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Obstetrics, Gynaecology-Textbook of Obstetrics and Gynaecology For Medical Students, 2nd Edition-Akin Agboola-2006

This document provides information about the second edition of the textbook "Textbook of Obstetrics and Gynaecology for Medical Students". It was edited by Akin Agboola and published in 2006. The preface discusses updates that were made for this second edition, including additional topics such as maternal infections, prenatal diagnosis of diseases, and aspects of labor. It also thanks contributors and proofreaders for their work on improving medical education in developing countries.

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Obstetrics, Gynaecology-Textbook of Obstetrics and Gynaecology For Medical Students, 2nd Edition-Akin Agboola-2006

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Prince Of Medicine-2014-BSUTH

Textbook of Obstetrics
and Gynaecology for
Medical Students
Second edition

Edited by
Akin Agboola
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Prince Of Medicine-2014-BSUTH
Scanned(2014) by The Prince Of Medicine @ bsuth by God's Grace

Textbook of Obstetrics and Gynaecology for

Medical Students

Second Edition

Editedby

Akin Agboola, MD (Lond), FRCOG, FMCOG, FWACS

Former Professor and Head ofDepartment of Obstetrics and Gynaecology,
College of Medicine, University ofLagos, Nigeria
Lately Professor, Department of Obstetrics and Gynaecology, School ofMedicine,
University ofZambia, Lusaka, Zambia

Heinemann Educational Books (Nigeria) Pic

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Prince Of Medicine-2014-BSUTH

HEINEMANN EDUCATIONAL BOOKS (NIGERIA) PLC

Head Office: 1 Ighodaro Road, Jericho, P.M.B. 5205, Ibadan
Phone: (02) 2412268, 2410943, 2411213; Fax: (02) 2411089, 2413237
E-mail: [email protected]
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Area Offices and Branches

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Ikeja .Dorin. Jos . Kano Katsina .Maiduguri Makurdi Minna .
. .
Owerri Port Harcourt. Sokoto Uyo Yola .Zaria .

©Akin Agboola (ed.) 1988, 200 1, 2006

First published 1988
Reprinted with minor corrections 1999
First published in this Revised Edition (2 volumes) by Heinemann
Educational Books (Nigeria) Pic 200 1
First published in this Omnibus Second Edition 2006

ISBN 978 129 934 7

AilRightsReserved
Nopart ofthispublication may be reproduced, stored in a retrieval
system or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the
priorpermission ofHeinemannEducationalBooks (Nigeria) Pic.
This bookissoldsubject to the conditionthat itshouldnot byway

of trade or otherwise be lent, re-sold, hired out or otherwise

circulated without the publisher s prior consent in any form of
binding or cover other than that in which it is published and
without a similar condition includingthis condition being imposed
on the subsequentpurchaser.

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Preface to the Second Edition

When the textbook was first published in 1988, there was a felt need for a textbook for
undergraduate medical students training in Nigeria and other tropical countries. It was done in two
volumes with volume one comprising gynaecology topics and volume two obstetrics. General
medical practitioners and postgraduate students in their early training were also meant to benefit by
reading the book. Reports from medical schools in Nigeria and some parts ofAfrica have confirmed
the usefulness of the book in terms of preparation and success in the final examinations by the
students. This has been very encouraging and the mission was felt accomplished.

In the year 2000 a revised edition of the volume two was published with the addition of Acquired
Immunodeficiency Syndrome (AIDS) to the chapters as it was thought that students especially those
training in sub-Saharan Africa needed to broaden their knowledge on tins special condition which is
ravaging the world. A chapter on severe anaemia was also included in this edition based on
experience in sourthern Africa which may be applicable to some other parts ofAfrica.

Inthis second edition the two volumes of the book have beencombined into a single volume for the
convenience of readers. This edition thus contains bothobstetrics and gynaecology.

There have been recent advances in the specialty since the first edition was published and it is
thought that medical students in developing countries should be aware of these developments.
Topics like maternal infections, prenatal diagnosis of haemoglobinopathies and some inherited
diseases and also special aspects of labour have been included to provide additional knowledge-
Some other topics have also been expanded in line with recent advances.

Ihave brought in more contributors some of them with expertise in their own special fields. To
these new contributors and also those of my colleagues who took part in writing the first edition as
well as this second edition, 1extend my great appreciation. There is no doubt that we have all made
an impression as regard the growth of medical education in the tropics and also the developing
countries.

Ithank Dr. Abiodun Oladipo for the preliminary proof reading and Dr. P. A. Oyekanmi for the final
proof reading which indeed was a difficult and strenuous task. My gratitude also goes to the various
secretaries who typed the manuscripts.

Akin Agboola
2005

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Prince Of Medicine-2014-BSUTH
ppÿ
List of Contributors
O. Q.Abudu, ME, BS, FRCOG, FRCS, FMCOG, FWACS
Professor andformer HeadofDepartment of Obstetrics and Gynaecology,
College ofMedicine, University ofLagos

B. B.Afolabi, MB, ChB, MRCOG, FMCOG, FWACS

Lecturer; Department of Obstetrics and Gynaecology,
College ofMedicine, University ofLagos

Akin Agboola, MD, FRCOG, FMCOG, FWACS

Former Professor andHead ofDepartment of Obstetrics and Gynaecology,
College of Medicine, University ofLagos, Nigeria

G. O. Ajayi, MD, S.h.c., ASSP, FAGG, FRDRP, FWACS, FMCOG

Professor andHead ofDepartment of Obstetrics and Gynaecology,
College ofMedicine, University of Lagos

R. L Anorlu, MB, CbB, MRCOG, FMCOG, FWACS, MPH

Senior Lecturer; Department of Obstetrics and Gynaecology,
College ofMedicine, University ofLago-

N.T. Clerk, MB, ChB, RSc., MRCOG

Lecturer; Department of Obstetrics and Gynaecology,
University Hospital of Wales, Cardiff

P. H.Daru, ME, BS, FWACS

Lecturer; Department of Obstetrics and Gynaecology,
University ofJos

B. Ekele, MB, BS, FWACS

Associate Professor of Obstetrics and Gynaecology,
Usman Danfodio University, Sokoto

C. C. Ekwempu, ME, BS, FRCOG, FMCOG, FWACS

Former Professor and Head ofDepartment of Obstetrics and Gynaecology,
Ahmadu Bello University, Zaria

C. C. Ekwempu Jnr, MB, BS, FWACS

Lecturer; Department of Obstetrics and Gynaecology,
University ofJos

O. O. Famuyiwa, MB, BS, MRC Psych, M Phil, FMC Psych, FWACP

Professor andHeadofDepartment ofPsychiatry
College ofMedicine, University ofLagos

H. S. Galadanci, ME, BS, MSc, FWACS, MRCOG

Senior Lecturer; Department of Obstetrics and Gynaecology,
Bayero University, Kano

E.S.Isamade,MB,BS, DA FMCA FWACS

LecturerandActingHeadofDepartment ofAnaesthesia, .

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Prince Of Medicine-2014-BSUTH

University of Jos

T.A. Jido, MB, BS, FWACS

Lecturer, Department of Obstetrics and Gynaecology,
Bayero University, Kano
J.A. Karshinia, MB, BS, FWACS
Consultant Obstetrician and Gynaecologist,
and Director WF Centre, ECfVA Evangel Hospital, Jos »

K. K. Kctiku, MB, BS, DMRT, FWACS

Associate Professor, Department of Radiation Biology and Radiotherapy
College ofMedicine, University of Lagos

O. Kyari, MB, BS, FRCOa, FWACS, FMCOG

Associate Professor, Department of Obstetrics and Gynaecology,
University of Afaiduguri

OA.. Ladipo, MB, BCh, FRCOa, FMCOG, FWACS

Former Professor and Head ofDepartment of Obstetrics and Gynaecology,
College ofMedicine, University ofIbadan

M. U. Mandara, MB, BS, FWACS

Consultant Obstetrician and Gynaecologist, National Hospital, Abuja

E. R. Ola, MB, BS, FMCOG, FWACS, FICS, FRCOG

Senior Lecturer, Department of Obstetrics and Gynaecology,
College ofMedicine, University ofLagos

AA. O. Orhue, MB, BS, FMCOG, FWACS, FICS, FRCOG

professor of Obstetrics and Gynaecology,
University ofBenin

J.M. Otubu, MB, BS, PhD:, MPH, FRCOa, FMCOG, FWACS

professor andformer Head ofDepartment of Obstetrics and Gynaecology,
University ofJos

I.C Pam, MB, BS, FWACS

Senior Lecturer andActing HeadofDepartment of Obstetrics and Gynaecology,
University ofJos

O. Shittiu, MB, BS, FWACS

Senior Lecturer andActing Head of Department of Obstetrics and Gynaecology,
University Bello University, Zaria

E.U. Udocyop, MB, BS, FWACS, MRCOG

Lecturer, Department of Obstetrics a/td Gynaecology,
University Of JOS
Vii
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Prince Of Medicine-2014-BSUTH

Contents

SECTIONA- GYNAECOLOGY

1. Anatomy ofthe pelvic organs * 1

JA.M. Otubu

2. Embryology ofthe female reproductive organs and congenital anomalies 12

J.A.M. Otubu

3. Physiology ofthe female genital organs 19

H S. Galadcmci
JA.M Otubu

4. Urogenital prolapse and the displacement ofthe uterus . 31

AkinAgboola

5. Fistulae 39
J. A. Karshima
J.A.M. Otubu

6. Urinary conditions 52
E. U. Udoeyop
J.A.M. Otubu

7. Pelvie infections
1. C. Pam
JAM. Otubu

8. Vaginal discharge..
O. O. Abmhi
R. 1. Anorlu

9. Sexually transmitteddiseases ..
O. O. Abudu
R. I.Anorlu

11. .Pruritusvulvae.
O. O. Abudu
M. L Anorlu
...
10. Acquired immunodeficiency syndrome (AIDS)
AkinAgboola

12.Miscarriages
1. C. Pam
J.A.M. Otubu viii
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13. Ectopic pregnancy

I. C. Pam . mi
1UI
J.A.M. Otubu

14..Disorders of menstruation ,
E.HOla

15..Endometriosis ÿ22
O.A. Ladipo

16. Infertility I2g

J..A.M. Otubu

17. Tubal surgery in gynaecology 139

J.A.M. Otubu

18. Contraception 145

N. T. Clerk
0. A. Ladipo

19. .Tumours of the vulva 155

•
O.O.Abudu

20.Tumours of the vagina 163

AkinAgboola

21. ..Tumours of the cervix uteri 167

R. l.Anorlu

22. Tumours of the corpus uteri 183

.....
AkinAgboola

24. Tumours of the

E. R. Ola
..
23 .Tumours of the fal lop iantube
AkinAgboola
194

197

218
25. Trophoblastic tumours
AkinAgboola
225
26. Radiotherapy and chemotherapy for treatment of genital cancer
RfCKetiku
934
27. Endoscopy in gynaecology
N. T. Clerk
O. A. Ladipo
IX

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28. Intersex 23 £
R. 1.Anorlu

29. Psychiatric aspects of gynaecological practice 1M

O. O. Famuyiwa

30. Preoperative and postoperative management 251

O. O. Abudu
B. B. Afolabi
5 1. Prolonged pregnancy and shoulder dystocia.. . . 412
AkinAgboola
417
52. Abnormal presentations
T. A. Jido
J.A.M. Otubu
423
53. Preterm labour and premature of membranes
Premature rupture of membranes
A.A.E. Orhue
XI
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Prince Of Medicine-2014-BSUTH

54.

55.

57.

58.

59.

60.

61.

62:

63.

64.

65.

66.

Index
Induction of labour.
A. A.E. Orhue

Prolonged labour.
A..-I.E. Orhue
JA.M. Otubu

Problems of labour.
A.A.E. Orhue

C. C. Ekwempu

Maternal injuries
C. C. Ekwempu

Postpartum haemorrhage
O. S. Shittu
J.A.M. Otubu

Instrumental delivery.
I.C Pam
JAM Otubu

Caesarean section
JA.M Otubu

Abnormal puerperium.
C. C. Ehverpu Jrtur.
J.AM. Otubu

Analgesia and anaesthesia in obstetrics

£. S. Lsamade
JAM Otubu
.
Local abnormalities and pelvic tumours in pregnancy

Psychiatric aspects of obstetric practice

0.0. Famuyrwa

Maternal and perinatal mortality

- B. Ekele
JAM Otubu

.....
Imaging in obstetrics and gynaecology....
L C Pam
PH. Daru
JAM Otubu
-
.

xii
.

* V;.
439

442

472

477

401

489

495

504

509

5\ 9

ÿ6

.
ÿ2

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542
Prince Of Medicine-2014-BSUTH

SECTION A - GYNAECOLOGY

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Chapter 1
Anatomy of the pelvicorgans
The female pelvis is a bony bowl prominent feature of the vulva. They are two
reinforced on the inside by muscles, fascia longitudinal skin folds, which contain loose
and peritoneum and on the outside by adipose connective tissue and lie on either
muscles, fascia and skin. It has a pelvic side of the vaginal opening. They are usually
diaphragm, which separates the internal covered by hair on the lateral surface while
the media surfaces are smooth andmoist. The
genitalia from the external genitalia. The
two labia majora are connected posteriorly to
external genitalia consists of the mons form the posterior commissure while
pubis, labia majora, labia minora, clitoris, anteriorly they join to form the anterior
the vestibule andthe vestibular glands. The commissure, which is part of the Mons pubis.
bony pelvis is made up of four bones the Because of the sensitivity to the sex
right and left innominate (hip) bones hormones produced by the ovaries, the labia
anterolaterally and the sacrum and coccyx majora are less prominent before puberty and
posteriorly. The internal genitalia consists atrophic after menopause. The loose nature of
of the vagina, uterus, two Fallopian tubes the adipose tissue also makes the labia
and a pair of ovaries. majora, a site for fluid collection and hence
oedema formation.
The external genitalia
Mons pubis Labia minora: these are two smaller
•Labium majus longitudinal skin folds, also containing
Prepuce of clitoris
adipose connective tissue, but no hair. They
Glans of clitoris
lie medial to the labia majora and form the
Urethral |
orifice borders of the vestibule. Posteriorly, the two
labia minora become less distinct and join to
Vagina form the Fourchette. Anteriorly, each labium
Labium minus
minus divides into medial and lateral parts.
The lateral parts join to form the prepuce
7"Posterior while the medialjoin to form the frenulum of
Fourchette commissure the glans of the
Anus
clitoris. The medial surfaces of the labial
minora, like those of the labia majora contain
Figure 1.1 External genitalia numerous sebaceous follicles.
Clitoris: this is a small structure that projects
The external genitalia are collectively in the midline and in front of the urethra. It
referredto as the vulva (Fig 1.1) consists of the glans,body andthe crura. Only
Monspubis: this refers to the area above the the glans of the clitoris is visible externally.
symphysis pubis and consists mainly of a The clitoris consists mainly of erectile tissue,
pad of fat covered by hair. It is also called blood vessels and nerves. It receives its skin
the Mons veneris. covering from the labiumminus on each side.
It isthe homologue of the penis inthe male. It
plays an important role in sexual response.
Labiamajora: these represent the most
Vestibule: this is the name given to the space
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between the two labia minora. Located within Muscles of the perineum: fig 1:3 shows the
this space are the urethral and vaginal orifices muscles of the perineum. In the anterior
and the opening of vestibular glands. The triangle, the muscles are: the transverse perinei,
urethral orifice occupies the anterior aspect of superficialis, the bulbo spongiosus, the
the space. The orifice is surrounded by small ischiocavernosus, the transverse perineal
paraurethral (Skene) glands, which open into profundus and the sphincter urethrae. The
the urethrathrough a pair of ducts. tranverse perineal superficialis forms the base
The vaginal orifice is located in the posterior of the urogenital triangle taking its origin from
part of this space. Inthe virgin it has a covering
the ischial tuberosity and getting attached to the
of thin fold of mucous membrane called
perineal body. The function of this muscle is
probably to fix the perineal body. The
Hymen. Lying deep on the either side of the
bulbospongiosus surrounds the vaginal orifice
vaginal orifice are the two Bartholin's glands and acts as a weak sphincter to the vaginal
(greater vestibular glands). These glands open orifice. The ischiocarvemosus arises from the
into the vaginal orifice by a pair of ducts. The ischial tuberosity and gets attached to the crus
Bartholin's glands produce secretions, which of the clitoris, which it compresses to produce
lubricate the vagina. erection of the clitoris during sexual
excitement. The transversus perinei
Perineum: this area is diamond-shaped and profoundus runs behind the vaginal orifice and
bound anteriorly by the symphysis pubis, has a similar action to that of the transverse
laterally by the ischial tuberosities and perinei superficialis. The sphincter urethrae
posteriorly by the coccyx (figl.2). It can be encircles the urethra orifice and acts as a
dividedinto two triangles by a line constrictor of the urethral orifice. The muscle of
the anal canal isthe external anal sphincter. This
Symphysis pubis
striated muscle competely surrounds the whole
anal canal. Its function is to keep the anal canal
Urogenital triangle and anus closed.
,abium majus

- Ischiocavernosus
Ischial tuberosity
Urogenital diaph
• Bulbospongiosus
Anal triangle
erficial trans¬
Central tendon"" verse periheus
of perineum

Coccyx ÿSphincter Ani

Extemus
• Gluteus
Figure O Schematic representation of diamond shaped Levator ani Maximus
perineum consisting of anterior (urogenital)
and posterior (anal) triangles
Figure 1.3 Muscles of the perineum of the female
drawn from one ischial tuberosity to the other
and passing through the perineal body. The Perinealbody: this is a muscular condensation
anterior triangle iscalled the urogenital triangle (fig 1.3), which lies between the orifice of the
and contains all the external urogenital organs vagina anteriorly and the anal orifice
described above. The posterior triangle is posteriorly. Its central point receives muscle
called the anal triangle and contains the anus. fibre from bulbospongiosus,
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Anatomy of the Pelvic Organs 5

superficial transverse perinei, external ani become fused into a single innominate bone.
sphincter and deep fibre from the levator ani The sacrum is a large triangular bone formed by
muscles. The perineal body can be torn during the fusion of five sacral vertebrae. The sacrum
childbirth and if this tear extends to and divides
is in the posterior part of the pelvic cavity and
the external anal sphincter, it is called a third
degree tear. inserted like a wedge between the innominate
bones. The coccyx is a small triangular bone
Pelvic diaphragm: the internal reproductive consisting of four rudimentary vertebrae. Its
organs are separated from the external base has an articular surface, which joins with
reproductive system by a pelvic diaphragm. the apex of the sacrum.
The pelvic diaphragm is perforated by the
urethra anteriorly and the anus posteriorly and peLvis
Sacral ala
Iliac crest Iliac fossa
the vagina in between these two. The pelvic
diaphragm is made up of the levator ani and
coccygeus on the either side.The levator ani is a Sacral
£
broad muscle, which sweeps from the inner promontory

aspect of the pelvic sidewall to the midline Anterior Superior

where it meets its counterpart from the opposite Iliac spine
Pelvic
side. It is attached to the inner surface of the Pelvic brim •. Sacro-coccygeal
joint
body of pubis, lateral to the ischial spine and to (illo-pectineal line) \
Coccyx
Ischial spine
the thickened pelvic fascia covering the
obturator internusmuscle. Figure 1.4 The Bony Pelvis

The coccygeus arises from the inner surface of

the ischial spine and sacrospinous ligament and Symphysis pubis is formed by the joint at the
is attached to the coccyx andthe side of the fifth articular surfaces of the two pubic bones
segment of the sacrum. anteriorly. Sacroiliac joints are formed by the
The levator ani takes part in constriction of the articulation of the articular surface on each side
rectum and vagina. The pelvic diaphragm
supports the weight of the viscera and internal
of sacrum with similar surface on the ilium.
genital organs. Sacroiliac joints are the largest and most
important pelvic joints. They are subjected to
Bony pelvis massive strains as the full weight of the body is
transmitted through them to the lower limbs in
The bony pelvis: it is the bony framework on erect position.
which the external and internal reproductive
systems lie. The bony pelvis is made up of the During pregnancy and labour, the large amount
innominate (hip) bones, right and left sacro¬ of sex hormones produced soften all the pelvic
iliac joints, the symphysis pubis and the ligaments leading to separation of the articular
sacrococcygeal joints (fig. 1.4 ). The surfaces with enlargement of the pelvic
innominate (hip) bone is made up of three
capacity, which facilitates childbirth.
separate bones, ilium, ischiumand pubis.
These bones are unitedby cartilage at the site of
the acetabulum and at the time of puberty the The pelvic brim is a boundary line between the
cartilage becomes calcified and the three bones false pelvis above and the true pelvis below. It is

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the boundary line between the abdominal and longer than the anterior wall about 7.5cm. The
pelvic cavities. The false pelvis is formed on vagina is also wider at the vault than its opening
each side above the pelvic brim and the sacral
ala and the fossa of each iliac bone. The true into the vestibule. The wall of the vagina
pelvis is a curved bony canal, the posterior (the contains two layers of smooth muscles; an inner
sacrum) being considerably longer than the circular and an outer longitudinal. The inner
anterior wall (the symphysis pubis). It is part of the vagina has a mucous membrane,
through the true pelvis that the fetus passes
during delivery. which is thrown into transverse folds. The
membrane is covered by nonkeratinised
stratified squamous epithelium. Ordinarily, the
Internal genital organs
vagina is a collapsed tube except when it serves
its function as an organ of copulation and as
Vagina:this is a tubular, muscular canal whose
orifice opens into the vestibule (fig. 1.5). It is birth canal, fu these circumstances, the vagina
directed backwards and upwards from the is capable of tremendous distension. Remnants
vestibule and terminates where it is attached of the mesonephric ducts may sometimes be
around the cervix. The upper blind end of the
vagina where it is attached around the cervix is demonstrated along the vaginal wall in the
called the vault. The recess between the cervix subepithelial layers and may give rise to
and vagina in this area is called fornix. There Gartners duct cyst.
are two lateral fomices and an anterior and a
At puberty, the epithelium of the vagina is rich
posterior fornix ( fig 1.5). The anterior wall of
the vagina is relatedto the bladder and urethra. in glycogen and the fermentative action of
The posterior wall is related to the rectum and bacteria (Doderlein's bacillus), on this makes
rectouterine pouch (also called the pouch of the fluid in the vagina acid. Before puberty and
Douglas ) above and the anal canal below. The
posterior wall of the vagina (about 1Ocm) is after menopause, the protective acidic
environment of the vagina is absent and the
Uterus (anteverted)
vagina is prone to infections. The mucous
\\ Pouch of membrane of the vagina has no glands; hence
Douglas
the lubricationof the vagina is derived from
Posterior fornix
fundus
Anterior fornix
Intramural part
Bladder Isthmus
Rectum
Body off Endometrium Ampulla
Uterine
Symphysis Uterus 1 myometrium
cavity
pubis

-L
ÿ
Isthmus
Anal Canal Cervix Cervical canal
Vaginal Infundi-
Perineal body fornix bulum
Vagina External Os. Fimbria Fimbriae
Ovarica

Figure 1.5 Lateral view of internal genital

organs showing relationship to Figure 1.6 Schematic representation of an anterior
bladder in front and rectum behind section through uterus, fallopian tubes
and upper part of vagina

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mucus produced by the cervix and secretions and the inner mucous layer. The outer serous
from a the Bartholin's glands. The vaginal layer is a peritoneal covering. The middle
muscular layer is called myometrium and
epithelium responds to changes in sex consists of smooth muscle arranged in three
hormone levels in circulation. Cellular debris layers, the external, intermediate and inner
from the vaginal wall may therefore be layers. The external layers contain longitudinal
studied to determine the predominance of fibres, the intermediate contains longitudinal,
oestrogen or progesterone. oblique and transverse fibres while the inner
layer contains longitudinal and circular fibres.
Uterus: it is a pear-shaped, thick walled organ The muscular layer of the uterine wall
that lies in front of the rectum but behind and undergoes marked hypertrophy in pregnancy
above the bladder (fig. 1.5). The uterus can be with deposition of collagen tissue. This
divided into two parts; the upper part is the hypertrophy is inresponse to marked distension
body or corpus and the lower is the neck or of the cavity by the contents of the conception
cervix (fig. 1.6). The Fallopian tubes join the and also massive production of oestrogens and
body oi the uterus on either side towards its progesterone. The disposition of the different
upper rounded end. The rounded, muscular
area above the point, where the Fallopian muscle layers and fibres is also important in the
tubes join the body of the uterus is called the haemostatic control after delivery of the
fundus. The body of the uterus is held in its placenta. The inner layer is the mucous
upper end to the pelvic wall by the broad membrane, which is also called the
ligaments and round ligaments. The cervix is endometrium. It is covered by columnar
held to the pelvic wall by utero-sacral epithelium and some of the cells are ciliated.
ligaments posteriorly and the cardinal or
Mackenrodt's ligaments laterally. These The subepithelial layer contains tube-like
supports of the uterus will be described in glands, which open into the uterine cavity. The
detail later in this chapter. A small constricted endometrium undergoes profound changes
portion of the body ot the uterus immediately during the ovarian cycle, culminating in the
above the cervix is called the isthmus (fig. monthly shedding of the superficial layers of the
1.6). This area becomes the lower segment of endometrium (menstruation). It is true to say
the uterus in later part of pregnancy, and in that the endometrium is the mirror of the
labour. Suspended as the uterus is in the
pelvis, it tends to assume varying postitons. It activities of the ovary. Endometrium is usually
is usually deviated from the midline towards obtained in an operation called dilatation and
the right side. The whole uterus (body and curettage and this endometrium can be studied
cervix) may be inclined forward and histologically to determine the hormone status
anteriorly (anteversion) or backward and of the woman.
posteriorly (retroversion). The uterus may
also be flexed forward on itself at the isthmus Cervix: it is about 2.5cm inlength and is narrow
when it iscalled anteflexion. and more cylindrical thanthe body of the uterus.
The uterus measures about 7.5cm in length, It projects through the vagina, which divides it
5cm in width and 2.5cm in thickness. The into supra-vaginal and vaginal parts. The cervix
cavity of the body of the uterus is triangular has a canal, which is fusiform and broader inthe
with the apex pointing towards the cervix. middlethan at the ends.The canal opens into the
This cavity opens into the canal of the cervix uterine cavity through the internal os and into
through the internal os. The wall of the uterus the vagina through the external os (fig. 1.6).
consists of three distinct layers: the outer The mucous membrane of the upper two-thirds of
serous layer, the middle muscular layer, the cervixhas deep glandular follicles, which secrete

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Chapter 2
m
mm Embryology of the organs
and congenital
aM—

The development of the female genital organs is

important in the understanding of the anatomy
Paramesonephric
and physiology of the reproductive system. It is duct
also useful in gynaecological practice. The
urinary and genital systems share a common
developmental origin from the mesoderm of the Mesonephric
duct
intermediate cell mass. As a result of this
intimate association, congenital anomalies of
Mesonephros
the genital tract may often in practice be
associated with congenital anomalies of the
urinary systems. Gonda

Development of uterus and Fallopian tube

The uterus and Fallopian tube develop Mesonephric duct

essentially from the paramesonephric Urter

(Mullerian) duct system. The development of

the paramesonephric duct system with a total Cloaca

regression of the mesonephric duct system in

the female is due to the absence of a Y- Figure 2.1 Early development of uterus, Fallopian tube
chromosomal influence in the female. The and Ovaries Shows relationship of
development of the paramesonephric ducts is mesonephros, mesonephric duct and
first noticed at six weeks of intrauterine life. Paramesonephric ducts
The paired ducts appear as groove-like
invagination of the coelomic epithelium on the
lateral aspect of the mesonephric ridge At about eight weeks of intrauterine life, the
(Wolffianbody) near the cranial end. Eachduct paramesonephric duct turns medially, crosses
opens into the coelomic cavity cranially at a the mesonephric duct at the caudal end of the
point destined to become the tubal ostium. The mesonephros and enters the genital cord. The
blindend of the ducts then grows caudally inthe two ducts come intoclose apposition and reach
ridge as solidrod of cells. As the ducts lengthen, the S dorsal wall of the urogenital sinus. The
two blind ends of the ducts produce an
they acquire lumen. The paramesonephric duct elevation on the urogenital sinus called
runs lateral to the mesonephric (Wolffian) duct Mullerian tubercle. Each paramesonephric
throughout the extent of the mesonephros (fig. duct at this stage consists of t vertical, cranial
2.1). and caudal parts with an intermediate
horizontal region (fig. 2.2a, b).
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EiH&rpofogy ofikefemale reproductive organs andcongenitalanomalies IS

|PpH| *> iv,.j
&mmm ' w* IMirwIMHPWWÿ

Normal
fusion and
One mullenan Canalisation
duct absent
Two mullerian

Normal
Uterus
Total failure
of fusion

Uterus Didelphys
+ Septate vagina

Figure 2.2a Development of Uterus and Fallopian tubes

from two mullerian ducts

Absent Mullerian
duct

i-t

Both Mullerian duct

are absent

Figure 2.2b Developmental anomalies from mullerian ducts

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The cranial part forms the Fallopian tube. The The urogenital sinus undergoes relative
caudal parts of the two paramesonephric ducts fuse shortening in a craniocaudal direction to form the
with each other to form the uterovaginal vestibule which opens on the surface through the
primordium. This gives rise to the lower part of the cleft betweenthe genital folds.
uterus. The dissolution of the septum between the
fused paramesonephric ducts leads to the
Development of the ovary
development of a single uterine fundus, cervix and
upper vagina. As this enlarges, it takes in the The development of the ovary begins from the
horizontal parts to form the fundus and most of the undifferentiated stage - the primitive gonad. The
uterus. The stroma of the endometrium and uterine primitive gonad is derived from (i) primordial cells;
musculature, myometrium, is developed from the (ii) mesoderm; and (iii) coelomic epithelium of the
surrounding mesoderm of the genital cord. The genital ridge. The primordial germ cells are first
glandular epithelium of the Fallopian tubes, uterus identified at the fourth week of intrauterine life in
and cervix is derived from the paramesonephric human embryos at the adjacent part of the yolk sac.
duct.
By migratory movement in the mesentery, they
The mesonephric ducts degenerate
come to lie on the medial sidfes of the mesonephric
progressively from 10 to 16 weeks in the female
ridges. This becomes the developmental site of the
fetus although vestigial remnants of the latter may
be noted in adults (Gartner's duct cyst, gonads. The formation of the gonads begins in the
Paroophoron, andEpoophoron). fifth week of intrauterine life by the appearance on
the medial side of the mesonephric ridges of an area
of thickened coelomic epithelium. The proliferation
Development of the vagina of this thickened epithelium and its subsequent
The site of a future hymenal orifice is marked early projection into the coelomic cavity results in the
in development by an epithelial proliferation formation of a gonadal ridge. The proliferating
(sinovaginal bulb), which arises from the dorsal epithelium forms the gonadal cords separated by
wall of the urogenital sinus in the region of the mesenchyme. The gonadal cords form the cortex
sinus tubercle. This proliferation extends while the mesenchyme forms the medulla. In the
gradually, andcranially as a solid anteroposteriorly female, the medulla regresses while the cortex is
flattened plate in the tubular mesodermal invaded by connectivetissue and vessels to form the
condensation of uterovaginal primordium. This stroma of the ovary.
eventually becomes the fibromuscular wall of the
The cranial part of the gonadal ridge becomes
vagina.
sterile and produces the suspensory ligament of the
The solid plate formed by the sinus proliferation
ovary. The middle of the gonadal ridge produces the
extends cranially and enlarges into a cylindrical
ovary while the caudal part also sterile is
structure and the central cells desquamate to form
the vaginallumen. The upper end of the vaginal incorporated inthe ovarian ligament (fig2.3).
plate enlarges and grows up into the mesoderm The oogonia are derived from the mitotic division
around the cervix to form the vaginal fornices. The of the primordial germ cells. The epithelial capsules
lower end of the vaginal plate enlarges and of these cells are derived from the proliferation of
invaginates the dorsal wall of the urogenital sinus the coelomic epithelium and are called the pre-
around the hymenal orifice, trapping a thin layer of granulosa cells.
mesoderm aroundthe orifice to form the hymen. The oogonia are incorporated into the cortical

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ÿMM
Embryology ofthefemale reproductive organs and congenitalanomalies .17. 1
—NHNNNMMhhH I
sex cords of the gonadal ridge. The first The ovary in early development is attached to
evidence of follicles is noted at about 20 the mesonephric fold by the mesovarium
weeks. At this time germ cells are surrounded (homologous with the mesorchium). It is also
by flattened cells (granulosa cells) derived attached to the ventral abdominal wall through
from cortical sex cords of coelomic the inguinal fold. The fibromuscular
epithelium and theca cells of mesenchymal gubernaculum also develops with the inguinal
origin. The oogonia enter the prophase of the
folds and gives rise to the round and ovarian
first mitotic division and are now called
ligament later. These two ligaments are
primary oocytes. It is estimated that at 20
homologous to the gubernaculum testis of the
weeks of intrauterine life, there are about five
male. The restricted descent of the ovary
million primary oocytes, but at birth they are
compared to the testi§ is attributable to these two
about two million and at seven years of age
there are only about 300,000 primordial
follicles.

Mesonephric

Germ

mesonephric
swelling
Genital ridge

"ÿCoelomic epithelium

f Mesonephric tubules

Germ cells-

Coelomic epithelium
(primitive germinal epithelium)

Degenerating
Mesonephric tubules
and
duct

Mesentery of
ovary
Primitive follicles

Figure 23 Development of the Ovary

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~t —HHH|
'
18 Obstetrics andGynaecology .=#
Mm

ligaments. above, into which the urethra and vagina open.

Development of the external genital organs
Clitoris
The appearance of the external genital area is the
same in males and females before the seventh
week of intrauterine life. At the seventh week, fjjjSI — •— Labjum
majus

there appears a surface elevation of the genital Vestibule

Labium
tubercle at the cranial end of the cloacal minus Posterior
membrane. The elevation lengthens to form the commissure

phallus. A longitudinal endodermal mass called Anus

the urethral plate develops with the phallus. This
plate grows forward from the wall of the cloaca Clitoris
Prepuce
and urogenital sinus towards the tip of phallus.
The lower part of the urethral plate makes contact -Urethra

with the ectoderm lining a median groove called Ducts of gland

of Skene
the primary urethral groove. This groove has
developed on the caudal surface of the phallus.
The raised margins of this groove are called —Labium
genitalfolds (fig.2.4). minus
Disintegration of the cells of the urethral *» Vagina
plate and contiguous endoderm occurs giving rise
Labium majus
to a definitive urethral groove. While these
changes are taking place, two labioscrotal ÿGreater vestibular
(genital) swellings appear on each side of the base Figure 2. 4 Develoment of the external genitalia
of the phallus. These folds extend caudally and
remain separated from the labioscrotal folds by
distinct grooves. The female phallus becomes the Congenital anomalies of the female genital tract
clitoris. The labioscrotal (genital) swellings
remain separated as labia majora and the genital 1. UterusandFallopiantubes
folds remain separated to form the labia minora. Many variations and combinations in
The perineal orifice of the urogenital sinus is development, fusion, canalisation can occur in
retained as the cleft between the labia minora the development of the uterus. Lack of
Genital
tubercle
_ development (agenesis), incomplete
development (hypoplasia), incomplete
Labial
swelling" canalisation (atresia), and completely separate
developments can occur. Anomalies of the
Urogential
membrane Urethral
Fallopian tube are uncommon. Aplasia or
fold atresia of the Fallopian tubes may accompany
Anal —
membrane r* —a*;**;. ;
uterine aplasia or atresia. Accessory ostia are
common, fig 2.5a, b show variations in
development of the uterus.

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ÿhhhhh
"
li ' i

Embryology ofthefemalereproduc&veorgam andcortgmitalwwmalies

mikm

2. Vagina
The common anomalies of the vagina include
(i) Imperforate hymen - this occurs at the site of
the vaginal plate in its contact with the
urogenital sinus; (ii) Longitudinal and
transverse vaginal septaoccur at the upper and
A - Uterus arcuatus. Arcuate = curved like a bow or arched. middle third of the vagina; (iii) Vaginal atresia
B - Uterus subseptus
-
C Uterus Septus
- this represents a lack of canalisation at
cranial or caudal part of vaginal plate; (iv)
Double vagina - commonly associated with
complete separate development of the uterus in
uterus didelphys; (v) Vaginal agenesis - usually
represents a total absence of the vagina. When
associated with absence of the uterus and
t Fallopian tubes, it is called Rokitansky-Kuster-
Hauser syndrome.

.
3 Ovary
Congenital duplication or absence of ovarian
tissue may occur. Ovotestis with subsequent
Figure 2.5a intersex problems may occur as a result of
failure of the usual regression of the male
system during embryonic development.
Rudimentary streak ovaries are a common
feature of Turner's syndrome 45X0, a genetic
Uterus didelphys
chromosomaldisorder.

4. Externalgenitalorgans
The anomalies of the external organs are described
Double uterus
ingle vagina inthe chapter onIntersex.

Clinical presentation of congenital

anomalies of the female genital tract.
The symptoms associated with female genital
tract anomalies are quite variable. Imperforate
Bicornuate hymen, vaginal hypoplasia/atresia, may
Uterus
present with primary amenorrhoea,
dyspareunia, dysmenorrhea, and cyclic pelvic
painand inability to achieve penile penetration.
Fusionand canalisation anomalies of the uterus
Figure 2.5b Variations in the development of the uterus may present with irregular vaginal bleeding,

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20 Obstetrics and Gynaecology

infertility/subfertility, habitual abortion, vaginal septum. Plastic operations (metroplasty,

premature labour and postpartum vaginoplasty) are done for uterine and vaginal
haemorrhage. anomalies. Plastic operations are also done for
Physical examination usually reveals a vaginal ambiguous genitalia.
mass (haematocolpos), abdominal mass
(haematometra), absent uterus and cervix, Bibliography and suggested further
absent or short vagina and ambiguous genitalia. reading
Inobstetrics, fetal malpresentationandretained
placenta are common findings. Bloom M.L., Dongen L.v. (1972). Clinical Gynaecology:
Hysterosalpingography, ultrasonography, Integration of Structure and Function. Williams
hysteroscopy and laparoscopy are very useful Heinemann MedicalbooksLtd.London.
diagnostic tools.
GovanA.D.T., Hodge C., Gallander R. (1985).
Gynaecology illustrated. Churchill Livingstone 3rd ed.
Treatment pp. 3-9.

The treatment depends on the type of anomaly and Warwick R, Williams P.L eds (1978). Gray s Anatomy.
the presentation. Simple excision can be done for WB Saunders. London.

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sinnpi
lUMWi
Chapter 3 : 1ÿ , "S- '' t <$&4

Physiology of the female genital organs

ÿ
»tSJ# • ÿH

Introduction arrives at the pituitary gland in the blood and

produces the release of follicle stimulating
The hormones produced by the hypothalamus, hormone (FSH) and luteinising hormone (LH)
pituitary and ovaries interact in the control of while prolactin inhibiting hormone (PIH)
the menstrual cycle. These hormones also act produced by the hypothalamus regulate the
on the uterus and produce the cyclical
secretion of prolactin from the pituitary gland.
menstruation in the female. This chapter GnRH is normally secreted in episodic burst and
describes the physiological mechanism its secretion is controlled mainly by oestrogen
involved in the regulation of the normal and progesterone and to a lesser extent by FSH
menstrual cycle and provides a basis for and LH through a complex system of feedback
understanding the diagnosis and management mechanism.
of the gynaecological patient presenting with
abnormal menstrual function.
Pituitary
In discussing the physiology of the female
genital organs, the hormones produced by the The anterior pituitary produces gonadotropins
hypothalamus, pituitary and ovaries would be and prolactin under the hypothalamic control,
discussed as well as the interplay of these while the two major hormones of the posterior
hormones and their roles in puberty, menstrual pituitary are oxytocin and vasopressin.
cycle and menopause.
Hypothalamus Gonadotropins
The hypothalamus is that part of the FSH and LH are the two gonadotropins. They
diencephalons lying at the base of the brainand are glycoproteins and are very similar in structure
forming the floor of the third ventricle and part to thyroid stimulating hormone (TSH) and
of the lateralwalls. The hypothalamus provides humanchorionic gonadotropins (HCG).
an important link between the central nervous FSH is responsible for the early maturation of the
system and the pituitary gland. This link is ovarian follicles and FSH and LH together are
important inthe control of the menstrual cycle. responsible for their final maturation. FSH and
The hypothalamus contains special cells, LH are found in the blood stream throughout life
neuroendocrine cells which secrete neuro including fetal life. During the first half of
hormoneswhich are transported to the pituitary pregnancy, very high levels of gonadotrophins
gland through a portal vessel system are present in the fetus and they probably
(hypothalamus-pituitary capillary system). stimulate the huge proliferation of oogonia
The peptides and bioamines observed inthe fetus during this stage. The levels
(neurotransmitters) produced by the however subsequently fall quite low as the fetal
hypothalamus can be either stimulatory or hypothalamus appears to become sensitive to the
inhibitory with respect to individual pituitary negative feedback by placental oestrogen. After
hormones. delivery, removal of the placental oestrogen
Gonadotrophin releasing hormone (GnRH) is a causes the level of gonadotrophins in the baby to
decapeptideproducedby the hypothalamus and be elevated. This however fads over the
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ÿMggpÿgeepÿpÿ|ppp!||Pi|ÿ||ÿr#ÿ
ÿ 22 Obstetrics andGynaecology

next four years probably due to increasing Oestrogens and progesterone.

hypothalamic sensitivity to negative feedback.
The gonadotropins gradually rise again after
about the age of8 years but the mechanism of this Biosynthesis of steroid hormones
is unknown. This is followed by a gradual rise in
The pathway for production of steroids by steroid
oestrogen from the stimulated ovarian follicles
and this leads to the first menstruation. At
producing endocrine organs is similar and is
shown in fig 3.1. The human ovary produces all
menopause, oestrogen deficiency caused by
three classes of sex steroids viz oestrogens,
depletion of ovarian primordial follicles leads to
progesterone, and androgens. Unlike the adrenal
very highgonadotropin levels.
gland, the normalovarian tissue does not produce
corticosteroids and mineralocorticoids because it
Prolactin is deficient of two enzymes viz 21-hydroxylase
Prolactin structurally resembles growth hormone and II (3 hydroxylase. Acetate is converted into
and human placental lactogen. It is a polypeptide cholesterol. Cholesterol is converted into
inthe form of a single long chain. Prolactin is the pregnenolone. This takes place in the
only trophic 'hormone of the anterior pituitary mitochondria and involves initial hydroxylation
at carbon 20 and 22 positions by 20-hydroxylase
that is controlled mainly by inhibition from the
hypothalamus. The others are controlled mainly and 22-hydroxylase enzymes. LH is the principal
by a release. Prolactin seems to be essential for hormone taking part in this reaction. From this
point, pregnenolone can continue in one of two
normal follicular steroidogenesis, particularly in
the corpus luteum.Very low levels of prolactin do pathways (i) Aÿ- pathwayproceeds to 17-hydroxy
pregnenolone and then to
not interfere with gonadotrophin excretion but
high levels, a condition called dehydroepiandrosterone (ii) A4 pathway
hyperprolactinaemia, inhibit ovarian function proceeds through progesterone to 17<*-
and can cause anovulatory infertility. This is hydroxyprogesterone.Thel7»c-
because excess prolactinblocks gonadal response hydroxyprogesterone and
to gonadotrophins and also interferes with the
dehydroepiandrosterone can be converted to the
control of gonadotrophin excretion. Prolactin is C-19 steroids, androstenedione and testosterone.
These C-19 steroids are converted to C-18
the stimulus for normal lactation and
galactorrhoea is a common symptom of steroids, (oestrogens) by a process of
aromatisation.
hyperprolactinaemia.
The follicle within the ovary is the site of
steroidogenesis. Two cell layers inthe follicle viz.
Ovary theca and granulosa cell layers under the
influence of LH and FSH respectively are largely
The two main functions of the ovary are (i) responsible for production of androgens and
gametogenesis, (the production of haploid female oestrogens. The two-cell theory states that
gametes) for periodic, cyclical release into a production of androgens and oestrogens is
hormonally primed reproductive tract and (ii) compartmentalised in the two cell types of the
steroidogenesis (synthesising steroid hormones). ovarian follicle. Androgens are produced in the
Provided that the two processes (gametogenesis theca cell layers under the influence of LH. The
and steroidogenesis) are in phase, the ovaries androgens so produced must diffuse into the
provide optimal conditions for fertilisation, granulosa ceil layer where aromatisation occurs
implantation and maintenance of pregnancy. The converting the androgens into oestrogens.
two main hormones produced by the ovary are Oestrogens produced inthe granulosa layer then
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ÿH

Physiology ofthefmtaleÿahtdorgans
ÿ BHHH
return through the theca cell layer into the Oestrogen
peripheral bloodvessels. There are three naturally occurring
The level of oestrogen, produced as a oestrogens, which are oestradioI17p, oestrone
result of the co-operative effort of the theca and and oestriol (Fig 3.1). They are C-18 steroids
granulosa cells, provides the most important and are
signal inthe control of the menstrual cycle.

Cholesterol

P450 sec

ck3 Pregnenolone
c«3 A4
C-0 C-0 Pathway
°H
I Pathway
* o
17-Hydroxypregnenolone
Progresterone

\ C«3
C -0
OH

HO
Dehydropiandrosterone 17-Hydroxypregnenolone

Androstenedione Testosterone
Aromatase

Estrone (E,)
I 17P Estradiol (Ej)
16-Ketoestrone
$
16a - Hydroxyestrone OH ÿ

OH
...J

MO
Or
Estriol Figure 3.1 Biosynthetic pathway for production of steroids

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30 Obstetrics andGynaecology

include inheritance, nutrition, rural living, high period. These changes are modified by the
altitudes, i.e colder climates and other severe different cultural patterns. They manifest as
teenage "teething" problems that include
diseases such as diabetes mellitus, obesity and
hetero-sexual inclinations and attractions,
blindness.
crave for freedom and independence from
parents, conflicts at home and sometimes a very
Development of secondary sex characteristics volatile mood.
Breasts: the development of breasts starts on the
average at about the age of 10 years but the Delayed puberty
range is between 9 and 11 years. It takes up to 5 This is a failure of development of all the secondary
years at most to complete. Its development is sexual characteristics including menarche. This
usually described in 5 stages after Marshall and is a rare condition in girls and when it occurs,
Tanner viz. (i) elevation of papilla only (ii) genetic disorder or hypothalamic-pituitary
breast budding (iii) enlargement of breast with disorder must be suspected. Anatomic
glandular tissue without separation of contour abnormalities of the genital organs viz. uterus,
(iv) secondary mound formed by areola (v) cervix, vagina should be ruled out. Primary
single contour of breast and areola. hypothalamic failure may be temporary as in
Pubic and axillary hair growth: the true delayed puberty that will invariably
average age of this event is about 12 years with a resolve spontaneously or it may be permanent
range between 10 and 13 years. It is also as in Kallman's syndrome that is associated
described in 5 stages after Marshalland Tanner with impaired sense of smell (hyposmia).
viz (i) no pubic hair (ii) labial hair present (ill) Primary pituitary failure is rare and the
labial hair spreads over mons pubis (iv) slight possibility of a pituitary tumour or a
craniopharyngioma compressing the pituitary
lateral spread (v) further lateral spread to form
or its stalk must be considered. Primary ovarian
inverse triangle and reachmedial thighs. failure due to ovarian dysgenesis as in Turner's
Distribution of fat: there is deposition of syndrome where the ovaries are mere streaks of
fat in certain areas such as the hips, the thighs, fibrous tissue without any follicle is not
genital regionandbeneaththebreast. uncommon. Delayed menarche is failure to
Cutaneous gland development: axillary and menstruate at age of 16 years. When it is not
pubic apocrine glands begin to function at associated with delay in other pubertal
approximately the same time as the pubic and development, and secondary sexual
axillary hairs appear causing characteristic development is normal, the cause may be an
change inbody odour. imperforate hymen or atresia of vagina or
Acceleration of body growth: growth cervix resulting in cryptomenorrhoea.
spurt occurs in girls about 2 years earlier than in Sometimes a minor endocrine disorder of the
boys. The average girl reaches her growth peak hypothalamic-pituitary ovarian axis may be
about 2 years after breast budding and 1 year responsible. Testicular feminisation (Androgen
prior to menarche. The average height at insensitivity syndrome) may present as delayed
menarche is 160cm. with a range between 153 menarche.
and 167cm. Precocious puberty
Emotional and psychological changes:
behaviouralattitudes are greatly modified at the This is defined as the onset of secondary sexual
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« , jj$$$ f
I&jsisfogpefikeXemalegenitalorgans 31
iMWliWto» lilii§?iiltoi e jf&Ji

and hypothalamus leading to secretion of

characteristics (appearance of breast
development or pubic hair) before the age of 8 large amounts of FSH and LH. These hormones
appear in blood and measurement of them can
years or menarche occurring before the age of 9
be used to confirm menopause or the
years. Two main varieties of precocious
puberty may occur. In one, true or climacteric period. Serum levels of over
constitutional sexual precocity, hormones are 40iullitre are diagnostic. Apart from the fact
that there is still some oestrogen production by
secreted by maturing gonads (gonadotrophins
from ectopic sites or cerebral tumours). In the
the ovary after menopause, oestrone is also
other, precocious pseudopuberty, maturing
produced by peripheral conversion in fat tissue
normal gonads are not the source of the sex from adrenocortical and ovarian androgens
steroids (increased sex steroids from ovarian precursors, especially androstenedione. This is
why obese women after menopause have more
tumours, adrenal feminising and masculinising
oestrogen than thin women and are therefore at
tumours andtesticular tumours).
greater risk of developing endometrial
The treatment will depend on the
underlying cause identified. Danazol, carcinoma.
The fall in oestrogen production causes
cyproterone acetate, medroxyprogesterone
various local and systemic effects known as
acetate (DMPA), and GnRH agonists have been
symptoms and signs of menopause. When
found to be effective in the treatment of central
severe, these manifestations are considered
true precocious puberty.
abnormal and require treatment.
Menopause
This is the permanent cessation of menstruation Effects and complications of menopause
due to failure of ovarian follicle development Vasomotor changes: these manifest as
Climacteric is the physiological period in a sensation of warmth which occurs on the trunk
woman's life during which there is a regression and spreads to the face. These are known as hot
of ovarian function. The age of menopause flushes' and are usually accompanied by
varies from country to country and is sweating and palpitation. The exact cause is
genetically predetermined. In Nigeria, the unknown, but it is suggested that a
mean age of menopause is 48 years plus or hypothalamic disturbance leads to the
minus 5 years andthe range is between 43 years vasomotor response associated with a burst of
and 53 years. LH secretions. They are usually suppressed by
Menstrual periods seldom stop oestrogen or progesterone .
suddenly, what is more often the case is that the
cycle first becomes irregular and then gradually Musculoskeletal changes: the lack of
lengthens before it stops. In practice oestrogen results in increased bone resorption.
recognition of menopause requires six months associated with increased calcium excretion
absence of menstruation. and collagen loss. Loss of bone particularly
from the vertebrae causes a reduction in height
Physiology' of menopause with forward bending and kyphosis in extreme
As a woman approaches menopause, the cases. There is an increased incidence of
ovaries become depleted of oocytes resulting in fractures due to osteoporosis especially that of
circulating oestrogen falling to low levels. This the neck of the femur and the distal end of the
results in diminished negative feedback effect radius. Ligaments lose their elasticity and loss
of ovarian oestrogen and progesterone on the of collagen leads to degenerative changes in the
anterior pituitary joints known as osteoarthritis.
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Cardiovascular changes: atherosclerotic vasomotor symptoms, urogenital atrophy,

changes gradually occur due to a progressive osteoporosis and coronary heart disease. HRT
increase in the plasma concentration of
cholesterol, low and very low density will produce improvement in sexual response,
lipoproteins so that the mortality rate from mood, sleep and memory. The advantage of
ischaemic heart disease comes to equal that of giving HRT must be balanced against the risks.
men.
Unopposed oestrogen therapy increases the risk
Urogenital tract changes: the cervix and of endometrial cancer, which can be reduced by
vaginal epithelium undergo atrophic changes, the addition of cyclical progesterone. This
resulting in thinning and dryness. The pH rises cyclical treatment might cause withdrawal
to about 7.2 compared to 4.5 inthe reproductive bleeding.
years because of the absence of glycogen for
Doderlein'sbacilli to convert to lactic acid.This Premature menopause
produces susceptibility to infection and This is cessation of menstrual bleeding before
atrophic vaginitis. The transitional epithelium age 35 to 40 years. It is due to primary ovarian
of the bladder trigone undergoes atrophy, so
failure but other causes of secondary
also the urethra.
amenorrhoea including pregnancy must be
Emotional and psychological changes: these ruled out. The cause of premature menopause is
include depression, insomnia, loss of libido, unknown but it may be due to either excessive
headaches, general aches and pains, irritability, and early depletion of primordial follicles or
lassitude and palpitations. The three phases of deficiency of the original number.
psychological adjustment to the menopause are Excessive exposures to ionizing radiation or
(i) period of impact (ii) period of recoil and (iii) surgical operations that impair ovarian blood
period of adjustment. supply are other causative factors.

Skin changes: the epidermis thins Bibliography and suggested further

progressively and sebaceous and sweat glands
reading
functions also decline. This leads to the skin
becoming dry and easily traumatised. Ganong W.E (1999). Review ofMedicalPhysiology. 19th
ed. Lange Medical Publications, LosAltos.

supravaginal cervix, if it is well supported by
*

phase, or a large detrusor pressure rise may be the ligaments, may become elongated as a result
observed whenthe woman stands up. of constant downward traction by the lower
cervix and vaginal vault when these have
prolapsed.
Differential diagnosis
Uterine or vaginal prolapse should be Urinary tract disease: incomplete emptying of
distinguished from the following: the bladder may occur in case of a large
Cervical polyp. cystocele. Urinary stasis with consequent
Vaginal cyst. infection may follow. The end result may thus
Hypertrophy or elongation of the cervix. be pyelonephritis. In procidentia, the ureteric
anatomy may be distorted causing some degree
In all these conditions, a careful vaginal
of ureteric obstruction which may be severe
examination will be of great help inarriving at a enough to cause urinary backflow and
correct diagnosis. eventually hydroureter and hydronephrosis.

Complications
The following complications may be associated Carcinoma of the cervix: this is mentioned in
some textbooks as a possibility but in a few
with uterovaginal prolapse: keratinisation of
cases of procidentia seen with decubital
the vagina. This is due to exposure of the ulceration, none of them developed into
vaginal epithelium which subsequently carcinoma. This complication seems to be rare
becomes thickened. inour community.
Decubital ulceration: this may complicate
Treatment
procidentia when the prolapsed cervix become Management of uterovaginal prolapse may be
ulcerated as a result of friction with the underpants palliative or curative.
and the thigh although it has also been postulated
Palliative
The use of ring pessary as palliative measure
has now become very limited. Itmay sometimes
be used during pregnancy to hold up a
troublesome prolapsed uterus in the first
trimester, or in very old women who may
decline operation or be deemed to be poor
operative risks.
Physiotherapy exercises are sometimes
employed for cases of first degree uterovaginal
prolapse. To provide a permanent cure, an
operative procedure is mandatory. The
operations commonly performed are:
Figure 43 Uterovaginal prolapse showing decubital ulcer Anterior colporrhaphy: this is for the treatment
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ÿ

Urogenitalprolapse anddisplacement ofthe uterus 37

for a second degree uterovaginal prolapse if it is

of a cystocele or urethrocele. The basic necessary to remove the uterus at the same time.
principles of this procedure include the In this operation, hysterectomy is combined
dissection of the anterior vaginal wall to free it with anterior colporrhaphy and posterior
from the bladder, bladder neck and urethra, colpoperineorrhaphy.
excision of redundant vaginal skin, separation The abdominal approach is sometimes
of the bladder from the ureters, upward employed to repair uterovaginal prolapse. In
displacement of the bladder and insertion of this technique, a Merselene tape is fixed on the
supporting stitches through the pubocervical posterior surface of the uterus and anchored to
fascia. The vaginal wall isthenreconstructed. the anterior longitudinal ligament over the
Posterior colpoperineorrhaphy: this is the sacral promontory. The method is relatively
operation for the cure of rectocele together with simple and it has the advantage that the
any perineal deficiency. Triangular incisions Merselene tape is inert, stong, flexible and
are made through the vaginal and perineal skin remains retroperitoneal.
with the base at the introitus, and the posterior Sometimes the method described is combined
vaginal wall is dissected away from the rectum. with a Burch retropubic urethropexy. In the
A strip of the redundant vaginal epithelium is presence of an enterocele, resection of the
excised, and the underlying rectovaginal fascia is peritoneum of the pouch of Douglas is carried
supported with some stitches. The levatores ani out and repair of the levator ani performed.
are then stitched together followed by This abdominal technique isalso quite adequate
reconstruction of the vaginal wall and perineal for a recurrent genital prolapse.
skin. The aim of any of these procedures is to restore
Nowadays, this procedure is rarely done alone. anatomical structures and maintain sexual
It is normally done as part of Fothergill or function.
Manchester operation or vaginal hysterectomy. Post-operativecomplications
Forthergill or Manchester operation: this The following complications may occur
procedureincorporates anterior colporrhaphy, following colporrhaphy or
posterior colpoperineorrhaphy and amputation colpoperineorrhaphy:
of the cervix. In addition, the cut cardinal 1.Dyspareunia, due to shortening of the vagina
ligaments are approximated in front of the and introitus. Some gynaecologists prefer to do
amputated cervix thus tightening them and just a minimum posterior colpoperineorrhaphy
anteverting the uterus. The cervix is also pulled to avoidthis complication.
upward and backward by this process. If an 2. Delay in second stage of labour ifthe woman
enterocele is present, the pouch of Douglas is becomes pregnant subsequently. This is
opened, the hernia sac isreduced andthe excess invariably due to scar tissue formation in the
peritoneum excised. The pouch is then closed vagina. Complications of Manchester repair
and supporting stitches placed to approximate resulting directly from amputation of cervix
the uterosacral ligaments in the midline to include: infertility.
prevent further herniation. abortion
premature labour
Vaginal hysterectomy and pelvic floor repair: cervical dystocia or rigidity
this is the ideal operation for procidentia in a precipitate labour
postmenopausal woman. It may also be carried out intrapartumand postpartumhaemorrhage.

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Some of these complications are due to high and backward and the body of the uterus is
level of amputation of the cervix while others again felt through the posterior fornix instead
may be due to fibrosis formation. The of the anterior fornix. The two conditions of
explanation for infertility isunclear but may be retroversionand retroflexion may coexist in an
partly psychological and partly as a result of individual (fig.4.4).
post operative ascending infection causing
tubal blockage.
Opinion is divided about the mode of delivery
of a woman who becomes pregnant after a
Manchester repair or colporrhaphy operation.
While one school of thought will perform an
elective caesarean section, the other advocates
vaginal delivery but with a generous
episiotomy.
Prognosis
The prognosis after operative cure is
satisfactory although recurrence of the prolapse
may sometimes be seen mostly due to poor
operative technique. There may also be failure
to cure any associated stress incontinence either
due to poor operative technique or because its
aetiology is more of detrusor instability.
Displacement of the uterus
The uterus may be displaced in the following
directions:
Figure 4.4 Displacement of the uterus fqj Anteversion
forward
Normal(b) Retroversion (c) Retroflexion
backward
upward
Incidence: A normal uterus is anteverted and
lateral
The aetiological factors include pelvic anteflexed but it is not necessarily abnormal to
tumours, pelvic haematocele especially in have a retrovertedand retroflexed uterus. Infact,
chronic ectopic pregnancy, pelvic adhesions it is said that about 15 percent of normal
and idiopathic. The history is usually that of the individuals have retroverted uterus. This is
primary cause. The type of displacement is felt probably correct inour community as well.
at bimanualexamination.
No investigation is required. The treatment is 'Types: The following types have been
that of the primary cause. described:- Developmental: when retroversion
Retroversion and retroflexion of the uterus is present in a nulliparous woman and has been
In a retroverted uterus, the cervix points the case all her life.
downward and forward and the body of the Acquired: this is fairly common in our
uterus is felt through -the posterior fornix environment mostly as a result of pelvic
instead of anterior fornix. However, in a adhesions which may be postoperative or
retroflexeduterus, the cervix points downward following pelvic inflammatory disease.

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Puerperal: this occurs inthe puerperium when of the bladder leading to acute retention of
the uterine supports are relaxed. After the urine. The clinical symptoms include a history
puerperium, the uterus may return to its of inability to pass urine in a woman who is
anteverted state. about three months pregnant, and sometimes
Clinical symptoms: A number of symptoms acute abdominal pain.
havebeenascribedto retroversion. Clinical examination will reveal a central cystic
These include dysmenorrhoea, backache, lower abdominal mass that is arising from the
dyspareunia, and infertility. It is, however, pelvis, and which is the overdistended bladder.
debatable whether most of these symptoms are Pelvic examination will confirm a retroverted
due to retroverteduterus per se. gravid uterus with the cervix displaced behind
Clinical signs: On bimanual examination, the the pubic symphysis.
body of the uterus is felt through the posterior
fornix while the cervix points forward and The treatment is to catheterise the patient and
downward in a retroverted uterus. The cervix leave the catheter indwelling for a couple of
however points backward and downward in a days untilthe uterus corrects itself. The woman
retroflexeduterus. is also encouraged to lie down or sleep in the
Management: Inthe past, the use of Hodge type Sims' or lateral position during this period.
of pessary to correct retroversion was quite
popular. Its popularity is however diminishing
in our practice in Nigeria probably because Inversion ofthe uterus
many cases of fixed retroversion are
encounteredand correction cannot beachieved
by pessary.
Correction of retroversion bimanually under
general anaesthesia also no longer enjoys
popularity.
Operative procedures like Gilliam's operation
or ventrosuspension when the round ligaments
are shortened by plication have virtually been
abandonedbecause of their uselessness. Infact,
within two years of this operation, the uterus
may be observed to have fallen back to its Figure4.5 Different degrees of inversionofthe uterus
previous retroverted state as the round
ligaments become stretched with time. Inversion of the uterus may be acute or chronic
Some gynaecologists have however, continued (fig. 4.5).
to practise a modificationof this operation. The acute type is an obstetrical emergency
Retrovertedgravid uterus problem which may follow badly managed third
If a pregnant woman is found to have a stage of labourwhen the placenta is delivered by
retroverted uterus early in pregnancy, no fundal pressure or traction of the umbilicalcord.
problem is usually envisaged because the The treatment has always been to transfuse
uterus normally corrects itself by the tenth blood adequately and reduce the inversion
week of pregnancy. However, it may manually under general anaesthesia.
occasionally happen that the uterus may fail to
correct itself even by the twelfth week of The chronic type may occur during or after the
pregnancy and may become impacted in the puerperium. There may be a history of shock
pelvis. The end result is displacement

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r-
B 48 Obstetrics and Gynaecology

following the last delivery. The woman may

complain of vaginal discharge or irregular Bibliography and suggested further
vaginal bleeding since last delivery. The reading
treatment is first to treat the infection andthen
Bami, L.E (1997). Synthetic slingfor genital Prolapse in
carry out an operative procedure by dividing Young Women. Int.J. Gynaecol. Obstet 1:57.
the constricting ring of the cervix and
replacing the fundus of the uterus. The two Cardozo, L. (1981) "The use of cystometry in the
operations that are usually employed are understanding of urinary incontinence" Progress in
Obstetrics and Gynaecology, Vol. 1, 151. Studd, J. ed,
Haultain's (abdominal approach) and Churchill Livingstone,Edinburgh.
Spinelli's (vaginal approach). Hysterectomy
could also be done if there is no desire for
further chiidbearing. Inversion of the uterus Hughes, P.N., Jackson, S.R. (2000). The Scientific Basis
has become a rare event. This may be ofProlapse. InThe Obstetrician andGynaecologist!: 10.
attributed to improved standard of obstetric
practice inour urban environment. Lecuru, E, Taurelle R., Clouard C., Attal J.R (1944).
Surgical treatment ofgenito-urinary prolapses by
Abdominal Approach. Ann. Chir. 11: 1013.

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er 5

istulae
A fistula is defined as a pathological deliveries. VVF is found in all parts of Nigeria
communicationbetween two epithelial surfaces but the prevalence is more in the North-West,
or cavities. The commonest fistulae seen in NorthEast, North-Central, South-East and
gynaecology are Vesicovaginal fistula (VVF), South-South geopolitical zones. Inthese zones,
Rectovaginal fistula (RVF) and Ureterovaginal there are dedicated centres that do between 500
fistula (UVF) in which there is connection and 1500WF surgeries per annum.
betweenthe vagina and the bladder, rectum and
vagina, ureter and vagina respectively. The Aetiology: The commonest cause of WF in
other less common ones are enterovesical, Nigeria is obstetric trauma from prolonged
obstructed labour due to cephalopelvic
enterouterine (connection between the bowel
disproportion (Table 5.1). Rupture of the uterus
and the bladder or the uterus); vesicoperineal,
may sometimes be associated with a tear in the
vesicocutaneous (connection between the bladder. This occurs if the bladder is adherent to
bladder and the perineum or anterior abdominal a previous caesarean section scar. During the
wall). course of repair of a ruptured uterus, the bladder
may be caught in the sutures causing a fistula.
Vesicovaginal fistula (VVF) The bladder may be injured during a caesarean
This is the commonest type of fistula found in hysterectomy. The bladder can also be injured
gynaecological practice in developing during operative vaginal deliveries (forceps
countries. delivery especially Kiellands and destructive
operations especially craniotomy). The
Incidence: The real incidence of this condition operation of symphysiotomy cancause injury to
is not known but available health facility data the bladder. The bladder may also be injured
show an estimate of between 400,000 and during a caesarean section.
800,000 cases with an annual incidence of 4 per Femalegemtalcuttingsarecommontraditional
1000 practices among many communities inNigeria.
These include clitorectomies and other forms of
female circumcisions, "yankan gishiri or
angurya". The latter involves the incision of the
vaginal walls. These incisions are commonly
done in obstructed labour in the hope that the
incisionwould enlarge thebirthcanals.
Other non-obstetric surgical operations such as
pelvic floor repair, abdominal or vaginal
hysterectomies could also be complicated by
vaginal injuries that can lead to fistula
formation.
Cancers of the genital tract, bladder and
rectum can result into fistulae when advanced. So is
irradiationnecrosis from the treatment of carcinoma
Figure 5.1 They come in their numbers

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mam HHll
Mi /-

of the cervix with radium or caesium. Other rare the pubic bones.Acertain amount of bruising of
causes of WF include congenital occurrence, the bladder is quite normal in labour especially
coital injuries (common with young adolescent around the bladder neck. When however,
prolonged labour occurs in the presence of
marriages), penetrating vaginal injuries, pelvic
cephalopelvic disproportion it is these same
fractures from road traffic accidents and
areas that get compressed over a long period
packing the vagina with caustic salts. Others
between the fetal skull and the pubic bones in
include infections, notably lymphopathia front; or the fetal skull and the sacral bone
venereum, which may cause incontinence of behind with resultant pressure necrosis on the
urine. During vulval ulceration associated with pelvic soft tissues. The presence of unrelieved
lymphopathia, the urethra may be amputated full bladder makes the situation more
down to its junction with the bladder leaving a precarious as the urine inthe bladder also exerts
WF. a hydrostatic pressure on the bladder wall. The
sum of pressure from the pelvic bone, fetal bone
Aetiologicai factors No of patients % and the hydrostatic pressure from urine
compromises the intervening soft tissues of the
Obstetric traumas (a) 781 83.8 pelvis. This results in tissue devitalisation with
Surgical traumas 92 9.9 tissue necrosis. The necrosed area usually
sloughs off between 3 and 10 days of the
Female Genital cutting
puerperium resulting inurinary incontinence. If
(yankan gishiri, etc) 47 5.0 the pressure has been severe enough, part of the
rectovaginal septum may also slough off
Genital cancers 8 0.9 resulting in rectovaginal fistula. The latter is as
Trauma (b) 4 0.4 a result of the recto vaginal septum being
wedged between the fetal skull and anterior
surface of the upper part of the sacrum
Total 932 100.0 especially the promontory. It is not uncommon
Table S.l Aetiologicai factors of fistulae in patients seen at to see the entire vagina and the levator ani
the EvangelWF Centre
muscle devitalised inthe injury. The devitalised
Pathology tissue heals by secondary intentionwith various
degrees of scarring. F severe cases, this may
The commonest cause of genital fistula is tissue
necrosis following obstructedlabour.This is similar
manifest in form of vaginal atresia, stenosis, or
in pathophysiology to pressure necrosis as seen in tough fibrous band in the vagina especially
bed sore. Inobstetric injury complex, the injury may posteriorly where severe devitalisation might
involve the lower urinary tract, the genital tract, the have taken place. Severe stricture of the vagina
anorectal tract and the pelvic floor muscle, hence or urethra or rectum or all the three structures
injury involves a larger areaof tissues and strictures commonly occurs. Destruction of the urethra is
thanjust the holethat is seen. Ingenital fistulae as a not uncommon. This may be so severe that only
result of surgical complications, the injury is focal a stump of urethra is left. This often leads to
and there is not much involvement of the stress incontinence even when the fistula has
Surrounding tissues and structures. been closed.
During labour, the bladder is normally displaced
upwards bringing the bladder base and bladder neck Classification of genital fistulae
to lie between the fetal head and the back of ITiecriteria usedinthe classificationof genital

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fistulae include the site of the fistula, degree of

scarring and the extent of damage to
neighbouring structures like the ureter, urethra,
and anal sphincter. The determinants of
prognosis are the degree of scarring and the
extent of damage to the bladderneck.
Vesicovaginal fistulae are classified as
(i) Juxtaurethral, when the fistula is near the
urethra or involves the urethra (ii) Mid-
vaginal, when it is limited to the mid-vagina
and the underlying bladder (iii) Juxta-
cervical, when it is near the cervix or involves
die cervix, (iv) Large or massive, when there
is a .coalition of these demarcations (v)
Circumferential juxta-urethral when the
urethra is amputated from the bladder (vi)
Vault, when it occurs after a hysterectomy and
involvesthe vault of the vagina andthe bladder.

