemia.
Red cell folate ± Red cell folate should be measured if anaemia is
present without marked microcytosis.
Sickledex test and haemoglobin ± Sickledex test and if positive haemoglobin
electrophoresis electrophoresis for sickle-cell trait. If the woman
is Sickledex positive, her partner should be
tested and appropriate counselling given about
the prenatal diagnosis.
Haemoglobin A2 ± Haemoglobin A2 quantitation is required for
thalassaemia and, again if a positive result is
obtained, the partner should be tested.

Iron-deficiency anaemia should be treated with iron supplementation. Initially this should be oral
(e.g. ferrous sulphate), but if not tolerated by the patient can be given by intravenous infusion
(Venofer). The rarer folate and B12 deficiencies should be treated with appropriate supplements. The
aim should be to correct anaemia before delivery. However, as folic acid reduces the risk of neural
tube defects, it should be recommended to all women.
Heterozygous sickle-cell carriers usually have no problems and do not require treatment. They may in
extreme situations (e.g. hypoxia, infections) develop ‘crises’. Homozygote carriers are likely to have
been affected by ‘crises’ and have chronic haemolytic anaemia all their lives. In pregnancy, they have
increased perinatal mortality and are at risk of thrombosis, infection and sickle ‘crises’. Treatment
includes exchange transfusions, screening for infection, folic acid and avoidance of precipitating
factors for crises. Iron should be avoided.
For women with heterozygous a-thalassaemia, iron and folate supplementation are required. In
ß-thalassaemia, heterozygous women have a chronic anaemia that can worsen during pregnancy.
They may require transfusion. Pregnancy in homozygous individuals is uncommon. In these cases,
folic acid is required, but iron should be avoided.
OSCE COUNSELLING CASE 5.1 – I have diabetes and want to become

pregnant.
A1: What pre-pregnancy counselling would you provide for this woman?
The diabetic control should be optimized before pregnancy in order to reduce the risk of congenital
anomalies. If the patient is not regularly monitoring her blood sugar levels, this would need to be
commenced with the aim of adjusting insulin to keep pre-prandial levels to between 4 and 7 mmol/L.
A glycated haemoglobin concentration would give an indication of longer-term control and should
ideally be <7 per cent before conceiving.
The provision of glucagon would need to be checked because of the increased risk of hypoglycaemic
attacks with the tighter control. It would be important for the woman’s partner to know when and
how to administer the glucagon.
Commence folic acid supplementation (5 mg daily) to reduce the risk of neural tube defects and
aspirin (75 mg daily) to reduce the risk of pre-eclampsia.
Check whether the woman is rubella immune and give immunization before stopping contraception,
if she is not.
Emphasize the need to report early after a missed period to ensure early referral to a specialist
multidisciplinary antenatal clinic.
Arrange an eye examination to identify pre-existing retinopathy, which should be treated before
pregnancy.
OSCE COUNSELLING CASE 5.2 – I have epilepsy and I want to become

pregnant.
A1: What pre-pregnancy care and counselling would you give this woman?
Most babies who are born to mothers with epilepsy are normal. However, women with epilepsy,
particularly those taking antiepileptic drugs, are at increased risk of giving birth to a baby with
congenital anomalies (e.g. neural tube defects).
Before and during pregnancy, the aim should be to prescribe the lowest dose and number of
antiepileptic drugs necessary to protect against seizures. Suggest referral to a neurologist to consider
pre-pregnancy withdrawal of antiepileptic drugs or a change to monotherapy.
Emphasize the importance of periconceptual folic acid.
Recommend a detailed ultrasound scan at 18–20 weeks to identify fetal anomalies.
Check whether the woman is rubella immune and provide immunization, if appropriate.
REVISION PANEL
HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome is associated with impending
eclampsia in women with pre-eclampsia.
Gestational diabetes is associated with a high risk of type 2 diabetes in later life. This risk can be
significantly reduced by lifestyle (diet and exercise) changes.
Optimal control of diabetes periconceptually and during pregnancy reduces the risks of pregnancy-
associated complications. Folic acid should be given at 5 mg dose to reduce the risk of neural tube
defects and low dose aspirin should be commenced at 8–12 weeks to reduce the risk of pre-eclampsia.
The only 'cure' for pre-eclampsia is delivery of the fetus and placenta.
6 Puerperium
Questions
Clinical cases 68
Answers
Clinical cases 70
Revision panel 75
68 Puerperium
Questions
Clinical cases

diagnosis?
CASE 6.1 – My baby has just been delivered and I am bleeding heavily.
A 36-year-old woman with five children and a history of previous short labours delivered her baby 10 min
ago. She had been in labour on this occasion for 12 h after a spontaneous onset. She continues to bleed
heavily.
CASE 6.2 – I had a baby 3 days ago and feel shivery.

A 34-year-old primiparous woman had a traumatic vaginal delivery after an 18-h labour. Labour was
induced after pre-labour rupture of the membranes for over 48 h. Three days post-delivery, the woman
feels shivery and has had a temperature of 38.4 ºC and 38.5 ºC measured 4 h apart. She is a smoker, but
had stopped smoking during pregnancy.
CASE 6.3 – The midwife is concerned because I have little interest in

my baby.
An older primigravida feels that she has very little interest in her baby 3 days after delivery. She is a
solicitor by profession and became pregnant after assisted conception. The pregnancy and delivery were
uneventful. There is no past history or family history of mental illness.
Questions 69
OSCE COUNSELLING CASE 6.1 – Should I be breast-feeding my baby?

A primigravida has just delivered a healthy 3600 g baby.
Q1: What are the advantages and disadvantages of breast-feeding?
OSCE COUNSELLING CASE 6.2 – My baby has breathing difficulties after

a caesarean birth.
A baby has been admitted to the neonatal unit with breathing difficulties after a caesarean section
at term because of failure to progress. There was no fetal distress or birth asphyxia. The baby started
grunting at 30 min of age. Clinical examination and radiograph suggest transient tachypnoea of the
newborn (TTN).
Q1: Explain to the mother what is wrong with her baby and how it will be managed.
70 Puerperium
Answers
Clinical cases
CASE 6.1 – My baby has just been delivered and I am bleeding heavily.
Primary postpartum haemorrhage:
Atonic uterus, with or without retained placenta or placental segments.
Cervical, vaginal or perineal trauma.

Grand multiparity and prolonged labour are both risk factors for atonic postpartum haemorrhage.
A history of induced labour, retained placenta, previous postpartum haemorrhage, surgical delivery,
polyhydramnios, multiple pregnancy, antepartum haemorrhage, previous caesarean section and a
coagulation defect would all increase this woman’s risk of postpartum haemorrhage.

Examination would include measurement of pulse and blood pressure for evidence of shock. An
assessment of blood loss and continuing loss is required. Abdominal examination would include
palpation of the uterine fundus to identify a poorly contracted uterus. A check for obvious vaginal/
perineal trauma should be made and the midwife should be asked to check the completeness of the
placenta.

FBC ✓ To identify anaemia and platelet count.
Blood cross-match ✓ To replace blood loss and treat shock.
Clotting screen ✓ To identify a coagulopathy.

Initial management should be to obtain intravenous access (two wide bore Venflons) and commence
intravenous fluids. The uterine fundus should be ‘rubbed up’ if it is not contracted. An intravenous
oxytocin (Syntocinon) infusion should be commenced and intramuscular/intravenous ergometrine
given to contract the uterus. Any vaginal or perineal trauma should be sutured.
If the bleeding continues, manage shock and call for senior obstetric and anaesthetic assistance. Give
oxygen and commence colloid and/or blood when cross-matched, or O-negative blood. Ensure that
an adequate request has been made for cross-matched blood (at least 8 units) and check clotting.
Continue to compress the uterus bimanually if it is not contracted. Continue the intravenous infusion
of Syntocinon. Consider giving rectal, intramuscular or intramyometrial prostaglandin. Catheterize
the patient to monitor urine output and insert a central venous pressure line. If the bleeding persists,
Answers 71
examine under an anaesthetic to check that the uterine cavity is empty of retained products of
conception, and to identify and suture any trauma to the cervix, vagina or perineum. If bleeding
still persists, consider a Rusch balloon, B-Lynch suture, interventional radiology to embolize uterine
arteries or laparotomy with ligation of the internal iliac arteries or hysterectomy.
CASE 6.2 – I had a baby 3 days ago and feel shivery.

Endometritis.
Perineal wound infection.
Breast infection/abscess.
Urinary tract infection (UTI).
Chest infection.
Deep venous thrombosis (DVT).

Symptoms of shivers and a temperature are suggestive of an infection. Perineal lacerations and
episiotomies can become infected. A prolonged labour with ruptured membranes and repeated vaginal
examinations during induction of labour can result in endometritis. Smoking is a risk factor for chest
infection. A maternal pyrexia of >38 ºC is not usually associated with deep venous thrombosis, which
causes a low-grade pyrexia.
For endometritis, the lochia may be offensive. A history of frequency and dysuria may indicate a UTI,
which is a common cause of postpartum pyrexia. If the patient is also catheterized during labour, this
can lead to a UTI. An enquiry should be made to ensure that the placenta was complete at the third
stage of labour, to exclude infection of a retained placenta. This history may not be diagnostic.

Pulse, blood pressure, peripheral perfusion and signs of cyanosis should be sought. Examination is
required of the chest, breasts (enlargement, warmth and tenderness and a fluctuant tender mass,
together with enlarged axillary lymph nodes may be caused by an abscess), abdomen (to check for
involution of the uterus), loins (for renal tenderness), and intravenous access sites and legs (for swelling
and tenderness). Vulval examination of the perineal wound is also indicated. A vaginal examination
should also be performed to determine whether the cervical os is open. It may indicate retained products
and an enlarged tender uterus. If the patient had a caesarean section, a wound haematoma infection or
abscess would need to be excluded.

FBC ✓ Blood for white cell count – increased
polymorphs would indicate infection.
CRP ✓
HVS and endocervical swabs ✓ For culture and sensitivity testing for infection.
Urine culture ✓ To exclude a UTI.

72 Puerperium
Blood cultures ✓ To exclude septicaemia in view of the patient’s

high temperature.
Chest radiograph ✓ To exclude a chest infection if clinical signs.
Ultrasound Doppler of leg/pelvic veins ✓ To exclude a DVT if clinical signs.

Endometritis: co-amoxiclav (Augmentin) and metronidazole or erythromycin and metronidazole
(covers anaerobes).
Urinary tract infection: cephalosporins, penicillins/co-amoxiclav (Augmentin) (covers Gram-negative
cocci). Increase fluid intake.
Perineal wound infection: administer broad-spectrum antibiotics, which should include
metronidazole. Keep the wound clean and dry to allow rapid healing. If an abscess is present, any
sutures should be cut to allow the abscess to drain.
Breast infection/abscess: stop breast-feeding from the affected breast, but still continue to express the
milk. Administer penicillins/broad-spectrum antibiotics. Incise and drain if there is an obvious abscess.
Chest infection: chest physiotherapy, and amoxicillin/co-amoxiclav (Augmentin) (covers Gram-positive
cocci).
Deep venous thrombosis: low molecular weight heparin, e.g. Fragmin.
Management of DVT should be arranged in collaboration with the physicians so that the appropriate
anticoagulant regimen is administered. Risk markers should be tested 6 weeks postpartum (i.e. protein S
and C deficiency, factor V Leiden mutation and anti-thrombin III levels).
CASE 6.3 – The midwife is concerned because I have little interest in

my baby.
Postpartum ‘baby blues’.
Depression.
Puerperal psychosis.

In most cases with the given history, there is no psychiatric problem because minor psychological
symptoms are common after birth. Postpartum ‘baby blues’ are at their worst around days 3–5 after the
birth, but resolve by about day 10. However, this case needs further investigation in order to exclude
major psychosis or depression, particularly if the symptoms occur later, around 4–6 weeks after birth.
Lack of family history and past history of mental illness support a benign transient phenomenon, but
the woman’s age, higher social class, primigravidity and infertility treatment are all risk factors for major
mental illness.
The history should explore psychological symptoms such as variation in mood, poor sleep, weeping,
lethargy, irritability, hallucinations, delusions, etc. Operative mode of delivery, multiple pregnancy and
complications during pregnancy all increase the likelihood of major mental illness.
Answers 73

A mental state examination is required.

TFT ✓ Thyrotoxicosis should be excluded if major
mental illness is suspected.

Postpartum blues: psychological support and reassurance should be offered.
Refer the patient to a psychiatrist if depression or psychosis is suspected. Early diagnosis is important,
because it can interfere with mother–baby bonding.
Depression: antidepressants (e.g. imipramine, which does not interfere with breast-feeding).
Puerperal psychosis: admission to a psychiatric ward is essential, because there is a risk of suicide.
The mother should be separated from the baby because there is a risk of neglect and harm.
Neuroleptics may be used.
74 Puerperium
OSCE COUNSELLING CASE 6.1 – Should I be breast-feeding my baby?

A1: What are the advantages and disadvantages of breast-feeding?
Advantages include:
No cost.
No risk of infection from bottles.
Breast milk contains protein, fat and solute content ‘designed’ for babies (i.e. appropriate nutritional
content).
Contraceptive when fully breast-feeding.
Provides protection against infection (by providing passive immunity via maternal antibodies) and
allergies in neonate.
Reduced respiratory and gastrointestinal illness in the child.
Infant–mother bonding promoted.
Protection against maternal breast, endometrial and ovarian cancer.
Rapid reduction in maternal weight gained from pregnancy.
Effect on child development (e.g. potentially improved cognitive function).
Disadvantages include:
Breast milk jaundice is more common.
Can lead to maternal exhaustion because it involves feeding on demand.
Can cause pain/discomfort as a result of breast engorgement.
Leaking of milk from breasts may occur.
Without good support/encouragement, particularly in the early days when establishing breast-feeding,
there is a greater likelihood of giving up because of poor milk flow.
Despite these minor disadvantages, all mothers should be encouraged to breast-feed their babies.
OSCE COUNSELLING CASE 6.2 – My baby has breathing difficulties after

a caesarean birth.
A1: Explain to the mother what is wrong with her baby and how it will be
managed.
Transient tachypnoea of the newborn:
A benign transient problem with recovery within 1–2 days.
A problem of retained lung fluid.
Managed with supportive treatment such as oxygen and intravenous fluids.
Antibiotics can be prescribed, but are not always necessary.
There are no long-term sequelae.
The differential diagnosis is of either infection or respiratory distress syndrome.
Answers 75
REVISION PANEL
Grand multiparity, prolonged labour, polyhydramnios and multiple pregnancy are risk factors for
atoric postpartum haemorrhage.
The latest confidential enquiry into maternal deaths identified genital tract infection as being the
leading direct cause of death. Evidence of infection in the puerperium must therefore be monitored
closely and treated early and appropriately.
All women should be considered post-partum for DVT risk and commenced on appropriate
prophylaxis depending on that risk.
7 Abnormal uterine
bleeding
Questions
Clinical cases 78
Key concepts 80
Answers
Clinical cases 81
Revision panel 87
78 Abnormal uterine bleeding
Questions
Clinical cases

diagnosis?
CASE 7.1 – My periods are regular but heavy.

A 36-year-old nulliparous woman presents to the gynaecology outpatient clinic with heavy, regular
periods. Her menstrual cycle is 28 days. The periods last for 5 days, with clots during the first 2 days.
Up to 20 sanitary towels and supersize tampons are required for each period. The patient has no
significant dysmenorrhoea and there is no intermenstrual bleeding. She complains of feeling ‘run
down’ and lacking in energy. Her recent smear was negative and she is not using any contraception.
CASE 7.2 – My periods are heavy and irregular.

A 47-year-old schoolteacher with two children complains of a 9-month history of heavy irregular periods.
Her menstrual cycle is erratic and can vary between 3 and 6 weeks, with periods lasting 5–7 days. Before
the onset of menstrual problems her cycles were regular (every 4 weeks). Her recent cervical smear is
negative, and she has no intermenstrual bleeding. The patient has been sterilized.
CASE 7.3 – I have vaginal bleeding after intercourse.

A 32-year-old woman presents with a 6-month history of bleeding after intercourse. She is uncertain
about when her last smear was taken. She has four children and currently uses the combined oral
contraceptive pill for contraception.
Questions 79
OSCE COUNSELLING CASE 7.1 – Should I have surgery for heavy periods?
A 45-year-old woman presents with an 18-month history of increasingly heavy periods. She has a
regular cycle with 7 days of bleeding every 28–30 days. Clinical examination and investigations are
unremarkable. A diagnosis of dysfunctional uterine bleeding (DUB) is made.
Q1: If she opted for surgical management, what factors would you consider important when
counselling her?
OSCE COUNSELLING CASE 7.2 – Will hysterectomy affect my sex life?

A 44-year-old woman is having considerable problems with heavy menstrual bleeding (DUB), which has
been unresponsive to medical treatment. She has been offered a hysterectomy by her gynaecologist,
who has given her some time to consider this option. She mentioned this to a friend, who told her that
the operation ‘ruins your sex life and makes you incontinent’.
Q1: Can you reassure her? What factors would you consider important when counselling her?
Key concepts
key concepts.
MENORRHAGIA
The preferred term is now heavy menstrual bleeding (HMB). Excessive loss of blood during menstruation
is objectively measured to be >80 mL. In practice, this definition is seldom used and the effect of heavy
menstruation on the patient’s quality of life is considered to be more important.
Dysfunctional uterine bleeding (DUB) is classified when there is no organic disease of the genital
tract. It accounts for two-thirds of all heavy menstrual bleeding cases. It can be anovular or more
commonly ovular, i.e. with a regular cycle.
Heavy menstrual bleeding can also be caused by bleeding disorders such as idiopathic
thrombocytopenia (ITP), von Willebrand’s disease (factor VIII deficiency) or anticoagulation therapy
(uncommon).
DYSMENORRHOEA
Painful menstrual periods:
Primary: not associated with organic disease of the genital tract or a psychological cause.
Secondary: a cause can be found, e.g. endometriosis, chronic pelvic inflammatory disease (PID).
PREMENSTRUAL SYNDROME
Recurrent somatic, psychological or behavioural symptoms occurring in the premenstrual phase and up
to the point of menses. They produce social, family and occupational disturbance, usually relieved by
menstruation.
Answers 81
Answers
Clinical cases
CASE 7.1 – My periods are regular but heavy.

Ovular DUB.
Uterine leiomyoma (fibroids).
Adenomyosis is a form of uterine endometriosis where the endometriosis is found in the
myometrium.
Secondary to other causes, i.e. ITP, von Willebrand’s disease.

HMB is commonly associated with ovular DUB or fibroids. Anovular DUB would lengthen the cycle and
is more common in perimenopausal women (see Case 7.2). Intermenstrual bleeding could be associated
with anovular DUB, endometrial or cervical polyp or, very rarely, carcinoma, but highly unlikely at this
age. Clots and the large number of sanitary towels and tampons required indicate the severity of the
problem. Painful periods (dysmenorrhoea) could indicate endometriosis or adenomyosis.
Indications for the quality of life (e.g. effect on social life, days off work, sexual relationships, family
life) to establish the severity of the problem. Enquire about drug history and family history of bleeding
disorders.

Pallor on general examination may indicate anaemia caused by blood loss. Bimanual pelvic examination
should be undertaken to assess uterine size, mobility and uterine fibroids. Uterine tenderness/bogginess
would indicate a suspicion of adenomyosis.

FBC ✓ To exclude iron-deficiency anaemia (indicated by
low mean cell volume [MCV]).
TFT ✗ Not required as a routine investigation.
USS ± Can give the position, size and number of

fibroids or show normal pelvic viscera (DUB).
Endometrial biopsy ✗ Only essential in women over 45 years of age
because in premenopausal women <45 years
the risk of endometrial cancer is extremely low
(<4:100 000). It may be undertaken in younger
women with menorrhagia who are not
responding to medical treatment.