*Juxtacervical
ÿ Midvaginal fistula
ÿJuxtaurethral fistula
Uterus

bladder

fistula # Highrectovaginal fistula

ow rectovaginal fistula

Figure 5.2 Diagram of the female pelvis sagittal view

to show types of fistulae
[irVT

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u
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mm
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iraliaFg'
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Bg,. j

'• / \
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*
ÿJ3Bi

uimJiiiRÿss«assf'_iS
v

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m

5.4 Shows a Midvaginal fistula

Ay"-
:

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ÿ

Figure 5.5 Shows a large vesicovaginal

total urethral destruction

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m
•

Figure 5.3 Demonstrates double fistulae

with
m
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.
Fistulae 43

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Rectovaginal fistulae (RVE) are There may be tenderness in the renal

classified as (i) High, when it is in the upper
ÿ

angles if pyelonephritis has supervened.

half of the vagina (iij Low, when it is in the Abdominal examination may reveal a previous
lower half of the vagina, (iii) Third degree
perineal tear, when there is a tear of the anal lower abdominal scar suggestive of previous
sphincter andthe rectum and (iv) Large,when abdominal deliveries. There may also be lower
greater than half of the posterior vaginal wall abdominal masses suggestive of pregnancy,
and underlying rectum are involved. Difficult urinary retention, and tumour or stone. Lower
fistulae are the ones where there is severe
degree ÿof scarring or the ureters open at the abdominal pain and/or tenderness in fistula
edge of the fistula or the ureter is amputated patients often suggest bladder stone. The lower
from the bladder. These fistulae usually have limbs may be wasted or the deformity may be
poor prognosis in terms of post fistula limited just to foot drop involving one or both
continence. feet.
Genital fistulae are also classified On pelvic examination, the vulva is
according to size: small, when less than 2cm. usually wet with urine and vulval excoriation
medium when 23 cm. large when 4-5 cm and may be present if the patient's standard of
extensive when 6 cm or greater. The size of the hygiene is lost. The urethra may be split (in
fistula is not a factor for determining good Gishiri type fistula) or missing in cases of severe
prognosis. . tissue destruction. The vagina may be stenosed
for which reason it is advisable to precede
Clinicalhistory speculum examination by a digital examination
The typical clinical history is that of total as this not only allows for easy location of the
incontinence soon after prolonged obstructed fistula but also enables the examiner to
labour, usually of the first pregnancy. The determine the size of speculum (usually a Sims')
delivery is often spontaneous but in a few that could be most suitable without hurting the
cases, there is a history of operative vaginal patient. The examination will also allow for the
delivery or caesarean section. The fetus is palpation of the bladder for stones, absence or
usually stillborn or dies during the neonatal presence of the cervix and uterus and pelvic
period. There may be a history of previous masses. Speculum examination inthe left lateral
gynaecological operations such as position helps to expose the fistula and the size,
hysterectomy or pelvic floor repair or incision site and accessibility are determined. An
of the vagina by traditional birth attendants. examination of the posterior vaginal wall may
Some may complain of secondary reveal a co-exising rectovaginal fistula though it
amenorrhoea and pain or weakness in the is more easily diagnosed by a rectal
lower limbs. . examination.

Clinical findings Investigations

On examination, the patient is usually an These should start with the haemcgram and
unkempt, miserable looking, often depressed, retroviral screening to determine haemoglobin
young woman, smelling strongly of urine. level and HIV status. Serum urea and electrolyte
Malnutrition may be evident but anaemia is are determined as a way of testing renal
not usually a feature. Some of the patients function. A urine specimen (by catheter in small
present in the middle age of life and so may be fistulae and by pipette in large fistulae) is
hypertensive. A cardiovascular system examined for pus cells and any organisms and
examination can help exclude high blood their sensitivity. Renal sonography and
pressure and irregular pulse. intravenous urogram may be useful

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r in ruling out the presence of

hydronephroureters as a result of ureteric
jV *-v :
"

J. ,
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U
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rx. 4 -
Fistulae

history of initial retention of urine that is later

45
:
vfU.
-•
.

*
:
-J.

•
>•

followed by incontinence. On examination, the

obstruction from pyelonephritis or impacted cause of retention such as pelvic tumour, pelvic
prolapsed bladder mucosa through the fistula. haematocoele or some nervous lesion will be
It also helps to show any bladder or ureteric evident
stones. Cystoscopy may be advised where
ureteric fistula is suspected. The three-swab test
This test is used to distinguish ureterovaginal
Differential diagnosis fistula from vesicovaginal fistula and can also
A vesicovaginal fistula must be distinguished rule out stress incontinence. About 100ml of
from stress incontinence, urge incontinence, strongly coloured methylene blue is instilled
ureteric fistula, and overflow incontinence. In into the bladder and three cotton wool or gauze
stress incontinence, urine is lost involuntarily swabs are placed in the vagina; one high up, one
only when the patient strains such as during inthe middle and one near the outlet. The patient
laughter or coughing or when making sudden is then asked to walk about for 10 to 15 minutes
changes in position. Usually small amounts of after which the swabs are examined. If the
urine are passed at a time whereas in lowest swab is wet andblue then the patient has
vesicovaginal fistula, incontinence is total and stress incontinence. If the upper swabs are wet
patient is continuously dribbling urine. When and blue then the patient in all likelihood has
the patient with stress incontinence is asked to VVF. If the upper swabs are wet but not blue,
cough, there is a spurt of urine from the
thenthe indication is that the patient hasureteric
urethra, an event that is absent invesicovaginal
fistula.
fistula. A cystogram will reveal the loss of
urethro-vesical angle incontinence.
Inurge incontinence, the history is that the Complications associated with genital fistulae
woman usually has an urge to void but empties Prolonged obstructed labour that results in
her bladder involuntarily before she can get to a genital fistula also produces a field injury in the
convenience. Usually a large amount of urine pelvis that gives rise to many other birth-related
is passed. Cystography, usually demonstrates injuries now described as Obstructed Labour
theusualpattern of detrusor overactivity. Injury Complex, (see Table 5.2). These injuries
Ureteric fistula can be difficult to then manifest in diverse problems that the
distinguish from vesicovaginal fistula. In
ureterovaginal fistula the patient is able to fistula patient copes with. Hence focusing
empty her bladder intermittently while at the simply on the "hole" between the bladder and
same time she dribbles urine constantly. One the vagina ignores the multifacetednature of the
easy way of distinguishing VVF from both injury that many of these patients have
stress incontinence and ureterovaginal fistula sustained.
is by the three swab test (described below). An Urological injury
intravenous urogram can also be helpful in
excluding a ureterovaginal fistula but this
Vesicovaginal fistula
requires a very good film and an experienced Urethrovaginal fistula
radiologist as the point of entry of dye into the Ureterovaginal fistula
vagina may be obstructed by the bladder Ureterouterine fistula
shadow. Uterovesical fistula
In overflow incontinence, there is usually a Urethralstricture

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impracticable. In such a situation, the patient is Tahzib, F. (1983) Epidemiological determinants of

then left with a permanent colostomy. vesicovaginalfistulas. Brit.J. Obstet. Gynae. 90: 387-391.

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" a«rv,7BHP HM||

Chapter 6* |
Urinary conditions li
Urinary symptoms are a common presentation intravesical pressure. During normal filling of
among women, especially inthe elderly and the the bladder, there is minimalincrease invesical
childbearing age group. Although these are pressure in spite of a rise in bladder volume.
rarely life threatening, they adversely affect the This is due to the fact that the bladder is a
quality of life due to social isolation and the compliant organ. Continence is also maintained
physical and psychological trauma these by involuntary contraction of urethral smooth
conditions inflict on the women. muscle to maintain a highurethral pressure.
The urinary tract is embryologically, When intra-abdominal pressure increases at
anatomically and physiologically closely straining or coughing, the pressure is
related to the genital tract. Thus, conditions transmitted equally to the bladder and proximal
affecting one usually affect the other. Since urethra, both being intra-abdominal. Thus the
these symptoms often date back to child high closure pressure is maintained. Further
bearing, patients usually seek gynaecological protection is afforded by reflex contraction of
the striated muscle of the external sphincter,
rather than urological consultation.
which is inserted through the levator ani to the
In order to appropriately investigate
perineal body and acts to compress the urethra
and offer effective treatment for urinary tract
and accentuate the posterior urethro-vesical
conditions, its anatomy, physiology and
angle.
pathophysiology inrelation to the lower genital
tract must be fully understood.
Mechanism ofvoiding
The urinary tract is traditionally
Impulses generated by bladder distension are
divided into an upper tract comprising the
normally unconsciously inhibited but with
kidneys, renal pelves, and the ureters and a
rising stimulation become consciously
lower tract consisting of the bladder and the
inhibited until conditions are suitable for
urethra. While the upper urinary tract is
voiding. This reflex can be inhibited by painful
responsible for the production and transport of stimuli as occurs in postoperative urinary
urine, the lower urinary tract functions to store retention or following laceration at childbirth.
and expel urinewhen conditions are favourable
to do so. This chapter is mainly concerned with The sequence of events leading to normal
lower urinary tract conditions. The anatomy of micturition is as follows:
the lower urinary tract has been described in ® Removal of inhibition from higher
another chapter of this book. centres inthe cerebral cortex

Maintenance of urinary continence

• Voluntary relaxation of pelvic floor
muscles andurethral sphincter
voiding is controlled by the pontine micturition • Funnelling of the bladder neck,
centre in the brain and involves co-ordination of associated with straightening of the
detrusor contraction and urethral relaxation. urethro-vesical angle
Urinary continence is maintained as long as the © Parasympathetic stimulation and
urethral closure pressure remains greater than the contraction of detrusor muscle leading

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p I
—
I HHMHHHBHHMHiÿ
to a rise inintravesical pressure.
• Emptying of the bladder.
__
chapter.
_...Urinary conditions 55
ÿÿ ÿ

• Voluntary contraction of pelvic floor Stress incontinence

muscles and external urethral Stress incontinence is defined as the
sphincter to squeeze the urethra dry. involuntary loss of urine with a sudden rise in
• Relaxation of detrusor muscle intra-abdominal pressure when coughing,
sneezing,jumping, running, laughing and
• Reinstatement of higher centre •

dancing. It is a symptom and a sign but not a

inhibition to restore urethral closure
pressure. diagnosis as it can be caused by a number of
pathological conditions.
Stress incontinence constitutes a major
Symptoms oflower urinary tract disorders clinical and social problem in the Caucasian
population. It is relatively rare among Afro-
Symptoms of lower urinary tract disorders Caribbean women. This may however result
includethe following: from failure of the patients to seek help due to
Frequency: The passage of urine every two embarrassment or acceptance of the condition
hours or more than seven as a normal process of ageing or a normal
times during the day is termed aftermath of repeated childbirth. Yet others are
increased frequency. unaware that there is effective treatment for
Nocturia: Interruption of sleep more than suchconditions.
once in order to void. (Other The two main causes of stress
reasons like insomnia, incontinence are genuine stress incontinence
lactation or pains of any sort, and detrusor overactivity.
which interrupt sleep, are
excluded). Genuinestress incontinence (GS1):
Urgency: A strong and sudden desire to Genuine stress incontinence or urethral
void urine. sphincter incompetence is defined as the
Dysuria: Pain either in the bladder or involuntary loss of urine when the intravesical
urethra during or at the end of pressure exceeds the maximumurethral closure
micturition. pressure in the absence of detrusor activity. A
Incontinence: Involuntary loss of urine. diagnosis of GSI can only be made after
Enuresis: Involuntary voiding of urine urodynamic assessment.
during sleep. Genuine stress incontinence is prevalent in the
Urinary incontinence middle age, most often inthe age group 45 to 54
years when a number of factors combine to
Urinary incontinence is a common symptom produce the symptoms.
seen by gynaecologists worldwide. It has a
variety of presentation, which on detailed Causes of GSI
history may revealthe cause. GSI results from failure of bladderneck support
Five main types of urinary incontinence by the pelvic floor muscles or failure of the
recognised are listed inTable 6. 1 intrinsic urethral sphincter and in some cases
both. A combination of different factors rather
Continuous incontinence than one mechanism, usually leads to the
Fistulaehavebeendiscussed in detail in a separate development of GSI.

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u' 56 Obstetricsand Gynaecology

Type Cause Treatment

(I) Continuous Congenital: Surgical

Ectopic ureters
Ectopia vesicae
Acquired:
WF, UVF

(ii) Stress Defective urethral Conservative:

Sphincter Pelvic floor exercise
Surgical:
Colposuspension, MMK,
Sling procedures, Anterior
repair, TVT, Collagen
injection.

(in) Urge
Sensory Hypersensitivity to Antibiotic and surgery
infection or calculi

Motor Idiopathic detrusor overactivity Conservative:

Bladder retraining
Anticholinergics
Surgical:
Interrupt nerve supply
Increase bladder size

(iv) Overflow Chronic retention Longrterm catheterisation

Large residual volume Removal of pelvic mass
Diabetic neuropathy
Radical pelvic surgery
Pelvic mass 'ÿfYsraoo s

(v) Reflex Loss of cerebral control Indwelling catheter

it raoii l&U

'-n A .rfiod
>7

Table 6.1 Types of urinary incontinence -

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The causes ofGSI includethe following:

(i)

(ii)
Pelvic trauma arising from vaginal and
instrumental deliveries leads to
denervation and weakening of pelvic floor
support including the external urethral
sphincter.
Oestrogen withdrawal after the menopause
leads to atrophy of collagen and other
connective tissues as well as nerve
__ _ _
this.
----
-----,,
_
HI ... I I

Presentation:
Urinary conditions 57 -
HBH—
abnormality and decreasing oestrogen levels,
although there is no firm evidence to support

Idiopathic detrusor overactivity presents with

iiritative bladder symptoms. The commonest
are frequency and urgency of micturition,
which occur in about 80% of patients.
degeneration. Nocturia, defined as voiding more than once at
.(iii) Weakening of the pelvic floor support night is another common symptom. Urge
leads to urogenital prolapse making the incontinence, the involuntary loss of urine
bladder neck hyper mobile and extra preceded by a strong desire to void, is typical of
abdominal. IDO. Coughing, sneezing, or physical activity
may also provoke detrusor contraction causing
(iv) The urethral sphincter tone is lost urge incontinence.This type of incontinence is
following scarring by repeated vaginal indistinguishable from stress incontinence
surgery, VVF, radiotherapy and from history alone.
recurrent urinary tract infection. Adult onset nocturnal enuresis has a strong
(v) Raised intra-abdominal pressure as in association with IDO,as is incontinence during
pregnancy, chronic cough, abdominal intercourse.
or pelvic mass, chronic constipation,
ascites, heavy lifting and possibly Other causes of frequency and urgency include:
Urinary tract infection
obesity are risk factors for development
of GSI. •° Interstitial cystitis
Radiation fibrosis
° Calculus
Idiopathic detrusor overactivity (IDO)
° Transitional cell carcinoma
This is a condition that also presents with ° External pressure (fibroids, pregnancy)
G

involuntary loss of urine, but unlike inGSI, it is

associated with detrusor contraction. It is ° Drugs
G
(diuretics)
Diabetes
defined as a condition in which the bladder is
° Neurological disease (multiple sclerosis)
Excessive fluid intake
ishown objectively to contract, either ° Habit
spontaneously or on provocation, during
bladder filling, while the subject is attempting °
to inhibit micturition.
It is the second most common cause of
Overflow incontinence
urinary incontinence in the developed world This is a condition in which the bladder
after GSI. Its incidence increases with age, becomes flaccid and over distended with little
accounting for an increasing proportion of or no detrusor activity. The patient fails to void
incontinence among the elderly population. to completion and the bladder merely leaks
The pathophysiology of IDO is poorly small volumes of urine. It is diagnosed when
understood. Unstable detrusor contractions are the residual urine is more than 50% of the
associated with degenerative neurological bladder capacity.

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________
Prince Of Medicine-2014-BSUTH

_______
_________
________
ÿÿÿÿB

$SSKf Obstetrics andGynaecology

- .....
. .

HHHmBhHH
occur in some patients. Vaginal examination
usually shows a profuse redness of the vagina in
and HIV/AIDS infection
the acute infection. Frothy, greenish, vaginal
(ii) diabetes mellitus discharge may be found in some patients. The
(iii) use of broad spectrum antibiotics and cervical epithelium may also be damaged
(iv) use of immunosuppressive drugs. leading to contact bleeding. The appearance of
The common presentation is that of thick the cervix on examination is sometimes
whitish curdy vaginal discharge accompanied described as the "strawberry cervix".
by pruritus and labial pain. The vagina may be The diagnosis can be made by microscopic
red and the discharge may be moderate in examination of a wet mount preparation using
amount without a significant odour. The pH of normal saline. At microscopy, actively motile
the vagina is usually normal. Diagnosis can be flagellate - Trichomonads are easily
confirmed at microscopy and culture whenboth identifiable. Itcan also be isolated at culture.
spores and filament of Candida are identified. The drug of choice in treatment of
The treatment is by the use of antifungal agents. trichomoniasis is metronidazole(flagyl). It is
Three groups of antifungal agents are available. given as an oral dose of 400mg thrice daily for 5
The polyzene antifungals, exemplified by to 7 days or as a single dose of 2g. Both the
nystatin act by increasing the permeability of patient and her husband or partner should be
fungal membrane causing a leakage of cellular treated. The effectiveness of the oral dose is
content. Nystatin is not absorbed orally and is almost 100% but very rarely patients fail to
used in infections of skin and mucous respond to this treatment and rectal or
membranes. Pessaries or soft gelatin capsules intravenous doses may be used. Trichomonads
are inserted into the vagina. The imidazole may playa role as vectors in the transport of
antifungals, exemplified by miconazole and bacteria from the lower genital tract to the
clotrimazole alter the structure and property of uterus, Fallopian tube and pelvic peritoneum.
the fungal cell membranes. They are used This may make trichomonads a factor in the
locally in the form of pessaries and are causation of endometritis, salpingitis and
unsuitable in pregnancy because of vaginal pelvic peritonitis.
absorption. The triazole antifungals Bacterial Vaginosis: The term non-specific
exemplified by fluconazole are absorbed orally vaginitis was used previously for any infectious
vaginitis which was not due to the two
and are suitable for both local and systemic
identifiable agents above (candida albicans and
candidiasis. Nystatin, clotrimazole and trichomonas vaginalis). It has now been
fluconazole are commonly used in this country recognised that this clinical variety of vaginitis
for treatment of candidiasis. is caused predominantly by Gardnerella
Trichomoniasis: This is caused by a protozoan (Haemophilus) vaginalis, a Gram-negative
Trichomonas vaginalis. The disease affects noncapsulated, non-motile and facultative
mainly the vagina but also the lower urinary anaerobe. The common presentation is that of
tract in women and men. In about 50% of vaginal discharge which may vary from
infected women, it is asymptomatic. It is a scanty to profuse in amount and is
sexually transmitted disease. The symptoms usually yellow or grey in colour
include a foul smelling vaginal discharge with with an offensive fishy smell. The
itching, burning and occasionally painful pH of vaginal discharge is usually
intercourse. Urinary symptoms such as dysuria between 5.0 and 6.5. The patients may also i
andurethral discharge may occur in some patients. complain of pruritus and a slight
Severe pruritus and dyspareunia may also abdominal discomfort. The pruritus may lead to

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HHHHHHHhHHHHHHHHHHI
vulval excoriations with punctuate used. Where no specific cause is identified for
haemorrhage. On microscopy, there is the the cervicitis, treatment with cryosurgery or
characteristic presence of 'clue cells' (vaginal electrocautery should be done when symptoms
epithelial cells which have been so coated with persist.
bacteria that the borders are obscured). On
Gram-stained smears and culture, short Gram- (iii) Pelvic inflammatory disease (PID)
negative bacilli (Gardnerella vaginalis) are This is an infection involving the upper genital
predominantly identified. tract (the uterus, Fallopian tubes, ovaries and
The treatment of choice is metronidazole the pelvic peritoneum). The infection usually
(flagyl) given at 500mg twice daily for 5 to 7 spreads from the lower genital tract (vagina and
days' or a single dose of 2g. Topical application cervix). The organisms may arise from the
of metronidazole gel can beused. normal commensals in the vagina or may be
introduced into the vagina during sexual
(ii) Cervicitis intercourse, vaginal examinations or surgical
This refers to infection of the cervix, which procedures such as dilatation and curettage or
may be acute or chronic. The endocervical other gynaecological procedures such as
glands of the cervix make it prone to persistent hysterosalpingogram (HSG) and insertion of
infection. Trauma to the cervix from childbirth intrauterine contraceptive devices (1UCD).
or surgical procedures also predisposes the Although, infection ascends from the lower
cervix to infection. The infection may be genital tract to the upper genital tract in pelvic
caused by organisms commonly found in the inflammatory disease, in rare cases infection
vagina especially staphylococci and can spread from the bowel or can be blood
streptococci. Neisseiria gonorrhoea and borne.
Chlamydia trachomatis may also be involved. PID is a broad term and can be defined as a
The common presentation is that of vaginal clinical syndrome, which results from
discharge which may be mucopurulent, lower ascending spread of microorganisms from the
abdominal pain, dyspareunia and post coital vagina and cervix to the endometrium
bleeding. On speculum examination, the (endometritis), Fallopian tube (salpingitis) and
cervix looks inflamed. Nabothian follicles, peritoneum (peritonitis). This excludes
which are retentioncysts of the cervical glands, postabortal, puerperal or postoperative
may be seen in chronic cervicitis. Contact infections which are described elsewhere inthis
bleeding occurs easily when the cervix is book.
swabbed. Eversion of the colwnnar epithelium PID as a clinical syndrome is important because
may be seen as cervicalerosion. Cervical swab it results in tubal damage which leads to tubal
should be taken for culture to exclude factor ininfertility and ectopic pregnancy.
gonorrhoea, chlamydia and the three common PID is common with an incidence of about 1 %
organisms causing vulvo-vaginitis. A in women aged 15 to 34 years but it rises to
Papanicolaou smear shouldbetakenandwhere about 2% in women 15 to 24 years. In the
ulcerationis present, a colposcopy andcervical African society, Pill has a very high incidence of
Ibiopsy to exclude malignancy should be done. about 4%. The high incidence of PID is related
IWhere chlamydia or gonorrhoea is found, the to the prevalence of sexually transmitted
Impropriate antibiotic treatment should be diseases especially with sexual promiscuity
Igiven. Tetracycline or doxycycline and among youths.
[metronidazole (flagyl) could be Several factors have been associated with the

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64 Pdvie infections

ascent of micro-organisms from the lower transitional epithelium. Gonococcal disease of

genital tract to the upper genital tract. Sexual the female genital tract involves penetration of
activity is an important factor in the prevalence glandular mucosa, and submucosal lymphatic
of PID as it is more common in women with and contiguous surface spread. Initial infection
multiple sexual partners. The act of sexual involves Skene's, Bartholin's, anorectal and
intercourse apart from introducing organisms endocervical glands. This is then followed by
from outside, also aids ascent of bacteria from spread to the endometrial surface, endosalpinx
the vagina to the upper genital tract. It is and finally the peritoneum. Inflammatory
suggested that at orgasm during sexual exudates from endosalpingitis at the fimbriated
intercourse, a suction effect allows ascent of end of the Fallopian tube usually spill into the
organisms from the vagina into the upper peritoneal cavity resulting in peritonitis. The
genital tract. Spermatozoa andtrichomonads by gonococcus can then spread along the free
virtue of their motility are and can be vectors in surfaces of the peritoneum up the paravertebral
the ascent of micro-organisms to the upper gutter towards the liver surface where it can
genital tract. Studies have shown that cause a perihepatitis.
spermatozoa and trichomonads deposited inthe The initial symptoms due to gonococcal
vagina arrive in the upper genital tract with infection appear 3 to 5 days after sexual
micro-organisms carried on them from the exposure in men but in women, this is longer
vagina. It is similarly thought that varying from 3 to 14 days.
microorganisms ascend along the tail of the In the female, the initial areas infected are the
intrauterine contraceptive device (IUCD) from urethra, paraurethral glands and cervix.
vagina into the uterine cavity. Ascent of Infection may involve the Bartholin's glands
microorganisms is also enhanced during the and this may lead to Bartholin's abscess. When
menstrual period as menstruation removes the it involves the cervix, it may lead to purulent
barrier created by cervical mucus against ascent cervicitis with vaginal discharge. In the
of microorganisms. It isalso thought that ascent endometrium, it causes endometritis. Acute
of micro organisms occurs through the salpingitis occurring due to gonococcal
endocervical mucosa as well as the lymphatic infection may progress to pyosalpingitis,
drainage of the cervix. following secondary invasion of the Fallopian
tube by anaerobes.
Aetiological agents Chlamydia trachoma tis: Itis a Gram-negative
Single agents causing primary damage in PID obligate, intracellular parasite. It possesses the
include Neisseria gonorrhoea, Chlamydia properties of bothbacteriaandviruses. Ithas 15
trachomatis, Ureaplasma urealyticum and serotypes that cause a range of infections from
rarely tuberculosis. Anaerobes can cause lymphogranuloma venereum to neonatal
secondary infection and the common ones conjunctivitis. The species, Chlamydia
include peptostreptococcus, peptococcus trachoma tis is responsible for infections in
species, bacteroidesand fiisobacterium. human. It infects the epithelium of the urethra,
Nesseiria gonorrhoea: This is a Gram negative cervix, Fallopiantubes, and conjunctiva.
kidney or bean shaped diplococcus. It is a strict The organism is the commonest cause of genital
aerobe. The optimal growth occurs at 34 and 35 infection in the Western world. It is isolated from
degree Celsius and the pH range of7.2 to 7.6. It is up to 25% of women attending STD clinics and up
intracellular and is a pathogen for columnar and to 60% of women having infection with

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organisms. The common aerobic organisms are

gonorrhoea. It is responsible for 50% of all staphylococci,p-haemolytic streptococci,
cases of non-gonococcal urethritis. It has a
Haemophilus influenzae and Escherichia coli.
longer incubation period than gonorrhoea .It is The common anaerobes are
a common cause of acute salpingitis and
peptostreptococcus, peptococcus species,
endometritis.
Clostridium species, bacteroides, and
fusobacterium. These organisms are present in
Mycoplasma: These are the smallest free-living the normal vaginal and cervical flora and it is
organisms. They have no rigid cell wall. The uncertain if they are primary or secondary
elementary body is the minimal reproductive invaders of the upper genital tract in PID. It is
unit and is about 0.2-1ji long. There are two thought that an initial structural damage to the
strains that are related to genital infections, upper genital tract produced by primary
namely Mycoplasma hominis and Ureaplasma invaders such as gonococcus and chlamydia
urealyticum. Mycoplasma hominis grows best sets the stage for secondary invasion by the
in alkaline environment with pH 7.5 whereas anaerobic and aerobic organisms.
Ureaplasma urealyticum prefers an acidic
environment. These organisms normally Clinicalfeatures
inhabit the vagina and cervix. Inthe presence of The commonest presentation is that of
infection in the vagina or cervix, the presence abdominal pain. The pain is usually continuous
of mycoplasma increases three to four folds. and is in the lower abdomen. It is bilateral and
These organisms have been isolated from the persists during menstruation (dysmenorrhoea).
Fallopian tubes and uterine endometrium of There is also pain during coitus (dyspareunia),
women with salpingitis and infertility but it is and there may also be pain during micturition
difficult to establish a primary role of these (dysuria). Patients may complain of irregular
organisms in the damage to the structure of menstrual period with menorrhagia and
these organs. intermenstrual bleeding being the common
Mycobacteria tuberculosis: The tubercle menstrual abnormalities. Vaginal discharge
bacilli are thin, straight rods and are may also occur. In acute cases, fever and
approximately 3-5|i long. They are acid-fast vomiting may accompany severe abdominal
bacilli. They are primary invader and the initial pain. In this country, the chronic variety with
human host reaction is characterised by chronic pelvic pain and infertility is
polymorphonuclear neutrophilic inflammatory particularly common. These patients present
exudates. Tuberculosis is primarily an infection after several consultations with traditional
of the respiratory tract. Infection of the female 'doctors' and chemists.
genital tract can develop from haematogenous On physical examination, the patient may be
dissemination of organisms and their febrile with temperature reaching over 38°C in
subsequent location within the Fallopian tube. acute cases. The patient usually has tachycardia
Itmay take Ito 10 years betweenactual seeding but the blood pressure may be normal.
andclinical manifestationsof disease. Abdominal examination shows generalised
lower abdominal tenderness with no palpable
Other infecting agents masses. There is rebound tenderness as
There are other endogenous and exogenous evidence of pelvic peritonitis. On speculum
pathogens that have beenrecovered from the genital vaginal examination, there may be purulent
tract in PID. These include aerobic and anaerobic discharge from the cervical os. At digital

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66 Obstetrics and Gynaecology

vaginal swab (HVS) is of little diagnostic value

examination, the Bartholin's gland should be in PID except for detection of trichomonads
palpated for tenderness, as inflammation of and gardnerella.
this organ is common in PID. On bimanual Ultrasonography: It is useful in the diagnosis
examination, there is marked uterine of adnexal masses in chronic PID and in
tenderness and cervical excitation or motion distinguishing adnexal abscess or other cystic
tenderness on moving the cervix. Bilateral pelvic collections. It will also confirm
tubo-ovarian massesare palpable inthe adnexa intrauterine pregnancies in suspected ectopic
especially inthe chronic variety. pregnancy.
The diagnosis of PID can only be made in Laparoscopy: It is the most accurate method of
about 60% of cases from clinical features. diagnosing PID. Laparoscopic findings in PID
The abdominal symptoms of Pill are common show signs of acute inflammation of the
to other disease conditions, which must be Fallopian tube and the peritoneum. There is
considered inthe differential diagnosis of PID. hyperaemia of the external surface of the tube
These disease conditions are listedbelow. and marked oedema of the tube especially the
fimbriated ends with the fimbriae standing
Acute appendicitis distinct. There may also be an exudate from the
Ectopic pregnancy ostium of the tube. In severe cases, pus may be
Ruptured corpus luteum cyst seen dripping from the tubal ostium.
Septic abortion Laparoscopy is also useful to exclude ectopic
Acute urinary tract pregnancy which is a common differential
infection Endometriosis diagnosis of PID. In chronic PID laparoscopy
will demonstrate adnexal masses, tubo-ovarian
Table 7.1Differential diagnosis of PID masses and liver adhesions (Fitz-Hughes-
Curtis syndrome). At laparoscopy, peritoneal
Investigations fluid can betaken for culture.
Blood: A full blood count should be done.
Anaemia is a common finding in Pill, in this Treatment
country. Neutrophil leuocytosis may be found The treatment of PID should be aimed at relief
indicating an acute infection. An elevated of symptoms and the preservation of the
erythrocyte sedimentation rate may indicate functions of the Fallopian tubes. Early
infection but in the tropics where parasitic diagnosis and treatment will reduce the
infestations are common, this result should be complications of Pill. Antibiotic therapy is the
interpretedwith caution. mainstay of treatment and this should be
Urine: A midstream specimen of urine should be commenced as soon as the swabs for culture are
taken for microscopy, culture and sensitivity to taken andthe diagnosis is suspected. Antibiotic
rule out urinary tract infection. A pregnancy test treatment should be aimed at covering all the
should be done if there is a suspicion of ectopic aetiological agents in PID., viz Neisseria
pregnancy. Microbiology culture: Swabs should gonorrhoea, Chlamydia trachomatis,
be obtained from the urethra, endocervix Ureaplasma urealyticum and anaerobes.
and rectum for culture and sensitivity. The choices of antibiotics should be dictated
It is important that swabs obtained are by the local sensitivities of these
immediately plated in transport medium before organisms. In Nigeria, as in some developing
transfer to the microbiology laboratory. A high countries, the abuse of antibiotics,

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Pelvic ittfec&ons *67.

ÿlML-

a consequence of poor control of access to the treatment of PID.

prescription drugs makes resistance to It is our usual practice to treat outpatients with
antibiotics very high. The antibiotics ingeneral doxycycline lOOmg twice daily for 14 days in
use in treatment of PID include the penicillins, combination with metronidazole 500mg orally
cephalosporins ,metronidazole, clindamycin, twice daily also for 14 days. Ofloxacin 400mg
tetracyclines, chloramphenicol and orally twice daily can be combined with
aminoglycosides. clindamycin 450mg orally or metronidazole for
Patients with PID can be treated either as 14 days.
outpatients or inpatients. The tetracyclines and For inpatients, it is important to give
metronidazole have been commonly used for intravenous antibiotics for the first 48 hours of
outpatient treatment. admission. Cefoxitin is given at a dose of 2g
The tetracyclines continue to enjoy wide usage intravenously every 6 hours for 48 hours. As an
inthe treatment ofPID . Their main advantages alternative clindamycin 900mg intravenously is
include oral absorption, good coverage of combined with gentamycin
aerobes, anaerobes, chlamydia and 1.5mg / kg body weight intramuscularly or
ureaplasma. Doxycycline, a second generation intravenously every 8 hours for 48 hours.
tetracycline has a higher compliance rate Thereafter doxycycline lOOmg daily
because it is given as a twice-daily dosage. orclindamycin 450mg four times daily can be
Metronidazole provides wider coverage over given orally for 14 days.
anaerobes and also enjoys wide usage in In Nigeria, the costs of antibiotics can be a
treatment ofPID. constraint in the treatment of PID. Fortunately,
Cephalosporins provide antibacterial activity doxycycline and metronidazole, which are in
for many strains of Gram-positive cocci and common use, are affordable to most of these
Escherichia coli. Cefoxitin, a second patients.
generation cephalosporin provides additional
coverage for anaerobic organisms. Complications ofPID
Clindamycin is a member of the macrolide Complications may result from inappropriate or
family and has good antibacterial activity delayed treatment of PID. Chronic pelvic pain,
against anaerobic organisms and Gram- ectopic pregnancy and infertility are the
positive cocci. common complications of PID.
Aminoglycosides have excellent activity Chronicpelvicpain: Acute PID tends to recur in
against enteric organisms, but has no about 25% of patients with previous episode.
antibacterial activity against anaerobes. Lower abdominal and pelvic pains become
Gentamycin , a commonly used recurrent. This is responsible for several
aminoglycoside in treatment of severe PID is gynaecological consultations by these patients.
best used incombination with other antibiotics. Improper or late treatment of the disease results
Because of the common complication of in a progression to the chronic variety where
renal toxicity, its use should be carefully there is adhesion formation. Closure of the
monitored. fimbrial end of the tube with pus collection
Quinolones as exemplified by of loxacin results in a pyosalpinx while the collection of
and ciprofloxacin have good antibacterial fluid within die tube results in a hydrosalpinx.
activity against Gram-positive and These are responsible for the chronic pain in
Gram-negative organisms and chlamydia. chronic PID. The pelvic organs also become
They are also used in combination in matted together and with healing by

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68 Obstetrics andGynaecology

to HIV/AIDS, it is once again moving to the

fibrosis, a frozen pelvis results. Chronic pelvic
centre stage. The disease is common in parts of
pain, menstrual disorders and dyspareunia are
common at this stage. Medical treatment with
Africa, Asia, Middle East and Latin America
but is still rare inEuropean countries.
antibiotics and analgesics are helpful but
The primary site of infection for tuberculosis is
surgical management may be necessary and is
the lung. Inits early spread to the pelvis, it takes
usually successful in relieving chronic pelvic
the lymphohaematogenous route to the
pain.
Fallopian tube, endometrium and then ovaries.
Ectopic pregnancy: There is a strong
It produces chronic salpingitis, endometritis
association between PID and ectopic
and peritonitis (chronic pelvic inflammatory
pregnancy. Women with previous history of
disease).
episodes of PID have a high
The common presentation of pelvic
chance of having ectopic pregnancy. Infection
of the Fallopian tube especially with Neisseria
tuberculosis is infertility and menstrual
gonorrhoea and Chlamydia trachomatis results disorders. Oligomenorrhoea, amenorrhoea and
menorrhagia are common menstrual disorders.
in damage to the cilia while hydrosalpinges
Chronic abdominal and pelvic pains are
cause flattening of the tubal folds and also
common while ascites may be found in
deciliation. This damage to the tubes results in
advanced cases. Pelvic examination may reveal
decreased tubal motility, which is partly
normal findings in40% of the patients.Adnexal
responsible for ectopic implantation.
Infertility: PID is major cause of female
tenderness, adnexal masses and sometimes
infertility. It has been shown by Westrom in a complete fixation of pelvic organs by adhesive
process may be found.
Swedish study that infertility rate increases
Chest X-ray, endometrial biopsy in the
directly with the number of episodes of acute
secretory phase of the menstrual cycle,
PID. The risk of infertility is 13% after one
pyelogram, urine culture and
episode, 36% after two episodes and 75% after
three or more episodes of PID. Varying degrees
hysterosalpingogram provide useful
information for diagnosis. Materials obtained
of tubal damage are responsible for the
from endometrial biopsy or curettage should be
infertility. The end results are largely total or
sent for culture and animal inoculation.
partial terminal tubal obstructions by
Laparoscopy is also useful in diagnosis of
adhesions. Early diagnosis, prompt and proper
treatment of PID is necessary to reduce
pelvic tuberculosis.
Treatment is usually medical with varying
Fallopian tube damage.
combination of antituberculous drugs
Pelvic tuberculosis ' (rifampicin, isoniazid and ethambutol).
Mycobacterium tuberculosis used to be a Surgical treatment is done for pelvic masses
foremost cause of pelvic infection over 100 with chronic pelvic pain. Surgery for tubal
years ago. With the advent of antibiotics, it obstruction in infertile patients is most
diminished in importance but with the unrewarding.
emergence of immunosuppression due

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sfliliii Pelvic infections 69

Bibliography and suggested further

reading
Beers MH(1999). Gynaecological inflammation and
MacleanA.B.(1999). Pelvic Infection. InDewhurst'stextbook
infections In Merck Manual of Diagnosis and Therapy.
17th ed. Merckand Co. Inc,White house station, NJ USA. 1948- of Obstetrics and Gynaecology for Postgraduates. D.Keith
1954. Edmondsed, 6th ed. BlackwellScience (Publishers). 393-409.

Herbst.A.I, Mishell DR, Stenchever, MA, Droengenmuller, W. Monif GRG (1982). Infectious dieseases in Obstetrics and
eds (1992). Comprehensive Gynaecology. Mosby Year Book Gynaecology. 2nd ed. Harper andRow PublishersLimited.
(Publishers).
Westrom L. (1975). Effect of acute Pelvic Inflammatory
Lavery H.A.( 1984). Sexually Transmitted Diseases of the
Vulva: InProgress in Obstetrics andGynaecology. Vol 4.
.
disease on fertility. AmJ. Obstet. Gynaecol. 121:707-7 13
John Studd ed. Churchill Livingstone publishers). SSI-
SSI.

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Chapter 8
Vaginal
Incidence pathological vaginal discharge. The following
Vaginal discharge is a common complaint in may cause this disruption: (i) antibiotics, (ii)
gynaecological clinics and general practice. In hormones, (iii) contraceptive preparations
a survey of 500 women (age group 15-40 (oral and topical), (iv) douches, (v) vaginal
years), attending the gynaecological and medications, (vi) sexual intercourse, (vii)
antenatal clinics at the Lagos University STDs, (viii) stress and (ix) change of partners.
Teaching Hospital, 85.8% of them responded Oestrogens increase the glycogen
yes to a question asking if they had vaginal content of the vaginal epithelium. Glycogen is
discharge occasionally or most of the time. metabolised to glucose and subsequently to
Seventyseven per cent of these women were lactic acid mainly by lactobacilli. Lactic acid is
married,and 76.4% were sexually active.
responsible for the low pH of the vagina (less
Patho-physiology than 4.5) that provides some natural defence
The aetiology of vaginal discharge could be against exogenous organisms and proliferation
physiological or pathological. The vagina is of endogenous organism to pathological levels.
lined by squamous epithelium, which contains Therefore, before puberty and at menopause,
no glands. It is always kept moist inthe healthy when the amount of oestrogens available is
state by a thin vaginal secretion. This thin small, the natural defense mechanism is poor.
coving is an admixture of secretions from the During a menstrual period, after an abortion
endometrial glands, cervical glands and and in the early puerperium the vaginal pH is
Bartholin's glands (especially during sexual
arousal), desquamated vaginal epithelial cells raised and the natural defense mechanism at
and lactic acid. The amount of the normal these periods is poor hence the high rate of
vaginal secretion is increased during infection during these periods.
pregnancy, in patients on hormonal Pathological causes of vaginal
contraceptives, at ovulation period and in the discharge can be of infective or non-infective
premenstrual phase of the menstrual cycle. origin. If of infective origin, it is called
This physiological increase in vaginal vaginitis and can be due to specific organisms
secretion is termed leucorrhoea and if such or non-specific organisms. Specific organisms
secretion is examined microscopically there that cause vaginal discharge amongst other
will be very few or no leucocytes present and symptoms are Neisseria gonorrhoea (see
no pathogen isolated or cultured.
section under sexually transmitted diseases),
The vaginal environment consists of a
complex interrelationship among the Trichomonas vagina lis and Candida albicans.
endogenous microflora, metabolic products of Micro-organisms associated with vaginal
the microflora and the host, oestrogen and the discharge due to non-specific vaginitis include
pH level- the vaginal ecosystem. The Gardnerella vagina lis, Corynebacterium
microflora is made up of numerous micro species. Escherichia coli, Bacteroides species,
organisms, such as yeast, Gram-positive Gram-positive and Gram-negative anaerobic
and Gram-negative aerobic, and cocci, Fuso bacterium species and
facultative and obligate anaerobic bacteria. Clostridium species. Recently Gardnerella
Disruption in the equilibrium of the vaginalis has been associated more often
vaginal ecosystem leads to vaginitis and with non-specific vaginitis vaginal discharge.

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Vaginal discharge 71

Vulvovaginal candidiasis clothings. The reason why patients on

It is a common cause of vaginal discharge antibiotics are more susceptible to candidiasis
worldwide. In Lagos, the prevalence rate of C. may not only be because antibiotics kill off
albicans in all female genital swabs is about other bacteria and thus remove restraints to the
18.7 per cent. Candida vulvovaginitis is growth of the Candida spp. but may be due to
commoner in pregnant than in non-pregnant the fact that antibiotics decrease phagocytosis
women. or depress immune response Insome way.
It is established that C. albicans can be
Agent transmitted sexually though this is rare. Being
Candidiasis is caused by the fungus, Candida an organism that is prevalent in the
species. Candida organisms include C. gastrointestinal tract the practice of oral and
albicans, C. tropicalis, C.pseudotropicalis, C. anal sex will perpetuate the infection. In the
Krusei and C. stellaloidea. Other strains are males it may cause symptomatic balanitis or
Torulopsis glabrata and Rhodotorula. penile dermatitis.
Candida albicans accounts for 60% to 80% of
vaginal fungal infections; C. glabrata (20%) Clinicalfeatures
and C. tropicalis (6% to 23%). Two or more Most patients will complain of vaginal
species can be found in an infection, with the discharge. Other symptoms include pruritus
combination of C. albicans, T. glabrata and C. vulvae, soreness of the vagina, dyspareunia or
tropicalis being the most frequent All the apareunia and dysuria. In some women itching
may occur before and after menses and remit at
species are sensitive to antimycotic agents but
midcycle. Some other patients may not have
the non-albicans may be more difficult to
any of these symptoms but would be found to
eradicate.
have florid vulvo-vaginal candidiasis on
Predisposingfactors examination.
(i) diabetes mellitus On examination the vulva may be wet, red,
(ii) pregnancy swollen and bear the hallmark of
(iii) immunosuppressive therapy pruritus/scratches. This type of vulvitis must be
(cytotoxic drugs, steroids, etc) differentiated from the diabetic vulvitis, which
(iv) antibiotics could be complicated by Candida infection.
(v) oral contraceptives Also red papules or fissures may be found at the
(vi) immunodeficient conditions (HIV,
posterior fourchette. When a speculum
examination is performed, the vaginal
Cancer, chronic illness). Indeed
discharge characteristic of candidiasis may be
recurrent Candida vaginits may be
seen. It is usually profuse, thick, white, cheesy
thefirstpresentingsign ofHIV and forms plaques, which are found adherent to
infection inwomen. the vaginal wall. Whenthese plaques are peeled
(vii) tightfitting and nylonundergarments off petechiae, are seen. The same lesion can be
Heat and moisture favour the growth seen in the oral cavity ('thrush') commonly
of Candida spp and it is postulated that found inbabies, who perhaps contracted it from
women who wear tight pants and trousers
their mothers. Insome cases the discharge may
not be characteristic and in patients who
are more prone to candidiasis than those
douche there may be no vaginaldischarge at all.
who wear skirts and loose fitting

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Investigations for the high non-compliance rate. Most women

At speculum examination specimens must be do not complete the course. It is also useful
taken from the cervix, lateral vaginal walls and where there is allergy to the azoles. Other
the introitus using a cotton swab. It is wise to antimycotic agents are 1 % or 2% gentian
use a speculum that is "lubricated" with water violet solution painted over the vagina and
and the opportunity provided must be taken to vulva, which is effective but stains the
do a cervical smear for cytology. The swab underpants and may be aesthetically
specimens are subjected to microscopy and unacceptable to the patients, and boric acid
then cultured. For microscopy, a wet saline powder (600mg powder in gelatin, capsule
preparation can be made in the side laboratory administered once daily for 14 days), or even
when spores and pseudohyphae of Candida common yoghurt, which is reported to be
species could be seen under the microscope. useful. Patient noncompliance is high in the
Culture is only mandatory when the patient is treatment of candidiasis so much so that failure
known to have had a douche before may be ascribed to reinfection or non¬
examination or when Candida is strongly compliance. Short treatment regime is inuse to
suspected but typical spores and overcome this problem.
pseudohyphae are not seen Oral azoles include ketoconazole,
at microscopy. Sabouraud's medium or itraconazole and fluconazole. They are
Nickerson'smedium is used for culture. reserved for severe infection, recurrent
Because of possible concurrent infection with infections or in nonalbicans candidiasis that is
gonococus, endocervical swabs are taken for difficult to treat. They interact with many drugs
Gram stain and culture for N. gonorrhoeae. If and have many serious side effects such as
dysuria is present, a mid stream specimen of hepatotoxicity and anaphylaxis and should
urine is sent for microscopy and never be used inpregnancy.
bacteriological culture to exclude urinary tract For systemic infections oral Nystatin (500,000
infection or gonococcal urethritis. IU.) is given four times daily for 10 days.
Treatment Recurrent or chronic vulvovaginal candidiasis
The options for therapy include intravaginal This is defined as four or more symptomatic
preparations and oral agents. The imidazole episodes annually. It can be difficult to treat.
(azoles) group of drugs are the mainstay of The following may be responsible:
intravaginal treatment. The azoles for (i) diabetes mellitus
intravaginal preparations (creams, tablets and (ii) non-compliance
suppositories) include clotrimazole, (iii) re-infectionfrom an infectedpartner
miconazole, butaconazole, tioconazole and (iv) HIV
terconazole. They come in lOOmg, 200mg and (v) gastrointestinal reservoir
500mg tablets or suppositories and 0.52% (vi) non-albicans candidiasis not
creams. The courses of therapy in respondingto common drugs
uncomplicated cases range from a single daily A careful and detailed history should be
dose to 3 to 7 days of therapy. In complicated taken from patients with chronic or
infection (severe or recurrent) or in nonrecurrent candidiasis. In addition they should
albicans candidiasis, 10-14 days of topical or be screened for diabetes mellitus, and
oral azoles are required. Nystatin pessaries counselled for HIV screening. Recurrent
(100,000 units) inserted high in the vagina candidiasis may be the first presenting
each night for 14 days is effective except symptom of HIV infection in women. Of 140

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Vaginal discharge 73

M ÿM3K99

patients with vaginal discharge screened for females.

HIV at the Lagos University Teaching
Hospital, over a period of four months in Year
2000, four were positive and all the four had Clinicalfeatures
candidiasis. In patients with recurrent The vaginal discharge is malodorous, frothy,
candidiasis prolonged treatment, like vaginal profuse, thin, creamy or slightly greenish and
clotrimazole (100 mg) daily for 6 days in a may cause itching. The classic yellow-green
month or vaginal clotrimazole (500 mg) once a discharge is found in 20% to 35% of patients;
month for 6 months, is rewarding. Oral azoles more often the discharge is grey or white. The
or oral nystatin (500,000 units) given four patient may also complain of dyspareunia,
times daily for 10 days may also be used. post-coital bleeding, pruritus vulvae, frequency
Infected symptomatic sexual partner should be of micturition and dysuria. Characteristically,
treated. vulvitis is minimal or absent compared with
Trichomoniasis candidiasis.
It is the commonest sexually transmitted On speculum examination apart form
disease worldwide. It was originally thought to the discharge, a cervical erosion may be seen
be innocuous, but has now been found to be and in severe cases multiple, small punctate
associated with pelvic inflammatory disease haemorrhages, and swollen papillae may be
(PID), preterm labour, premature rupture of found on the cervix ("strawberry" cervix) and
membranes andincreasedperinatal loss. vagina.

Investigations
Agent The vaginal pH is usually 5-5.5 in trichomonas
Trichomonal vaginitis is caused by the infection. Applying a litmus paper to the
trichomonas organism, which is a small, unlubricated speculum after it has been
flagellated, motile and anaerobic protozoon. withdrawn from the vagina easily tests the pH.
The particular trichomonad responsible for A saline wet mount of the swab taken from
vaginitis is Trichomonas vaginalis, which isthe the vagina or cervix will show motile
type found in the vagina. Other trichomonads,
flagellated protozoa and leucocytes. Wet mount
which include T. buccalis found in the mouth alone detects 64% infection in asymptomatic
and T. hominis found in the anal canal and
women, 75% of those with clinical vaginitis
rectum are known but do not cause vaginal
discharge as they cannot survive in the vagina. and 80% of those with characteristic
T vaginalis has been demonstrated in the male symptoms. The use of culture (Feinberg-
urethraand prostate gland. Whittington or Diamond culture) gives a
sensitivity of 86% - 97%. Pap smear has a
Source detection rate of about 50% - 86%.
It is usually sexually transmitted. The organism Monoclonal antibody staining is also used. It
may survive for several hours in urine, wet is sensitive and is reported to detect 77% of
towels and even on toilet seats. The possibility those missed on wet mount. In some research
of transmission by these routes had been centres polymerase chain reaction (PCR) is
suggested but not completely proven. usedand gives a detection rate of about 97%.
Incubation period is 4 to 20 days with an T. vaginalis may be recovered from the
average of 7 days. Males are usually midstream specimen of urine in patients with
asymptomatic but they can easily infect treated frequency of micturitionor dysuria.

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Treatment which cause the typical fishy malodour that patients

Metronidazole 200mg orally thrice daily for 7 experience.
days or a single dose of2.0gm orally is the
Source
treatment of choice but should be used with
caution in pregnant women especially in the It usually occurs in sexually active patients.
Some of the risk factors associated with BV
first trimester. Ootrimazole, which is both a
include being sexually active (especially with
fungicide and trichomonacide can be used
multiple sexual partners), low socio-economic
intravaginally, usually in pregnancy, in the
status, presence of intrauterine device and prior
same dosage regime as in candidiasis. In
STD. It is still debatable whether it is sexually
persistent infection it is best to treat the patient transmitted, however in support of this is the
and her male sexual partner simultaneously. recovery of G vaginalis in the urethra of male
Bacterialvaginosis partners.
It is one of the commonest causes of vaginal Clinicalfeatures
discharge worldwide. It is a new term for the It is characterised by a malodorous, profuse,
vaginal inflammation syndrome that had been thin, homogeneous yellow, white or grey
previously called Haemophilus vaginalis discharge that is adherent to the anterior and
vaginitis, nonspecific vaginitis, and lateral vaginal walls. Typically the patient may
Gardnerella vagina lis vaginitis. It results from complain of a fishy odour during or shortly after
complex alteration of the vaginal ecosystem intercourse and also during menses. The
leading to an overgrowth of several bacterial alkaline nature of blood or semen (pH>7) brings
species. In bacterial vaginosis the total about a transient increase in the vaginal pH and
concentration of bacteria in the vagina is this causes the release of amines, which the
usually increased 100-fold to 1000-fold above patient perceives as fishy odour. Indeed
normal levels to levels of 107 to 1011 increased odour with intercourse is often
organisms per ml. It is said to have a high helpful in differentiating patients with BV from
prevalence in sexually active women. Bacterial other women who complain of an odour. This
vaginosis (BV) is associated with postpartum typical discharge may be found on examination
endometritis, amniotic fluid infection, in some patients who in fact have not
chorioamnionitis, premature rupture of complained of a vaginal discharge. The fishy
membranes, preterm delivery of low-birth smell of the discharge is the main problem and
weight infants, pelvic infection following is often responsible for sexual disharmony
termination of pregnancy or other invasive between partners. Vulvitis and pruritus are very
procedures, posthysterectomy cuff cellulitis minimal or totally absent.
and irregular menstrual bleeding. Many women with BV may have no symptoms
at all.
Agent
Bacterial vaginosis (BY) results from an
overgrowth in G. vaginalis, anaerobic Investigations
organisms (especially Bacteroides and
Clinical criteria
Mobiluncus species) and Mycoplasma hominis
Four easily identified features of vaginal
with the absence of normal hydrogen peroxide- discharge (homogenous vaginal discharge, pH,
producing lactobacilli. The overgrowth results amine odour, and clue cells) are usually present
in an elevated vaginal pH and the production of inwomen with BV.
amines, putrecine and cadaverine,

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----
Prince Of Medicine-2014-BSUTH
~
F
*

ft. -......

(i)
......
..—
;
__
___
....
-------
__ J

Homogenous vaginal discharge. The

—
HBHHI I
>: Vaginaldischarge
I——HHI —....—I—I—Hi
75

in this condition. Though virtually all patients

discharge in patients with BV is thin, with BV have G vaginalis isolated on culture, it
watery and does not form clumps. It is must also benotedthat the organism can also be
adherent to the anterior and lateral cultured in40% to 50% of women with normal
vaginal walls. flora.
(ri) pH. The pH of the vaginal discharge is
often greater than 5 and this in the Treatment
absence of T. vaginalis is highly The standard therapies for the treatment of BV
suggestive of BV. If pH is 4.5 or less, in nonpregnant women are oral metronidazole
patient will generally either have a 500mg twice daily for 7 days; clindamycin
normalvagina flora or candidiasis. cream 2%, one applicatorful (5g) intravaginally
(iii) Amine odour. The production of a at bedtime for 7 days or metronidazole gel one
fishy, amine odour after the addition of applicatorful (5g) intravaginally once or twice a
one to two drops of 10% potassium day for 5 days. Alternatively clindamycin is
hydroxide (KOH) solution to the given orally 300mg twice a day for 7 days or a
discharge is what is called a positive
single dose of metronidazole 2g. The male
amine test or "Whiff test This amine
partner must be treated as well. Condoms are
test is positive in patients with BV as
also recommended for several weeks as a
well as those with trichomoniasis.
means of altering the vaginal flora thereby
(iv) Clue cell. A vaginal epithelial cell
covered by a large number of Gram preventing reoccurrence. In pregnancy BV
variable coccobacilli is what Gardner should be treated with metronidazole 250mg 3
and Duke called a "clue cell". The times a day (alternatives; metronidazole 2gm
epithelial cell becomes so covered single dose, clindamycin 300mg twice a day; or
with these bacteria that its borders metronidazole gel).
become obscured. The presence of
clue cells making up at least 20% of the Gonorrhoea
cells in a discharge is exceedingly Agent
diagnostic of BV. Neisseria gonococcus
Three of the abovefour criteria should be met
to make a clinical diagnosis of bacterial
vaginosis. Source
Sexually transmitted
Gram stain
The absence or fewer than four lactobacilli per Clinicalfeatures
high power field plus the presence of G It is usually asymptomatic. In symptomatic
vaginalis and one or more bacteria cases patients may complain of mucopurulent
morphological types i.e. Gram-positive cocci, vaginal discharge. For details see Chapter on
Bacteroides (small Gramnegative rods), Sexually transmitted diseases.
Mobiluncus (curved Gram-variable rods or
fusiforms) is highly diagnostic of BV. Chlamydia Infection
This may also be asymptomatic. About one
Culture third may have symptoms including
It is the least accurate in making a diagnosis of BV mucopurulent vaginal discharge. For details
as there is overgrowth of many vaginal organisms see Chapter on Sexually transmitted diseases.

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: i.« '

76 Obstetrics and Gynaecology

Non-infective causes of vaginal discharge and swab specimens are taken for microscopy,
There are other causes of vaginal discharge culture and sensitivity tests. Also because of the
which are not infective in origin. A careful risk of genital tract malignancy inthese women,
history and vaginal examination is therefore the hallmark of which is postmenopausal
required inall cases of vaginal discharge. bleeding, they should be subjected to
examination under anaesthesia, hysteroscopy
Foreign bodies: Foreign bodies like cotton and a diagnostic curettage. Histopathological
wool, tampons or contraceptive pessaries left studies of specimen so obtained are mandatory.
for a long time in the vagina often cause non-
infective vaginal disharge. There is usually Treatment
secondary infection associated with foreign When the discharge is found not to be due to
bodies inthe vagina. Tampons left inthe vagina known causative agents and malignancy is
for days are responsible for toxic shock ruled out, topical use of oestrogen preparation is
syndrome, which occurs inyoung women. helpful. Premarin (equine oestrogen) 0.625mg
vaginal pessary once daily or topical
Allergy or drug sensitivity:Allergic reaction to application of the cream canbe prescribed.
drugs antiseptics, perfumed soaps or powders,
nylon panties or chemical spermicides can also Vulvovaginitis in Children
cause non-infective vaginal discharge. Prepubertal children are susceptible to both
specific and non-specific vaginal infection. The
Malignancy: Malignant diseases ofthe genital contributing factors for this are poor hygiene,
tract do present with profuse watery and the proximity of the vagina to the anus, the lack
offensive vaginal discharge, which mayor may of protective hair and labial fat pad, and the lack
not be blood stained. This type of discharge is of oestrogenisation. The vulval skin is also
due to break down of necrotic malignant tissue, susceptible to irritation and is easily
which usually becomes secondarily infected traumatised by chemicals, soaps, medications
by mostly anaerobic bacteria. and clothing.

Treatment Agent
This will depend on the cause. The offending (i) Respiratory and enteric pathogens, sexually
foreign bodies are removed and the vagina transmitted infections and Candida can cause
irrigated with warm water. Incases of allergic vulvovaginitis in children; (ii) parasites like
reaction the patient is advised to change thread worms or pinworms are notorious causes
antiseptics or soaps. Malignant lesions are of vaginitis in children and the attending
treated inthe usual way. pruritus is intense; (iii) foreign bodies inserted
into the vagina at play have been found to be a
Senile vaginitis
cause of vaginitis inchildren.
This occurs in postmenopausal women and
the patho-physiology is as described Source
earlier. The complaint is mainly that of a This depends on the type of infection
blood stained vaginal discharge. On and therefore could be from foreign
examination, atrophy of the vulva and vagina bodies, nasopharyngeal infection,
may be obvious. The vaginal skin is thin and faecal carriage or skin infections. The source
has patchy haemorrhagic areas. Smears could also be the mother or the caretaker

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..
.........
........
.....
.....
.......
.......
... .....
--

s
' i :v ,
-• Vaginal discharge 77 ]
- - . -
and from sexual contact as in the case of re-infection. Harsh soaps and tight underpants
sexually abusedchildren. must be avoided.
The choice of antibiotics depends on culture
Investigation and sensitivity results. In cases of candidiasis
A complete history is very important. The topical application of clotrimazole or Nystatin
information that should be obtained is appropriate. Mebendazole (an antihelmintic)
includes the quantity, duration, odour, and is used if the vaginitis is due to threadworms or
type of discharge; perineal hygiene; recent use pinworms. When no organism is isolated,
of medications; symptoms of anal pruritus and application of 1 % gentian violet might be
recent infection in the mother or the caretaker.
helpful.
Also questions on sexual abuse should be
asked. The child as well as the mother or
caretaker must have a complete physical Bibliography and suggested further
examination and laboratory tests where reading
feasible. The examination of the childshould be Abudu, 0.0. (1981) "Vaginal discharge and vaginitis". Nig.
done in a stepwise fashion (i) do a general Med FractitionerNol.1: 17-20.
physical examination; (ii) inspect the
Abudu,0.0.,0dugbemi T.O. Agboola,A.( 1982).
perineum, vulva and vaginal introitus; (iii)
"Coiynebacterium vaginale and vaginitis" WestAfr. J. Med
visualise the vagina and cervix (an auroscope 1(4),.17-19.
can be used in place of an ordinary speculum if
there is a need for this examination); (iv) obtain Abudu, O. O. Odugbemi T.O. (1985).
"Gardnerella vaginalis vaginitis in pregnancy".
specimen for wet saline preparation, Gram stain
West Afri. J.. Med. 4(1), 5-7.
and culture; (v) do a recto-abdominal
examination. If the child is uncooperative it ACOG technical bulletin (1996). Int JGynecol Obsiet 53,
may be necessary to carry out the described 271-280.
examination under anaesthesia. In all these
examinations, care must be taken not to injure
the hymen. Emmans, SJ., Laufer, M.R., Goldstein D.P. (1998). Pediatric
andAdolescent Gynaecology
Treatment 4th ed., Lippincott-Raven, Philadelphia.
Hygiene must be emphasised in the
Eschenbach, D.A. (1989). Bacterial vaginosis: emphasis
treatment of vulvovaginitis in children.
on upper gential tract complications.
It is important to educate the mother or Obstetrics and Gynaecology Clinics of NorthAmerica 16 •-«

caretaker about simple rules of hygiene likethe (3),593-610. .

... .
child must have frequent change of underwear
and her own separate towel to prevent

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Sexually transmitted disease (STD) is an Incidence

euphemism for venereal disease. STDs are among Though some of these are notifiable diseases, their
the most common causes of illness in the world and true incidences in Nigeria are not known. Sexually
have far reaching health, social and economic transmitted diseases are however commoner in
consequences. There are between 350-400 million sexually promiscuous individuals like prostitutes
new cases each year worldwide. They are therefore and those with multiple sexual partners. The
a major public health problem. Complications of reported clinical prevalence of gonorrhoea is much
STDs include pelvic inflammatory disease (PID), higher than other diseases like syphilis, chlamydia
chronic pelvic pain, monorrhagia, dysmenorrhoea, and mycoplasmal infections because of the
dyspareunia, infertility, cervical cancer, ectopic unavailability of facilities for thorough
pregnancy, fetal wastage, stillbirths, low birth investigations inmost part of the country.
weight, eye damage, neonatal pneumonia and
laryngeal polyps. Aetiology
Recently STDs have gained high recognition due to The micro-organisms causing sexually transmitted
their association with the Human diseases include bacteria, protozoa, fungi, viruses
immunodeficiency virus (HIV). Patients with STDs and ecto parasites.
are more susceptible to HIV, while the infectivity of
HIV patients is increased ifthey have STD. Ineffect
Table 9.1 shows the types of common sexually
STDs facilitate the spread of HTV. It is necessary to
transmitted diseases andtheir causative agents.
offer individuals with STD voluntary HIV
counselling and testing. Some sexually transmitted
diseases are more commonly spread by other means
Sexually Transmitted Diseases (STD) Causative agents
Syphilis Treponema pallidum
Gonorrhoea Neisseria gonorrhoeae
Candidiasis Candida albicans
Trichomoniasis Trichomonas vaginalis
Lymphogranuloma venereum Chlamydia trachomatis
Trachoma J
Mycopasmal infection ( Mycoplasma hominis
) Ureaplasma urealyticum
Hepatitis Hepatitis B virus
Genital herpes Herpes simplex hominis Type2
Genital warts Human papilloma virus
Scabies Sarcoptes scabiei
Granuloma Inguinale Donovania granulomatis
Chancroid (soft sore) Haemophilus ducreyi
Acquired immune deficiency syndrome Human immunodeficiency virus

Table 9.1 Sexually transmitted diseases (STDs) and their causative agents

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&4 Obstetrics and Gynaecology

i
3lUS( -A™,*., .a.

Treatment
Tetracycline 250 mg orally four times a day for
10 days or erythromycin 250mg four times
daily for
10 days.

Genital herpes
Herpessimplex hominis type 2 (HSV-2) virus is
the causative micro-organism. In 5% to 15% of
cases it is caused by herpes hominis type 11
(HSV 1). Herpes infectioncan bedivided into:
(i) primaryfirst episodes, inwhichthe
patient has no antibody to HSV-1or
HSV-2.
Figure 9.2 Multiple fenestration of the labia as a result (ii) non-primaryfirst episodes, inwhich
of Lymphogranuloma venereum
the patient already has antibody to
one type ofHSV and gets re-infected
Investigation with another type (usually a HSV
type 2 infection with antibodies to
The most diagnostic test is the Frei test. This is HSV type 1).
an intradermal test using "lygranum" antigen
(0.1 ml). If a papule of at least 6mm develops (iii) recurrences.
48-72 hours after, the test is positive. Genital herpes is a common cause of genital
ulcers. HSV-2 has been associated with
Treatment carcinoma of the cervix. In pregnancy it can
cause abortion, chorioamnionitis and pre term
Tetracycline 250 mg four times daily orally for labour. Neonatal herpes, which has a mortality
20 days is the treatment of choice. Where of up to 50% and causes neurological
rectovaginal fistula and rectal strictures have impairment in those who survive has also been
developed, these would have to be managed recorded.
and treated surgically. Sulphonamides could
also beused. Pathology
The virus enters the dorsal ganglia following
Mycoplasmal infections the primary episode and remains dormant.
The common organisms found in the female Upon reactivationby various stimuli e.g. stress,
genital tract are Mycoplasma hominis, menstruation, immunosuppression and coitus,
Ureaplasma urealyticum and Mycoplasma the virus moves down along nerves to the skin
and mucosa of the lower genital tract. This is
fermentans. While it is established that these responsible for recurrences.
organisms are sexually transmitted and U.
urealyticum in particular is responsible for
non-specific urethritis inthe male their roles in
infertility and intrapartum infections remain Clinicalfeatures
debatable. Definitely, their isolation rate inthe The cervix isthe commonest site of infection thougl
developing countries is minimal because of the patient may not be aware of the lesion and the
unavailability of facilities.