SUPPORTIVE
If investigations are normal, reassure the patient about the absence of pathology. Treat anaemia with
therapeutic doses of iron supplements. Compliance can be assessed by asking about dark stools. Iron
therapy itself can improve quality of life.
MEDICAL
Tranexamic acid taken during the menses is the first-line treatment of choice. It will reduce menstrual
blood loss by approximately 50 per cent.
Mefenamic acid is useful if there is associated pain. It can be used in conjunction with tranexamic acid.
Combined oral contraceptive pill, only if risk factors have been excluded, i.e. smoking, raised body
mass index, diabetes, hypertension.
Levonorgestrel intrauterine system (LNG-IUS) – warn of irregularity of menstrual cycle, which can last
up to 9 months.
Progestogens should be used in high doses throughout the cycle. It is ineffective when used in low
doses and in the second half of the menstrual cycle. Primarily used for anovular DUB (see Case 7.2).
Danazol – should not be used due to side effects such as acne, weight gain and voice changes.
SURGICAL
Not applicable to this patient because her family is not complete.
Endometrial ablation when the family is complete. There are several different types available,
e.g. first-generation resection or rollerball and second-generation global endometrial ablation devices
such as hot water, microwave or bipolar energy sources. They all have a success rate of approximately
80 per cent. Success rates depend on uterine size and presence of fibroids and adenomyosis.
In cases of submucous fibroids (Fig. 7.1), hysteroscopic myomectomy of the submucous component
only would be suitable if fertility is to be preserved. Success rate is approximately 80 per cent.
Treatment of subserosal or intramural fibroids does not usually result in appreciable menstrual loss
improvement.
Hysterectomy (abdominal, laparoscopic, subtotal or vaginal) is definitive, if the family is complete.
Subserosal
fibroid
Submucous fibroid (amenable

to hysteroscopic resection)
Intramural
fibroid
Figure 7.1 Different types of fibroids.

Answers 83
CASE 7.2 – My periods are heavy and irregular.

Anovular DUB.
Endometrial pathology (e.g. hyperplasia).
Climacteric (period of 2–3 years before menopause).
Fibroids/adenomyosis.
Ovarian pathology.

Perimenopausal women have failing ovarian function and this, associated with an irregularity of the
oestrogen/progesterone balance, gives rise to an irregular cycle. In anovular DUB, unopposed high
oestrogen levels can cause a prolonged cycle in which the endometrium undergoes hyperplasia
(endometrial glands are dilated and crowded). The duration of symptoms is an indication that this
condition is unlikely to resolve spontaneously without treatment.
Menopausal symptoms of hot flushes, night sweats, loss of libido and dry skin associated with the
climacteric should be sought. Obesity, hypertension and diabetes are risk factors for hyperplasia and
endometrial cancer.

General examination to exclude pallor. Abdominal examination to exclude pelvic mass secondary to
fibroids. Bimanual examination to assess uterine size/mobility and adnexal pathology. This would exclude
fibroids and ovarian pathology.

FBC ✓ To exclude iron-deficiency anaemia.
FSH ± To check for ovarian function, if there are any

menopausal symptoms. Gonadotrophin levels
such as follicle-stimulating hormone (FSH) levels
should be measured during or just after menses.
USS ✓ To exclude uterine and ovarian pathology.
Endometrial thickness indicates endometrial
pathology. Uterine fibroids or adnexal masses
may be visualized.
Outpatient hysteroscopy ✓ To exclude endometrial polyps/submucous
fibroids.
Outpatient endometrial biopsy ✓ Endometrial biopsy is the definitive way to
exclude hyperplasia and carcinoma of the
endometrium. It is recommended that all women
over 45 years of age with irregular vaginal
bleeding should have an endometrial biopsy.
Outpatient biopsy is diagnostic of detecting
endometrial pathology when it is present and
should be used wherever possible instead of
inpatient general anaesthetic biopsy (D&C).

SUPPORTIVE
Treat anaemia with iron supplements.
MEDICAL
If the patient is in the climacteric (perimenopausal), combined hormone replacement therapy may be
prescribed (see Case 8.3 and OSCE Counselling Case 8.1).
Progestogens in high doses throughout the cycle.
With anovular DUB that has resulted in endometrial hyperplasia (without atypia), progestogen
treatment is required in a continuous high-dose manner.
Consider using a levonorgestrel intrauterine system, which has the advantage of releasing continuous
progestogens locally in the uterus for up to 5 years.
SURGICAL
Hysterectomy (abdominal, laparoscopic, subtotal or vaginal) is definitive. When hyperplasia is
associated with cellular atypia, total hysterectomy with bilateral salpingo-oophorectomy is mandatory.
CASE 7.3 – I have vaginal bleeding after intercourse.

Cervical ectropion.
Cervical polyp.
Cervicitis.
Cervical carcinoma.

The pill is associated with cervical ectropion. The pill together with pregnancy and puberty are risk
factors that are commonly remembered as the three Ps.
It would be important to ascertain this woman’s social status, her employment, sexual history (age at
first intercourse, number of sexual partners) and whether she is a smoker because all of these are risk
factors for a cervical abnormality such as dyskaryosis or cervical carcinoma. A vaginal discharge may be
associated with cervicitis.

A careful inspection of the vulva and speculum examination of the vagina and particularly the cervix is
mandatory. (See Case 12.1 for details of examination in cases of vaginal discharge.)

Cervical ✓ Obtain report of last smear, or take one if there
is no bleeding at speculum smear examination.
Vaginal or cervical swabs for ± Only if infection is suspected or in cases
microscopy and culture associated with vaginal discharge.
Answers 85
Colposcopy and cervical biopsies ± Mandatory if there is any suspicion of malignancy

or if cervical smear result is abnormal.
Hysteroscopy ✗ Only necessary if there was associated persistent
intermenstrual bleeding, indicating the
possibility of an endometrial polyp.

SUPPORTIVE
Reassure the patient if there is no pathology.
MEDICAL
Infection should be treated with appropriate antibiotics according to the results of culture and sensitivity
reports.
SURGICAL
If a polyp is evident, this should be avulsed and sent for histopathological assessment. This can be
done as an outpatient procedure without anaesthesia.
Cervical ablation: if the smear is normal, a cervical ectropion can be reasonably treated in the
outpatient clinic (e.g. with cryotherapy, cold coagulation, laser or large loop excision of the
transformation zone – LLETZ).
OSCE COUNSELLING CASE 7.1 – Should I have surgery for heavy periods?
A1: If she opted for surgical management, what factors would you consider
important when counselling her?
The surgical approaches that are available (i.e. endometrial ablation or hysterectomy):
Second-generation endometrial ablation can be carried out in the outpatient setting, using local
anaesthesia. The success rate is approximately 80 per cent, but amenorrhoea is not guaranteed. There
is a possibility that a hysterectomy may be required at the time of surgery if a complication arises,
particularly with first-generation techniques, or at a later date if ablation is not successful. In addition,
pregnancy should be avoided and sterilization may be considered at the same time as ablation.
Recovery rates are short.
If a hysterectomy is decided on, consideration would need to be given to the route, i.e. vaginal,
abdominal or laparoscopically-assisted. If abdominal, whether this would be total or subtotal.
Consideration should be given to whether the ovaries should be removed in order to reduce the risk
of future ovarian cancer. Oestrogen-alone hormone replacement treatment may be required, but
combined HRT is needed in subtotal hysterectomy. Risk of ovarian cancer is low if there is no family
history.
Hysterectomy recovery rates are reducing with the introduction of enhanced recovery methods, i.e.
early mobilization, early introduction of diet, early discharge, which lead to full recovery as early as
3–4 weeks, rather than the traditional 6–12 weeks.
OSCE COUNSELLING CASE 7.2 – Will hysterectomy affect my sex life?

A1: Can you reassure her? What factors would you consider important when
counselling her?
Bladder function: the bladder innervation may be altered, but evidence of an increased incidence of
incontinence is conflicting.
Bowel function: again there is conflicting evidence, with some studies suggesting an increase in the
incidence of irritable bowel syndrome and constipation, and others showing no change.
Sexual function: both psychological and physical factors influence sexual function. It is generally
accepted that sexual function remains unchanged and may even improve as the inherent problem of
heavy periods has been resolved. There is no benefit in performing subtotal hysterectomy in terms of
preserving sexual function.
Answers 87
REVISION PANEL
For clinical purposes, HMB should be defined as excessive menstrual blood loss, which interferes
with the woman’s physical, emotional, social and material quality of life, and which can occur alone
or in combination with other symptoms. Any interventions should aim to improve quality of life
measures rather than focusing on menstrual blood loss.
Therapeutic iron supplements alone can significantly improve quality of life.
In premenopausal women, the risk of endometrial cancer is extremely low, but endometrial
hyperplasia has to be excluded.
In women with HMB alone, with a uterus no bigger than a 10-week pregnancy, endometrial
ablation should be considered preferable to hysterectomy.
Although hysterectomy is a definitive option for heavy menstrual bleeding, it should not be offered
as first-line treatment unless gross disease is present, e.g. large multiple fibroids.
8 Amenorrhoea
and menopause
Questions
Clinical cases 90
Key concepts 92
Answers
Clinical cases 93
Revision panel 100
90 Amenorrhoea and menopause
Questions
Clinical cases

diagnosis?
CASE 8.1 – My periods are infrequent. I have not had any for 7 months.
A 26-year-old woman attends a gynaecology clinic concerned that she has not had a menstrual period
for 7 months. She had her first period when she was 12 years old. Her periods have been gradually
becoming more infrequent. She keeps athletically fit and has recently been training for a marathon and
has lost some weight. She has a normal healthy appetite and diet. She claims not to have been sexually
active for the past 12 months. Her home pregnancy test is negative.
CASE 8.2 – I have intolerable menstrual periods.

A 35-year-old woman has been experiencing pelvic pain, irritability, bloatedness and breast pain for
3–4 days before her periods. These symptoms have occurred cyclically over a period of 4–6 months
and they disappear after the onset of menses. Her periods are regular and painful but not heavy.
She has two children and uses condoms for contraception. There is no history of psychiatric illness.
CASE 8.3 – Should I take HRT (hormone replacement therapy)?

A slim 52-year-old university lecturer presents with an 18-month history of amenorrhoea and a 3-year
history of hot flushes and night sweats. She has a family history of heart disease and breast cancer.
Questions 91
OSCE COUNSELLING CASE 8.1 – HRT compliance.

A 48-year-old woman has menopausal symptoms. As a result of this and the fact that she has a family
history of osteoporosis, she wishes to start HRT. However, compliance is a problem in women who start
HRT.
Q1: What issues should be considered for improving this woman’s compliance?
Q2: What would be an appropriate screening programme for this patient if she were happy to
start HRT?
OSCE COUNSELLING CASE 8.2 – Controversies with HRT.

A 54-year-old has been told that she should stop taking her combined HRT because this is associated
with an increased risk of breast cancer. She has enjoyed the HRT benefits and does not want to stop
treatment.
Q1: What are the benefits and risks of HRT in the light of current evidence?
Q2: How can the HRT preparation be altered to suit her so that she can continue using HRT?
Key concepts
key concepts.
PUBERTY
Time of onset of ovulatory and endocrine ovarian function, making an individual capable of
reproduction.
Delayed puberty is a lack of secondary sexual characteristics by the age of 14 years.
AMENORRHOEA
Lack of menstruation (this is a symptom, not a diagnosis).
Primary: lack of menstruation by 16 years of age in a girl with normal growth and secondary sexual
characteristics.
Secondary: amenorrhoea for 6 months or for a duration of more than three times the length of
previous menstrual cycles after an individual has formerly had menstrual periods.
OLIGOMENORRHOEA
Infrequent periods with a menstrual cycle longer than 35 days.
MENOPAUSE
Lack of menstruation for more than 12 months, associated with cessation of ovarian function and
reproductive capacity.
PREMATURE MENOPAUSE
Menopause before the age of 35 years.
HIRSUTISM
Excessive growth of sexual (androgen-dependent) hairs.
VIRILISM
Androgenic changes more extensive than hirsutism, including amenorrhoea, breast atrophy,
clitoromegaly and temporal balding.
Answers 93
Answers
Clinical cases
CASE 8.1 – My periods are infrequent. I have not had any for 7 months.
Secondary amenorrhoea:
stress-related amenorrhoea;
polycystic ovarian syndrome (PCOS);
hyperprolactinaemia;
hyper-/hypothyroidism.
Premature menopause.

Pregnancy, the most common cause of secondary amenorrhoea, is unlikely in this case because the
patient is not sexually active and a urinary pregnancy test is negative. Although she normally keeps
fit, the excessive recent training over and above her normal routine level of fitness is likely to be a
possible cause of her amenorrhoea. Moreover, as she has a normal diet, she does not have anorexia
nervosa-related amenorrhoea.
An additional history should be obtained about menopausal symptoms (i.e. hot flushes, night sweats),
in order to exclude premature menopause. Precise information about weight loss will be helpful because
sudden excessive loss of >10 kg is associated with amenorrhoea. PCOS would normally be associated
with infertility and oligomenorrhoea. Headaches and visual disturbances may suggest pressure on the
optic chiasma from a prolactinoma in the anterior pituitary. Symptoms of intolerance of extremes of
temperature, feeling very energetic or lethargic, and excessive weight loss or weight gain would be
consistent with hyper-/hypothyroidism. A drug history (e.g. progestogens and major tranquillizers such as
phenothiazines) is associated with a lack of menstruation.

The patient’s weight should be measured (this may not be diagnostic, but it will be helpful in
management and follow-up). The condition of the skin and hair may indicate thyroid abnormalities.
Hirsutism and acne are associated with PCOS. Evidence of striae and stigmata of virilization may be an
indication of severe PCOS or a hormone-producing tumour. The visual fields should be examined in cases
of prolactinoma. A breast examination should be performed to ensure normality of secondary sexual
characteristics and to check for galactorrhoea (a sign of prolactinoma). An abdominopelvic mass would
indicate a possible pregnancy or hormone-producing ovarian tumour.

Pregnancy test ✓ Hospital pregnancy tests are more reliable than
home tests.
LH and FSH ✓ An LH:FSH ratio/measurement (taken during
menses or just afterwards) of 3:1 was previously
taken to indicate PCOS. However, raised LH levels
are common, particularly in anovulatory women,
and a specific but not very sensitive index of
PCOS. Many patients with all of the other clinical
and biochemical features of PCOS have normal
LH levels. The diagnosis is made primarily on
clinical (amenorrhoea/oligomenorrhoea) and
ultrasound criteria. The finding of raised
testosterone and/or LH merely complements the
clinical diagnosis. An FSH level of >25 IU/mL is
highly indicative of premature menopause.
Serum testosterone ✓ Serum concentrations of testosterone and other
androgens are raised in PCOS, therefore a useful
screening test.
Serum prolactin ✓ If hyperprolactinaemia is confirmed, further tests
(computed tomography or magnetic resonance
imaging of head for pituitary adenoma, and
visual field assessment) for prolactinoma may be
required.
TFT ✗ This test is required only in cases with symptoms
or signs of hypo-/hyperthyroidism, or if there is
hyperprolactinaemia, which is known to be
associated with hypothyroidism.
USS ± The ultrasound criteria for the diagnosis of a
polycystic ovary are eight or more subcapsular
follicular cysts <10 mm in diameter and
increased ovarian stroma. A thick endometrium
is associated with polycystic ovaries, but a thin
endometrium is associated with premature
menopause.

SUPPORTIVE
After cessation of excessive training and an increase in body weight, spontaneous resolution and
return of menses would be expected.
MEDICAL
PCOS – combined oral contraceptive (COC) if the patient wishes to have periods. If pregnancy is
desired, then commence ovulation induction (see Case 12.2).
Menopause – COC, combined HRT (see Case 8.3 and OSCE Counselling Case 8.1).
Hyperprolactinaemia – bromocriptine, cabergoline (dopamine agonists).
SURGERY
Surgery for pituitary adenoma is rarely required nowadays.
Ovarian drilling for PCOS.
Answers 95
CASE 8.2 – I have intolerable menstrual periods.

Premenstrual syndrome (PMS).
Secondary dysmenorrhoea:
endometriosis – adenomyosis;
pelvic inflammatory disease.
Pelvic venous congestion.

Premenstrual syndrome is common around the age of 35 years. This complex problem of unknown
aetiology occurs during the week before menstruation and is classically resolved by menstruation.
Adenomyosis is associated with painful periods that are usually heavy.
Tension, aggression, depression and ‘fluid’ retention are other common symptoms of PMS. Any
susceptibility to accidents, criminal acts and suicide indicates severe disability, which occurs in 3 per cent
of cases.

General examination with pelvic examination is necessary to exclude ‘organic’ disease (e.g. pouch of
Douglas nodularity, which may be caused by endometriosis). A mental state examination is essential
because depression and neurosis can present as PMS.

Symptom diary ✓ The diagnosis of PMS is confirmed by
establishing that the recurrent symptoms are the
same, that they occur regularly and that there is
a symptom-free period between menses.
USS ± A pelvic ultrasound examination may show
ovarian endometrioma (termed ‘chocolate cysts’).
Diagnostic laparoscopy ± Not required as a routine test, but may be
considered if there is any suggestion of an
organic cause for the pelvic pain.

SUPPORTIVE
Treatment is empirical because the cause is unknown. Sympathetic handling, support, reassurance
about the absence of pathology and understanding (particularly by family members) are very important.
Cognitive and relaxation therapy.
Any treatment has a high (75 per cent) placebo response rate.
MEDICAL
COC (not progesterone alone).
Evening primrose oil.
Vitamin B6 (pyridoxine).
Selective serotonin reuptake inhibitors (SSRIs) are effective in severe cases.

High-dose oestrogens may be helpful, but progestogens would be required as well to prevent
endometrial hyperplasia/malignancy.
Gonadotrophin-releasing hormone agonists can be used to stop ovarian function temporarily.
Symptomatic relief is both diagnostic and therapeutic.
Diuretics are not usually successful.
SURGICAL
A last-resort permanent solution would be bilateral oophorectomy by performing a concomitant
total abdominal hysterectomy. ‘Oestrogen-alone’ HRT as a non-cyclical preparation may be used
subsequently without causing a recurrence of symptoms.
CASE 8.3 – Should I take HRT?

Menopause.

The average age of menopause in the UK is 51 years. This patient has had menopausal symptoms for
3 years, indicating that the climacteric and menopause are occurring at the appropriate age.
Other symptoms of the menopause include depression, loss of libido, hair loss, dry skin and painful
intercourse as a result of a dry vagina (dyspareunia). It is important to check whether there is any
family history of osteoporosis, breast cancer or ischaemic heart disease, or early menopause, as well as
checking factors such as smoking, previous Colles’ or hip fracture, sedentary lifestyle and low body mass
index. It would be important to exclude any evidence of vaginal bleeding, which would warrant further
investigations (see Case 10.3).

General examination, including blood pressure measurement, is necessary to exclude hypertension.
Examination of the breasts is mandatory, but it is likely that, if the patient is registered with a general
practice, she will have been called for breast screening through the national screening programme
initiated at 51 years of age. Pelvic examination would be necessary only if a recent cervical smear had
not been taken.

The diagnosis of menopause is firm in this case and, therefore, a determination of FSH levels is not
required. However, it may be prudent to offer this patient genetic counselling and screening for breast
cancer (BRAC-1 and BRAC-2 genes) if at least two first-degree relatives (mother or sisters) have had
breast cancer.

This patient should be given combined oestrogen and progestogen preparations because she has an
intact uterus. ‘Oestrogen-only’ preparations should be prescribed only in patients who have undergone a
hysterectomy.
Answers 97
There are several different preparations of HRT available (oral, patches, implants and gel). They can
induce monthly withdrawal bleeding, 3-monthly withdrawal bleeding or no withdrawal bleeding. The
continuous combined preparations would be highly suitable for this patient because she has been
amenorrhoeic for at least a year. This would improve her long-term compliance with HRT.
This patient would need careful counselling about the benefits and disadvantages of HRT because
she has a family history of heart disease and breast cancer. Current evidence does not support the
use of HRT when there is a history of heart disease and breast cancer, although HRT would not be
contraindicated if the patient was adequately counselled (see below). Counselling should be reinforced
with written literature.
OSCE COUNSELLING CASE 8.1 – HRT compliance.

A1: What issues should be considered for improving this woman’s compliance?
Explore any concerns that she may have about the treatment.
Ensure that she has realistic expectations of the treatment.
Emphasize the benefits of treatment – both short-term symptomatic benefits (e.g. relief from flushes)
and long-term benefits (e.g. reduced risk of osteoporosis).
Provide accurate information about the risks and potential complications (e.g. cancer and
thromboembolism).
Discuss the appropriate method of administration and type of HRT for the patient.
Ensure regular review.
Give the patient a leaflet/literature about HRT.
A2: What would be an appropriate screening programme for this patient if

she were happy to start HRT?
Pre-treatment:
blood pressure measurement;
weight;
breast examination;
cervical smear;
pelvic examination.
Six-monthly:
weight;
blood pressure measurement.
Yearly:
breast examination.
Three-yearly:
mammography;
cervical smear (pelvic examination).
OSCE COUNSELLING CASE 8.2 – Controversies with HRT.

A1: What are the benefits and risks of HRT in the light of current evidence?
HRT ADVICE FOR PRESCRIBERS
For the treatment of menopausal symptoms, the benefits of short-term HRT are considered to
outweigh the risks in most women.
Each decision to start HRT should be made on an individual basis with a fully informed woman.
In all cases, it is good practice to use the lowest effective dose for the shortest possible time and to
review the need to continue treatment at least annually. This review should take into account new
knowledge and any changes in a woman’s risk factors and personal preferences.
For postmenopausal women who are at an increased risk of fracture and are aged over 50 years, HRT
should be used to prevent osteoporosis only in those who are intolerant of, or contraindicated for,
other osteoporosis therapies.
Answers 99
Table 8.1 Benefits and risks associated with using HRT
Condition Number of cases/1000 Reduced number of cases in 1000

non-HRT users HRT users over 5 years’ HRT use
Benefits over 5 years Oestrogen only Combined HRT
Relief of menopausal symptoms, Effective Effective

i.e. hot flushes, night sweats, vaginal
dryness and discomfort, difficulty
in sleeping and consequential
depression, mood swings,
tiredness and poor concentration
Colorectal cancer 6–10 No significant 1–3 (± 2)

effect
Fracture of neck of femur 0.5–5.5 0.3–3 (± 2) 0.3–3 (± 2)
Cumulative cancer risk over 5 years EXTRA number of cases in 1000

HRT users over 5 years’ HRT use
Breast cancer 14–16 0–1.5 (± 1.5) 4–6 (± 4)
Endometrial cancer 3 5 (± 1) Cannot be

estimated
Ovarian cancer 3 1 (± 1) Not known
Cardiovascular risk over 5 years
Stroke 3–15 2–6 (± 4) 1–4 (± 3)
Venous thromboembolism (VTE) 3–11.5 1–4 (± 4) 4–9 (± 5)
Coronary heart disease (CHD) No benefit No benefit
Cognitive function or dementia No benefit No benefit
Numbers are best estimates (± approximate range from 95 per cent confidence intervals).
Women who are receiving HRT for their menopausal symptoms will benefit from the effect of HRT
on osteoporosis prevention while on treatment.
Healthy women who have no menopausal symptoms should be advised against taking HRT because
the risks outweigh the benefits.
HRT does not prevent coronary artery disease or a decline in cognitive function and should not be
prescribed for these purposes.
HRT remains contraindicated in women who have had breast cancer.
For women without a uterus, oestrogen-only therapy is appropriate.
For women with a uterus, oestrogen plus progestogen is recommended. However, women should be
fully informed of the added risk of breast cancer and be involved in the decision-making process.
A2: How can the HRT preparation be altered to suit her so that she can
continue using HRT?
For this patient, the insertion of the levonorgestrel intrauterine system releasing the progestogen
component of HRT (with systemic E2 preparation) may reduce her breast cancer risk because systemic
progestogens are implicated in the increase in breast cancer risk. This is extrapolated from the randomized
controlled trials data that there is no increase in risk of breast cancer in oestrogen-alone HRT users.
REVISION PANEL
Weight loss below a certain threshold (e.g. athletes, ballet dancers) or weight gain can cause
amenorrhoea.
PMS is a debilitating condition that requires careful diagnosis, assessment and treatment.
The modal age of menopause in the UK is 51 years.
Progestogens as part of HRT are required for endometrial protection, but are implicated in the
increased risk of breast cancer.
Contraception should be continued until 2 years after the last period in women under 50 and
1 year in women over 50 years.
9 Incontinence and prolapse
Questions
Clinical cases 102
Key concepts 104
Answers
Clinical cases 105
Revision panel 112
Questions
Clinical cases

diagnosis?
CASE 9.1 – Every time I cough, I leak urine.

A 36-year-old parous woman complains of involuntary urinary loss on exercise, sneezing or coughing.
She has suffered from this problem since the birth of her first child 10 years earlier, which was assisted
with forceps. She is fit and healthy, but has to wear sanitary protection all the time. Otherwise, she voids
five or six times a day and once at night, passing good volumes of urine without difficulty.
CASE 9.2 – I have to rush to the toilet, otherwise I leak urine.

A 60-year-old woman complains of voiding difficulties. She has frequency of 10–12 times during the day.
At night, she gets up three or four times to void. There is also involuntary urinary loss, particularly when
she cannot reach the toilet in time. She has had this problem for the last 5 years, but it has gradually
been worsening since her periods stopped 10 years ago. She is not on hormone replacement therapy
(HRT). Recently, the urinary loss has increased so much that it has become a major hygienic problem.
Her social activities have become severely restricted because of the worsening of the condition. She has
been treated for urinary tract infections on several occasions in the past. There is no history of diabetes
or hypertension.
CASE 9.3 – I feel something coming down.

A 56-year-old shopkeeper presents to a gynaecology clinic with a 3-month history of a sensation of
‘something coming down’. She feels a ‘lump’ in her vagina, which is worse towards the end of the day,
in association with a dragging backache. She has had four vaginal deliveries, one of which was assisted
by forceps. There were no macrosomic babies. She does not have urinary or bowel incontinence.
Questions 103
OSCE COUNSELLING CASE 9.1 – What investigations am I going to have

for leaking urine?
A 56-year-old woman presents with a history of incontinence of urine and urinary frequency. She
describes a sudden urge to pass urine followed by incontinence, but she can also leak when lifting
and coughing. You have excluded a urinary tract infection and pelvic examination is unremarkable.
You decide to perform urodynamic investigations.
Q1: In counselling this patient, what points would you wish to make about the reasons for
performing the investigation?
Q2: What does the investigation involve?
OSCE COUNSELLING CASE 9.2 – Can my prolapse be treated without

surgery?
A 65-year-old woman is referred with a procidentia that is reducible. There are no pelvic masses or
urinary or faecal problems.
Q1: Discuss the non-surgical management options and any potential problems that may be
encountered with these treatments, as the patient is medically unfit for surgery.
Key concepts
key concepts.
CONTINENCE
Ability to hold urine in the bladder at all times, except when voiding.
INCONTINENCE
Involuntary urine loss that is objectively demonstrable, which is a social or hygienic problem.
URODYNAMIC STRESS INCONTINENCE (USI)

This was previously called genuine stress incontinence. USI is noted during filling cystometry and is
defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a
detrusor contraction.
DETRUSOR OVERACTIVITY
This was previously called detrusor instability. Detrusor overactivity is a urodynamic observation
characterized by involuntary detrusor contractions during the filling phase, which may be spontaneous
or provoked.
FREQUENCY
Normal frequency is usually every 4 h. Voiding more often than six times a day or more frequently than
every 2 h is usually regarded as abnormal.
NOCTURIA
Interruption of sleep as a result of micturition more than once every night. Voiding twice at night over
the age of 70 years and three times over the age of 80 years is considered to be within normal limits.
UTEROVAGINAL PROLAPSE
Descent of the pelvic genital organs towards or through the vaginal introitus:
First degree: descent of the cervix and uterus within the vagina but not up to the introitus.
Second degree: descent of the cervix and uterus up to the introitus.
Third degree: descent of the cervix and the whole uterus through the introitus.
Procidentia: cervix and whole of the uterus completely out of the introitus and is usually accompanied
by cystourethrocele and rectocele.
Answers 105
Answers
Clinical cases
CASE 9.1 – Every time I cough, I leak urine.

USI, most likely.
Detrusor overactivity (urge incontinence).
Mixed incontinence (USI and detrusor overactivity).
Neurological disorder (uncommon).

A history of involuntary urinary loss resulting from a rise in intra-abdominal pressure during exercise,
sneezing or coughing in the absence of voiding difficulties is suggestive, but not a definite feature
of USI. Difficult childbirth can be a risk factor. Quality of life is measured by the impact of the urinary
problem on the patient’s usual activities.
A specific history of urgency and urge incontinence with or without associated urinary tract infections
(UTIs) is suggestive of detrusor overactivity. Urinary frequency is more than five or six times per day,
and sleep is also disturbed as a result of nocturnal frequency. Urodynamic stress incontinence will often
be associated with multiparity, prolonged labour, and symptoms of uterovaginal prolapse and faecal
incontinence. In neurological disorders such as multiple sclerosis, incontinence will usually be a secondary
symptom.

Physical examination should be performed with a comfortably full bladder, when incontinence should be
demonstrated by asking the patient to cough. However, this finding does not conclusively indicate USI.
Pelvic examination is usually normal in women with incontinence. Incontinence is sometimes associated
with pelvic masses (e.g. a large fibroid uterus causing pressure effects). Occasionally, incontinence is
associated with neurological disease. Urodynamic stress incontinence may be associated with evidence
of perineal deficiency on inspection and uterovaginal descent on straining.
It is important not to rely solely on the patient’s history and examination for diagnosis.

MSU ✓ To exclude urinary tract infection.
Bladder diary ✓ To evaluate intake and output with recording episodes

of urgency and leakage and precipitating events.
Urodynamic investigations ✓ To differentiate between USI and detrusor
overactivity. In USI, urodynamics are normal, i.e.:
urine flow rate >15 mL/s (Fig. 9.1);
bladder capacity >300 mL;
residual volume <50 mL;
bladder pressure rises by <15 cm H2O during
filling;
detrusor remains stable throughout filling
and voiding.
(a) (b) (c)

Normal Urodynamic Detrusor
bladder stress overactivity
incontinence
Bladder
pressure
Intra-
abdominal
pressure
Detrusor
pressure
Urine
flow
Filling Filling Filling
Cough Cough Cough
(a) (b) (c)

Normal bladder Urodynamic stress Detrusor overactivity
• No increase in detrusor incontinence • Detrusor contraction
pressure with filling • No increase in detrusor after cough
• No detrusor contraction pressure with filling • Urine flow with detrusor
with cough • No detrusor contraction contraction if increase in
• No urine flow with cough with cough bladder pressure is
• Urine flow with cough sufficient to overcome
urethral pressure
Figure 9.1 Urodynamic investigations.

SUPPORTIVE
The local incontinence advisory service should be involved in management. USI can be treated
conservatively using techniques for pelvic floor re-education (pelvic floor exercises and other
physiotherapy techniques, including vaginal cones, perineometry, electrical stimulation).
Answers 107
MEDICAL
Drug therapy includes a-agonists (e.g. phenylpropanolamine), which increase urethral resistance.
SURGICAL
Surgery is used to support the proximal urethra and to elevate the bladder neck to restore the
suburethral hammock support. This is commonly done using retropubic and transobturator
tapes (tension-free tapes) and previously colposuspension. Alternative surgical techniques
include paraurethral bulking. These techniques should be employed in preference to anterior
colporrhaphy and anterior repair, which do not have the desired long-term benefits compared
with colposuspension procedures.
CASE 9.2 – I have to rush to the toilet, otherwise I leak urine.

Detrusor overactivity (urge incontinence), most likely.
Urodynamic stress incontinence.
Mixed incontinence (USI and detrusor overactivity).
Neurological disorder (uncommon).

A history of urgency, frequency and nocturia with or without associated UTIs is highly suggestive of
detrusor overactivity. At this patient’s age, frequency every 2 h is abnormal. Quality of life is measured by
the patient’s social activities being restricted and her having hygiene problems. Postmenopausal atrophic
changes of the bladder will also be a contributory factor in this case.
Fluid intake habits, particularly in relation to tea, coffee and alcohol, are important with regard to the
symptomatology. Haematuria may indicate a bladder stone or tumour. Involuntary urine loss as a result
of a rise in intra-abdominal pressure (e.g. caused by exercise, sneezing or coughing) in the absence of
voiding difficulties is suggestive of USI. Incontinence may be associated with symptoms of uterovaginal
prolapse and faecal incontinence. In neurological disorders such as multiple sclerosis, incontinence will
usually be a secondary symptom.

Physical examination should be performed with a comfortably full bladder, when incontinence may
be demonstrated by asking the patient to cough. Signs of oestrogen deficiency may be evident on
inspection of the genitalia. There may be uterovaginal descent on straining. Pelvic examination may reveal
a pelvic mass, which may be the cause of urinary symptoms resulting from pressure effects. Occasionally,
incontinence is associated with neurological disease. Examination of S2, S3 and S4 dermatomes is essential.

MSU ✓ To exclude urinary tract infection.
Bladder diary ✓
Urodynamic investigations ✓ To differentiate between USI and detrusor

overactivity. In detrusor overactivity, urodynamics
might show:
reduced bladder capacity (<300 mL);
high bladder pressure, increasing to >15 cm H2O
during filling;
spontaneous detrusor contractions during filling,
or contractions in response to provocation such
as a change in posture.
Urodynamic investigations are not essential as a
matter of routine. They should, however,
be undertaken in patients who are not
responding to supportive and medical therapeutic
measures.
Cystoscopy ✓ In resistant cases.

SUPPORTIVE
The incontinence advisory service should be involved in management. Fluid intake habits may have to
be altered in order to manage the symptoms (e.g. last drink at 18:00, reducing tea, coffee and alcohol
intake). Detrusor overactivity can be treated conservatively using techniques for bladder training and
bladder drill to re-establish central bladder control.
MEDICAL
Drug therapy in this case might include HRT. Urinary tract infections should be treated with appropriate
antibiotics. Anticholinergic drugs include oxybutynin, tolterodine and newer drugs include solifenacin,
fesoterodine and darifenacin. Side effects include dry mouth, blurred vision and constipation.
SURGICAL
There is no place for surgery as a primary intervention. Only when all other methods have been
exhausted should complex procedures such as clam cystoplasty be considered. These are end-stage
procedures with a high morbidity rate and long-term problems.
CASE 9.3 – I feel something coming down.

Cystocele.
Uterine prolapse:
first degree;
second degree;
third degree (procidentia).
Rectocele.
(Enterocele – pouch of Douglas hernia, which contains loops of bowel.)

‘Something coming down’ is a symptom of the various types of uterovaginal prolapse (Fig. 9.2). Prolapse
premenopausally is uncommon. Childbirth and particularly traumatic delivery indicates that there may
have been possible pelvic floor damage. It is difficult to ascertain the type of prolapse from the history
Answers 109
Uterovesical Peritoneum
pouch
Bladder Uterus
Cystocele
Urethra
Combined urethra
and bladder Small
prolapse is Cervix bowel loops in
urethrocystocele pouch of Douglas
Second degree First degree
uterine uterine
Urethrocele prolapse
prolapse
Enterocele
Rectocele
Third degree Rectum

uterine
prolapse
(procidentia)
Figure 9.2 Different types of prolapse.
alone without examination. It is said that women who have a physically demanding job are at high risk
of prolapse. The sensation of prolapse is typically worse at the end of the day.
It is important to ascertain a history of urinary incontinence (see Cases 9.1 and 9.2). In general, stress
incontinence is not associated with cystocele. Constipation or difficulty on emptying fully can suggest
a rectocele. The use of HRT may reduce the risk of prolapse. Postnatal exercises are considered to be a
preventive measure for future prolapse. Smoking history and cough associated with respiratory illnesses
may exacerbate the symptoms of prolapse. Chronic cough is a poor prognostic factor for the success of
prolapse surgery. It is also important to establish whether the patient is sexually active as any potential
surgery can affect sexual function (see A6 below).

Record the patient’s weight and perform a general physical examination to assess her fitness for surgery,
if this is intended. Exclude an abdominal mass and examine the external genitalia to assess signs of
atrophy. Ask the patient to cough in order to detect any stress incontinence (although elicitation of
this at the time of examination is not conclusive evidence of her incontinence). During straining, any
components of prolapse can be described, but the different types can be distinguished only using a
Sim’s speculum in the left lateral position. A bimanual examination should be performed to exclude a
pelvic mass.

The diagnosis is primarily made on the basis of the clinical examination. If there is concurrent
incontinence, urodynamics would be mandatory before surgery (see OSCE Counselling Case 9.1).

SUPPORTIVE
Weight control.
To stop smoking.
Pelvic floor exercises.
Vaginal pessaries (e.g. ring or shelf) may be used to provide symptom relief if the patient is unfit for
surgery or wishes to avoid surgery. Pessaries are more likely to be helpful in women with a prominent
suprapubic arch and strong perineal body for support; otherwise, the pessary is easily expelled.
Pessaries are generally replaced every 6 months.
MEDICAL
Vaginal oestrogen cream or HRT.
SURGICAL
Cystocele: anterior repair (colporrhaphy).
Uterovaginal prolapse: cervical amputation with shortening of the uterosacral ligaments
(Manchester–Fothergill repair). This operation should be performed only if a vaginal hysterectomy
is not possible.
Vaginal hysterectomy: this removes the prolapsed organ. Anterior repair and posterior repair are
performed if appropriate. The vaginal vault should be suspended.
Rectocele: posterior repair and perineal repair in cases where there is a deficient perineum from
previous childbirth (posterior colpoperineorrhaphy).
In all surgical interventions, the rate of recurrence is high if preventive measures are not implemented
(e.g. using HRT, reduction in body weight and stopping smoking in the case of chronic cough). In any
repair operation, the vagina and introitus should not be obliterated, which would inhibit intercourse and
possibly be a cause of dyspareunia.
Answers 111
OSCE COUNSELLING CASE 9.1 – What investigations am I going to have

for leaking urine?
A1: In counselling this patient, what points would you wish to make about
the reasons for performing the investigation?
Urodynamics measures the pressure in the bladder and how the bladder works when it is filled and
emptied.
The performance of the test will identify why the woman’s incontinence is occurring (i.e. whether it is
caused by a weakness in the supports of the bladder neck, or whether it occurs because the bladder
is sensitive and contracts with even little urine in it).
It is important to differentiate between USI and detrusor overactivity, because the treatment for each
problem is different, i.e. surgical options for USI and medical options for detrusor overactivity. Using
the surgical option for detrusor overactivity could make the patient’s problem worse.
The procedure is performed in the outpatient clinic without any analgesia or anaesthesia.
A2: What does the investigation involve?