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i I I
vulva is only secondarily affected. In primary detection of virus. Culture may take about 48
infections vesicles appear on the labia, hours. Other methods used to detect the virus
vestibule, vagina and/or cervix; they rupture in from scrapings include immunoflourescent,
1 to 3 days to produce small painful ulcers enzyme immunoassay and PCR techniques.
which often coalesce to form extensive Cervical smear (Pap smear) may show
superficial ulcers. The ulcers are shallow, characteristic intranuclear inclusion bodies and
tender and non-indurated with inguinal multinucleated giant cells. Colposcopy of the
lymphadenopathy. The patient usually cervix may revealulcers andnecrotic areas and
experiences local burning or itching (irritation) increased surface vascularity.
i before the appearance of the vesicles. There is
Antibody tests can be used to detect a recent,
also dysuria due to the ulcers. Systemic past or reactivated infection. A rise in IgM
symptoms like headache, fever, myalgia, and antibody followed by IgG antibody is most
malaise are often present. Patients may also convincing of a recent infection. Where IgG is
have neurological symptoms such as aseptic detected and the titres are stable, it is an
meningitis, sacral anaesthesia, urinary evidence of a past infection, but when the titres
I retention (usually due to painful vulva), and are rising it means there is a current active
constipation that may last 4 to 8 weeks. Ano¬ disease or reactivation. Viral culture remains
rectal symptoms in primary infections include
the best method for diagnosing herpes
I discharge, pain and tenesmus. Large numbers infection.
Iof virus are shed from the lesions especially the
|ones on the cervix. Healing takes one to four Treatment
Iweeks.
I Recurrences are common and the associated Various anti-viral agents e.g. idoxuridine,
I symptoms are less severe. The number vidarabin (Ara-A) or acyclovir can shorten
Ioflesions are less and are usually on the vulva duration of symptoms and viral shedding,
I rather than in the vagina or cervix. The lesions prevent formation of new lesions, and reduce
I are atypical ulcers systemic symptoms, but they do not offer cure
I and fissures. About 24 hours before onset of of the disease. Also therapy does not prevent
recurrence the patient may experience later recurrences. The common anti-viral agent
j prodromal symptoms like neuralgia in the used is acyclovir (oral, topical and intravenous
|| buttocks, groin or legs and itching or burning preparations are available). The usual dose is
sensation.VIrUS shedding ismuch less and healing oral acyclovir 200 mg five times daily or 400
Iis faster than in the primary lesion. In mg three times daily for 7 to 10 days for
immunocompromised patients such as patients symptomatic primary herpes. Acyclovir 400
with HIV or those on immunosuppressive drugs, mg five times a day or 800 mg three times a day
±e recurrences may be more frequent and more for 7 to 10 days is recommended for herpes
severe. proctitis. Additional measures include sitz
baths with warm water, use of analgesics,
Investigations cleaning of ulcers with antiseptic solution and
I History from patient and inspection of the topical application of acyclovir cream. Incases
I ulcers usually help in making a diagnosis. A of very severe herpes patient may be
I tender, painful vesicle, pustule, or yellowish hospitalised and given intravenous acyclovir.
I ulcer should make the clinician think of HSV. Recurrences are treated symptomatically, but if
ISterile swabs are rubbed vigorously over the they are severe, therapy is given as above (it is
|| base of ulcers or vesicles to obtain scrapings usually commenced inthe prodromal period).
| for viral culture or other tests for

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»> "• i
' a; A I
*$! 86 Obstetrics andGynecology ph
ÿNHMHHNMMMNI K:

Apatient with genital herpes is advised not form cauliflower growths covering the whole
to have sexual intercourse until lesions are vulva. At times they are small solitary and
healed. She should be counselled on risk of discrete and they should not be confused with
recurrence, the possibility of transmission the syphilitic condylomalata. They may cause
(especially in the prodromal period and during burning sensation, pruritus and dyspareunia.
asymptomatic shedding), and to avoid self- Investigations
inoculation to the mouth and fingers. The
The appearance of the warts, especially the
patient should also be counselled for HIV
gross exophytic ones, is usually diagnostic.
screening and also screened for other STDs.
Very tiny lesions become white (acetowhite
Genital Warts (Condylomata acuminata) lesions) after painting with 3% or 5% acetic
acid solution. In some cases especially when
Genital warts are caused by the human papilloma the presence of HPV is questioned, punch
viruses (HPV). They are mucosotropic and biopsy should be obtained for pathological
cutaneotropic and commonly affect the skin, evaluation. It is important to counsel patients
lower genital tract, larynx, oral cavity, urethra, with genital warts for HIV testing and
and anal/perianal epithelium. Genital warts tend screening for other STDs.
to increase in patients on oral contraceptives, in
pregnancy, and immunosuppressive states as in
Treatment
renal transplant, cancer and HIV patients. Genital warts usually regress with time, some
Genital warts is one of the presenting features of may take up to five years. Those in pregnancy
HIV patients in Nigeria. There are about 65 regress after delivery. However treatment is
HPV types; HPV types 6 and 11 are associated offered for cosmetic reasons or patient's
with exophytic "cauliflower" genital warts preference. The following methods are
often seen on the cervix, vagina, vulva and employed:
perianal region;HPV types 16, 18,3 1,3 3,and 35
cause flat condylomata and are associated with Podophyllin. Warts are painted with 25%
cervical dysplasia and anogenital cancers. podophylin in liquid paraffin weekly till they'
Types 16 and 18 are particularly associated with disappear. Patients must be instructed to wash
invasive .cancer ofthe cervix. off the podophyllin four hours after treatment
A mother infected with genital warts can as podophyllin is a toxic agent. The
transmit the virus to the newborn at time of surrounding skin should be protected by the
delivery and this can lead to laryngeal application of petroleum jelly. It is
papillomatosis (polyps). It can also be contraindicated inpregnancy.
transmitted through the use of contaminated
towels of an infected person. Genital warts are Trichloroacetic acid (TCA). This chemical is
usually sexually transmitted and often co-exist used in strengths of 80% and 90%. It must be
with other sexually transmitted diseases.
applied carefully to the warts to avoid bums to
the surrounding normal tissues. Normal saline
or aloe vera gel can be used to ease off the
Clinicalfeatures
burning sensation.
Warts appear on the vulva and perineum and may
extend to the anal region and up into the vagina Imiquimod. A new therapy, the 5% cream is
andcervix. They are usually small butcoalesce to applied three times a week to the external genitalia

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Sexually transmitted diseases 87

and the warts for 16 weeks. The area is washed granulomatous ulcers (see figs. 9.3 and 9.4.) It L _
is a

off 6 to 10 hours after application. pre-cancerous condition. Lymphadenopathy is

rare. It is prevalent amongst the low socio¬
Cautery. Small lesions on the vulva or perianal area economic class.
can be cauterised.
Cryocautery. Liquid nitrogen at very low
temperature is used to destroy the warts.

Laser. Carbon dioxide laser is used to bum off the

lesions. It is very effective with high cure rates. It
has the advantage that vulval, vaginal, cervical and
perianal lesions can be treated at the same time.The
disadvantage of laser is high cost and this includes
cost of equipment and maintenance.
5-Flurouracil. This is applied in the form of a
5% cream once every two weeks. It is used
where other treatments have failed or in
immunosuppressed patients who have a high ;«j;:
risk ofrelapse.
Localexcision. Surgical resection of the wart can be
done in some cases.

Simple vulvectomy. Simple vulvectomy may be

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Acquired immunodeficiency ÿfitdrome {AIDS) 91

i—m i
Vaginal swabs for candidiasis countries.
Cervical cytology to exclude cervical It has now been shown that a combination of three
intraepithelial neoplasia antiretroviral drugs, including one protease
Chest X-ray for tuberculosis and pneumonia inhibitor is the most effective treatment presently
Stool culture for bacterial infection available to suppress the replicationof HIV.
Urine culture for bacterial infection
Blood for CD4 cell count where facilities are This disease has so far proved incurable
available whatever drug is administered and prevention
remainsthe key word.
Management
Once the diagnosis has been confirmed, the Prevention
woman will require further counselling and Events have shownthat it is safer to prevent this
emotional support by the family. dreaded disease while still working towards an
Opportunistic infections should be vigorously effective curative therapy.
treated with appropriate and newer antibiotics.
Anti-tuberculous drugs should be prescribed
for tuberculosis. i Sexual education and HIV counselling
Herpes zoster should be treated with should be provided in all secondary
appropriate antibiotics. institutions. Counselling centres should
Salmonella infection requires appropriate also be provided for adolescents and
treatment Oral candidiasis is treated with adult at the village and city levels.
gentian violet lozenges. Churches, mosques and the media
Vaginal candidiasis is treated with should not be left out in this campaign.
clotrimazole or nystatinpessaries. The role of moral instruction in fighting
The use of intravenous fluids is mandatory if this scourge is not indoubt.
there is profuse, watery diarrhoea. ii. Testing of women attending the
Other supportive measures include gynaecological clinic may be
antimalarials, ironand folic acid supplements. considered inan affected area if there is
Ina big medical centre, the physician shouldbe obtained an informed consent after due
consulted for ajoint management of the patient counselling.
with the gynaecologist/obstetrician. iii. Sexual promiscuity should be
The antiviral drug usually employed in the discouraged among women
treatment of this disease is zidovudine (AZT) iv. Infected women should be identified
although some other drugs have been tried but and counselled against sexual
have not been found to be more superior or intercoursewithout the use of condom.
effective. The drug is normally administered v. Condom shouldalso be worn by women
orally but could also be given by the at risk of contracting the disease from
intravenous route when necessary. The life their male partners.
span of affected patients couldbe prolonged by vi. Women should encourage their strange
about two years on this therapy but it has been male partners to wear condoms for safe
found too expensive forAfrica and developing casual sex especially if their HIV Sta-

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tus is unknown
deep needle stick injury sustained
1
during surgery.
Vll. Prostitution in any population should xii. Contact with blood or body fluids
be discouraged. In the alternative, splashed from an HIV positive patient
prostitutes should be made to have could be avoided by suggesting to the
counselling and HIV testing and in attendants to wear glasses or goggles.
additionbe given free condoms for xiv. Doctors and nurses are also advised
use by their clients. to wear gloves when taking blood
Vlll. Sexually transmitted diseases in samples from patients.
women should be treated vigorously xv. The wearing of double gloves by
and this also applies to their male surgeons while operating on HIV
consorts. positive patients has also been
IX. Nosocomial infections should also be advocated.
adequately treated.
X. Blood for transfusion should be Acknowledgement
properly screened for HIV and other
relevant infections Ithank Professor A. F. Fleming for making
XI. In hospitals and clinics, all surgical available to me his manuscripts on HIV and
equipment should be carefully AIDS.
autoclaved or sterilized.
Xll. Needle stick injury should be avoided. Bibliography and suggested further
This may particularly occur while reading
resheathing needle after blood
collection or during pelvic surgery on WHO international Collaborating Group for the study of
an HIV positive patient. Prophylactic WHO staging system (1993). Proposed "World Health
Organization staging system for HIV infection and
treatment with the antiviral drug, disease". Preliminary testing by an International
zidovudine, has been advocated for CollaborativeCross-sectional study.AIDS 7,7 11-718.

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Chapter 11
W&mffl I m 1
§5 .

vulva
Incidence A.
--, .!M-
Localcauses ofpruritus vulvae are:

Itching of the vulva is a common symptom in 1. Infections: Candidiasis, trichomoniasis,

herpes genitalis, genital warts,
gynaecological practice. It is estimated that
condylomata, lymphogranuloma
about 10% of gynaecological patients complain
venereum, chancroid, molluscum
of pruritus vulvae. Pruritus is defined as "that contagiosum and dermatophytosis.
unpleasant sensation whichprovokes the desire 2. Infestations: Scabies, pediculosis pubis,
to scratch" threadworm.
3. Contact dermatitis: Due to allergy or
Patho-physiology irritant substances such as reaction to
The stimulation of the Merkel and Meissner drugs, vaginal douches, spermicidals,
neural endings in the skin causes sensory soaps, deodorants, nylon pants, and
impulses to be sent to the brain via the small depilatory creams or following
myelinated fibres of the ipsilateral dorsal root prolonged contact with urine as in
ganglia, to the opposite antero-lateral vesico -vaginal fistula, lichen simplex,
spinothalamic tract, through the thalamus and psoriasis, seborrhoeic andjuvenile
the internal capsule to the sensory cortex. dermatitis herpetiformis.
Psychological factors dampen or amplify 4. Vulval dystrophies Lichen sclerosis,
perceivedimpulses. leucoplakia, kraurosisvulvae.
It is possible that proteases released by 5. Neoplasia: Vulval intraepithelial
keratinocytes initiatedthe process. The pruritus neoplasia, carcinoma, lymphoma,
of candidiasis may be related to the Paget's disease.
fermentation of carbohydrates and the
subsequent release of acetaldehyde, acetic acid, B General causes:
pyruvic acid, and .mycotoxins. It is knownthat 1. As part of generalised dermatosis.
inflamed skin shows increased amount of 2. Generalised pruritus associated with
prostaglandin and it is postulated that metabolic diseases such as obstructive
prostaglandin may sensitise some receptors to jaundice. Avitaminosis A and B,
the pruritic effects of other agents. achlorhydria, chronic renal failure,
tropical diseases such as onchocerciasis
and filariasis.
Aetiology
3. Psychogenic
The causes of pruritus vulvae are many. They
can be grouped under local, general and C. Idiopathic
idiopathic causes. Vaginal discharge and
vaginitis due to Candida albicans and Clinical history
trichomonas vaginalis are the major causes Most of the patients would complain of vaginal
(about 80% to 85%) of pruritus vulvae. A list of discharge (mentioned earlier). Detailed
causes is given belowand most of the causes are systemic review of the patient and family
discussed under appropriate sections in this history (especially as regard psoriasis and
book. diabetes mellitus) are rewarding.

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Clinicalfindings
. .______.
.....
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—. |Wj

u
—
94 Obsre&ics and Gynaecology
BBBBI

Complete physical examination of the patient

is mandatory though the majority of the causes

of pruritus vulvae are local causes; stigmata of
metabolic diseases shouldbe lookedfor.
Underwear and beddings must be washed and
ironedthereafter.

Pediculosis pubis is treated with gamma

benzene or dicophane (DDT) powder.

Threadworm (Enterobius vermicularis) is

T*PT7.'t

Investigations treated by systemic antihelminthics such as

Vaginal discharge if present must be fully pyrantel pamoate (combantrin) in a single dose
investigated as described earlier to identify the of 10-20 mg/kg body weight.
causative organism(s). Contact dermatitis due to allergens or irritants
is best treated by discontinuation of the use of
Urinalysis for sugar and ketones must be done the substances concerned. Psoriasis and other
to exclude diabetes mellitus. dermatitis like lichen simplex may be treated
by topical corticosteroids.

Skin snips can be taken for microscopic Severe vulval dystrophies can be contained by
analysis especially with dermatosis and simple vulvectomy ifnecessary.
dermatophytosis.
Metabolic diseases are treated as appropriate.
Where the vulval appearance is suspicious of a Diabetic vulvitis is treated by control of the
carcinoma or whenever an ulcerative condition diabetes and local application of clotrimazole
is present, a diagnostic biopsy is mandatory. topically.

Treatment
The treatment of vaginal discharge isdiscussed Bibliography and suggested further
elsewhere in this book. Dermatophytes can be reading
treated with topical application of benzoic acid
compound ointment (Whitfield's ointment) or Goolamali SK (1981). Pruritus vulvae. Clinics in Obstetrics
andGynaecology 8 (I),227.
clotrimazole cream.

Scabies is treated with gamma benzene

hexachloride applied once daily for 2 days.

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Chapter 12
Miscarriage
Miscarriage is defined as loss or expulsion of a Threatened miscarriage
pregnancy before 28 weeks gestation. In This presents as vaginal bleeding in a
developed countries where the special care pregnancy less than 28 weeks gestation. It is a
baby units are well developed and can salvage very common gynaecological emergency. The
babies below 28 weeks, viability would be bleeding is usually slight to begin with and may
defined as gestation age of 20 to 24 weeks or be associated with cramping and lower
fetal weight of 500gms andabove. abdominal pain. Spontaneous resolution of
In the mind of the public, the term symptoms is usual but a third of the patients
abortion is usually confused with a deliberate may go on to miscarry. Speculum examination
:ermination or interruption of a pregnancy and usually reveals that the cervical os is closed.
criminal abortion while miscarriage is an Other causes of bleeding in early pregnancy
accidental or spontaneous end to a pregnancy. such as ectopic pregnancy and cervical lesions
To the medical person, the terms miscarriage should be excluded.
d abortion are synonymous. Once the diagnosis of threatened
The incidence of miscarriage varies miscarriage is made, the patient should be
om 15% in clinically recognisable pregnancy counselled about the possible outcome. There is
25% inpregnancies before 6 weeks. no treatment for threatened miscarriage. Bed
Miscarriages can be subdivided into rest with or without sedation has been
inical types viz. (i) Threatened (ii) Inevitable traditionally used, but there is no evidence that
i) Incomplete (iv) Complete (v) Early this is beneficial. Hospital admission is usual
bryonic or fetal demise (vi) Septic (vii) but some patients can be managed at home
abitual(fig 12.1).
MISCARRIAGES

THREATENED

EARLY FETAL DEMISE INEVITABLE CONTINUING VIABLE PREGNANCY

INCOIV 'PLETE COMPLETE

SEPTIC

Figure 12.1 Clinical types of miscarriage

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Prince Of Medicine-2014-BSUTH ÿ

96 Obstetrics andGynaecology

after proper counselling and reassurance.

1
described above. In this state, some products of
The administration of progesterone has not been conception have been passed and other products
proven to be beneficial. A positive pregnancy test is remain inside the uterus. The cervical os is open
reassuring and serial measurements of HCG titres and severe haemorrhage is usual. This is due to
and progesterone levels have been suggested for retained products of conception, which prevent
prognosis. Ultrasound scan of the uterus will confirm the contraction of the uterine myometrium. The
viability of the fetus and will distinguish between a severe haemorrhage associated with this
blightedovum and missed abortion. condition may lead to shock requiring urgent
resuscitation.
Inevitable miscarriage Once the diagnosis is established, an intravenoi
A threatened miscarriage can continue and line should be set up and blood taken foi
progress to inevitable miscarriage. At this stage, haemoglobin or packed cell volume anc
nothing can be done to salvage the pregnancy. crossmatched blood requested. A specuh
There is usually a severe lower abdominal pain examination should be done and loose product
and also low back pain. Vaginal bleeding is of conception at the cervix can be removed wit
a sponge holding forceps. Ergometrine maleate
usually severe andthere
0.5mg may be given intramuscularly, while 2(
may be loss of amniotic fluid from rupture of
units of syntocinon are added to 500mls of the
membranes. A speculum vaginal examination intravenous fluid. Blood transfusion may be
usually reveals an open cervical os with or necessary if bleeding is profuse. This procedi
without products of conception protruding usually reduces blood loss while preparing the
through or distending the cervix. patient for theatre with or without genera
Once the diagnosis of inevitable miscarriage is anaesthesia. The procedure for evacuation
made, the uterus should be evacuated by uterine of retainedproducts isdescribed separately later.
or suction curettage to decrease the blood loss
and reduce infection. Complete miscarriage
Blood loss may be excessive where products of In this state, complete passage of the products
conception distend the cervix and may cause of conception is described by the patient.
shock, which may also be due to sympathetic Cessation of bleeding and pain, usually
stimulation. At speculum examination, removal indicates completion of the miscarriage.
of the products of conception distending the Confirmation of an empty uterus can be made
by ultrasound scan. It is best to assume that
cervix will relieve the shock. Blood should be
miscarriage of pregnancy below 12 weeks
taken for haematocrit, blood group and cross gestation is
incomplete while those above 12
matching. Intravenous infusion of normal saline weeks are usually more likely to be complete.
should be started. Haemorrhage can be arrested When in doubt especially where ultrasound
with the use of intravenous syntocinon 20 units scan is unavailable, it is advisable to do a
or ergometrine maleate 0.5mg. Evacuation of the dilatation and evacuation.
uterus can be done under general anaesthesia or
sedation. Suction evacuation should be Septic miscarriage
performed. The use of sharp curettes should be In this variety, there is infection of the products ,
avoided as perforation of the soft uterus can of conception. This is a serious complication and
occur. may result from inevitable, incomplete oi
complete, or missed miscarriage or induced
Incomplete miscarriage (criminal) abortion.
Thisis an extension ofthe inevitable miscarriage The infection usually involves the conceptus.

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p uterus and upper genital tract. The organisms

procedure rises with gestational age.

Termination can be done either surgically or abdominal approach. It is used only in
medically. Prior to any termination of exceptional cases. The procedure is usually
pregnancy, the women should have adequate done under general anaesthesia.
assessment and counselling. Assessment should Medical methods
include haemoglobin or haematocit estimation, These methods are used for pregnancy over
confirmation of pregnancy and possible
12 weeks as surgical risks in these
screening for infections. Medical history should
be taken to determine any contraindications to circumstances are very high.
surgery or anaesthesia. History of drug allergies Prostagladins can be given by extra-
or reactions should be obtained. Adequate amniotic route. Prostaglandin F2 a and E2 are
counselling should be done. The opportunity commonly used.
should betaken to offer contraceptive advice. Prostaglandins stimulate uterine
contractions and expulsion of the uterine
contents. Itmay be necessary, sometimes to use
Surgical methods
infusion of oxytocin to supplement the action
1. Suction evacuation: This is the of prostaglandins on the uterus. Care must be
commonest method of termination of taken to avoid water intoxicationwith oxytocin
pregnancy. It is used commonly in both because of itsantidiuretic action.
developed and developing countries. An antiprogestogenic agent, Mifepristone
Suction isobtained either by the Karman or RU 486 induces abortion by blocking
syringe or by electrical pump. It is progesterone receptors inthe uterus. This agent
suitable for a pregnancy less than 12 has been used for early termination of
weeks. The need for cervical dilatation pregnancy. Mifepristone has been used in
especially in later pregnancies causes combination with prostaglandin for effective
pain during the procedure. The termination of pregnancy.
procedure may be done with or without
general anaesthesia. The use of
Complications
paracervical block and analgesic drugs
The complications of termination of
(pethidine or fentanyl) allows cervical
dilatation prior to insertion of the plastic pregnancy include (i) haemorrhage; (ii)
suction curette. The cervix can be primed incomplete abortion; (iii) septic abortion; (iv)
with prostaglandins or laminaria tents to cervical tears; (v) uterine perforation and (vi)
avoid cervical tear and cervical infertility due to tubal damage.
incompetence, which are common
complications of mechanicaldilatation.
2. Dilatation and Evacuation (D & E): Bibliography and suggested further
Dilatation of the cervix and evacuation reading
of the uterus under general anaesthesia is
O'Brien P.M.S., Grudzinskas J.G; eds. (1997)
rarely done today. Here the products of
conception are removed with sponge -
Problems of early pregnancy Advances in diagnosis and
management. London RCOG
forceps followed by blunt curettage.
Herbst A., Mishell D.R., Stenchever M.A., Droegenmuller
3. Hysterotomy: Inthis procedure,the contents of W. eds. (1992) Comprehensive Gynaecology. Mosby Year
the uterus are evacuatedthrough an Book pp. 425-456.

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iChapter 13

* Ectopic pregnancy
The implantation of an embryo at sites outside steady increase in incidence of ectopic
the uterine cavity is referred to as ectopic pregnancy over the years noted in Europe is
pregnancy. This is a common cause for thought to be related to increase in incidence of
emergency admissions in gynaecological wards pelvic inflammatory disease and also improved
especially in the tropics. When rupture occurs at diagnostic techniques. The incidence varies
the ectopic site of implantation, it is usually from 1 in300 pregnancies inEurope to as high as
associated with profuse infra-abdominal 1 in 20 to 50 pregnancies in Africa and West
haemorrhage and this has a high maternal
Indies. In Nigeria, rates of 1 in 20 pregnancies
are reported in the Southern cities compared to 1
mortality.
In a rare situation, an intrauterine in5 0 inthe Northerncities.
pregnancy may co-exist with ectopic pregnancy
when it is referred to as a heterotopic pregnancy. Aetiology
Fig. 13. 1 shows the sites of ectopic implantation. Fertilisation takes place at the ampullary portion
The commonest site is the Fallopian tube, which of the Fallopian tube. The embryo is transported
represents 98% of all cases of ectopic pregnancy. through the ampulla, isthmus and intramural
In the Fallopian tube, it can implant at the portion of the tube into the uterine cavity where
fimbria, ampulla, isthmusand intramural portion implantation normally takes place. Transport of
of the tube. It can also implant on the cervix, the the embryo along the Fallopian tube is aided by
rudimentary hom of the uterus, the ovary, broad
the ciliary movement of the ciliated cells and
ligament and peritoneal cavity.
tubal muscular activity. Conditions which
Rudimentary
interfere with normal tubal motility would cause
Cornual Interstitial
horn ectopic pregnancy.
\ / Infectionof the tube results in damage to the
Isthmic ciliated cells and adhesions within and outside
the Fallopian tubes. This can cause entrapping of
board
ligament the embryo in the tube resulting in ectopic
Ampullary pregnancy. Operations on the Fallopian tube
Cervical especially, reconstructive surgery can cause a
distortion of the anatomy of the Fallopian tube
and interfere with tubal motility causing ectopic
Overian pregnancy. Hormonal imbalance could also be a
Fimbrial cause of ectopic pregnancy. Excessive
Figure 13.1Sites of ectopic pregnancy circulatory oestrogen or progesterone could
interfere with normal tubal motility and would
Incidence cause ectopic pregnancy. Such conditions may
The incidence of ectopic pregnancy varies exist in the use of progesterone releasing
among and within countries. The incidence is intrauterine contraceptive devices and
related to the prevalence of pelvic inflammatory
progesterone only contraceptives. Also increase
disease. A
inoestrogen and progesterone levels occurs after
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102 Obstetrics and Gynaecology

ovulation induction with clomiphene citrate and characterised by spotting or may stimulate
human menopausal gonadotropins. Women menstrual bleeding. Rarely, bleeding may be as
conceiving after such treatment may have heavy as that which occurs in spontaneous
increased rate of ectopic pregnancy. miscarriages. Patients may occasionally notice
Other factors, which are related to pelvic passage of decidual casts. Pain usually occurs
infection, include history of previous abortion, before vaginal bleeding in ectopic pregnancy
previous ectopic pregnancy and history of while the reverse is the case in spontaneous
infertility.
miscarriages.
Clinical features Syncope: Severe intra-abdominal haemorrhage
after ruptured ectopic pregnancy may result in
The symptoms and signs of ectopic pregnancy shock. Inthe acute dramatic clinical picture, this
are varied depending on whether it is acute or
may be an early presentation.
chronic. The acute dramatic picture is presented
in the ruptured ectopic pregnancy where sudden Physical examination
lower abdominal pain is associated with
syncope. General examination usually reveals pallor from
A high index of suspicion is very important blood loss in ruptured ectopic pregnancies. Cold
in the diagnosis of ectopic pregnancy. For clammy extremities with tachycardia are noted
example, the possibility of ectopic pregnancy as a result of hypotension. On abdominal
must be thought of in women who have the risk examination, there will betenderness in either of
factors described under aetiology above andwho the iliac fossae. In ruptured ectopic pregnancy,
present with symptoms described below. there will be generalised abdominal rigidity with
rebound tenderness. Where there is a large
Symptoms
haemoperitoneum, the abdomen may be soft
Pain: This is the commonest presenting with mildtenderness and doughy consistency.
symptom and occurs in about 90% of cases. The Pelvic examination: speculum or bimanual
pain may be vague or colicky in nature, examination must be done with care and in
unilateral or bilateral initially, but may become environment where facilities for resuscitation
generalised. At the time of rupture, the pain is are available since this examination may
usually described as intense, sharp and sudden.
Shoulder tip pain occurs in patients due to
provoke rupture of the ectopic gestation. On
peritoneal irritation from free blood in the digital examination, cervical excitation
peritoneal cavity. tenderness can be elicited. The uterus may be
enlarged and an adnexal mass may be palpable..
Amenorrhoea: Missed periods (amenorrhoea)
may be a presenting symptom in up to 60% of Investigations
cases. The periods may be missed for up to six
weeks or more. Rupture of an ectopic pregnancy Culdocentesis
may occur before a missed period. This is the passage of a wide bore needle through
the posterior fornix into the pouch of Douglas.
Vaginal bleeding: Vaginal bleeding is usually The presence of non-clotting blood is evidence
abnormal or irregular and is due to decidual of haemoperitoneum. The absence of blood does
endometrial sloughing. The bleeding may be not exclude an ectopic pregnancy.
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Ultrasonography suspicion of ectopic pregnancy. Laparoscopy

Ultrasound can be used to diagnose ectopic should be resorted to where there is suspicion of
pregnancy. The finding of an extrauterine sac ectopic pregnancy. For example, an inpatient
with embryo or embryonic remnant may provide with secondary amenorrhoea and undiagnosed
a reliable diagnosis. Other common ultrasound lower abdominal pain for more than 24 hours
features include, the finding of an empty sac or a should require laparoscopy.
heterogenous adnexal mass or the presence of
fluid in the pouch of Douglas. In abdominal Abdominal X-ray
pregnancy, fetal parts and placenta can be found Abdominal X-ray is useful in the diagnosis of
outside an empty uterine cavity. advanced extrauterine pregnancies found
commonly in the developing countries. Lateral
Measurement of human chorionic
view of the abdomen would show fetal parts
gonadotrophin (hCG) lying on the maternal spine.
The measurement of p -hCG has improved the Hysterosalpingogram (HSG) would outline
diagnosis of early unrupturedectopic pregnancy. the empty uterine cavity and has been useful in
hCG is produced by the trophoblastic tissues and the diagnosis of advanced extrauterine
can be detected in serum about 7-10 days after pregnancy.
ovulation. The amount of hCG produced
increases exponentially and serial serum Dilatation and Curettage
measurements have shown a doubling time of 48 In a few cases of ectopic gestation, the
hours. Abnormal patterns of increase in serum endometrium shows the presence ofArias-Stella
value of hCG may signify diagnosis of early cells. This represents areas of focal decidual
ectopic pregnancy. In serial measurements of reaction in the endometrium in response to
serum (3-hCG, it is expected that an intrauterine hormonal changes of pregnancy. Endometrial
pregnancy should be detectable at serum (3-hCG curettings also show absence of placentalvilli.
level of 6500 units/ml. This level of hCG is said
Management
to be discriminatory as it is the level of p-hCG
above which, the gestational sac of an The management of ectopic pregnancy is mainly
intrauterine pregnancy should be detectable by surgical. The patient should be resuscitated as
ultrasonography. This presence or absence of an fast as possible and then a laparotomy should be
intrauterine pregnancy gestational sac is the done. In developing countries, where ruptured
principal point in distinction between ectopic pregnancies are largely seen, it is
intrauterine and tubal pregnancy. This has been important to have surgery done as quickly as
useful in the diagnosis of early unruptured possible to stop the intra-abdominal
ectopic pregnancy. haemorrhage. Blood transfusion before surgery
should be given when available, otherwise
Laparoscopy plasma expanders can be used prior to surgery to
The direct visualisation of the pelvis at save the life of the patient. At laparotomy, the
laparoscopy gives a definitive diagnosis of bleeding points should be clamped as quickly as
ectopic pregnancy. Laparoscopy has certainly possible while suction of the haemoperitoneum
improved the diagnosis of ectopic pregnancy. In continues.
some developing countries, facilities for Surgery on the ruptured or
laparoscopy are not available and laparotomy is unruptured Fallopian tube may be
still resorted to where there is radical (salpingectomy-removal of the

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Prince Of Medicine-2014-BSUTH

104 Obstetrics and Gynaecology

whole tube) or conservative (partial ectopic tubal pregnancies occur commonly.

salpingectomy - segmental resection of the
tube). With the unruptured ectopic pregnancy, Abdominal pregnancy
conservative micro-surgical procedures such as Pregnancy in the abdominal cavity usually
salpingotomy, salpingostomy and "milking" of occurs secondary to a tubal abortion. Here the
the tube can be done. Salpingotomy is the embryo is extruded through the fimbrial end of
procedure where the pregnancy is removed the tube into the peritoneal cavity. Most embryo
from the tube through an incision on the
so extruded die and are absorbed. Occasionally
antimesenteric border and then a primary
the embryo may continue to grow and acquire
closure of the incision with fine nylon sutures.
blood supply from surrounding structures. The
Salpingostomy is similar to the above but here
embryo may grow up to term as an abdominal
the incision site is left open and allowed to heal
by secondary intention. In milking of the tube, pregnancy. Primary abdominal pregnancy,
the gestation sac is digitally expressed through where de novo fertilisation occurs in the
the fimbrial end of the tube. With improved peritoneal cavity, is rare. In abdominal I
diagnostic procedures, these surgical pregnancy, the fetus may die and become
procedures are now performed at laparoscope mummified to form a lithopaedion whose bones
Laparoscopic surgery for unruptured ectopic may be extruded through the abdominal wall,
pregnancies is still rarely done inthis country. rectum, bladder or pouchof Douglas.
Early unruptured ectopic pregnancies can Abdominal pregnancies still remain a
be treated medically also. Since early 1980, problem in developing countries. The common
successful treatment of early unruptured presentation is that of recurrent abdominal pain
ectopic pregnancy with methotrexate had been with all signs of pregnancy still present. On
reported. Methotrexate diluted in saline has abdominal examination, the fetal parts are
been injected into small ectopic gestation sac at easily palpable. Ultrasonography has
the time of laparoscopy inthe treatment of early improved the diagnosis of these cases as it
unrupturedectopic pregnancy. Local injections demonstrates the uterus separate from the
of progtaglandinF2ahave also beentried. fetus. Lateral X-ray of abdomen would show
In the medical treatment of ectopic fetal bones overlying the maternal spine.
pregnancies, there is need for selection of cases. Management is usually by laparotomy
Best results are for example, obtained with and extraction of the fetus, dead or alive. There
ectopic gestation sacs less than 2cm in is usually no difficulty with the extraction of the
diameter. Serial HCG monitor combined with fetus but the placentamay present difficulty as it
ultrasonography is necessary for follow up is usually embedded in highly vascular and
of medical treatment. In some centres vulnerable sites in the peritoneal cavity.
in developed countries, with adequate Attempts to remove the placenta from these
monitoring facilities, expectant management of sites may provoke severe haemorrhage. It is
small unruptured ectopic pregnancies is advised that the placenta be left in situ after
being studied. This is done with the belief clamping and cutting and removing the cord.
that spontaneous regressions of small The placenta may undergo autolysis.
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Bibliography and suggested further

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reading
O'Brien PMS, Grudzinkas JG (eds). (1997) Problems of Herbst A, Mishell DR, Stenchever MA, Droegemuller W
early Pregnancy - Advances in diagnosis and eds. (1992) Comprehensive Gynaecology. Mosby Year Book,
management. London RCOG. Pp. 457-490.

Lindblom B, Hahlin M, Lundorf P, Thorburn J (1990). Lawson JB, Harrison KA, Bergstrom S (2001) Maternity
Treatment of tubalpregnancy by Laparoscopy-guided Care in Developing Countries, RCOG Press Pp. 291-302.
injection ofProstaglandin F2»=.
FertiLSteril. 54:404.

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Chapter 14
Disorders of menstruation

1. Amenorrhoea Primary amenorrhoea

2. Dysfunctional uterine bleeding The first menstrual period is known as the
3. Dysmenorrhoea menarche. The age at menarche varies with the
society although it seems to be decreasing
Amenorrhoea universally; it usually occurs at age 12 or 13.
The World Health Organization defines
Amenorrhoea is essentially a symptom rather primary amenorrhoea as the absence of
than a disease entity. Amenorrhoea is the spontaneous menstruation in a woman who is
absence or cessation of the menstrual period. more than 16 years old.
Amenorrhoea may be physiological or
pathological. Two types of amenorrhoea are Physiological causes
recognised: primary and secondary. Primary 1. Pre-puberty
amenorrhoea is said to occur when spontaneous Before puberty, an insufficient release of
menstruation fails to begin in a girl of 16 years gonadotrophins results in failure to stimulate
of age. Secondary amenorrhoea is the absence normal ovarian function, thus resulting in
of menses for six months in a woman in whom delayed periods.
normal menstruationhasbeenestablished.
2. Adolescence
Oligomenorrhoea is menses occurring at an At this period of development, due to
interval exceeding 42 days. temporary inadequate ovarian stimulation by
the gonadotrophins, irregularity of
The incidence of primary amenorrhoea in the menstruation is frequent in the first 2 or 3 years
USA is said to be about 2.75% while that of after the menarche.
secondary amenorrhoea in the general
population is variable, from 3% to 100% the 3. Pregnancy and lactation
latter under conditions of extreme physical or Pregnancy is a major cause of amenorrhoea and
emotional stress. must beruled out inany patient presenting, with
amenorrhoea. Amenorrhoea in pregnancy is
Aetiology due to suppression of the FHS while in
Normal menstruation depends on an intact lactational amenorrhoea it is associated with
raised levels of circulating prolactin.
hypothalamic pituitary system stimulating the
ovary to produce oestrogen and progesterone,
Pathological causes
and a uterus that will respond to both hormones
and a patent vagina for the passage of the Chromosomal causes
effluent. Amenorrhoea may therefore be caused
by aberrations at any level of the hypothalamic i. Testicularfeminisation syndrome
(46XY karyotype end - organ resistance).
-
pituitary ovarian - uterineaxis.
Amenorrhoea may be physiological or In this condition the individual develops
pathological innature. phenotypically as a female lacking a uterus and
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BPP 3< i 112 Obstetrics and Gynaecology

sometimes following endometrial resection or Premature menopause does occur in some

ablation for menorrhagia. women before the age of 40 years. The condition
may be idiopathic or associated with other
ii. Tuberculous endometritis may also present as autoimmune disorders such as hypothyroidism,
amenorrhoea especially in developing countries hypoparathyroism, Addison's disease and
where there is a high incidence of tuberculosis. diabetes mellitus. Also ovarian resistance
(Savage's) syndrome can present with primary
iii. Uterine synechiae (Asherman's syndrome). ovarian failure. Patients with the syndrome have
This is also known as amenorrhoea traumatica. It elevated LH and FSH levels and the ovaries
arises as a result of formation of intrauterine contain primordial germ cells. A defect inthe cell
adhesions following over enthusiastic or receptor mechanism is the presumed cause. One
excessive curettage for termination of woman in three, diagnosed as having ovarian
pregnancy, evacuation for retained products of failure, unexpectedly ovulated and menstruates
conception, or late puerperal bleeding and some years after the diagnosis.
sometimes following manual removal of Also ablation or radiation will eliminate
placenta. The diagnosis is usually made responsiveness of the ovaries to gonadotrophins.
Post oophorectomy will also result in primary
following negative response from progestogen
ovarian failure, causing premature menopause.
challenge, or by hysterosalpingography as
multiple filling defects or total occlusion of ii. Granulosa-theca cell tumours If this is
endometrial cavity. present during the reproductive period,
amenorrhoea usually occurs due to large amount
of oestrogen synthesis by the tumour cells.

iii. Polycystic ovarian syndrome (PCO or Stein-

Leventhal syndrome)
This is a syndrome of oiigomenorrhoea or
amenorrhoea, hirsutism, sometimes obesity
together with infertility. The ovaries in such cases
consist of single or may be multiple small
follicles, a thick capsule and well developed
stroma tissues. The exact pathophysiologic
Figure 114.1 Asherman's syndrome (Uterine Synechiae)
mechanism is unknown but the current
The uterus shows a filling defect
explanation is that the condition is due to
inappropriate stimulation of the ovaries by the
Ovarian causes
gonadotrophins. The basal concentration of LH is
i. Premature ovarian failure (Primary ovarian raised, whilst that of FSH is relatively lower than
failure). a normal menstrual cycle. This is said to be due to
Primaiy ovarian failure is said to be responsible inceased androgen production. Follicles are
for 5% of the cases of secondary amenorrhoea. prevented from developing into mature ova. The
This is characterised by elevated gonadotrophins elevated levels of androgen (hyperandrogenism)
and low oestradiol. Some of these patients have a
can cause obesity, facial hair, and acne, but these
familial tendency to premature menopause.
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Prince Of Medicine-2014-BSUTH

Disorders of menstruation 113

Pituitary causes Destruction of the pituitary cells may also occur

following ablation and irradiation of the
Pituitary tumours - Pituitary hyperplasia and
pituitary as management of pituitary tumours or
adenoma resulting inhyperprolactinaemia.
following iron deposition in patients with
Under normal conditions prolactin production
by the pituitary gland is inhibited by the prolactin haemosiderosis.
inhibiting factor released by the hypothalamus. Hypothalamic causes
The mechanism of hyperprolactinaemia and
amenorrhoea is not very clear. However, Hypothalamic factors are said to contribute as a
hyperprolactinaemia resulting inamenorrhoea is major cause of secondary amenorrhoea. Loss of
said to be as a result of the effects of the raised LHRH pulse production - This can occur in the
prolactin suppressing the oestrogen mediated' following conditions:
release of GnRHfrom the hypothalamus thereby
i. emotional factors (environmental and
blocking the LH surge needed for ovulation and
psychosomatic). These factors are said to inhibit
also interfering with the actions of the
the release of the gonadotrophin-releasing
gonadotrophin on the ovary itself. So most
hormones (GnRH) or affect dopamine
causes of hyperprolactinaemia will result in
metabolism.
amenorrhoea. Other causes of
hyperprolactinaemia are dealt with later in this ii. severe depression (melancholia) -
chapter. Amenorrhoea is very common in these patients.
The depression could occur after a change of
Hypopituitarism (Sheehan's syndrome) - work, environment, separation or mental
Postpartum amenorrhoea results following disharmony.
postpartum pituitary necrosis, which is
secondary to severe haemorrhage and Other factors affecting the LHRH pulse
hypotension. This occurs during severe production are:
antepartum and/or postpartum haemorrhage but * acute and chronic illness
most commonly postpartum with shock, causing * acute starvation and anorexia nervosa
arrest of blood supply to the anterior lobe of the * excessive exercise and weight abnormalities
pituitary, and this may result in complete or (weightless)
partial ischaemic necrosis of the lobe. It is a rare Loss of pulsatile secretion due to diminished
condition. secretion of the releasing hormone from the
The degree of necrosis is directly related to the hypothalamus occurs when body weight has
severity of the haemorrhage and shock. All the fallen more that 25% belowthe ideal.
hormone- producing cells of the pituitary are
affected and absence of these trophic hormones Amenorrhoea and hyperprolactinaemia
profoundly alters body endocrine functions.
Apart from amenorrhoea, there is failure of Relationship between amenorrhoea and
lactation, deficiencies of the growth hormone, hyperprolactinaemia has already been discussed
melanotrophic hormones, adrenocorticotrophin, under pituitary tumours. Other causes of
thyrotrophic and gonado-trophic hormones. hyperprolactinaemia that may result in
The danger of the disease is thathypothermic amenorrhoea are:
episodes or hy pogly caemic coma i. Hypothalamic encephalitis, basal meningitis
occur frequently. and trauma.
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114 Obstetrics and Gynaecology

ii. Primary hypothyroidism: Serum TSH levels uterus. Also symptoms of thyroid, adrenal and
are elevated as a result of increased pituitary disorders shouldbe sought.
hypothalamic TRH release. This in turn Clinical examination noting the build and
stimulates the production of prolactin. sexual maturity of the patient, weight changes,
presence of hirsutism or acne, galactorrhoea and
iii. Drug induced: The sex steroids,
thyroid enlargement must be sought.
antidepressant and tranquillizers, oral
contraceptives, antihypertensives such as Abdominal examination to identify any
methyldopa or reserpine and certain abdominal scars, the presence and size of any
antihistamines such as maxolon. uterine or ovarian swellings. Pelvic examination
to ascertain presence of uterus or any ambiguous
iv. Nipple stimulation may increase prolactin genitalia as causes.
concentration by stimulation of afferent Every woman with secondary amenorrhoea
neurogenic pathways. must be considered to be pregnant until proven

v. Chronic renal failure in a decreased

otherwise, therefore before undertaking extreme
clearance of prolactin. and expensive evaluation, pregnancy should be
ruled out.
Other endocrine causes
Ifan underlying endocrine disorder is suspected,
1. Hypo and hyperthyroidsm
a useful approach would be to determine
2. Adrenal causes - Adrenal hyperplasia as part whether it is hypothalamic, pituitary or gonadal
of adrenogenital syndrome and of Cushing's in origin. The investigations considered are as
disease as a cause of ' amenorrhoea since follows:
androgens oppose the effect of oestrogen on the
1. HormonalAssays
endometrium.
i FSH and LH. In PCO the LH level
Diagnosis is raised, in ovarian failure the levels
of FSH is exceptionally high and if
A careful history and clinical examination along the FSH level is iow the problem
the listed causes will be necessary to make an lies inthe hypothalamus or pituitary.
accurate diagnosis.
Such history will include age at menarche ii Prolactinlevel. A raised prolactin
and development of sexual characteristics, level on two or more occasions
history of previous menstrual irregularity, family necessitates cone radiography, I
history of hirsutism, history of weight changes, tomograms and CAT scan or
dietary habits, hot flushes, galactorrhoea, MRI of the sella turcica to rule
medications such as the pill or anti out pituitary macroadenoma.
hypertensives, rigorous exercise, recent
emotional upset or psychological stress, ii TSH and serum T4. ElevatedTSH
previous surgery, dilatation and endometrial signifies thyroidism and this
curettage, previous deliveries, postpartum occurs in 1-2% of amenorrhoiec
haemorrhage, retained placenta and women. Hypothyroidism is said
laparotomy for uncoutrollable uterine to be unusual in women with
bleeding i.e. hysterectomy for ruptured normal prolactin level.
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Disorders ofmenstruation IIS

iv. In the presence of hirsutism, encouraging the woman to begineatingagain.

estimation of the ovarian and Menses and ovulation will return when the
adrenal hormones should be woman regains her normal weight.
undertaken. If there is hypothyroidism, treatment with
thyroxine isindicated.
2. Progestogen challenge test If hyperprolactinaemia is present, three groups
This test indirectly determines whether the ovary are identified:
is producing oestrogen. The test depends on the Group 1 - Largest group, they are made up of
fact that progesterone is unable to provoke patients with raised serum prolactin levels with
uterine bleeding in the absence of circulating no evidence of prolactinoma (functional
oestrogen necessary for priming of the hyperprolactinaemia). If they desire pregnancy,
endometrium. Medroxyprogesterone lOmg is bromocriptine is effective in inducing ovulation
given orally daily for 5 days or progesterone and return of menses. If not, they require 1-3
100-200mg intramuscularly as a single dose. If yearly interval assessment including CAT scan
this provokes normal menstrual bleeding within orMRI.
7 days it can be assumed that the woman has
normal circulating levels of oestradiol. Ifthere is Group 2 - Women with microadenoma (< 1Omm
no bleeding it can be concluded that there is no in diameter). They do not require treatment
oestrogen or that patient has Asherman's unless they are infertile or oestrogen deficient.
syndrome. They need to be assessedeach year.

Hysterosalpingography or Hysteroscopy is Group 3 - This is the smallest group of women

carried out to make a diagnosis of who have a tumour which extends out of the
Asherman's syndrome (Fig. 14. 1). pituitary fossa (macroadenoma). This group
requires treatment. Dopamine agonist such as
- In a patient who does not have Asherman's bromocriptine is the widely accepted primary
syndrome and does not respond to the treatment. It suppresses the secretion of prolactin
progestagen challenge test, the ovarian and causes the tumour to shrink by 90%. In
dysfunction may be of ovarian or patients who cannot tolerate this, lysuride or
hypothalamic origin. cabergoline has also been found to be very
effective as alternative therapy. Bromocriptine is
3. Diagnostic curettage or endometrial biopsy given in divided doses ranging from 2.5mg to
7.5mg daily and treatment is continued until
- In countries where tuberculosis is common, prolactin level is normal and thereafter
diagnostic curettage may beindicated.
continued at a lesser dose. During the period of
Treatment treatment, patient is followed up with regular
measurements of prolactin level, and annual
The treatment given depends on the identified CAT scan is essential. Surgery such as
cause of amenorrhoea. transphenoidal partial hypophysectomy or
In cases of emotional disturbances where radiation is only advised if treatment with
psychogenic or psychiatric factors are present, dopamine agonist fails or there is severe
appropriate counselling is all they need. In case headache and visual disturbances. This is
of weight loss, treatment should be directed to because the surgery may be complicated causing

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hypopituitarism, and recurrence of hyper- Otherwise others that fall into the idiopathic
prolactinaemia post operatively has been premature ovarian failure group cannot be made
reported in 20% of such cases. If pregnancy to ovulate. Treatment may be needed to control
occurs after treatment such patients should be menopausal symptoms. In vitro fertilisation
monitored by clinical symptoms and (IVF) with donor oocytes is the only way they
bromocriptine treatment discontinued. canhave children.
Adrenal hyperplasia is treated with Ashermaris syndrome is treated by division
cortisone. In hypothalamic - pituitary of uterine adhesion followed by insertion of a
dysfunction, if the body weight is normal and non copper intrauterine device such as lippes
FSH or LH, Prolactinand TSH levels are normal, loop to prevent recurrence of adhesions and to
ovulation can be induced in over 80 percent of allow endometrial development to occur. Where
women using clomiphene initially or tamoxifen facilities exist, hysteroscopy assisted lysis is
or cyclofenil. Gonadotrophins are used if any of done rather than blind dissection with uterine
these fails to induce ovulation. The progestogen sound as commonly done in our environment.
challenge test helps to determine the best Proliferationof the endometrium can be aided by
approach to treatment and if withdrawal the use of ethinyl oestradioPor stilboestrol for
bleeding has not occurred following the test, 14-21 days. Once the patient has hadthree to six
clomiphene alone is unlikely to be successful. If normal menstrual cycles the intrauterine device
progestogen stimulation fails, gonadotrophins canberemoved.
are used. Commonly used is pergonal, a mixture
of FSH/LH in 1/1 ratio, also known as human Prognosis
menopausal gonadotropin (HMG). This is
combined with human chorionic gonadotrophin With appropriate therapy based on correct
(HCG). Inthis regimen 3 ampoules of HMG are evaluation, the prognosis for secondary
given on days 1,3 and 5 followed by HCG 10,000 amenorrhoea is good. Majority of those who
unit on the day the main follicle has reached 20- wish to be pregnant become pregnant provided
25 mm in diameter using ultrasound there are no other causes of infertility: virtually
measurement. Occasionally gonadotrophin
all amenorrhoeic women who do not have
releasing hormones (GnRH) in pulsatile doses premature ovarian failure can be made to ovulate
with bromocriptine, clomiphene citrate, j
given subcutaneously or intravenously are
sometimes administered using battery-operated corticosteroid, HMG or GnRH.
auto-infusion pump. Dysfunctional Uterine Bleeding
Polycystic ovarian syndrome is treated by
inducing ovulation with clomiphene and Dysfunctional uterine bleeding (DUB) is an
recently GnRH are in use. Where amenorrhoea abnormal uterine bleeding in which there is no
persists inPCO despite therapy, such patients are organic cause. Normal menstruation is a
treated surgically by wedge resection of the complex process involving functional reciprocal
ovaries. interrelationship between the hypothalamus,
In patients with primary ovarian failure pituitary, ovaries and the endometrium. A
(premature menopause), ovulation induction is normal cycle has interval of about 28 days with a
almost impossible except in rare circumstances. range of 20 to 40 days considered as normal,
Patients with reversible ovarian failure include duration offlow normally varies from 2 to 7 days
those with autoimmune oophoritis who can and the volume average is 30 to 180 mis with
successfully be treated with corticosteroids. most women using 3 to 5 pads per day.

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mmmmmDisturbances in the reciprocal relationships and

Disorders ofmenstruation H&: j.

spontaneous cure is the rule. However, when it

BR |

the effect of emotions are involved inmany cases occurs in premenopausal women, a diagnostic
of abnormaluterine bleeding. endometrial curettage is strongly advised to rule
DUB may be psychological in origin, in out carcinoma of the endometrium.
which acting through the hypothalamus may
impair the normal reciprocal release of 3. Cyclical bleeding at long intervals - This
gonadotropins, and consequently affect normal describes menstrual periods that occur at regular
ovarian steroid production thus influencing the intervals of more than 35-40 days. The cycle is
degree of endometrial stimulation.The degree of prolonged and is said to be generally due to
hormonal influence varies and consequently the prolongation of the follicular phase. The
endometrium may show a variety of histological condition may be due to ovarian, pituitary or
pattern. hypothalamic causes.
Dysfunctional uterine bleeding may be If however this condition occurs irregularly,
associated with ovulation in which there is then it may be the beginning of oligomenorrhoea
persistent corpus luteum cyst or short luteal or amenorrhoea of the polycystic ovarian
phase. However most often it is associated with syndrome.
anovulation. The exact cause of the anovulation
Anovulatory dysfunctional bleeding
is not truly understood but probably represents
dysfunctions of the hypothalamic pituitary This group is the most common type of
ovarian axis resulting in continued oestrogenic dysfunctional uterine bleeding seen in the
stimulation of the endometrium. tropics, and it is an example of an oestrogen
withdrawal or oestrogen breakthrough bleeding.
Ovulatory dysfunctional bleeding The condtion is commonly found inpostpubertal
teenagers and at the climacteric and the bleeding
1.Mid-cycle spotting - This usually occurs at the is prolonged. The exact cause of anovulation is
time of ovulation i.e two weeks after the last not properly understood but it is said in general
menstrual period in a 28 - day cycle. It is as a
result of endometrial shedding which occurs due
to be due to dysfunction in the hypothalamic -
pituitary - ovarian axis.
to temporary fall in the level of oestrogen at the
time of rupture of the Graafian follicle. It i. Menorrhagia - Inthis condition the menstrual
consists of slight bleeding per vaginam but bleeding is heavy or prolonged and it may occur
occasionally the flow may be substantial. at regular intervals.
Histology reveals a late proliferative
endometrium. ii. Metrorrhagia - Also known as Metropathia
haemorrhagica. In this condition the bleeding
2. Ovulatory polymenorrhoea - Cyclical occurs irregularly. It occurs predominantly in
menstrual bleeding at short intervals. In this post adolescence and premenopausally. The
condition the period is cyclic, and occurs at too amount and duration of bleeding is variable. It

I
frequent intervals only 18-21 days with a follows a period of amenorrhoea of 6-1 Oweelcs
follicular phase of only 4 -7 days and a constant and is painless. This condition is said to occur
secretory phase of 14 days. The condtion occurs due to continued oestrogen stimulation of the
as a disturbance in the rhythmic disturbance of endometrium inducing a poliferative
die gonadotropins from the pituitary. It is endometrial hyperplasia, otherwise known as
commonly seen in.early adolescence and cystic hyperplasia. Due to the absence of
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118 Obstetrics and Gynaecology

progesterone, the endometrium attains an Pelvic examination will involve both

abnormal height without local structural speculum and digital examinations. Speculum
support. It thus overgrows its blood supply, examination will rule out lesions in the vagina
partially breaks down and is sloughed in an and cervix such as vaginitis, vaginal ulceration,
irregular manner and consequently resulting in cervical erosions, cervicitis or cervical polyp.
opening of the multiple vascular channels. Digital examination will assess the size and
The excessive oestrogen so produced shape of the uterus, and the ovaries. Pap smear
inhibits the pituitary with resultant decrease in may betaken at this time.
FSH and diminished stimulation of the ovarian
theca cells. Oestrogen levels then fall and
Investigations
withdrawal bleeding occurs. 1. Full blood count is usually done to rule out
anaemia and blood dyscrasias.
Management 2. Cytology examination is done to rule out
Clinical history
cervical pathology.
3. Endometrial biopsy: This test allows
Inthe management of this conditionexclusion of histological diagnosis of ovulatofy
pathological causes of abnormal uterine endometrium, endometrial hyperplasia or
bleeding is essential to establishthe diagnosis of carcinoma.
dysfunctional uterine bleeding. Therefore a 4. Basal body temperature chart (BBT) for 3
careful gynaecological history and pelvic consecutive months. The pattern is biphasic in
examination are essential. Possibility of ovulatory bleeding and monophasic in
pregnancy must be considered as well as the use anovulatory bleeding.
of oral contraceptive pills, I.U.Ds. and 5. FSH,LHandProlactinlevels.
hormones. Apart from these, the history will 6. Thyroid and adrenal functions tests
includethe number of pads, the presence of clots 7. X-ray of the sella turcica or CT scan
inthe menstrual flow, the length of the menstrual 8. Hysteroscopy - direct visualisation of the
cycle, duration of flow of menstrual period and endometrium.
intermenstrual bleeding. History of menarche
Treatment
and menopause must be sought. History of
previous pelvic operations especially those Not all the patients will need interventional
involvingthe ovaries is very important.A history treatment Observational therapy i.e reassurance
of emotional stress or tension, recent weight gain may be all that is necessary in some of the
or loss, and symptoms of thyroid dysfunction postpubertal girls with ovulatory mid-cycle
should be noted. History of galactorrhea, spotting. The treatment given depends on the
headache or visual disturbances may suggest type of dysfunctional uterine bleeding
pituitary abnormality. Physical examination
directed at signs of pituitary, thyroid, adrenal I. For mid cycle spotting. This may be
disorders acne, obesity and hirsutism is effectively treated with 2 to 3 months course of
mandatory. Also, the abdomen should be oral contraceptive pills.,
examined for enlarged uterus taking cognisance ii. Pre-menstrual spotting. Treatment of this
of the size and shape to rule out myomas or condition is with progesterone therapy, which is
pregnancy and also for ovarian cysts/masses. commenced from day 18 to day 25 in order to
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Disorders of menstruation 119

control the excessive flow and to restore normal 2. Secondary (pelvic pathology is present)
corpus luteum function. Oral contraceptives 3. Mernbranousfeafet ofEndometrial cavity is
may also be given for 3 - 6 months if pregnancy shed as a single entity).
is not desired.
Primary dysmenorrhoea
iii. Ovulatory polymenorrhoea - If it occurs in
women in their twenties and thirties, oral This is also referred to as spasmodic or true
contraceptive pill is used for 3 consecutive dysmenorrhoea. It is most frequent in virgins,
cycles so as to produce artificial anovulatory 28- arises few months to S years after menarche and
day cycle. After that it is stopped and normal maximal between 15 and 25 years of age. It is
menstrual cycle will resume. less frequent in married women and practically
never a problem in parous women. It almost
iv. Cyclical bleeding at long intervals. Such invariably occurs inovulatory cycles. The pain is
patients should be thoroughly investigated and colicky in nature, intermittent in character and
therapy is only given when the cause is that is why the disorder is referred to as
identified. spasmodic dysmenorrhoea. Pain normally starts
few hours before onset of menstrual bleeding
Anovulatory dysfunctional uterine bleeding and persists throughout the first 12-48 hours of
menstruation. Nausea and vomiting, diarrhoea
This is treated with cyclical progestogens for 3 and headache may occur. Physical examination
consecutive months. 50% of these receive does not usually reveal any significant pelvic
spontaneous cure after a diagnostic curettage is pathology.
carried out and having excluded malignancy. In The pathophysiology of primary
premenopausal women, hysterectomy shouldbe dysmenorrhoea has only recently beenattributed
considered if there is recurrence of bleeding to prostaglandin activity leading to uterine
following curettage. myometrial hypercontractility as prostalandins
are found to be present in much higher
Dysmenorrhoea concentrations in women with dysmenorrhoea
than in those-with mild or no pain. Also
The term dysmenorrhoea means painful psychological factors and emotional anxieties
menstruation. It is one of the most frequent due to academic or social demands may be a co-
gynaecological complaints, being a symptom factor.
complex and not a disease. Many women
experience mild discomfort during Treatment
menstruation, but the term "dysmenorrhoea" is A. Medical
reserved for those whose pain prevents normal
activity and requires medication. Itoccurs in30 - Most cases of primary dysmenorrhoea will
50-% of post pubertal females and 10 percent are respond to prostaglandin antagonist or to
suppression of ovulation.
incapacitated for 1-3 days each month. Three
types of dysmenorrhoea are described: a. Prostaglandin synthetase inhibitors-
Acetylsalicylic acid (aspirin). Naproxen,
1. Primary (no detectable pelvic pathology
Ibruprofen. They act by reducing synthesis of
or organic cause)
prostaglandin.
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128 Obstetrics andGynaecology

They are found to offer considerable relief to menstruationand is usually relieved on day 4-
especially inmildto moderate cases. 5 of bleeding.
b. Drugs reducing prostagladin synthesis and Secondary dysmenorrhoea is usually associated
opposing its actions on the tissues - This with:
group is found to be more effective and very
useful in severe cases. Such drugs as 1. Endometriosis/adenomyosis
mefenamic acid 500mg 8hrly, flufenamic 2. Pelvic infections (especially chronic PID)
acid 2Q0mg 8hrly are found to give 3 . Intrauterine contraceptive device
excellent reliefinmore than 85 % of cases. 4. Fixedretroversion of the uterus
5. Uterine fibroids, fibroid polyps
c. Oral contraceptives
6. Cervical stenosis
Cyclical administration of oral
contraceptives to suppress ovulation over a The treatment is aimed at the underlying
period of 6 -12 months offers a great relief. gynaecological disorder and this has been
Many women continue to be free of pain described elsewhere inthis book.
after treatment has been discontinued.
d. Analgesics and antispasmodics Membranous dysmenorrhoea
Drugs such as Codeine, Buscopan, Baralgin
would have been tried by most girls (2 This is the painful passage of an endometrical
tablets four times a day) before they consult cast of the uterus.
a doctor. They do provide good pain relief in
some patients especially in the mild to Aetiology
moderate cases. The aetiology is not known but has previously
been attributed to endometritis though there is no
B. Surgical histological evidence of history ofinfection. The
In a few women, no relief is achieved with cause has also been linked with excessive
medical treatment. Cervical dilatation, development of a premenstrual secretory
uterosacral ligaments division and presacral endometrium.
neurectomy had been tried and even sometimes
hysterectomy. These had not been found to be a Clinicalfeatures
substitute for medical treatment in primary The disorder is rare. The patient is usually young
and the painful periods date from puberty. The
dysmenorrhoea and failure to achieve relief only
periods are often heavy and prolonged. On the
points to the need for the doctor to search for
organic pathology such as endometriosis,
second, third or fourth day the cast is passed
accompained by intense colicky abdominal pain,
adenomyosis or uterine abnormalites.
nausea and vomiting. The pain ceases after the
Secondary dysmenorrhoea cast is extruded.

This is seen in older women, uncommon before Pelvic examination may reveal no abnormally but
the age of 30 years. The pain begins 4-5 days prior in some reported cases the uterus hasbeen found to
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Disorders ofmenstruation 121

be small or retroverted or hyperplastic andhard. International, Inc., London, Pp. 662 - 669.
Treatment - Dilatation and curettage usually 3. Giwa-Osagie O. O. F. (1988) - Disorder oj
fails to give any relief. Combined contraceptive menstruation In Textbook of Obstetrics ana
pill to suppress ovulation for a couple of months Gynaecologyfor MedicalStudents. Akin Agboola ed..
may offer acure insoipe cases. Univerity Services Education Publishers, Lagos. Pp
136-157.
4. Llewellyn-Jones, D. (1990) - Abnormal Uterine
Bibliography and suggested bleeding In Fundamentals of Obstetrics and
Gynaecology, Vol 2, Gynaecology, Wolfe Publishing
further reading Ltd.,London, Pp. 63-70.
1. Browne, F. J., McClure Browne, J. C. (1964):
Postgraduate Obstetrics and Gynaecology 3rd ed. 5. Llewellyn-Jones, D. (1990) - Amenorrhoea and
Butterworths, London, Pp. 212 - 213. Oligomenorrhoea InFundamentals of Obstetrics and
Gynaecology, Vol 2 Gynaecology, Wolfe Publishing
2. Gerbie, M. V. (1994) - Complications of Ltd.,London, Pp. 7 1-80.
Menstruation; Abnormal Uterine Bleeding in
Obstetrics and Gynaecologic Diagnosis and 6. Thorney Croft., I. H. (1994) - Amenorrhoea
Treatment, Dechemey H. A. and Pernoll, M. L. eds, In Obstetrics and Gynaecologic Diagnosis and
8thed., Prentice-Hall Treatment, Dechemey H. A. and Pernoll, M. L. eds,
8th ed., Prentice-Hall International, Inc., London, Pp.
1007-1015.

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Chapter 15

Scngtl (Mkmal) ScxfE rn (Kmktbm

Fxn3
ftriaweiai rracrs
Superiktsi Eado >3cm SuwrScai Sax >xa
R- Orrrj R.Tebe
Supcrfkiil Eado <lcn rim" Aÿtcsians *-:ÿ3
Fifav Achesccs <13 R-Oary
Total poena Fieri AiKxras <33
LTeW
Stase 't&eSMS < ."•
L Otri
Deec Sox <-*cn
Fallopian tube ttesK •Aesn.-rei <3.3
Tool pawns
'F'xa nsccanea; cnmaec

Stage II (MtkJ) Stage IV ('Seeerri

Poos Foots
Ptritoaeam PeriseBcim
D«c Eirio >3an 6 Saxrknsi Ei»x
R. Ovnry L. Oarr
Snxrfioil E-ido <lcm 1 DecoEni?
Filmy Adheswas <13 1 E»ase A&eRoes
L, Ovnrv LTnie
SuperSc.il EaJo <1,3 I DesseAihaasss
Total points 9 TesJ poind 53
"FHxi tssÿecxa: axcioi

Stage ID (Moderate) Stage TV (jcrcre.)

Pouas Fwss
ry_ •r
Peritoneum ia KIMCIII

DeepEmJo >3cm 6 Superivai Eax- "•sea e

Cri-dc-sac CnMe-nc
Pnmal Obliteration 4 Compose Ofctaenatc ÿ«
L. Ovary R. Owt
Deep I-3an 16 DespEsfc 1-3 . 16
Total poats 26 Dorse Ada-aas >13 4
LT*ke
DeaseAAesoas >23 16
L Oary 4
Deep )-3cra 16
Dose Adbescns >23 16
Teed pwBti 114

Table 15.1 The American Fertility Society Revised Classification of Endometriosis

Examples and Guidelines

Bibliography and suggested further

reading Montir.6{5) 1042-6.
Abdalla, H, and Rizk, B. (1998). FastFacts Series. Health
Bergqxist Act all (2001). biterleukins Ibetam.
Press, Oxford
Interleukin-6, and tumour necrosis factor - all in
Barbieri, R. L. (1998). Stenosis of the external os: cm endometriotic tissue and in endometrium. Fertil.
association with endometrisis in women with chronic Steril. 75 (3)4S9-95.
pelvicpain. Fertile. Steril 70,57 1-3.
Kosugi, et all (1999). Increased heterogeneity of
Barcz, Kominski P, Marianowski L. (2000). Role of chromosome 17 aneuploidy in endometriosis. Am.J.
cytokines inpathogenesis ofendometriosis, Med Sci. Obstet. Gynecol. 180:492-7.