A catheter is placed in the patient’s bladder and in her back passage (rectum).
Some minor discomfort may be experienced when the catheters are inserted.
Each is connected to a machine that measures bladder and abdominal pressure.
The bladder is filled through the catheter in the bladder, and the pressure in the bladder is measured
while this is being done. The amount of fluid present in the patient’s bladder before she feels that she
needs to pass water will be measured.
She will then be asked to stand up and cough, to see whether urine leaks.
Finally, she will be asked to empty her bladder into the commode so that the flow rate can be
measured.
The patient will be followed up in the clinic after the results of the test have been obtained.
OSCE COUNSELLING CASE 9.2 – Can my prolapse be treated without

surgery?
A1: Discuss the non-surgical management options and any potential problems
that may be encountered with these treatments, as the patient is
medically unfit for surgery.
MANAGEMENT OPTIONS
No treatment and just reassurance if the patient remains problem free. The procidentia is unlikely to
cause any serious harm, but it is considered to be a progressive condition.
Topical weekly/twice weekly oestrogen application in the vagina to counteract excoriation and
dryness. Alternatively, combined HRT can be prescribed.
To help to keep the procidentia reduced, insert a ring pessary of appropriate size.
If the ring pessary fails to stay in place, a shelf pessary of appropriate size should be tried. This has a
higher likelihood of success, but is usually incompatible with sexual function.
PROBLEMS
Ring and shelf pessaries will require replacement every 6 months. They can cause bleeding as a result
of pressure on atrophic vaginal skin. If excoriation or ulceration occurs, the pessaries should be left
out and topical oestrogen cream prescribed daily for 2–4 weeks. Reinsertion is appropriate after
complete healing.
Sometimes the pessaries can cause urinary retention and/or faecal impaction.
REVISION PANEL
Urinary incontinence has a high prevalence, affecting approximately 20–30 per cent of the adult
female population.
The most common causes of urinary incontinence are USI and detrusor overactivity.
The mainstays of treatment for USI are physiotherapy and surgery, whereas for detrusor overactivity,
these are bladder retraining and anticholinergic medication.
Childbirth injury is the major aetiological factor in organ prolapse.
10 Neoplasia
Questions
Clinical cases 114
Key concepts 116
Answers
Clinical cases 117
Revision panel 122
114 Neoplasia
Questions
Clinical cases

diagnosis?
CASE 10.1 – My cervical screening test is abnormal.

A 35-year-old single woman is found to have an abnormal test on routine screening. She has had regular
tests since the age of 25 years, and previous results have been normal. She has two children aged 2 and
7 years. She is separated from her partner, who fathered both children. She is currently using the oral
contraceptive pill; she is not in a stable relationship.
CASE 10.2 – I am menopausal and my abdomen is distending.

A 68-year-old woman presents with gradual enlargement of the abdomen, changes in bowel habit and
weight loss. The general practitioner had felt a lower abdominal mass and referred the patient urgently
to the gynaecology clinic.
CASE 10.3 – I have gone through the change and I have recently had
some vaginal bleeding.
A 54-year-old woman has been amenorrhoeic for the past 18 months, and recently had an episode of
fresh vaginal bleeding. Her last cervical screening test, taken 2 years ago, was normal. She is not on
hormone replacement therapy (HRT).
Questions 115
OSCE COUNSELLING CASE 10.1 – My cervical screening test report is

abnormal. Do I have cancer?
Having had a routine cervical screening test 2 weeks earlier, a 36-year-old woman returns to see you
(her GP) about the result. She has received a card through the post indicating that the test has shown an
abnormailty and she is very anxious about the implications of this.
The test result, which you have available, is as follows:
Good cellularity.
Endocervical cells present.
Moderate dyskaryosis.
Q1: Counsel this patient about her screening test result.
OSCE COUNSELLING CASE 10.2 – I have warts. Will I get cancer?

A 26-year-old woman presents with genital warts. She is worried that the virus that causes warts also
causes cervical cancer. She has never had a cervical screening test.
Q1: What would you say to her?
116 Neoplasia
Key concepts
key concepts.
Human papillomavirus (HPV) infection leads to premalignant change in the cervical epithelium, to
result in cervical intraepithelial neoplasia (CIN), which has the potential to turn malignant.
There are over 100 different virus types of HPV, with types 6 and 11 causing genital warts, and types
16, 18, 31 and 33 having oncogenic cancer properties.
The National Health Service Cervical Screening Programme (NHSCSP) in the UK tests women aged
between 25 and 49 years every 3 years, and women aged between 50 and 64 years every 5 years.
In the UK, the ‘Pap’ smear has been superseded by liquid-based cytology (LBC), in which a small
brush is used to sample cells from the transformation zone and the cells examined cytologically to
indicate different degrees of maturity (dyskaryosis – borderline, mild, moderate and severe).
LBC has reduced the number of inadequate samples from over 9 per cent before LBC to 2.5 per cent.
Only histological analysis of cervical tissue can give a definitive diagnosis of CIN.
In the UK, a national programme of HPV vaccination for girls aged 12–13 and 17–18 years started in
2009 to prevent HPV types 16 and 18 (types found in over 99 per cent of cervical cancers).
Answers 117
Answers
Clinical cases
CASE 10.1 – My cervical screening test is abnormal.

An abnormal screening test could be associated with:
Infection or inflammation.
Dyskaryosis (which may be reflective of cervical intraepithelial neoplasia) (see Fig. 10.1).
Malignancy.

Although an abnormal screening test often leads to concern about cancer, in most cases, it is associated
with a benign condition (infection, inflammation or cervical intraepithelial neoplasia). From the given history,
one can elicit only some of the risk factors for cervical intraepithelial neoplasia (e.g. multiparity and multiple
sexual partners). However, it is not possible to be certain of the diagnosis without further investigation.
The history of additional risk factors associated with cervical intraepithelial neoplasia and cancer should
be obtained, e.g. young age at first intercourse, sexually transmitted infection, particularly HPV and
herpes simplex virus 2 (HSV-2), cigarette smoking and low socioeconomic status. Gynaecological
symptoms such as intermenstrual bleeding and postcoital bleeding may be indicative of a local lesion.
Vaginal discharge may be associated with infection or inflammation. The current partner’s history of
sexually transmitted infection may be relevant.

Inspection of the vulva and vagina may reveal discharge or infection. Inspection of the cervix may show
a cervical ectropion, a polyp or a tumour. In most cases, however, cervical inspection with the naked eye
will be normal. Bimanual examination should be performed to assess for a cervical mass, cervical fixity,
pelvic mass and pelvic tenderness. In the case of cervical cancer, examination will also determine staging,
but this is usually performed under anaesthesia together with cystoscopy. If a sexually transmitted
infection is diagnosed, the male partner will also need to be examined and tested.

Colposcopy and cervical biopsies ✓ If the abnormality in the screening test shows
moderate or severe dyskaryosis, colposcopy
(inspection of the cervix under magnification
using a binocular microscope) should be
performed. During colposcopy, directed biopsy
samples should be taken to establish a
histological diagnosis.
Cervical and vaginal swabs ± If infection is suspected, appropriate vaginal
and cervical swabs should be obtained for
microbiological investigation.
118 Neoplasia
Columnar
cells
Squamous
metaplasia of
columnar epithelium
Squamo-
columnar
junction
(SCJ)
New Transformation
Squamous Columnar squamo-columnar zone
cells epithelium junction
(SCJ)
Cervix
view
Ectocervix
Cervical ectropion representing Columnar epithelium undergoes

Endocervix pouting of columnar epitheluim squamous metaplasia under
which is subject to acidic the influence of acidic vaginal
vaginal environment. environment and ‘trauma’.
This ‘weak’ epithelium is now This is called the ‘transformation
subject to ‘trauma’ from risk zone’ where CIN and
factors e.g. HPV, HSV-2, cervical carcinoma originate. This zone
multiple partners. Cervical ectropion is tested by the cervical screening
commonly occurs in the three Ps: programme
Puberty, Pill and Pregnancy
Figure 10.1 Mechanisms of abnormal cervical screening tests. HPV, human papillomavirus; HSV, herpes
simplex virus; CIN, cervical intraepithelial neoplasia.

SUPPORTIVE
Explanation depending on findings of clinical examination and degree of abnormality of screening test
report and need for further investigation and follow-up. The specific treatment depends on the cause.
MEDICAL
Infection: treat according to cause and repeat the test after 6 months.
SURGICAL
Cervical ectropion: observation only, or cryotherapy for symptomatic relief for troublesome postcoital
bleeding.
Cervical intraepithelial neoplasia: excision or ablation of the lesion and follow-up tests.
Answers 119
Cervical cancer: chest radiograph, intravenous urogram, cystoscopy, examination under anaesthetic,
cervical biopsy, surgery and/or radiotherapy according to stage.
Table 10.1 Appropriate actions to be taken in response to cervical screening test report
Cervical screening test report Appropriate action
Normal Repeat test every 3 or 5 years depending on age
Inadequate Repeat
Borderline Repeat test at 6 months – if abnormality is persistent,

refer for colposcopy
Mild dyskaryosis Refer for colposcopy or repeat test after no more than
6 months. If abnormality persists, refer for colposcopy
Moderate/severe dyskaryosis Refer for colposcopy
Suspected invasive cancer or glandular Refer urgently to colposcopy for cone biopsy,
abnormalities hysteroscopy
CASE 10.2 – I am menopausal and my abdomen is distending.

Pelvic mass arising from the ovary, fallopian tube or uterus.
Ascites.
Bladder distension.
Bowel problems (e.g. flatus, faeces, cancer).

Gradual abdominal distension and changes in bowel habits in a postmenopausal patient with a pelvic
mass are highly suspicious of an ovarian tumour.
Nulliparity, early menarche, late menopause, higher social class and history of breast cancer
are associated with ovarian neoplasm. Use of the oral contraceptive pill has a protective effect.
Postmenopausal bleeding can be a symptom of ovarian cancer, but it may also be the result of
endometrial or fallopian tube cancer. A urinary and bowel history should be obtained. The diagnosis
cannot be definitively established without further investigation.

A general examination should be performed, looking for lymphadenopathy and lower limb oedema.
Chest examination should specifically exclude pleural effusion. Ascites should be elicited on abdominal
examination. Ascites is dull to percussion in the flanks, compared with central dullness in an ovarian cyst.
Bimanual examination will detect pelvic mass and delineate the mobility and relationship to the uterus.
120 Neoplasia

Investigations should be performed to exclude ovarian tumour.
CA-125 ✓ This is an ovarian tumour marker.
USS ✓ Abdominopelvic ultrasound examination can

demonstrate the presence of ascites. If a mass
is detected, its nature (whether cystic or solid)
and origin may be determined by the scan.
Chest radiograph ✓ This may be required in order to assess pleural
effusion, or as a preoperative test for fitness for
anaesthesia.
Ascitic sample ± This may be taken for cytological examination.
MRI ± If USS is not helpful.

SUPPORTIVE
Pain relief and drainage of ascites or pleural effusions.
SURGICAL
Surgical excision of tumour (hysterectomy, bilateral salpingo-oophorectomy, omentectomy and
debulking of tumour, aiming to reduce the tumour bulk to <2 cm in diameter).
MEDICAL
Chemotherapy, depending on the stage determined at surgery.
CASE 10.3 – I have gone through the change and I have recently had
some vaginal bleeding.
Atrophic vaginitis.
Endometrial polyp, hyperplasia and carcinoma.
Cervical polyp and cancer.
Adnexal malignancy (uncommon).

This vaginal bleeding is classified as postmenopausal bleeding (PMB), with a 10–15 per cent likelihood of
endometrial pathology, particularly endometrial cancer. Further investigations are therefore mandatory to
exclude this.
Postcoital bleeding could also suggest a cervical polyp or cancer. Hypertension, diabetes and obesity are
risk factors for endometrial hyperplasia and cancer. Information about cervical screening reports must be
obtained, bearing in mind that a negative screening history does not exclude the possibility of cervical
cancer in women with symptoms of postmenopausal bleeding. Symptoms of hot flushes and night
sweats may indicate that any HRT dose taken may not have been sufficient. In this case, there might also
be a history of painful dry vagina during intercourse, which would suggest atrophic vaginitis.
Answers 121

A general examination should be performed to exclude pallor and lymphadenopathy. Speculum
examination will exclude local causes such as atrophic vaginitis and cervical polyps or cervical carcinoma.
Bimanual examination should be performed to assess uterine size, mobility and adnexal pathology.

The primary aim of investigations is to exclude gynaecological cancer, particularly endometrial cancer.
USS ✓ A pelvic ultrasound examination is performed
for endometrial thickness measurement and
adnexal masses (ovarian tumours can present as
PMB). Current evidence suggests that a regular,
thin endometric and an endometrial thickness
(ET) of <4 mm substantially reduces the
likelihood of endometrial cancer. Endometrial
biopsy would then not be required unless there
were additional USS features of endometrial
irregularity and fluid.
Outpatient endometrial biopsy ✓ It is mandatory to obtain an endometrial sample
for histological assessment if the endometrial
thickness is $ 4 mm.
Outpatient hysteroscopy ± Only required if there is a failure to get an
endometrial biopsy in the outpatient setting or
biopsy results are reported as insufficient with
an ET $ 4 mm, or if an endometrial polyp is
suspected on USS. This allows direct
visualization of the uterine cavity, which is
particularly useful for excluding endometrial
polyps.
Inpatient D&C ± Only required if outpatient assessment is
impossible to perform.

SUPPORTIVE
No pathology is found in most cases. If this is so after thorough investigations, then the patient can be
reassured.
MEDICAL
Vaginal oestrogen cream would supplement the existing HRT for treatment of atrophic vaginitis.
Alternatively, the HRT dose may be altered to provide a preparation with higher oestrogen content.
Progestogens (oral/LNG-IUS) for endometrial hyperplasia without atypia. Follow-up biopsies would be
required to ensure regression.
SURGICAL
Polypectomy.
For complex endometrial hyperplasia with associated atypia, total hysterectomy and bilateral salpingo-
oophorectomy would be mandatory as the risk of progression to endometrial cancer can be as high
as 40 per cent in untreated cases.
If endometrial cancer or another gynaecological cancer is detected, it is treated according to stage.
122 Neoplasia
OSCE COUNSELLING CASE 10.1 – My cervical screening test report is

abnormal. Do I have cancer?
A1: Counsel this patient about her screening test result.
The nature of the report:
Does not indicate cancer.
Indicates that abnormal cells are present.
Requires further investigation to exclude pathology; the pathology is usually a precancerous
condition.
Suggests that, if a precancerous condition is found, it will require further treatment to prevent
progression.
The nature of the investigation and treatment would be as follows:
Referral for colposcopy (examination of the cervix with magnifying binoculars).
The need for punch biopsies or large loop excision of the transformation zone (LLETZ).
Treatment by laser/cold coagulation/LLETZ.
Regular follow-up screening tests would be needed according to the findings.
OSCE COUNSELLING CASE 10.2 – I have warts. Will I get cancer?

A1: What would you say to her?
Many factors are associated with the development of cervical cancer and the virus that causes warts
is just one of them.
The wart virus is very common and there are many different types. Not all of these types are
associated with cervical cancer.
Even if the warts are caused by a type of virus that is associated with cervical cancer, the risk of
developing it is small.
Regular cervical screening tests will identify cervical change before the development of cervical
cancer. These changes are easily cured before they become cancerous.
Perform a speculum examination (to confirm that the cervix appears normal) and take a cervical
screening test. One should be taken every 3 years.
REVISION PANEL
In the UK, the National Health Service Cervical Screening Programme has prevented up to 70 per
cent of cervical cancer deaths since its inception in 1988.
Other HPV types have been implicated in the pathogenesis of cervical cancer and the long-term
benefits of the HPV types vaccine remain unknown.
There is some correlation between cervical screening test grade, i.e. low (borderline and mild) or
high (moderate and severe) grade dyskaryosis and the degrees of CIN I, II, III, but it is not totally
reliable.
Most investigations for PMB are now carried out in the outpatient setting, using local anaesthesia
for difficult cases only.
11 Discharge and pain
Questions
Clinical cases 124
Key concepts 126
Answers
Clinical cases 127
Revision panel 133
Questions
Clinical cases

diagnosis?
CASE 11.1 – I have constant irritating vaginal discharge.

A 25-year-old single woman has vulval and vaginal itching and discharge. Her recent cervical smear was
normal. She has recently started a new relationship and is currently using the oral contraceptive pill.
There are no urinary symptoms. She recently had a severe bout of flu for which she was given antibiotics.
CASE 11.2 – I am unwell and have abdominal pain and discharge.

A 22-year-old woman presents with fever, lower abdominal and pelvic pain, and a foul-smelling vaginal
discharge. Her last menstrual period was 1 week ago. She has recently changed her sexual partner. There
are no urinary or bowel symptoms.
CASE 11.3 – My periods are painful and I also have pain during
intercourse.
A 30-year-old nulliparous professional woman presents with severe and incapacitating menstrual pain
that requires bed-rest and interferes with her employment. The menstrual pain has been present for
1 year, but it has gradually been increasing in severity over the last few months. The patient’s periods
are not heavy and she has no desire for fertility. She recently started a relationship and finds intercourse
painful. The couple have been using condoms for contraception.
Questions 125
OSCE COUNSELLING CASE 11.1 – I am having a diagnostic laparoscopy.

Should I be concerned?
A patient with chronic pelvic pain is going to be admitted to hospital for diagnostic laparoscopy under
general anaesthesia. Her clinical pelvic examination and ultrasound scan (USS) are normal.
Q1: What information will you need to provide when counselling her about the investigation?
OSCE COUNSELLING CASE 11.2 – I have had a diagnostic laparoscopy.

What happens next?
The above patient underwent an uneventful diagnostic laparoscopy. The laparoscopic findings are of a
normal pelvis.
Q1: What information will you need to provide when counselling her before discharge from
hospital?
Key concepts
key concepts.
PELVIC INFLAMMATORY DISEASE

Infection of the upper genital tract, with salpingitis as the most prominent feature:
Primary PID: caused by infection ascending from the lower genital tract.
Secondary PID: caused by direct spread from adjacent organs, e.g. appendix.
SEXUALLY TRANSMITTED INFECTION

Genital tract infection caused by sexually transmitted infective organisms (e.g. gonorrhoea, Chlamydia
sp., herpes). Pelvic inflammatory disease is a serious complication of a sexually transmitted infection (STI).
CHRONIC PELVIC PAIN

Constant or intermittent, cyclic or acyclic pain located in the pelvis, which may or may not be related
to menstruation, is associated with adverse effects on quality of life and has lasted for more than
6 months. No pelvic pathology is found in 50–60 per cent of cases with chronic pelvic pain.
DYSMENORRHOEA
Pain associated with menstruation:
Primary dysmenorrhoea: pain not associated with any organic disease. It is common at menarche.
Secondary dysmenorrhoea: pain associated with organic disease such as endometriosis or PID.
DYSPAREUNIA
Pain associated with sexual intercourse. This can be classified as superficial or deep.
Answers 127
Answers
Clinical cases
CASE 11.1 – I have constant irritating vaginal discharge.

Infection:
Candida sp. (thrush);
Trichomonas vaginalis;
bacterial vaginosis;
Chlamydia sp.;
gonorrhoea;
herpes.
Inflammation.
Foreign body, e.g. forgotten tampon.
No pathology, e.g. cervical ectropion.