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Prince Of Medicine-2014-BSUTH

Chapter 16

Infertility
Infertility is a worldwide problem. an infertile couple are similar worldwide. These
Developments inthe investigation and treatment include (a) to accomplish a thorough
of infertile couples and the dissemination of this investigation (b) to treat any abnormalities
knowledge, have meant a new hope for the detected and discuss the chances of success (c) to
infertile couple. Infertility may sometimes educate the couple (literate and illiterate) on the
ordinarily be called "childlessness", but it is to be requisites for normal fertility, (d) to provide
differentiated from sterility which is more emotional support for the patients (this may be
absolute or finite and refers to an irreversible very important in the traditional African society
state. For example, a woman who has congenital where fertility reflects a woman's status). The
absence of the vagina, can be said to be "sterile". attainment of the above goals in this country is
Infertility, is the inability to achieve a pregnancy, hampered by: (i) inadequate facilities to
despite regular, unprotected intercourse. It may thoroughly investigate and treat these patients
be primary, when no pregnancies ever resulted (ii) in the unusually busy gynaecological clinics
from the marriage, or secondary, when previous with few specialists, the emotional support is
pregnancies have resulted, irrespective of the often neglected and time does not usually permit
outcome of these pregnancies - abortions or a detailed discussion with the couple and this
ectopic pregnancy. may explain the high rate of "doctor shopping"
It is estimated that 60% of married couples by patients. The role of "quacks" (dispensary
having regular, unprotected intercourse, would attendants, traditional healers, and chemists)
achieve pregnancy after 6 months of further complicates the issue, (iii) the degree of
cohabitation. At the end of 12 months, up to 90% pelvic inflammatory disease following post
would have achieved pregnancy. At the end of 18 abortal and puerperal sepsis, and lately, sexually
to 24 months, 95% would have achieved transmitted disease, is usually severe, leaving
pregnancy. Infertility may therefore be irreparable damage to the Fallopian tube, (iv)
diagnosed after one year of cohabitation and traditionally, the extended family system makes
regular unprotected intercourse, has failed to the African woman a keeper of her brother's or
achieve a pregnancy. There is however, a need sister's children, yet adoption has not met total
for less rigidity about the definition of infertility acceptance in this society. Adoption is not
as regards the duration of exposure. The age of covered by the laws of this country. It is
the wife should be taken into consideration. therefore, sometimes not wise to tell these
Fertility is maximal betweenthe ages of 18 and women that they cannot have children. This may
24 years. It declines after the age of 35. it may break an otherwise happy marriage. Polygamy
therefore, be necessary to investigate a 35 year tends to absorb some of these shocks.
old woman after a short duration of exposure Polygamous marriages in our infertility clinic
while an 18 year old wife may be investigated are as highas 20%.
after two or more years ifthe history and physical
examination appear "normal". An 18 year old Incidence
wife who gives a past history of termination of
pregnancy with morbid postabortal period In developed countries, infertility affects about
shouldbe investigated at once. 10% to 15% of married couples. InNigeria, the
The goals of any medical practitioner managing incidence varies from 20% to 30%. Despite the
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Prince Of Medicine-2014-BSUTH

Infertility 129

growing concern about overpopulation and Clinical history

undernutrition in Africa, it is estimated that
about 30% to 40% of women in sub-Saharan It is a good practice to interview both partners at.
Africa, would complete their reproductive years the initial visit. In this country, the woman is
without having a child.This may be relatedto the usually the first to request for help. It is
high incidence of genital infection, and makes sometimes difficult to enlist the early co¬
infertility a public health concern in some parts operation of the husband. "There is nothing
ofAfrica. wrong with me, it is my wife that needs to be
investigated". Such statements are common
Aetiology among male partners at the initiation of the
investigations. This should not deter the
An understanding of the requisites for normal practitioner. Early educationonthe requisites for
fertility is essential in establishing aetiology. normal fertility usually helps to bring some of
Healthy spermatozoa must be deposited in the these men around. A detailed history from the
vagina and at the cervical os, (Male factor). woman is a very important step in the screening
These spermatozoa ascend through a receptive process of the infertile couple. The use of a
mucus produced by the cervix, (Cervical factor). translator in obtaining a history from illiterate
They pass through the uterus into a normal patent patients is common practice in this country. It is
Fallopian tube, (Tubal factor). The ovary important that the question put to the patient is
produces a mature ovum (Ovulation factor), understood by him or her, otherwise the wrong
which is picked up at the right time by the answer is obtained.
fimbriae of the Fallopian tubes. The mature Female, The duration of infertility, previous
ovum is transported to the ampulla where
reproductive and sexual experiences, menstrual
fertilisation takes place. After fertilisation, the
pattern, gynaecological and obstetrical history
embryo must travel through the normal patent and previous contraceptive history should be
Fallopian tube to the uterine cavity. Endometrial obtained. Sexual history must include the
conditions must be favourable (Uterine factor) frequency of intercourse, any postcoital
for implantation to occur. Peritoneal adhesions practices and extramarital activities if any. In
from previous surgery or infection, and our busy gynaecological clinics, patients are
endometriosis, may distort the Fallopian tube or reluctant to respond to some of these questions
cover the ovary, making the physical rupture of but it is important to obtain this history.
the Graafian follicle difficult Simplified as this Traditionally, women from polygamous
may seem, the processes describedabove require marriages have reduced frequency of
a fine endocrine balance to occur. The intercourse and because of the "shared time",
achievement of a normal pregnancy must intercourse may take place at the "safe periods."
therefore be seen as a test of the anatomical and Postcoital douching is also practised in some
functional integrity of the endocrine and traditional African societies. The menstrual
reproductive systems of both sexes. The major history should include age at menarche, duration
causes of infertility are (a) Male factor (b) of menstrual flow, amount of blood loss, cycle
Cervical factor (c) Tubal factor (d) Uterine factor length, and dysmenorrhoea. "Scanty flow" or
(e) Ovulation factor and (f) Peritoneal factor. "dark blood" may be used by patients merely to
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BSUBMWro

find 2 cause for their infertility. So also may the infertility.we have not seen a case in this country
description of hiiigraiory pain round the body"'" attributed solely to this cause. It may be useful to
of the patter:.. Gynaecological history should avoid wearing such undent ears if no other cause
include previous consultations and operations. for infertility can be identified.
Diktarion and Curettage (D&C) is erroneously
thouÿi by most patients to he the cure for Clinical findings
asfeCifiy. Repeated D&Cs are done by quacks
and medical practitioners alike, as patients insist Female: A thorough physical examination is
on 'washins out their wombs..* History of usually required. Nutritional status should he
previous fertility operations such as assessed and anaemia must he excluded. Height
conventional tuboplasty, myomectomy. and weight are recorded. Evidence of thyroid
% esSrosuspenston. ssd ovarian wedge resection
disease should 're sought. Breast development
should be assessed and the breasts must he
parttctha: attention should he -given to the last
confinement. Puerperal and pasterortai sepsis carefully examined for any presence of
are common causes of pelvic mriammalory galactorrheea (abnormal secretion of breast
disease. The history of previous abortions is milk). The presence of galactorrhea will alert
sometimes withheld by patients because the practitioner on the need to determine the
tsmsmSLm of unwanted pregnancy is still not level of serum prolactin. There is a relationship
covered by me law? of this country. Fast medical between hyperprolactinaemia and anovulation
and surgical history should be recorded. The use (failure to ovulate). Excess hair distribution ii
cf drug's, akohol and tobacco should be sought. the female hirsutism) should also he noted. The
1: is so,merries necessary to ask piatients to bring presence of scars (from previous operation) or
the drugs to the cumc fee menuhear o m the abdomen and masses in the abdomen are!
important. Leiomyomas uteri tend to be large!
Mwk:: A detailed hlsuory should he obtained
and multiple in this area. Pelvic examination
from the male partner. The occupation may be
important! A truck driver who travels long aims at detecting any abnormalities of external
distance awsy horn home every week would and internal genitalia Extensive pelvic adhesive
ÿrtBafi}' not itsve regular intercourse. He may disease should alert the practitioner on tubal acq
also have nrafSirle sexual partners in peritoneal factor.
exErmEaarital affairs and haÿe sexually
trarsmfried infernocs with damage of the vas Jfiafer A general physical examination is done.
deferens. Frequency oicoitas, mrkntnuao-fy and Particular attention is given to the genital tract.
venereal crseases and ooegem'tai mauonmahacs the size, position and consistency of the testes.
amecmrg the reproductive- organs should be status of the vas deferens and epididymis
sough:. Previous medical and surgical presence of a varicocele, and the consistency ofj
procedures shornd be encuzrec into. The 'use of the pro-state.
mugs, arc habits such as smoking and use of
__
aico '-lx.. . s.jioguw re so..,.a .. 1* k . .i.* a ~se is
I.mves:tigatiiO'iii:s
assacdsited with decreased srerm count.
Malefactor: Semen analysis isthe most imiportaal
assessner: cf the male fact.cr in infertility. It q

mcerwear has :her beer c nee as a cause cf male ::: tats urv cstt cation. Tnis is mors so id
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polygamous marriages in this country. It is the testicle may confirm this. The testicular
however a good practice to obtain semen for failure may result from mumps orchitis.
analysis irrespective of claim of past paternity or Testosterone levels in blood may be measured
present pregnancy from one of the other wives. and will be low.
Semen is best produced for analysis by Volume 1.5ml
masturbationbut may be obtained by interrupted
coitus. Sterile wide mouthed specimen bottles Count 20 million/ml
should be used for collection. There should be Motility 60%
abstinence from sexual intercourse for 2 to 3 Morphology 60% normal forms
days before collection. Condoms should not be
Cells (WBC etc.) None
used as these contain spermicides. Production of
semen specimen within the hospital premises is Table 16.1Minimumcriteria for normal semen
not popular among male patients in this country.
Semen produced at home must be transferred to If FSH and LH are normal in men with
the laboratory as soon as possible. In the azoospermia, it usually indicates obstruction
laboratory, a wet preparation is made and quick along the seminiferous tubules. In this country,
assessment of motility is done. A sample of
this is a common sequela of infectious process
semen diluted with 1 percent formalin indistilled
from sexually transmitted diseases and
water is then placed into a haemacytometer for
tuberculosis. Vasography is mandatory to
counting. The Makler chamber may be used
demonstrate the vasa deferentia and seminal
instead of the haemacytometer for research
vesicles. Surgical exploration to determine the
purposes. A semen smear should also be stained
site of the block may be undertaken.
to study the sperm morphology. Because of the
known variability in the results of semen Oligospermia may be due to severe acute illness
analysis, a final diagnosis based on the quality of or a chronic disorder such as tuberculosis.
semen should only be made after three Certain drugs may also depress the sperm count.
consecutive analyses at least three weeks apart. Oligospermia may be reversible. If there are
The minimum criteria for normal semen is numerous pus cells in the semen, this usually
shown in Table 16.1 Azoospermia refers to indicates inflammatory disease of the prostate
complete absence of spermatozoa from the and seminal vesicles. Specific micro-organisms
ejaculate while oligospermia refers to reduced can be grown by the microbiology laboratory.
sperm density or count, usually less than 20 Asthenozoospermia refers to decreased sperm
million per milliliter. These terms have to be motility. True impaired sperm motility is
differentiated from aspermia which means difficult to treat but reduced motility may be due
absence of semen. Azoospermia may result from to the semen being collected in a condom, long
testicular failure or blockage of the seminiferous time interval between collection and
ducts with normal spermatogenesis occurring in examination in the laboratory or storage of
the testes. Follicle stimulating hormone semen in the refrigerator before transfer to the
FSH) and Luteinising hormone (LH) should laboratory. Finally, antisperm antibodies in
be measured. Testicular biopsy should also be serum and seminal plasma may also cause
done. High FSH and LH may signify testicular infertility. The litres of these should be
failure. The histology of biopsy taken from determined.
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132 Obstetrics andGynaecology

Cervical factor: The cervix is the gateway intercourse, the patient is examined anc
through which the spermatozoa must pass into endocervical mucus aspirated from the cervix.
the uterus on its way to the site of fertilisation in and examined under the microscope. The
the ampulla. The endocervical cells produce a number of spermatozoa inthe mucus is assessed.
complex secretion called the cervical mucus. so is the motility (forward progression or shale.
One of the important constituents of the mucus, motion). The presence of at least 6 spermatozoa
is glycoprotein. The mucus has certain physical per high power field, with forward progressive
properties such as viscosity, flow elasticity, motion and a Spinnbarkeit of more than 6cm, is
capacity to draw into threads (Spinnbarkeit) and considered a positive test. A negative test needs
stickiness. These properties are mainly due to the some caution in the interpretation. A negative
glycoprotein content of the cervical mucus and test in the presence of poor cervical mucus ma}
are regulated by the circulating levels of merely be due to inappropriate timing of the test
oestrogen and progesterone. At periods of high The presence of antisperm antibodies in cervical
levels of oestrogen, copious but watery amounts mucus may be a cause of a negative post-coital
of mucus are produced while high levels of test, and is indeed a recognised cause of
progesterone cause the production of scanty but infertility. Serum and cervical mucus levels of
thick mucus. These variations in the type of antisperm antibodies may be determined.
mucus produced affect the ability of sperm to
penetrate and survive in the cervical mucus. Tubalfactor
Sperm penetrability is best around the period of The human Fallopian tube is a dynamic organ.
ovulation. Evaluation of the cervical mucus, a The myosalpinx, endosalpinx with its secretory
few days before ovulation would help determine and ciliated cells, and the tubal fluid secreted by
whether the mucus is favourable or hostile to them, play an important role in the transport]
spermatozoa! penetration. Mucus can be nutrition and survival of the spermatozoa,,
collected from the endocervix with the use of the oocytes, and the early embryo. Ovarian steroids
tuberculin syringe. The mucus is examined for have a direct influence on the function of the
the amount, Spinnbarkeit, cellular content, and Fallopian tubes and the transport of the embryo.
ferning. Ferningrefers to the crystal formationof Damage to tubal function commonly follows
the cervical mucus on drying on glass slide. This pelvic inflammatory disease due to gonorrhoea,
property of cervical mucus is most marked at the puerperal and postabortal sepsis, and
pre-ovulatory phase of the cycle. tuberculosis. Tubal occlusion may alsd
accompany extensive peritubal adhesions
Post-coitaltest: This is done to assess the ability following previous surgery for acute
of the spermatozoa to penetrate and survive inthe appendicitis, ovarian cyst or peritonitis. Tubal
cervical mucus. Inthis test, the couple is advised factor is particularly important in this country.
to abstain from sexual intercourse for 2 to 3 days. is also usually severe because of the inadequate
Itisbestdone inthe pre-ovulatory phase of the cycle self-medication by patients. Tubal factor m
as close to the ovulation as possible. Thebasal body usually diagnosed by (i) Hysterosalpingogramj
temperature chart is used to help determine a (ii) Tubal Insufflation (iii) LaparoscopJ
suitable time for the test. A few hours after Hysterosalpingogram (HSG). This procedure is I

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Prince Of Medicine-2014-BSUTH

Infertility 133

best performed between day 7 and day 12 of a 28

day cycle. A water soluble radio-opaque contrast
medium is preferable although oily medium is
sometimes indicated. It is an outpatient
procedure and aseptic technique is required. No
special preparations are necessary although
anxious patients may require analgesic/sedatives
while antispasmodics may be required to prevent
tubal spasm. The contrast medium is injected
through a uterine cannula (Leech Wilkinson or
Williams) into the uterus and Fallopian tubes.
Adequate amount of contrast medium should be
injected and radiographs are taken (fig. 16.1).
Where facilities exist, an image intensified
television fluoroscopy is an advantage. When
properly performed, valuable information can
often be obtained which may include fimbrial
occlusion with hydrosalpinx formation (fig. 16,
2a,b), uterine anomalies (fig. 16.3a, b),
Asherman's syndrome (fig. 16.4), tubal polyps,
salpingitis isthmica nodosa, pelvic adhesions, and
tuberculosis. The procedure is not totally devoid

Figure 16.3a Bilateral hydrosalpinges

16.1 Normal findings at HSG

Figure 16.3a Bicornuate uterus

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Prince Of Medicine-2014-BSUTH

134 Obstetrics and Gynaecology

sfil _i »:S Ife J sL IBiSSlb — SB & «

_ _5
gynaecologists.
Laparoscope?:This procedure is complementary
to an hysterosalpingogram. It provides certain
information about the pelvic organs which may
not be diagnosed at HSG. It is always a
necessary procedure before Fallopian tube
surgery. This procedure is described in detail in
other chapters of this book.

Ovulation factor: The ovary serves the dual

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Prince Of Medicine-2014-BSUTH

240 Obstetrics and Gynaecology

tissue in a moist state. All abdominal Special microsurgical instruments

packs and gauze swabs used within the Special instruments are needed at tubal surgery.
abdominal cavity should be moistened. These include needle holders, scissors and
Powder commonly used on gloves may forceps to beused with the fine suture materials,
cause peritoneal irritation and result in 8/0,10/0 and magnification. Special flamed
adhesion formation. It is important to glass rods are used to handle and inspect the
wash the powder off the gloves before tubes. Fig. 17.1 a-d show some special
entering the peritoneal cavity. All raw microsurgical instruments.
areas on the peritoneum should be
carefully closed using fine nylon
sutures.

(iv) Special equipmentfor surgery

Special equipment required for tubal
surgery are expensive. This is partly
responsible for the limited availability
of the instruments in developing
countries.

Magnification
Magnification is required in all the surgery
performed. Magnification can be obtained by
using the operating microscope or the operating
loupes. These instruments are available in this
country inmost departments of Ophthalmology
and Otolaryngology.

Electrocautery
The use of electrocautery reduces blood loss
and also reduces adhesion formation.
Eiectromicrosurgery produces bloodless and
atraumatic fieldof operation.

Suture materials
The type of suture mater ialused is important in
tubal microsurgery. Catgut has been shown to
Figure 17.la Instruments for microsurgery
beassociated with greater fibrosis, scarring and (a) Micro scissors
anatomical distortion compared to nylon. In (b) Dissecting forceps
tubal surgery, nylon or prolene sutures should (c) Needle holder
be used. It is actually recommended that non- (d) Uterine holding clamps (Shirodkar)
reactive suture material such as nylon or (e) Fine sucker
prolene should be used in all reconstructive (f) Silastic plateform
pelvic surgery.

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Tubal surgery ingynaecology 141

f#r *ÿ":ÿ

• . t i" ÿ

' -V-

fpgH|
K'i'*

Figure 17.1d Kirschner four bladed retractor.

Fluid for peritoneal irrigation

Allowing the peritoneum to dry can cause

adhesion formation. In tubal surgery and other
reconstructive pelvic surgery, continuous
Instruments for tubal surgeiy irrigation of the peritoneum with a balanced
Figure 17.1b (a), (b) Flamed glass rods
(c) Bipolar diathermy solution such as sodium lactate is
(d) Insulated unipolar diathermy recommended.
Preoperative assessment
A proper assessment of tubal function is
important before tubal microsurgery. A good
history and a thorough physical examination
and full infertility work-up should be carried
out to exclude other causes of infertility before
considering tubal surgery. Four specific
investigations are essential to adequately assess
the pelvic organs. These are: (i)
Hysterosalpingogram (HSG); (ii) Laparoscopy;
(iii) Hysteroscopy and (iv) Salpingoscopy.
(i) Hysterosalpingogram (HSG)
This procedure outlines the inner lining of the
Figure 17.1c (Operating microscope Qpmi uterus and Fallopian tabes. Conditions such as
(Carl Zeiss) salpingitis istkmica nodosa (SIN), cornual
polyps,presence or absence of mucosal folds of
thetubes are best diagnosed on HSG.

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Prince Of Medicine-2014-BSUTH

142 Obstetrics and Gynaecology

(ii) Laparoscopy

Endoscopic examination of the pelvic organs is

essential before any tubal surgery. It confirms
the diagnosis and allows the surgeon to plan the
surgery. Laparoscopy should be carefully done
and in great detail. The pelvic organs should be
systematically inspected. The use of a second
puncture site and a probe to lift and inspect the :s
ÿ

/ •* ÿ
ÿ

tubes and ovaries are essential. General

anaesthesia is preferred to local anaesthesia as
Figure 17.2a Photograph shows normal uterus, Fallo¬
this allows the manipulations and careful pian tubes and ovaries in their normal re¬
inspection of the pelvic organs. Other lationship
abdominal organs shouldbe inspected also. The
liver should be inspected for liver adhesions, the
presence of which is evidence of previous
peritonitis (due to Neisseria gonorrhoea or
Chlamydia trachomatis) and is a bad prognosis
fci tubal surgery. The ovaries are also inspected
for stigma. There may be a pointer that
ovulation has occurred, fig. 17.2a-e show some
findings at laparoscopy inJos.

(iii) Hysteroscopy
This provides a direct visualisation of the
Figure 172b Photograph shows a distal tube occlusion
uterine cavity. It provides confirmatory with hydrosalpinx formation. The Hydro¬
diagnosis of intrauterine pathology such as salpinx is further dilated with methylene
intrauterine adhesions, submucous fibroids, and blue dye at hydrotubation.
endometrial polyps. These can also be
surgically treated at hysteroscopy.
ÿ

.- "
-

(iv) Salpingoscopy
This procedure allows direct visualisation of
the Fallopiantube lumen.Intramuraladhesions,
which may hinder ÿmbryo transport, can be
diagnosed.

Figure 17.2b Photograph shows a band of thick rather

avascular adhesion on that side is cover the
right adnexa. Fallopian tube on that side is
covered by adhesion. On the left side, the
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left Fallopian tube can be seen coiled on itself.
Prince Of Medicine-2014-BSUTH

Tubal surgery ingynaecology 143

surgery in a woman with frozen pelvis.

Types of tubal surgery

The types of surgery performed will be
discussed under the following headings: (i)
Adhesiolysis; (ii) Salpingostomy: (iii)
Tubocomual anastomosis; (iv) Tubocornual °
implantation; (v) Tubotubal anastomosis.
(i) Adhesiolysis
Microsurgery aims amongst other things to
prevent or reduce adhesion formation. Inmost
Figure 17.2d Photograph shows rudimentary horn patients in the tropics, marked adhesion
of the uterus.
formation is seen prior to adhesiolysis. In 100
consecutive laparoscopics performed on
infertile patients at the Jos University Teaching
Hospital in 1985, over 55% had some degree of
adhesion in the pelvis. Adhesion formation is a
£I particular problem in this country and in most
ÿ

cases, it is severe.
*89 W\ Adhesiolysis refers to division of
adhesions. When adhesions around the
Fallopian tubes are divided to free the tubes, it
is called salpingolysis. When adhesions over
the ovary are divided, it is called ovariolysis.
When the omentum is involved in adhesive
process, a partial omentectomy can be done.
Figure 17.2e Photograph shows typical "Violin
String" adhesions betweenthe liver and
the anterior abdominal wall (Fitz- (ii) Salpingostomy
Hughes-Curtis Syndrome). This refers to the creation of a new ostium in a
Counselling tube totally occluded at its terminal end.
After the investigations, the extent of disease is Fimbrioplasty refers to the surgery performed
to correct a partially occluded end of a
determined and this is discussed with the
patients including the possibility of success at Fallopian tube. There is need for a distinction
betweenthe two as partial closure of the fimbria
tubal surgery. It is very important in this
(phimosis) is the result of a mildinfectionwhile
country to discuss the chances of success with
total occlusion is a result of a more severe
the patients whether they are literate or not.
infection. Distal tubal disease resulting in
Where the chances are slim, the patients should
hyarosalpinges is the commonest Fallopian
be discouraged from having the surgery. It is tube disease seen in this country. The operation
difficult to discourage patients from having of creating a new ostium in a hydrosalpinx
surgery, as they tend to "shop" around for other (salpingostomy) is also the commonest
doctors. Itis however, no use attempting tubal operationperformed inthis country.
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744 Obstetrics and Gynaecology

(iii) Tubocornualanastomosis is thought by some that it can maintain patency

This refers to surgery performed to restore of the tubes and improve the pregnancy rates. In
patency in a. blocked cornual portion of the our unit in Jos, we do not perform
Fallopian tube. In this country, a cornual block hydrotubationpostoperatively.
is commonly due to post abortal and puerperal
infection and is usually severe. It could also be
due to adenomyosis, salpingitis isthmica
Prevention of postoperative adhesion
nodosa and congenital atresia. Surgery at the formation
The prevention of adhesion formation
cornua requires the use of magnification as the postoperatively is a major concern after tubal
diameter of the tube at this portion is very small surgery. As the aetiology of adhesion formation
and cannot be properly anastomosed by naked
remains uncertain, several agents have been
eye surgery.
studied in adhesion prevention. They include:-
(iv) Cornualimplantation anticoagulants (heparin), steroid
This operation is indicated when there is (hydrocortisone), dextran 70, anti¬
complete block of the whole length of the inflammatory agents, and prostaglandin
intramural portion of the tube. Inthis operation, synthetase inhibitor. In Jos, we add heparin to
the tube is implanted either through the fundus the irrigation fluids used during operation. We
or posterior wall of the uterus. also add heparin to sodium lactate and instill
this into the peritoneal cavity at the conclusion
(v) Tubotuhai anastomosis
of the tubal surgery.
Tubal blockage may occur at different portions
of the isthmus and ampulla. The blocked
portion is excised and a tubo-tubal anastomosis Laparoscopic surgery
can be performed. These anastomoses are best Advanced surgical techniques through the
done with magnification. laparoscope were pioneered by Kurt Semm. It
has since been popularised in the developed
Postoperative supportive therapy countries. The procedure requires special
Some procedures are carried out training and adequate special instruments
postoperatively in the hope of improving developed for special purpose during the
fertility after tubal surgery. Some of these surgery. The indications for laparoscopic
procedures remain controversial but could be surgery have widened over the years. Tubal
discussedhere for completeness. surgery can be done through the laparoscope. It
feas the advantage over conventional
Antibiotics laparotomy, of a short hospitalisation and
Recurrent infections can cause failure of tubal reducedcost to patients. There is also improved
surgery. Systemic antibiotic is usually given during result of tubal surgery as there is less tendency
the operation and may be continued to postoperative adhesion formation.
postoperatively. In this country, the choice is of a
broad spectrum antibiotic, which is given pre and
Bibliography and suggested further
postoperatively to all patients havingtubal surgery.
reading
Hydrotubation
This is a procedure whereby normal saline is flushed Chamberlian G, Winston R. ed. (1982) Tubal Infertility, -
transcervically and through the Fallopian tubes. It Diagnosis and treatment. Blackwell Scientific
Publications.
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Prince Of Medicine-2014-BSUTH

IContraception
Chapter 18

Throughout the world for thousands of years, the combined oral contraceptives was
child spacing has been practised using various developed when researchers observed that the
traditional methods. In the African context, addition of oestrogen to progestogen increased
culture and traditional practices were very bothmenstrual cycles and efficacy. Worldwide,
strong in the past in most societies to enforce it is estimated that 200 million women have
child spacing for improving the health of used COC since its introduction for clinical use.
mothers and childrenand not for limiting family Many brands of COC pills are available
size. However, in the past two decades most with varying dosages of oestrogen and
African countries have changed in favour of progestogens. The oestrogens are
family planning programmes to moderate ethinylestradiol (20,30,35 and 50mcg) or
demographic trends, for health reasons and Mestranol (50mcg). While the progestogens are
more recently as a fundamental human right. Norethisterone acetate (0.5,1.0 and 1.5mg) and
Regrettably, governments' position on family Levonorgestrel (150 and 250 meg). These are
planning is not paralleled by the provision of second generation progestogens while the third
qualitative services; hence the very low level of generation progestogens are Gestodene
contraceptive use and a huge imminent need for 750mcg, Desogestrel 150 meg and
fertility control. Contraceptive prevalence in Norgestimate 250 meg. COC containing a fixed
Nigeria, representing the percentage of couples content of oestrogen and progesterone are
in the reproductive age group using modern termed monophasic and those with varying
contraception is about 6% compared to over contents are bi or triphasic. In clinical practice
50% wordwide. Contraceptives do fail the monophasic pills are preferred to the
occasionally. Failure rates are described by the biphasic or triphasic regimes.
Pearl Index, which refers to the number of The COC is a convenient, reversible and
failures per 100 women using the contraceptive highly effective contraceptive with a perfect
for a year (100 woman years). use failure rate of 0.1 % in the first year. The
mode of action is a combination of inhibitionof
ovulation (90-95% of time) through
Current methods of contraception A. suppression of the pituitary release of follicle
stimulating hormone (FSH) and luteinising
Combined oral contraceptive (COC)
hormone (LH), alteration of the cervical mucus
This is a widely available method of and endometrial atrophy.
contraception that was first introduced in 1956
as a combined pill composed of synthetic Contraindications
oestrogen and progestogens. Synthetic Although there are some contraindications the
progestogens were first used as oral use of a medical eligibility checklist would help
contraceptives in the late 1950s. During the in identifying those that should not use COC.
process of refining these progestogen-only Table 18.1 illustrates important
contraceptives, contraindications.
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Prince Of Medicine-2014-BSUTH

ABSOLUTE RELATIVE
Suspected pregnancy Irregular vaginal bleeding
Suspected malignancy; breast, genital tract Obesity
Focal migraine * Heavy smoking
Acute heart or severe liver disease Diabetes mellitus
Ischaemic heart disease (Angina) Long-term immobilisation
Severe hypertension Age over 35 (with other factors)
Cerebrovascular accident Sickle cell disease
Acquired or inherited prothrombotic tendency
Risk factor for cardiovascular disease
Thrombo-embolism

Table 18.1 Contraindications to combined oral contraceptives

Advantages inbenignbreast disease.

The COC pills have many non-contraceptive •, Colorectal cancer - the risk of death froi
effects that are beneficial: colorectal cancer is reduced in thoj
(a) Menstrual current and past users of COC.
• Regular menstrual cycles
°Lighter menstrualloss (c) Sexual benefit
® Painlessmenstruation
• Intercourse is spontaneous and not linked
• Eliminates mid-cycle ovulation pain with the use of COC
•Delay timing ofmenstruationand frequency, • Diminished risk of pregnancy leads to
e.g. Incases of endometriosis.
© Improvement of pre-menstrual syndrome.
enhancedsexual enjoyment.

(b) Reducedrisk ofmalignancy (d) Others

• Epithelial ovarian cancer -50% reduction • Reducedrisk ofpelvic inflammatory
in risk of ovarian cancer if COC is used disease
for 5 years and 80% reduction ifusedfor • Reducedrisk of anaemia
10 years. This protection extends to 20 • Treatment for acne, hirsutismand
years after cessation of use. androgenic symptoms, e.g. inpolycystic
G
-
Endometrial cancer use of COC for 1 ovarian syndrome (PCOS).
year is associated with about 50% • Reducedrisk of ectopic pregnancy
reduction in risk, while use for 4 years • Psychologicalbenefits. '
gives up to 60% reduction in risk of
endometrial cancer; a benefit which Complications
lasts up to 15 years after (a) Venous thromboembolism
discontinuation. • Women who use oestrogen-containing
• Breast masses - there is a 25 % reduction pills have increased risk of venous
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Prince Of Medicine-2014-BSUTH

thromboembolism (VTE) however this risk headache and loss of libido.

islessthan with pregnancy. Breast: mastodynia
The higher the oestrogen dose the greater Genitourinary system: irregular
the pro-thrombotic tendency and risk of bleeding, vaginal discharge, cystitis and
enlargement offibroids.
VTE.
Alimentary system: nausea, vomiting,
© Similarly there is evidence that cholestatic jaundice and weight gain.
progestogens, in particular COC containing Leg cramps and facial pigmentation.
the third generation progestogens are
associated with a marginal increasedrisk of Drug interaction
VTE. Drugs that induce hepatic enzymes can
« The risk of VTE are : accelerate the metabolism and so reduce the
5 per 100,000 for normalpopulation. efficacy of oral contraceptives. These enzyme-
15 per 100,000 for users of second
inducers include barbiturates, phenytoin, St.
John's wort, carbamazepine, ritonavir,
generation COC griseofulvin and particularly the rifamycins.
3 0 per 100,000 for users of third generation Some broad spectrum antibiotics such as
COC penicillins, tetracyclines and cephalosporins
60 per 100,000 for pregnant women. can alter intestinal absorpion of COC and
(b) Myocardial infarction andstroke reduce efficacy, therefore, additional
• Women at increased risk are heavy smokers contraceptive measure' should be
over age 35, women with diabetes, recommended. Diarrhoea and vomiting can
hypertension, hyperlipidaemia, high body similarly reducethe bioavailability of COC.
mass index and severe migraine. Missed pills
• There is a smallrisk of myocardial infarction Any COC missed for less than 12 hours should
or stroke in young healthy women using have no consequence if the pill is taken
COC. immediately. Over 12 hours, the client is
3 per million non-smokers under 35 35 per advised to take the most recent missed pill and
millionsmokers under age 35. continue pill taking for at least the next 7 days.
This may mean avoiding the pill free gap and
Neoplasia starting the next pack if there are less than 7
remainingpills inthe current pack.
• There is a relative risk of 1.24 of developing
breast cancer incurrent COC users. B. Progestogen only pills (POP)
• Benign liver tumours (hepatic adenoma) This method of contraception is suitable for
although rare is occasionally found in COC clients who exhibit oestrogen intolerance or have
users. oestrogen related risk factors such as
• There is an increased risk of cholelithiasis cardiovascular disease. A pill is taken every day
and cholecystitis in women on COC with with no break. POP has a failure rate of 1-3 per
highdose oestrogen (50 meg). 100 woman years and this is achieved through
multiple mechanisms of action, namely:
Other side effects
Central nervours system: depression, • Prevention of ovulation in half the cycles
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Thickening of cervical mucus rendering Use with caution in undiagnosed

the mucus impervious to sperms. vaginal bleeding
Endometrial changes that decrease Use with caution in clients with
receptivity to implantation. previous ectopic pregnancy

Advantages Drug interaction

Decrease inmenstrualloss Similar to COC but is not affected by broad-
Decrease in dysmenorrhea and ovulation spectrum antibiotic therapy.
pain C. Injectable contraceptives
Not coitally related, hence it facilitates There are two main groups of injectable
spontaneity. contraceptives. The first group contains
Possible protection against endometrial progestogen only injectables namely depot
cancer medroxy progesterone acetate (DMPA) 150mg
Possiblereductionof PID risk. and norethisterone oenanthate 200mg. The
Rapidreturnto fertility. second group has combined oestrogen-
progestoiien injectable. The main preparation
It is particularly recommended for the following in this group is Lunelle containing a suspension
clients: of 25mg medroxyprogesterone acetate and 5mg
Breastfeedingmothers oestradiol cypionate.
Women over 35 years including smokers The contraceptive effectiveness of
andthose with hypertension injectable is 0.1-2 failures per 100 woman-
Women with migraine, diabetes, years. DMPA is the most popular of the three
thromboembolism and sickle cell methods because it is administered
disease. intramuscularly every 12-13 weeks, while
nonethisterone oenanthate is injected every 8
Disadvantages weeks and Lunelle every 4 weeks.
(a) Menstrual The mechanism of action of progestogen
Unpredictable irregular bleeding but injectables is similar to that of the POP, while
reducedoverallbloodloss. that of Lunelle is similar to combined oral
Amenorrhoea - unacceptable in some contraceptives.
cultures.
Advantages
(b) Psychosexual Safe and highly effective.
Unpredictable spotting/bleeding may Can be used by lactating mothers.
interfere with sexual relationship. Prevents haemorrhagic corpus luteum cysts.
Depression, anxiety, mood swings or Suppresses ovulation pain.
irritability. Convenience, not coitally related. J
(c) Others Diminishedfear ofpregnancy.
No protection against sexually
transmitted infections (STI) Disadvantages
Associated with benignpersistent ovarian Unpredictable spotting and bleeding in the
follicles first 1-3 months.
Mustbe taken at same time every day. Mood swings, depression and anxiety may

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Prince Of Medicine-2014-BSUTH

Contraception 149

develop. for Implanon is 0.0% due to its complete

o Weight gain. inhibition ofovulation.
o Delay in return of fertility (DMPA).

' Q Not immediately reversible if Mechanism of action

unacceptable side effects occur. • Thickening of cervicalmucus consistently
#
Mastalgia in some women. through the cycle to prevent sperm
@
No protection against STL penetration
• Ovulation suppression
D. Subderma! progrestogen 0 Disordered luteal phase and impaired
contraceptives oocyte maturation.
Contraceptive implants are increasingly being ° Suppression of oestradiol-induced cyclic
used for fertility regulation all over the world. maturation of the endometrium
They have the practical advantage of (hypotrophic change)
overcoming the risk of user failure and low
continuation rates associated with other Advantages
methods that require continuous motivation. ° Decreases dysmenorrhoea and
Although there are two main groups, ovulation pain
biodegradable and non-biodegradable, it is the © Decreases menstrual blood loss
latter group that is available for clinical use. Requires little user compliance or
One group of products marketed is multi- motivation
capsule preparations, Norplant I and II, ° Highly effective
containing levonorgestrel in 6 and 2 silastic • Secondary amenorrhoea with a reduced
capsules, respectively. The other group incidence of iron deficiency anaemia
containing a single rod preparation, Implanon © Can be used by women who have
contains Etonogestrel 68mg in ethylene vinyl contraindications to oestrogen
acetate (EVA). The duration of action of ® Convenience and reduction of
Norplant Iis 5 years, while Implanonprovides pregnancy risk may improve sexual
adequate contraception for 3 years. pleasure
• May reduce the risk of endometrial
Insertion cancer
Insertion of implants is performed under local o Decreased risk of PID
anaesthesia. The usual location is subdermal in o Very suitable for adolescents and breast
the lower third of the medial aspect of the arm. feeding mothers.
Removal is also under localanaesthesia through
a 2mm skin incision. Incorrect insertionmakes Disadvantages -
removal much more difficult, hence the • Irregular bleeding and spotting during the
importance of adequate training. first 12 months
• Spotting and bleeding may interfere with
Effectiveness sexualandcultural activities
Both the typical and perfect use failure rate for • Persistent ovarian follicle syndrome
Norplant in the first year is 0.05%, and the • Insertion and removal require trained
cumulative 5 year failure rate is 1.1 %, while that personnel (provider dependent)
• Risk of infection, bleeding of haematoma
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ISO Obstetrics and Gynaecology

on site of insertion • The progesterone only method consists ol

® Unacceptable to clients who dislike two doses of levonorgestrel 750mq
foreign bodies or haveneedle phobia (Levonelle-2), which are also taken Y
© Offers no protection against STI hours apart, the first within 72 hours
Weight gain unprotected intercourse.
° Headache, mastodynia, bloating, acne, Levonelle-2 prevents 85% of pregnanes
hair growth or hair loss. expected without treatment with significantb
° Potential allergy to anaesthetic or other less vomiting and nausea associated with PC-
agents used for insertion/removal method. Additionally, it is safe for women i:
• Risk of ectopic pregnancy with whom oestrogen use is contra-indicated.
Norplant
© Depression and irritability. The copper intrauterine contraceptive devic
can help prevent unwanted pregnancy if ust
E. Post-Coital Contraception up to 5 days of unprotected intercourse.
After a single act of unprotected intercourse, the estimated pregnancy rate is 0.1 - 0.15%.
risk of pregnancy can be as high as 30% Mirena ® intrauterine system has a slowc
depending on when in the menstrual cycle action compared with the effect of cop]
intercourse occurs amongst other factors. Post¬ devices on sperm and blastocysts and is nc
coital contraception, sometimes referred to as recommended. lUDs so inserted, c<
"morning after" or emergency contraception, subsequently be left in place for continue
provides a second chance for women who contraception. In all cases of emergenc
experience contraceptive failure or do not use a contraception, if the client has not had
method, as well as for women who experience menstrual period within 3 weeks of treatment,
unplanned intercourse, including coerced sex or pregnancy must beexcluded.
rape.
The two primary methods of emergency
F. Intrauterine contraceptive devices
contraception are:
(1) Use of a higher dose of oral contraceptive The modern intrauterine devices (lUDs) haÿ
pill and either copper or levonorgestrel on their
(2) Insertion of an intrauterine contraceptive and are of varying shapes and sizes.
device. original lUDs are obsolete as they wei
associated with menorrhagia and sevei
The most commonly usedhormonal post-coital dysmenorrhoea (e.g. Lippes loop and Saf-
contraceptives are: coil) or increased risk of pelvic inflammatoi
•The combined method - Schering PC4 -
two tablets each containing 50mcg
disease (Dalkronshield).

ethinylestradiol and 250mcg The copper lUDs are very effective andlicensed
levonorgestrel (or 500mcg of to last 3-10 years, e.g.,
norgestron) repeated after 12 hours. The Copper T 3 80A
first dose must be taken within 72 hours First year failure rate 0-4 per 100 worm
of unprotected intercourse (Yuzpe - 5 years failure rate 1.3 per 100 women
regime). This regime reduces the risk of 10 years failure rate cumulative faih
aresulting pregnancy by around 75% 2.1-2.8%
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NovaT® 380
First year failure rate 0.5 per 100 women
• remember
Ideal method for women who cannot
to use pills every day.
Two year failure rate 1.6 per 100 women t Improves menorrhagia and may decrease
hysterectomy rates (Mirena® IUS).
The Mirena®
Levonorgestrelcontaining intrauterine Disadvantages
system (IUS) • Increase in menstrual loss (Copper IUD
only).
Effectiveness 0-1 per 100 women
Gynefix • Slight risk of pelvic infection in first 20
days post insertion (1per 100 women).
New frameless device with 6 copper
sleeves on a propylene thread. This is • May increase dysmenorrhoea (Mirena®
IUS).
anchored 1 cm into the myometrium at
the uterine fundus. • Spotting and uterine cramps in the first 3
months post insertion.
Mode of action Some women dislike digital checks for
• Locally induced inflammatory reaction the string.
inthe endometrium © Insertion may be painful resulting in
Toxic effect of copper on sperms: vaso-vagal attack.
inhibiting sperm mobility and activation o Risk of infection, perforation and
of acrosome reaction (Copper IUD). expulsion. Clients accepting intrauterine
•Local endometrial suppression and contraception should be counselled about sexually
transmitted diseaseandcondom use ifneeded.
thickening of the cervical mucus making
it impervious to sperms (Mirena® IUS).
G Barrier methods of
Centra-indicafions
contraception
•
Congenital malformationof the uterus.
Q Genital tract malignancy.
Male method
o Suspicion of pregnancy.
Condoms have been available since the late 19th
© Immunosuppressive states - HIV.
century and are currently popular in view of the
® Unexplaineduterine bleeding.
rising rates of sexually transmitted infections,
G
Previous history of pelvic inflammatory including HIV/AIDS. They are mechanical
disease. barriers made of latex, polyurethane or natural
® Previous history of ectopic pregnancy.
membrane of varying sizes, with or without
Q Allergy to copper andWilson's disease.
spermicides and of varying colours. For
individuals who are allergic to latex, hypo-
Advantages
allergic latex condoms and polyurethane
© Convenient method of contraception with
condoms can be substituted. Couples should be
very low failure rate.
instructed that condoms should be worn before
©Method not related to intercourse,
sexual contact and the penis should be
permittingspontaneity of sexual activity. withdrawn before removal of the condom. The
© Rapidreturn offerdlitv on removal.
JL • « perfect-use technique not only improves the
© Costeffective.
contraceptive effectiveness (2-5 per 100 woman-
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Prince Of Medicine-2014-BSUTH

152 Obstetrics and Gynaecology

years), but it also proves optimum protection consistent use. The contraceptive sponge
from sexually transmitted infections. Couples contains spermicide and can be inserted high
using the condom should also be aware of the into the vagina hours before intercourse. Ithas a
need for emergency contraception should the Pearl index of 9-25 and not very effective.
condom break or slip during use at a potentially
fertile period. Spermicides
The major drawback is that it may interfere Spermicides appeal to many women seeking
with spontaneity of sexual act, reduce sensation contraception. In countries where they are
during intercourse, vaginal based petroleum available, obtaining them usually does not
products may affect latex condoms. Condoms require a prescription or a provider's help.
should not be reused and should be disposed Spermicides are easy to use when needed.
safely. Presently marketed vaginal contraceptive
formulation contains a surfactant as active
Female condoms ingredient, the most common one being
The female barrier condom, Femidom®, is a Nonoxynol-9 (N-9). These compounds
disposable, polyurethane sac with an outer ring function by disrupting the membrane integrity
at level of introitus and a loose inner vaginal of spermatozoa and that of STI causing
ring. The typical use failure rate is about 21 % organisms, including HIV. However, pregnancy
hence the need for emergency contraception to rates are high and in a typical use, is about 26%
be accessible, if the female condom is the in the first year. The disadvantages are
primary method of contraception. Unlike latex messiness, increased risk of urinary tract
condoms it is not affected by petroleum and oil infection, disruption of vaginal wall integrity
based creams or lubricants. and signs of vaginal irritation, possibly
The female condom can be inserted up to increasing susceptibility to HIV. They have a
2-3 hours before sex to allow more spontaneity. short dissolution time and require intercourse to
Like the male condom, it is available over the take place rapidly, reducing spontaneity. The
counter, provides protection against STI and delivery system has some limitations, whether
may decrease the risk of HIV and genital warts. these are foams, gels, creams, suppositories,
films or tablets.
Diaphragm and cervical cap and sponge
These are female barrier methods that are H. Sterilisations
popular with some women. They are usually Both male and female sterilisation are permanent
used with spermicides to improve efficacy and methods of contraception hence it is imperative that
they require fitting for the appropriate size by a clients requesting these methods should be
family planning practitioner. Using spermicide adequately counselled and written consent
with cervical caps is associated with a one-year obtained. Although the consent of the sexual partner
pregnancy rate ranging between 5 and ,21%, is not usually legally required, it is good practice to
while without spermicide the rate is 20 and 40% includethem in discussionswhere possible.
for nulliparous and multiparous clients,
respectively. Similarly, the 12-month Female sterilisation
pregnancy rate for clients using the diaphragm Tubal sterilisation is achieved surgically or
with spermicide ranges between 10 and 12%. chemically. It is generally peformed as an interval
The messiness, cost and inconvenience of using procedure or in the immediate postpartum. The
spermicide with a diaphragm can discourage method of choice is the laparoscopic approach,
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Contraception 153

however, where there may be technical deferens. Assessment and counselling are
difficulties, a mini-laparotomy approach is essential for all couples considering vasectomy.
preferred although the Fallopian tubes can be Post operatively the client should wear a scrotal
approached through the posterior vaginal fornix - support (or well-fitting briefs) day and night for
colpotomy. Client information shouldinclude: up to 2 weeks. Eighty per cent return to work
• Sterilisation should be regarded as within 3 days and about fifty per cent of men
permanent procedure resume sexual activity within 7 days.
• Techniques of tubal opclu§jpn -Filsche clip,
Hulka clip, bi-polar cautery, Fallope ring, Complications of vasectomy include:
Pomeroy technique and Laser cautery. • Pain (significant in 8%).
o Failure rate - 1 in 300 to 500 cases. 10 years •
Bleeding and haematoma (4%).
cumulative failure rate (0.9 -3.7%). ® Infection (2%).

• Complications - infection, wound •

Failure-early or late.
haematoma, haemorrhage, vascular injury, •
Post vasectomy pain syndrome (3-8%).
injury to bowel,bladder, uterus, mortality - 1- •
Possible psychological effects.
2/100,000 (anaesthetic). Long-term risk of • Possible link with prostate or testicular
change in menstrual pattern, hysterectomy, cancer.
regret due to death of children or change in
The couple must understand that vasectomy is
marital status.
not immediately effective. To prevent a couple
• The procedure is generally done under
general anaesthesia but may also be
conceiving while waiting for operation or before
receiving the negative postoperative semen
performed under conscious sedation.
analysis, an acceptable interim method of
A non-surgical method of female sterilisation has
contraception should be considered. The failure
also been developed. Quinacrine sterilisation.
rate of vasectomy is less than 1 in 1000, with a
Many women in developing countries are at high low risk of complications, hence it is ideally
risk of complications with the standard surgical suited for men who have completed their family
methods or may refuse sterilisation because of the or who are absolutely certain that they do not
fear of surgery. Limited availability of trained want children. It isalso highly cost effective.
surgical and anaesthetic personnel is also a
constraint. A trained nurse using localanaesthesia L Other contraceptive methods
perform transcervical insertion of 252mg The natural family planning method is favoured
quinacrine pellets using a modified IUD inserter. by some couples because of religious or cultural
lis chemical method of sterilisationhas a failure reasons. It is essential that the couple abstain
rate of 2 per 200 woman years after 2 years and an during the calculated unsafe period as
:topic pregnancy rate similar to that of surgical determined by changes in the cervical mucus,
intraception (0.8%). basal body temperature, softness of cervix and
gaping of the external os and a combination of at
alesterilisation least 2 of the above (sympto-thermal method).
isectomy is a permanent male contraception that The disadvantages include:
yolves division and ligation or cautery of the vas © High failure rate (25 per 100 woman

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IS4 Obstetrics midGynaecology

years). the cafeteria of contraceptives available to both

© Requires discipline and full commitment men and women in the 21" century to suit their
of both partners. various cultures and needs. Only then will we
© May not be helpful during stress or at the reduce the incidence of STI and unplanned
peri-menopausal period. pregnancies and the need for unnecessary
o Does not protect against STI. pregnancy termination procedures and septic
Lactation amenorrhoea method (LAM) is an abortions which contribute greatly to female
effective temporary method of contraception morbidity and mortality in the developing
with a failure rate of 0.5% - 2% in the first 6 world.
months postpartum. When the woman actively
breast feeds, the reflex surge of prolactin
suppresses oestrogen production, ovulation and Bibliography and suggested furthe]
menstruation. reading
Coitus interruptus also known as the
'withdrawal method' is the oldest known Baird, D.T. & Glasier, A.F. (1999) Sciences, medicine and th

contraceptive method dating back to the Old future: Contraception. BMJ.3 19:969-972.
Testament of the Bible. It has a high failure rate Emmergency Contraception (1998) J. American Medico
as pre-ejaculatory secretions can contain Women's Association. Supplement 2.53,5. Pp 212-269.
millions of spermatozoa, and relies heavily on Guhadi, A., Anara, M & Soejoenoes, A. (1998)
self-discipline and control. Four year Clinical Evaluation of Quinacrine Pellets for Non-
Surgical Female Sterilisation. Relevances in Contraception.
Conclusion 14: (1)69-77.
In the past 40 years women and men have
witnessed a revolution in their ability to control Guillebank, J & D' Souza, R. (2000) Contraception Past
Present and Future. In: The Year Book of Obstetrics
their reproductive lives with the technological
Gynaecology. O'Brien, P.M.S. ed. Pp 255-269. R.C.O.(
advances in contraceptive development. New press UK.
methods are gradually being added while
existing methods are improved to ensure safety, Meirik,O., Parley T.M.M. & Sivin I.(2001) Safety and Efficacy
efficacy and acceptability. Interesting of Levonorgestrel Implant, Intrauterine Device, and
Sterilisation. Obstetrics & Gynaecology. 97(4)539-547.
developments in new forms of contraception
include low dose oral mifepristone, a Network (2000) Female Barrier Methods, vol. 20,2. pp
new contaceptive patch containing 20mg 4-27: FHI.USA.
ethinyloestradiol and 150 mg norgestimate,
combined injectable contraceptives, self-fitting O'Brien, P.A. (1999) The ThirdGeneration Oral Contraception
Controversy. BMJ.3 19.135.
progesterone-releasing vaginal rings, implants
(STI 435 and Nomogestrel acetate) and Potts Mai Short, R.V., (1999) Condoms for the Prevention
immune approach with vaccines against hCG HIV Transmission: Cultural Dimensions. AIDS, 3j
in women and gonadotropin releasing (Suppl.)S259-SW263.
hormone (GnRH) in men. These
research innovations will no doubt improve

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Tumours of ikevulva 159

Peritoneum
Retracted
Medially
M. Psoas
M lliacus Internal
M Transversaiis X iliac Artery

,Bifuraction
Node
Inquinal
Ligament External
"
Iliac vessels
M. Sartorius
Fat Containing
External
M. ilio-Psoas ~ """ -
Iliac Nodes
wÿÿDeep Epigastric
-"Vessels
Femoral = =• ÿ
•- Obturator
Artery
Femoral
Vein
\ Anastomotic Vein
-Node ofCIoquet

J-•MPectineus
Inquinal
Ligament

Saphenous
Vein

Figure 19.5 The exposure of the deep lymph nodes in the

extended radial vulvectomy

Clinical history
.-
— - nr tz *''"% mfmfm.
•

The patient complains mainly of a sore on the

vulva. Other symptoms like foul smelling
vaginal discharge, pain, dysuria and bleeding
are seen in the neglected cases. Pruritus vulvae
may be present insome cases.

Clinical findings
On examination of the vulva, three types of
growth may be seen, the cauliflower growth
(fig. 19.6), the excavated ulcer or the flat
indurated ulcer. The vulva may be ©edematous,
.....
- t
a*

..o81rifiiK-ÿT
-tel.
i-

• I'/
n ,, -

and the legs may be swollen too. The inguinal '

and femoral nodes may be enlarged and • T: : Hi '

palpable. The nodes might have coalesced, and

form a groin ulcer. Despite the severe local
"ungating state of the vulva, the physical state of
the patient beliesthe gravity of the situation.
*
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160 Obstetrics and Gynaecology

Description TNM
T,NoMo
la Lesion confined to vulva with less than 1mm invasion, superficially invasive T,N,Mo
vulval carcinoma
lb All lesions confined to the vulva with a diameter less than 2 cm and no
clinically suspicious groin lymph nodes

II All lesions confined to the vulva with a maximum diameter greater than 2 cm TjNoMo

and no suspicious groin nodes T2N,Mo

III Lesions extending beyond the vulva but without grossly positive groin nodes T3NoMo
T,N,Mo
TjNjMo

Lesions of any size confined to the vulva and having suspicious nodes T,NjMo
T2NjMo

IV Lesions with grossly positive groin nodes regardless of the extent of the primaiy. TjNjMo
T2N3Mo
T3N3Mo
T,N3Mo
Lesions involving mucosa of rectum, bladder, prethra, or involving bone
T,NoMo
T4N,Mo
T«N2Mo
All cases with pelvic or distant metastases
M,A
A,B

Table 19.1 Staging systems for vulval cancer

Investigations Management
Diagnosis is obvious after inspection and
Early cancer lesion: Wide local excision is
palpation, but in doubtful cases a local or
advocated and it is important for the incision to
excision biopsy is advisable.
be clear of the lesion by about 1Omm all round.
Staging This is the way to avoid local recurrence. By
Two methods of staging have been used in this method, the local recurrence rate has been
carcinoma of vulva - The FIGO staging and reducedto about 7% according to some authors.
the TNM system which is a composite of Advanced cancer lesion: The recommended
primary tumour, nodaland metastatic status. treatment is radical vulvectomy. Many years ago it
was the Stanley Way's incision that was used and

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Prince Of Medicine-2014-BSUTH

this left a wide area which was allowed to

granulate or covered by a graft. Inrecent years
however, incisions have been modified so as to
enable closure of the wound if possible at the
end of the operation thus limiting wound
morbidity. Novak's incision was used by some
surgeons but currently the Triple incision
technique is preferred (fig. 19.7).

Figure 19.7 Diagram showing the triple incision

incision Figure 19.8 The scar after radical vulvectomy
technique for surgical treatment of using Novak's incision
carcinoma of vulva
chemotherapy for vulval cancer are still at the
Lymph node involvement invulval cancer may
be as high as 50% so the operation must be preliminary stage. Some authors have even
accompanied by node dissection to improve suggested employing chemoradiation.
cure rate. For smaller lesion (<2cm) ipsilateral
or bilateral groin node dissection could be Postoperative management
performed, but wider lesion or more advanced Convalescence after surgery could be stormy
growth may require en block and is complicated by anaemia and infection.
lymphadenectomy. Thus for early lesions Liberal blood transfusion is given to keep the
ipsilateral or bilateral groin node dissection is packed cell volume at about 35%, and
carried out while for advanced cases, post prophylactic broad spectrum antibiotics whose
operative pelvic radiation in place of spectruiti must include anaerobes are used.
previously practised iliac lymphadenectomy is Frequent microbiological studies including
now recommended inaddition to the dissection
sensitivity tests must be carried out and the
of the inguinal and femoral nodes.
appropriate antibiotics instituted.
Radiotherapy: Since carcinoma of the vulva is
of the squamous cell type which is sensitive to Complications
radiotherapy, opinions have been expressed to The main complications and causes of death are
treat this lesion by radiotherapy. Indeed some sepsis and haemorrhage resulting from the
authors have used radiotherapy for the tumour eroding the femoral vessels or damage
treatment of primary tumour preoperatively to to the femoral vessels at surgery, and pulmonary
reduce the extent of radical excision, or embolism inthe elderly due to prolonged stay in
postoperatively to reduce risk of local bed.
recurrence. However, more evidence on this is
being awaited. Prognosis
Chemotherapy: Studies on the use of The prognosis after treatment depends on the
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Prince Of Medicine-2014-BSUTH

J62 Obstetrics and Gynaecology

histological state of the lymph nodes. The prognosis of malignant melanoma of

According to an author, the overall survival for the vulva is very poor. When the benign variety
all cases of histologically proven groin node (pigmented naevi) is seen, prophylactic wide
negative cancer is approximately 70-90%. localexcision of the lesionshould be carried out
However, when the nodes are positive, this to prevent progressionto the malignant type.
drops to between25 and 45%.
In our own environment, the survival rate Sarcoma of the vulva
ismuch lower due to complications from sepsis This is a very rare tumour of the vulva. The site
with accompanying breakdown of the wound, of origin is usually in the labium majus or the
and anaemia. We also encountered cases of clitoris, and only rarely in the labium minus or
recurrence in the groin which the literature has the urethral meatus.
shown to be virtually always fatal. Most sarcoma of the vulva are spindle
celled. Spread is by both blood stream and
Basal cell carcinoma of the vulva
lymphatic permeation. Local spread to
(Rodent's ulcer)
surrounding structures takes place also.
This tumour accounts for about 2-4% of vulval
malignancies. It is a rare form of locally The main complaints are vulval swelling,
invasive cancer. Its behaviour is similar to the irritation and pain.
lesion seen on the face. The patient complains Treatment is radical vulvectomy.
of chronic ulcer on the vulva, the lesion having Lymphade-nectomy offers no advantage. Local
first appeared as a small lump which broke recurrence in the scar is common. External
down to form an ulcer with a rolled edge. radiotherapy and chemoradiation are yet to be
Treatment is local wide excision biopsy of the assessed as adjuvant therapy. Prognosis in
lesion. The excision must be wide and deep to sarcoma of the vulvais very poor.
prevent recurrence. As a rule this tumour does
notmetastasise.
Bibliography and suggested further reading
Melanoma
Malignant melanoma accounts for about 10% Luesley, D.M. (1999) Malignant disease ofthe vulva and
of vulval malignancies. The sites of origin are vagina. In Dewhurst's Textbook of Obstetrics and
usually the clitoris, labium minus and labium Gynaecology. Edmonds, D.K. ed, 6th ed. Blackwell
majus. The majority of malignant melanomas Science, Oxford.
arise from chromatophore cells.
The tumour is a soft dark blue or dark brown Way S, Benedet J.L, (1973) Involvement of inguinal
lymph nodes in carcinoma of the vulva. A comparison of
swelling which ulcerates readily to cause
clinical assessment with histological examination.
irritation and discharge. The main complaint is Gynaecologic Oncology 1.119-122.
a blood stained purulent discharge associated
with an ulcer. Novak E.R, Woodruff J.D. (1979) Novak 's
The tumour spreads by blood stream giving rise Gynaecologic and obstetric pathology. 8th ed, W.B.
to generalised metastases, and by lymphatic Saunders, Philadelphia.Pp. 37-53.
permeation affecting the inguinal, iliac and
lumbar lymph glands. Way S. (1977) Carcinoma of the vulva. In Recent
Treatment is radical vulvectomy with removal advances in obstetrics and gynaecology. Stallworthy J.
and Bourne G. eds., ChurchillLivingstone. Edinburgh.
of lymph nodes inareas at risk.

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Chapter 20

Tumours of the vagina

Vaginal cysts may be congenital or acquired: anterior vaginal wall cyst is diverticulum of the
urethra and it is always advisable to pass a
Congenital cysts catheter in the urethra to see if this will end
inside a diverticulum.
Cysts of Gartner's duct
Treatment
Majority of vaginal cysts arise usually from
vestigial remnants of the mesonephric Symptomless cysts do not require treatment but
(Gartner's) duct found in the antero-lateral wall if they are big and causing symptoms such as
of the vagina. The cysts are usually small but dyspareunia or pelvic discomfort they may be
sometimes they may be bigenough to apprear at excised andthe base marsupialised.
the vulva. - Benign tumours
Cysts of Skene's tubules may be seen lowdown
Benign tumours of the vagina include:
on the anterior vaginal wall.
Papilloma This may be in form of multiple
Acquired cysts warts. Sometimes it may also be sessile or
pedunculated.
These include:
Adenoma
Inclusion cysts

When tags of vaginal mucosa become buried in Fibroma and Fibromyoma, which may be
the lacerations following childbirth or colpo- pedunculated and protrude at the introitus.
perineorrhaphy. The buried detached mucosa Lipoma
may then undergo cystic changes. The cysts Angioma
when present are usually on the posterior wall. Myxoma
Endometriotic cysts Treatment
These cysts are due to implanted endometrium No treatment is required for small symptomless
in scars of incisions made invginal wall during tumours. However, if the tumours are big and
operative procedures. They are said to be most causing symptoms such as dyspareunia, bladder
commonly seen in the posterior fornix in irritation, tenesmus due to rectal irritation or
association with endometriosis of rectovaginal perhaps infertility, they should be excised.
septum.
Malignant tumours
Differential diagnosis
Malignant tumours of the vagina may be
An important differential diagnosis of an primary or secondary.
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164 Obstetrics and Gynaecology

Primary carcinoma Some authors have however reported cases of

\
vaginal clear cell carcinoma with no history of
Staging: Carcinoma of the vagina can be staged
intrauterine diethylstilboestrol exposure.
using the F.I.G.O. Classification:
Pathology
Pre-invasive carcinoma
The commonest site for primary carcinoma is
Stage O Carcinoma insitu, intraepithelial carcinoma. the posterior vaginal wall.
The histological picture is that of squamous cell
Invasive carcinoma: type in over 90% of cases. However,
adenocarcino-matous type has been reported in
Stage 1 The carcinoma is limited to the the literature. In such a case, the tumour
vaginal wall probably arises from gland-like structures inthe
Stage 2 The carcinoma has involved the vaginal mucosa. Spread may be by direct
sub-vaginal tissue but has not extension, lymphatics or blood stream.
extended to the pelvic wall Lymphatic spread of lesions in upper third of
Stage 3 The carcinoma has extended the vagina behaves in the same fashion as
onto the pelvic wall cervical carcinoma while lesions in lower third
Stage 4 The carcinoma has extended drain to the inguinalandexternal iliacnodes.
beyond the true pelvis or has
involvedthe mucosa of the Clinical history
bladder or rectum The woman may give a history of vaginal
discharge usually offensive or blood-stained. In
Incidence
advanced cases, there may be urinary or rectal
Carcinoma of the vagina is rather uncommon in
symptoms.
our population in Nigeria. Most authors have
however, quoted an age incidence of between Clinical findings
60 - 80 years for invasivecarcinoma.
Usually, a growth will be visualised or felt on
Aetiology vaginal examination. It may be ulcerative or
friable. Like carcinoma of the cervix, it also
The tumour has beenlinked with prolonged use bleeds readily to touch.
of vaginal ring pessary or neglected pessary.
The wearing of ring pessary for utero vaginal Investigations
prolapse is not common among the Nigerian
population and this may perhaps explain the The usual investigation is biopsy of the lesion
rarity of this tumour. for histopathology. Cystoscopy, rectal
The occurrence of clear cell examination and chest X-ray should also be
adenocarcinoma of the vagina has been carried out.
recorded in daughters whose mothers received
stilboestrol during pregnancy. Again, this Differential diagnosis
particular tumour is very rare in our
environment. The risk of developing this cancer Carcinoma of cervix with spread to the vaginal
issaid to be greatest around the age of 24 years. walls.
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I'. i„
ÿmhmhhhi Tumours of the vagina 165 |

Secondary carcinoma
Carcinoma of rectum with spread to the
vagina Carcinoma of vulva spreading to lower Secondary carcinoma of the vagina is far more
third of the vagina Vault endometriosis. common than the primary carcinoma in the
Nigerian population. Secondary carcinoma
Complications may be due to spread from:

These include haemorrhage, sepsis, urinary and Carcinoma of the cervix

rectal symptoms
Cervical carcinoma is the commonest cancer in
Management the Nigerian female population. The growth
spreads to the vagina either directly or via the
Pre-invasive carcinoma lymphatics. It is seen in both the anterior and
Topical chemotherapy has been tried in pre¬ posterior vaginal walls. Because most of these
invasive lesions. The response rate has been women with cancer of the cervix still present
quoted to be as highas 60%. late to the hospital, many cases of vaginal
secondaries are seen regularly in our clinic. The
In older patients, radical surgery such as clinical features and treatment are those of the
vaginectomy may be preferred. Radiotherapy primary lesion.
has also beentried as a mode of treatment.
Choriocarcinoma
Invasive carcinoma
Intravaginal radiation and supplement of Choriocarcinoma is another common neoplasm
conventional deep X-ray therapy may be in the Nigeria female population next only to
employed. the cervix and the breast.

If surgery is preferred, this must take the form The vagina is a common site for metastases
of radical hysterectomy plus vaginectomy from Choriocarcinoma and the anterior vaginal
using the abdomino-vaginal approach. Surgery wall is more frequently affected. The lesion
may also becombined with radiotherapy. presents usually as a blackish (haemorrhagic)
nodule in the lower third of the anterior vaginal
Chemotherapy may be used as an adjuvant wall and is usually called suburethral nodule. In
treatment. fact, this may be the first evidence of the disease
The treatment of clear cell adenocarcinoma is in our women. A positive pregnancy test or a
radiotherapy, external beam and intracavitary high level of serum hCG 0-subunit will confirm
the diagnosis.
caesium.

However, irrespective of the type of treatment, The treatment is that of the primary lesion
the 5-year survival rate is quoted to be only which is described in detail elsewhere under
about 30 percent. Choriocarcinoma.
Endometrial carcinoma

I
In the case of clear cell adenocarcinoma, the
prognosis is good and a maximum 5-year Vaginal metastases may occur from endometrial
survival rate can be achieved. carcinoma. Spread may occur by lymphatics or

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Prince Of Medicine-2014-BSUTH

166 Obstetrics and Gynaecology

possibly blood stream. A recurrence may also chemotherapy. A recommended combination of

follow hysterectomy. The vaginal vault and drugs by some authors is vincristine,
anterior vaginal wall are sites for such actinomycin-D andcyclophosphamide. Further
metastases. treatment may be in form of deep X-ray therapy
and/or surgery. Surgery which is radical
The treatment is radiotherapy. Radiotherapy consists of extended hysterectomy and total
may be supplemented with chemotherapy. vaginectomy. Chemotherapy may precede
surgery, and radiotherapy is postoperative.
Other less common primary malignancies
which may spread to the vagina are: Prognosis of this tumour with the above
treatment regime is said to have considerably
Carcinoma of the ovary, improved in recent times and some of these
Carcinoma of the urethra children are now reported to have survived for
Carcinoma of the vulva over 5 years.
Carcinoma of the rectum
Melanoma
Sarcoma
Melanoma of the vagina is very rare. The
Vaginal sarcoma is very rare in our clinical features and treatment are those of
environment. This special tumour in childrenis vaginal carcinoma and the prognosis is said to
known as sarcoma botryoides. be poor.
Sarcoma botryoides is a tumour which occurs in
children usually below the age of 10 years. It Bibliography and suggested further reading
may present as vaginal bleeding. Clinical
examination under anaesthesia may reveal a Dewhurst, (1983) Botryoidsarcoma ofthe cervix and
grape-like or polypoidal tumour in the vagina. the vagina in children. In Progress in obstetrics and
Investigations should include cystoscopy, gynaecology.\ vol 3. Stud, J. ed., Churchill
Livingstone, Edinburgh, P. 15 1.
rectal examination, chest X-ray, intravenous
urogram and body scan. Haines, M., Taylor, C. W. (1975) Gynaecological
A biopsy of the tumour will confirm the pathology, 2nd ed., Churchill Livingstone,
diagnosis histologically. The histological Edinburgh.
picture is that of a mesodermal mixed tumour
Wang G, Sun, J. (1998). Clear Cell Carcinoma of
which may also be referred to as embryonal Vagina Report of 3 Cases and Review of
sarcoma. Differential diagnosis includes clear Literatures. Chug HFuChanko Tsa Chih 7:425.
cell adenocarcinoma earlier described and
endodermal sinus tumour.
T reatment consists of chemotherapy since the
tumour is now known to be sensitive to

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Chapter 21

Tumours of the cervix uteri

Benign tumours of the cervix Pre-malignant and malignant
diseases of the cervix
Cervical polyps
Cervical polyps are benign growths on the Introduction
cervix. They are common in pre-menopausal Cancer of the cervix, a potentially preventable
women and are thought to be due to the effect of disease, is the second most common
unopposed oestrogens, which is common at this malignancy in women worldwide and the
leading cancer in women in developing
period of a woman's life. Cervical polyps can be
countries. In northern Nigeria it is the
single or multiple, arise from the cervical canal
commonest cancer in women while in southern
and are usually seen at the external os. They are Nigeria it is second to breast cancer. In
small in size and often reddish in colour. developed countries the incidence of the disease
Microscopically, a cervical polyp consists of a has decreased over the years because of the
distended cervical mucous gland in a vascular availability of well-organised cervical cancer
bed of fine fibrous tissue. It is usually covered screening programmes. Screening allows the
by columnar epithelium, but sometimes detection of the curable pre-malignant disease.
squamous epithelium. It is estimated that screening at 3 year intervals
They can be symptomatic or asymptomatic. for women aged 35-64 years can reduce the
Their main symptom is mucous discharge, incidence of invasive cancer by over 90%.
which may be bloodstained. Other symptoms
include post-coital bleeding and intermenstrual Epidemiology and risk factors
bleeding, possibly due to inflammation and Cervical cancer usually occurs in the fifth or
ulceration. Treatment is by polypectomy sixth decade of life at a mean age of 54 years.
(usually by avulsion) and cauterisation of the The pre-malignant disease frequently occurs in
base. Uterine curettage should be performed at younger women, often under the age of 40
the same time, as there may be associated years. It is common in women of low
endometrial polyps inabout 15% of cases. . socioeconomic Status.
The following are risk factors for carcinoma
Fibroid polyp status:
This is usually a submucous fibroid of the i. early age at first sexual intercourse
endometrium with a long pedicle which has ii, multiple male sexual partners
prolapsed through the cervix. It is not a tumour iii. male sexual partners who themselves
have had multiple sexual partners
of the cervix perse. It may present as irregular
(high risk males)
isinal bleeding, intermenstrual bleeding or iv. early age at first birth
t-coital bleeding. Treatment is by avulsion. v. Multiparity
vi. Smoking
vii. long-term use of oral contraceptive pills
viii. immunosuppressed states e.g.
HIV/AIDS, renal-allograft
transplantation or Hodgkin's
disease.
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3 168 Obstetrics and Gynaecology

ix. low social class

Carcinoma of the cervix is almost unknown in
the virgins. This is a reflection of the strong 2 and (iii) the histone and protamine of the
association of this disease with sexual sperm. These carcinogens can induce changes
intercourse. It is even referred to as a "sexually in the metaplastic cells which may eventually
transmitteddisease" become malignant

Pathogenesis Histologicalchanges in pre-malignant disease

The pre-malignant disease, also known as The classification is based on the degree of
cervical intraepithelial neoplasia (ON), abnormality of the epithelium, (fig21.1)
precedes the invasive disease by about 10-15
years. The cervix has two types of epithelium, Superficial
the non-kcratinising squamous epithelium that layer
covers the ectocervix and the columnar ® J Intermediate
layer
epithelium that lines the endocervical canal.The Parabasal
junction of the two types of epithelium is the layer
squamo-columnar junction. The columnar
epithelium extends beyond the cervical canal to
the ectocervix in some cases, and becomes Normal squamous epithelium
exposed to the acid pH of the vagina. The acidity
of the vagina irritates the columnar epithelium
and induces the process of metaplasia whereby
this epithelium is replaced by squamous
epithelium. This area of the cervix is called the
transformation zone. The original squamo-
columnar junction forms the lower border of the
transformation zone and the highest point that CIN 1-Mild dysplasia
the squamous metaplasia reaches forms the
upper border. The transformation zone is an
active zone. The process of metaplasia occurs
most actively during:
i. fetal development in utero
ii. adolescence
iii. first pregnancy CIN 11-Moderate dysplasia
The risk of developing CIN and invasive cancer
is increased if the transformation zone is
exposed to carcinogens at the height of
metaplasia as in adolescence and during first
pregnancy. This is possibly the reason why early
age of first sexual debut and of first pregnancy
are risk factors for this disease. Some of the
carcinogens that have been implicated include, CIN III - Severe dysplasia
(i) the human papilloma virus (HPV); HPV type
16 and HPV type 33, (ii) herpes simplex type Figure 21:1 Histological changes in pre-malignant
disease.

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I Tumours oftke cervix uteri 169

CIN I:This is equivalent to milddysplasia. The Papanicolaou, who first performed the smear in
upper two thirds of the epithelium is normal 1946. It is an outpatient procedure. Cervical
and the cells of the lower one third show smear is a tool to detect pre-cancer and not
nuclear pleomorphism and have increased cancer. To obtain a smear, the patient is put in
the dorsal or lithotomy position and a speculum
nuclear cytoplasmic ratio.
is passed to expose the cervix. The projection of
the spatula is put in the cervical canal and
CIN II: This is equivalent to moderate
rotated through 360° to scrape cells from the
dysplasia. The upper half of the epithelium transformation zone. There are different types
shows stratification andmaturationwhile basal of spatulas. In cases where the transformation
cells andimmature cells occupy the lower half. zone has receded into the cervical canal, as in
older women, the cytobrush is used. The smear
CIN III: This is equivalent to severe dysplasia. obtained is spread evenly on a clean slide and
There is almost complete loss of stratification, quickly fixed in equal parts of 95% alcohol and
loss of polarity of the cells with majority at ether and stained by the Papanicolaou's method.
right angles to the surface and the remaining Cytological examination is performed to detect
irregularly arranged, with nuclear abnormal cells that are characterised by
pleomorphism and increased cytoplasmic enlarged nuclei, increased mitotic figures,
ratio; cells losetheir squamous appearance and hyperchromasia, and increased nuclear
mitotic figures are found at alllevels. cytoplasmic ratio. Ideally a smear must contain
squamous cells, endocervical cells, metaplastic
Natural history of pre-malignant disease This cells and some endocervical mucus. Adequate
precedes the invasive disease by about 10-15 smears contain squamous cells and at least two
years. It is worth noting that not all cases of pre- of the remaining three elements. It must be
malignant disease progress to invasive cancer. notedthat the technique ofsmear taking is very
Indeed most cases of CIN Iregress without any important as poor smear taking can miss 20%
or more ofpre-malignant abnormalities.
treatment. The high-grade lesions (CIN II,CIN
Cervical smear is mandatory for all women
j III) have the potential to progress to invasive or
who are sexually active and need to be done
frank cancer in about 18% at lOyears and 36%
every three years or earlier if indicated.
at 20 years. This not withstanding, there are
cases where the period is shortened, but
unfortunately it is impossible to predict such Cytological classification of cervical
cases. It therefore becomes necessary to treat
and follow up all cases of high- grade lesions. smear Two classifications are used:

The Bethesda classification: - In this

mear classification the term squamous intraepithelial
The smear is taken from the transformation lesion (SIL) is used. Low grade
zone to obtain cells for cytological squamous intraepithelial lesion (LGSIL) includes
examination. The cervical smear is also cellular changes associated with HPV
referred to as cervical Papanicolaou smear, infection and CENI. High grade
named after a Greek American, George squamous intraepithelial lesion (HGSIL)
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176 Obstetrics and Gynaecology

includes those cellular changes associated Colposcopy

with CIN 2 and CIN 3. In addition to LGSIL Intraepithelial lesions are generally not visible
and HGSIL, the Bethesda system to the naked eye. The colposcope, discovered in
classification includes a group of lesions 1925 by Hinselmann, a German, is a
characterised by "atypical squamous cells of microscope designed to allow examination of
undetermined significance" (ASCUS) the cervix with a magnification ranging from 6
to 40-fold. It permits the identification of
The British Society for Cervical Cytology mucosal abnormalities characteristic of CIN or
classification. The term dyskaryosis is used invasive cancer. The 5% acetic acidtest. During
in this classification. Mild, moderate and colposcopy 5% acetic acid solutionis applied to
severe dyskaryosis are terms equivalent to the cervix. The acetic acid coagulates the
histological diagnosis of CIN I, CIN II, and protein in the nucleus. The effect of acetic acid
CIN III(mild, moderate and severe dysplasia) depends on the amount of nuclear protein
respectively. Mild dyskaryosis is equivalent present. Abnormal cells have high nuclear
to LGSIL and moderate or severe dyskaryosis density and therefore higher concentration
is equivalent to IIGSIL. The term borderline
is roughly equivalent to ASCUS.
(Table 2 1.1).

Bethesda system British Society for Cervical Cytology Histological equivalent

ASCUS Borderline Mild dysplasia (CIN 1)

LGSIL Mild dyskaryosis Moderate dysplasia (CIN 2)

HGSIL Moderate dyskaryosis Severe dysplasia (CIN 3)

Severe dyskaryosis

ASCUS = Atypical Squamous Cell of Undetermined Significance

LGSIL = Low Grade Squamous Intraepithelial Lesion
HGSIL = High Grade Squamous Intraepithelial Lesion

Table 21.1 Cytological classification of cervical smear results

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Tumours of the cervix uteri 171

of protein and will undergo coagulation and potassium iodide solution) to normal
prevent light from passing through the epithelium will therefore produce a dark
epithelium. This makes it less easy to see the brown almost black stain, whereas columnar
subepithelial vessels, which confer a pink and abnormal epithelial cells both of which
color to normal squamous epithelium; the contain little or no glycogen remain relatively
abnormal epithelium therefore appears white. unstained. Apositive Schiller's test refers to
The higher the abnormality, the higher the non-staining (i.e. iodine-negative) epithelium
concentration of proteins and the whiter the andvice versa.
epithelium will appear. Abnormal vessel patterns such as mosaicism,
punctuation and abnormal branching found
The Schiller's iodine test. This is another test in abnormal epithelium are visualised using
used to detect abnormal epithelium. The the colposcope.
rationale behind this test is that normal
epithelium contains abundance of glycogen, Management of cervical smear findings
whereas abnormal epithelium contains
relatively little or no glycogen. The Patients with positive smears should have a
application of Lugol's iodine (iodine and colposcopic examination. The extent of the lesion
INADEQUATE NEGATIVE POSITIVE
I
Repeat smear
,/V
ft- ia
Routine Recall Inflammatory

i
Repent smear | HPV only Milddyskaryosis Moderate or severe Handular
(1-3 year) Borderline (LGSIL) + HPV dyskayosis neoplasia or
severe
changes (ASCUS) changes (HGSIL)
dyskayosis suspicion of
+ HPV changes (HGSIL)j-HPV Invasive glandular
HVS4ECS changes carcinoma neoplasia

I
Treat infection
Colposcopy
Repeat smear
at 6 months
Repeat smear
at 6 months
i
urgent referral
on gynecological

I
1
Repeat smear in oncologist
3-6 months
Changes persist Changes persist

Persistent
Inflammatory
Changes Colposcopy
I
Colposcopy Colposcopy
urgent referral
to gynecological
oncologist

Prince Of Medicine-2014-BSUTH

174 Obstetrics and Gynaecology

90-95% of cases and an adenocarcinoma in the (iii) verrucous

remaining 5-10%. It arises from either the The large cell non-keratinising variety carries
ectocervix or from the endocervix. The site of the best prognosis, while the small cell type
the growth bears no relation to the histological carries the worst prognosis.
Metastasis of squamous cell carcinoma to the
type as some squamous carcinomas are found
ovary is rare.
inthe endocervical canal.
The tumour is of three types: (fig 21.3) Adenocarcinoma
(i) ulcerative This forms 5-10% of the cervical cancers. It
(ii) proliferative "cauliflower", exophytic or arises from the columnar epithelium of the
Everting endocervix. The histological appearance is like
(iii) excavating, endophytic or inverting growth that of the adenocarcinoma found anywhere in
the body. Unlike the squamous cell carcinoma,
it metastasises to the ovaries. It is more
common inyoung women.

Other histological types include:

(i) adenosquamous carcinoma
(ii) small cell carcinoma
(iii) adenoid cystic carcinoma
(iv) undifferentiated carcinoma
Small cell carcinoma carries the worst prognosis.

Spread
Cancer of the cervix spreads by three routes:
i. Direct: the cancer can spread by direct
infiltration into the adjacent tissues;
laterally to the parametrium,upwards
to the corpus uteri, caudally to the
vagina, anteriorly t the bladder and
posteriorly to the rectum and the
uterosacral ligaments.
A. - Normal ii. Lymphatics: This spread is through
B. - Exophytic growth the paracervical nodes like the
C. - Ulcerative Type internal and external iliac and the
D. - Endophytic growth para-aortic nodes.
iii. Bloodstream: Spread by this route is'
Figure 21.3 Clinical types of carcinoma of the cervix uncommon
Squamous cellcarcinoma Symptoms
The three main histological types described are: In the early stage the patient may be
(i) large cell non-keratinising asymptomatic; or present with:
(ii) large cell keratinising i. Vaginalbleeding. The bleeding may take

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Ia1 Stromal invasion no greater than 3.0mm in depth and 7.0mm or less in horizontal
spread
T1a1

ia2 Stromal invasion more than 3.0mm in depth and not more than 5.0mm with a T1a2
horizontal spread 7.0mm or less8
lb Clinically visible lesions confined to the cervix or microscopic lesion greater than T1 b
Stage Ia2/T1a2
Ib1 Clinically visible lesion 4.0cm or less in greatest dimension T1 b1
Ib2 Clinically visible lesion more than 4.0cm in greatest dimension T1 b2
Tumour invades beyond the uterus but not to the pelvic wall or to the lower third T2
of the vagina
Ha Without parametria! invasion T2a
lib With parametria! invasion T2b
III Tumour extends to the pelvic wall and /or involves lower third of the vagina and/or T3
causes hydronephrosis or non-functioning kidney
Ilia Tumour involves lower third of vagina, no extension to pelvic wall T3a
lllb Tumour extends to pelvic wall and/or causes hydronephrosis or non-functioning T3b
kidney
IV The carcinoma has extended beyond the true pelvis
IVa Tumour invades mucosa of bladder or rectum and/or extends beyond true pelvisb T4
IVb Distant metastasis M1

'Note: The depth of invasion should not be more than 5mm taken from the base of the epithelium, either
surface or glandular from which it originates. The depth of invasion is defined as the measurement of the I
tumour from the epithelial-stromal junction of the adjacent most superficial epithelial papilla to the deepest j
point of invasion. Vascular space involvement, venous or lymphatic does not affect classificatioi
"Note :The presence ofbullous oedema is not sufficient to classify a tumour as T4.
—
Table 2 1.2 Carcinoma of the Cervix Uteri Staging -FIGO 2000

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Tumours of the cervix uteri 179

Treatment Other complications of surgery include:

The treatment of cervical cancer is highly i. haemorrhage andshock
specialised and involves the combined effort of ii. damage to the bladder or rectum
the gynaecologists and the radiotherapists. iii.bladder dysfunction
There are three modes of treatment: surgery iv. urinary retention
alone, radiotherapy alone, and combined v. venous thrombosis and embolism
surgery and radiotherapy. Surgery is vi. sepsis
performed for early lesions of stages I-IIa and vii. lymphocyst
radiotherapy for advanced lesions. Stage la In patients with stage lb and stage lib who are
not fit for surgery e.g. obese or aged,
Simple hysterectomy or cone biopsy is radiotherapy is indicated. Radiotherapy is also
performed in women, of childbearing age, who indicated where there is no skilled
wish to preserve their fertility. The risk of gynaecologist with experience in performing
distant spread is less than 1 % in stage lal and radical surgery.
less than 5% in stage Ia2. A five-year survival
rate exceeds 95% among women treated by Stages lib, IllandlVa
simple hysterectomy.
Patients with stage lib, HI or IVa tumours are
Stages lb andlia treated with radiotherapy, which results in five
year survival rates of 65%, 40% and less than
The use of surgery or radiotherapy for the 20% respectively. Radiotherapy may be for
treatment of stage lb or early stage Ha disease radical treatment. The palliative treatment is for
produces equivalent results (survival rate at reliefof symptoms such as pain or bleeding.
five years, 80%to90%). Radical hysterectomy
and resection of pelvic lymph nodes is the Stages TVb
surgery performed. This is referred to as the The tumour at this stage cannot be cured. The
Wertheim-Bonney-Meigs operation. It patient may benefit from local radiotherapy
involves removal of the body of the uterus, and/or chemotherapy. Platinum-based drugs are
cervix, a 2-3cm cuff of the vagina, the used. The most active agent for treatment of
parametria, and the utero-sacral and cardinal metastatic squamous-cell cancer of the cervix is
ligaments en bloc. Pelvic lymph node cis-platin. Other drugs that have been used
dissection involving the removal of lymph include ifosfamide and mitolactol.
nodes in the obturator fossae, internal iliac, Chemotherapy may function as radiosensitisers
external iliac and lower common iliac chains is potentiating the effects of radiotherapy. In
performed as well. Oophorectomy is not addition, chemotherapy may help in the
compulsorily performed in the pre-menopausal eradication of micro-metastasis. Hyperbaric
woman, as metastasis to the ovaries is rare and oxygen, fractional radiation dosage and neutron
also carcinoma of the cervix is not hormone therapy are new promising techniques to
dependent. The common morbidity of the improve the effect of radiotherapy.
operation is ureteric fistula due to avascular
necrosis, which results from dissection of the Management of recurrent disease
uretersto make it possible to remove the cervix,
andthe adjacent pelvic fascia. About 3 0% of patients with invasivecervical cancer

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I 180 Obstetrics and Gynaecology

die from recurrent or persistent disease after the Stages Ib-IIa

initial therapy. Management of recurrent Inthe first trimester Wertheim's hysterectomy is
disease shouldbe done ina specialised centre. It performed. Radiotherapy is not usually advised
may involve other specialists like the radiation as these women are young and it is necessary to
or medical oncologist. The patients may benefit preserve ovarian and sexual functions. Where
from either radiotherapy or pelvic exenteration. radiotherapy is the choice, external beam is
Exenteration is performed in only special units applied to induce abortion and it is followed by
where the surgical, nursing and ancillary staffs caesium insertion. In the second trimester,
are confident and experienced in managing hysterotomy to remove the fetus is done first
such patients. Pelvic exenteration is performed followed by Wertheim's hysterectomy. If
where there is a local spread to the bladder, radiotherapy is to be done surgical removal of
rectum or both. There are three types of pelvic the fetus is followed by radiotherapy. In the
exenteration: anterior, posterior and total third trimester when the fetus has reached
Anterior exenteration consists of the removal of viability caesarean section and Wertheim's
hysterectomy are performed at the same time.
the uterus, vagina and bladder with
Where radiotherapy is the choice, caesarean
implantation of the ureters into an artificial section is performed followed by radiotherapy
bladder made from a loop of the ileum (ileal two to four weeks later.
conduit). Posterior exenteration consists of the
removal of the uterus, vagina and rectum with Stages Ilb-IV
the construction of terminal colostomy. Total
In early pregnancy external radiation is first
exenteration is a combination of the anterior
applied to induce abortion followed by caesium
and posterior exenteration. Contraindications insertion, hi late pregnancy hysterotomy or
to exenteration include: caesarean section is performed followed by
L patient more than 75 years old ii. tumour radiotherapy.
size greater than 4cm in diameter iii. evidence
of infiltration of lymphatic or lumbosacral Management of terminal disease
plexus e.g. lymphoedema of the legs and Pain relief is the mainstay in the management.
backache iv. presence of a fistula v. evidence Narcotics are usedto relieve pain. Insome cases
of extra pelvic metastasis. Chemotherapy has intrathecal injection of phenol is also used for
been used in some cases of recurrent disease pain relief. This effects pain relieffor about 3-6
with encouraging results. months. Psychological support which may
come from the health personnel, local vicar,
Invasive disease in pregnancy pastor, imam and relations, is also important.
Patients should be made to die in comfort and
Invasive carcinoma of the cervix presents as with some dignity. Colpocleisis (complete
abnormal vaginal bleeding or may be closure of the lower vagina) can be done in
asymptomatic in 20% of cases. This makes it cases where there is vesico vaginal fistula or
necessary to do a speculum examination in any recto vaginal fistula.
case of abnormal bleeding inpregnancy.
The management of invasive cervical cancer in Survival
pregnancy depends on the gestational age and The five-year survival rate depends on the stage
the stage of the disease. of the disease.

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13 Stage la >95%
Tumours ofthe cervix uteri 181

radical surgery with postoperativeradiotherapy

Stage Ib >80% isindicated. With smaller fibroids hysterectomy
Stage IIa >60% may be performed after the radiotherapy
Stage IIb 50% treatment is completed.
Stage III 25%
Stage IV 5% Cancer of the cervix in children
This is very rare and nearly all of them are
Follow-up after treatment for cervical adenocarcinomas. The presenting symptom is
carcinoma almost always vaginal bleeding. Carcinoma of
the cervix in children is very rare; when it does
These patients must be followed up for life. occur, it is more likely to be a glandular type
They shouldbe seen every 3 months for the first than the epidermoid or squamous type. Benign
2 years, then every 6 months thereafter. At each tumours of the cervix are even more rare in
follow up visit, a history is taken with particular children than malignant ones. Children with
reference to weight loss, pelvic pain or vaginal cervical tumours usually present with a
bleeding. A general examination is performed. purulent and watery vaginal discharge and
Careful abdominal, vaginal and rectal genital bleeding. A few of them may expel
examinations are done to check for evidence of fragments of necrotic tissue from the vagina.
metastasis and recurrence of tumour. Blood is Early diagnosis and Wertheim's operation and
taken to detect anaemia. A vault smear is done partial vaginectomy with removal of
(note vault smears should be done for the rest of paracervical connective tissue and pelvic
life), CT scan and also MRI are done in some lymphadenectomy, but with preservation of
cases. The body weight should be recorded at healthy ovaries is the treatment of choice.
eachvisit. Postoperative irradiation can only be given if
the ovaries havebeendisplaced out of the pelvis
Pelvic infection and carcinoma of the at the time of the operation.
cervix
Summary
A laparotomy may be indicated to assess the
situation, and bilateral salpingo-oophorectomy Cervical cancer is often a preventable disease.
with drainage of the pus under appropriate Creation of public awareness for cervical
antibiotic cover is sometimes performed. cancer and its prevention, prevention of
Radiotherapy is then given as soon as the sexually transmitted diseases, adolescent
wound is healed. Wertheim's hysterectomy is reproductive health education, provision of
however performed if this is technically resources necessary to perform and interpret
feasible. Pap smears and government commitment are
important steps toward reducing the
Fibroids and carcinoma of the cervix prevalence, the morbidity and mortality from
With stage Idisease associated with large fibroids, this disease.

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develop a stalk and become a fibroid polyp. vessels containing blood are formed into cystic
Cervical, when it is situated in the cervix. The spaces within fibroid tissue.
incidence of cervical fibroid is quoted as 1-2
percent of all cases offibroid. Lymphangiectasis. In this case the lymphatics
are distendedand form cystic spaces.
Broad ligament (Intraligamentary) when a
subserous fibroid burrows intothe broad ligament. Clinical history

Degenerative changes Fibroids may be symptomless especially ifthey

are small. Symptoms associated with fibroids
Fibroids frequently undergo some changes include:
which are usually due to inadequate blood Menorrhagia. This is more common with the
suppy. These changes include: submucous type, which increases the
endometrial surface from where bleeding
Atrophy. The fibroid undergoes shrinkage and occurs. Other explanations for the menorrhagia
this may occur after the menopause. are increased vascularity associated with the
Hyaline degeneration. In this case, the fibroid tumour and also more degree of endometrial
becomes softer due to formation of hyaline hyperplasia.
tissue within the substance of the tumour. This
isbest seen whenthe tumour is cut open. Abdominal mass. The woman may complain
of a swelling in the abdomen or increased
Cystic degeneration. This may follow hyaline abdominal girth ifthe tumour is a big one.
degeneration. The hyaline tissue liquefies and Irregularbleeding. The menstrual patternmay
forms cystic areas thus making the whole become irregular and the bleeding heavy in the
tumour become soft and cystic. presence of a fibroid polyp or when a
submucous fibroid becomesulcerated.
Fatty degeneration. This may occur when fat is
deposited in a fibroid and the tumour then Pressure symptoms. A large fibroid may
assumes a yellowish appearance. compress the surrounding organs and present
corresponding symptoms.
Red degeneration. This is sometimes referred
to as necrobiosis. It is frequently seen in Bladder - whenthe bladder is compressed there
pregnancy especially in the second trimester. may be frequency of micturition or retention of
However, the aetiology is probably unknown urine.
although the reddish colour of the tumour may
suggest a kindof infarction. Rectum - compression of this organ may result
inconstipation or dyspepsia.
Calcification. Fibroids may become calcified and Lymphatics - oedema of the legs is caused by
this is visible on an X-ray. This degeneration may
compression of the lymphatics by fibroid.
occur postmenopausally or secondary to necrosis.

Telangiectasis. This term is usedwhen distended Veins - varicosity of the veins in the legs is the
result of compression ofveins likethe iliac veins.
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186 Obstetric and Gynaecology

190 Obstetrics and Gynaecology

nulliparity, obesity, late menopause, Ila (G123) Endocervical glandular

hypertensive disease, diabetes mellitus, uterine involvement only
fibroid, excessive exposure to exogenous Itb (G123) Cervical stroma invasion
oestrogen and history of previous endometrial ffla (G123) Tumour invades serosa or
hyperplasia. Some gynaecologists have adnexa or positive peritoneal
established a family history of cancer insome of cytology
their patients. Illb (G123) Vaginal metastases
Pathology fflc (G123) Metastases to pelvic or para¬
aortic lymph nodes
Endometrial carcinoma may arise from an area IVa (G123) Tumour invasion of bladder or
of variable size and is usually papillary, soft or bowel mucosa
friable. The polypoidal masses may fill and IVb (G123) Distant metastases including
distendthe uterine cavity. intra-abdominal and/or inguinal
Histologicalgrading lymph nodes
G1 - Well differentiated
The histological types of endometrial G2 - Moderately differentiated
carcinoma are: G3 - Poorly differentiated
1. Adenocarcinoma: This accounts for
approximately 90 percent of the cases. It is a (Gl, G2, or G3 could be applicable in all stages).
well differentiated colummar cell tumour with

1
glandular pattern. Table 22.1 Surgico-pathological staging
2. Adenoacanthoma: This contains malignant endometrial carcinoma FIGO
glandular and squamous elements and accounts
for about 5 percent of the cases.
3. Adenosquamous carcinoma: When the The above staging is done at laparotomy and
squamous element containedis malignant. with subsequent histology report. Thus there
4. Anaplastic carcinoma: This tumour consists couldbe highrisk with a poor progrosis andlow
of undifferentiated columnar cells. The risk with a good prognosis.
glandular pattern isalso difficult to distinguish. Spread
Staging Endometrial carcinoma can spread by the
following routes: -
In 1989, FIGO introduced a surgico-pathological
staging system which incorporates the presence or Direct spread - The tumour infiltrates the
absence of myometrial invasion, positive peritoneal myometrium and may go as far as the serous
cytology and involvment of lymphnodes. coat. The tumour may also spread down to the
cervix.
Stage
la (G123) Tumour limited to endometrium Lymphatics - This may bethe mode of spread to the
lb (G123) Invasionconfined to inner half Fallopian tubes and ovaries. The upper vaginal
ofthe myometrium walls may also be involved in this way.
Ic (G123) Invasion in outer halfof the The lymph nodes usually involved are the para¬
myometrium aortic, internal, external and common iliac groups.

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Tumours ofthe corpus uteri 191

Haematogenous - Tumour emboli enter the Ultrasound scan

blood stream and may be carried to distant
organs in the body. This may also be the mode Treatment
of tumour spread to lower vagina. For stage 1 disease, total abdominal hysterectomy
and bilateral salpingo-oophorectomy is advocated.
Clinicalsymptoms If patient is considered a high risk, postoperative
radiotherapy is administered in addition. This may
The clinical symptoms may be irregular uterine
be in form of both external beam therapy and
bleeding or blood-stained discharge occurring
intravaginal caesium application.
some years after the menopause. Bleeding may
later become prolonged and heavy. In a For stage II cases, total abdominal hysterectomy
premenopausal woman the bleeding may be and bilateral salpingo-oophorectomy is
intermenstrual. Vaginal watery discharge may recommended. Postoperative radiotherapy is also
also occur and when this becomes infected the added. Some surgeons however prefer Wertheim's
discharge may become offensive. or extended hysterectomy to be followed by
external radiotherapy post-operatively.
Clinical signs
The uterus may be enlarged but sometimes it For stages III and IV, the treatment is more of
may appear normal in size especially in palliative with external beamradiotherapy.
postmenopausal women.
Uterine tenderness may be present whenthere For high risk cases of stages III and IV or
is extensive spread of the growth. recurrent disease, progestogen administration
may be helpful in addition to radiotherapy as it
Investigations has been shown that some tumours respond
well to progestogen.
Cytological examination of aspirate from the
posterior fornix may reveal malignant Prognosis
endometrial cells.
The prognosis depends on the grade, myometrial
Cervical cytology may sometimes reveal the
invasion and lymph node involvement. Before the
diagnosis if malignant endometrial cells are
new 1989 FIGO staging, some centres reported a
present.
cure rate of about 70 percent.
Examination under anaesthesia and curettage
will no doubt reveal the diagnosis. Usually the Choriocarcinoma
curettings are profuse, cheese like and darkish
This tumour is described in detail in a later chapter,
incolour. Histology will confirm the diagnosis.
Uterine sarcoma
Other investigations include:
Sarcoma of the uterus is a veiy rare tumour in our
Chest radiography environment. This may seem paradoxical since
uterine fibroid is a common tumour. The tumour
Cystoscopy
constitutes about 1% of all uterine malignancies
Sigmoidoscopy according to some authors. The age incidence is
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192 Obstetrics and Gynaecology

usually between 50-60 years. Clinicalfindings

Pathology Clinical examination may reveal an enlarged
Sarcomas may be homologous or heterologous tender uterus. A friable polypoidal tumour may
according to their histological patterns and the also be seen in the external os in some cases.
elements that they contain. The homologous Investigations
types include leiomyosarcoma, endometrial An examination under anaesthesia is usually
stroma sarcoma, angisarcoma, fibrosarcoma, performed and a diagnostic curettage carried
and fibromyxosarcoma while the heterologous out and the specimen sent for histology. A chest
varieties are rhabdomyosarcoma (including X-ray is also mandatory.
sarcoma botryoides), chondrosarcoma,
osteosarcoma, liposarcoma and mixed Treatment
mesodermal tumour.
The main treatment is surgery if the tumour is
The tumour spreads mostly by the blood stream still operable. Surgery should consist of total
and a common site for metastasis is the lungs. hysterectomy and bilateral salpingo-
oophorectomy. Radiotherapy has very little
Staging place in the management because of the
tumour's early haematogenous spread.
The UICC staging system of sarcoma is:
Chemotherapy has been tried as an adjuvant
treatment. This may be in form of combination
Stage I Sarcoma confined to the corpus uteri
Stage II Sarcoma involving the corpus and cervix
chemotherapy (vincristine, dactinomycin-D
Stage III Sarcoma extending outside the uterus andcyclophosphamide).
but confined to the pelvis Stage
IV Sarcoma extending beyond the true Prognosis
pelvis including distant metastases
The prognosis of uterine sarcoma is very poor
and the 5 - year survival rate has been quoted to
Clinical history be lessthan 10 percent.

The clinical symptoms are irregular uterine

bleeding and discharge which is blood-stained Bibliography and suggested further reading
and often offensive. In some cases, there may
be a history of lower abdominal mass (uterine Goldfarb, H.A. (2000) Myoma Coagulation (Myolysis)
mass), which has rapidly increased in size. Obstet Gynecol. ClinNorthAm 27:421.
Lower abdominal pain may also be
Jeffcoate, N(1975) Principles ofGynaecology, 4th ed.
experienced. Loss of weight also sets in fairly
rapidly.

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Tumours ofthe corpus uteri 193

Butterworth, London. Minko-Mi-Etoua, D. (2000). Endometrial carcinomas in

Gabon Sate 10:43.
Kuzel, D., Toth D., Fucikova, Z., Cibula, D., Hruskova, H.,
Zivny, J. (1999) Hysteroscopic resection of submucosal Ravina, J. H., Aymard, A., Ciraru-Vigneron, N., Ledreff 0.,
myomas in abnormal uterine bleeding: Results of a 4- Merland, J. J. (2000). Arterial embolization of uterine myoma.
yearprospective study. CeskaGynekol 64:363. J. Gynecol Obstet Boil Reprod(Paris) 29:272.

La, D., Zheng, M., Shen, L (1998). Laparoscopic Assisted Seinera, P., Farina, C., Todros, T (2000) Laparoscopic
Transvaginal Hysterectomy. Chug Hua Fu Chan Ko Tsa myomectomy and subsequent pregnancy. Human reprod
Chi 33:342. 15:1993.

Meye, J. F., .Mabicka, B. M., Belembaogo, E., Minko-Mi- Willemsen, W. N., de Kruif, J. H., Velthausz, M. B., Meelen, B.
Etoua,, D. I.,Engongah-Beka,T, T (2000) Fibroidsandfertility. NedTijdschr Geneeskd 22:789.

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Chapter 23
Tumours of the fallopian tube

Incidence Secondary carcinoma

Sarcoma
Primary cancer of the Fallopian tube is one of Choriocarcinoma
the rarest female genital cancers. Most authors
have quoted its incidence to be about 0.3% of all Primary Carcinoma
genital tract malignancies. In Nigeria, the Primary carcinoma is a very rare tumour and is
incidence isbelieved to bemuch lower thanthis usually of the papillary adenocarcinomatous
as most gynaecologists have not reported a type.
single case. Of course, this tumour may
sometimes be overlooked unless a routine Aetiology
microscopic section is done in all cases of
endometrial carcinoma when the uterus and There is no known aetiological factor although
appendages are removed. an association between the tumour and
inflammation of the tube has sometimes been
Pathology observed. This is however, not conclusive.

Tumours of the Fallopian tube can be classified Pathology

into primary and secondary, and benign and
malignant varieties. The benign tumours are The cancer is usually in the form of a raised
rarer than the malignant ones while secondary papillary nodule located in the mucosa of the
tumours are about 10 times as common as middle third or distal third of the tube. The tube
primary tumours. is more often enlarged probably as a result of
occlusion of its cornual and fimbrial ends.
Benign
Spread
Examples of benign tumours are Papilloma
Lipoma The tumour may spread by spill through the
abdominal ostium or by lymphatics to the
Angioma uterus, ovaries, iliac, lumbar or supraclavicular
lymph ] nodes. Distant spread by the blood
Fibromyoma
stream may also occur to organs like liver,
Cystic teratoma (dermoidcyst) lungs spleen, stomach, intestine and the
diaphragm.
Adenomatoid tumour
Clinical history
All these tumours have been described though
are exceedingly rare. The commonest age incidence is between 50 and
60 years. The patient may present with sero-
Malignant
sanguinous or blood-stained vaginal discharge.
Examples of malignant tumours are Primary Colicky lower abdominal pain may sometimes be
carcinoma 1 a feature. Abdominal swelling may be present if
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Age: - Data on relationship between age at History of tubal ligation and hysterectomy
menarche and menopause and the risk of Pathogenesis
ovarian cancer is inconclusive, however a weak
relationship is said to occur between early The aetiology of ovarian tumours is
menarche and late menopause and increased multifactorial.
risk of ovarian cancer. Three hypotheses have been proposed:
Incessant ovulation
Race - Lifetime risk is higher among white women The gonadotrophin stimulation
(1.86%) thanAfrican-American women (1.08%). Pelvic contamination
Nulliparity, Infertility - The increased risk is Incessant ovulation hypothesis
not in all infertility cases but depends on the
cause and duration of "exposure". The risk was It is based on the postulate that repeated minor
higher among women with infertility of ovulatory trauma to the epithelial surface of the ovary
origin. The cause of increased risk is believed to caused by continuous ovulation increased the
be that fertility drugs increase ovulation. likelihood of ovarian cancer. The protective effect

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200 Obstetrics and Gynaecology

conferred by parity, oral contraceptives,

lactation and pelvic surgery as well as the
A
benign and malignant are included and referred
to as of borderline malignancy (carcinoma of
increase in risk with fertility drugs seem to low malignant potential). They are
support this hypothesis. characterised by an unusual degree of epithelial
cell proliferation, increased mitotic activity,
The gonadotrophin hypothesis nuclear abnormalities and cytologic atypical
The hypothesis postulates that the exposure of cells. With a stage 1 borderline ovarian tumour.
the ovary to continuous, high circulating levels the survival rate after surgery alone is nearly
of pituitary gonadotrophin increases the risk of 100%, therefore no adjuvant therapy is usually
malignancy. required. Thus if a young woman is found to
This hypothesis suggests that factors that have a unilateral ovarian tumour that is not
inhibit suppression of the secretion of obviously malignant at laparotomy, only a
gonadotropins reduce the risk of ovarian unilateral salpingo-oophorectomv need be
cancer, which explains the protective effect of
performed, and if at frozen section a diagnosis
of a borderline ovarian tumour is made, no
parity and the use of oral contraceptives.
further surgery need be carried out if a careful
Pelvic contamination theory check of the other ovary, pelvis and abdominal
cavity including diaphragm, omentum.
This is postulated to explain the role of some retroperitoneal lymph nodes and cytological
exogenous chemicals. The hypothesis suggests washings show no evidence of malignancy. A
that carcinogens may come in contact with the routine section should of course be undertaken ;|
ovary after passage through the genital tract. to confirm the absence of invasion. If a similar
This is in accordance with the increased risk condition is found in an older woman who has
observed with the use of talc. completed her family, total abdominal
hysterectomy and bilateral salpingo-
Classification of ovarian tumours oophorectomy is the operation of choice.
We do not know for sure, the nature or origin of provided that a thorough check has again
many ovarian tumours. The ovary, because of demonstrated no metastasis. Patients whc
its very varied structure and complex however have extra-ovarian involvement by
embryological and histogenetic make-up, gives borderline ovarian tumours, stage IIto stage IV.
rise to a wider variety of cysts and tumours than should be given the full treatment as for)
any other organ in the human body. As a result, invasive carcinoma for the respective stages.
ovarian tumours are classified according to The epithelial tumours
their tissue of origin. A modified version of the The epithelial tumours account for 90% of
World Health Organization (WHO) ovarian cancer and they arise from the surface
classification of ovarian tumour is shown in epithelium of the ovary.
Table 24.1. They are classified according to cell type
histological and cytological features and
Tumours of borderline malignancy
clinical behaviour as benign, borderline or
Inthe classification of epithelial tumours, some malignant (Table 24.2) About 10 - 15% of all
tumours which are intermediate in their ovarian malignancies are classified as
histological features and behaviour between borderline or having low malignant potential.
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p Common epithelial tumours (benign, borderline III.

Tumours of the ovary 201

Germ cell tumours

andmalignant) A. Dysgerminoma
A. Serous B. Endodermal sinus tumour (yolk sac
B. Mucinous tumour)
C. Endometrioid C. Embryonal carcinoma
D. Clear cell (mesonephroid) D. Teratoma
E. Brenner E Mixed tumours
F. Mixed epithelial IV. Soft tissue tumours not specific to ovaiy
G. Undifferentiated V. Unclassified tumours
H. Unclassified. VI. Metastatic tumours.
n. Sex cord stromal tumours
A. Granulosa - theca cell tumour
B. Sertoli-Leydig cell tumour
C. Unclassified
Table 24.1 Modified histological classification of ovarian tumours (WHO)

BENIGN OFBORDERLINE MALIGNANT

MALIGNANCY
SEROUS TUMOURS:
CYSTADENOMA PAPILLARY CYSTADENOMA ADENOCARCINOMA
CYSTADENOMA SURFACE PAPILLARY PAPILLARY ADENOCARCINOMA
PAPILOMA ADENOFffiROMA CYSTADENOMA SURFACE SURFACE PAPILLARY CARCINOMA
CYSTADENOFIBROMA PAPILOMA MALIGNANT ADENOFffiROMA
ADENOFffiROMA MALIGNANT CYSTADENOFffiROMA
MUCINOUS TUMOURS:
CYSTADENOMA CYSTADENOFIBROMA
ADENOFffiROMA CYSTADENOCARCINOMA
CYSTADENOFIBROMA CYSTADENOMA ADENOCARCINOMA
ADENOFIRBROMA MALIGNANT ADENOFffiROMA
ENDOMETRIOID
TUMOURS: CYSTADENOFffiROMA
ADENOMA CYSTADENOMA
ADENOMA
ADENOFffiROMA CYSTADENOMA
CARCINOMA
CYSTADENOFTBROMA ADENOFffiROMA
ADENOCARCINOMA
CYSTADENOFffiROMA
ADENOACANTHOMA
ADENOSQUAMOUS CARCINOMA
MALIGNANT ADENOFffiROMA
MALIGNANT C Y STADENOFIRBROMA
ENDOMETRIOID STROMAL SARCOMA
MESODERMALADENOS ARCOMA
MESODERM AL MIXED TUMOUR

CLEAR CELL TUMOUR:

ADENOFffiROMA ADENOFffiROMA CARCINOMA
ADENOCARCINOMA
BRENNER TUMOURS - These may be benign, of borderline malignancy or malignant.
MXXEDEPTHELIALTUMOURS - These may be benign, of borderline malignancy or malignant.
UNDIFFERENTIATEDCARCINOMA
UNCLASSIFIED EPITHELIAL TUMOURS

«
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202 Obstetrics and Gynaecology

Epithelial tumours desirous of maintaining reproductive function.

Benign epithelial tumours In older women above 40 years of age,
Serous cystadenoma hysterectomy with bilateral salpingo-
Serous tumours are characterised by a oophorectomy isrecommended. Where rupture
proliferation of cuboidal epithelium has occurred 5-10% dextrose solution should
resembling that which lines the Fallopian tubes. be injected into the abdominal cavity to liquefy
They are seen in patients between 20-40 years the mucin andthensuctionis carried out.
of age, usually unilocular and bilateral in about
Endometriomata (Endometrioid)
30% of cases, have a smooth surface lining and Endometriotic lesions in the ovary are usually
contain thin, clear yellow fluid. They may grow associated with other evidence of
to any size but usually are of moderate size and endometriosis elsewhere in the pelvis. They
smaller than their mucinous counterparts. They rarely become malignant. The only clearly
may become malignant inabout 30% of cases. recognisable benign endometrioid tumours are
Treatment is surgical and this is guided by the the endometrioid adenofibroma and the
age of the patient, by the risk of malignancy proliferative endometrioid adenofibroma.
which occurs in 30% of the cases and whether Patients occasionally present with symptoms
they are bilateral or unilateral. In younger relating to the mass or they are accidentally
patients conservative surgery is recommended, discovered on pelvic examination.
however for women above 40 years of age a total Management is as described under
abdominal hysterectomy with bilateral salpingo- management of endometriosis of the ovary.
Clear celltumour
oophorectomy isrecommended.
The benign form is limited to the clear cell
Mucinous cystadenoma Eighty five percent of
adenofibroma. Presentation is also the line of
mucinous tumours are benign and they are any other benign ovarian mass and diagnosis is
found in women in the third to fifth decades of only made after histological examination.
life. The cysts are lined with tall columnar cells, Prognosis isexcellent.
and they resemble the mucus-secreting cells of Transitionalcell (Brenner) tumours
the endocervix, generally mutilocular, active
Brenner tumours represent 1 -2% of primary
and continually secrete mucin into the cell. ovarian tumours and are unilateral in nearly 95%
They may grow into enormous size and are the of cases. They represent adenofibromas in which
largest gynaecological tumours. Usually the proliferating epithelial element has a
asymptomatic and rarely malignant, patient transitional cell appearance. Brenner tumours are
occasionally presents with large abdominal usually benign and appear grossly as solid, white
distension and discomfort or the cyst may or pale yellow discrete fibroma-like masses but in
rupture leading to continuing accumulation of some 30% of instances they have some cystic
mucin in the peritoneum and a condition components. When they are of borderline
referredto as pseudomyxoma peritonei. malignancy they are called proliferative Brenner
tumours. Brenner tumours are typically
The treatment is surgical and it is dictated by the multicystic with papillomatous growth within the
age of the patient and whether the tumour is still cysts. They are usually of small size and
encapsulated. Unilateral salpingo-oophorectomy occasionally may be up to 5-8cm in diameter and
is recommended in young women who are still then present as an adnexal mass. Treatment is

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Tumours ofthe ovary 203

basically surgical and is done to establish the cases a midline incision should be made for
diagnosis and remove the tumour. adequate exploration and frozen section is
helpful in' identifying the type and the
Connective tissue neoplasm (Fibromata) neoplastic potential of the tumour. For older
Fibromata form 5% of ovarian neoplasm and women above 40 years who are not desirous of
they are derived from the mesenchymal retaining their fertility, total abdominal
connective tissues. The tumour may exist alone hysterectomy and bilateral salpingo-
or may be found in association with oophorectomy is generally recommended.
cystadenomata or with Brenner tumour. They
Malignant epithelial tumours
are also usually solid tumours but may contain
areas of oedema or cystic degeneration. They Serous carcinomas
are usually small but occasionally grow to a Serous carcinoma is the most common
large size. In 10 percent of cases they are histological type of ovarian malignancy. It
bilateral. In certain conditions, fibromata are accounts for 50% of all epithelial ovarian
associated with ascites and hydrothorax, a carcinoma. Serous tumours of the ovary are
clinical condition referred to as MEIG'S usually cystic but may show a combination of
syndrome. The explanation for the cystic and exophytic surface growth. They
accumulation of the fluid is not clear but it has typically form unilocular cysts but may be
been suggested to be due to leakages of fluid bilateral in up to one inthree cases, and usually
from the areas of oedema within the tumour. contain serous fluid even though occasionally
They rarely grow malignant. Treatment is they may contain mucinous fluid. Their
surgical removal and this is accompanied by diagnostic features are fine papillarity with
disappearance of the fluids. irregular, often slit-like glandular lumina and
presence ofpsammoma bodies. These calcified
Principles of management of benign granules or psammoma bodies are
ovarian cyst characteristic, though not specific for serous
carcinoma and may be seen in a wide variety of
The treatment of an ovarian cyst is influenced by
other ovarian neoplasm both malignant and
the size, associated complications, nature of the
benign and also in inflammatory conditions of
cyst, the age and parity of the patient. Observation
the ovary.
to confirm the persistence and the character of an
ovarian cyst is the best policy. However, if the Mucinous carcinoma
cyst becomes complicated at any time then
These are the second most common type of
surgery becomes imperative. Majority of the
epithelial ovarian tumours, accounting for about
cysts that are physiological regress on their own.
35% of borderline tumours and 10-15% of frankly
If it is asymptomatic and persists through at least
malignanttumours.
three menstrual cycles then prompt and thorough
Grossly, mucinous tumours are large and
investigation is imperative. Excision of the cyst multiloculatedwith smooth external surfaces. Solid
with preservation of the ovary if feasible is more
areas and papillary projections are morecommon in
desirable. In young women, large cystic benign the frankly malignant variant. A mucinous cyst may
epithelial tumours may require unilateral ovarian contain benign, boderline and malignant
cystectomy with preservation of healthy ovarian
components all within a single tumour. It is
tissue unless there is no ovarian tissue seen. In such sometimes very difficult to distinguish between
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204 Obstetrics and Gynaecology

mucinous cystadenoma of borderline 12%), and lacks the prominent stromal

malignancy and mucinous cystadenocarcinoma. calcifications present in most malignant
Borderline mucinous tumours are Brenner tumours.
distinguished from the invasive tumours by the
following criteria as outlined by Hard and Pattern of metastasis
Morris: (i) presence or absence of invasion, The primary mode of dissemination of
(ii)the degree of stratification of the epithelium, epithelial ovarian cancer is by implantation on
and (iii) the degree of atypia. peritoneal surfaces.
Direct local extension of ovarian cancer may
Endometrioidcarcinoma also occur to the surrounding tissues including
Endometrioid carcinoma was first described by bladder, uterus and Fallopian tubes and the
Sampson in 1925 and'it accounts for about 10 to sigmoid colon. Haematogenous spread is rare
25% of all epithelial ovarian tumours. It is found but it is not uncommon as a late manifestation.
in association with endometriosis in about 10% By lymphatic spread, but precise incidence of
of cases. Most tumours are cystic, frequently lymphatic metastasis is not known. Factors that
with papillary structures filling the tumour. seem to support the risk of lymphatic
Occasionally, they are solid. Bilateral dissemination include the FIGO staging,
involvement occurs in about 30% to 50% of histological grade, and vascular space
cases, with about 50% of patients having stage I involvement.
disease.
Clinical features of ovarian
Clear cellcarcinoma tumours
Clear cell carcinoma accounts for about 5% of Early symptoms are non specific such as
epithelial ovarian malignancies. Most tumours abdominal discomfort, nausea or dyspepsia. As
are partly cystic. Bilateral tumours occur in40% the tumour enlarges it causes compression of
of cases andalmost 50% of cases are staged. surrounding pelvic structures resulting in such
symptoms as constipation, urinary frequency or
Brenner tumour pelvic pressure.
Malignant Brenner tumours are composed of
Also malignant tumours may undergo changes
invasive transitional or squamous cell carinoma
similar to benign tumours such as torsion,
and sometimes contain mucinous elements. The
haemorrhage and rupture and will therefore
tumours are usually large and multicytic with
present with features of acute abdominal pain
polypoidal masses projecting into the tumour.
and resulting in a surgical emergency.
Most are unilateraland stage I.
Abdominal distension occurs as the ascites
Transitional cell carcinomas develops and this will also lead to weight gain.
Weight loss may also occur occasionally in
Histologially, these tumours differ from malignant
association with chronic anorexia and intestinal
Brenner tumours only by the absence of a benign
obstruction.Abnormal vaginalbleeding inform
Brenner component. Also, the transitional cell
of menstrual irregularity or postmenopausal
carcinoma is more likely to spread beyond the ovary
bleeding may be seen occasionally in hormone
(69% versus 19%), is more likely to result in
secreting ovarian tumours e.g. granulosa cell
death even if confined to the ovary (57% versus
tumours. Clinical examination may reveal a

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Tumours of the ovary 205

palpable pelvic or pelvic abdominal mass. It is associated with obstruction.

clinically difficult to differentiate between a benign
or malignant ovarian tumour as there are no Chest X-ray: - detects pleural effusions or
definitive pathognomonic clinical features. pulmonary metastasis.
However it is suggested that benign tumours tend to
be cystic, smooth, unilateral and mobile whereas Intravenous urogram: - may show ureteric
malignant tumours tend to be solid, nodular, and displace-ment in
immobile or fixed and with accompanying ascites. obstruction or a pelvic
Ascites is occasionally found in benign lesions such kidney
as in Meig's syndrome. Presence of hepatomegaly
and or "Sister Joseph nodule" in the umbilicus Barium enema - may reveal diverticular
(umbilical metastasis) may be seen in patients with disease, colon cancer or
advanced disease.
involvement of the
Diagnostic evaluation
rectosigmoid by ovarian cancer.
The differential diagnosis of a pelvic mass
(This is preferably done in conjunction with
includes benign ovarian tumours and pelvic
inflammatory disease. Common non- proctosigmoidoscopy)
gynaecological causes include diverticular
disease, tumours of the colon or appendix, Barium swallow and follow through: - to rule
retroperitoneal tumours, metastatic cancer and out gastric ulcer and gastric cancer
a pelvic kidney. metastasis to the ovary.
CT scan - to detect pelvic and para aortic node
Routine blood studies: - including full blood metastasis.
count and blood chemistry form
part of the pre-operative Ultrasonography
evaluation.
This may be used to differentiate a benign
CA125 determination is also tumour from the malignant tumour. Malignant
recommended tumours are generally multiloculated, more
because an estimated 80% of solid or echogenic, and larger (> 5cm) with
patients with epithelial ovarian thick septa andsolidnodule.Ascites ifpresent is
cancer have an abnormal value
at diagnosis.
easily detected. Computerised tomography
Radiographic studies: These are helpful in the (CT) is useful in detecting retroperitoneal
differential diagnosis and preope¬ lymph nodes and omentum and also hepatic
rative evaluation of patients. metastasis and intrauterine disease. Magnetic
resonance imaging (MRI). This is a relatively
Plain X-ray of abdomen: -differentiates benign new technique and the primary advantage in
cystic teratomas with associated evaluating ovarian masses is the ability to
calcifications and characterise tissue. The presence of fat,
hyperlucency: haemorrhage, mucin, fluid and solid tissue
- psammomatous calcification within an ovarian mass can be determined using
of serous carcinoma MRI. It detects 95% of surgically proven
- indication of associatedascites or ovarian masses with a correct characterisation
dilated loops of small intestine of malignant disease in 100% of cases.
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206 Obstetrics and Gynaecology

Surgical Evaluation said to have theoretical survival advantage.

Staging of the disease Some centres have suggested that paclitaxel, a
recently introduced drug has improved
The stage of the disease is determined by the
responses whenusedwith platinum drugs.
extent of the tumour at the initial diagnosis
when laparotomy is performed. Non-Epithelial Tumours
The stage of the disease has been significantly
linked with the survival rates. Unfortunately The non-epithelial tumours account for 10
most or about 2/3 of the cases present instage III percent of all ovarian tumours, the mos
or IV. The five year survival rate is said to be common being the germ cell tumours and
highest for stage Idisease and it is about 70- sex cord stromal tumours.
90% for epithelial cancer. The powerful
predictor of outcome in stage I is the Sex Cord Stromal Tumours are derived froi
histological grade. Patients with well groups of cells inthe developing gonads andthe
differentiated or grade 1 tumours have an gonadal mesenchyme or stroma. They onh
excellent result with a five year survival rate of account for about 6% of ovarian neoplasms
95%. For patients with grade 2 or 3 tumours, less than one in ten of ovarian cancers. Theyj
survival rates are about 75% to 80% and 50% to include all the neoplasms which contain the se:
60% respectively. Other factors that influence cord or stromal elements alone or ir
prognosis significantly are large volume of the combination - See Table 24.3.
tumour, presence of ascites, dense adherence
andclear cell histological type. GRANULOSA CELL TUMOUR
FIBROMA
Adjuvant therapy THECOMA
SCLEROSING STROMAL TUMOUR
The need for adjuvant therapy is based on LEYDIG CELL TUMOUR
adequate surgical staging information and HILUS CELL TUMOUR
reliable pathological analysis. In our centre ANDROBLASTOMAS
adjuvant therapy applies to all patients. SERTOLI - LEYDIG CELL TUMOURS
However in certain centres the suggested GYNANDROBLASTOMA
practice is that patients with stage 1A and grade UNCLASSIFIED.
1 need no adjuvant therapy., The standard Table 24.3 Sex Cord Stromal Tumours
treatment now agreeable is a combination
therapy which must be platinum based. In our Germ Cell Tumours (See Table 24.4) account
centre we use cisplatinum, adriamycin and
for 25% of all ovarian neoplasms, the dermoid
cyclophosphamide. This is given on a 3 weekly
cyst or mature cystic teratoma being the ]
courses. We give a minimum of 6 courses.
commonest type. Malignant forms of these
There is no doubt that these drugs are very toxic
tumours are extremely rare and account for less
but the combination has reducedthe dose given
than 3% of ovarian cancers. Unfortunately.
compared with when it is used alone and wili
these malignant forms are rather more common
therefore reduce some of the side effects. The
use of intraperitoneal chemotherapy has been
inchildrenand premenopausal women.

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pnw DYSGERMINOMA or may be arranged in diffuse masses,

ENDODERMAL SINUS TUMOUR trabeculae, islands or cords. Their nuclei are
EMBRYONAL CARCINOMA typically round, oval or angular, pale and
POLYEMBRYOMA grooved. Granulosa cell tumours should always
CHORIOCARCINOMA (PRIMARY IN OVARY) be considered as potentially malignant.
TERATOMAS DERMOID CYST
(DERMOID CYST, WITH MALIGNANT Fibromas are derivatives of ovarian stromal
TRANSFORMATION. RARE) cells. They are solid tumours composed of
STRUMA OVARII chalky white hard fibrous tissue but may
CARCINOID contain areas of oedema or cystic degeneration.
OTHERS. Microscopically, they typically contain
Table 24.4 Germ cell humours
intersecting fascicles of spindle shaped
fibroblasts that produce collagen, but
occasionally a storiform pattern is observed.
Sex Cord Stromal Tumours
About 40% of fibromas over 10cm in diameter
Granulosa cell tumours: Granulosa and theca are accompanied by ascites, which is believed
cell tumours are the most common sex cord to be due to leakage of fluid from areas of
stromal tumours accounting for 1.5 percent of oedema within the tumour. Meig's syndrome, a
rare condition occurring in less than 1 in 100
all malignant ovarian tumours. Pure theca cell
fibromas presents with ascites, and hydrothorax
tumours which are usually benign, are virtually
usually right sided which disappears with
unknown. Most tumours are a mixture of
removal of the tumour. Fibromas are very rarely
benign theca and malignant granulosa elements
malignant.
and are composed of grey, white or yellow, firm
or softish tissue. They can occur at any age but Thecomas are derivatives of the ovarian
are most frequent in post menopausal women. stromal cells. They are softer than fibromas, are
They are usually associated with oestrogenic uniformly yellow or white flecked with yellow
effect and may therefore cause: areas. They may contain areas of oedema or
cystic degeneration and contain fibroblast-type
sexual pseudoprecocity before menarche.
cells and round cells containing lipid.
irregular bleeding or amenorrhoea during the Thecomas can produce menopausal bleeding
reproductive era. and amenorrhoea or irregular bleeding during
the reproductive years but they do not cause
postmenopausal bleeding after the climacteric. pseudoprecocity. They can also produce
They are also usually associated with cystic changes inthe endometrium similar to that seen
hyperplasia of the endometrium with varying in cases of granulosa cell tumour. They are
rarely malignant.
degrees of pre-cancerous atypicality or
occasionally even a low grade carcinoma of the Sclerosing Stromal Tumours have features
endometrium. Sometimes, they are solid but betweenthose offibromas andthose of thecomas.
may have unilocular or multilocular cysts. They are characterised by an intimate, disorderly
On microscopic examination, they may form admixture of fibroblasts and theca cells often
microfollicles (Call-Exner bodies) or large associated with cellular pseudolobules. These
follicles resembling cystic Graafian follicles typically have a rich supply of thin walled vessels.
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208 Obstetrics and Gynaecology

Dense sclerosis and often areas of oedema and with areas of haemorrhage, necrosis, gelatinous
cyst formation are also characteristic features. degeneration and cyst formation. Rupture of
The tumours are usually benign. this capsule is very common and it is found in
up to one infour cases at the time of surgery.
Sertoli-leydig cell tumours They are very rare
tumours and are macroscopically very similar to Embryonal Carcinoma is different from the
granulosa cell tumours and thecomas. endodermal sinus tumour in both its
Microscopically they contain Sertoli and Leydig
morphological and clinical features.
cells which show varying degrees of maturity.
Microscopically it is composed of solid masses
These tumours are potentially malignant and
with glandular arrangements, and papillary
most of them are associated with virilisation as a
result of the production of a variety of androgens formations composed of anaplastic cells
by the Leydig cell component of the tumour. A resembling those of the germ disc of the
few of these tumours are non-functioning and embryo. It contains isolated
some may even be associated with oestrogenic syncytiotrophoblast cells in nearly all cases. It
manifestations. is more common in children than the
endodermal sinus tumour and it is capable of
Gynandroblastoma contains cells of both endocrine manifestation because of its
testicular and ovarian types. The World Health chorionic gonadotrophin secretions. Thus it can
Organization criteria for the diagnosis of cause sexual precocity in the child, menstrual
gynandroblastomas include the presence of fully disturbance or rarely androgenic changes in the
developed easily recognisable male and female adult. In this condition the chorionic
cells, both in significant proportions. They are gonadotrophin and alpha-fetoprotein levels in
indeed very rare. the blood are elevated.

Germ CellTumours Choriocarcinoma - Primary choriocarcinoma of

Dysgerminoma - Accounts for 2-5 percent of all the ovary is rare: it is composed of
primary malignant ovarian tumours and 40 cytotrophoblasts and syncytiotrophoblasts and is
percent of all malignant germ cell tumours. It rarely seen in its true form. Because it secretes
occurs in women less than 30 years old and forms chorionic gonadotrophin, it may result in sexual
a large lobulated mass composed of soft or firm pseudo-precocity in children and menstrual
pale yellow or cream coloured tissue. It has abnormalities and/or androgenic changes inadults.
rounded polyhedral cells with abundant clear
cytoplasm, and prominent central nuclei. The Polyembryomas are very rare and contain a
cytoplasm is clear because of its large glycogen large quantity of embryoid bodies which
content. It contains varying numbers of mitotic resemble normal early embryo. They often
figures and lymphocytes. contain trophoblastic elements which secrete
chorionic gonadotrophin and this of course
Endodermal Sinus Tumour- (Yolk Sac Tumour) gives rise to relatedendocrine manifestations.
This contains elements resembling extra-embryonic
Teratomas can be classified into three major
structures and embryonic components in the form of
glands lined by intestinal-type epithelium, with
categories:
goblet cells. It is composed of grey to yellow tissue, a. Immature teratoma - a tumour containing
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Tumours of the ovary 209

elements from all three embryonic Dermoid cysts are benigncystic teratoma.
layers -endoderm, mesoderm and * They are relatively common and are
ectoderm and includes at least some derived from the primordial germ cells.
Therefore they contain elements from all
immature elements. Microscopically it the three embryological layers-
contains a wide variety of components endoderm, mesoderm and ectoderm-
(but mainly neuroectodermal), some of Most often the ectodermal layer
which are almost always mature. predominates. The cysts contain hair, skin
and its appendages and often teeth or
Mature teratoma - is composed almost cartilage. The tumour is usually unilateral
entirely of well differentiated fetal to except in about 10% of cases when it may
adult-type tissues. Sometimes it is solid, be bilateral. It is also usually small rarely
but is almost invariably benign. The exceeding 10cm in diameter. Sometimes
most common form of mature teratoma it may undergo torsion because of its long
is the dermoid cyst, so named because pedicle. Dermoid cysts are found between
the ages of 20 and 40 years. Treatment is
its lining is composed mainly of skin
usually surgical - ovarian cystectomy.
and its appendages but may contain
portions of respiratory epithelium or c. Monodermal or Monophyletic teratoma
glial tissue, thyroid, teeth, in fact has a predominance of single tissue
virtually any structure might be present element which is generally highly
(See fig. 24.1). Secondary malignant differentiated e.g. thyroid (strumaovarii),
change occurs in 1 or 2% of dermoid carcinoid and very rarely other types of
tissues.
cysts and in 4 out of 5 cases the
malignant tumour is a squamous cell Lipid (Lipoid) Cell Tumours: Sometimes this
carcinoma, but very rarely the type of tumour is lipid-richandhas an orange or
malignantchange might be a sarcoma. yellow hue, but when it contains little or no
lipid it is reddish brown, brown or even black if
the neoplastic cells contain large quantities of
lipochrome pigment.
SECONDARY (METASTATIC) TUMOURS
Account for about 8% of ovariantumours. Most
of them originate from the gastro-intestinal
tract, the large intestine being more often
responsible than the stomach. Metastases from
the stomach are usually solid and rarely contain
cysts. On microscopic examination they are
characterised by the presence of "signet cells"
Fig. 24.1 Dermoid cyst of ovary. Contains a hairy skin
and are called KRUKENBERG tumours (See
covered eminence adjoining a bony plate with teeth figs. 24.2 a & b). They may also arise from
projecting, (from Haines, M., and Taylor, C.W. breast cancer. Advanced cancer of the
Gynaecological Pathology, 1975. By kind permission of genital tract may spread to the ovaries, and
ChurchillLivingstone Publishers) rarely a carcinoid tumour, most often from the

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210 Obstetrics and Gynaecology

ileum may present clinically as an ovarian

mass. Melanomas and renal cell carcinomas
may also very rarely present as ovarian masses.
Ovarian lymphomas are usually secondary, but
may occasionally appear to be primary e.g.
Burkitt's lymphoma seen mainly inAfrica.

Figure 24.2b Section of Krukenberg tumour with

prominent 'signet ring' cells x 190 (from Haines, M.,
and Taylor, C.W. Gynaecological Pathology, 1975.
By kind permission of Churchill Livingstone
Publishers)

Figure 24.2a Krukenberg tumours. The bilateral early stage of the disease. It should also
solid tumours have a characteristic bossed outline.
decrease when the tumour is successfully
(From Haines, M., and Taylor, C.W.
.Gynaecological Pathology, 1975.By kind treated. Some of these tumour markers are
permission ofChurchillLivingstonePublishers) antigens and it is now possible to measure a
significant number of them in the serum of
ovarian cancer patients. Unfortunately, none of
Immunodiagnosis OfOvarian Cancer them so far has been found to be universally
elevated in patients with early stage ovarian
Medical researchers have for many years been cancer, whichmkes them lessthan adequate for
looking for a serum test that is specific for ovarian screening asymptomatic women. Some of
cancer. The ideal serum test will be a tumour these tumour markers are found only in
marker producedby the ovarian tumour at a very epithelial ovarian cancers, whereas others are
specific for ovarian germ cell tumours.

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Tumours of the ovary 211

Benign ovarian tumour Malignant ovarian tumour

AGE Usually during reproductive
phase. Tumours at extremes of life are more likely to
be malignant, so tumour before menarche and
after the age of 40 years must be viewed with
great suspicion.
PAIN None, unless in the presence of
torsion or some other A typically persistent abdominal and
complications. pelvic pain is almost always present.

BILATERAL
TUMOURS Not common
Common
ASCITES None, except with fibroma Usually present
*

FIXITY OF
TUMOUR Not usual in the absence of OJten present even in the absence of pelvic
pelvic inflammatory disease inflammatory disease.

CACHEXIA Rare Common in late stages

BLEEDING None
Usually present
LOCAL
METASTASIS None

DISTANT Common in late stages

METASTASIS None

VAGINAL
BLEEDING None Present in certain types of tumour.

Table 24.5 Differences between benign and malignant ovarian tumours

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212 Obstetrics andGynaecology

FIGO Stage Tumour characteristics

I Growth limited to the ovaries
IA Growth limited to one ovary; no ascites; no tumour on the external
surface; capsule intact.
IB Growth limited to both ovaries; no ascites; no tumour on the external
surfaces; capsule intact.
1C Tumour either stage IA or IB but with tumour on surface of one or
both ovaries; or with capsule ruptured; or with ascites present containing
malignant cells; or with positive peritoneal washings.
II Growth involves one or both ovaries with pelvic extension
HA Extension or metastases to the uterus or tubes
IHB Extension to other pelvic tissues
IIIC Tumour either stage HA or IIB, but with tumour on surface of one or both]
ovaries; or with capsule ruptured; or with ascites present containing
malignant cells; or with positive peritoneal washings.
Ill Tumour involves one or both ovaries with peritoneal implants outside
the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial
liver metastasis equals stage II.Tumour is limited to the true pelvis but
with histologically proven malignant extension to small bowel or omentum.
IIIA Tumour grossly limited to the true pelvis with negative nodes but with
histologially confirmed microscopic seedling on abdominal peritoneal surface.
IIIB Tumour of one or both ovaries with histologically confirmed implants on
abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are
negative.
IIIC Abdominal implants greater than 2cm in diameter or positive retroperitoneal
or inguinal nodes

IV Growth involves one or both ovaries, with distant metastases. If pleural

effusion is present, there mut be positive cytology to allot a case of stage
IV.Parenchymal liver metastasis equals stage IV.