Associated itching, a new sexual partner, use of the oral contraceptive pill and recent use of broad-
spectrum antibiotics could all be associated with candida infection (although most infections involve
a mixture of organisms). Urinary symptoms, absent in this case, could be associated with chlamydial
infection, gonorrhoea or herpes.
Specific enquiry should be directed towards the colour and consistency of the discharge. Typically, a thick
white discharge is caused by Candida sp., a thin green discharge is associated with bacterial vaginosis,
a grey frothy discharge results from Trichomonas sp., and a yellow mucopurulent discharge is caused by
Chlamydia or gonococci. The relationship between discharge and menstruation should be established.
Candida infection is usually premenstrual and gonococcal infection is postmenstrual. Intense itching that
is worse at night is a feature of candidiasis, but could be associated with trichomonas infection. Pain,
dyspareunia and burning are features of trichomonas and gonococcal infections. Poor personal hygiene
and use of talcum powder, deodorants, douches and tight synthetic undergarments may lead to itching.
The history of an STI in the woman’s partner should also be obtained. A family history of diabetes and
symptoms of polyuria and polydipsia may indicate diabetes mellitus, which is associated with candida
infections.

Inspection of the vulva may reveal erythema or congestion, which is much more marked with candida
than with trichomonas infection. The erythema may extend perianally. Gonococcal infection may be
associated with painful vulval swelling and urethral discharge. Multiple small vesicles with ulcers are
associated with herpes. Speculum examination may demonstrate discharge with associated erythema.
Trichomonas infection is associated with reddish–purple spots in the vagina and cervix (strawberry
cervix). A search should be made for any foreign bodies, e.g. a forgotten tampon. A sample of the
discharge should be taken for microscopy, culture and sensitivity. Cervical ectropion may be a cause of
discharge without infection. A bimanual examination should be performed to assess pelvic tenderness,
which may suggest PID. The male partner should also be examined and tested.

Urine dipstick ✓ For glycosuria, leucocytes and nitrites.
MSU ✓ For microscopy and culture.
pH of discharge ✓ The pH of the discharge is more alkaline (>5) in
trichomonas infections or bacterial vaginosis. Normal
vaginal pH is an acidic environment of 3.5–4.5.
Whiff test of discharge ✓ If the discharge is mixed with potassium hydroxide,
it produces a fishy odour in bacterial vaginosis.
Microscopy of discharge ✓ A sample of the discharge should be mixed with
saline and examined under the microscope. No
organisms are usually seen in physiological discharge.
Mycelial filaments and spores are seen in candida
infection. Motile flagellated protozoa may be seen in
trichomonas infection.
Gram stain of discharge ✓ Gram staining of the discharge will show blue cells
with a serrated border in bacterial vaginosis, and
Gram-negative diplococci in gonococcal infection.
Vaginal and cervical swabs ✓ Depending on the patient’s risk factors for STIs
and the findings at examination, swabs should be
obtained from the upper vagina, endocervix and
urethra for culture. Separate swabs should be taken
for Chlamydia sp. Investigations of the male partner
should also be carried out.

SUPPORTIVE
Advice on personal hygiene and clothing. Specific treatment depends on the cause.
MEDICAL
No organisms – no treatment if the problem is not persistent. Otherwise, treat as candida infection.
Candida – clotrimazole cream or oral fluconazole.
Trichomonas or bacterial vaginosis – metronidazole.
Chlamydia – doxycycline, azithromycin single dose.
Gonococci – penicillin, erythromycin.
Herpes – aciclovir.
Treat the male partner simultaneously.
SURGICAL
Cervical ectropion – observation only, or cryotherapy for symptomatic relief.
Answers 129
CASE 11.2 – I am unwell and have abdominal pain and discharge.

Acute PID:
STI;
iatrogenic cause (e.g. caused by intrauterine contraceptive device);
secondary PID.
Acute abdomen:
ectopic pregnancy;
ovarian cyst/torsion;
conditions related to bowel, e.g. irritable bowel syndrome/constipation.

Pyrexia, pelvic pain and foul-smelling vaginal discharge are probably the result of PID. A recent change
of sexual partner is a risk factor for PID. Although ectopic pregnancy is unlikely because this patient’s last
menstrual period was 1 week ago, ectopic pregnancy should be considered because menstrual history is
an unreliable indicator of pregnancy.
Specific enquiry should be directed towards the nature and onset of the pain and the pattern of fever.
Swinging high-grade pyrexia is typically associated with a pelvic abscess. A sexual history should be
obtained, enquiring about the number of sexual partners, any recent casual sexual encounters, history
of STIs and previous history of PID. The oral contraceptive pill reduces the risk of PID, but does not
necessarily prevent it. Copper intrauterine contraceptive devices, recent gynaecological surgery, delivery
or miscarriage are associated with PID.

General examination should include measurement of temperature, blood pressure and pulse to assess
shock. Inspection of the vulva, vagina and cervix may demonstrate discharge with associated erythema.
A sample of the discharge should be taken for microbiology. Separate swabs for gonococci and
Chlamydia sp. should be taken from the endocervix and urethra. Digital examination of the cervix may
elicit excitation. Bimanual examination should be performed to assess pelvic tenderness, which may
suggest PID. It may also reveal a mass, e.g. pelvic abscess/ovarian cyst.

Urine hCG ✓ To exclude pregnancy.
FBC ✓ A full blood count (FBC) should be taken for
leucocytosis.
U&Es ✓ If sepsis is suspected.
USS ✓ A pelvic ultrasound examination should be performed
to support clinical examination, particularly excluding
any pelvic masses, e.g. pelvic abscess/ovarian cyst.
MSU ✓ For microscopy and culture.
Vaginal and cervical swabs ✓ Samples of the discharge should be examined under
the microscope, with Gram staining and culture.
Blood cultures ± Only if there are signs of septicaemia.

SUPPORTIVE
If there is clinical shock, resuscitation should be performed while examination and investigations are
being undertaken. An indwelling catheter should be used to monitor urine output.
MEDICAL
Oxygen, fluid resuscitation and intravenous broad-spectrum antibiotics should be administered in cases
of septic shock. Otherwise, treat PID with antibiotics according to the suspected organism or culture and
sensitivity reports.
SURGICAL
Once the patient is relatively stable, surgery may be required, depending on the diagnosis:
PID with pelvic mass that is not responding to medical treatment requires surgical drainage of
abscess.
Acute abdomen – laparotomy.
CASE 11.3 – My periods are painful and I also have pain during
intercourse.
Endometriosis.
Chronic PID.
No associated pathology (primary dysmenorrhoea).

The patient’s age would be against the diagnosis of primary dysmenorrhoea, which usually occurs in
teenage girls. The combination of painful intercourse (dyspareunia) and painful periods is typical
of endometriosis, a condition that is more prevalent in nulliparous women of higher social class.
Pelvic pain caused by endometriosis is typically cyclical and at its worst at the time of menses, but
can start a few days before. However, primary dysmenorrhoea usually eases within 1–2 days of the
onset of menses. Previous infertility and a family history of the condition may support the possibility
of endometriosis. Endometriosis may be associated with bowel or urinary symptoms.

Speculum examination may reveal spots or (blue) nodules of endometriosis in the posterior fornix.
Bimanual examination should be performed to assess uterine fixity and pelvic tenderness, which might
suggest either PID or endometriosis. Nodularity in the uterosacral ligaments is typical of endometriosis,
particularly on the left side. There may be an adnexal mass associated with endometrioma (ovarian cyst
endometriosis).
Answers 131

Investigations for gynaecological infections ✓ Investigations should be performed for
infection if the history and examination
suggest PID (see Case 11.2).
USS ✓ A pelvic USS should be performed,
which, although not specific for
endometriosis, would exclude an
ovarian endometrioma.
Diagnostic laparoscopy ✓ The definitive diagnosis of
endometriosis is established by
laparoscopy. However, no pathology is
seen at laparoscopy in 50–60 per cent
of patients with chronic pelvic pain.
MRI ± Particularly if deep tissue endometriosis
is suspected, i.e. in the rectovaginal
space.

SUPPORTIVE
Explain the nature of the problem. Endometriosis is not a curable disease.
Monitor the disease and its symptoms by means of ultrasound or magnetic resonance imaging.
MEDICAL
The aim of medical treatment is to provide pain relief and induce amenorrhoea. Endometriosis
(and its symptoms) often recurs after cessation of medical treatment.
Non-steroidal anti-inflammatory drugs (NSAIDs) should be given for dysmenorrhoea.
The combined oral contraceptive pill given continuously for at least 3 months, but preferably for
6 months. If this alleviates the symptoms, the diagnosis is very likely to be endometriosis. This
treatment regimen could then be continued indefinitely (up to 38–40 years of age) or until pregnancy
is desired.
Progestogen (oral, injectable or intrauterine device).
Danazol, limited use as side effects include acne, hirsutism, voice changes and weight gain.
Gonadotrophin-releasing hormone analogues (side effects include menopausal symptoms, which are
treatable with add-back hormone replacement therapy). Long-term treatment without add-back HRT
is not recommended beyond 6 months due to the risk of drug-induced osteoporosis.
SURGICAL
Specific treatment of symptomatic endometriosis depends on the severity of the condition and the
patient’s desire for fertility.
Mild endometriosis (few peritoneal spots at laparoscopy, no scarring): surgical ablation or excision,
which has been shown to improve fertility chances, possibly followed by medical treatment for
3–6 months (if fertility is not desired);
Moderate endometriosis (peritoneal and ovarian spots at laparoscopy, minor scarring): surgical
ablation or excision plus adhesiolysis, possibly followed by medical treatment for 6 months;
Severe endometriosis (peritoneal and ovarian spots at laparoscopy, severe scarring, tubal
blockage): surgical excision of endometriosis (hysterectomy and bilateral salpingo-oophorectomy
if appropriate); medical treatment for 6 months as for moderate endometriosis after conservative
surgery.
OSCE COUNSELLING CASE 11.1 – I am having a diagnostic laparoscopy.

Should I be concerned?
A1: What information will you need to provide when counselling her about
the investigation?
Laparoscopy is being performed to look for a cause for pelvic pain. It allows a telescopic examination
of the gynaecological and abdominal organs. It is regarded as an intermediate operative procedure
and is performed as a day case, although it does carry risks.
The procedure is conducted as follows: once the patient is asleep under general anaesthetic,
CO2 is introduced into her abdomen by a small needle inserted in the navel. This enables
a telescope to be inserted via a small incision in the navel. The surgeon then examines the
pelvic area and reproductive organs to see if there is any obvious reason for the pelvic pain,
such as endometriosis. If this is the case, this may be treated surgically at the same time. If
there is no obvious cause for the pain, no further treatment is necessary. The surgery does
not usually result in any noticeable discomfort, and the patient can be discharged home a
few hours after laparoscopy. There are two or three small cuts on the abdomen and may not
even require stitches. If stitches are required, they may be self-absorbing so that they may not
need to be removed later. There should be minimal scarring from these incisions under normal
circumstances.
Although laparoscopy is a relatively safe procedure, like any other surgical procedure, it is not
without risks and side effects. These include possible damage to organs (bowel, bladder,
ureters and blood vessels) inside the abdomen. However, the likelihood of such complications is
minimal.
If complications do occur, they will have to be dealt with by an open operation (laparotomy). If this is
the case, an inpatient stay of several days postoperatively may be required.
There are also risks associated with the general anaesthesia.
A written information leaflet about diagnostic laparoscopy should be given to the patient to reinforce
verbal information.
OSCE COUNSELLING CASE 11.2 – I have had a diagnostic laparoscopy.

What happens next?
A1: What information will you need to provide when counselling her before
discharge from hospital?
The laparoscopy shows a completely normal pelvis. This is the case in 50–60 per cent of women who
undergo laparoscopy for chronic pelvic pain.
It is reassuring in that there is no evidence of endometriosis, adhesions, PID or other gynaecological
pathology.
This does not exclude other causes of pelvic pain, e.g. irritable bowel syndrome. Information on
improving dietary fibre and fluid intake should be given.
In the absence of organic pathology, no specific gynaecological treatment is required. However,
further investigation of other possible causes of pain might have to be performed.
If the two or three cuts on the abdomen have been stitched, provide information about how they
are to be managed. Also provide information about simple postoperative painkillers, and reassure the
patient that scarring from these incisions will be minimal under normal circumstances.
Answers 133
After discharge from hospital, if the postoperative pain does not show progressive improvement, the
patient must contact the hospital.
Advise the patient about follow-up arrangements. If the pelvic pain does not settle in response to
simple measures, assessment in a combined pain clinic (where an assessment can be made by a
psychologist or anaesthetist interested in chronic pain management) may be necessary.
Provide the patient with a written information leaflet.
REVISION PANEL
In STIs, all attempts to contact present and previous partners should be encouraged.
Incomplete treatment of STIs should be avoided as there is a high chance of recurrence with long-
term risks, such as infertility.
Chronic pelvic pain accounts for 15 per cent of all new gynaecological referrals. It has an annual
prevalence of 38/1000 compared to asthma (37/1000) and chronic backache (41/1000).
Endometriosis can be mistaken for symptoms similar to irritable bowel syndrome and interstitial
cystitis.
12 Infertility
Questions
Clinical cases 136
Key concepts 138
Answers
Clinical cases 139
Revision panel 145
136 Infertility
Questions
Clinical cases

diagnosis?
CASE 12.1 – We are unable to have a pregnancy.

A young couple present with a history of inability to conceive despite unprotected intercourse for the
past 2 years. The couple have had no previous conceptions. The gynaecological history is unremarkable.
The female partner has had regular menstrual cycles without the oral contraceptive pill. The frequency
of intercourse is two to three times per week. In addition, the couple have been timing intercourse
according to an ovulation kit for the last 6 months. There is a history of mumps in childhood in the male
partner.
CASE 12.2 – My periods are irregular and I cannot conceive.

A 28-year-old woman with a body mass index (BMI) of 30 presents with an inability to conceive despite
unprotected intercourse for 18 months. Her periods are erratic, sometimes with 6 weeks between
periods. She started taking the pill at the age of 18 years and stopped 18 months ago. Her periods were
irregular before commencement of the pill. She has had no previous pregnancies, but her partner has
fathered a child previously.
CASE 12.3 – I have been pregnant before, but I cannot conceive now.
A 32-year-old married nurse presents with an 18-month history of inability to conceive after removal of
an intrauterine contraceptive device (IUCD). The IUCD had been in place for 3 years, was inserted after
the birth of her second child, and was removed because of her wish to try for another child. Her periods
are regular with mild dysmenorrhoea, and she is with the same partner who fathered her previous
children.
Questions 137
OSCE COUNSELLING CASE 12.1 – Is my coital timing correct?

A 30-year-old woman has been trying for her first pregnancy for 10 months. She thought that
pregnancy occurred around the time of menstruation, but has recently heard from a friend that this is
not the case. She feels that she does not understand the best time for her to conceive. She has always
had a regular 32-day cycle.
Q1: How would you counsel this patient about coital timing?
OSCE COUNSELLING CASE 12.2 – Should my ovaries be stimulated to

produce eggs?
A 28-year-old woman attends for the results of her infertility investigations. These are summarized in
Table 12.1.
Table 12.1
Test Value obtained Normal range
Luteal phase progesterones (ng/mL) 7, 12 and 9 on three separate occasions >20
Prolactin (IU/mL) 300 150–500
LH (mIU/mL) 12 1.8–13.4
FSH (mIU/mL) 4 3.0–12.0
Rubella Immune –
Husband’s semen Normal –
Q1: What is the potential reason for this patient’s infertility and what first-line treatment are
you going to recommend for rectifying this?
138 Infertility
Key concepts
key concepts.
INFERTILITY (SUBFERTILITY)
Involuntary failure to conceive despite regular unprotected sexual intercourse for one or two years in the
absence of known reproductive pathology (it is a symptom, not a diagnosis). After the first year a further
50 per cent of couples will fall pregnant in the subsequent year.
Primary infertility: no previous pregnancy has been achieved.
Secondary infertility: previous pregnancy (regardless of outcome) was achieved.
CAUSES OF INFERTILITY
Male factor 25 per cent.
Anovulation 25 per cent.
Unexplained 25 per cent.
Tubal blockage and other causes 25 per cent.
(Tubal blockage is more common when there is a high prevalence of pelvic infection.)
POLYCYSTIC OVARIAN SYNDROME

Polycystic ovarian syndrome (PCOS) is a condition in which the ovaries often produce more small follicles
than normal, but the woman does not ovulate. It requires the presence of at least two of the following
three criteria:
Oligo- and/or anovulation.
Clinical and/or biochemical hyperandrogenism (hirsutism, raised testosterone and
dehydroepiandrosterone sulphate levels and reduced sex-hormone binding globulin [SHBG] levels).
Polycystic ovaries on ultrasound with at least 12 subcapsular follicles measuring 2–9 mm in diameter
and/or an ovarian volume in excess of 10 cm3. Other causes of polycystic ovaries should be excluded,
such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing’s syndrome.
Answers 139
Answers
Clinical cases
CASE 12.1 – We are unable to have a pregnancy.

Primary infertility:
male factor;
fallopian tubal block;
anovulation;
unexplained infertility.

Regular periods are usually a feature of an ovulatory menstrual cycle. The couple have been timing
intercourse according to an ovulation kit, and it should be confirmed that intercourse is occurring before
ovulation. It is unlikely that the cause of the problem is anovulation. Although none of the above factors
can be confirmed or excluded from the given history alone, the history of mumps supports the possibility
that a male factor is the cause.
A diagnosis of tubal block would be supported by a gynaecological history of vaginal discharge
associated with pelvic pain. Pelvic pain may also be the result of endometriosis, which could be
associated with tubal blockage due to an inflammatory process or adhesions. A male factor may also
be associated with primary infertility, so information should be sought about general health, testicular
descent, urethral discharge (e.g. associated with sexually transmitted infection (STI)) and occupational
exposure (e.g. excess heat, smoking, alcohol and drugs).

Obesity and hirsutism on general examination may indicate polycystic ovarian syndrome (PCOS).
The breasts should be examined for galactorrhoea. Speculum examination might reveal discharge or
infection. Bimanual examination should be performed to assess uterine fixity and pelvic tenderness,
which might suggest either pelvic inflammatory disease (PID) or endometriosis. The male partner should
also be examined, looking for signs of virilization, gynaecomastia, cryptorchidism, varicoceles, testicular
size, and epididymal and prostatic tenderness.

Rubella IgG ✓ To confirm the female partner’s immunity to
rubella. If she is non-immune, rubella
immunization (and appropriate contraception)
is necessary.
Semen analysis ✓ This should be performed on a fresh specimen
after 3 days’ abstinence. Any abnormality of
semen should be confirmed on two specimens
obtained at a 2–4-week interval, although
140 Infertility
biologically, the optimal time for the second

sample is at least 3 months after the initial
sample because the cycle of spermatozoa
formation takes about 3 months to complete.
In the case of low sperm count and/or motility,
additional investigations should include
microbiological tests for infection, such as
chlamydia infection, and an immunological test
for anti-sperm antibodies. Sperm abnormalities
should be investigated and managed by a
specialist. Karyotype and hormonal assays
(follicle-stimulating hormone (FSH), luteinizing
hormone (LH) and testosterone) may be
indicated as part of the investigation for
oligo-/azoospermia.
Mid-luteal serum progesterone ✓ This confirms ovulation.
Chlamydia infection ✓ To rule out asymptomatic infection.
USS ± Depending on the history and examination of

the female partner, a pelvic USS may be
indicated to diagnose polycystic ovaries.
Laparoscopy and dye hydrotubation ± If there is a possibility of pelvic adhesions caused
and/or hysterosalpingography by a history of infection, endometriosis or
positive chlamydia infection, these tests may be
performed to assess the severity of the condition
and its amenability to treatment.
Female partner: Folic acid supplements to prevent neural tube defects.
Male partner: Specific treatment of male factor (oligo-/azoospermia) depends on the cause.

MEDICAL
Infection: treat according to cause, or empirically for chlamydia infection.
Hypogonadotrophic hypogonadism: clomifene citrate or gonadotrophins.
SURGICAL
Varicocele: high ligation of varicocele.
Obstruction of vas: vasovasostomy.
Donor insemination in case of azoospermia.
Intrauterine insemination of prepared partner’s sperm.
Intracytoplasmic sperm injection (ICSI).
In vitro fertilization and embryo transfer (IVF-ET).
CASE 12.2 – My periods are irregular and I cannot conceive.