Table 24.6: FIGO staging of primary carcinoma of the ovary

Treatment of malignant ovarian in order to gain adequate access to the entire

tumours abdominal cavity. Sample of ascitic fluid or
peritoneal washings for cytological evaluation is
1. Surgery taken first. This is followed by systematic
examination of the omentum, sub-diaphragmatic
Laparotomy is essential for both staging and treating areas, liver, anterior abdominal walls paracolic
ovarian cancer.Amidline vertical incisionis made gutters, surface of the smalland large bowel, pelvic

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Tumours of the ovary 213

r
\

organs, and pelvic and para-aortic nodes. Biopsies irradiation should be added.
of suspicious areas are taken in the absence of
gross upper abdominal disease. Sometimes, initial STAGE III:- Total abdominal hysterectomy,
assessment might not be feasible until primary bilateral salpingo-oophorectomy and
debulking is carried out. Radical surgery wherever omentectomy are carried out. Also, as much
technically practicable is the most recommended tumour as possible must be resected from all
treatment. This is followed by adjuvant therapy in other sites. This is followed by post operative
the nature of radiotherapy or chemotherapy. The chemotherapy and/or pelvic/abdominal
aim of the surgery is to remove all the tumour - this irradiation.
is known as cytoreductive or debulking surgery.
STAGE IV: - Some of these cases are
inoperable, but in a few others, debulking, that
Primary surgery
is, removal of as much tumour as feasible is
STAGE I:- This is treated by total abdominal done. This is followed up with chemotherapy
hysterectomy, bilateral salpingo- and later by interval surgery insome cases.
oophorectomy and infracolic omentectomy. It Over the past 20 years, maximum cytoreductive
may be followed only in cases where the surgery has been advocated on the premise that
tumour is poorly differentiated or positive women with less residual tumour have better
peritoneal or cytological washings by post prognosis than those having a bulkier disease
operative chemotherapy or pelvic and remaining.
abdominalradiation. Interval (intervention) debulking surgery -
This is the term used for a planned procedure
Conservative surgery performed in advanced ovarian cancer, when
primary surgery is incomplete and has been
This is reserved for young women with a followed by several courses of chemotherapy.
borderline or good prognosis early stage Following surgery, chemotherapy is continued.
ovarian cancer. Women with stage la well or This procedure has been found to improve
moderately differentiated epithelial tumours, median survival by 5-6 months and survival at
who wish to have a family can be treated with a three yeais by up to 20 percent in the group
unilateral salpingo-oophorectomy alone. The undergoing the additional surgery (van. Der
removal of the other ovary is advisable Berg et al, 1995). Some of the recent analyses
following completion of the woman's family as have also suggested that the most important
the rate of recurrence or new tumour formation factor in survival is the use of platinum-based
in the remaining ovary is unknown. It is drugs.
paramount that a good staging procedure is
carried out and occult cancer in the peritoneum Secondary surgery
and the other ovary is excluded.
This includes second look surgery, secondary
STAGE II:- This is treated by total abdominal debulking and palliative surgery. Second look
hysterectomy, bilateral salpingo-oophorectomy and surgery- This refers to laparoscopy and laparotomy
infra colic omentectomy. Pelvic and para-aortic performed on patients who have had extensive
lymphadenectomy is no longer practised but where disease at the first look and who have responded
a suspicious node is seen, biopsy is taken. Post well to chemotherapy based on clinica'
operative chemotherapy and/or pelvic /abdominal and radiological assessment. It may also be done
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214 Obstetrics and Gynaecology

with a view to stopping chemotherapy in Other single agent regimens that were
patients who appear to be in remission. historically popular were the alkylating agents-J
Laparotomy is more accurate than laparoscopy cyclophosplamide, melphalan and |
as this allows excision of residual disease. chlorambucil.
There is no evidence that second look affects Cisplatinum as a single agent or in] I
outcome and is therefore of no clinical effect. combination has been found to be superior to I
Palliative surgery - This is most often carried cyclophosphamide and others. Platinum-basec
out for bowel obstruction. Bowelresection and therapy has been adopted as the standard
by pass procedure isaimed at. therapy against which new regimens must br
judged. Two platinum drugs are incommon use
2. Chemotherapy at the present time: cisplatin and carboplatm.1
Cisplatin causes severe nausea and vomiting I
This is a recommended treatment following but this is usually well controlled with 5-1
surgery in most cases as not all microscopic hydroxytryptamine receptor antagonists such
disease will have been removed, however as ondansetron. Cisplatin can give rise to severe
extensive the operation. The only acceptable renal damage unless it is given with forced I
exception is in early stage ovarian cancer with diuresis. It also causes peripheral neuropathy I
good prognosis. (Stage la or lb well or Combination chemotherapy has been found to]
moderately differentiated tumours). be more effective. Inour hospital a combination I
of cisplatin, adriamycin and cyclophosphamide I
In epithelial ovarian tumours, chemotherapy is is being used and this is given over a period of I
given as adjuvant therapy after surgery except 24 ! Hours.;
in stage la or lb, and before interval debulking
surgery. Recently a combination of cisplatinum and paclitaxe". I
Chemotherapy plays a central role in (taxol) has beenreportedto be very effective.
treatingmalignant ovarian cancers and it is now
often used in preference to radiotherapy as an Taxol is a taxane drug and acts by stabilising
important adjuvant to surgery. The smaller the microtubules in the cell, blocking division and '
tumour mass after surgery, the better are the
thus tumour growth. It is very active in ovarian
cancer andhas been found to be the most active
chances of success with chemotherapy.
drug tested in patients with platinum-resistan:
Germ cell tumours which occur in young
ovarian cancer. The side effects include myelo
women have a better prognosis than epithelial
suppression, sensory neuropathy,
cancers and treatment is primarily by
hypersensitivity reactions and totalhair loss.
chemotherapy which is not only curative but
also preserves fertility. 3. Radiotherapy
Single agent regimen and multi agent regimen
are the various forms of chemotherapy in ovarian Radiotherapy is little used in the modern
cancer. However, the multi agent regimen hasbeen management of ovarian cancer except for very
found to improve survival more than the single few ovarian tumours notably pure
agent regimen. dysgerminomas that are very radiosensitive. As
The most effective single agent regimen is at present there is no role for external
cisplatinum. Cisplatinum drugs are heavy metal radiotherapy in ovarian cancer as part of a
compounds which cause cross linkage of the DNA radical course of treatment as the required dose
strands in a similar fashion to alkylating agents. islimitedinorder to protect theradiosensitive
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Chapter 25

Trophoblastic tumours
Trophoblastic tumours can be subdivided into The chromosome constitution of majority of
three the complete mole is 46 XX. Minority have a
categories. 46 XY constitution.
Hydatidiformmole
Invasivemole Partialmole
Choriocarcinoma The characteristics of the partial mole include:
a. Some villi show slowly progressing
Hydatidiform mole hydatidiform changes while others appear normal,
Incidence b. Usually focal and sometimes
Inthe far East, figures of 1in 500 (Singapore), 1 inconspicuoustrophoblastic hyperplasia.
in 294 (Japan), 1 in 314 (Iran) have been c. An embryo or a fetus is always present
reported. In Nigeria, a high figure of 1 in 379 although it tends to die early in gestation. Most
has also been quoted. Generally, hydatidiform if not all partial moles are triploid with a
mole is more common in the far East and Africa karyotype of 69 XXY, 69 XXX etc.
than in the western world. A calculated
incidence of 1.54 per 1000 live births has been Aetiology
quoted from Britain. Attempts have been made to associate the
aetiology of trophoblastic disease with some
Pathology external factors like viral, chemical, dietary,
Hydatidiform mole is a benign tumour of the and genetic but results are still rather
trophoblast. There are partly degenerative and inconclusive. Blood group B has been
partly hyperplastic changes affecting both the incriminated in some studies as regard
syncitiotrophoblast andthe cytotrophoblast: the hydatidiform mole.
villi become cystic, the mesodermal core
becomes myxomatous and avascular, and the Clinical history
whole villous system becomes vesicular, giving The patient usually complains of vaginal
the appearance of a bunchof grapes. bleeding which may be dark brown or bright
There are two types of hydatidiform mole: red,after a period of about two to three months
Complete mole amenorrhoea. Infact shethinks she is pregnant.
Partial mole Other symptoms may include:
Hyperemesis
Complete mole Breathlessnessdue to anaemia
The characteristics of the complete mole Abdominal pain
include: Passage of vesicles per vaginam
a. Rapidly progressinghydatidiform Ankle swelling
changes involving all placentalVilli. Eclamptic fits (rare)
b. Widespread and gross trophoblastic Currently with routine Erst trimester
Hyperplasia ultrasonography a significant proportion of
c. Absence of an embryo patients are asymptomatic at the time of diagnosis.

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Tumours of the ovary 219

Clinical findings Differential diagnosis

Clinical examination may reveal a uterus which 1. Abortion
is usually large for dates (bigger than period of 2. Multiple pregnancy
amenorhoea). It may however happen that the 3. Pre-eclampsia or Pregnancy induced
uterus is of normal size or even small for dates hypertension
in a minority of cases. Other features commonly
observed include: Complications
1. Uteruswhich is doughy inconsistence. 1. Haemorrhage
2. Absence of fetal parts. This is now 2. Heart failure due to thyrotoxicosis or
confirmed by ultrasound. pulmonary trophoblastic embolisation.
3 . Absence of fetal heart sound. This can also 3. Uterine perforation resulting from
be confirmed by uitrsound. invasive mole.
4. Enlarged cystic ovaries which may 4. Uterine sepsis following expulsion of the
sometimes be bilateral. These are theca¬ mole especially if incomplete.
lutein cysts due to increased production of Management
humanchorionic gonadotrophins. 1. Evacuation of the uterus. This can be
5. Anaemia due to excessive bloodloss. achieved by suction curettage and is now the
6. Pseudo-toxaemia which consists of systolic method of choice. Dilatationand curettage is no
hypertension, oedema and proteinuria. longer recommended. Because of the lack of
7. Manifestation of thyrotoxicosis as molar fetal pÿrts a suction catheter, up to a maximum
thyrotrophin is produced by trophoblastic cells. of 12mm, is usually sufficient to evacuate all
8. Eclampsia. This is rare but has been complete molar pregnancies. The products
observed inpatients with very large uterus. shouldbe sent for histopathology.
Investigations 2. Medical termination should be avoided for
The following investigations may be carried there is theoretical fear over the routine use of
out: potent oxytocic agents because of the potential
1. Hormonal assay to embolise and disseminate trophoblastic
a. Urinary assay of hCG is markedly elevated tissue through the various systems. Any agent
inmost cases. Values higher than 100,0001.U./ that may cause uterine contraction should be
Litre may be diagnostic, avoided. Thus oxytocics and prostaglandin
D. Serum P subunit hCG assay which is analogues are contraindicated except when
likewiseelevated. there is significant haemorrhage after complete
2. Ultrasonic scanning evacuation of the mole thus necessitating
Scanning of the enlarged uterus may reveal administration of oxytocic infusion.
typical snow storm echoes. This has replaced 3. Hysterectomy.
the use of plain X-ray of the abdomen. Such a This is the method of choice for women over
lesion is a trophoblast deposit. The finding of the age of 40 years or those who have
multiple cystic spaces in the placenta at completed child bearing. This procedure may
ultrasound is suggestive of partial molar reduce the risk of subsequent malignancy.
pregnancy. 4. Evacuation of a partial mole with a suction
3. Chest X-ray to note any lesion. curette may present seme difficultv because of the

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size of the fetal parts. In such a case, a medical Recurrent molar pregnancies have been
termination may becarried out. reported in some women. The risk of second
5. Twins and molar pregnancy. In twin molar pregnancy inBritain is less than 1%.
pregnancy with a viable fetus and a molar
pregnancy, whether complete or partial, the Invasivemole
pregnancy should invariably be allowed to When a hydatidiform mole invades the
proceed to term but bearing in mind that live myometrium it becomes known as an invasive
birth rate couldbe as low as 25 percent.
mole.This condition should not be confused with
Follow-up the pathological temi, chorioadenomadestruens.
Patients should be seen at four-weekly intervals
for one year. A follow-up period longer than this Incidence
is not necessary.
The true incidence is not known in many
At each visit, a clinical examination including a countries especially as the confirmatory
pelvic examination is carried out. Serum (3 diagnosis is not always easy.
subunit hCG assay is performed, and a chest X-
ray is repeated if indicated. Pathology
The uterus is often enlarged and in some cases
Contraception
The use of contraceptive is advised during the nodules may be seen on its surfaces. Protrusion j
follow-up period so as to avoid pregnancy. There of molar tissue may also be visible in rare
is no objection to the use of the pill after cases. A section of the uterus after
evacuation of a mole provided the serum hCG hysterectomy will show molartissue within the
becomes normal before the patient commences substance of the myometrium.
on it. Other forms of contraceptive Clinical findings
recommended include the diaphragm with a Ifthe serum hCG continues to rise or fails to fall
spermicidal cream. Pregnancy should be
after a thorough evacuation of a mole, invasive j
avoided until after six months of normal hCG
mole may be suspected. Clinical examination I
level.
may reveal an enlarged! uterus which may be
Chemotherapy tender. Other signs of hydatidiform mole may
Ifthe serum |3 subunit hCGremains high, that is, also be present. Son, . times the patient may
25 mlU/ml 4-6 weeks post evacuation of a mole,
present as an acute! abdomen ifperforation of the
chemotherapy is indicated because of the
uterus by the molej has occurred. The peritoneal
danger of uterine perforation by invasive mole
or of choriocarcinoma developing. There is also
cavity inthis case may be filled with blood.
an indication for chemotherapy if hCG is Investigations
detectable in the serum 4-6 months after Apart from the history, the following
evacuation of a mole. investigationmay be of help:
Prognosis 1. Ultrasound: This may show a vesicular
The prognosis of this condition is good if a patten (snow storm echoes) in the
careful and systematic follow-up is adopted. myometrium.
However about 5-15 percent of the cases may 2. Laparoscopy: Some bluish or darkishnodule
progress to choriocarcinoma. may be seen onthe surface of the uterus.

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wmamm3. Endometrial curettage: This is only pelvic cellular tissue,vulva, lungs andbrain.
diagnostic if the histology shows molar
tissue surrounded by myometrialtissue. Staging
A clinical staging for choriocarcinoma hasbeen
Treatment: adopted by F.I.G.O.
1. Hysterectomy is the treatment of choice in older Stage I The tumour is confined to the uterus
women who have completed childbearing. Stage II Tumour spreads to the pelvis and vagina
Stage III Metastases to the lungs
2. Local uterine resection may sometimes be Stage IV Generalised metastases or distant
attempted in case of solitary tumours. This metastases to the liver, brain, kidney, spleen, gut
is only practised in sophisticated centres. etc.
3. Chemotherapy is advocated by most
clinicians. Patients who havehad surgery as Clinical history
indicated above should also be given Most patients present with recurrent or profuse
chemotherapy post operatively. bleeding after evacuation of hydatidiformmole,
abortion, or term pregnancy. Invery rarecases
Prognosis the bleeding may follow an ectopic pregnancy.
The prognosis is usually good provided the
Other symptoms include:
patient is followed up for a period of not less
Abdominal mass
than 2 years. The procedure of follow-up is as
Abdominal pain
described for choriocarcinoma.
Headache
Cough
Choriocarcinoma Vomiting
Incidence Haemoptysis
While choriocarcinoma is a rare tumour in the Dyspnoea
Western world, it is in actual fact a fairly Haematuria
common tumour in the far East and also in Jaundice
Nigeria. In the latter it is the third commonest
tumour next to the cervix and breast. In Clinicalfindings
Indonesia for instance, the incidence varies Clinical examination may reveal signs of
from 1 in 186 to 1 in 1,035 pregnancies while in respiratory difficulty due to metastases in the
Nigeria it is 1in300 to 1in 1,000. lungs, or signs of hemiplegia due to metastases
in the brain. The uterus and liver may also be
Pathology enlarged due to the presence of the tumour.
j It is a haemorrhagic tumour which histologically Tumour metastases may also be seen in the
shows lack of villous pattern with areas of vagina (sub-urethral nodule) or the vulva. In
widespread haemorrhage within the stroma. late stages, patient may be cachectic, severely
anaemic,jaundiced, and comatose.
Spread
It spreads rapidly by haematogenous means, the Investigations
commonest sites of metastases being the vagina, The following investigations may be carried out:
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222 Obstetrics and Gynaecology

1. Fullbloodcount chemotherapy have been adopted. The treatmei

2. Liver function tests regimes inLagos are as follows:
3. Renal function tests Regime A: this is the Methotrexate wit
4. Serun hCGp subunit assay. (The value is citrovorum factor rescue therapy. Methotrexat
usually greatly elevated, normal value belongs to the group of chemotherapeutic agent
being less than l.OmlU/ml, using a high knownas Folic acid antagonists:
sensitivity assay procedure). EVI Methotrexate 1 .Omg/kg body weight/48
5. Chest X-ray to demonstrate the typical hours x 4 doses followed 30 hours after eacl
cannon ball secondaries which are rounded injection by EVI Folinic acid (calciui
opacities. Other less common lung leucovorin) 0. 12mg/ kgbody weight.
secondaries are the snow storm type and the
embolic type. Regime B: EVI Methotrexate 1.0mg/kg./48
6. Doppler colour flow imaging has replaced hours x 4 doses followed 30 hours after each I
pelvic angiogram in most specialised injection by EVI Folinic Acid (calcium
centres. leucovorin) 0. 12mg/ kgbody weight.
7. Liver scan. plus IV Actinomycin-D 2mg single dose at the
8. Computerised axial tomography of the brain same time as the first EVIdose of Methotrexate.
(CAT scan).
Regime C: Methotrexate 5mg/kg body weight*
Treatment 24 hours by slow IV infusion followed at 24
Choriocarcinoma is a disease that is highly hours after beginning of infusion by IM or oral
curable despite widespread metastases. The folinic acid (calcium leucovorin) 15mg 6 hourly I
standard treatment is the use of multi-agent for 72 hours.
chemotherapy but in Nigeria there is a limit to
Regime D: IV Actinomycin-D 10|ig/kg body
thenumber of such agents that are available and
weight daily x 5 doses. This regime is preferred
affordable. Efforts have therefore beenmade to
ifliver function tests are abnormal.
adopt some regimes as presently used inLagos.
Regime E: MAC
1. Chemotherapy is the primary treatment of Methotrexate 15mg IM )
choriocarcinoma. Actinomycin-D 0.5mg IV ) daily x 5 doses
2. Surgery such as hysterectomy, or ligation Cyclophosphamide 3.Omg/kg body weight orally)
of both internal iliac arteries may be indicated every 2 or 3 weeks
in addition if there is uncontrollable
Or
haemorrhage. However, recently uterine artery
Methotrexate 1 5mg IM) \
embolisation has been used as method of
treating such haemorrhage inchoriocarcinoma.
Actinomycin-D 0.5mg IV I daily x 5 doses
3. Local excision of sloughy vulval secondaries ( every
may also be carried out to reduce sepsis and Chlorambucil 6- 1 Omg orallyJ 2 or 3 weeks
makethe patient more comfortable. Regime F: 5- Fluorouracil 28-30 mg/kg body
4. Local excisions of secondaries inthe lungs weight/day dissolved in 500ml 5% dextrose by
or brainare done inspecialised centres. slow I.V. infusion over 8 hours for 10 days every
A number of treatment regimes by way of 2-3 weeks
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Tumours of the ovary 223

This regime is alo preferable if there is liver WBC and differential count
involvement (Sung, 1982). Bloodurea andcreatinine
Choice of drugs SGOT., SGPT., Alkaline phosphatase
To decide on what regime to use, a simple SerumhCGp subunit assays shouldbecarried out
guideline is as follows: weekly.
Invasive mole -v
Criteria for discontinuation of drugs:
iRegime A, B,C,or D Chemotherapy shouldbe discontinuedto prevent
Low risk choriocarcinoma ) fatality if:
High-risk choriocarcinoma -Regime E
Hb<8gm/100ml
Regime F has been used for both risk WBC < 3 000/cu.mm
categories (Sung et al, 1984). Platelet count <100,000/cu.mm
To determine whether a tumour is low risk or Pyrexia<38°C
high risk, factors such as age, parity, antecedent Abnormal renal function tests
pregnancy and time of diagnosis or institution
of treatment, blood group, presence of Criteria for response to treatment
metastases, staging, hCG titre etc. will have to
be taken into consideration. For example, a 38
a. Marked fall in serum hCG p - subunit assay
after a maximum of 3 courses of treatment,
year old woman, para 4, who develops the
disease a year after a term pregnancy with B. A 50% reduction in size of radiological or
| secondaries in the liver obviously falls into a clinically measurable metastases.
high risk category while a 21year old lady, para
IO + 1 and with no secondaries present will fall Completion of treatment
into a low risk category.
After achieving a maximum response (hCG p
I Monitoring therapy subunit of less than 5mlU/ml) depending on the
I Inthe developing countries it isadvisable that all sensitivity of the assay method, on 3
Ipatients should receive broad spectrum consecutive occasions at weekly intervals, the
patient isdeclared cured.
Iantibiotics during chemotherapy as a
I trophylaxis against infection. The minimum Drugtoxicity
Iinterval between each course should be 10 days. Toxicity may occur with the use of these
ITo prevent precipitation of methotrexate in chemotherapeutic drugs. Features of toxicity
renal tubules, urine should be alkalinized to pH may include vomiting, stomatitis and
16.5-7.0 by giving oral sodium bicarbonate 5 x gingivitis, diarrhoea, skin rash, alopecia,
|625mg every 3 hours or Diamox paronychia, anaemia, leucopenia and
I(acetazolamide) 500mg orally 4 times daily for thrombocytopenia.
I die duration of treatment and 24 hours after. There are some drugs, which may cause a
IDaily investigations of the following should be potential for increased toxicity if used
learnedout while on chemotherapy: concurrently with methotrexate. These drugs
ÿHbor PCV
include salicylates, sulphonamides, diphenyl
hydantoins, tetracycline, and para-
IPlatelet count aminobenzoic acid, and they should be avoided.

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224 Obstetrics andGynaecology

Followup Prognosis
Choriocarcinoma carries a highmortality rate
After completion of treatment (see fig 25.1) because of its rapid growth with early
patients should be seen in the outpatient clinic dissemination. This may be as high as 40 - 60
every two weeks initially then every four weeks
percent in the developing countries where
for the next two years. At each visit, clinical
examination including a pelvic examination is patients are seen late and the intervalbetween
performed to detect any sign of recurrence. antecedent pregnancy and diagnosis or
Blood is also taken for serum hCG p-subunit institution of treatment is much greater than
assay. A chest X-ray is ordered every three four months. The prognosis is worse if the
months. During the two-year follow up period, disease follows term pregnancy as opposed to
the patient must not get pregnant. hydatidiform mole. However in the
Contraceptive advice is thus offered. After the developed western countries a remission rate
follow up, the woman could embark on a of 85 - 90% hasbeenreported.
pregnancy if she so desires. Successful
pregnancies have been reported from many
centres includinj Bibliography and suggested
further reading
Agboola, A., Abudu O. O. (1984) Epidemiology
trophoblast disease in Africans - Lagos. In Hume
trophoblast neoplasm; Advances in experimentc
medicine and biology. Pattillo, R. A., Hussa, R. O. eds ,
176:187.

Bagshawe, K. D. (1984) Clinical applications of hCG

Ibid., 176:313.

Cohn DE, Herzog TI (2000) Gestational Trophoblastk

A: Before Chemotherapy disease: new standardsfor therapy. CurrOpin Oncol. 12:492

Royal College of Obstetricians and Gynaecologists (1995 . I

The management of gestational Trophoblastic disease
GuidelineNo 18.

Sung, H. C, Wu, P. C. and Wang, Y. B. (1984) Re-evaluatic

of 5-fluorouracil as a single agent for gestational
malignant Trophoblastic neoplasms, Ibid., 176:355.

Gemer, O., Segal S., kopmar, A season E, (2000) The ct

clinical presentation of complete molar pregnancy.
Gynecol Obstet 264:33.

B: After Chemotherapy

Figure 25.1 Secondaries in the vagina and vulva from

choriocarcinoma

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Chapter 26
Radiotherapy and chemotherapy
for treatment of genital cancer
Cancer is an abnormal mass of tissues with an the tissues around and within the malignant
excessive and uncoordinated rate of growth. growth. External beam irradiation is
Radiotherapy is the practice whereby ionizing administered by the use of megavoltage X-ray
radiation is administered to patients for the and gamma-emitting radio-isotope machines
treatment of malignant diseases. The ionizing like the Linear Accelerator and Cobalt-60
radiation causes damage to the DNA molecules machines respectively. These are more deeply
in cancer cells thereby interfering with cell penetrating and are suitable for the treatment of
division and this leads eventually to cell death. deep seated tumours.
Radiosensitivity of a tissue is directly
proportional to its mitotic activity and inversely Prior to the commencement of radiotherapy,
proportional to its degree of differentiation. patients must be properly worked up and staged
Therefore cancer cells would receive more both clinically and under anaesthesia if
damage compared to the normal tissues around necessary. The treatment policy depends on the
it. In addition, the repair cancer mechanism of stage of the disease. The tumour volume must
normal cells is greater than that of irradiated be well defined if possible with the aid of
cancer cells. This differential response between radiological investigations like
normal and abnormal cells forms the basis of lymphangiography, tomograms, ultrasoundand
radiotherapy in the management of malignant computerised axial tomography (CAT Scan) so
disease. as to assess the size, site and extent of spread of
the disease for the purpose of radiation
Radiotherapy has a very useful role in the planning.Biopsy must be performed to confirm
treatment of most gynaecological histological diagnosis inall cases.
malignancies. In fact it is the treatment of
choice for carcinoma of the cervix and could Patients who are going to receive radiation
also be the sole treatment in some cases of treatment must be in a reasonably good
carcinoma of the endometrium and vagina. The nutritional state to be able to tolerate treatment
three main types of radiation therapy used for well and a highhaemoglobin level is essential
the treatment of tumours of the female genital as the effect of radiation is enhanced by good
tract are intracavitary, interstitial and external tumour oxygenation. The radiation response
beam irradiationtechniques. and survival rate are lower in those with low
haemoglobin level. Blood transfusion should
The intracavitary methodinvolves the insertion therefore becarried out when necessary and any
of sealedradioactive applicators into the natural infection controlled as radiation treatment in an
body cavities as in the treatment of carcinoma area of infection could lead to severe
of the uterine cervix and corpus. Radium was inflammationand septicaemia.
used for many years but has now been replaced
with caesium by most radiotherapy centres as During radiation treatment for gynaecological
the latter has a shorter halflifeof 30 years and a tumours some patients will experience a few side
lower energy. It is therefore safer to use with effects which may occasionally lead to interruption
respect to radiation protection of medical of treatment if not controlled. These include moist
personnel. With the interstitial approach, sealed skin reactions, nausea, vomiting and diarrhoea,
radioactive needles are inserted directly into radiation cystitis and proctitis. Good skin care,

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226 Obstetrics and Gynaecology

simple anti-emetics, mist kaolin et morph, and surgery and yet has less attendant morbidity.
in extreme cases intravenous fluid replacement Treatment must be properly planned once the
will control these symptoms in most patients. staging of the disease has been confirmed by
The importance of a well fractionated clinical examination under anaesthesia and
radiotherapy cannot be over emphasised as this laboratory and radiological investigations
will prevent many of such untoward effects which include serum electrolytes and urea,
including such late effects as tissue necrosis, intravenous urogram and chest X-ray. The
fibrosis and stricture of the intestines which choice of treatment for carcinoma of the cervix
may cause obstruction. depends largely on the stage of the disease.

The practice of radiotherapy in Nigeria as in There are two main methods of radiation
most other developing countries is fraught with treatment for carcinoma of the cervix:
a considerable number of problems. They intracavitary irradiation and external beam
include lack of essential facilities for pelvic irradiation. The choice of one or
investigation and treatment of cancer patients combination of the two depends largely on the
and well trained personnel, inadequate cancer stage of the disease. Inmost cases treatment must
education, poverty and ignorance. be individualised as rarely do patients present in
the same manner. The most commonly used
Over 60% of the patients present inthe last stage radioactive source for intracavitary radiation is
with poor nutritional status, anaemia, necrotic caesium (Cs 137). In the technique, a central
and infected tumours. These factors adversely uterine tube is loaded with about 50mg caesium
affect the overallresults of cancer management. sources intandem to deliver sufficient dose to the
mid-line structures. In order to spread the dose
Maximum use must be made of the limited laterally two vaginal caesium sources, each
facilities available in the few radiotherapy containing 20mg caesium, are inserted into the
centres in the developing countries. In this
lateral fornices. The technique of intracavitary
regard patients with early and curable disease caesium insertion can be a pre-loading one in
and children must be given first priority on the which the caesium sources are previously loaded
waiting list for treatment. Palliative treatments into the applicators before insertion into the
should be short and effective to control the pelvis in the theatre during examination under
symptoms. Facilities and drugs for pain control anaesthesia, or after-loading method when only
during terminal cancer should be available. the applicators are positioned in the theatre and
Hospices are expensive to run but intheir place later these are loaded with caesium sources at the
social workers and health visitors should be patient's bedside when pelvic X-ray has shown
trained to fill this gap. The close relations that the applicators are in satisfactory position.
should be actively involved and encouraged to The after-loading technique is highly
participate inthe management. recommended as this reduces radiation exposure
to personnel and allows for more careful and
Carcinoma of the cervix accurate insertionof the applicators.

Radiotherapy is now the treatment of choice for Three methods of intracavitary techniques have
all cases of carcinoma of the cervix. Even inthe evolved over the years. The first popular technique
early cases the results are as good as those for originated in Paris inthe early 1900s. The vaginal

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Radiotherapy and chemotherapyfor treatment ofgenital cancer 227

sources were placed in corks which were

packed into the lateral fornices. Occasionally
an additional midline cork was also used, and
all these remained in situ for five days. The
Stockholm technique was a later modification
utilising a metal intrauterine tube and flat silver
boxes placed in the lateral fornices. In this
technique two intensive, short radium
treatment delivering a high dose to the cervix,
uterine body and vault of the vagina were
employed. The Manchester method which is
very popular and widely used is a modification
of the Paris technique utilising an intrauterine
radiumand 2 rubber or plastic ovoids instead of
corks, and a spacer. The doses at selected points
are used as a measure of administration of Figure 26.1 The Henschke's after loading
adequate treatment. Therefore two points intracavitary applicator. A hollow tube is introduced
namely A and B were chosen. Point A is located into the uterus and extends to its full length. Lateral to
this are two vaginal ovoids placed in the fornices.
2cm above the lateral fornix and 2cm lateral to These also contain hollow tubes in which radioactive
the mid-line of the cervical canal. It is the point sources (Caesium 137) are inserted ata latertime.
where the uterine artery crosses the ureter. It
thus represents a point of tissue radiation About 30 per cent of the dose given to point A
tolerance as well as tumour control. Point B is during intracavitary radiation is delivered to
3 cm lateral to point A and the dose to this area is point B because of the rapid decrease in
ameasure of treatment to the pelvic wall nodes. exposure with distance from the caesium
The average dose of 7500cGy (rads) is sources. Therefore external beam therapy is
delivered to point A with the standard used to supplement the treatment to this area
Manchester treatment technique giving a dose and experience has shown that the total dose at
rate of 57R per hour at point A through two this point has to approach 5500cGy to achieve a
insertions of 3 days each with an interval of one remarkable sterilisation of positive nodes.
week. At the Lagos University Teaching
Hospital, Henschke's rigid applicators (fig. A weekly joint oncology clinic is run by the
26.1) were used with the same principle as the radiotherapy and gynaecology departments to
Manchester technique. A dose of 7200cGy was plan the treatment of patients. All cases of stage
delivered to point A in a single insertion over 6 lband IIwill receive intracavitary and external
days using caesium sources.

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beam irradiation. Shielding of the mid-line with curietron machine. The unit has the start and
4cm wide lead is done during the external stop treatment switches located outside the
irradiation. It is a known fact that in stage lb patient's room (fig. 26.2) which allow the
disease pelvic lymph node metastasis has treatment to be started and stopped from
already occurred inabout 14 percent of all cases outside the room via the remote control to
and therefore additional radiationis given to the
enable personnel and visitors to enter the
area by external radiotherapy.
treatment room inbetweentreatment.
For external irradiation, anterior and posterior
opposed fields are used and a mid-line dose of
3500 cGy is given in 3 weeks with a cobalt-60 ÿ»V.!" v

or linear accelerator. External beam pelvic

radiation is the treatment for stage III in most
cases. A single anterior and two oblique
posterior fields or a four field block technique is
used. A tumour dose of about 6000 cGy is given
to the pelvis in 6 weeks. Instage IV cases a dose
of 4800 cGy with externalbeamtherapy may be
given to the whole pelvis to treat symptoms.
Treatment is not indicated where fistula is
present and patient has no serious symptoms.

For many years, Henschke's rigid applicators

were used at the Lagos University Teaching Figure26.2 Diagram of the Curietronroom
Hospital based on the same principle as the
Carcinoma ofthecervicalstump
Manchester technique; The recent advances in
the treatment of carcinoma of the cervix have This occurs if cervical carcinoma is diagnosed
led to the development of the remote after- inpatients who hadhad subtotal hysterectomy 2
loading, low dose-rate technique, which helps years previously. Cases occurring less than 2
to avoid radiation exposure to hospital years post-operatively are usually regarded as
personnel and to achieve a general overall coincidental. Clinical staging of the disease is
improvement of dose distribution and accuracy the same as for other cervical carcinomas.
positioning compared with existing caesium
manual after-loading technique. It uses the As the uterine body is no longer present
principle of pneumatic engineering whereby standard intracavitary irradiation cannot be
the radiation sources which are pre-loaded into performed. Therefore, the results of treatment
a lead safe are driven by remote control through of stump carcinoma are much worse than when
connecting cables into caesium applicators the uterus is intact.Treatment rests on insertion
previously inserted into the patient under of vaginal cylindrical Perspex colpostat loaded
anaesthesia. Examples of such equipment with 50mg caesium combined with external
are the cervitron, curietron andthe selection, all beamirradiation.
of which utilise radioactive caesium pel lets.
Two insertions of about a week apart to give 70 Carcinoma ofthe cervix duringpregnancy
Gray to point A are recommended. This occurs in about 2% of patients with carcinoma
The radiotherapy department inLagos uses the
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of the cervix.Treatment depends both on the clinical
Prince Of Medicine-2014-BSUTH

Radiotherapy and chemotherapyfor treatment ofgenitalcancer 229

stage of the disease and the stage of pregnancy. External irradiationis given to the entire pelvis,
Inthe first trimester no consideration is taken of using large anterior and posterior parallel
the pregnancy. The patients are first opposed fields and a tumour dose of 3500 cGy is
commenced on external beam pelvic therapy delivered in 3 weeks on the Co-60 megavoltage
with megavoltage delivering a dose of 4000 machine. If the gynaecologist prefers pre¬
cGy in 4 weeks during which period abortion operative radiotherapy, surgery is performed 6
and uterine involution would have taken place. weeks after completion of external
Further treatment which may include radiotherapy. However, the prognostic
intracavitary radiation will depend on the stage information that will influence decision on
of the disease. Treatment inthe second trimester radiotherapy can only be obtained during
is very similar to the above except that surgery.
hysterotomy should be performed before
commencing radiotherapy. Radiation therapy alone can be used in patients
who are unfit for surgery as a result of severe
When diagnosis is made in the last trimester medical problems such as obesity,hypertension
treatment is delayed until the fetus is viable or diabetes. The five-year survival rates are
except if the disease is too advanced and inferior to those achieved either with surgery
bleeding is life threatening. Delivery is alone or with surgery plus radiationtherapy.
achieved by caesarean section and treatment is
commenced by external beam pelvic irradiation Where the general condition of the patient is
thereafter followed by intracavitary insertion poor enough as to preclude general anaesthesia
depending on the stage of the disease. or the disease is too advanced, external
radiotherapy alone is used. A mid-pelvic dose
Prognosis of carcinoma of the cervix in of 5,500 cGy is given over a period of 5 weeks.
pregnancy is the same as for non-pregnant Progestational agents have been found to be
patients. effective as palliative treatment for patients
with advanced disease and as adjuvant
Carcinoma of the endometrium treatment in patients considered to be at high
risk or recurrence. About 30% of patients will
Both surgery and radiation therapy are effective show clinical evidence of response.
primary treatment modalities in the management
of carcinoma of the endometrium.Total abdominal The prognosis of carcinoma of the endometrium
hysterectomy and bilateral salpingo- is good if treated adequately as most of the
oophorectomy with excision of upper third of the tumours are slow growing and are well
vagina, or sometimes extended hysterectomy isthe differentiated. The five-year survival rate is about
standard treatment. Radiation is used in addition in 80% in stage I. Prognosis is poor where spread to
patients with poor prognostic factors and these the cervix or vagina or parametrium is present.
include: Carcinoma of the vagina
(a) enlargement of the corpus
(b) extension to the cervix or fornices Primary carcinoma of the vagina is rare and occurs
(c) deep myometrial invasion mostly in older women over 60 years of age. The
(d) high grade malignancy. tumour tends to spread rapidly into the surrounding

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Prince Of Medicine-2014-BSUTH

230 Obstetrics and Gynaecology

structures. Primaries from the cervix, uterus, the results of management. Multiple agents like
vulva and other places have to be excluded Vincristine, Actinomycin-D and!
before diagnosis is made. The tumours are Cyclophosphamide are usually used.
usually undifferentiated epidermoid
carcinoma. Sarcoma botryoides are frequently Carcinoma ofthe vulva
the variety seen inchildrenunder 6 years of age. Tumours of the vulva are usually slow growing |
well differentiated squamous cell carcinoma. |
The choice of radiotherapy method of treatment Surgery is the treatment of choice for carcinoma |
depends on the site and extent of the tumour. of the vulva. Radical vulvectomy and inguinal
Tumours occurring inthe vault are treated inthe lymphadenectomy would be curative in a large I
same way as carcinoma of the cervix, that is, by number of cases. Though most vulval I
intracavitary irradiation. Treatment of lesions carcinomas are radiosensitive there is limited I
lower down is by insertion of cylindrical tolerance to radiation because of skin reactions!
Colpostat with line sources of radium or due to the moistness of. the area. However, some!
caesium extending the full length of the vagina. gynaecologists have tried radiation therapy inl
A dose of 6000 cGy is delivered in 6 days. advanced cases where surgical resection cannot I
External irradiation is indicated as well in all be completely performed.
cases where extension to the paravaginal and
parametria! tissues has occurred. Small solitary The prognosis for early vulval carcinomas is
lesions present in the lower parts of the vagina good giving a five-year survival rate of over
may however be treated with interstitial 80% but this may fall to about 36% where '
implantation of sealed radioactive sources e.g. lymph node metastases are present.
radium, caesium or iridium. Carcinoma ofthe Fallopian tube
The prognosis for vaginal carcinoma is poor with Primary carcinoma of the Fallopian tube is
a five-year survival rate of about 25%. The usually an adenocarcinoma. Most of the cases
treatment for Sarcoma botryoides involving the are far advanced at the time diagnosis is made.
vagina is radical surgical removal. Post The treatment of choice is total abdominal
operative irradiation is given where resection is hysterectomyand bilateral salpingo-
incomplete or there is high risk of residual oophorectomy. Post operative pelvic
disease especially in high grade tumours. irradiation is indicated almost in all
Radiation therapy must be carefully planned to cases as surgical excision is hardly complete.
avoid the ovaries where possible and to minimise This is also true for cases considered
gastrointestinal symptoms. The entire pelvis is inoperable. A tumour dose of about 5000 cGy
in 4 weeks is given by a parallel opposed
irradiated to a dose of 4500 cGy in 4 !4 weeks.
anterior and posterior pelvic fields on the
Where pelvic lymph nodes are involved the
Cobalt-60 machine
fields must include the entire pelvis and para¬
aortic region up to level of L. 1. An additional More often secondary carcinoma of the Fallopian
dose of 1000 cGy should be given to any area of tube is seen rather than the primary due to direct
post-operative macroscopic residual disease. extension from tumours arising from other peivici
or abdominal structures. The treatment will vary '
Adjuvant chemotherapy must be given to all patients according to the nature, site and extent of spread
as there is abundant evidence that this improves

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of the primary tumour.

Carcinoma oftke ovary CHEMOTHERAPY

Approximately 90% of ovarian cancers arise CERVICAL CANCER

from the surface epithelium. The rest are of The effectiveness of radiotherapy in the
germ ceil or ovarian stroma origin. Only about treatment of cervical cancer has resulted in
30% of patients will have localised disease at limited experience in the use of chemotherapy.
diagnosis. However, when chemotherapy has beenused it
Surgery plays the most important role both inthe has been for patients with recurrence following
accurate staging and management of ovarian extensive radiotherapy.
carcinoma. The recommended surgical Several factors are responsible for the poor
procedure is total hysterectomy, bilateral response to chemotherapy for recurrent disease.
salphingo-oophorectomy and omentectomy Most of these patients have had previous
aimed at radical cytoreductive treatment. Only extensive surgery and/or radiotherapy resulting
dysgerminoma and some granulosa cell tumours in decreased pelvic tissue vascularity and
are sufficiently radio-sensitive. Therefore the decreased chemotherapy perfusion to the
amount of residual disease following surgery tumour site. Impaired renal function, which is
appears to be the most important prognostic common inadvanced disease also limits the use
factor in ovarian carcinoma. Postoperative total of some more potent drug agents. Previous
abdominal irradiation may be employed in the pelvic irradiation also reduces bone marrow
management of suchradio-sensitive tumours. reserve. There is also the difficulty inmeasuring
There are two main techniques of total disease response as a result of the considerable
abdominal irradiation and in each method the scarring from prior surgery and/or radiotherapy.
treatment field extends from the xiphistemum
down to the pubis. In one method single wide-
field anterior and posterior parallel opposed Initial chemotherapy has beenadvocated in the
abdominal portals are used to cover the area late stages of cervical cancer. The hope is that
mentioned above and a midline dose of 3000 this may shrink local disease and give better
cGy is given in 4 weeks using the Cobalt-60 controland prevent metastases.
machine. The other method for which facilities
are not available at the Lagos University Various chemotherapeutic agents have been
Teaching Hospital is the moving-strip technique used for recurrent and advanced cervical
and this is superior to others as side effects are carcinoma. These drugs can be used as single
less and is more tolerable to the patient. In each agents or incombinationtherapy. .
method the kidneys must be shielded with
leadblocks after IVUlocalisation so that they do Single agents
not receive more than a dose of 2000 cGy to
prevent radiation damage. Full blood counts Cisplatinum and Ifosfamide are among the
especially the white cell and platelet counts chemotherapeutic agents used for cervical cancers,
must be monitored daily and gastric that have shown the most consistent activity as
symptoms relieved with simple medication. single agents. The duration of response is about 4-6
A boosting dose of 2500 cGy must be added to
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Prince Of Medicine-2014-BSUTH

ÿ 232 Obstetrics and Gynaecology

months with an average survival of 6 - 9 months. Response appears to be higher inpatients below
50 years of age, in patients with long disease-
Combination regimens
free interval and in those with well
Combination chemotherapy has been reported differentiated tumours and metastases to the
to give high response rates greater than 50% lungs. The progesterone receptor assay will
even in patients who had prior radiotherapy. help inpatient selection.
Buxton et al 1989, obtained an objective
Non-hormonal chemotherapy
response rate of 69% and 20% complete
response in both irradiated and non-irradiated Cytotoxic chemotherapy is not widely used for
sites using a combination of bleomycin, endometrial carcinoma. Response is poor being
Ifosfamide and cisplatinum. It is not certain if 20-40%
there is any survival benefit over single agent
cisplatinum only. A combination of OVARIANCARCINOMA
cisplatinum, methotrexate and bleomycin also
About 60% of patients with ovarian cancer
gave 67% response rate when used as
present with advanced disease as a result of
neoadjuvant and 27% in recurrent or metastatic
failure to detect the tumour early. Therefore,
disease (Hoskin, 1991). chemotherapy is now widely used for the
adjuvant treatment of ovarian carcinoma and
CANCER OF THE ENDOMETRIUM also for the management of recurrent and
inoperable advanced cases. Many factors
The use of systematic therapy in endometrial
influence the results of treatment and these
cancer has involved mostly the use of hormonal
include the stage, histological grade, age,
therapy with little use of cytotoxic chemotherapy. amount of residual disease, physical fitness of
It is believed that the mechanism of action of this the patient and previous treatment. Patients who
treatment is due to the direct effect on endometrial relapse or are refractory to radiotherapy will be
cancer by the production of endometrial atrophy
less responsive to chemotherapy.
from the regular use of high doses of
progesterone. Therefore it is more effective in
Alkylating agents have been extensively used in
ovarian carcinoma with an initial response rate of
well differentiated tumours where it bears a close
40 - 60% while about 5-15% continue to respond
resemblance to the normal epithelium. two years after initial treatment. The median
The two agents in use are hydroxyprogesterone survival of patients treated with alkylating agents
caproate (Delalutin) given l-2gm weekly and is about 12 months. All alkylating agents appear to
have almost equal activity but those commonly
medroxyprogesterone acetate (Provera) which
used are melphalan, cyclophosphamide and
can be given orally at 200-800mg daily or weekly
chlorambucil. The intraperitoneal use of alkylating
by intramuscular injection and also as Depo-
agents has not been found to be as effective
provera at 400-800mg at monthly intervals. as intravenous administration. Many
other chemotherapeutic agents have shown
Objective response is about 30% for both some response either as single agents
agents with a mean survival of 25-30 months or in combination in the treatment of advanced
(Reifenstein, 1971 and Kistner, 1969). ovarian carcinoma. Of these, cisplatinum
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Prince Of Medicine-2014-BSUTH

Radiotherapy and chemotherapyfor treatment ofgenital cancer 233

endometrial carcinoma. A review. Cancer, 34: 1587-1592.

was found to have highactivity when used as a
single agent. It is now used in combination Gusberg S. B. (1976) The evolution of modern treatment
with other agents, most especially adriamycin of corpus cancer. Cancer, 38:603-609.
and cyclophosphamide and many randomised
studies have shown these to give high -
Hoskin P. J., Blake P. (1991) Int. J. Gynecol Oncol 1:75 80

response rates of about 60 - 90% compared Joslin C.A., and Smith C. W. (1971) Postoperative
with single alkylating and non-cisplatinum radiotherapy in the management of uterine corpus
containing combinations and a median carcinoma. ClinicalRadiology 22,118-124.
survival of 18 - 40 months. However there is
an increased toxicity in patients given Lambert H(198 1) Treatment of epithelial ovarian cancer.
Br J. Obstet. Gynae., 88: 1169-1173.
combination chemotherapy. Patients with
minimal microscopic disease have the highest Medical research council study on chemotherapy in
response rate andsurvival. advanced ovarian cancer (1981) Br.J. Obstet. Gynae 88:
1174-1185
Taxol is a new drug found to be effective as a
Musento M. S., Perry M. C., and Yarbro J. W. (1982).
first line chemotherapy agent for ovarian
Chemotherapy of cervical carcinoma Semin Oncol. 9:
carcinoma. It can be used in combination with 373-387.
carboplatin or cisplatinum. Overall response
rates of 60-70% havebeenreported. Recfenstein E. C. (1971) Hydroxyprogesterone caproate
therapy in advancedendometrial cancer. Cancer 27: 485 -502.
VAGINAL AND VULVAL CARCINOMAS
Rutledge. F, Smith J. P. and Franklin W. W. (1970)
Chemotherapy gives disappointing result in Carcinomaofthe vulvaAm. 7. Obstet. Gynaecol 106: 117
recurrent vaginal and vulval carcinomas.
Smith J. Rutledge F. (1970) Chemotherapy in the
treatment of cancer of the ovary. Amer J. Obstet Gynecol
Bibliography and suggested further 107:691-703.
reading
Snelling M (1973) Carcinoma of the cervix.
Bonte J, Decoster J. M, Ide P, and Billiet G. (1978) RadiotherapyProc. Roy. Soc. Med 66:935- 936.
Hormonoprophylaxis and hormonotherapy in the treatment
of endometrial adenocarcinoma by means of
Underwood P.B., Lutz M. H., Kretner A et al. (1977)
medroxyprogesterone acetate. Gynaecologic Oncology, Carcinoma of the endometrium: radiation followed
6:60-75. immediately by operation. Am. J. Obstet. Gynaecol 128:
86-98.
Beck R.E, Boyes D.A: (1968) Treatment of 126 cases of
advanced Ovarian carcinoma with cyclophosmide. Ca. Med.
Kistner R. W. (1969) The use of Progestins. In Obstetric
ASSES. J 539-541
&Gynecology Year Book Medical Publishers. Chicago,
p. 129.
Bush R. S„ (1979) Therapy of advanced ovarian carcinoma
N.Eng. J. Med., 300:676. Young R. C. (1975) Chemotherapy of ovarian cancer:
Buxton E. J et al (1989) - J. Natl Cancer Inst 81: 35a-61. -
past and present. Semin. Oncol 2: 267 276.
Donovan J. F. (1974) Nonhormonal chemotherapy of

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Chapter 27

Endoscopy in gynaecology
Introduction Laparoscopy

Endoscopy is the direct visualisation of any part Laparoscopy is an endoscopic procedure, which
of the interior of the body by means of an optical allows inspection of the peritoneal cavity and
viewing instrument, the endoscope, and has contents through the anterior abdominal wall. In
been one of the major surgical advances of the developed countries, laparoscopy is used for an
past century. Historically, endoscopy dates array of operative procedures with very limited
back to Hippocrates in Greece around 400 BC. morbidity and mortality. However, very few
He described rectal and vaginal specula. physicians in Africa have acquired these skills
Bozinni is credited with the first attempt at because of resource constraints and limited
inspecting the urethra with a tube and training opportunities. The indications for
candlelight recognising the need for laparoscopy are both diagnostic and therapeutic
illumination in 1806. Pantaleoni in 1869 thus avoiding laparotomy.
described the first successful hysteroscopy Indications
when he demonstrated endometrial polyps.
Diagnostic
Jacobeus first described laparoscopy in a
investigation of unexplained pelvic pain e.g.
human in 1910. Perhaps one of the most
infection, adhesions
enthusiastic advocates of laparoscopic surgery
suspected endometriosis infertility e.g. tubal
inmoderntimes is Semm of Germany.
patency tests,
Advances in electronics and engineering assessment for tubal surgery
have made it possible to perform most suspected ectopic pregnancy
abdominal operations laparoscopically. The second look evaluation e.g. post cancer
current terminology for endoscopic surgery is treatment
universally accepted as Minimal Access suspected uterine perforation
Surgery (MAS). There are basic requirements investigation of amenorrhoea and
for all MAS procedures. These include an oligomenorrhoea
appropriate telescope, distension medium, a assessment of genital tract anomalies
good source of light and a camera with a video
monitor. It is equally important to have a skilled Therapeutic (operative)
surgical team. Surgical success will to some laparoscopically assisted vaginal
extent also depend on appropriate patient hysterectomy
selection. This chapter will confine itself to the ovarian cyst aspiration, drilling, cystectomy or
basic procedure rather than elaborate on oophorectomy
advanced surgical techniques and will discuss tubal surgery salpingostomy or
laparoscopy, hysteroscopy and cystoscopy. salpingectomy
Other endoscopic procedures such as ablation of endometriosis
colposcopy, culdoscopy and fetoscopy will not adhesiolysis
procedures for incontinence e.g. Colposuspension
bediscussed.
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ÿHMH Endoscopy ingynaecology

procedures for genital prolapse e.g. from dissolved carbon dioxide.

sacrocolpopexy
retrieval of foreign body e.g. extruded IUCD Complications
laparoscopic sterilisation using Filshie clips, •failure to gain access into abdominal cavity
Fallope rings or diathermy
excision of ectopic pregnancy
•haemorrhage from injury to intra-abdominal
major vessels e.g. aorta
non gynaecological procedures e.g.
cholecystectomy, appendicectomy •injury to anterior abdominal wall vessels
•gas embolism and surgical emphysema
Procedure •incisional hernia

Laparoscopy is commonly performed under

•infection
•injury to abdominal organs e.g. bladder,
general anaesthesia or under conscious uterus and bowel (1-4/1000 cases)
sedation using intravenous pethidine 100 mg
and diazepam 10 mg with subumbilical local Contra indications
anaesthetic infiltration with 10 ml of 1 % plain
Absolute
lignocaine. The patient is appropriately
intestinal obstruction
positioned, cleaned and draped. The bladder is
emptied and the abdominal cavity insuflated present or past generalised peritonitis
with gas, usually carbon dioxide through an limited cardiopulmonary function
umbilical incision. The needle commonly used advanced pregnancy
for creating pneumoperitoneum is a Veress Relative
needle with a protective spring-loaded
gross obesity
obturator to reduce the risk of injury to intra¬
abdominal structures. Special insufflation large abdomino-pelvic tumour
equipment is required with the capability of advanced malignancy involving the anterior
adjusting the gas flow rate with concurrent abdominal wall
measurement of the intra-abdominalpressure.
A trocar is then inserted through the Hysteroscopy
umbilical incision and the obturator replaced Hysteroscopy isthe endoscopic examination of
with a laparoscope, connected to a light source the uterine cavity through the uterine cervix.
and a camera-video system. Other secondary
The telescope usedis a hysteroscope and can be
trocars can be inserted under direct vision
rigidor flexible of whichthere are diagnostic or
depending on the intended procedure. These are
inserted usually into the suprapubic region or operating hysteroscopes with channels for the
into either iliac fossae. Views of the pelvis can insertion of micro-instruments. Liquid is
be improved with Trendelenburg or head down commonly used as the distension medium
tilt of the operating table. At the end of the although carbon dioxide can be used for
procedure, the pneumoperitoneum is released diagnostic hysteroscopy. Normal saline is
followed by closure of the skin incisions. Inthe usually used for diagnostic procedures and
immediate postoperative period, bruising of the other non-electrolyte solutions such as glycine
abdominal wall may occur as well as sub¬ and dextran can be used for operative
diaphragmatic irritation with referred pain to hysteroscopic procedures involving
the shoulder tips from carbonic acid resulting electrosurgery such as diathermy.
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236 Obstetrics and Gynaecology

Indications Cystourethroscopy
Diagnostic Cystoscopy refers to the endoscopic
abnormal uterine bleeding examination of the urinary bladder and
post menopausal bleeding cystourethroscopy involves cystoscopy and
fertility and recurrent miscarriages endoscopic evaluation of the bladder neck and
suspected uterine malformation or urethra. The telescope used is a cystoscope of
Asherman's syndrome which there are rigid and flexible types. The
location of lost IUCD flexible type has the advantage of a more
endometrial polyps and submucous fibroids complete view of the bladder especially the
anterior wall of the bladder.
Operative
endometrial ablation Indications
retrieval of foreign body e.g. IUCD Diagnostic haematuria
adhesiolysis recurrent infections
correction of uterine malformation history of frequency and urgency not
(melroplasty) responding to treatment
myomectomy or fibroid resection suspicion of bladder stones, tumour,
polypectomy and biopsy of suspicious lesions endometriosis or inflammatory disease
during continence procedures to exclude
Procedure bladder injury e.g. tension-free vaginal
tape (TVT) procedure evaluation of
Under appropriate anaesthesia usually general
anaesthesia or local paracervical block, the refractory incontinence
patient is placed in lithotomy position. She is Operative
cleaned and draped and the hysteroscope resection and biopsy of tumours
introduced under direct vision, transcervically stone or foreign
into the uterine cavity. This may be facilitated body retrieval
by dilatation of the cervix if necessary. With the bladder neck injection for incontinence using
aid of the appropriate distension medium, the collagen, silicone etc.
uterine cavity is systematically inspected and incision of urethral strictures
any therapeutic procedure isundertaken.
Procedure
Complications
cervical damage or incompetence Cystoscopy can be performed under general or
uterine perforation local anaesthesia. In females the procedure can
haemorrhage be performed with lubrication only. The
fluid overload cystoscope is introduced with the patient in
infection lithotomy position under direct vision with
running irrigation fluid. The operator
Contra indications
systematically inspects the urethra, bladder
pregnancy
neck and bladder walls including the trigone and
active lower genital tract sepsis
ureteric orifices. The landmark gas bubble can be
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Endoscopy ingynecology 237

seen at the bladder fundus. The mucosal walls resulting in more procedures requiring less
appear pale yellow with interwoven fine blood anaesthetic input and analgesia. Advocates of
vessels. The ureteric orifices appear as slits at MAS argue the advantages and these include
the lateral margins of the bladder base. quicker patient recovery and less time in hospital,
Additional procedures can be performed less analgesic requirements, less socio-economic
including cannulating the ureters. Care must be disruption to patients, better postoperative
taken not to overdistend the bladder. cosmetic results and better, magnified
visualisation of existing pathology. There will
Complications always be the initial costs of equipment to
bladder rupture overcome as well as time for appropriate training
bladder perforation of the surgeons and their surgical team. As new
neuromuscular bladder injury from treatments are publicised, patients will
overdistension increasingly demand MAS procedures. The key to
urethra trauma and perforation success is training, understanding of equipment
urinary tract infection and careful patient selection.

Contra indications Bibliography and suggested further

There are few contraindications to this
reading
procedure and one must perhaps have a clear
indicationfor the procedure.
Carry, R., (1997) Laparoscope In: Gynaecology 2"W.
Shaw, R.W., Soutter, W.R, Stanton, S.L. eds. Gynaecology
Conclusion 2nded. Edinburgh: Churchill Livingstone, pp. 53-70.
For centuries, physicians have been trying to Petrussco, O.M. (2000) Endoscopy in the Millennium.
look into body cavities. Recent advances In: The Yearbook of Obstetrics and Gynaecology O' Brien
in technology have now made this possible. S.P.M. ed. London: RCOG Press, pp. 325-343
The emphasis in endoscopy is continuously
Waller, K.G., Lews, B.V. (1997). Hysteroscopy In:
shifting from diagnostic to therapeutic Gynaecology2*ed Shaw, R.W.,Soutter, W.P., Stanton, S.L.
procedures. Current developments now eds. Edinburgh:ChurchillLivingstone, pp. 41-5 1.
include microendoscopes and instruments

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I

Chapter 28

region of the Y chromosome which is located in

Psychiatric aspects of gynaecologicalpractice 1247

Aetiology include construing menstruation as 'the price

lere are no well-established aetiological paid for being a woman' or regarding it as
ictors, the most popular theories are those 'messy', and some thoroughinvestigations have
- hich implicate
-stem.
deranged female sex hormonal
One hypothesis postulates high blood
elucidated a noteworthy correlation between
childhood family tension and discomforting
ivels of oestrogenrelative to progesterone. menses (painful and heavily flowing),
lother suggests direct effect of progesterone diminished capacity for feminine psychosexual
its low blood level relative to oestrogen. To role and failure to accept psychosexual role
functions. There is no doubt that one or a
ippreciate the rationality of these two
combination of these psychological postulates
>otheses it is relevant to refer to the normal
cyclical hormonal changes which are elsewhere would be applicable in some cases of PTS but
more refined enquiries are needed to clarify
m this book (Chapter 3) elaborated upon.
their validity.
A third hypothesis relates to water and salt
retention which could be an oestrogen effect
Diagnosis
iccounting for the weight gain reported by
some women. Diagnosis confusion can arise in the socio-
Increased aldosterone and angiotensin II economically under-priviledged countries with
secretion have been suggested to be a endemic prevalence of sub-clinical infection,
contributory factor in these metabolic changes. malaria, climate-undermined discomfort and
The other stimulating biological theories are highrate offemale menial employment, each of
those which propose the activity of an which could exert substantial physical and
endometrial factor called 'mefrotoxin', emotional strain.
magnesium deficiency, and postaglandins. To be considered also is the ordinary
There is to date inadequate evidence to uphold tolerable premenstrual discomforting
the validity of these findings. The same can be experiences which are so common as to be
said of the hypotheses of vitamin A deficiency regarded as statistically normal! However, the
and hypocalcaemia whichhave no strong basis. demarcating line of this majority group from
The elusive search for a scientifically the pathological PTSgroups israther blurred.
founded organic basis for PTS has stimulated An interesting clinical variant is the
substantial inclination to psychogenesis. As premenstrual exacerbation of pre-existing medical
mentioned above, neurotic women tended to disorders such as bronchial asthma, dermatological
report more premenstrual symptoms as they disorders, (for example, ache and urticaria) and
generally do with any symptoms anyway, and recurrent psychoses. Athorough historytaking will

this may cause over-estimation of the true help the diagnostician to make useful distinctions.
Some women with neurotic disposition make the
incidence of PTS. However, a number of
most of relatively minor commonplace
plausible hypothesis have been documented.
premenstrual discomfort for secondary
Clinical evidence reveals that mothers of many
psychological gains such as manipulation
patients with PTS were misinformed innegative,
of their spouse and others within their social
and derogatory fashion concerning the nature of
orbit. However, it should be emphasised that
menstruation. Examples of the resultant attitude
clinical impression of such neurotic sick-role
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248 Obstetrics andGynaecology

playing requires thorough understanding of the preparing the patient psychologically for
subject's personality and her past and present periodic morbidity.
social circumstances. A helpful generally It is the responsibility of the attendii
accepted working definition of PTS is any physician, usually the family doctor, ti
combination of emotional or physical features enlighten the less informed patient on the lii
(such as listed above) which occur cyclically betweendistress andthe menstrual phenomenoi
shortly before menstruation and which regress and also dispel any misconceptions aboi
or disappear during menstruation. menstruation particularly those which relate
the psychosocial and sexual feminine roles.
Treatment
Menopausal distress and other
On the basis of the hormonal aetiological perimenopausal disorders
theories discussed briefly, a number of drugs
Menopause is defined as cessation o:
have been reported to achieve symptom relief.
menstruation and this often occurs in a rather]
For instance, the adherents of the theory of high
progressive manner usually between the ages
level of circulating oestrogen have used
45 and 52. The climacteric is a peri(
numerous methods either to lower the level or
oppose its effect. Such methods include the use
characterised by atrophic involution of
of oral progestogens like norethisterone to ovaries and associated changes with consequent
offset the so-called oestrogen-progesterone diminished circulating plasma oestrogen. This L«
imbalance. also a progressive change which at some poii
Suppression of ovarian cycle has been beyond a certain dysfunctional level there
shown to be effective in some cases of PTS. insufficient oestrogen to stimulate uterine
This is achieved by subcutaneous implants of endometrial changes normally discernible
oestradiol, resulting in relatively constant menstruation. In established climacteric, the
plasmaoestrogen levels for up to 6 months. oestrogen level becomes very low and this
Other therapies that have been tried include eventuates in negative feedback pituitary
diuretics, bromocriptine, pyridoxine (Vitamin hypersecretion of gonadotrophins which some
B6) and the prostagladin synthetase inhibitor, claim are responsible for the menopausal
mefanamic acid. Their beneficial effects are symptoms. These include hot flushes, headache.
however not conclusive. irritability, sleeplessness, impaired
It appears that non-specific use of concentration, diminished sexual drive and
anxiolytic agents such as bromazepam, anxiety-depression complexes. However, a
lorazepam and diazepam in moderate doses school of thought explains these clinical
may help significantly to reduce aroused mood changes as drug abstinence symptoms similar to
states such as tension, and irritability and those characteristically associated with
induce sleep in the majority of PTS sufferers. addictive psychoactive.
Any of these drugs should be administered as A biological basis of menopause distress 1
adjuvant to organised social network support is without question but it is important to bear in
for the patient. Of particular significance is the mind that the climateric exemplifies the interplay
encouragement of regular charring of mood of biological and social factors in a transitional
changes and impairment of bodily functions phase of a lifecycle and hence knowledge of the
relatedto the premenstrualperiodwith aviewto patient's total environment, and peculiar personal

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Psychiatric aspects ofgynaecologicalpractice 249

circumstances must be incorporated in acceptable coping mechanisms.

treatment programmes. The roles of certain life
experiences, ordinarily associated with the Psychological reactions to hysterectomy
period immediately preceding the beginning of
middleage, should be appraised. These Introduction
experiences include the threat of loss of The uterus, has from the early days of
youthfulness, solitude contingent to children
documented medicine been a focus of interest
leaving parents to settle in their own marital
and concern to physicians of various
homes and the difficulty intaking a decision on
the use of one's time. All these potentially persuasions. The word 'hysteria' which
interact with the aforementioned biological designates a neurotic disorder per excellence is
phenomena to give rise to the psychological derived from the ancient but erroneous notion
overlay of the distress which comprises inter that the disorder was due to abnormal
alia, anxiety, despair, depression movement of the uterus in the body.
andestangement. Hysterectomy which is the surgical removal of
the uterus for therapeutic purpose as mentioned
Diagnosis elsewhere in this book is often accompanied by
general non-specific psychological changes
The menopausal disorders are not yet which may be observed in relation to any other
recognised as an entity in clinical psychiatry major abdominal surgery, and more specific
and the most widely used classificatory slot is emotional changes determined by their
not the 'psychophysiological disorders' group. focalised significance of the removal of the
The 10th edition of the WHO's International uterus as an organ in its own right. The latter
Classification of Diseases even classifies it group of psychological sequelae which are of
under 'Diseases of the Genito-urinaxy system' special relevance to this chapter will be
and this grouping may tend to underplay its elaborated on accordingly.
significant, psychological import. Diagnosis is The quality and intensity of the
made partly by exclusion of demonstrable non- psychological changes of hysterectomy vary
endocrine disorders, the time phase of according to some ensemble of factors, most
symptoms development, the cluster of importantly being the individual's past surgical
symptoms mentioned above, and raised serum history, personality assets and adequacy of
gonadotropins especially follicle stimulating social network support. A traditionally
hormone. neglected fact is the perception of an attitude of
Treatment the patient to the indications for hysterectomy
in the first place. For instance profuse and
Oestrogens have been found helpful in the control intractable uterine bleeding may be construed
of hot flushes, irritability, anxiety and even by a woman as genital damage and mutilation
depression. Usually required are small daily doses more so if this occurs against a background of
of ethinyloestradiol in 21 day courses repeated certain religious andethno-cultural beliefs.
every month over a couple of months.This should The significance of these indications apart,
be supplemented with psychotherapy designed to a number of reaction patterns have been
be relevant to each individualwoman's needs; the documented. These are enumerated an
emphasis being on providing continuous support succinctly discussed as follows:
for her and helping her to develop effective and 1. Anxiety. This emerges from the fear of
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2S0 Obstetrics and Gynaecology

irreversible damage to the urogenital and masculinity despite other obvious residua-
gastrointestinal systems, debilitation, and even feminine features. This conception can lead to
death. Morbid fears may also arise from aggressive demeanour and even subjective
diminution of sexual function more so if there growth of hair on the face and arms and
were substantial preoperative heterosexual unnaturally boisterous male postures.
difficulties. A remarkable feeling isthe sense of 5. Guilt: Hysterectomy can unleash feelings of
loss of a part of self, which can never be guilt and shame arising from societal, religious J
recovered. or sexual prohibitions such as are sometimes in
2. Loss ofchild-bearingfunction: The capacity premarital, or extra-marital sexual intercourse.
for child-bearing, the mark of womanhood is previous illegal abortion and masturbation. In j
lost permanently with hysterectomy, and these instances, the operation is viewed as
resultant sense of loss could be very intense punishment for personal moral failing, real or ]
even with unequivocal indication for surgery imagined. On the other hand, previous birth of a
among those who do not at all desire more defective child can minimise guilt and make
children. The wish for a child of particular sex hysterectomy an acceptable procedure in that
as rampant in some indigenous African
the uterus, the cage of the child conceived as a
communities could accentuate the misery badpart ofself is removed.
contingent to the obliteration of reproductive The knowledge of these psychological
ability. The sense of loss has beenlikened to the reaction patterns is crucial to the meaningful
preoperative psychotherapeutic interaction
process of mourning or bereavement which if
with the patients. Furthermore at a higher
not worked throughadequately could eventuate
clinical level hysterectomy is fraught with a
in frank emotional decompensation warranting
number of psychiatric sequelae, which should
active psychiatric intervention.
be expected particularly in patients with
3. Loss ofmenstruation: Deutschhas remarked personal or family history of mental disorders.
that no woman really renounces womanhood as Western workers found that the rate of
long as monthly or even irregular bleedings psychiatric referrals following hysterectomy is
remind her of this possibility. From menarche, significantly higher than the rate for the general
once referred to as the badge of femininity, a population. Similar prÿern should be expected
woman continuously feels reassured of her for the indigenousAfrican populationwhere the
womanhood with her menstrual cycles. She high premium placed on child rearing and the
may elaborate the mechanism of 'denial' after special meaning of somatic wholeness are parts
hysterectomy with the development of of ordinary thinking stereotypes. Common
phantom, pseudo-menstrual bodily changes. post-hysterectomy psychiatric changes with
Women with history of dysmenorrhoea or significant intensity include chronic depression
heavy bleeding, however, could develop a often associated with loss of child-bearing
capacity even when this was the: indication for
sense of relief after hysterectomy despite their
surgery in the first place, physic
full awareness of the loss of a vital organ!
polysymptomatic state, sexual maladjustment
4. Sexual identity: The loss of the uterus is am chronic anxiety.
often regardedby some women as a tilt towards
Management
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Psychiatric aspects ofgynaecologicalpractice 251

Most of the psychological changes discussed Hysterectomy in this country is in most cases
above are to be expected andshouldbe regarded performed on women who have completed
as falling within the normal spectrum of human child-bearing, and the biological and psycho¬
reactions provided they are not significantly social problems following surgery which are
distressing or unduly protracted. Perhaps the discussed above are minimal in our local
most crucial approach is a well-presented experience.
preoperative counselling which should be
truthful, informative and reassuring. It was Bibliography and suggested further
generally believed that most surgeons simply reading
explained the rationale for hysterectomy and
unwittingly omit to impress on the patient the Chynoweth, R. (1973) 'Psychological complications of
biological andpsycho-social implications of the hysterectomy.' Australian and New Zealand Journal of
operation. Understanding of the surgery and its Psychiatry, 1; 102. *
repercussions will surely boost the patient's
Desjarlais, R; Eisenbery, L; Good, B and Kelinman ,A.
coping ability and minimise emergent
(1995) WorldMentalHealthProblems andPriorities in
emotional distress. Particular emphasis should Low-income Countries OxfordUniversity Press pp. 179-
be laid on loss of child-bearing capacity, 206.
cessation of menstruation, and the probability
Koran, L.M. and Hamburg, D.A. (1975).
of some immediate postoperative impairment
'Psychophysiological endocrine disorders.' In
of general health usually manifesting in Comprehensive Textbook of Psychiatry, Vol. 2, 2nd ed.,
constipation, pains in the back, poor appetite, Firedman,Kaplanand Sadock, eds.
frequent micturition, depressive reaction, joint
pains, and anxiety related to resumption of Olatawura,M.O.,Ayorinde, A., Ogunlusi, S. (1977), The
sexual intercourse. Specific therapeutic efforts Premenstrual Sydrome in Nigerians, Nig. Med: J. 7:57-
65.
shouldbe geared towards:
(1) Stabilisation of patient's immediate social Schwab, J.J., McGinnis, N.H., Norris, L.B.., and
Schwab, R.B. (1970) Psychosomatic Medicine and
orbit particularly her marital relationship. Contemporary Social Science,Am J. Psych. 126: 1632.
Couples should ideally be supported jointly in
regular individual psychotherapeutic sessions Studd, J. ed. (1984) Progress in Obstetrics and
before and after surgery. Gynaecology, Vol. 4. Churchill Livingstone,Edinburgh.