Primary infertility:
anovulation (polycystic ovaries, hyperprolactinaemia);
unexplained infertility.
Answers 141

A diagnosis of anovulation is supported by a history of menstrual irregularity that also pre-dates the use
of the oral contraceptive pill.
A recent history of weight changes and hirsutism should be noted. A history of galactorrhoea would
indicate hyperprolactinaemia. A past history of an STI and a family history of polycystic ovaries should be
sought.

Obesity and hirsutism on general examination may indicate PCOS. The breasts should be examined for
galactorrhoea. A speculum and bimanual examination should be performed. The male partner should
also be examined.

Mid-luteal serum progesterone ✓ Confirmation of anovulation is essential. As the
menstrual cycle is irregular, the test should be
taken weekly and the results interpreted in the
light of the date of the next menstrual period.
LH, FSH and androgen levels ✓ In PCOS, the LH:FSH ratio (measured on day 3
of the cycle) is >2. Raised testosterone and
dehydroepiandrosterone sulphate levels and
reduced sex hormone-binding globulin (SHBG)
levels.
Serum prolactin ✓ To test for hyperprolactinaemia. If confirmed,
further tests (computed tomography or
magnetic resonance imaging of the head for
pituitary adenoma, and visual field assessment)
for prolactinoma may be required.
TFT ✗ Not required as a routine test. It is necessary
only in hyperprolactinaemia, which may be
associated with hypothyroidism.
Semen analysis ✓ To rule out male factor.
Chlamydia infection ✓ To rule out asymptomatic infection.
USS ± A pelvic USS to assess for polycystic ovaries.
Laparoscopy and dye hydrotubation ± If there is a possibility of pelvic adhesions as a

and/or hysterosalpingography result of a history of infection, endometriosis or
positive chlamydia infection, these tests may be
performed to assess the severity of the condition
and its amenability to treatment. These tests
may also be indicated if infertility persists
despite treatment.
rubella. If she is non-immune, rubella immunization
(and appropriate contraception) is necessary.
142 Infertility
Female partner: Considering a diagnosis of anovulation:

Folic acid supplements to reduce the risk of neural tube defects.
Timing intercourse around ovulation (using an ovulation kit if necessary).
Induce ovulation with clomifene citrate (see OSCE Counselling Case 12.2).
Specific treatment depends on the cause.

MEDICAL
Polycystic ovarian syndrome – induce ovulation. If clomifene is not successful, use clomifene
and metformin (as this patient has a BMI of >25), gonadotrophins.
Hyperprolactinaemia – bromocriptine.
SURGICAL
Polycystic ovarian syndrome – ovarian drilling.
In vitro fertilization and embryo transfer – a last resort treatment.
CASE 12.3 – I have been pregnant before, but I cannot conceive now.
Secondary infertility:
Tubal blockage.
Unexplained infertility.

The IUCD may have been associated with a clinical or subclinical infection that has led to damage
of the fallopian tubes. Regular periods are usually a feature of ovulation, and previous pregnancies
from the same partner indicate that male factor may not be involved. These factors would have to be
investigated.
A diagnosis of tubal block resulting from pelvic infection will be supported by an obstetric history of
deliveries associated with postpartum pyrexia and foul lochia, or by a gynaecological history of vaginal
discharge associated with pelvic pain. Pelvic pain may also be the result of endometriosis, which could
be associated with tubal blockage. Male factor may also be associated with secondary infertility, so
information about the frequency and timing of intercourse should be sought.

Speculum examination might demonstrate discharge or infection. Bimanual examination should be
performed to assess uterine fixity and pelvic tenderness, which might suggest either PID or endometriosis.
The male partner should also be examined for testicular size and varicocele (see Case 12.1).

Laparoscopy and dye hydrotubation ✓ To assess for tubal blockage, severity of
and/or hysterosalpingography the condition and its amenability to
treatment.
Answers 143
Mid-luteal serum progesterone ✓ Confirmation of ovulation is essential.
Semen analysis ✓ To rule out male factor.
Chlamydia infection ✓ To rule out pelvic infection.
USS ± A pelvic USS may be indicated on the basis of

abnormal pelvic examination.
rubella. If she is non-immune, rubella
immunization (and appropriate contraception)
is necessary.
Female partner: Folic acid supplements to prevent neural tube defects. Specific treatment depends on
the cause.

MEDICAL
Pelvic infection: treat according to cause or empirically for chlamydia infection.
Endometriosis: medical treatment for stage I–II disease is not indicated as it leads to delays in
achieving a pregnancy.
SURGICAL
Endometriosis: for mild endometriosis, ablation or excision at laparoscopy improves fertility and
obviates the need for medical treatment.
Tubal block: adhesiolysis, salpingostomy, and excision of blocked segment and re-anastomosis.
Success rates are poor.
Assisted conception (IVF-ET) has better success rates.
144 Infertility
OSCE COUNSELLING CASE 12.1 – Is my coital timing correct?

A1: How would you counsel this patient about coital timing?
Conception occurs around the time of ovulation, not during menses.
Ovulation occurs 14 days before the onset of menstruation. Therefore, in a 32-day cycle ovulation
occurs on day 18 (32 minus 14).
Sperm can survive for up to 7 days.
Eggs survive for only 24 h.
Intercourse should occur before ovulation, so that there are sperm ready to fertilize the egg.
The ‘fertile period’, therefore, lasts for 7 days (i.e. days 12–19 counted from the first day of
menstruation in a 32-day cycle). However, as ovulation can occur slightly early or slightly late in
different cycles, it would be reasonable to regard the fertility period as occurring 1 week before and
a few days after the expected time of ovulation.
Abstinence is not beneficial. As long as intercourse occurs every 48–72 h during the fertile period,
sperm will be in the vicinity of the egg at around the time of ovulation.
The likelihood of pregnancy in any one cycle is 15–25 per cent (not 100 per cent) even in a perfectly
normal (fertile) couple having intercourse at the right time.
OSCE COUNSELLING CASE 12.2 – Should my ovaries be stimulated to

produce eggs?
A1: What is the potential reason for this patient’s infertility and what first-line
treatment are you going to recommend for rectifying this?
The three luteal phase progesterones are low, indicating that anovulation is the most likely cause
of infertility. The LH:FSH ratio is likely to indicate the diagnosis of polycystic ovaries but is now not
considered the only diagnostic criteria. Additional features seen on USS and raised androgen levels
are now important for PCOS (see Key concepts section).
The first-line therapy for ovulation induction is clomifene citrate.
The starting dose is 50 mg/day from day 2 to day 6 of the patient’s menstrual cycle.
A progesterone level in the luteal phase should be checked in order to evaluate the response to
treatment. Intercourse should be timed, using a home ovulation kit if necessary.
If there is no response to treatment, the dose of clomifene citrate can be increased by 50 mg in the
subsequent cycle, going up to a maximum of 150 mg/day. Treatment should be for a maximum of
12 months. This regimen usually leads to ovulation, but pregnancy is achieved in only 50 per cent
of cases. Pregnancy loss occurs in about 20 per cent of cases, so it cannot be guaranteed that the
mother will have a baby even if pregnancy is achieved.
The risks of clomifene treatment are multiple pregnancy (5 per cent risk and, therefore, ultrasound
monitoring should be used) with associated poor pregnancy outcome and hyperstimulation of the
ovaries (rare). There is an association with ovarian cancer and prolonged use is, therefore, inadvisable.
If clomifene treatment is unsuccessful, ovulation may be induced with gonadotrophins, and assisted
conception techniques may be required. Laparoscopic ovarian drilling is an alternative because it
is as effective as gonadotrophin treatment and is not associated with an increased risk of multiple
pregnancy. However, adoption, fostering and a child-free life are other alternatives.
Answers 145
REVISION PANEL
In the general population (which includes people with fertility problems), it is estimated that
84 per cent of women would conceive within 1 year of regular unprotected sexual intercourse.
This rises cumulatively to 92 per cent after 2 years and 93 per cent after 3 years.
Coitus every 2–3 days is likely to maximize the overall chance of natural conception, as spermatozoa
survive in the female reproductive tract for up to 7 days after insemination.
Women (and men) who have a BMI of more than 29 are likely to take longer to conceive (or have
reduced fertility).
The use of basal body temperature charts to confirm ovulation does not reliably predict ovulation
and is not recommended.
Women who smoke are likely to have reduced their fertility (including passive smoking), which is
likely to affect their chance of conceiving. Likewise there is an association between smoking and
excessive alcohol intake (>4 units per day), which is detrimental to semen quality in men.
13 Fertility control
Questions
Clinical cases 148
Answers
Clinical cases 150
Revision panel 159
Questions
Clinical cases
Q1: What issues in the given history have implications for the request?
Q2: What additional features in the history would you seek to support her request?
CASE 13.1 – I had unprotected intercourse last night and wish for
contraception.
A 32-year-old woman has unprotected intercourse during mid-cycle and comes to the family planning
clinic seeking advice for contraception. She is also in need of reliable long-term contraception because
she wishes to delay her family for at least 3 years. She smokes 10 cigarettes a day.
CASE 13.2 – My family is complete and I now wish to be sterilized.

A 27-year-old woman with three children requests sterilization. She has three sons aged 7, 5 and
3 years. She has been using the oral contraceptive pill since her last child was born. She has recently
separated from her husband after a 10-year marriage and she feels that she does not want to have
any more children. She does not currently have a sexual partner.
CASE 13.3 – I am pregnant and don’t want to be.

A 22-year-old woman finds out that she is pregnant. She is not in a stable relationship and she requests
termination of pregnancy. She was using condoms for contraception and she has not had any previous
pregnancies.
CASE 13.4 – I have just had a baby and I now require contraception.
A 38-year-old woman had a normal delivery 14 days ago and is fully breast-feeding without
supplementation. This is her second child and the two pregnancies were narrowly spaced. She previously
became pregnant within 2 months of using the progesterone-only pill. She now wishes to have reliable
contraception.
Questions 149
OSCE COUNSELLING CASE 13.1 – How should I take ‘morning-after’

pills?
A 17-year-old university student presents on the morning after having had a condom ‘accident’. She is
extremely concerned about the possibility of pregnancy, which she feels would be a disaster at this stage
in her life. Her last menstrual period was 15 days previously and she has a regular cycle. You decide to
prescribe emergency hormonal contraception.
Q1: What instructions would you give her?
OSCE COUNSELLING CASE 13.2 – How should I take the pill?

A young single nulliparous girl is requesting the combined oral contraceptive (COC) pill. She has never
used contraception before and has no contraindications for use.
Q1: Explain to her how to take the pill and give her any additional information about missed
pills.
Answers
Clinical cases
CASE 13.1 – I had unprotected intercourse last night and wish for
contraception.
A1: What issues in the given history have implications for the request?
Emergency contraception is not a substitute for a reliable long-acting reversible contraceptive (LARC) method.
A2: What additional features in the history would you seek to support her
request?
It is important to establish the timing of intercourse because this will determine the type of postcoital
contraception that would be suitable for the patient. Her sexual history, including the number of
partners (and including casual relationships), should also be sought in order to determine her risk of
sexually transmitted infections (STIs).

If there is a risk of an STI, specific examination of the vagina and cervix will be necessary (see Case 12.2).

If there is a risk of an STI, specific investigations such as high vaginal and cervical swabs will be needed
(see Case 11.2). Otherwise, pelvic examination is not necessary.

Emergency contraception:
The ‘morning-after pill’ reduces the likelihood of conception at mid-cycle from 15–25 per cent
to 1 per cent. It has to be taken within 72 h of the time of last unprotected intercourse. However,
hormonal preparations are more effective if they are taken within 24 h, rather than 72 h.
The ‘Yuzpe regimen’: two tablets of a combined oral contraceptive pill (equivalent to 100 μg
ethinyloestradiol and 500 μg levonorgestrel) are taken, and the dose is repeated 12 h later. Prevents
57 per cent (95 per cent CI 39–71 per cent) of expected pregnancies. It is now not recommended to
use this regimen.
Progesterone-only pills: 0.75 mg levonorgestrel repeated 12 h later prescribed within 72 h of
intercourse. This method prevents 85 per cent (95 per cent CI 74–93 per cent) of expected
pregnancies. Nausea and vomiting are significantly less frequent with the levonorgestrel regimen
compared to Yuzpe regimen.
Levonelle One Step has now replaced the two tablet 12-h apart regimen (above) and contains 1.5 mg
levonorgestrel given as a single dose within 72 h of intercourse.
Newer methods are now available: EllaOne, 30 mg ulipristal acetate (synthetic progesterone receptor
modulator) given within 5 days of intercourse, which has a primary mode of action of inhibiting or
delaying ovulation.
If the patient presents after 72 h, but within 5 days of intercourse, insertion of an intrauterine
contraceptive device (IUCD) will usually prevent implantation.
Answers 151
CASE 13.2 – My family is complete and I now wish to be sterilized.

The peak age for sterilization requests is between 30 and 34 years. The patient’s young age, all male
children and recent separation from her husband are factors that could lead her to regret her decision in
the future. It is possible that she may have made this decision in reaction to her separation. She might
change her mind if she was to be reconciled with her husband or found a new partner.
request?
Is the patient absolutely certain about her request? The history is targeted to determine the patient’s
fitness for anaesthesia, to make a choice of operative approach in the light of previous operations, and
to explore the cervical smear history. The patient’s last menstrual period date should be checked on the
day of her admission to ensure that she is not pregnant before surgery.

A cardiovascular and respiratory examination should be performed to assess fitness for anaesthesia.
Examination of the abdomen should be made for surgical scars that may increase the risk of intra-
abdominal adhesions and surgical complications.

FBC ± Now not required in low-risk women for
the assessment of fitness for anaesthesia.
Urinary pregnancy test ✓ To exclude pregnancy at the time of
admission to hospital before surgery.
Cervical smear ✓ If not done during the last 3 years.
Table 13.1 Long-term contraception
Advantages Disadvantages Mode of action Failure rates per Other comments

100 women years
(PEARL indexa)
Combined oral Good cycle control, Higher doses have a Inhibits ovulation by 0.16–0.27 Would be suitable for this
contraceptive reduces menses flow, higher risk of venous suppressing LH and patient (possibly with
(COC) pill reduces dysmenorrhoea, thromboembolism, FSH release condoms to reduce her
and is well accepted. particularly if the woman risk from STIs)
Risks of endometrial is a smoker (see below).
and ovarian cancer and Also not suitable for
endometriosis are those aged over 40 years,
reduced. There is also and for hypertensive
a reduction in morbidity and overweight women.
of rheumatoid arthritis Does not protect
and thyroid disorders against STIs
Progesterone- Safe to use in older Daily tablet, Cervical mucus 2–3 Depot progestogens have
only pill (POP) women and following meticulous timing becomes hostile to similar mode of action to POP.
pregnancy in (±3 h) is extremely sperm and can Injection every 3 months means
lactating women. important for it to inhibit ovulation in that compliance is excellent.
There are no be effective. Does up to 40 per cent of Can result in initial troublesome
increased risks of not protect against women irregular bleeding patterns,
thrombosis STIs but causes prolonged
amenorrhoea after
long-term use
Intrauterine Highly effective and Both types can result Prevents implantation 0.2–0.3 Mirena coil can cause
contraceptive once-only preparation, in pelvic infection and, therefore, irregular bleeding for
device (IUCD) needing to be changed from and perforation considered by some up to 6–9 months
every 3 years (copper) to to be an abortifacient
5 years (progestogen
intrauterine system –
Mirena). Latter reduces
menstrual blood loss with
up to 97 per cent of cases
being amenorrhoeic within
12 months
Condoms Protects against all Higher failure Barrier method of 3.6
types of STIs. rate if not used contraception
Essential for casual properly
sexual encounters
Cap/ Woman has control over Needs well-motivated Barrier method of Up to 20

diaphragm contraception, and the individual to use it contraception
method is non-hormonal properly. Needs to be
inserted before
intercourse and
removed at least 6 h
later. Inconvenient to
use and provides
limited protection
against STIs
Natural Lactation has a major Unreliable and offers ‘Rhythm’ method Up to 30

contraceptive role no protection against avoids intercourse
worldwide, as well as having STIs during the fertile period
major benefits for the around ovulation,
neonate and infant i.e. duration depending
(see OCSE Counselling on maximum sperm
Case 6.1) (7 days) and ovum (24 h)
survival (see OSCE
Counselling Case 12.1).
‘Withdrawal’ involves
removal of penis
before ejaculation,
but sperm can be
Answers 153
released before
orgasm
a
If the PEARL index is 4, of 100 women using it for a year, 4 will be pregnant by the end of the year.
FSH, follicle-stimulating hormone; LH, luteinizing hormone; STI, sexually transmitted infection.
Table 13.2 Disadvantages of the combined oral contraceptive (COC) pill
Incidence of thromboembolism
per 100 000 women/year using COC pill
All women not using ‘pill’ 5

Pregnant women 60
Women using older 30 μg pill 15 (second-generation pill containing levonorgestrel)
Women using new 30 μg pill 25 (third-generation pill containing desogestrel or gestodene)
Women smoking and using pill 60

CONSENT AND COUNSELLING
It must be stressed that the sterilization operation is a permanent and irreversible procedure.
In general, a 1:200 (0.5 per cent) failure risk is present. In the case of sterilization failure, it is more
likely to be an ectopic pregnancy.
There are newer hysteroscopic sterilization methods available (ESSURE and Adiana), which can be
performed in the outpatient clinic setting using local anaesthesia.
The traditional method is a general anaesthetic day-case procedure using a laparoscopic technique.
It involves two small abdominal scars – subumbilical and suprapubic (or iliac fossa). There may be
shoulder-tip pain resulting from referred pain from diaphragmatic irritation secondary to abdominal
distension with carbon dioxide.
Although the procedure is very safe, there are inherent risks associated with laparoscopic surgery –
primarily visceral damage to bowel (1.6–1.8 in 1000 cases), bladder and blood vessels
(1 in 1000 cases), which may warrant a midline laparotomy. Consent must, therefore, be obtained
for a laparotomy in the event of complications.
Check that the patient is certain of her request, despite knowing that sterilization will not stabilize an
insecure marriage.
Alternative long-term effective, but reversible, forms of contraception are available (e.g. IUCD).
It is possible that the patient will experience heavier periods after stopping the oral contraceptive pill.
If the couple had still been together, it would have been better to obtain consent from both partners
and to advise them that the alternative is vasectomy, which is a quicker procedure, performed under
local anaesthesia. However, failure rates are higher.
Agreement to sterilization must never be a prior condition for agreement to undertake termination
of pregnancy.
Childbirth and abortion are both stressful times for the patient, and extra care and time must be
given to allow her to reflect on the sterilization decision at these times.
THE PROCEDURE
Laparoscopic sterilization is a day-case procedure which should be carried out using the Filshie clip
(2.7/1000 as it has the lowest failure rate.) Other methods have been used but are now not recommended:
Falope ring (17.7/1000), unipolar (7.5/1000) and bipolar diathermy (24.8/1000). The patient should be
advised to use the current form of contraception until the start of the next period after sterilization.
CASE 13.3 – I am pregnant and don’t want to be.

A request for termination of an unplanned and unwanted pregnancy (therapeutic abortion) is a common
request. This is usually a result of either poor motivation to use contraceptives or failure of contraception.
Answers 155
Reliable contraceptive advice and counselling would, therefore, be mandatory because abortion should
never be used as a method of contraception.
request?
It would be essential to obtain information about the date of the last normal menstrual period, the
menstrual history and cycle regularity in order to establish a gestational age (see Case 1.1). A history of
asthma would preclude the use of prostaglandins as a treatment option.

If surgical termination of pregnancy is anticipated, the chest should be examined to assess fitness for
anaesthesia. Abdominal examination would also be necessary in order to determine uterine size.
A palpable uterus on abdominal examination would indicate a gestation of more than 12 weeks.

FBC ± Now not required in low-risk women for the
assessment of fitness for anaesthesia.
Blood group ✓ To check the patient’s rhesus status (if she is
rhesus negative, prophylactic anti-D will be
required).
USS ✓ To determine the gestational age accurately.

CONSENT AND COUNSELLING
It should be made clear that there is a risk of infertility after an abortion, which could lead to
considerable psychological trauma in the future. Psychological morbidity and regret can be
considerable, and counselling should be offered as part of the termination service. There is evidence
that this psychological morbidity is lower in women who choose medical methods of abortion.
The complication rates are lower with medical methods, particularly the risk of sepsis (which can lead
to future infertility). Perforation of the uterus and visceral damage can occur with surgical methods,
but are rare and dependent on the surgeon’s expertise.
The risk of pregnancy is highest in the first 4 weeks after an abortion, and thus adequate
contraceptive advice, such as the COC pill, depot progestogens or IUCD, is mandatory. This
contraception should preferably be started before the patient is discharged.
The treatment options are as follows:
MEDICAL
Up to 9 weeks’ gestation – oral mifepristone (an anti-progesterone abortifacient) followed by vaginal
prostaglandins administered 24–48 h later would result in complete abortion in 95 per cent
of cases. The earlier the gestation, the higher the probability of complete abortion.
A gestation of 6 weeks or less – surgical abortion would not be advisable because the pregnancy
can be missed. However, before this method is considered, an ultrasound dating of the pregnancy is
essential to ensure that the pregnancy is less than 9 completed weeks.
SURGICAL
Surgical evacuation of the uterus, normally with a suction curette, is the most common method of
terminating pregnancy, and is usually performed as a day-case procedure under general anaesthesia.
Local anaesthesia procedures have now been developed. This procedure is safe up to 12 weeks’
gestation. In nulliparous women, cervical ‘ripening’ agents (e.g. prostaglandins, mifepristone) are
essential to soften the cervix before cervical dilatation in order to reduce the risk of trauma to the cervix
and potential cervical incompetence in the future. The administration of prophylactic antibiotics at the
time of termination of pregnancy reduces post-abortal pelvic infection.
CASE 13.4 – I have just had a baby and I now require contraception.
Breast-feeding (lactational amenorrhoea method) is the most common type of contraception used
worldwide. It works by preventing ovulation and causing amenorrhoea. Fully breast-feeding without
supplementation provides more than 98 per cent protection until one of three conditions occur: menses
return, breast-feeding frequency is reduced or the baby reaches 6 months of age. This patient requires
a more reliable form of contraception than full breast-feeding. The progesterone-only pill is safe to
use in lactating women, but is effective only if it is taken religiously. It can cause irregularity of the
cycle, which can result in non-compliance. This method failed after the patient’s last pregnancy. Thus,
another reliable form of contraception is necessary to reduce the risk of an unwanted pregnancy. It is
possible that ovulation can occur before the menses and, therefore, it is essential to prescribe a more
effective form of contraception almost immediately. The patient’s age and the fact that she is breast-
feeding are significant factors to consider when choosing an appropriate contraceptive. The COC pill is
contraindicated in women who are breast-feeding and it suppresses lactation.
request?
A history of smoking and obesity would increase the patient’s risk of venous thromboembolism if she
were to be prescribed the COC pill. Enquire whether the patient’s family is complete because she might
then be a candidate for sterilization.

No specific examination is necessary. Pelvic examination is required only if there are gynaecological
symptoms.

No specific investigations are required.

Encourage full breast-feeding because it has many benefits (see OSCE Counselling Case 6.1). However,
the contraceptive benefit of breast-feeding will not be sufficient for this patient. Any of the methods
described below will be suitable for her:
Depot progestogens (Depo-Provera): this is a 3-month form of contraception and it is effective if
compliance is going to be a problem. It is safe to prescribe for women who are breast-feeding. It can
also be used to avoid pregnancy after postnatal rubella immunization. It can cause irregular bleeding
and prolonged amenorrhoea.
IUCD: this is highly effective, particularly in poorly compliant women. It is a LARC and it is suitable for
older women. It can normally be placed after delivery of the placenta or 6 weeks postnatally. There is
a higher probability of expulsion in the former case because the uterus contracts rapidly postnatally.
There is also a risk of perforation (caused by a soft uterus) and infection in the immediate postpartum
period.
Answers 157
Sterilization: when performed after 3 months following delivery, this is known as ‘interval
laparoscopic sterilization’. If performed immediately postnatally, it would require a mini-laparotomy
procedure because the uterus is still enlarged to between 14 and 16 weeks’ size, which does not
permit a laparoscopic approach. Filshie clip application and modified Pomeroy (cutting the fallopian
tube) are equally effective (equal failure rates for both procedures [6/1000]). The latter method needs
to be discussed with the couple during early pregnancy to ensure that they are completely happy
about the permanent and irreversible nature of the procedure. However, the morbidity to the mother
is considerably less at interval sterilization because it can be performed as a day-case procedure and
also allows an adequate safe interval to assess whether the neonate is healthy before proceeding to
a permanent form of contraception. Newer hysteroscopic methods, e.g. ESSURE, can be used in the
interval period.
OSCE COUNSELLING CASE 13.1 – How should I take ‘morning-after’

pills?
A1: What instructions would you give her?
There are two forms of emergency hormonal contraception:
the progestogen-only emergency contraceptive consists of 0.75 mg levonorgestrel repeated
12 h later. It is more effective and has fewer side effects (nausea and vomiting in 23 and
6 per cent, respectively) than the combined pill. It is the treatment of choice. A single dose
of 1.5 mg levonorgestrel is now just as effective;
two tablets of a COC pill (equivalent to 100 μg ethinyloestradiol and 500 μg levonorgestrel) are
taken, and the dose is repeated 12 h later. This treatment is now not recommended due to side
effects and poorer efficacy.
Nausea and vomiting are common problems (in up to 50 and 20 per cent of cases, respectively)
with the COC pill. If the tablets are expelled in the vomitus, treatment may need to be repeated.
An antiemetic could be prescribed.
Advise the patient to use barrier methods until her next period.
Warn her that her period may be early or late.
Advise her that she needs to return for follow-up, whether or not she has a period or light bleed, to
ensure that she is not pregnant and that she has effective contraception for the future (choosing one
of the options from Table 13.1).
OSCE COUNSELLING CASE 13.2 – How should I take the pill?

A1: Explain to her how to take the pill and give her any additional
information about missed pills.
Explain how to take the pill:
start on day 1 of the menstrual cycle;
stop after 21 days;
have a 7-day break during which a withdrawal bleed should occur;
restart a new packet for 21 days;
give the patient a leaflet about pill taking.
Mention the need for additional protection if the patient has vomiting or diarrhoea or takes
antibiotics. This would mean using a condom for the duration of her illness or during the use of
antibiotic treatment plus for an additional 7 days after.
Indicate what to do if she misses one or more pills:
if she misses a pill during the first 14 days, she should take the most recently missed pill and use a
condom for 7 days. Then continue as normal;
if she misses a pill during the last 7 days, she should take the most recently missed pill, use
condoms for 7 days and start the next packet without the usual 7-day break;
give her a leaflet about missed pills.
Mention the possible minor side effects (e.g. nausea, lighter ‘periods’).
Mention the need for follow-up in 6 months, or earlier if she experiences any problems.
Advise that the pill does not protect against STIs.
Answers 159
REVISION PANEL
In the UK, contraception is widely available and unique in that it is provided entirely free of charge.
LARC, e.g. copper IUCD or levonorgestrel IUS, is now recommended and is highly effective as is
independent of user-related failure rates.
Induced abortion is one of the most commonly performed gynaecological procedures in the UK.
Around 200 000 terminations were performed in England and Wales in 2008.
Over 98 per cent of terminations in the UK are undertaken because the pregnancy threatens the
mental and physical health of the woman or her children.
Index
a-agonists 107 biophysical profile 20, 21

a-thalassaemia 65 colour 51, 54
abdomen, acute 129 excess (polyhydramnios) 17, 26,
abdominal distension/abdominopelvic mass 93, 27, 29
114, 119–20 meconium staining 51, 51
abdominal examination reduced (oligohydramnios) 17
cephalopelvic disproportion 54 volume 24, 26
contractions 38 amniotic fluid index (AFI) 17
ectopic pregnancy 5, 8 amoxicillin 72
inadequate uterine contractions 53 anaemia 58, 64–5, 81, 82
placenta praevia 35 analgesia 55
postpartum haemorrhage 70 ankle clonus 60, 61
pre-eclampsia 60 anovulation 141, 142, 144
spontaneous labour 50 antepartum haemorrhage 36, 41
sterilization 151 anti-D
abdominal pain antepartum haemorrhage 41
early pregnancy 2, 7–9 early pregnancy loss 12
late pregnancy 32, 37–9 ectopic pregnancy 12
miscarriage 4, 6 late pregnancy bleeding 35
vaginal discharge and 124, 129–30 antibiotics
ablation breast abscess/infection 72
cervical 85 combined oral contraceptive pill and 158
endometrial 82, 86, 87 miscarriage 7
abruptio placentae 37–9 pelvic inflammatory disease 130
abscess see also individual drugs
breast 71, 72 anticardiolipin antibodies 11
pelvic 129 anticholinergic drugs 108
aciclovir 128 anticoagulants 72
acne 93 anticonvulsants 61
adenomyosis 81, 95 antidepressants 73
adhesiolysis 131 antiemetics 10, 158
adhesions, pelvic 140, 141 antiepileptic drugs 66
adnexal malignancy 120–1 antihypertensive therapy 61
adnexal mass 130 antiphospholipid syndrome 11
amenorrhoea 89–100 antiprogestogens 37
definition 92 appendicitis 9
early pregnancy 2, 5, 8 artificial rupture of membranes (ARM) 35,
ectopic pregnancy 7 36, 55
exercise and 93 ascites 119–20
investigations 94 assisted conception 8, 143
primary 92 atonic uterus 70
secondary 92, 93–4 atosiban 38
treatment options 94 atrophic vaginitis 120, 121
amniocentesis 25, 29 attitude 48
amniotic fluid Augmentin (co-amoxiclav) 72
assessment 20, 38, 51 azithromycin 128
162 Index
b human chorionic gonadotrophin (bhCG) 5, 7, breast-feeding 69, 74

8, 28 as contraception 153, 156–7
B-Lynch suture 71 breast infection 71–2
b-thalassaemia 65 breathing difficulties, baby 69, 74
B12 deficiency 65 bromocriptine 94
baby
breathing difficulties 69, 74 C-reactive protein (CRP) 7, 8
gestational diabetes risks 63 CA-125 120
lack of maternal interest in 68, 72–3 cabergoline 94
large 14, 26–7 caesarean section
small 14, 15, 24–6, 28 breathing difficulties 69, 74
bacterial vaginosis 127–8 cephalopelvic disproportion 54
bedrest 7 fetal distress 52
betamethasone 27 placenta praevia 35
biophysical profile 20, 21 post-term pregnancy 56, 56
biopsy postpartum pyrexia 71
cervical 85, 117, 119, 122 wound haematoma/infection 71
endometrial 81, 83, 121 cancer
biparietal diameter (BPD) 24 breast 91, 96, 99, 99
birth attendant 55 cervical see cervical cancer
Bishop score 49, 49, 55, 56 endometrial see endometrial cancer
bladder 106 fallopian tube 119
distension 119 see also neoplasia
post-hysterectomy 86 candida infection 127, 128
postmenopausal changes 107 cap 153
bladder diary 106 caput 48, 53, 54
bladder drill 108 cardiotocography (CTG) 17–19
bladder training 108 abnormal/non-reassuring 18, 18–19, 20, 52
bleeding accelerations 18, 20
abnormal uterine 77–87 classification 19, 20
after intercourse 78, 84–5, 120 components 17
early pregnancy 2, 5–9 decelerations 18, 18, 19, 19, 20
late pregnancy 32, 33, 34–6, 40 fetal distress/hypoxia 17, 19, 44, 52
miscarriage 5–7, 11 fetal movement reduction 37
postmenopausal see postmenopausal fetal well-being 38
bleeding (PMB) indications 17
postpartum 48, 68, 70–1, 75 normal features 18, 18
bleeding disorders 80 placenta praevia 35
blood clotting screen 70 reassuring 20
blood cross match 35, 38, 70, 78 small baby 24, 28
blood cultures 72, 129 cardiovascular disease 97, 99
blood film 64 cephalopelvic disproportion 52–4
blood glucose monitoring 62, 63 cephalosporins 72
blood group and save 53, 54, 78 cervical ablation 85
blood grouping 35, 38, 78 cervical amputation 110
blood pressure measurement 24, 36, 38, cervical biopsy 85, 117, 119, 122
50, 70, 96 cervical cancer 84, 114, 117–19, 122
body mass index (BMI) 136, 145 genital warts 115, 122
bowel conditions 86, 119 postcoital bleeding 120
Braxton Hicks contractions 37 cervical dilatation 51
breast abscess 71–2 cervical ectropion 84, 118, 118, 128
breast cancer 91, 96, 99, 99 cervical effacement 49
breast examination 93, 96, 139 cervical examination 84, 117
Index 163
cervical infection 117 thromboembolism 154

cervical intraepithelial neoplasia (CIN) 116, 117, use instructions 149, 158
118, 118, 122 complete miscarriage 6
cervical lesions 34 conception 144
cervical os 5, 6 condoms 153
cervical polyp 84, 120, 121 congenital anomalies 66
cervical ripening agents 156 continence 104
cervical screening test contraception
abnormal 114, 117–19, 122 barrier methods 153
benign conditions 117 emergency 149, 150, 158
counselling 115, 122 long-term 152–3
mechanisms 118 post-pregnancy 148, 156–7
treatment options 118–19, 119, 122 uncertain dates 22
cervical swabs 71, 84, 117, 128, 129 see also individual types
cervical trauma 70–1 contractions 32, 37–9, 50–1
cervical tumour 117 Braxton Hicks 37
cervicitis 84 inadequate 52–3
cervix labour 44, 50–1
labour induction 55 cord compression 18, 19
strawberry 127–8 cordocentesis (fetal blood sampling) 25, 52, 52
chemotherapy 120 cough 102, 105–7
chest examination 119 cystocele 109, 110
chest infection 71, 72 cystoscopy 117, 119
chest radiographs 72, 120
chlamydial infection 127–8, 129, 140, 141, 143 danazol 82, 131
‘chocolate cysts’ (ovarian endometrioma) 95 deep vein thrombosis (DVT) 71, 72, 75
chorioamnionitis 38, 39 dehydration 9, 50
chorionic villus sample (CVS) 25, 29 delivery
chromosomal analysis 11 bleeding following 68, 70–1
chromosomal anomaly 25 gestational diabetes 63
clam cytoplasty 108 pre-eclampsia 61
climacteric 83, 84 preterm 38–9
clinical shock 130 prolapse 108
clomifene citrate 142, 144 ‘denominator’ 48
clonus 60, 61 Depot progestogens (Depo-Provera) 152, 156
clotrimazole 128 depression 72–3, 95
co-amoxiclav (Augmentin) 72 detrusor instability see detrusor overactivity
coital timing 137, 144 detrusor overactivity 104, 106, 107–8
coitus 145 diagnosis 105, 107–8
colpoperineorrhaphy, posterior 110 dextrose 63
colporrhaphy 107, 110 diabetes 26–7
colposcopy 85, 117, 122 candida infection 127
colposuspension 107 gestational see gestational diabetes
combined oral contraceptive (COC) pill 152, 154 periconceptual control 66
antibiotics and 158 type 1 59, 66
contraindications 156 diabetic retinopathy 62, 66
dysmenorrhoea 131 diagnostic laparoscopy 125, 132–3
emergency contraception 158 counselling 125, 132
heavy menstrual bleeding 82 ectopic pregnancy 8
missed 158 endometriosis 131
polycystic ovarian syndrome 94 follow-up arrangements 133
premenstrual syndrome 95 hospital discharge 132–3
side effects 158 postoperative pain 133
164 Index
diagnostic laparoscopy (continued) endometrial ablation 82, 86, 87

procedure 132 endometrial biopsy 81, 83, 121
risks/side effects 132 endometrial cancer 81, 87, 119, 120–1
diamorphine 55 HRT 99
diaphragm 153 endometrial hyperplasia 83–4, 87, 120, 121
diet 62 endometrial polyp 84, 120
digital examination 35 endometrioma 95, 130, 131
dilation and curettage (D&C) 83, 121 endometriosis 81, 130–1, 133, 139
dipstick testing 58 treatment options 131, 143
discharge 123–33 endometritis 71, 72
abdominal pain and 124, 129–30 engagement (fetal) 48
clinical examination 127–8 Entonox 51, 55
colour 127 epidural analgesia 51, 55
consistency 127 epilepsy 59, 66
diabetes mellitus 127 ergometrine 7, 70
foreign bodies 128 erythema, vulval 127
Gram stain 128 erythromycin 72, 128
infection 127 essential hypertension 60
irritating 124, 127–8 estimated date of delivery (EDD) 22
microscopy 128 ethinyloestradiol 150, 158
pelvic inflammatory disease 129 evening primrose oil 95
personal hygiene 127, 128 eye examination 66
pH 128
whiff test 128 factor VIII deficiency (von Willebrand’s disease)
diuretics 96 80
Doppler ultrasound 25, 61, 62, 72 faecal incontinence 105, 107
Down’s syndrome 15, 28–9 fallopian tube(s)
doxycycline 128 blockage 138, 139, 142, 143
drug history 93 cancer 119
dye hydrotubation 140, 141, 142 damage 142
dysfunctional uterine bleeding (DUB) 79, 80, 83–4 ectopic pregnancy 7
anovular 81, 83 ferritin 65
dyskaryosis 84, 117 ‘fertile period’ 144
dysmenorrhoea 80, 126, 131 fertility control 147–59
primary 80, 126, 130 fetal abdominal circumference (FAC) 16
secondary 80, 95, 126 fetal blood sampling (cordocentesis) 25,
dyspareunia 96, 126, 130–1 52, 52
fetal compromise 25, 36
early pregnancy 1–12 fetal crown–rump length 23
bleeding in 4, 5–9 fetal death 36, 37
nausea 2, 9–10 fetal distress 17, 51, 52, 63
pain 2, 7–9 fetal growth 13–29
vomiting 2, 9–10 fetal heart monitoring 35, 36, 63
ectopic pregnancy 4, 6, 7–9, 129 fetal hydrops 26
histology 7 fetal hypoxia 51
investigations 8–9 fetal lie 48
milking 9 fetal movements
rhesus prophylaxis 12 counselling 40
risk factors 7, 8 recording 33, 37, 40
treatment 8–9 reduction 32, 36–7
unruptured 9 fetal position 48, 52
EllaOne 150 fetal tone 21
emergency contraception 148, 150, 158 fever (pyrexia) 68, 71–2
Index 165
fibroids 81, 82 haemoglobin A2 65