(2) Liaising with community social workers Tonks, C.M. (1976) 'Premenstrual Tension. Contemporary
Psychiatry.' Br. J. Psycho. Special Publication No. 9.
where practicable in providing continuing
Silverstone and Barraclough, ed. 399-408.
support to the hysterectomised woman vis-a¬
vis her functional losses and their impact on
body image, self image, sexual identity and
sexualroles.

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Chapter 30
m
Preoperative and postoperative

It is important to adequately prepare a patient History

for surgery. Inadequate preparation only A careful history taking is essential in the
increases the incidences of complications preoperative preparation. It is recommended
during and after surgery. In preparing patients that the gynaecologist should take the history
for surgery, there is need for close co-operation personally as personal contact with the patient
between the anaesthetist, physician and the enables the surgeon to have a good overall
surgeon. The main objectives of preoperative picture of the patient.
care are (i) to obtain preoperative information Detailed history of all systems should be
on the health of the patient (history, physical
taken. Mental history is important as
examination and relevant investigations),(ii) to unsatisfactory sexual relations may present
symptoms resembling those due to organic
allay the anxieties and fears of the patient and
pelvic disease.
(iii) to obtain an informed consent. Most of the
An accurate and detailed menstrual history
gynaecological operations are elective and this
should be taken. A detailed urological history is
allows for sufficient time to prepare the patient
important as plastic or suspension operations
Even in emergency situations, attention to have been performed for urinary symptoms
details is important in preparation as short cuts whenthe reallesionis inthe bladder.
may result incomplications. History of the current medication should be
InAfrica, endemic diseases and conditions sought; certain drugs in use by patients may
like malaria, parasitic infections, malnutrition need to be stopped, or continued with adjusted
and dehydration may complicate the course of a dosage especially those acting on the
surgical operation. Morbidity and mortality of cardiovascular, nervous or endocrine systems.
any operative procedure are related or directly The anaesthetist requires such information
proportional to the pre-existing conditions. because of drug interactions during induction
For most patients, there is fear of surgery and maintenance of ar ÿsthesia.
whether minor or major and the gynaecologist
Physical examination
must take time to answer all the questions the
A thorough physical examination should be]
patient may haveand allay her fears. done. Inthe respiratory system, important signs
The doctor should be able to explain in the of respiratory disease should be sought and an\
local language the nature of the surgery. abnormalities should be discussed with the]
Preoperative care should begin from the physician and anaesthetist. In the
outpatient clinic. It is here that detailed history cardiovascular system, particular attention
should be paid to assessment of heart rate.
taking and thorough physical examinations are
cardiac murmurs and raised blood pressure.
done and a diagnosis made. Investigations are This may require the attention of the physician I
ordered and results reviewed before booking before the surgery. Abdominal and pelvic
patients for surgery. examinations should be done. Other systems areJ
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Preoperative andpostoperative management 253

examined in detail especially when there are Other special investigations

symptoms related to these systems. For Chest X-rays are necessary in patients who
example, a detailed urological examination show signs of underlyingpulmonary or cardiac
may be necessary in a patient with disease. In the tropics where malnutrition is
vesicovaginal fistula. common and tuberculosis coexists, chest X-
rays may be necessary preoperatively.
Laboratory investigations Urograms are necessary in patients with
Certain laboratory investigations are required large abdomino-pelvic masses where ureteric
before surgery is performed. Haemoglobin compression or distortion of its normal course
(Hb), packed cell volume (PCV), white blood is suspected. It is also necessary in those
count (WBC) and differential count and patients with pelvic cancer.
urinalysis (for albumin, sugar and acetone)
should be done on all patients before surgery. General preoperative preparations
Blood film should be obtained for malaria Minor gynaecological operations require that
parasites. patients are admitted as day cases or a day
The blood group should be determined and before surgery. Patients for major surgery are
where necessary blood should be cross¬ admitted about two days before surgery.
matched and kept for major obstetric and The fear of pain following surgery may
gynaecological surgery. require the use of sedatives the night before the
Blood for sickling test and if necessary surgery. The anaesthetist should be consulted
haemoglobin electrophoresis should be done on adequate night sedation for the patient.
routinely on all patients in this country. Prophylactic antibiotics are given where
Screening for hepatitis especially B, is necessary before surgery. Rectal metronidazole
increasingly becoming necessary in this before laparoscopy has beenrecommended.
country. Bowel preparation is important before
Serum electrolytes, blood urea, uric acid certain surgical procedures. Bowel evacuation
and creatinine estimations are done where with enema and bowel sterility with antibiotics
necessary. are necessary steps before the repair of
The screening of patients for HIV rectovaginal fistulae.
antibodies should be done after obtaining the Prophylaxis against thromboembolic
patient's permission and following proper disease should be considered in women at risk
counselling. In-country or in-hospital for example, obese women and women with
guidelines for HIV testing shouldbe followed. previous history of thromboembolic disease.
Urine should be obtained for microscopy, Low dose heparin is commenced before
culture and sensitivity where urinary tract surgery.
infection is suspected. There is need to empty the stomach before
Urethral, cervical and vaginal swabs should surgeiy. The stomach should be empty for at least
be taken for microscopy, culture and sensitivity four hours before operation.
where pelvic inflammatory disease is suspected An empty bladder is also required for surgery.
or where Fallopian tube surgery is planned. The bladder couldbe emptied at the time of surgery.
Cervical smear should also be taken for Shaving of hair over the abdomen andthe mons
cytology in patients who are at risk for veneris is required before abdominal surgery but
carcinoma of the cervix.
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254 Obstetrics and Gjipaecology

not for minor vaginal surgery. chart, which includes urine output, loss by
The patient is asked to give an informed vomiting or diarrhoea should be careful!}
consent for the surgery. The consent form maintained. The patient is offered graduated
should be duly signed and witnessed after a oral fluids as bowelsounds return.
proper explanation of the procedure to the
patient.
Antibiotics should be given where
indicated. The routine unselective use of
Postoperative care antibiotics postoperatively should not be
The patient is usually transferred to a recovery encouraged. Early ambulation is the rule after a
room after the operation. The transfer from the major gynaecological surgery. Patients should
theatre to the recovery room or ward is a be encouraged to move the legs and sit out of [
decision of the anaesthetist, depending on the bed on the first postoperative day. Thereafter. ]
patient's condition. The airway is kept in complete mobilisation is encouraged to avoid |
position untilthe patient regains consciousness. thromboembolism.
The vital signs should be monitored carefully
after operation. The patient's pulse and blood Care of the bowel
pressure are monitored quarter-hourly after a The patient shouldbe commenced on graduated I
major operation. Where the condition is oral fluids once bowel sounds are found to be
obviously satisfactory, the pulse and blood present. It is our practice to start with 30mls of
pressure should be monitored half-hourly. The fluids every hour to be sipped slowly on the first
respiratory rate and temperature should also be postoperative day. This fluid can be in form of
monitored. Postoperative pain requires that water or tea sweetened with sugar or fruit juice. :
analgesics be administered as soon as the effect This intake should be stopped immediately, if it
of anaesthesia wears off. It is usual to prescribe induces vomiting. On the second day, the
analgesics for the first 24 to 48 hours patient is given light diet and then graduated on
postoperatively. Pethidine hydrochloride may to a solid diet. It isadvisable to allow the patient
beused at a dose of lOOmg 4-6 hourly.Morphine to eat what she likes thereafter. Mildcathartics
or pentazocine may also be used,
may be given where necessary. Routine use of
intramuscularly.
enema must be avoided. Special bowel care
After 24 hours, analgesia can be provided with
after repair of vesicovaginal fistula is described
less potent analgesics such as paracetamol or
indetail inthe appropriate chapter inthis book.
prostaglandin synthetase inhibitors. Fluid intake
and output balance is important postoperatively.
Most patients who have had major surgery under Paralytic ileus
anaesthesia usually return from theatre with an Postoperative gas distension may fail to subside
intravenous infusion running. Where there has been and result in paralytic ileus. In this condition the
excessive haemorrhage, bloodtransfussion is given. abdomen becomes grossly distended by dilated
In the first 24 hours after operation, intravenous coils of paralysed intestine which contain gas and
fluid replacement is given as 1000 mis of 5% large amounts of fluid derived from unabsor'oed
dextrose alternating with normal saline 8 hourly. This secretions. Once the diagnosis is established the
provides adequate intake in an uncomplicated treatment consists of relieving distension by
postoperative patient inthe first 24 hours.The output aspiration of contents of the stomach and small

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intestine and replacing lost electroytes and fluids

by intravenous infusion as appropriate. A Ryle's
tube is passed down into the stomach, aspiration
is carried out every Vi hour initially and the
interval is gradually increased depending on the
amount that is being aspirated. To determine the
amount of fluid to be given intravenously, it is
important to keep an accurate fluid chart and
record the amount of aspirate as well as the
amount of urine passed every 24 hours. The
amount of fluid to be infused intravenously over
a 24-hour period will bethe sum of the amount of
urine passed and the total aspirate in the last 24
hours. An additional 1.5 litres per day, being the
amount of insensible loss in the tropics is also
mandatory. The fluid should preferably be in
form of 5% dextrose in water alternating with
dextrose in normal saline. Blood sample should
be taken every morning for electrolytes and urea
estimationandthe type offluid infused should be
adjusted accordingly after obtaining the
---- _
„
| x

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-- g
Preoperative andpostoperative management 255

gastric tube should be passed and gastric

contents aspirated if vomiting occurs. If there is
any suspicion of pus forming, a laparotomy
should be performed and the pus drained. Incase
of localised pelvic peritonitis however, it may be
possible to drainthe pus from below by posterior
colpotomy

Care of the bladder

Retention of urine occurs frequently after
vaginal operations. This causes great discomfort
to the patient and may cause a breakdown of the
vaginal repairs. It is the normal practice to
maintain a continuous bladder drainage after
vaginal operations. This is done using a Foley
catheter. It is important that the tubings are
sterile and a closed unit drainage system is
utilised. Continuous bladder drainage can be
maintained for up to 10 days depending on the
type of vaginal surgery. After repair of
vesicovaginal fistula, it shouldbe maintained for
10 to 14 days.
electrolyte level results. Potassium and
There is increasing interest in the use of
bicarbonate should be added if the patient is
suprapubic bladder drainage instituted by a
found to be deficient in these.As a rough guide a
puncture using a trocar and cannula. This method
minimum amount of 3 litres over 24 hours could
has the advantages that the operative vaginal area
be infused on the first day.
is undisturbed and the patient suffers no
The regime described above is continued until discomfort at the re-establishment of micturition.
the patient's condition improves clinically and After abdominal operations, it is the
bowel sounds are present. practice of the authors to leave an indwelling
catheter, which is removed in 12 to 24 hours
Peritonitis postoperatively. Some surgeons have a policy of
inserting no catheter but allowing intermittent
Any pelvic operation may result in peritonitis catheterisation as the situation demands. While
postoperatively. The peritonitis is usually localised the indwelling catheter has its advantage in terms
to the pelvis and is called pelvic peritonitis. of patient's comfort and ease of nursing, there is
Sometimes it may spread further up and result in no evidence that it has a greater risk of infection
generalised peritonitis. The treatment is usually compared to intermittent catheterisation.
conservative in the first instance. This consists of Whatever the chosen policy, it is important to
giving intravenous fluid to correct water and routinely examine urine for evidence of infection
electrolyte imbalance and administering full doses and to piace the patient on urinary antibiotics like
[of broad spectrum antibiotics together with co-trimoxazoie or nitrofurantoin, while awaiting
|metronidazole to take care of anaerobic organisms. the results of urine microscopy, culture and
' These drags are given by intravenous route. Naso- sensitivity.
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256 Obstetrics and Gynaecology

Care of the wound indication for its placement.

Wounds after abdominal operations are dressed Perineal stitches are usually absorbable and
firmly and plaster applied. As long as the patient require no removal. Where silk sutures are
remains afebrile, it is unnecessary to disturb the applied to the perineum, these should be
dressing. Where superficial drains have been removed on the 7th day.
inserted under the anterior rectus sheath
because of unsatisfactory haemostasis, the Discharge from hospital
drains should be removed in 24 to 48 hours or as The day of discharge of the patient depends on
soon as the amount of drainage dictates this. her progress. Wheie the postoperative period
Pfannenstiel incisions are increasingly has been uneventful, patients may be
being used in this country and drainage should discharged on the 8th day. Patients who have
be used to reduce the haematoma formation subcuticular non-absorbable stitches and who
which often complicates this incision. Skin have had normal postoperative period could be
sutures of nylon or silk should be removed on discharged earlier. In taking the decision on
the 7th to 8th day. Where deep tension sutures early discharge from hospital, careful
have been applied, they should be removed on examination where necessary should be done
the 10th to 14th day. A subcuticular absorbable before discharge. The patient should have
abdominal skin stitch is preferred by the authors appointment for four weeks in the outpatient
and requires no removal but where subcuticular clinic.
nylon sutures have been used, a "pull through"
removal shouldbe done on the 8th day.
After vaginal operations, perineal wounds Bibliography and suggested further
usually require no dressing. A perinealpad should reading
be placed over the vulva, after an antibiotic spray
Agboola, A. (1999) Preoperative and postoperative
over the wound. A vaginal pack left to control
management: In Textbook Of Obstetrics And
oozing and haematoma formation should be Gynaecology For Medical Students. Agboola, A. ed. lfi
removed in 24 to 48 hours, depending on the ed. Vol. 1.HeinemannEducational Books (Nigeria) Pic.

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g.
3

SECTION B - OBSTETRICS

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Chapter 31
Antenatal care

Antenatal period is the interval from throughout pregnancy. Antenatal care should
conception to the delivery of the fetus. This have well defined measures aimed at
period is usually associated with physiological preventing the development of any pregnancy
as well as psychologicalchanges inthe woman. disorders or complication. Antenatal care
The psychological changes are dependent to a should address the psychosocial and medical
needs of the woman within the context of the
large extent on whether or not the pregnancy is
health care delivery system and the culture in
wanted, the social circumstances around the which she lives.
woman and how her body responds to the
normal physiological changes in pregnancy. Visits to antenatalclinic
The physiological changes in pregnancy are The concept of antenatal care has now shifted
mostly aimed at creating effective changes in from providing medical management of
the mother's body; hormonal, cardiovascular, pregnant women to a combination of
renal among others in order to ensure that the information sharing, medical care and helping
fetus is adequately catered for while in the the pregnant woman make informed decisions
uterus. about her life in general and the pregnancy in
Antenatal care is the process whereby particular. The pregnant woman should no
mother andthe growing fetus are systematically longer be a passive receiver of medical care,
examined throughout the antenatal period. Itis a rather she should participate actively inthe care
form of preventive medicine in which risk of herself and the fetus. For this reason
emphasis has now shifted from issues such as
factors are recognised early in the antenatal
the number or times of antenatal visits to the
period and specific interventional measures are
concept of the quality of the antenatal care given
instituted. Pregnancy is a special event and the at each visit. This concept is even more
family and community should treat a pregnant important in developing countries where there
woman with particular care. The WHO are few doctors attending to a large number of
technical working group on antenatal care was pregnant women. The WHO has recommended
of unanimous opinion that antenatal care makes a minimum of four antenatal visits for a woman
a significant contribution to maternal and with a normal pregnancy. This is not to imply
perinatal health and is therefore an essential that where more visits are practicable, it should
component of care for mothers and babies bereducedto the minimum. Rather, it is to focus
together with family planning, clean and safe on the content of care and to set a basic essential
delivery andessentialobstetric care. standard for quality of care for all pregnant
women particularly in developing countries
(Table 3 1.1).
Aims of antenatal care Traditionally, visits to the antenatal clinics in
The main aim of antenatal care is to ensure a healthy normal pregnancy are regimental depending on
mother and infant at the end of the pregnancy. To gestational age, so that women attend antenatal
attain this objective, antenatal care should be seen clinic ever>' four (4) weeks until 28 weeks then
as a major preventive health measure which every two weeks until 36 weeks then every week
guarantees that the mother remains healthy until delivery. This is excellent when there are
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258 Obstetrics and Gynaecology

adequate numbers of health care providers to to women on health education, risk assessment,
attend to these pregnant women. In situations nutrition and life style (smoking, alcohol, use of
where there is inadequate number of health drugs) which may affect the fetus. For some
providers to attend to a large number of medical diseases such as diabetes mellitus,
pregnant women, this approach may overload preconception control would reduce the effect
the service provided. of the disease on the fetus. In this country, very
The midwife, general practitioner and the few hospitals runpreconception clinic.
obstetrician regardless of the provider and the The first visit (Booking visit) traditionally
level of health facilities provide antenatal care; occurs at about 16 to 18 weeks, although
the antenatal clinic must adequately provide booking earlier is advisable as some obstetric
healthpromotion and care. interventions, such as cervical cerclage,
chorionic villus biopsy, amniocentesis are
1. First Visit (between 14-16 weeks)
ÿ
required at an earlier gestational date.
Screen and treat anaemia
The first antenatal visit consists of three
Screen for risk factors and medical
components; history taking, physical
conditions that can be addressed early in
pregnancy
examination and special investigations.
ÿ Initiate prophylaxis-haematinics
ÿÿÿ Plan individualised antenatal care and History
delivery The booking history is divided into several
sections. These include (i) Demographic
2. Second visit (between 24-28 weeks) details (ii) Menstrual history (iii) Past obstetric
ÿÿÿ Screen for anaemia history, (iv) Past medical and surgical history
(v) Family and social history and (vi) History of
3. Third visit (around 32 weeks) the present pregnancy.
ÿ Screen for pre-eclampsia, multiple
pregnancy, and anaemia (i). Demographic details: These include
ÿ Review birth plans patient's name and address, age, parity, marital
status and ethnicity or nationality. The patient's
4. Fourth visit (at 36 weeks) name and contact address are documented. The
ÿ Screen for anaemia contact address allows for social workers to be
<ÿ Identify fetal lie and presentation sent after sick patients who default at the clinic.
ÿ> Assess the pelvis The maternal age remains an important
ÿ> Update the individualised birth plans screening test in the antenatal history. Maternal
age below 18 years and above 35 years are
Table 31.1 Recommendedminimumnumber, timing and associated with increased maternal morbidity
content of antenatalvisits and mortality. Maternal age above 35 years is
also associated with an increased risk of
First antenatal visit (Booking visit) chromosomal disorders and spontaneous
This is important, as it is the visit at which the miscarriages. Primiparity and graridmultiparity
medical risk factors are ascertained. Ideally there are antenatal risk factors. A history that the
should be a preconception visit, which should be the patient is unmarried or that the patient and her
first visit. This visit should provide information husband are of a low social class is associated
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mmmm
with higher maternal and perinatal morbidity
"" '* - Wm&L
Antenatal care 259

including complications if any are carefully

and mortality. ascertained. Details of the early neonatal i
periods should also be taken. A history of
(it) Menstrual history recurrent miscarriages or premature deliveries
The menstrual history must be taken accurately may be due to cervical incompetence and/or
as it is important in the calculation of the uterine anomaly. These would require further
gestational age. The date of the last menstrual investigations and treatment. A history of
period should be ascertained. Uncertainty of stillbirths and intrauterine deaths may point to
this date is a common problem in the antenatal medical diseases such as hypertension, diabetes
booking clinic. The regularity and the average
mellitus, Rh iso-immunisation that would
require expert care in the pregnancy.
length of the menstrual cycle should be sought.
Sometimes, it may be necessary to obtain
It should also be determined whether the
reports or records from other hospitals where
menstrual period before the pregnancy was antenatal and delivery care took place. History
abnormal and where this is so, the date of the of labour must include onset (spontaneous or
last 'normal' menstrual period should be induced), duration of labour and method of
ascertained. The first day of the last 'normal' delivery (spontaneous vaginal delivery, forceps
menstrual period should be obtained as this is or ventouse delivery, or caesarean section).
used in the calculation of the expected date of History of third stage abnormalities such as
delivery (EDO). postpartum haemorrhage will increase
The average duration ofpregnancy calculated surveillance to avoid a recurrence. History of
from the first day of the last menstrual period is puerperal abnormalities such as puerperal
about 280 days or 40 weeks. It is usual to estimate sepsis should also be noted. History of neonatal
the EDD by adding 7 days to the date of the 1stday complications (neonatal jaundice, neonatal
of the last menstrual period (LMP) and counting sepsis or neonatal death) may require special
back 3 months (Naegele's rule). For example, if a neonatal surveillance.
patient's LMP. began on 2nd June, the EDD would
be 9th March. In calculating the EDD, the first day (iv) Past medical or surgical history The
of the LMP is used. Ina normalmenstrual cycle of history of previous medical diseases such as
28 days, ovulation occurs on the 14th day and diabetes mellitus, hypertension, chest diseases
fertilisation can only take place thereafter. The (pulmonary tuberculosis, asthma or bronchitis),
gestational age so calculated is two weeks longer
viral diseases (hepatitis), renal diseases",
cardiac disease and haemoglobinopathies
than the "fertilisation age" or "ovulation age".
should be ascertained as these tend to affect the
course of pregnancy and may require joint
(Hi) Past obstetric history A management with specialist physicians.
careful history of the past deliveries of the patient Previous surgical operations may affect the
should be documented. The total number of decision as to mode of delivery. Previous
deliveries and miscarriages is noted. The total myomectomy, vesicovaginal fistula repair,
number Gf pregnancies including the current plastic operation on the uterus are some of such
pregnancy (gravidity) is noted.The total number of operations. A history of blood transfusion in a
deliveries (parity) is also documented. Details of previous pregnancy especially where reactions
the antenatal, intrapartum and postpartum periods to transfusion occurred, should be sought.
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26Q Obstetrics and Gynaecology

(v) Familyandsocial history The family history Physical examination

of diabetes mellitus, hypertension, cardiac The height, weight, blood pressure should be
disease should be sought. The family history of measured. A midstream sample of urine should
twinning especially on the maternal side should be examined for protein,glucose and acetone.
be ascertained. This is important inthis country A thoroughphysical examination should be
where twinning rate is high. History of smoking
done. A general examination shouldbe done for
and alcohol consumption should be recorded.
pallor, jaundice, cyanosis and oedema.
Current drug medication and history of allergy
should be documented. Any history of Examination of the neck for thyroid gland and
HIV/AIDS especially of the husband is also lymph node enlargement is done. The breasts
important considering the prevalence of the should be examined for lumps and normal
disease in our environment. nipples preparatory for breast feeding.
The respiratory and cardiovascular systems
(vi) History of the present pregnancy The should be carefully examined. The abdomen
patient is asked for any symptoms and signs of should be examined for liver, spleen and kidney
pregnancy especially where these are enlargements. The fundal height (FH) of the
exaggerated. They include nausea, vomiting, uterus should be ascertained if the uterus is
urinary frequency, pain, vaginal discharge and abdominal at this time otherwise, bimanual
bleeding. Nausea and vomiting are known examination would determine the size of the
symptoms of pregnancy and commonly occur uterus andits consistency. . Pelvic examination,
in the morning (morning sickness) but can if done should be both speculum and digital
occur in the afternoon when they are excessive vaginal examination. Speculum examination
as in hyperemesis gravidarum. Multiple
ideally should be performed. State of the cervix
pregnancy or hydatidiform mole should be
excluded by ultrasonography. Urinary should be determined and a cervical - smear
frequency is common in early pregnancy but taken if one has not been taken in the past two
when accompanied by dysuria it is important to years.
exclude urinary tract infections. A moderate Digital examination should seek for pelvic
amount of whitish vaginal discharge is normal masses and their relationship to the uterus. It
in pregnancy but foamy yellowish discharge or shouldalso seek for vaginal stenosis or septum.
a white cheese like discharge may be due to
trichomonas or Candida infection respectively Investigations
andshouldbe investigated. Blood is taken for haemoglobin or haematocrit
Vaginal bleeding canoccur at about the time estimation, a full blood count and haemoglobin
of implantation of pregnancy. This is little and electrophoresis or genotype. The blood group
normal and usually comes from the uterine and Rhesus antibody testing isdone.The VDRL
lining away from the site of implantation (Venereal Disease Research Laboratory) test is
(deciduaparietalis). This may continue up to the done for syphilis. This test is done routinely in
12"' week of pregnancy. History of moderate this country, although the pick up rate is low.
bleeding in early pregnancy (threatened Screening for rubella antibody is done in most
miscarriage) should be noted as this may affect developed countries. Ithas become necessary to
placental function inlater pregnancy.

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offer human immunodeficiency virus (HIV) Africa, the above protocol is currently being
screening to all women booking for pregnancy reviewed inNigeria.
care because of the high positive rates in this Anaemia prevention is provided by
country and because this would help to reduce prophylactic medication with iron and folic
vertical transmission if women who are acid throughout pregnancy and for two months
positive receive treatment during the antenatal after delivery. In patients with
period. haemoglobinopathies, only folic acid
Urine testing is done routinely for proteins, supplementation is necessary unless there is
glucose and acetone. Urine may also be sent for laboratory evidence of irondeficiency anaemia.
microscopy and culture. Women with
asymptomatic bacteria can be identified and Health education
treated. Where glucose is present in urine, Important messages relating to the health of
fasting blood sugar test shouldbedone. women and infants should be conveyed to all
Ultrasound scanning has now become part pregnant women and where possible other
of the booking investigations. It is offered members of the community. It is crucial that
routinely to all women at booking. In this consistent and accurate messages are conveyed to
country, where the facilities are available, it is women, their families and community. These
done at 20 to 25 weeks or earlier for dating and messages could be effectively conveyed to
suspected multiple pregnancy. It is also used in pregnant women at the beginning of each
the diagnosis of structural and chromosomal antenatal visit, while waiting for weight and
abnormalities. In later pregnancy, ultrasound height to be taken. Women could watch some of
scan is done for specific indications such as these messages recorded and played on videos.
antepartum haemorrhage; macrosomic babies, Health care providers should be available to
intrauterine growth restriction, reduced fetal answer all questions that may arise from health
movements and premature rupture of fetal talks. InNigeria, songs on some of these messages
membranes. Assessment of fetal wellbeing is are composed and pregnant women sing these
also an indication. songs while waiting to be attended to. Some of the
health messages that need promotion include
Cbemoprophylaxis in pregnancy antenatal visits, essential services, clean and safe
InNigeria, it is still the practice for all pregnant delivery, danger symptoms and signs in
women to receive drugs for prevention of pregnancy, coping with emergency, nutrition and
malaria and anaemia. Malaria hygiene, newborn care, family planning, harmful
Chemoprophyiaxis is provided by giving all traditional practices, routine drugs for anaemia
pregnant women oral chloroquine 600mg base and malaria prevention and preparation for
on days 1 and 2 and 300mg base on day 3 at the breastfeeding and delivery and feeding options
booking antenatal clinic. This is then followed for HIVpositive mothers.
by daily oral proguanil 2Q0mg throughout
pregnancy. However in many institutions Indications for booking
proguanil is not given as a routine. Following
the initialdose of chloroquine it is also given as Indeveloped countries, where medical facilities are
prophylaxis at a dose of 300mg weekly well developed, not all pregnant women are
throughout pregnancy. expected to receive antenatal care and have their
With the emergence of chloroquine resistance in deliveries in specialised centres. Some women are
treating malaria in many developing countries in generally expected to have normal deliveries, such
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Prince Of Medicine-2014-BSUTH

262 Obstetrics mid Gynaecology

women are said to be low risk and could be Subsequent antenatal visit
allowed to deliver at home (where domiciliary In Nigeria, visits to antenatal clinics remain
deliveries are permitted) or in general regimental, so that women attend every 4 weeks
practitioner hospitals under general until 28 weeks, then every 2 weeks, until 36
practitioners or practising midwives. weeks and then every week until delivery. At
Some other women might have rather each subsequent antenatal visit, weight and
complicated antenatal period with features that blood pressure measurements are taken and
could be recurrent e.g hypertension, difficult urine is checked for protein, sugar and acetone.
delivery due to fetopelvic disproportion, Gestational age estimate and fundal height
measurement are also recorded.
history of other problems such as primary
postpartum haemorrhage, neonatal jaundice,
Weight gain
etc. Such women are said to be high risk since
All pregnant women should be weighed at
their problems are associated with every visit to the antenatal clinic. This allows
management, maternal morbidity and perinatal for early detection of pre-eclampsia. The total
morbidity and mortality. These high risk cases weight gain in pregnancy averages 10 kg. Most
have indication for booking for antenatal care of the gain occurs in the second trimester.
and confinement inspecialised centres. Excessive weight may be an important sign in
In Nigeria, all patients attending antenatal early detection of pre-eclampsia.
clinics are booked for antenatal care and
confinement inhospital. Bloodpressure
1. Poor obstetric history Blood pressure should be measured at every
2. Strikingly short stature visit to the clinic. It is to be noted that both the
3 . Very young maternal age, 15 years or less systolic and diastolic blood pressure are lowest
4. Nulliparity or grandmultiparity at the end of the second and beginning of the
5. Size-date discrepancy third trimester. A rise in systolic and diastolic
6. Unwanted pregnancy blood pressures is an important sign inthe early
7. Extreme social deprivation detection of pre-eclampsia.
8. History of preterm labour in previous
pregnancy. Urinalysis
9. Multiple gestation A urine sample should be obtained and tested
10. Abnormal lie/presentation for protein, sugar and acetone at each visit.
11. History of previous fetal abnormality, Proteinuria may be a sign of renal disease and is
perinatal or neonatal death. an important sign in early detection of pre¬
12. History of chronic medical disorders. eclampsia. Glycosuria in urine obtained in the
13. History of infertility fasting state may be the first sign of diabetes
14. Previous gynaecological operations. mellitus. Acetonuria may be a sign of
dehydration following excessive vomiting in
Table 31.2: Indications for booking for antenatal care pregnancy but can also be a sign of diabetes
and confinement inspecialised centres mellitus.
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Abdominal examination.
Mntenatalcare 263
m
are felt as irregular shapes on both sides of the
Abdominal examination should be done at midline, and the abdomen below the umbilicus
every visit to obtain a clear impression of (i) also looks flattened.
height of the fundus, (ii) lie of the fetus (iii) The last palpation is the palpation at the
position of the fetus (iv) presentation including pelvic inlet (pelvic palpation). The doctor turns
whether the presenting part is engaged or not and faces the foot of the bed or the patient's feet.
and (v) rate and character of the fetal heart. He places bothhands on bothsides of the lower
portion of the uterus. In this palpation, gentle
In doing this, a systematic palpation of the
pressure is exerted by distal phalanges of the
abdomen is done to locate the fetus within the
fingers which move towards the midline to
uterus. The gestational age should first be
identify the presenting part between both
assessedand recorded. This is usually done by a
hands. The head is usually hard and if
measurement of the symphysial-fundal height
unengaged is easily ballotable, and it could be
(SFH). SFH is measured in centimetres from
flexed or extended.
the symphysis pubis to the top of the fundus of
the uterus. The SFH in centimetres is
The examination is concluded by
equivalent to gestational age in weeks after 22
auscultation of the fetal heart sounds. This can
weeks until term.
be done by use of the pinard fetal stethoscope or
The abdominal palpation should be
the Doppler. The fetal heart sounds are usually
systematic and should begin with the palpation heard at a point over the fetal back. The
of the fundus of the uterus (fundal palpation). presence, rate and regularity of the fetal heart
The doctor or midwife stands by the patient sounds are recorded.
who lies supine on the examination couch. The
ulnar border of the left hand is placed over the Special concerns of pregnant women
uterus to delineate it and estimate the fundal
height. Bothhands are then placed on the fundal Rest and exercise
area and this is palpated carefully to determine Adequate daily rest and sleep is important for
whether the head or breechoccupies the fundus. maintenance of good health during pregnancy.
The fetal head feels hard and round while the Those who hold regular sedentary jobs should
buttockis soft and irregular. be allowed to continue inthe jobs till the time of
Next is the palpation of the lateral sides of maternity leave. Heavy physicaljobs should be
the uterus (lateral palpation). The hands of the discouraged during pregnancy. Exercise in
doctor are placed on either side of the abdomen pregnancy helps to maintain a feeling of
which is carefully palpated to determine on wellbeing. Strenuous exercise in pregnancy
which side the back of the fetus lies. In this should be discouraged. The amount of exercise
palpation the doctor should face the patient. In should be maintained at the same level before
this examination the back or the spine of the pregnancy. Inthis country, women have enough
fetus is identified as a soft regular continuous exercise from daily housework, trading or
firmness on one side while the limbs are felt as farming and do not need extra exercises.
irregular shapes or knobbles on the other side. Stressful exercises such as jogging should not
In occipitoposterior position, the fetal limbs be allowed inpregnancy.
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264 Obstetrics andGynaecology

Smoking/Alcohol consumption Smoking clothes should be loose. In this country, the

cigarette and drinking alcohol have adverse traditional wrapper is suitable for pregnancy
effects on pregnancy. It is important to but patients should be advised to tie this at the
discourage women from smoking and drinking waist rather than the abdomen. Most Nigerian
alcohol in pregnancy. In this country, it is women wear shoes that have low heels, or
generally believed that most women do not slippers. Shoes with high heels should be
smoke cigarettes but some of them use snuff. discouraged inpregnancy.
Patients shouldbe asked about their smoking or r

alcohol habits and they should be advised to Nutrition

stop the use or reduce the number of cigarettes The need for a balanced diet during pregnancy
smoked or the volume of alcoholconsumed. forms part of the health education talk at every
antenatal visit. Ideally, the diet should contain
Travel adequate amount of nutrients such as
Travel by car, train and airplane is not harmful carbohydrates, protein, fats, mineral salts and
during pregnancy. Long journeys should be water. In this country, the opportunity of the
avoided especially in the third trimester. healtheducationtalk istaken to demonstrate the
Patients who have antenatal complications local foodstuffs that contain the nutrients
should be discouraged from travelling. Airlines required by patients with emphasis on the
in this country require medical certification quality rather than quantity of the foodstuffs.
from doctors before accepting pregnant women Poverty, ignorance, taboos and superstitions
especially inlate pregnancy. contribute to the poor nutritional state seen in
Sexual intercourse some of these patients and nutritional advice
In this country, sexual intercourse is a taboo in given must take these factors into
pregnancy in some cultures. The doctor should consideration.
feel free to discuss this with his patients during
the antenatal period. Bibliography and suggested further
In early pregnancy, sexual intercourse reading
should be avoided in women who have
abdominal pain or vaginal bleeding following ABC ofAntenatal care (1997) Geoffery Chamberlain ed.
such act. It should also be avoided in women 3rd ed. BMJPublishing Group.
with premature rupture of membranes or Antenatal Care Report of a Technical Working Group
antepartum haemorrhage. Patients could be (1996) WHO/FRH/MSM/96.8.
advised to have normal sexual relationship only
if the pregnancy is progressing normally. Antenatal Care Maternal Health, How effective is it? A
Labour may follow sexual intercourse near or at review of the evidence (1992) C. Rooney ed.
term because of the presence of prostaglandinin WHO/MSM/ 92.4.
seminal fluid. Care of Mother and Baby at the health center. A practical
guide report of a technical working group (1994) WHO/
Clothes FHE/MSM/94.2 Revision2.
It is advisable that patients wear clothes that are Essential Elements of Obstetric Care at First Referral
designed to provide comfort in pregnancy. These level (1991) ISBN92 4 154424 4.
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Chapter 32
The Placenta, umbilical cord and
membranes
Development of the human placenta
Pregnancy occurs when an adequate number of
healthy spermatozoa travel up the genital tract
to fertilise a healthy ovum, within 24 hours of
ovulation. During the upward journey to the
ovum, an enzymatic change occurs that renders
the spermatozoa capable of fertilising the
ovum. This process is known as capacitation.
The sperm head containing all of the paternal
material penetrates the zona pellucida
surrounding the ovum and eventually enters the
cytoplasm of the ovum. A zonal reaction which Figure 32.2 Photomicrograph of the surface view of a
then takes place prevents the entry of a second living morula of approximately 32 cells. (Courtesy of
Prof. L.B. Shettles. From Boyd, J.D. and Hamilton, W. J.
sperm. The first cleavage occurs during the next
The human placenta, 1970. By kind permission of
36 hours and further division occurs while the MacmillanPress Ltd., Londonand Basingstoke).
conceptus (morula) is being transported along
the Fallopian tubes by peristaltic action to the
uterine cavity. This journey takes 6-7 days and
by the time it gets to the uterine cavity it has
been transformed into a blastocyst which then
implants within the endometrium. In the
meantime, the endometrium has been fully
prepared for implantationunder the influence of
progesterone from the corpus luteum. The
majority of cells in the wall of the blastocyst are
trophoblastic. (Figs.32.1,32.2,32.3,32.4).

Figure 32.1 Photomicrograph of a living morula of Figure 32.3 Photomicrograph of a section through a 58-
cell early human blastocyst. Estimated age 96
approximately 32 cells. (Courtesy of Prof. L. B. Shettles. hours.(Courtesy of Drs Hertig and Rock From Boyd, J.D.
From Boyd, J.D. and Hamilton, W. J. The human and Hamilton, W. J. The human placenta, 1970. By kind
placenta, 1970. By kind permission of Macmillan Press permission of Macmillan Press Ltd.. London and
Ltd., London and Basingstoke). Basingstoke).

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266 Obstetrics andGynaecology

inthe death of the embryo.

Structurally a villus has a core of
mesoderm or stroma and an epithelial covering.
The stroma consists of connective tissue in
which are embedded numerous fetal blood
vessels or capillaries. The epithelial covering
consists of a single inner layer of
cytotrophoblast (Langhan's cells) with definite
cell walls, and an outer layer of
syncytiotrophoblast, without definite cellwalls.
The surface of the placental villi is bathed in
maternal blood which circulates in lacunae
forming together the intervillous space. Thin
walled vessels carrying fetal blood are
separated from the maternal blood only by
scanty connective tissue of the villi and a thin
Figure 32.4 Photomicrograph of a section through a layer of trophoblast. The villi provide for
humanuterine blastocyst of 107 cells. Estimated age 108 transfer of metabolic products. Most of these
hours. (Courtesy of Drs Hertig and Rock. From Boyd, J. villi are free within the intervillous spaces but
D. Hamilton, W. J. The human placenta, 1970. By kind
permission of Macmillan Press Ltd., London and an occasional anchor villus attaches the
Basingstoke). placentato the deciduabasalis. (Fig.32.5).
d
Within a few hours of implantation, the
trophoblast invades the endometrium and
elaborates human chorionic gonadotrophin
(HCG). The cytotrophoblasts (Langhan's cells)
divide and proliferate and later give rise to
syncytiotrophoblast. The syncytiotrophoblast
which is the outer layer of the trophoblastic
cells is always in contact with maternal cells.
Maternal capillaries and venules are tapped by
the invading trophoblast to cause extravasation
of maternal blood and the formation of small
lakes (lacunae), the forerunners of the
intervillous space. The proliferated
trophoblastic cells at this stage constitute the
primary villi. They are later invaded by
mesodermal core thus converting them to
secondary villi, the principal organs of
Figure 32.5 Diagram of a chorionic villus.- (a) Branch
exchange inthehumanplacenta. of 1 umbilical artery (b) syncitiotrophoblast (c)|
The embryonic body stalk, later to become cytotrophoblast (d)mesoderm (e)Capillaries (f)Branch,;
the umbilical cord, then invades the stromal of umbilical vein. (From Myles textbook for midwives,
(mesodermal) core to establish the fetoplacental 11981. By kind permission of churchill Livingstone«j
circulation. Failure of this last step invariably results Publishers,Edinburgh)
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W: The Placenta, umbilicalcord, andmembranes 267

The placenta attains its definitive architecture a succenturiate lobe fails to come out with the
by about the 12th week of gestation but it parent placenta during the third stage of labour,
continues to grow and becomes subdivided into it may result in postpartum haemorrhage.
15 to 30 lobules by septa. Each interseptal
lobular space may correspond to one, two or Manual removal of the succenturiate lobe
more placental cotyledons which are fetal should be performed immediately to avert this
placental units of the branchedvillous tree. bleeding complication. (Fig.32.7)

The placenta at term Placenta membranacea - Sometimes the

The normal mature human placenta is a entire fetal envelope is a functioning placenta
rounded, flattened, discoid organ, 15-20cm in because the chorion laeve fails to atrophy. The
diameter and 2-4cm thick. It weighs 500-600 placenta may be oval or ring shaped with a
grams or about one sixth the normal weight of central defect which is occupied only by
the newborn baby. Placentae vary in weight, membranes. This type of placenta is of no
size, thickness, form and consistency. For clinical importance.
example, they are heavier than normal in
maternal conditions like syphilis, rhesus Bipartite placenta - This abnormality is
isoimmunisation and severe anaemia. uncommon. The placenta is divided into two
The basal plate is that part of the separate lobes but unitedby primary vessels and
placenta inserting on the maternal decidua membranes. Itis of no clinical importance. (Fig.
basalis. The opposite surface of the placental
disc remains in contact with the amnion and is
called the chorionic plate. The umbilical cord
which links the fetus to the placenta is inserted
on the surface of the chorionic plate. Through
the amniotic covering can be seen the umbilical
arteries and vein coming from the umbilical
cord and branching in all directions, until the
small twigs disappear into (he placenta close to
the edge.

Types of placenta Figure 32.6 Placenta circumvallata

Placenta circumvallata - In this type of
placenta, there is a small central chorionic plate
surrounded by a thick whitish ring that is
composed of a double fold of amnion and
chorion. Circumvallate placenta may
6
predispose to antepartum haemorrhage. (Fig.
32.6)

Placenta succenturiata - In this condition, there

may be an accessory cotyledon with vascular
connections to the mainbody ofthe placenta. When Figure 32.7 Placenta Succenturiata

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268 Obstetrics and Gynaecology

Other types of tumour include hydatidiform

mole and choriocarcinoma and have been
described elsewhere inthis book.
Placentalfunctions

The functions of the placenta include:

(i) Nutritive
(ii) Excretory
(iii) Respiratory
(iv) Barrieraction
(v) Endocrine
Figure 32.8 Bipartite Placenta
Nutritive
The key function of the placenta is transport of
Disorders of the placenta nutrient to the fetus.
Carbohydrates
The following disorders or diseases of the Glucose is the major metabolic fuel for the
placenta may occur: fetus. It crosses the placenta from maternal to
Placental polyp - A retained piece of placenta fetal blood by facilitated diffusion, i.e the
after delivery may develop into a polyp and be a direction of transfer is in accordance with the
cause of secondary postpartum haemorrhage. glucose concentration gradient between
maternal and fetal blood, but the rate of glucose
Placental infarct - True infarcts of the placenta transfer from mother to fetus is accelerated
are common and are due to interference with beyond that expected on physiochemical
the maternal blood supply to the intervillous ground alone. A potential store of glucose for
space. This condition is a common sequela of the fetus is the placental glycogen. The
pre-eclampsia. glycogen is used by the fetus for synthesis of
Syphilis of the placenta - This disease is now fetal tissues and therefore acts to some extent as
rare. The placenta is usually heavier than the liver of the embryo.
normal. It is now a known fact that the placenta
consumes something like one-third of all the
Calcification of the placenta - This lesionmay nutrients and energy devoted to the
be seen on the maternal surface of the mature fetoplacental unit.
placenta and is of no clinical importance.
Amino acids
Cyst of the placenta - Small cysts may be seen
in the chorionic plate of the placenta. They are Amino acids are transferred across the placenta by
of no clinical importance. the process known as active transport. The
concentration is generally much higher in the fetal
Tumours of the placenta - Primary tumour of the bloodthan in maternal blood, and the net transfer is
placenta is rare. It is of the solid variety and also thus against a gradient. Amino acids are delivered to
haemorrhagic. Chorioangioma is the term given the fetus for protein synthesis. They apparently
to it and it may be associated with hydramnios. contribute to requirements for fetal energy.
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I It has been stated that the placenta can also be

The Placenta, umbilicalcord, andmembranes 269

Minerals
responsible for de novo synthesis of essential The permeability of the placenta to sodium
nutrients for the fetus. An example isthe amino increases rapidly from about 9 weeks to 35
acid glycine, which is derived by placental weeks gestation. Thereafter it falls towards
conversion of serine. term. It has been established that the flux of
sodium was huge in relation to the amount
Proteins incorporated in fetal tissue; the exchange rate
Maternal plasma proteins despite their large was 1000 times the rate of accumulation by the
molecular size are transferred to the fetus. The fetus at term.
mechanism oftransfer is known as pinocytosis.
There are differences in the transfer rates The concentrations of sodium chloride, .
among the proteins, which cannot be explained potassium and magnesium are about equal in
on the basis of molecular weight. For example, bothmaternal and fetal blood.
it has been shown that IgG gamma globulin It has also been established that iron
which is over twice the size of albumin is circulates in the plasma partially bound to. a
transferred to the fetus at a faster rate. The specific protein, transferrin. Maternal iron is
selectivity appears to depend on specific released from transferrin at the placenta by an
receptors on the placental surface. Maternal active metabolic process similar to that
IgG passes through the placenta to the fetus and described for the reticulocytes, that is,probably
thus the newborn baby is equipped with almost handed to receptor sites on the placental
all the resistance to infectious disease membrane. Some iron is stored in the placenta
possessedby the mother. and released to the fetus slowly and there is a
The principal site of synthesis in the higher concentration in the fetal than in
placenta is the syncitiotrophoblast. There, a maternalblood.
broad spectrum of proteins and steroids are
produced including the pregnancy-associated Excretory
plasmaproteinA (PAPP-A). Ithas beenclaimed The placenta acts as a fetal kidney excreting
that in additionto specific proteins, the placenta waste material, uric acid, urea, creatinine and
also produces virtually every known protein salts into the maternal blood. These substances
and peptides that are produced in the adult but pass freely by simple diffusion and their levels
insmall quantities. are about equal in maternal and cord blood.
Transport of waste material away from the fetus
Lipids isanother key function of the placenta.
Most of the fat in fetal tissues is synthesised in
the placenta from carbohydrates taken from the Respiratory
maternalblood. However, it hasbeen suggested The placenta acts as the lungs of the fetus taking up
that some fatty acids, phospholipids and oxygen from the maternal blood and giving up
cholesterol may be transferred across the carbondioxide. In general, gases cross the placenta
placenta from the mother to the fetus. by simple diffusion; the concentration of oxygen in
the maternal blood is higher than in the fetal blood
Vitamins while the reverse is true for carbondioxide. The
The water-soluble vitamins appear to be release of carbondioxide from fetal haemoglobin at
transferred inthe same way as amino acids. the placenta is facilitated by the simultaneous

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270 Obstetrics and Gynaecology

uptake of oxygen (Haldane effect). Pick's law It is excreted in the urine as pregnanediol.
describes the factors that influence the rate of
diffusion. Oestrogens: In pregnancy the major site of
production is the placenta. The oestrogens
Barrier Action produced are secreted intothe maternalblood in
Although the placenta has the power to prevent the free form. They are conjugated to
harmful substances from passing to the fetus glucuronides and to a lesser extent, to sulphates
from the mother, this system israther imperfect. by the maternalJiyer .beforeurinary excretion as
For instance, in typhoid, malaria, tuberculosis, oestriol. Like progesterone, the level rises
syphilis, and viral diseases, organisms have progressively in pregancy and reaches a peak
been known to pass over to the fetus. This is just before labour.
probably a result of prolonged damage to the
chorionic epithelium, or rupture of delicate Human chorionic gonadotropin: This is a
villous vessels. Another hypothesis is that it glycopolypeptide hormone produced in the
may follow transient increases in intravascular syncytiotrophoblast. hCG is composed of two
pressure within chorionic capillaries. Some subunits: (a and p). The (X subunit is nearly
drugs such as morphine have also been known identical to the LH, TSH and FSH. The p
to pass from the mother to the fetus. All the subunit has been detected in the blood as early
same, the placenta can be said to be generally as 6 days after the first missed period and it
effective inits barrieraction.
reaches its peak concentration at about 60 days.
It is known that fetal levels of Cortisol are
The level is noted to decline after the first
significantly less than those of the mother. The
placental enzyme, 11 p-hydroxysteroid trimester. The function of hCG is to maintain
dehydrogenase determines the amount of the corpus luteum of pregnancy and stimulate
Cortisol that crosses the placenta to the fetus and progesterone and oestrogen production. After
also inactivates Cortisol to the biologically less the decline of the corpus luteum, the function of
active cortisone. Should this mechanism fail, the hCG may be to continue to influence
the fetus will be exposed to excess placental steroidogenesis.
glucocorticoid, and it has been suggested that
this might perhaps explain some of the long- Human placental lactogen: This hormone is
term sequelae of placental insufficiency. It is of synthesised by the syncytiotrophoblast of the
clinical importance to note that the synthetic placenta. It has structural, immunological and
corticosteriods used therapeutically to enhance biological similarities to both Human growth
fetal lung maturation are resistant to placental hormone and Prolactin. HPL is found in the
enzyme inactivation. urine, maternal serum, and amnotic fluid. There
is a correlation betweenHPL and placental size.
Endocrine Low levels correlate with pregnancies
Progesterone: The main source of its production complicated by hypertension and fetal growth
in pregnancy is the placenta. It is produced in the restrictionwhile high levels are associated with
syncytial cells of the trophoblast from maternal and conditions producing large placentae such as
fetal precursors. The level rises progressively in diabetes mellitus, rhesus isoimmunisation,
pregnancy and reaches a peak just before labour. multiple pregnancy, and severe anaemia.
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The Placenta, umbilicalcord, andmembranes 271

The Umbilical cord incidence is quoted as 1.0-1.5 per cent. The

The umbilical cord (funiculus umbilicalis) abnormality has also been found to be
connects the fetus with the placenta and associated with other congenital abnormalities
conveys blood to and from the latter. It is inthe fetus.
formed by the amnion crowding the yolk sac
and ventral stalk together. When fully Umbilicalcord insertion
developed, the cord consists of a thin band of The normal insertion of the umbilical cord into
specialised connective tissue known as the placenta is described as central, or eccentric
Wharton's jelly which is surrounded by a sheath when it is just outside the central point. It
becomes pathplogical when it is marginal, that
formed by the amnion. Included within the cord
is, inserted on the margin of the placenta, or
are two umbilical arteries and one umbilical
velamentous when it is inserted on the
vein.The umbilical arteries are derived from the chorionic membrane outside the placental
internal iliac (hypogastric) arteries of the fetus margin. In a population study in Lagos, central
and carry venous blood from the fetus to the insertion accounted for 26.5% while eccentric,
placenta. The umbilical vein carries oxygenated marginal, and velamentous claimed 62.5%,
blood from the placenta to the fetus. 9.2% and 1.8% respectively. This study did not,
however, support some previously held views
Length of the cord that marginal and velamentous insertions of
The umbilical cord varies in length, with an the cord are associated with disturbance of
average of 50-60cm for infants bom at term. embryogenesis or have deleterious effect on the
Fromthe study carried out inLagos,the average fetus or its placenta. The clinical significance of
cord length for Nigerian infants was 57.48cm. velamentous insertion of the cord is that it may
(range =20-100 cm), thus showing no racial result in vasapraevia with consequent fetal
difference. asphyxia if there is rupture of the veins
traversing the membranes lying below the
Abnormalities of the cord Knots in the cord: presentingpart.
True and false knots may occur in the cord. A
true knot if tight enough may result in fetal The membranes
asphyxia or death. The membranes consist of the chorion and the
amnion.
Loops of the cord: Loops of the cord may wind The chorion constitutes the outermost
roundthe baby's neck.This is fairly common and embryonic covering of the conceptus as soon as the
hardly causes any harm to. the baby. It has amniotic cavity is established. The ectodermal part
however, been reported inthe literature that loops of the chorion is initially represented by the mural
of cord round fetal extremities have resulted in trophoblastic cells of the wall of the blastocyst. It,
strangulation of anarmor legor even fetal death. however, soon becomes lined by extra-embryonic
somatopleuritic mesoderm.
The amnion is of ectodermal origin and it usually
Torsion of the cord: Inextreme cases, this may
arises by folding of the extra-embryonic ectoderm
result infetal death.
roundthe margin of the embryonic area. Apposition
and fusion of these folds result in the isolation of
Single artery: Complete absence of one umbilical
the amniotic cavity itself and in the establishment of
artery has been reported in the literature and the
the amniotic membrane together with the chorion.
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272 Obstetrics and Gynaecology

The amniotic cavity provides a liquid medium external trauma.

in which the delicate embryonic tissues and (ii) serving as a medium for free fetal
appendages could develop symmetrically mobility as development continues.
without being compressed by their weight (iii) acting as a thermal insulator against
against surrounding structures. The amniotic temperature extremes.
cavity later enlarges and invests the umbilical (iv) acting as reservoirs for fetal wastes.
cord and also brings the amnion in contact with (v) providing nutritive elements such as
the fetal surface of the placenta. The connective lipids, carbohydrates, proteins, and
tissue on the outside of the amnion is closely electrolytes which are supplied to the
applied to the connective tissue on the inner fetus through swallowing and intestinal
side of the chorion although they can both be absorption.
easily separated.
Amniocentesis
Amniotic fluid - The amniotic fluid is turbid in
This procedure involves taking of amniotic fluid
colour and may contain solid particles such as
lanugo hair, epithelial cells from fetal skin, sample for analysis. It is relatively harmless
epithelial cells from the amnion, and sebaceous especially when performed under ultrasound
materials.The presence of meconium may give guidance. Indications for amniocentesis include:
it a greenish colour. The volume of amniotic
fluid is about 800- 1000ml at term although (i) determination offetal maturity. The four
there is some variation. Usually there are about constituents usually measured include
50ml present at 12 weeks gestation, 400ml at 20 bilirubin, creatinine, lipid staining cells
weeks and the peak volume of 1000ml at 38 and surfactant. At term, the bilirubin
weeks. This gradually decreases to as little as should have disappeared except in
100-500ml at 43 weeks. When the volume haemolytic disease, the creatinine
exceeds 2000ml, the term "hydramnios" is concentration should be at least
used. The origin of amniotic fluid is from 1.8mg/dl, at least 15% of cells should
several sources. There is evidence for fetal appear orange when stained with Nile
urine as a major source. There may be blue sulphate, and tests for surfactant
contribution from umbilical cordandthere may shouldbe positive.
also be contribution from secretory epithelium (ii) monitoring the severity of haemolytic
of the tracheobronchial tree and salivary disease by determining the deviation of
glands. Chorioangioma of the placenta is the optical density at wavelength of
associated with hydramnios and this may well 450nm usinga spectrophotometer.
be another source of amniotic fluid. However, it (iii) observing the presence of meconium
is now believed that most amniotic fluid
throughout pregnancy is derived from maternal which may indicate postdate pregnancy
perfusion activity of the chorioamnion and that or fetal distress.
the amniotic fluid volume is therefore (iv) determining fetal lung maturity by
proportionate to the increase in maternal measuring the lecithin-sphyngomyelin
plasma volume. The major means of disposal of ratiowhich should not be lessthan 2: 1.In
amniotic fluid is fetal swallowing. Nigerians, this ratio is obtained as early
as 33 weeks gestation.
Functions of amniotic fluid- These include: (v) determining alpha-fetoprotein levels to
(i) providing mechanical cushion against diagnose open neutral tube defects
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The Placenta, umbilicalcard, andmembranes 273

prenatally. This should be done as a Bibliography and suggested further

routine in pregnant women over the age reading
of 35 years who should be regarded as
prone to having babies with congenital Goodlin, R. C. (1984) 'The placenta and fetus' In
malformation. Current Obstetric & Gynaecologic diagnosis &
(vi) determining chromosome abnormalities Treatment, Benson, R.C. ed., 5™ ed., Lange Medical
prenatally. Publication, LosAltos, California.

Chard, T. (2000) The placenta as patient', In Yearbook

of Obstetrics and Gynaecology, Volume 8, O'Brien,
P.M.S ed. RCOG Press, London.

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Chapter 33
Medical in pregnancy
Si

(i) Vomiting sensitivity.

Nausea and vomiting are symptoms of Management is aimed at intravenous fluid
pregnancy. About 80% of pregnant women replacement and correction of electrolyte
would experience these symptoms during imbalance. Promethazine (phenergan) is
pregnancy. They occur as early as the 4th week helpful. Other antiemetics should be used with
of pregnancy and may continue up to the 18th caution.
week. Although these symptoms may be
distressing, they are usually not severe enough (ii) Jaundice in pregnancy
to produce electrolyte disturbances, weight loss
or ketones inthe urine. Jaundice is not a frequent occurrence in pregnancy.
The cause of vomiting in pregnancy is not It usually occurs in about one in 2000 pregnancies.
known. The high level of circulating steroid In the tropics, poor nutritional state may make the
hormones and human chorionic prognosis worse.
gonadotrophins in pregnancy may be partly The causes ofjaundice include:
responsible. In multiple pregnancy, and/or (i) Haemolysis from sickle cell disease, malaria. ]
hydatidiform mole, where high production of glucose-6-phosphate dehydrogenase deficiency.
human chorionic gonadotrophin occurs, septicaemia and incompatible bloodtransfusion.
pregnancy symptoms including vomiting are (ii) Liver damage by viruses especially infective]
excessive. Relaxation of smooth muscle of the hepatitis virus.
stomach may also play a part. (iii) Acute fatty liver of pregnancy, intrahepatic |
Management is mainly supportive.
Psychological support and the use of
cholestasis of pregnancy and gall bladder disease in J
pregnancy. - e

Chapter 34
Normal labour

DEFINITION AND CHARACTERISTICS features may fail to sustain the labour progress at
the rate required for active phase. In some of
For so long, labour has been difficult to these situations, oxytocin infusion treatment
appropriately define in a form that embraces all may be instituted to improve the uterine
that isknownabout labour. However, sufficient contractions and progress of labour. When a
facts are now knownabout labour, to allow for a woman at term who is already established in
focused definition. For practical proposes, active phase requires oxytocin infusion
labour is defined as the act of expulsion of the treatment to improve uterine contractions and
fetus and placenta to the outside world per labour progress, this is called oxytocin
vaginam with minimal risk to the mother and augmentation. When the response to this
fetus. It is characterised by the onset of painful, augmentation is good and the labour ends in
palpable and regular uterine contractions of vaginal delivery, it is still normal in spite of the
progressively increasing frequency and augmentation.
intensity and associated with progressively
increasing cervical effacement and cervical os
STAGES OF LABOUR
dilatation and descent of the presenting part
Labour is an act and therefore one continuous
leading to the delivery of the fetus and placenta
process, however, for the purpose of
per vaginam with minimal disturbance to both
discussion, analysis and research, it is divisible
mother and baby. Conventionally, the normal into three stages; each with its own
minimal uterine contraction frequency is one in
characteristics and duration. The stages are
every 10 minute intervals throughout labour.
first, secondandthird stages of labour.
Labour is strictly normal when the uterine
contractions spontaneously begin at term and FIRST STAGE OF LABOUR This is the stage
the fetus and placenta are expelled per vaginam which represents the dilatation of the cervical
within the 12 hour maximum duration
os from concept zero cm to the full cervical os
irrespective of whether or not some dilatation of 10cm in a parturient at term. This
interventions (like oxytocin augmentation) stage is composed of two phases, namely latent
were required to assist or facilitate the process.
phase and active phase.
When the fetus and placenta are being
expelled per vaginam before term (28 weeks to Latent phase labour
36 completed weeks) the process follows the This is a prodromal phase of labour and the
same pattern as for term and is often associated
earliest aspect of the first stage of labour in
with the same characteristics with minor which the cervix at term is progressively
variations. When labour at term begins effaced andthe cervical os dilated from zero cm
with spontaneous uterine contractions, this to 3 cm in the primigravida or 4cm in the
may progress with the characteristic increasing multigravida. Itmay occur inany woman of any
frequency and intensity till delivery of the age, parity or race who has attained term status.
fetus and placenta per vaginam. However, in The diagnostic features of latent phase depend
some women, the spontaneously
on whether the woman is a primigravida or
initiated uterine contractions with active phase multigravida.
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284 Obstetrics and Gynaecology

— Woman at term with labour pains period the woman now develops features of
— Uterine contraction frequency of at least active phase of labour.
once every 10 minute intervals irrespective
of strength or duration of the contractions. Prolonged latentphase
This is a latent phase in any woman that lasts a
** Sterile vaginal examination confirms duration of over 8 hours up to a maximum of 24
the following findings:
(a) Primigravida (i) cervical effacement less hours without the woman developing features
of active phase of labour.
Than 100%
(ii) cervical os dilatation False labour
less than 3 cm This concept has been the subject of some
(b) Multigravida (i) cervical effacement less controversy and confusion. Usually, when a
than 50% woman presents at term with labour pains,
(ii) cervical os dilatation clinical examination will confirm a diagnosis of
less than 4cm either active or latent phase labour. When the
** The cervical effacement and dilatation of os diagnosis is latent phase, it is expected that over
stated for each parity must be concomitant. time, she may become established in active
phase. When active phase features develop
Table 34.1 Features of latent phase labour within 8 hours, it is normal latent phase, but if
this active phase conversion occurs after 8
Primigravida hours but within 24 hours, it is prolonged latent
In the primigravida, latent phase is the phase. However, if after 24 hours the woman
diagnosis when clinical findings in a woman has not developed the features of active phase
with labour pains confirm uterine contractions labour but still maintains the features of latent
of at least a minimum frequency of one inevery phase, thenthe correct diagnosis is false labour.
10 minute intervals and sterile vaginal Thus, false labour is diagnosis inretrospect of a
examination reveals a cervix that is less than parturient at term admitted with a diagnosis of
100% effaced and cervical os that is less than latent phase that has not transformed into active
3cm dilated. phase labour after 24 hours. False labour can
occur inany woman of any age, parity or race at
Multigravida term but is slightly more prevalent in women
Inthe multigravida,latent phase is the diagnosis between 37 weeks and 40 weeks. There are two
when clinical findings in a woman with labour subdivisions of false labour viz. contractile
pains confirm uterine contractions of at least a false labour andnon-contractile false labour.
minimum frequency of one in every 10 minute
intervals and sterile vaginal examination Contractilefalse labour
reveals a cervix that is less than 50% effaced These are cases where latent phase features
andcervical os that is lessthan 4 cm dilated. have not transformed into active phase after 24
hours and uterine contractions of at least one
Normallatentphase every 10 minute intervals are still present. This
This is a latent phase in any woman at term that usually indicates that the woman may soon
lasts a maximumduration of 8 hours within which establish inactive phase labour.
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Norma!labour 285

Non-contractilefalse labour 10 minute intervals, at least 50% cervical

These are cases where the latent phase features effacement and cervical os which is at least 4cm
have not transformed into active phase after 24 dilated irrespective of the fetal presentation,
hours and uterine contractions are no longer descent or station of the presentingpart.
recordable, or the frequency is now much less Active phase labour is the more important
than one inevery 10 minute intervals. part of first stage labour and is dominated by
A woman diagnosed as having false labour strong uterine contractions throughout. These
may subsequently transform into active phase effect the dilatation of the cervical os (from 3 or
after a few hours, days or even weeks. This 4cm to full dilatation at 10cm) and propel the
woman may present in labour ward fetus from the uterine cavity by gradual descent
subsequently with overt features of active and finally ending in the expulsion of the fetus
phase or may present again with latent phase and placenta per vaginam. Thus, what the
(with normal or prolonged duration) before normal active phase becomes is determined by
transforming into active phase. Some the appropriateness of the uterine contractions
parturients have been known to present with which will drive the cervical os to dilate at the
false labour on two or more instances before appropriate normal rate and the presenting part
final active labour and delivery. to descend gradually until delivery with
minimalrisk to the mother and baby. Because of
Active phase labour the intense uterine activity generated in the
This is the second aspect of first stage labour active phase to sustain the uterine contractions,
that entails dilatation of the cervical os of the the fetus is subjected to periodic hypoxic stress
already effaced cervix from 3 cm in the during the contractions. The stress of the
primigravida or 4cm in the multigravida to the contractions on the mother shows in the
full cervix os dilation of 1Ocm. It is the phase of alteration of her vital signs. There is a limit to
the first stage often reffered to as the genuine or the duration of hypoxic distress engendered by
established labour. The diagnostic feature the uterine activity of the active phase that the
depends on whether the woman is a mother and fetus can normally withstand in
primigravida or multigravida. labour before deterioration occurs. That limit is
12 hours. Thus conventionally, a period of 12
Primigravida hours is the maximum duration of active phase
Active phase of labour is the diagnosis in the first stage labour beyondwhich the activ • phase
primigravida who presents at term with uterine is described as prolonged and this portends
contractions of a minimum frequency of one in unfavourable consequences for both mother
every 10 minute intervals, a 100% effacement and fetus. Any active phase duration of over 12
of the cervix and cervical os that is at least 3cm hours is prolonged labour and the causes should
dilated irrespective of the fetal presentation, be determined and appropriately treated so as to
descent cr station of the presenting part. forestall further fetomaternal complications.