degeneration 37, 38 haemoglobin electrophoresis 24, 65
submucous 82, 82, 83 haemoglobin levels 58
subserosal 82 haemolysis, elevated liver enzymes and low
Filshie chip 154 platelets (HELLP) syndrome 60, 61, 66
fluconazole 128 heavy menstrual bleeding (HMB) 80, 81, 82, 87
fluid balance chart 61 bleeding disorders 80
fluid intake habits 108 irregular periods 78, 83–4
fluid therapy 10, 70, 130 ovular dysfunction uterine bleeding 81
folate deficiency 64, 65 quality of life 81
folic acid supplementation 65, 66, 140, 142, 143 regular periods 78, 81–2
follicle-stimulating hormone (FSH) 83, 94, 141, 144 surgery 82, 86
forceps delivery 52 HELLP (haemolysis, elevated liver enzymes and low
foreign bodies, vaginal 128 platelets) syndrome 60, 61, 66
fractures 63, 98 hepatitis screening 24
frequency 104 hepatosplenomegaly 64
full blood count (FBC) herpes simplex virus (HSV) 38, 71, 118, 127, 128
anaemia 64, 81 hirsutism 92, 93, 139
ectopic pregnancy 8 histology 7
hyperemesis gravidarum 10 HIV screening 24
miscarriage 5 hormone-producing tumour 93
placenta praevia 35 hormone replacement therapy (HRT) 90, 96–7
postpartum haemorrhage 70 benefits/risks 98–9, 99
postpartum infection 71 breast cancer risk 91
fundoscopy 62 combined 84, 96
compliance 91, 98
galactorrhoea 93, 139 contraindications 97
gastrointestinal infection 9, 10 controversies 91, 98–9
genital atrophy 109 decision to take 90, 96–7
genital tract infection 75 incontinence 108
genital warts 115, 122 lowest effective dose 98
genuine stress incontinence see urodynamic stress osteoporosis prevention 98
incontinence (USI) preparations 96, 97, 99, 100
gestational diabetes 23, 26, 62–3 prescriber advice 98–9
antenatal care 62–3 prolapse 109, 110, 111
delivery 63 review 98
maternal complications 63 screening programme 98
multiprofessional team 63 HPV see human papillomavirus (HPV)
postnatal care 63 HRT see hormone replacement therapy (HRT)
risks 62, 63 human papillomavirus (HPV) 116, 118, 122
treatment options 27, 62–3 vaccination 116
type 2 diabetes risk 66 hydroandrogenism 138
glucagon 66 hydrosalpinges 8
glucose tolerance test (GTT) 26, 62, 63 hyperemesis gravidarum 9–10
glycated hemoglobin 62, 66 hyperprolactinaemia 93, 94, 141
gonadotrophin-releasing hormone agonists 96 hyperreflexia 60, 61
gonadotrophin-releasing hormone analogues 131 hypertension, in pregnancy 60–1
gonadotrophins 144 hypertensive retinopathy 60
gonorrhoea 127–8, 129 hyperthyroidism 93, 94
gravida 17 hypocalcaemia 63
hypoglycaemia 63, 66
haematuria 107 hypogonadotrophic hypogonadism 140
haemodynamic status 5, 8 hypothyroidism 93, 94
166 Index
hysterectomy 86 emergency contraception 150

counselling 86 infection 142
dysfunction uterine bleeding 84 removal, failure to conceive 136
heavy menstrual bleeding 82, 87 intrauterine growth restriction (IUGR) 16,
ovarian cancer risk 86 24–6
prolapse 110 fetal abdominal circumference 16
recovery rates 86 hypertensive disorders of pregnancy 61
sexual function 79, 86 investigations 24–5
total 121 management 25, 29
hysterosalpingography 140, 141, 142 risk factors 24, 25–6, 51
hysteroscopic myomectomy 82 intrauterine insemination 140
hysteroscopy 83, 84, 121 involuntary urine loss 102
iron-deficiency anaemia 64, 65
in utero transfer 39 iron supplementation 65, 82, 87
in vitro fertilization and embryo transfer (IVF-ET) ischial spines 51
140, 142, 143 isoimmunization 35
incomplete miscarriage 6, 7 itching 124
incontinence 101–12
causes 112 ketones 10
clinical examination 105, 107 kick chart 37, 40
definition 104 Kleihauer test 38, 40
faecal 105, 107
investigations 103, 106, 107–8, 110 labetalol 61
neurological disorders 105, 107 labour 43–56
pelvic masses 105, 107–8 antenatal preparation 55
treatment options 106–7, 108 induced 47, 55–6
uterovaginal prolapse 107, 109 not progressing 45, 52–4, 56
voiding difficulties 102 partogram 45, 46
see also individual types pain relief 47, 55
incontinence advisory service 106, 108 partner presence 55
indometacin 27, 39 preterm 37–9
induced abortion 159 spontaneous 44, 50–1
inevitable miscarriage 6 stages 48
infertility 135–45 tired baby 44, 44, 51–2
causes 138 treatment options 52, 52
coital timing 137, 144 see also contractions
definition 138 lactation see breast-feeding
male factors 139 lactational amenorrhoea method 156
primary 138, 139–40, 140–2 laparoscopy
secondary 138, 142–3 diagnostic see diagnostic laparoscopy
insulin 27, 62 ectopic pregnancy 9
intercourse primary infertility 140, 141
bleeding following 78, 84–5, 120 sterilization 154
coital timing 137, 144 tubal blockage 142
pain during 124, 126, 130–1 laparotomy 9, 71, 132
internal iliac artery ligation 71 large for dates (LFD) 17, 26–7, 29
interval laparoscopic sterilization 157 last menstrual period (LMP) 22
intracytoplasmic sperm injection (ICSI) 140 late pregnancy 31–41
intramural fibroids 82 abdominal pain 32, 37–9
intrauterine contraceptive device (IUCD) 152 fetal movements see fetal movements
advantages/disadvantages 152 vaginal bleeding 32, 33, 34–6, 40
breast-feeding 156 Levonelle One Step 150
ectopic pregnancy 8 levonorgestrel 150, 158
Index 167
levonorgestrel intrauterine system (LNG-IUS) 82, counselling 3, 11

84, 99 history 2, 5, 6
liquid-based cytology (LBC) 116 investigations 5–7, 6
liquor see amniotic fluid management 6
liver function test (LFT) 10, 60 postoperative recovery 11
long-acting reversible contraceptive (LARC) 156, treatment 7
159 types 6
lupus anticoagulant 11 see also individual types
luteinizing hormone (LH) 94, 141, 144 missed miscarriage 6, 7
lymphadenopathy 119, 121 modified Pomeroy 157
molar pregnancy 6, 7, 10
macrosomia 17, 26, 53, 54, 63 ‘morning-after pill’ 149, 150, 158
magnesium sulphate 61 moulding 48, 52, 54
magnetic resonance imaging (MRI), endometriosis multiple pregnancy 10, 26, 144
131 multiple sclerosis 105, 107
mammography 98 mumps 136, 139
Manchester–Fothergill repair 110
maternal well-being, labour 50, 53 National Health Service Cervical Screening
mean cell haemoglobin (MCH) 64 Programme (NHSCSP) 116, 122
mean cell volume (MCV) 64 natural contraception 153
meconium aspiration 51 nausea 2, 9–10
meconium staining 51, 51, 56 neoplasia
mefenamic acid 82 abdominal distension 114, 119–20
membrane rupture 50 abnormal cervical screening test 114, 115,
artificial 35, 36, 55 117–19, 122
menopause 89–100 postmenopausal bleeding 114, 120–1
abdominal distension 114, 119–20 neural tube defects 65, 66
average age 96, 100 neurological disorders 105, 107
contraception 100 neurosis 95
definition 92 nifedipine 38, 61
HRT see hormone replacement therapy (HRT) nocturia 104
investigations 96 non-steroidal anti-inflammatory drugs (NSAIDs)
premature 92, 93–4 131
symptoms 83, 93, 96 ‘non-stress test’ 17
treatment options 96–7 nuchal thickness (NT) measurement 28
vaginal bleeding 114
menorrhagia see heavy menstrual bleeding (HMB) obesity 139
menstrual periods oestrogen(s) 96, 107, 111, 121
infrequent 90, 93–4 oestrogen-only preparations 96
intolerable 90, 95–6 oligohydramnios 17
irregular, failure to conceive 136, 140–2 oligomenorrhoea 92, 94
painful 124, 130–1 oliguria 61
mental state examination 95 oophorectomy, bilateral 96
metformin 62, 63 opiates 51, 55
methotrexate 9 oral contraceptive pill
metronidazole 72, 128 cervical ectropion 84
micturation, in labour 50 combined see combined oral contraceptive
midstream specimen of urine (MSU) 10, 106, 107, (COC) pill
128, 129 pelvic inflammatory disease 129
mifepristone 7, 155 progesterone-only 150, 152, 156, 158
miscarriage 5–7 osteoporosis 98
cervical os 5, 6 ovarian cancer 144
conservative treatment 7 ovarian cyst 119, 130
168 Index
ovarian drilling 142, 144 position 48

ovarian endometrioma (‘chocolate cysts’) 95 post-term 17
ovarian tumour 119, 120 post-term pregnancy 47, 55–6, 56
ovary stimulation 137, 137, 144 postmenopausal bleeding (PMB) 114, 120–1
ovulation 144 investigations 121, 122
oxytocin (Syntocinon) 36, 45, 53, 56 postpartum ‘baby blues’ 68, 72–3
postpartum haemorrhage 48, 68, 70–1, 75
pain 123–33 postpartum infection 69, 71–2
abdominal see abdominal pain pre-eclampsia 60–1, 66
early pregnancy 2, 7–9 risks 61
labour 37–8 pre-term 17
pelvic see pelvic pain pregnancy
shoulder-tip 8, 154 dating 13–29
see also dysmenorrhoea early see early pregnancy
pain relief, labour 47, 51, 55 failure to conceive 136, 139–40
‘Pap’ smear 116 haemoglobin estimation 64
PAPP-A 28 high blood pressure 58, 60–1
paraurethral bulking 107 late see late pregnancy
parity 17 likelihood 144
partogram 45, 46, 50, 56 medical disorders 57–66
pelvic abscess 129 molar 6, 7, 10
pelvic adhesions 140, 141 multiple 10, 26, 144
pelvic examination 95, 105, 107, 109 sugar in urine 58, 62–3
pelvic floor re-education 106 uncertain dates 14
pelvic infection 143 unwanted 154–6
pelvic inflammatory disease (PID) 126, 129–30 uterine size 22, 23
acute 129 pregnancy-induced proteinuric hypertension see
primary 126 pre-eclampsia
secondary 126 pregnancy test, sterilization 151
pelvic mass 107–8, 119 premature menopause 92, 93–4
pelvic pain premenstrual syndrome (PMS) 80, 90, 95–6, 100
chronic 126, 133 presentation 48
endometriosis 139, 142 presenting part 48
gynaecological infection 131 preterm labour 37–9
penicillins 72, 128 procidentia 103, 104
penthidine 55 progesterone 140
perimenopause 83, 84 progesterone-only pill (POP) 150, 152, 156, 158
perinatal mortality 56 progestogens 82, 84, 96, 100, 121
perineal trauma 70–1 prolactin, serum 94, 141
perineal wound infection 71, 72 prolactinoma 93
phenylpropanolamine 107 prolapse 101–12
placenta, retained 71 management options 111–12
placenta praevia 32, 34, 34–6, 40 non-surgical treatment 103, 110–11
placental abruption 36, 41 see also individual types
placental insufficiency 16, 28 prostaglandins 7, 37, 56
pleural effusions 120 puberty 92
pneumonitis 51 puerperal psychosis 72, 73
polycystic ovarian syndrome (PCOS) 93–4, 138, puerperium 67–75
139, 141–2 pyrexia (fever) 68, 71–2
polyhydramnios 17, 26, 27, 29
polyps radiographs, chest 72, 120
cervical 84, 120, 121 rectocele 109, 110
endometrial 84, 120 recurrent miscarriage 11
Index 169
red cell folates 65 miscarriage 5

reflex examination 60 postcoital bleeding 84
respiratory distress syndrome 38, 41, 74 postmenopausal bleeding 121
retained products of conception 7, 71 prolapse 109
rhesus prophylaxis see anti-D sperm abnormalities 140
rhesus status 12, 25, 27, 35 spontaneous labour 45, 50–1
‘rhythm method’ 153 spontaneous miscarriage 4, 12
ring pessaries 110, 111, 112 station 48
ritodrine 38, 39 sterilization 148, 151, 154
rubella 25, 66, 139, 141 alternatives 154
Rusch balloon 71 consent 154
counselling 154
salpingectomy 9 investigations 151
salpingitis 126 post-delivery 156
salpingo-oophorectomy, bilateral 121 risks 154
salpingostomy 8 steroids
salpingotomy 9 polyhydramnios 27
scalp oedema (caput) 48, 53, 54 pre-eclampsia 61
selective serotonin reuptake inhibitors (SSRIs) 96 preterm labour 38–9, 41
semen analysis 139–40, 141 small baby 25, 28
septic miscarriage 5, 6 strawberry cervix 127–8
septic shock 130 subfertility see infertility
sexual function, post-hysterectomy 79, 86 submucous fibroids 82, 82, 83
sexual history 129 subserosal fibroids 82
sexually transmitted infections (STIs) 8, 126, suburethral hammock support 107
129–30, 133 surfactant 25
shelf pessaries 110, 111, 112 surgical termination 155–6
shivery, postpartum 68, 71–2 symphysiofundal height 14, 26, 36, 38, 51
shock 70 symptoms diary 95
shoulder dystocia 63 syncopal episodes 7
shoulder-tip pain 8, 154 Syntocinon (oxytocin) 36, 45, 53, 56
‘show’ 50
sickle-cell disease 64 teams, multiprofessional 63
sickle-cell trait 65 term 17
sickle crises 65 termination 148, 154–5, 159
Sickledex test 65 consent 155
Sim’s speculum 109 counselling 155
small for gestational age (SGA) 16, 24–6 infertility risk 155
fetal abdominal circumference 16 medical 155
risks 25–6 surgical 155–6
smoking testosterone 94
fertility 145 thalassaemia 64, 65
intrauterine growth restriction 24 therapeutic abortion 154
prolapse 109 threatened miscarriage 5, 6, 12
small baby 14 thrombocytopenia 80
‘snowstorm’ vesicles 6 thyroid function test (TFT) 73, 94, 141
‘something coming down’ sensation 102, thyroid-stimulating hormone (TSH) 10
108–10 thyrotoxicosis 10
speculum examination timed plasma glucose 23
discharge 127 tocolysis 39, 40
endometriosis 130 total hysterectomy and bilateral
genital warts 122 salpingo-oophorectomy 121
late pregnancy bleeding 35 tranexamic acid 82
170 Index
transcutaneous electrical nerve stimulation (TENS) uterine bleeding

51, 55 abnormal 77–87
transformation zone 118 dysfunctional see dysfunctional
transient tachypnoea of the newborn (TTN) 69, 74 uterine bleeding (DUB)
trauma 70–1 uterine evacuation 3
Trichomonas infection 127–8 uterine fundus, rubbed up 70
trisomy 18 10 uterovaginal prolapse 104, 108–10, 109
type 1 diabetes 59, 66 uterus
atonic 70
ulipristal acetate 150 palpation 29
ultrasound scan (USS) size in pregnancy 22, 23
ascites 120 tenderness 38
dysfunction uterine bleeding 81
ectopic pregnancy 8 vagina
endometrial cancer 121 dry 96, 111, 120
endometriosis 131 ‘lump’ 102
fetal anomaly 26–7 vaginal bleeding see bleeding
fetal movement reduction 37 vaginal discharge see discharge
fibroids 81 vaginal examination
hypertensive disorders of pregnancy 61 cephalopelvic disproportion 54
infertility 140 ectopic pregnancy 6
large for dates 26 inadequate uterine contractions 53
ovarian pathology 83 labour 38
pelvic inflammatory disease 129 retained products 71
pelvic mass 129 spontaneous labour 50, 51
placenta praevia 35 vaginal itching 124
polycystic ovarian syndrome 94 vaginal pessaries 110
premature menopause 94 vaginal swabs 84, 117, 128, 129
premenstrual syndrome 95 vaginal trauma 70–1
recurrent miscarriage 11 vas obstruction 140
retained fetal tissue 7 vasectomy 154
small for gestational age 25 ventouse delivery 52
uncertain dates 23–4 vertex 48
uterine pathology 83 viability 17
ureteric colic 38 virilism 92
urethral swabs 129 vitamin supplementation 10
urge incontinence see detrusor overactivity voiding difficulties 102
urinalysis 10, 24, 37, 50, 61 vomiting 2, 9–10
urinary tract infection (UTI) 10, 71, 72, 102 von Willebrand’s disease (factor VIII deficiency) 80
urine, sugar in 58, 62–3 vulval erythema 127
urine dipstick 128 vulval inspection 127
urodynamic investigations 103, 106, 106, 108, vulval itching 124
110
urodynamic stress incontinence (USI) 102, 104, ‘withdrawal’ 153
105–7, 112 wound haematoma infection 71
investigations 106, 106
uterine activity, inadequate 52–3 Yuzpe regimen 150
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Core

Gary Mires MBChB MD FRCOG FHEA

Khalid S. Khan MRCOG MSc MMEd

Janesh K. Gupta MSc MD FRCOG

Core Clinical Cases series edited by

Janesh K. Gupta MSc MD FRCOG

Why a problem-solving approach?

How will this book inspire problem-solving traits?

ICSI intracytoplasmic sperm injection

For each of the case scenarios given, consider the following:

Q1: What is the likely differential diagnosis?

CASE 1.1 – My period is 2 weeks late and I am bleeding.

CASE 1.2 – I am 8 weeks pregnant and have pain and bleeding.

CASE 1.3 – I am pregnant and cannot keep anything down.

OSCE counselling cases

OSCE COUNSELLING CASE 1.1 – I am upset that my ﬁrst pregnancy has

OSCE COUNSELLING CASE 1.2 – This is my third miscarriage. What can

BLEEDING IN EARLY PREGNANCY

CASE 1.1 – My period is 2 weeks late and I am bleeding.

A2: What issues in the given history support the diagnosis?

A4: What clinical examination would you perform and why?

A5: What investigations would be most helpful and why?

History Examination Investigation Management/outcome

Type of Pain Bleeding Cervical os Uterine size in Uterus on

Molar Slight/none Slight to Closed Consistent or Classic Will need surgical

CRP ✓ If temperature is elevated or there are other

USS ✓ To determine whether the fetus is intrauterine

A6: What treatment options are appropriate?

CASE 1.2 – I am 8 weeks pregnant and have pain and bleeding.

A2: What issues in the given history support the diagnosis?

A4: What clinical examination would you perform and why?

A5: What investigations would be most helpful and why?

Serum ßhCG ✓ Normally, a doubling of levels in 48 h is

A6: What treatment options are appropriate?

CASE 1.3 – I am pregnant and cannot keep anything down.

A2: What issues in the given history support the diagnosis?

A4: What clinical examination would you perform and why?

A5: What investigations would be most helpful and why?

Urinalysis ✓ The presence of ketones supports a history of

USS ✓ To exclude molar and multiple pregnancy.

TSH ± To exclude thyrotoxicosis. Note that thyroid-

A6: What treatment options are appropriate?

OSCE counselling cases

OSCE COUNSELLING CASE 1.1 – I am upset that my ﬁrst pregnancy has

OSCE COUNSELLING CASE 1.2 – This is my third miscarriage. What can

For each of the case scenarios given, consider the following:

Q1: What is the likely differential diagnosis?

CASE 2.1 – I think I am pregnant, but I cannot remember the date

CASE 2.2 – The midwife says my baby is small.

CASE 2.3 – The midwife says my baby is big.

OSCE counselling cases

OSCE COUNSELLING CASE 2.2 – I want to have screening for Down’s

SMALL FOR GESTATIONAL AGE (SGA)

INTRAUTERINE GROWTH RESTRICTION

150 Figure 2.2 Fetal abdominal circumference (FAC) in a

LARGE FOR DATES

Box 2.1 Cardiotocography

Features of a normal CTG (Fig. 2.3)

Acceleration Normal baseline with normal variability