Multigravida SECOND STAGE OF LABOUR

Active phase of labour is the diagnosis in the This is the stage of labour from full cervical os
multigravida who presents at term with uterine dilatation of 1Ocm till the baby is delivered. It is
contractions of a minimum frequency of one inevery now knownto be composed of two phases:
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286 Obstetrics and Gynaecology

Phase 1 placenta and significant blood loss exceeding

This begins from the full cervical os dilatation 500 m/.
until the leading part of the fetus is on the pelvic
floor which is often marked by the irresistible MECHANISM OF LABOUR This refers to
urge of the mother to push. When normal, this the various changes in position and attitude of
phase is marked by strong contractions, maternal the fetus during its passage through the birth
urge to push and descent of the presenting part. canal.
When it is abnormal, it is marked by poor The birth canal has various shapes and
contractions and maternal exhaustion
sizes at the brim (ovoid shape with a wider
transverse diameter of 13.5 cm than antero¬
manifesting as lack of the urge to push and no
posterior diameter of 11 cm), midcavity
descent of the presenting part with no clinical
(equally round with diameters of 12 cm in both
evidence of fetopelvic disproportion. The
transverse and antero-posterior) and outlet
duration of this phase is one hour in all women but
(ovoid shape with wider antero-posterior
may be prolongedby a recent epidural top-up.
diameter of 13.5 cm and transverse diameter of
11 cm).
Phase 2 During the passage of the fetus through the birth
This begins from the time the presenting part canal, the fetal head which also has different
touches the pelvic floor untilthe delivery of the longitudinal diameters depending on the
baby and is usually assisted by the voluntary position and attitude must constantly change its
expulsive effort of the mother because of the relationship to the pelvis to ensure that optional
persistent urge to push. The duration is one hour diameters of the skull are presented at each
in ail women. This phase is marked by strong stage of the descent. This series of changes in
contractions and assistance is only given with position and attitude of the fetus as it passes
the episiotomy to remove the resistance of a through the birth canal is what is known as the
rigid perineum. mechanism of labour and consists of the
following process in a vertex presentation in a
THIRD STAGE OF LABOUR gynaecoid pelvis.
This is the stage of delivery of the placenta which
occurs after the delivery of the baby. The drastic
Descent: This occurs throughout labour as a
decrease inthe volume of the uterine cavity after the
prerequisite for the b; Uiof the baby. Inthe first
stage and phase 1 of the second stage of labour,
expulsion of the fetus has the effect of shearing off
descent is dependent on the force of uterine
the placenta from the decidual attachment. This
contractions. This means that descent will be
separation is sustained by the contraction and
good and appropriate when contractions are
retraction of the uterine muscles reinforced by the
strong and adequate throughout first and second
voluntary contraction of the anterior abdominal wall
stages of labour. In phase II of second stage
by the mother during the act of bearing down. The labour, descent is facilitated by the voluntary
normal duration of the third stage is 10 minutes. The use of abdominal wall muscles. The head
hallmark of a normal third stage is strong uterine usually descends with the sagittal sutures inthe
contractions, easy separation and expulsion of the transverse direction which is wider than the
placenta with a normal blood loss of less than 500 antero-posterior diameter at the brim.
ml. An abnormal third stage will be marked by poor
uterine contractions, poor or no placental separation Flexion: The fetal head may not be completely
and expulsionwith consequent failure to deliver the flexed when it descends intothe pelvis but when
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Normallabour 287

the head enters the narrower midcavity,the rigid rotated by the pelvic gutters into the anterior
pelvic floor muscles force the chin into contact position, the shoulders enter the brim in the
with the fetal thorax during contractions to transverse direction. Thus when the head is
create a consequential flexion of the head. This delivered at the vulva with the occiput anterior,
flexion produces a smaller diameter of the shoulders now enter the mid-cavity in the
presentation changing to the suboccipito- oblique plane changing from the previous
bregmatic diameter of 9.5cm from the occipito¬ transverse to the antero-posterior plane, the much
frontal diameter of 10 cm. When contractions wider diameter of the outlet.The head therefore as
are weak or poor, this flexion which produces a soon as it is delivered realigns itself back to the
smaller diameter of presentation may not occur direction of the shoulder by rotationto the oblique
fully and the subsequent processes in the plane of the shoulders through one-eighth of a
mechanism of labour may not occur normally. circle. This is what is called restitution.

Internal rotation: As the head is flexed in its External rotation: When the shoulders now
descent into the pelvic gutters with the chin reach the pelvic floor gutters, they are rotated
being brought into contact with the thorax so into the roomy antero-posterior diameter
also it has to rotate from the lateral plane in completely from the oblique plane as a way to
which it entered the pelvis into the antero¬ facilitate their delivery. In consequence, the
posterior direction because the pelvic outlet head which now has been delivered readjusts
which the head now approaches has a much itself again by rotating further into the
wider antero-posterior than the transverse transverse plane and moving through a further
diameter. This is how and why the fetal head, one-eighth of a circle so that the face now looks
while being flexed also rotates from the lateral at the maternal thigh. This is what is known as
to the anteroposterior direction. Ina well flexed external rotation.
head, the leading occiput is forced into the
anterior direction. However, in an occipito- Delivery of the shoulders: When restitution
posterior position this internalrotation may still and external rotation occur, the shoulders now
occur* and convert it into an occipito-anterior at the outlet are inthe antero-posterior direction
position when contractions are strong and with the anterior shoulder being under the pubic
sustained during the descent. Extension: symphysis. The anterior shoulder is delivered
Following the internal rotation and with further first followed by the posterior shoulder.
descent, the sharply flexed head descends into
the vulva and the base of the occiput comes into
Delivery of the fetal body: After the delivery
contact with the inferior rami of the pubis and
of the shoulders, the fetal body, aided by lateral
the bregma is near the lower border of the
movement, is thendelivered easily.
sacrum. With further push and descent, the only
direction is for the head to extend because the
pubic rami act as a pivot and the head begins to MANAGEMENT OF LABOUR
crown and delivery* of the head occurs with the Pregnant women often present with the claim
occiput often directly anterior i.e the position it that they are in labour.The management consists
was forced by the earlier internalrotation. of an assessment to verily this claim. More
specifically, management depends on the stage
Restitutions:While the head enters the pelvic outlet of labour which may be first, second or third.

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288 Obstetrics and Gynaecology

First stage labour present. For some problems like transverse or

This stage is the time from the diagnosis of oblique lie, triplet pregnancy, two or more
onset of labour to full dilatation of the cervical previous caesarean sections, successful
os. It is the most important stage of labour vesicovaginal fistula repair and rickety or
because a normal first stage labour is the generally contracted pelvis, the management is
determinant of a normal outcome of second and arrangement for caesarean section delivery.
third stages respectively. The dilatation of the (ii) Latent phase with no obstetric problems
cervical os occurs in two phases, the latent and The principle of management is to observe the
active phases. woman closely till features of active phase
labour occur and the details are shown in Table
Latent phase management 34.2. This management strategy is based on the
firm belief that the latent phase is a mere
(A) Diagnosis innocuous prodromal aspect of labour,
The woman on presentation in the labour ward clinically representing the earliest aspect offirst
is admitted and a basic history taken. Antenatal stage labour which does not require any
card is checked for specific instructions and intervention in the absence of any other
detailed clinical assessment including vaginal concomitant obstetric problem. When
examination is performed. Ifthe findings are as complications like fetal distress, hypertension
shown in Table 34.1 then the diagnosis is first or rupture of fetal membranes develop during
stage latent phase labour which is the earlier the passive observations, then intervention will
aspect of first stage. The Bishop score is be justified. As shown in Table 34.2, false
assessed at the vaginal examination and labour is the diagnosis when latent phase
recorded. Although the beginning of the onset features have not converted to active phase
of labour is impossible to pinpoint, clinically parameters after 24 hours. This is the clinical
nowadays, the diagnosis of latent phase labour reality and the strategy of management is to
is easily confirmed and the management of that observe till active phase sets in. False labour is ;
phase may then beginthereafter. again, an innocuous prodromal aspect of the
earlier part of first stage labour, clinically
(B) Management
representing the end spectrum of latent phase
(i) Latest phasewith other obstetric problems
after 24 hours. The standard treatment of false
In this situation, the management of the specific
labour is to follow up the woman till she presents
obstetric problems takes priority. Common
again in labour provided there are no other
problems may be pre-eclampsia, eclampsia,
problems. The only exception is with the woman
prolonged pregnancy and medical problems like
who has had one or two prior episodes of false
anaemia, diabetes mellitus, renal disease, etc. For
labour especially if it is the contractile false labour
most of these cases, latent phase diagnosis at term
type which shouldbetreated by inductionof labour.
may be commonly managed by induction of labour
if other favourable conditions for the induction are

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Normallabour 289

(a) When other obstetric problems are present, Monitor fetomaternal signs regu larly to
follow the specific treatment of the obstetric exclude fetomaternal distress.
problem. Provide partnership and emotional
(b) No other obstetric problems. support.
Repeat vaginal examination at 4-8 hourly
(i) First eight hours:
intervals or when the woman isdistressed
Note Bishop score at the first vaginal
with pains or complications set in.
examination and at other repeat vaginal
Watch for spontaneous rupture of
examinations.
membranes; ifthis occurs at any time
Educate the woman about the diagnosis and
during these observations, the
the intention to watch till active phase occurs.
management must change from present
Sedate with potent analgesic and anti-emetic
observations,
sedative. (iii) Latent phase labour after 24 hours from first
Monitor and record fetomaternal vital signs vaginal examination (false labour)
/> hourly or hourly or 2 hourly as deemed When after 24 hours from the first vaginal
appropriate. examination a repeat vaginal examinations
Provide companionship, partnership and still confirms persistent latent phase features,
support. the diagnosis now isrevised as f al se
Allow fluids, light food and ambulation. labour irrespective of whether or not
Repeat vaginal examination to assess cervical contractions are still present.
effacement, Bishop score and os dilatation if The Bishop score isnoted.
woman is distressed with pains at any time or In the absence of any complications, the
the contractions become more frequent. woman is transferred to the lying-in-ward.
Transfer for active phase management ifactive After at least one day observation at the
phase features are found at any vaginal lying-in-ward without any more
Examination. contractions the woman may be
discharged for antenatalclinic follow-up.
(ii) Over eight hours to next 24 hours fromfirst
Table 34.2 Management of latent phase at term
vaginal examination:
(prolonged latent phase) Active phase management: For the woman in
At eight hours from first vaginal active phase labour, the history on presentation in
examination, mandatory repeat vaginal the labour ward and the vaginal examination
examination for Bishop score, cervical findings will confirm the presence of active phase
effacement and os dilatation even if the
labour diagnostic features as shown inTable 34.3.
contractions have stopped or reducfed to
Further management of the active phase: Active
exclude vaginal features of active phase.
When there are still no active phase features phase labour is the more important aspect of first
at this vaginal examination, the diagnosis stage labour representing the cervical os dilatation
Is now prolonged latent phase. from 3cm (in the primigravida) or 4cm (in the
Keep inthe labourward area. multigravida) to 10cm which is full cervical os
Allow ambulation, fluid or semi fluid diet. dilatation. Clinically, it is characterised by regular
Relieve pains as deemed appropriate. painful, palpable uterine contractions of
progressively increasingfrequency and intensity, that
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290 Obstetrics andGynaecology

are associated with progressive descent of the Continuity of care and emotional support
presenting part, effacement and dilatation of the The woman in labour should be informed about
cervical os till full dilatation which will lead to her labour and the expectation. All findings are
delivery of the fetus and placenta vaginally. Thus, usually explained in detail to her. Support is
a normal first stage will lead to normal second and arranged through companionship with ideally a
third stages of labour. Typically, in a normal midwife or student who stays with the woman
situation, the cervical os dilates steadily at the throughout the rest of the labour. The husband
minimum rate of 1 cm per hour especially when or a relation may be allowed as her companion
fetal membranes have ruptured. Uterine with due advantage.
contractions in frequency and intensity are only
considered as normal and adequate when they are Observation of the progress of labour
associated with cervical os dilatation rate of at Observation of the progress of first stage active
least 1cm per hour in any parturient. phase labour consists of regular assessment and
The essential principles of management of recording of fetomaternal vital signs, uterine
active phase labour are as follows:
contractions, descent of the presenting part, and
" Continuity of care and emotional support.
- Observation of the progress of labour with
timely intervention iflabourbecomes abnormal.
cervical os dilatation. Nowadays, these
observations are bestrecorded on the composite
partograph first produced by Philpott and Castle
e
Monitoring of fetal wellbeing.
in 1972 but subsequently modified by WHO
Adequate and appropriate pain relief. and recommended for worldwide use for the
ÿ
Adequate hydration to prevent ketosis.
supervision of labour. The partograph as
Woman at term with labour pains. recommended by WHO contains the Alert and
Uterine contraction frequency of at least once Action lines. These visually assist the staff who
every 10 minutes irrespective of strength or supervise labour to easily recognize normal
duration of contractions. labour progress which partographically is
- Sterile vaginal examination confirms the cervical os dilatation rate of at least 1 cm per
following concomitant findings: hour throughout active phase labour. The Alert
(a) Primigravida and Action lines concept is what makes the
(i) cervical effacement complete 100% composite partograph an effective clinical tool
(ii) cervical os dilatation of at least 3cm for labour management and any setting where
(b) Multigravida the partograph is in use without the Alert and
(i) cervical effacement of at least 50% Action lines being visually constructed, loses
(ii) cervical os dilatation of at least 4cm this obvious advantage of the partograph. See
* * The cervical effacement and dilatation of the os other details of the partograph later.
stated for each parity must be concomitant. Ifany of
the effacement or os dilatation is less than stated
above the diagnosis will still be latent phase.

Table 343 First stage active phase labour features

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Normal labour 291

Once active phase has been confirmed, compromise these changes are easily tolerated
(1) Inform the woman that she is inthe active without the fetus showing any sign of distress.
phase and assure her of companionship However, when the fetal status has being
partially compromised, these changes induce a
and support.
state of distress in the fetus. In all fetuses,
(2) Record on the composite partograph all including the normal uncompromised fetus,
findings in the woman (BP, pulse, temperature, these changes will induce distress when the
urinalysis); fetus (FHR, state of membranes, active phase duration is beyond 12 hours. It is
caput, moulding); about labour (contractions, with the aim to easily pick out changes in the
cervical os dilatation, head descent); and fetal status that the fetal wellbeing is usually
therapeutics (i.v. fluids, oxytocin, pain relief). monitored in labour. The evidences of distress
inthe fetus are:
(3) The woman may be encouraged especially (i) Meconium in the liquor which may be thin
in early active phase to walk around the when it is old or importantly thick when fresh
labour ward. especially when this is observed for the first
(4) Repeat observations at definite intervals on time after active phase began.
the partograph viz.% hourly for FH,pulse, (ii) Excessive fetal movement. This is
subjective when it is manually elicited but
contractions; Vi hourly for BP; 4 hourly for
objectively, it can be confirmed by the
temperature and urinalysis; 2-4 hourly for
electronic monitor, (iii) Fetal heart rate
vaginal examination to assess cervical os anomalies. Normal fetal heart rate in labour
progress. ranges from 120 to 160 beats per minute with a
(5) Encourage the woman to void urine at 1-2 mean of 140 beats per minute. An objective
hourly intervals using a bedpan. evidence of fetal distress is a significant
variation from the normal range. In the
(6) Subsequent care is done nowadays using the diagnosis of fetal distress the changes in the
strategy of active management of labour till fetal heart rate are often interpreted together
full cervical dilatationand delivery. against the background of the prior clinical state
of the fetus and/or duration of labour.
(7) Parturients are not allowed any feeds orally
Fetal heart rate recording is usually done with
and for durations beyond 6 hours, fluids and the following methods:
calorie requirements are givenby I.V.fluids.
Table 34.4 Management of active phase labour Pinard stethoscope: This is the commonest
method routinely used for recording fetal heart
Monitoringoffetal weUbeing rate and for detecting variations both in
The contractions of the active phase build up pregnancy and in labour. Usually the fetal heart
gradually in intensity and at the peak induce pain tone is listened to between contractions but when
and distress in the mother. To the fetus these there are worries about the fetal status, heart tones
contractions at the peak substantially reduce detection may be made during contractions.
placenta! blood flow to the point of causinghypoxia However, the Pinard stethoscope requires firm
in the fetus. Additionally, these contractions may pressure while listening with it during a
cause head and umbilical cord compression both of contraction and it is usually painful for the women.
which in combination, may cause hypoxaemia in
the fetus. In the normal fetus, without any prior Doppler: This instrumentdetects fetal heart tones
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292 Obstetrics and Gynaecology

electronically and is more conveniently used heart rate tracing which indicates fetal distress
during contraction without discomfort to the as a very early sign at a point when there may
woman. It is often a back up instrument to the not be either fetal acidaemia or fetal hypoxia. If
Pinard stethoscope in special circumstances such signals were routinely followed up with
like when fetal heart tones cannot be easily emergency caesarean section there would be
detected with the Pinard stethoscope or when high caesarean section rate since at birththese
there is the need to listen for heart tones during babies would not show any evidence of prior
contractions inorder to adequately elucidate the distress. Thus, for current practice, abnormal
nature of fetal heart rate anomalies.
fetal heart rate tracing is only an indication for
obtaining fetal scalp blood for pH
measurements as the basis for clinical decision
Electronic fetal monitoring. There are now
to effect delivery or allow the labour to
machines for electronic monitoring of fetal
continue.
heart tones in obstetrics. These electronic
In contemporary obstetric practice, there
devices allow continuous recording of both are three groups offetal heart rate anomalies.
fetal heart tones and uterine contractions
synchronously and they appear as tracings on Alteration in heart rate: In normal labour with
graph paper as permanent records. There are a normal fetus, the fetal heart rate is usually 120-
two types of electronic fetal monitoring 160 beats per minute. If the heart rate is beyond
devices: 160 this will be fetal tachycardia while a rate
(i) External monitor: The machine is used to below 120 per minute is bradycardia.
monitor fetal heart tones in pregnancy and in
labour without rupture of fetal membranes. It Baseline variability: Normal fetal heart rate
includes two ultrasound transducers which are shows a natural variability of 5-10 beats per
strapped to the abdomen with special belt for minute from the usual baseline in response to
the synchronous recording of the heart tones various physiological situations. When this
and uterine contractions. It is often commonly variability is less than 5 beats per minute the
used in pregnancy to assess the fetal status viz. tracing appears flattened. This may usually
the responsiveness of the fetal heart rate tracing happen in fetal hypoxia, hence fetal heart rate
to fetal movement and contractions. Its other tracing with decreased variability or flattening
use is in early labour to record synchronous is an indication for fetal scalp blood sampling
fetal heart rate and contractions. The main forpH to exclude acidaemia.
problem is that tracing may not beclear because
of poor contact or displacement from the initial Periodic heart ratevariation with contractions:
point of clear signals, (ii) Continuous internal Normal fetal heart tracing shows acceleration
monitoring: These machines are specially used from the baseline rate in response to
in labour only when fetal membranes have contractions with rapid return to the baseline
ruptured. The process involves the use of an rate at the end of contraction.
intrauterinecatheter to monitorthe contractions In circumstances when the fetus has hypoxia
and fetal scalp clip or spiral electrodes for the this characteristic acceleration of the heart rate
fetal heart rate tracing. It gives very precise will returnto the baseline during contractionthen
recordings of the fetal heart rates and vary into some pathologicalways:
contractions. (A) Early heart rate decelerations (type 1 dip). In
Oftenthis maternal monitoring device gives fetal

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Normallabour 293

this circumstance, the heart rate responds to is commonly the drug of choice if there is the
contractions with a decrease belowthe baseline pressing need for pain relief when delivery is
(up to 10 beats per minute) but with return to envisaged in two hours. Epidural analgesia is a
baseline at the end of the contraction. This may more effective form of painreliefandavoidsthe
commonly occur with mild fetal hypoxia or above-listed side effects on both mother andthe
umbilicalcord compression. baby. When epidural is administered in the
(b) Late heart rate deceleration (type IIdip). In active phase, it may not be directly causal to
this instance, the heart rate during contractions inducing any labour course anomalies but may
shows a decrease below baseline but this necessitate more assistance for delivery in the
decrease persists long after the end of the second stage of labour.
contractions which is an ominous sign of fetal
acideamia for which fetal scalp blood should be Adequate hydration to prevent ketosis
assessed for pH value to exclude fetal
hypoxaemia. Active phase labour management emphasises
(c) Variable deceleration: This is a fetal heart the close observation of progress to detect any
rate tracing which displays sporadic decrease deviation for early corrections. When active
below baseline tracing in the absence of any phase duration is within 6 hours, the fluid and
contraction or even fetal movement but the calorie requirements are usually not affected.
decrease rapidly returns to normal after 20 However, when active phase duration is over 6
seconds. It is not usually of any clinical hours, the strong contractions may induce
significance except it graduates especially to distress and shift inthe fluid andcalorie balance
type IIdip. more so as parturients are not allowed any oral
With these instruments, the fetal heart rate is feeding because of the potential for operative
easily assessed during the course of active intervention if anomalies develop. Thus,
phase labour and any departure from the normal women in active phase are usually managed
should be investigated further. with intravenous fluids especially when
duration is over 6 hours. The common fluid is
Adequate pain relief 5% dextrose in water with a flow rate to allow
Active phase contractions are painful and 500ml every 4 hours or 125ml per hour or 30
distressful especially in the late active phase as drops per minute flow rate when using the
whenthe cervical os is 6 cm and more. Commonly standard BP infusion set. Such intravenous
there is the need for pain relief and usually this is fluid regimen in labour will maintain adequate
with narcotics like pethidine lOOmg fluid and calorie balance to prevent ketosis.
intramuscularly. At times, there may be the need Excess infusion of 5% dextrose in water may
to repeat this twice or more in parturients staying cause infusion hyperglycaemia in the fetus
long in the active phase. Narcotics cause nausea resulting in reflex hyperinsulinism,
and vomiting in the women and respiratory hyponatremia and neonatal hypoglycaemia.
depression in the newborn if they are The ideal fluid for use in labour is Hartmann's
administered within two hours before delivery. solution or Ringer's lactate solution ifavailable.
The side effects of nausea and vomiting are reduced
when the narcotic is combined with antiemetics like Second stage labour
promethazine and depressant effect on the baby is Second stage is the aspect of labour from full
reduced when pethidine is combined with cervical os dilatation to the complete delivery of the
baby which occurs in two phases, namely, phase
nalorphine as in pethilorfan. This iswhy pethilorfan
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294 Obstetrics and Gynaecology

Iand phase II.Phase Iis from full dilatation till cervical os to the upper part of the vagina.
the presenting part touches the pelvic floor Separation of the placenta is an important
often manifested with the maternal urge to aspect of the third stage. The signs of placenta!
push. Phase separation are:
II is from the time the presenting part touches - lengthening oftheumbilical cord.
the pelvic floor till full delivery of the baby. - small gush of blood from the placental bed.
Phase II is often assisted by the voluntary
pushing effort of the woman and may be
- rise ofthe uterine fundus above the umbilicus.
shortened by an episiotomy where indicated.
- uterus assuming a more globular shape and
becominghardened.
Both phases last a duration of one hour each in
Management of the third stage involves assisting
all women and are facilitated by strong uterine
contractions from the first stage. with the delivery of the placenta rather than wait
Often attainment of second stage is for spontaneous expulsion with maternal efforts.
suspected when the woman expresses the The third stage is managed intwo mainways:
irresistible urge to pushwhich leads to a vaginal
examination that confirms full cervical os Passive or expectant management
dilatation. This is the end of Phase Iwhich This is the hands-off policy where signs of
usually is assumed to be the beginning of placenta! separation are awaited and placenta
second stage. In normal cases, the phase II of and membranes allowed to deliver
the second stage follows rather imperceptibly spontaneously with the aid alone of gravity or
when delivery of the baby follows the voluntary with nipple stimulation. By this method, once
pushing effort of the woman. The efficient the baby is delivered, it is allowed to lie
conduct of the Phase II in which the pushing betweenthe mother's legs and usually takes the
effort of the woman is well co-coordinated, first breath within seconds. The clamping and
combined with good guarding of the perineum
cutting of the cord may be delayed until after
may lead to the avoidance of episiotomy except
cessation of the cord pulsation which may also
in situations when the perineum threatens to
tear inspite of this good conduct
allow about 80ml of blood to be transferred
from the placenta to the baby. The signs of
Third stage labour placental separation are now awaited and after
separation, placenta delivery is allowed to
The third stage begins from the delivery of the baby occur spontaneously. While awaiting the signs
to the expulsion of the placenta andmembranes and of separation of the placenta, the nipple may be
occurs 1-lOminutes after the birth of the baby. The stimulated to aid separation and delivery of
placenta is said to be retained if it is not expelled 30 placenta. This method is easily complicated by
minutes after the baby is bom. Separation of the primary postpartumhaemorrhage (PPH).
placenta occurs from the sudden diminution of
uterine volume following the delivery of the baby.
Active management
This leads to shearing off of the placenta from the
uterine attachment along the decidua basalis layer. This is a package of interventions inthe third stage
Subsequent contraction and retraction pushes the comprising:
separated placenta to the lower segment of the (i) Administration of an oxytocic during or
uterine cavity and with further contractions and immediately after the delivery of the baby by any
retractions, it may be pushed through the dilated route.

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Prince Of Medicine-2014-BSUTH

Normallabour 295

(ii) Early or immediate clamping and cutting of have significant side effects like fever and
the cord without awaiting cessation of cord shivering episodes. It is also not as effective as
pulsation, (iii) Delivery of the placenta by other oxytocics inpreventingprimary PPH.
controlledcordtraction (CCT) without waiting
for the signs of separation of the placenta. THEPARTOGRAPH

The oxytocics commonly used are The partograph of today is a simple clinicaltool
intramuscular ergometrine 0.5mg (peak action which is a graphic record of all the events in
time 2 minutes), syntometrine (which is a labour. It encompasses the vital signs of the
mixture of 0.5mg ergometrine and 5 units of mother and fetus andthe variation of these vital
oxytocin) and peak action time is 3 minutes or signs to uterine contractions and therapeutics
oxytocin 10 units (peak action time 5 minutes). taken in labour over a given time scale. The
The time of administration is with the delivery WHO partograph shown in Fig 34.1 is the
of the anterior shoulder of the baby and the version recommended for worldwide use in all
choice of drug depends on the parity of the settings of health care. It allows for
woman. Primigravida and low parity women documentation of all data about the latent and
are treated with i.m. syntometrine or oxytocin active phases of labour. The Alert and Action
while the more parous women are treated with lines are brought into the active phase aspect
i.m. ergometrine except when this is with 4 hours spacing apart.
contraindicated by the presence of hypertensive Operationally, all findings in labour are
disease when i.m. oxytocin is used. In recorded on the graph including the contraction
grandmultipara and women with primary PPH details, descent of the head and cervical os
inprevious deliveries or those with high risk for dilatation. Abdominal and vaginal
PPH as in induced and augmented labour, the examinations are performed at four hourly
ergometrine or oxytocin (inhypertensive cases) intervals. In the normal labour, the graph of
is administered by the i.v. route with the cervical os dilatation which is a rate of at least
delivery of the anterior shoulder. When lcm per hour will be along the Alert line or to
administered by the i.v. route, the action time of the left of it. When cervical os dilatation rate is
these oxytocics is 45-47 seconds and hence in
slower than lcm per hour, the graph will cross
these circumstances, there should be a haste to
deliver the placenta as soon as the cord is the Alert line and eventually reach the Action
clamped and cut. line later if the cervical os dilatation rate is a
Recently, misoprostol tablets (cytotec) have quarter (0.25cm per hour) of thenormal state.
been used as the oxytocic and administered as When the partograph is being used in a
400 or 600 micrograms (2-3 tablets) at the peripheral (primaiy health centre) unit, normal
delivery of the anterior shoulder or after progress is a cervical os dilatation graph which
delivery of the baby and clamping of the cord. remains on the left of the Alert line till delivery with
Misoprostol is rapidly absorbed after oral fetomatemal vital signs remaining normal. For
administration and peak uterotonic action time women who are admitted in the latent phase in such
is 3-5 minutes hence it is effective in the active units, normal progress is a transformation to the
management of the third stage. It is reported as active phase within eight hours. In other situations
being as effective as oxytocin or syntometrine such as cervical os dilatation graph that crosses the
administered intramuscularly at the delivery of Alert line or a latent phase that is not transformed
the anterior shoulder. Misoprostol tablets into active phase within eight hours (prolonged

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:wJ?
296 Obstetrics and Gynaecology

latent phase) the woman must be transferred to worldwide in the same format which makes for
amore equipped hospital (secondary or tertiary easy analysis and comparison of results.
level care) for assessment of the cause of the (2) Allows early and easy recognition of abnormal
poor progress. labour progress for timely interventionworldwide,
For the woman in a hospital, (secondary or which action encourages safe motherhood.
tertiary level care) whose cervical os dilatation (3) Encourages referral of problem cases from
graph crosses the Alert line, an i.v. line is set up, the small to the big hospitals and within a
fetal membranes are ruptured and vital signs hospital, easy referrals from the junior to the
watched carefully and a review done every 2-4 more senior personnel indifficult cases.
hours intervals.A graph of progress crossing the (4) The graphic nature makes for easy
Alert line implies that the cervical os dilatation recognition of other problems like abnormal BP
rate is less than 1 cm per hour and if not and fetal heart rates, etc.
corrected may lead to active phase duration of (5) A good tool for teaching and handing over of
over 12 hours (prolonged labour). When the women in labour between shifts without resort
cervical os graph eventually crosses the Action to voluminous paper writing.
line, the case is reviewed; i.v. fluid is set up (if (6) It isthe incontrovertible evidence of how well
not done already) to correct any fluid a woman in labour was managed in explaining the
imbalance, fetal membranes are ruptured (if nature of labour outcome whether good or bad.
still intact) and careful abdominal and vaginal
examination performed to assess competence Problems of the WHO partograph
of contractions and exclude cephalopelvic The WHO partograph isexcellent for use at the
disproportion (CPD) and/or obstructed labour. peripheral units (primary health care level)
If labour is already obstructed or there is CPD, following the guidelines recommended. For
treatment will be immediate caesarean section. hospitals (secondary and tertiary care levels)
However, when the pelvis is assessed as equipped with personnel and materials for 24
adequate at vaginal examination, the treatment hours obstetric intervention, the use of the
will be oxytocin infusion titrated to improve the WHO partograph and guideline has several
contractions and hence improve the cervical os problems:
dilatation to at least 1 cm per hour till delivery. a) Space provided for recording the
If in spite of improved contractions from the findings for women inlatent phase is only up to
oxytocin augmentation, cervical os dilatation eight hours. There is no space for documenting
rate remains poor or stagnant, caesarean section prolonged latent phase and false labour which
is performed for CPD. Inthe case of the woman are important prodromal aspects of first stage
with prolonged latent phase in the hospital, the labour. By excluding from the records, women
management is as has been previously who go through prolonged latent phase and
described for latent phase of labour false labour, the WHO partograph is not a
management. complete record of all aspects of first stage
labour.
Advantages of the partograph b) The Action line is printed at 4 hours to the
(1) Allows the management of allthe phases of right andparallel to the Alert line. Viewing theAction
the first stage labour (latent andactive phases) line as the pointat which definite intervention is
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*€Normallabour 297
WBM - K-- > ;v ..

evoked to correct slow labour, the period of four partograph is very sparse since the partograph is
hours is too late a time for the intervention to more commonly used in tertiary than either the
reverse the causal factor and ensure return to primary or secondary health care levels. The
normalprogress ina hospital setting. type of partograph in use involves a uniform
spread of both the WHO type and plain
c) The use to which the Alert line should be put
composite partograph shown in Fig 34.2. A
in a hospital setting is not as clear as compared notable fact in the developing countries is that
to a peripheral centre where transfer is required knowledge of the use of the partograph for
when the Alert line is crossed. Similarly, no labour management is very low amongst
uniform action is recommended for progress nurses, midwives and doctors working in most
crossing actionlineand progress that isbetween secondary care levels and private health care
the Alert andAction lines. centres.
d) It is suggested that recording the latent phase At our department in Benin City, Nigeria,
on the partograph may encourage premature
the plain composite partograph (see Fig 34.2)
and not the WHO type is used for labour
intervention in this prodromal aspect of first
management because we believe (a) the latent
stage labour that requires only passive phase should not be recorded on the partograph
management. Hence, latent phase should not be and (b) the Action line should not be 4 hours
recorded at all inthe partograph. from the Alert line because this period is
deemed too late for any action to completely
The partograph incurrent obstetric practice reverse the slow progress to normal state. In
Although the WHO produced and practice we use the cervical os dilatation at the
recommended a composite partograph for admission in active phase to construct the Alert
worldwide use in all settings of health care, the line as the line drawn from cervical os dilatation
WHO partograph type is not the form of on the y-axis on a slope of 1cm per hour to the
composite partograph commonly used in most time of expected delivery on the x-axis. The
parts of the world for some of the reasons Action line is then drawn 2 hours to the right
already adduced. InUSA, the graphic records of and parallel to the Alert line. When the cervical
labour are still reliant on the Friedman's labour os dilatation graph touches or crosses the Alert
graph with separate normal labour graphs for and Action lines, the management is as
primigravida and multigravida respectively. described earlier. The only difference is that in
Notably, these labour graphs still display our practice, all women who are confirmed in
segments of latent phase acceleration and active phase have ARM performed and
deceleration phases. The WHO type of oxytocin augmentation is only carried out in
composite partograph is not popular in the US. In any woman whose cervical graph of progress
Europe, the WHO type partograph is also not crosses the Action line. Thus, in our unit,
commonly used but instead the composite augmentation is performed on the basis of a
partograph type as shown inFig 34.2 isused. This vaginal examination that shows poor cervical
composite partograph is plain with no printed os dilatation of less than 1cm per hour and not
Alert and Action lines or subdivision into latent on the clinical assessment of the uterine
and active phases. The guideline for the use of the contractions.
partograph varies from WHO guidelines
according to the extent to which consensus opinion Conclusion
varies. In developing countries, the use of the The WHO has helpedwith labour management by
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Prince Of Medicine-2014-BSUTH

298 Obstetrics andGynaecology

PARTOGRAPH
Wame Gravida Para Hospital; rax
Date of admission Time of admission Runturad membranes hours

,
170 . -4 4 4-
,,
Fetal
heart
155 — ~ |
f®B 130
123 1 1
lie
133 s 1 ...i.
yÿor
4~ 5 4" 1
ÿ? 4~
T Asfw !P?8 >8
/ X
P--5

/ / j

ObmMM 7 X v X I
iBotXt ÿ / /
5 / /
T
Deseed
oftesd
3 /
/
/
/ |
1
lateiÿfPru se
(Plate) 2
1: 1
Haasa 1 3 4 s e 7! 8 9 10 15 13 u 15 5§ 17 1S 18 20 2* 22 23 2*1
1tm£
;

t i 1 i
Oxtfadieits f | 1 j : ! i
I i j I i
per iQ ires | j i. i I I
1 }
'*
ÿ T J i

| | [ I f f 1
1I [[ 1 }1 \1 1f If
i j i I | I | {
drap&tei | j ÿ

J l f f. f f | ,i.,L

Dfv«8S«ÿ.,

1M
». 170
fy»« « 550
143
tea 13a
123
113
ep IDS
96
88
Tfi
W

Tem'O
n
ttSfefW
iokflW

Fig. 34.1;EfWO Partograph

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Prince Of Medicine-2014-BSUTH

Normallabour 299

Wfflt*

mmm&tm im
l,r., „. ,,ms. i m
ixmxt
mA&m

wmcm*-

tmo
WE23JFS
M
fUSfi

1%.34,2i Pimft Psriograph

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Prince Of Medicine-2014-BSUTH

producing a composite partograph and Principles of Active Management of Labour

recommending same for worldwide use in all (AML)
settings of health care. The WHO partograph is The practice ofAML is founded on the following
more useful and effective at the primary health Knowledge:
care centre to identify normal progress and i. Active phase labour is the more important
abnormal one for timely referrals. At the setting aspect of first stage labour,
in hospitals, the WHO type composite ii Normal progress in active phase is cervical
partograph and guidelines require some more os dilatation rate of 1cm per hour till
modification to allow for a more effective delivery,
labour management hence the plain composite iii. Uterine inertia and not CPD is commonly the
partographmore commonly is in regular use. cause of the failure of the cervical os to dilate
at 1 cm per hour in the active phase especially
Introduction to active management of labour in primigravida.
iv. Uterine inertia responds well to oxytocin
Several years ago, the scourge of obstetric augmentation with improved cervical os
practice was prolonged labour in which the dilatation in the active phase and head
duration was commonly over 24 hours with descent in the second stage,
associated high fetomaternal morbidity and v. Artificial rupture of membranes (ARM) in
mortality. Prolonged labour was assumed the active phase facilitates cervical os
commonly caused by CPD leading to dilatation of 1cm per hour,
obstructed labour especially in primigravida.
vi. Companion in labour and assurance that active
Since 1969, O'Driscoll and Associates •
phase duration will not exceed 12 hours
demonstrated with convincing data, the
enhance performance in labour and forestall
knowledge that in women especially 4.

frustration.
primigravida, a more common cause of
prolonged labour than CPD was uterine inertia
(poor quality uterine contractions) manifesting Practice of active management of labour
as slower than 1cm per hour cervical os Active management of labour (AML) is
dilatation in active phase labour. They showed defined as the strategic approach to the
further that uterine inertia respond very well to management of labour already established in
oxytocin augmentation with improved cervical the active phase aimed at the prevention of
os dilatation leading on to vaginal delivery. A prolonged labour. It is based on the anticipation
package of labour management was presented of normal progress of the cervical os dilatation
in which through close supervision of labour, rate of 1 cm per hour as the basis for the safe
early identification of slower cervical os delivery of the mother with no complication to
dilatation (rate less than 1cm per hour) and bothmotherandchild.
timely treatment in appropriate cases, labour This strategy was illustrated by the labour
duration was reduced to 12 hours from the prior outcome in 1000 consecutive primigravida with
24 to 30 hours. The package of care which the detailed procedure as follows:
brought about this revolutionary reduction in a) Once active phase labour was confirmed on admission,
labour duration to within 12 hours iswhat today vaginal examination and artificial rupture of membranes
is known as active management of labour which (ARM) were performed. Firm assurance was given that
currently, is the most suitable strategy for the labour will end within 12 hours and a nurse was assigned
conduct of active phase labour. as parturient's

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Normallabour Ml

companion and to help to monitor labour. antidote for the prevention of prolonged labour,
b) Repeat vaginal examination was the high cost of the implementation prevented
performed at hourly intervals for the first three its full practice. It is now clear that to ensure
hours in active phase labour. If os dilatation rate active phase labour duration of under 12 hours
was confirmed at 1 cm per hour, subsequent does not require the iron-cast reproduction of
vaginal examination was at two hourly intervals AML as originally published from Dublin. All
until delivery. that is required is the supervision of the active
c) For the women whose cervical os phase labour based on the conviction that ARM
dilatation rate was 1cm per hour, there was no when performed in the active phase facilitates
further intervention until delivery. Those whose progress and the anticipation of progress of a
cervical os dilatation was less than 1cm per hour cervical os dilatation rate of 1 cm per hour
were treated instantly with oxytocin infusion and through regular vaginal examination which
rate titrated to keep the cervical os dilatation rate may not be at hourly intervals. Such vaginal
of 1cm per hour till delivery. If there was no examinations may be performed at two, three or
progress after four hours of augmentation, four hourly intervals and women not
caesarean section was performed for CPD. progressing at 1cm per hour at these intervals
d) Pain relief was with parenteral pethidine or are treated with oxytocin augmentation to
epidural analgesia as deemed necessary. induce improved cervical os dilatation rate of at
e) When full cervical os dilatation was least 1 cm per hour. Modification of AML as
confirmed, the women were encouraged to bear above still leads to active phase labour duration
down only whenthere was the urge to push. Ifat of wdthin 12 hours though overall outcome of
full dilatation, there was poor head descent, no such AML cannot be as good as was obtained
urge to push and CPD had been excluded, from Dublin.
oxytocin augmentation was similarly begun to For the developing countries with a high
treat this phase 1 second stage defect. When prevalence of prolonged labour, AML is an
there was lack of progress in headdescent in 1- essential obstetric strategy for labour
2 hours of augmentation, caesarean section was management. The high cost however, does not
also performed for CPD. (f) The third stage of allow the use of the full protocol from Dublin;
labour was actively managed. instead the modified forms are commonly
The outcome was a prolonged labour rate utilised.
of less than 1%, caesarean section rate of 5%, The composite partograph allows the
low instrumentation rate, babies with good practice of AML with modifications of regular
Apgar scores and mothers with high morale at vaginal examination at 2-4 hourly intervals
delivery. The only problems were high with good result. Modified AML protocol has
oxytocin augmentation rate of 55% and very been in use at our department for over 10 years
frequent vaginal examinations in labour and andthe practice is as follows:
cost consequence of a nurse per woman in ( 1) As soon as active labour is confirmed, ARM
labour. The excellent results with the low is performed (if membranes are still intact) and
caesarean section and low prolonged labour the usual monitoring in labour commenced.
rate made AML very popular the world over in (2) All findings are recorded on the partograph on
spite ofthe highcost consequences. which there is an Alert line and the Action line
Although AML as described was a good sited at 2 hours to the right and parallel to theAlert
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line.
302 Obstetrics and Gynaecology

I
in the active phase, anticipation of labour
(3) Repeat vaginal examination is progress of 1 cm per hour using the partograph
performed at 4 hours (after the first vaginal
Alert line and regular vaginal examination at 2-
examinÿtL.; at which active phase was 4 hourly intervals. Oxytocin augmentation is
only carried out when cervical os dilatation
confirmed) and descent and cervical os
crosses the Action line (and not on the assessed
dilatation plotted on the partograph.
quality of the contractions) and 'personal nurse'
Subsequent vaginal examination is performed
was only assigned for women on oxytocin
at 2 hourly intervals till delivery.
augmentation. The outcome of this protocol
(4) When cervical os dilatation graph is on was a prolonged labour rate (active phase
the Alert line or to the left of it, progress is duration over 12 hours) of 2%, augmentation
normal and labour is allowed to progress till rate of 22%, and caesarean section rate amongst
delivery without any further intervention. those so managed of 10%. Thus, AML as
(5) Oxytocin augmentation is begun when modified for our circumstance has greatly
the graph of cervical os dilatation crosses the reduced the previously high prolonged labour
action line especially in the primigravida even rate with reasonable cost.
when contractions are clinically assessed as
adequate. However, before oxytocin Bibliography and suggested further
augmentatioin is begun ina multigravidawhose reading
cervical os dilatation graph crosses the Action Dudley, D.J. (1999) Dystocia. In Clinical Obstet, Gynaecol
line, an astute vaginal examination by a Senior 40. Pp 459-548
Residentisdone to first exclude CPD.
Symonds, E.M. (1998) Essential Obstetrics and
(6) Oxytocin augmentation is only for a Gynaecology. Churchill Livingstone, Publishers.
duration of 6-8 hours during which period
vaginal examination is performed 2 hourly and O'Driscoll, K. Meagher, D (1980) The Active Management
of Labour. London, Saunders.
a 'personal nurse' is assigned to monitor the
woman. When there is no progress after Spencer, J.A.D. (1991) Fetal Monitoring. Oxford Medical
augmentation in 4-6 hours, caesarean section is Publishers, OxfordUniversity Press.
performed.
Calder, A. A. (1990) Induction and augmentation of labour.
(7) Third stage is managedactively as routine. In Dewhurst's Textbook of Obstetrics and Gynaecology
for Postgraduates. 6th ed. Edmonds, D.K. ed Blackwell
The emphasis inthis AML protocol isARM science

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Chapter 35
Normal puerperium

The puerperium is the six week period after fibroelastic tissues. The excess protein
childbirth during which the pelvic organs and produced as a result of autolysis is removed in
other body tissues, which have undergone some the blood stream and excreted in the urine or to
physiologicalchanges during pregnancy, return some extent utilised by the body. The body is in
to their pre-pregnancy state. It is a period of negative nitrogen balance during this time,
considerable psychological vulnerability. The because more nitrogen is being excreted than is
rapid change in the size of the uterus in the first being taken in. While the enzymatic digestion is
two weeks, represents the most dramatic proceeding inthe uterine muscle, the superficial
change that occur during -the puerperium. layer of decidua undergoes ischaemia, necrosis
Other pelvic organs also undergo some and sloughing and is discharged as the lochia.
changes, which are not so dramatic. Some The lochia consists of erythrocytes, shreds of
abnormalities may however set in to alter these decidua, epithelial cells, leucocytes and
physiological changes and thus convert the bacteria which invade the uterine cavity from
puerperium to an abnormal one. Postpartum the vaginal commensals. For the first few days
care is aimed at identifying these deviations after delivery, the lochia is red (lochia rubra).
from the expected changes and initiating After 3 or 4 days, it becomes progressively pale
appropriate management protocol. in colour (lochia serosa). After about the 10th
day, it becomes yellowish-white colour (lochia
ANATOMICAL AND PHYSIOLOGICAL alba). Persistent red lochia suggests delay in
involution that is usually associated with
CHANGES
infectionor a retainedpiece of placental tissue.
Uterine involution:This refers to the process by With sloughing of the necrotic endometrial
which the postpartum uterus weighing about layer, endometrial regeneration begins and a
1000 gm returns to its pre-pregnancy state of new endometrial lining is laid down within
under 100 gm. This change in weight is more three weeks after delivery. Re-epitheliasation
dramatic inthe first one week when it decreases of the placental bed usually proceeds more
from 1000 gm to about 500 gm. Thereafter it is slowly and may extend to eight weeks after
gradual over the next five weeks when it returns to delivery. The growth of new endometrium from
the pre-pregnancy weight of under 100 gm. the basal areas will be influenced by the method
The uterus immediately after delivery extends of infant feeding. If lactation is suppressed, the
above the level of the umbilicus in some women uterine cavity may be covered by new
although in general it is about 4cm below the endometrium within three weeks and the first
umbilicus. It gradually reduces in size daily after menstruation may occur at 6 weeks after delivery.
delivery with the result that by the end of the second In breastfeeding mothers, ovarian activity is
week, it is no longer palpable above the symphysis suppressed and resumption of menstruation may
pubis. Uterine involution is achieved by a process be delayed for many months. Involution appears
of autolysis. Autolysis is the enzymatic digestion to be accelerated by the release of oxytocin in
of cytoplasm of muscle cells including digestion women who are breastfeeding as the uterus is
of blood clots, some blood vessels and other smaller than in those who are bottlefeeding.

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304 Obstetrics and Gynaecology

The process of involution may be slowed down or spinal) has beenused. This leads to retention
after caesarean section, in the presence of of urine. During childbirth, the urethra and the
uterine fibroids, retained placental products bladder may also be bruised or traumatised and
and intrauterine infection. These conditions this may further inhibit micturition. In some
may also be associated with sub-involution of cases, especially in difficult and prolonged
the uterus. It is therefore, important to measure labours, oedema, excessive bruising,
the height of the uterine fundus daily to ecchymosis and petechial haemorrhages may
ascertain the trend ininvolution. occur in the bladder and urethra and lead to
haematuria after delivery. The ureters and
Cervix: The cervix is flaccid and hypertrophied calyceal systems are usually dilated in
after delivery and hangs like a curtain into the pregnancy. The dilatation gradually passes off
vagina with its internal and external os open. and the ureters regain their pre-pregnancy size
although such changes may not be complete
With these changes, the cervix also shrinks
down rapidly and the internal and external os until as late as eight weeks after delivery. The
significance of this information lies in the fact
gradually reduce in size; the internal os becomes
closed to finger examination towards the second that intravenous urogram to investigate renal
week of the puerperium although the externals disorders should not be performed in the
os may remain open for quite a variable period puerperium as the result obtained will not be
accurate.
beyond the end of the puerperium.
Some changes in the urinary function occurring in
Vagina: The vagina is usually dilated and
the early puerperium should be noted. Retention of
stretched out with flattening and smoothening
of the vaginal wall. Within a few days after urine can occur in the first 24 hours of the
delivery, it shrinks down to its normal capacity puerperium because of urethralandbladder changes
with return of some of the rugae. Episiotomies referred to above. Retention of urine can also occur
and tears of the vagina usually heal quickly as a result of perineal pain following episiotomies
provided adequate suturing has been and perineal laceration, which reflexly causes the
undertaken. The fourchette and introitus return retention. Caesarean section may also cause
to their pre-pregnancy state gradually. retention of urine because of suprapubic pain from
abdominal wound. In all these cases of retention,
Other systems: The muscles of the anterior catheterisation of the bladder may be necessary if
abdominal wall are excessively stretched in residual urine and subsequent cystitis are to be
pregnancy. This stretching is more marked after avoided. Catheterisation should be as aseptic as
delivery of macrosomic babies, multiple gestations possible at alltimes.
and hydraminos. These stretched muscles gradually
shrink to their normal size in the first few weeks of Inthe first two days of the puerperium, diuresis
the puerperium thus giving the abdomen its pre¬ has been observed. At this time, some excess
pregnancy tone. Normal tone of the abdominal fluid retained during pregnancy is excreted.
muscles could return more rapidly if postnatal During labour, some women become dehydrated
exercises are commenced early in the puerperium. and this may lead to a slight rise in the body
temperature in the puerperium although such
The bladder is usually over-distended in labour and elevation of temperature settles down to normal
may remain atonic in the first few hours after within a few hours.
delivery, especially ifregional anaesthesia (epidural Constipation is a common problem in the
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Normalpuerperium 305

puerperium. This may be due to interruption in infant bonding.

the normal diet and dehydration in labour. It
Physiology of lactation: The human breast is
usually responds to adequate fluid intake and
unique in that the major part of breast
increase in fibre intake. Constipation may also
development occurs at puberty before the first
be the result of fear of evacuation due to pain
pregnancy so that the adult breast requires only
from a sutured perineum, anal fissures or
minimal exposure to the appropriate hormonal
haemorrhoids. The cardiovascular changes
stimuli to produce milk. During pregnancy,
reported during pregnancy also rapidly returnto
under the influence of the hormones oestrogen
normal during the puerperium.
and progesterone the lactiferous ducts and
The Breast and lactation alveoli proliferate and hypertrophy in
preparation of secretory activity. The lactogenic
The breasts undergo some changes during hormones, prolactin and human placental
pregnancy as referred to in another section of lactogen probably play a modulating role.
this book. Colostrum is secreted by the breasts Despite high levels of these lactogenic
during the terminal period of the pregnancy and hormones during pregnancy, only minimal
for the first several postpartum days. It is a deep amounts of milk are formed. This isbecause the
lemon-yellow coloured liquid and compared action of these lactogenic hormones is inhibited
with matured milk, it contains more minerals by the secretion of high levels of oestrogen and
and protein, much of which is globulin, but less progesterone by the placenta. With the removal
sugar and fat. Colostrum contains large fat of this inhibitory effect after delivery, milk
globules in so-called colostrum corpuscles. secretion is thus induced and this secretion
Colostrum secretion persists for about five days usually increases and becomes well established
with gradual conversion to mature milk during by the third or fourth day after delivery. Further
the following four weeks. Antibodies are production of breast milk however depends on
demonstrable in the colostrum and its content the suckling of the breasts by the baby.
of immunoglobulin A, in particular offers Two similar but independent mechanisms
protection for the newborn against enteric are involved in the establishment of successful
pathogens. Other host resistance factors as well lactation. Although these two mechanisms are
as immunoglobulins are found incolostrum and both activated by suckling, they are mediated
milk. These include complements, lactoferrin through two entirely different pathways (Figure
and lysozymes. 35.1 & 35.2). Following an episode of nipple
Lactation is the dominant physiological event stimulation by the suckling infant, sensory
of the puerperium in those mothers who impulse is sent via neural arc to the anterior
breastfeed. The primary function of pituitary and it is hypothesised that this impulse
breastfeeding is to provide continuing nutrition prevents release of prolactin inhibiting factor
for the newborn. The other secondary functions from the hypothalamus, thereby initiating the
include (i) protection against infant infection production of prolactin by the anterior pituitary
t ii) inhibition of ovarian activity (lactational
.Theaction of prolactin on the breast is believed
to be a direct one, acting on the secretory cells to
amenorrhoea) (iii) encouragement of uterine
involution and (iv) facilitation of mother- synthesise milk proteins.

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306 Obstetrics andGynaecology

Prolactin release

hormone causes contraction of the

myoepithelial cells surrounding the glands as
well as the myoepithelial cells lying
longitudinally along the lactiferous duct, which
therefore squeeze out or eject milk from the
Neural arc
nipple into the baby's mouth. This reflex.
Prolactin (in blood)
known as "milk let-down reflex" or the
"drought reflex" ensures continued emptying of
Milk secretion

suckling n
milk into the baby's mouth each time the baby
suckles. In contrast to prolactin, which is
secreted only in response to suckling, oxytocin
can be released in response to sensory inputs
Figure 35.1. Pathway of protein release from the anterior such as the mother seeing the baby or hearing
pituitary gland.
his cry. The oxytocin released by suckling
PP=Posterior pituitary
AP=Anteriorpituitaiy reflex also circulates to the uterus and causes
contraction of this organ, resulting in pain
experienced by the mother during
breastfeeding or suckling process. This
oxytocic action on the uterus contributes to the
rate of involution inthe puerperium.
If the baby is not put to the breasts early
enough, the breasts become engorged about the
third to fourth day after delivery because of the
increased production of milk at this time.
Cracked nipples, flat nipples, prematurity, cleft
palate, psychological disorders in the mother
could all depress breastfeeding and the
lactation process. In these conditions, the
breasts could become persistently engorged
thus causing discomfort to the mother. This
couldalso predispose to breast infections.
Figure 35.2 Pathway of oxytocin release from the
posterior pituitary
Management of normalpuerperium
PVN = Periventricular nucleus For the first hour after delivery, the woman
AP = Anterior pituitary should remain inthe labour ward. The pulse and
blood pressure should be monitored every
fifteen minutes or more frequently if indicated.
Once milk hasbeen produced under the influence of
The amount of vaginal bleeding is monitored
prolactin, it has to be delivered to the infant. The and the uterine fundus is palpated frequently
suckling of the nipples sends sensory impulses to to ensure that it is well contracted. If relaxation
the posterior pituitary gland, which responds by is detected, the uterus should be
pulsatile release of oxytocinintothe circulation.This massaged through the abdominal wall until it
remains contracted. Blood may accumulate
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Normalpuerperium 307

within the uterus without external bleeding. should be obtained at the time of delivery and
This may be detected early by identifying the infant's Rhesus blood group determined.
uterine enlargement through frequent fundal Mothers whose infants are found to be Rhesus
palpation during the first few hours postpartum. positive should receive Anti-D
Because the likelihood of significant immunoglobulin injection within 48 hours of
haemorrhage is greatest immediately delivery.
postpartum, even in normal cases a trained It is now fashionable to use subcuticular
attendant should remain with the mother for at catgut sutures for the repair of episiotomy as
least one hour after completion of the third stage these do not require removaland the mother can
of labour. After this period of observation, the be discharged home after 48 hours.
woman is transferred to the lying-in-ward. The The baby should be carefully followed up
vital signs are again checked and she is allowed and examined for any evidence of neonatal
to rest and regain her strength after the jaundice, sepsis, or other disorders which
exhaustion and mentalstrain of labour. should be investigated and treated.
In the early puerperium, the mother and Immunisation of the baby against
baby are naturally expected to be visited by the pulmonary tuberculosis should be performed
father, friends, relations and other well wishers. before discharge. Health talks should be given
As much as possible, visitors should be
in the lying-in-wards. Family planning advice
restricted to reducethe risk of infection.
should be given to the mother.
Discharge is usually done within 48 hours
The breasts should be inspected and the
in some units.
nipples cleaned and early breastfeeding
Six weeks appointment for the postnatal clinic
encouraged. Any disorders of the breasts should
attendance is given to the mother andher baby.
be attended to. The mental state of the mother
shouldbe carefully assessed.
Postnatal exercise: This should be carried out
The height of the uterine fundus is assessed
frequently during the puerperium under the
and noted.Fromthe observations of records of the supervision of the physiotherapist to ensure a
uterine fundal assessment, the rate of uterine good posture, good healthand good tone of the
involution can be followed. Where there is a delay abdominal andperineal mucles.
in involution, the cause should be identified.
The perineum is swabbed regularly and the Return of menses: The time of return of the
sanitary pad changed to reduce the risk of genital menses after a normal delivery is quite varied.
tract infection. The episiotomy site isalso inspected. Many women who are not breastfeeding may
Lochia loss usually stops about 10-14 days resume their normal menses about 6 weeks after
after delivery although it may linger on until the delivery. For mothers who are breastfeeding the
end of the puerperium. If the lochia is pink or picture is different.Those women who introduce
red in colour at a time when it is expected to be supplementary feeding to breastfeeding quite early
brown or white or if the quantity is heavy, an do not have a full suppressive effect
abnormal situation is setting inandthis requires of breastfeeding on ovarian function. Their
investigation and treatment. menses may return within six weeks after
The packed cell volume or haemoglobin is delivery. For mothers who embark on
usually determinedabout 48 hours after delivery. breastfeeding, uterine involutionis acceleratedand
The cord blood of all Rhesus negative mothers ovulation is effectively suppressed. The women
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308 Obstetrics and Gynaecology

discussedunder a separatenhapter inthis book.

I
in this category will remain amenorrhoiec as
they continue exclusive breastfeeding.
Spontaneous ovulation could occur in spite of Postnatalexamination:
the amenorrhoea and these women should be This is usually done inthe clinic, six weeks after
warned about intercourse, which may result in delivery. The mother is asked questions to
pregnancy. establish the progress of breastfeeding and any
symptoms of ill health concerning her or her
Minordisorders inthe puerperium baby. Specifically, she is asked about urinary.
Constipation may be a disturbing problem. bowel as well as sexual function and about the
Mild bowel laxatives like dulcolax tablets or date of her last menstrual period and the
vegetable laxatives may be prescribed to character of the menses. After obtaining all
stimulate the bowels. Catheterisation during the these facts inthe history, a physical examination
pueiperium may introduce infection causing is performed.
mild cystitis or acute pyelonephritis. This The mother is weighed and her pulse.
should be fully investigated and treated. temperature and blood pressure are recorded.
Incontinence of urine may occur in the Urine is also tested for protein, sugar and
puerperium. Overflow incontinence may occur. ketones. The breasts are examined with
In some developing countries, women may not particular attention to the nipples. All the other
have had antenatal care but only report to systems are examined.
hospital in advanced labour. Labour may be A pelvic examination is performed. A
obstructed and there is necrosis of a portion of cervical smear may also be taken if one had not
the bladder and vagina, which has been under been taken earlier. At the end of the
persistent pressure from the fetal head during examination, any abnormality detected should
the course of labour. Sloughing of the necrosed be discussed with the mother and treatment
tissues occurs after delivery and urinary promptly offered.
incontinence sets in about the 8th day The baby is weighed and a full physical
postpartum. Such an incontinence is said to examination is carried out. Immunisation
be due to a vesicovaginal fistula. The injury may schedule is explained to the mother and
also affect the posterior vaginal wall and rectum immunisation card detailing future
which will undergo tissue sloughing and lead to the immunisation for the baby is given to the
development of a rectovaginal fistula. In some of mother for recordpurposes.
these cases of urinary incontinence, continuous
bladder drainage for the first 10 to 14 days of the Bibliography and suggested further
puerperium may lead to spontaneous healing of the reading
vesicovaginal fistula. A vast majority of these
patients will require formal surgical repair of the 1. Gabbe S. G, Niebyl J. R. Simpson J. L. (1991).
fistula at a later date. This urinary condition is The Puerperium: InObstetrics Normal and Problem
Pregnancies,2nd ed, ChurchillLivingstone Inc.

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IChapter 36
i

f Maternal infections in pregnancy

Introduction obstetric unit, since isolation may be required.

The venereal diseases may be
Pregnancy andthe puerperium Any of the acute contracted at any time during pregnancy or the
or chronic specific infectious diseases may be
puerperium and those that could have fetal or
contracted during the course of pregnancy or
crippling effects on the fetus are tested for
the puerperium, and conception may occur in
women already subjected to infection. The during the antenatal period. Routine serological
coexistence of pregnancy may aggravate the tests for syphilis are performed during
risk to maternal life of the more serious of these pregnancy usually at the first visit together with
diseases, some of which constitute a hazard to other booking tests (Table 36. 1).
the fetus and the newborn. Fetal death may
result from contagion since some viruses, History taking
bacteria and protozoa are able to cross the
placental barrier, or it may be caused by General examination, especially heart, lungs and
placental insufficiency, hyperpyrexia or genital tract
maternal exhaustion and toxaemia. The Serological testing of blood
newborn may contract a transmissible disease * at booking for:
from close contact with an infected mother 1. treponemal disease (TPHA,VDRL)
shortly after birth, or as a result of maternal 2. markers of hepatitis B and C viruses
infection, may be born in a sickly and marasmic 3 . rubella immune status
condition and soon succumb to intercurrent 4. toxoplasma immune status 0
infection. In the early part of the puerperium, 5. HIV 1&2antibody []
parturient women are peculiarly susceptible to 6. Cytomegalovirus (CMV) immune status
serious infections of the genital tract and 7. Mumps immune status
childbirth fever has always been one of the most 8. Chlamydia
important causes of maternal death. Although 9. Herpes simplex
serious microbial disease is not well controlled 10. Varicella Zoster immune status
in Nigeria as in other countries, mothers of 11. 5 swabs-test (rectal, urethral,bartholin's, HVS
young children, particularly of those at school, & endocervical)
are exposed to the specific infectious diseases
of childhood and in addition to the common It is important that serum should be stored by the
upper respiratory tract infections, may contract laboratory until after the birth ofthe baby.
mumps, chickenpox, measles, rubella, scarlet D Insome overseas countries.
fever, acute bacterial tonsillitis, whooping D Inhigh-riskpatients,with maternal consent
cough, dysentery or viral diarrhoeas. As young
adults, the mothers may contract toxoplasmosis Table 36.1 Scrutiny for infectious disease in prenatal
or poliomyelitis. Some of these diseases have diagnosis & therapy centre CMUL, Surulere, Lagos 1996
important consequences in obsteric practice and
pose a problem if the mother's antenatal The other venereal diseases-gonorrhoea, chancroid,
condition necessitates admission to an granulomainguinale and lymphogranuloma

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310 Obstetrics andGynaecology

I
venereum are sought for during pregnancy at the specific as well as specific (immune)
routine antenatal clinical examination by eliciting mechanisms. The principal mechanism of
the medical and social history, by physical protection against invading micro-organisms is
examination and by appropriate laboratory tests. the immune system which is characterised by
Exacerbation of caries and dental sepsis occurs three attributes -specificity, memory and
during pregnancy and women with valvular recognition of self-antigens. Its function is to
disease of the heart are at risk of infective protect against foreign substance. The immune
endocarditis if dental surgery is necessary, as well status of individuals may be innate or acquired.
as at parturition. The incidence of vulvovaginitis Innate immunity is genetically or
is increased in pregnancy and is occasioned constitutionally determined and is not a function
largely by infections with members of the genus of cells of the immune system or of specific
Candida, the fungi of thrush. The other important antibody, but the result of physiological,
cause of vaginitis in pregnancy is the protozoan
biochemical or anatomical differences
parasite Trichomonas vaginalis. Vaginosis
principally betweenspecies.
associated with Gardnerella vaginalis is of less
Immunity is acquired either passively or
consequence.
actively. Naturally acquired passive immunity
The response of adults to antigen
follows the transfer of immune antibody of the
stimulation consists of production of IgM,
followed quickly by production of IgG IgG class from mother to fetus by the
antibodies. The pattern of response in the transplacental route and the ingestion of IgA
newbornis different; IgM is elaborated as a first antibody in colostrum. Artificially acquired
response, but this persists for several weeks passive immunity follows injection of immune
before IgG is elaborated. The fetus elaborates products such as antitoxins, antisera or immune
IgM in response to antigen exposure in utero globulin from the same or a different species.
and detection of specific antibody in the IgM The infant's mouth becomes colonised
fraction of cord blood is the most useful of the within a few days of birth andthe main source of
diagnostic tests for congenital infections such the colonising organisms is the maternal vagina.
as rubella or syphilis. Elevation of the non¬ At birth, the intestine may contain only a few
specific IgM level to 18 mg/lOOml is regarded bacteriabut is rapidly colonised.The flora of the
by many as indicative of intrauterine infection breastfed infant consists largely of anaerobes
and is used as a screening test in sickly or such as Lactobacillus and Bacteroides (about
debilitated infants. 99%) but coliforms are also present. After
The reasons for the poor response of the weaning, the flora resembles that of the adult.
newborn to certain infections are not clearly The upper respiratory tract is colonised soon
understood but there is some evidence that in afterbirth particularly after close contact with
addition to the physiological dysglobulinaemia the mother at the first feed.
mentioned above, the cellular response to
infection varies in the newborn and the Organism % Incidence
phagocytes are less active. There is a lack of Corynebacteria 84
antigen-presenting macrophages. Lactobacilli 82
Staphylococcus epidermidis 66
Host-parasite interactions Micrococci 37
Hostresistance depends on innate (genetic) as well Faecal streptococci 34
as environmental factors and is engineered by non- Microaerophitic and
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I
anaerobic,streptococci
Escherichia coli
Candida albicans
Myco plasma hominis
Beta-haemolytic streptococci
Group B
Group C
Group F and group G
Not groupable
Gram-variable coccobacilli
Proteus mirabilis
Bacteroides species
Staphylococcus aureus
Non-haemolytic streptococci
Torulosis glabrata
Trichomonas vaginalis
Neisseria species (phalyngis and
Catarhialis)
Klebsiella aero genes
Pseudomonas aeruginosa
Sought but not isolated
Lancefield group A streptococci
Clostridium pertringens
Nil
Neisseria gonorrhoea
Listeria monocytogenes
Haemophilus species
Not sought

Viruses, chlamydia, T-strain

mycoplasma
22
19
17
11
9
5
<1
<1

6
5
5
4
4
3

1
7

<1
<1
3

Nil

Nil
Nil
Nil
-
Maternalinfections inpregnancy / 311
I

ranges from 23 to 71 % for T-mycoplasmas and

from 4 to 3 9% for Mycoplasma hominis.
After the menopause, oestrogenic activity
decreases, glycogen is not deposited in the
vaginal epithelium, the vaginal secretions are
less acid and cocci are said to predominate
amongst the vaginal flora. Many of the
endogenous microbes isolated from the vagina
during pregnancy are members of pathogenic
genera. Some may be implicated in puerperal
sepsis and others in chorioamnionitis and
neonatal sepsis. Occasionally microbes are
isolated that are not part of the resident flora;
their presence may indicate disease of the
genital tract. Those microbes exogenous to the
genital tract are shown inTable 36.3

Lancefieldgroup A streptococci
Streptococcus pneumoniae
Clostridium perfringens
Clostridium tetani
Corynebacterium diptheriae
Mycobacterium pallidum
Neisseria gonorrhoeae Neiseria
meningitidis Haemophilus
influenzae Chlamydia
trachomatis Schistosoma
mansoni Schistosoma
haematobium Enterobius
vermicularis Cytomegalovirus
Rebella virus, or vaccine virus
Herpes hominis
Table 36.2: Flora of lower genital tract in280 unselected
pregnant women inprenataldiagnosis & therapy centre * Being either exogenous flora, or encountered
with frequency of lessthan 1in250.
The distribution of microbes isolated from the
posterior fornix of pregnant women is shown inTable Table 36.3 Abnormal pathogenic flora* of the
36.2. The incidence of large colony of mycoplasmas female genital tract
in pregnant women according to several authors
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Non-specific infections occurring in approximately 3-4 x 6-7 urn. The coccidiaii

pregnancy parasite exists in three forms - the trophozoite,
the tissue cyst and the cat-associated oocyst
Puerperalsepsis andwound infections The latter two are the principal forms
Puerperal sepsis includes a series of febrile implicated in transmission. Pregnant women
disorders of the lying-in period that share the should avoid the consumption or handling of
raw meat and wear gloves when gardening or if
commonaetiology of beingwound infectionsof
it is necessary for them to handle cat litter. Of
the genital tract Puerperal sepsis may occur
great importance in obstetrics is the fact that
after delivery or abortion and is occasioned by infection can be passed congenitally from
several genera of pathogenic bacteria, of which mother to fetus, insome species through several
the most notorious and dangerous are generations. The disease may be acquired
Clostridium and streptococcus. In the great during intrauterine life if the mother is infected
majority of fatal cases, the microbes are during pregnancy.
introduced from without, and such infections Illness is a rare accompaniment of this
are preventable. In general, endogenous common infection and the best known
microbes, harboured in the vagina, such as manifestation of acquired toxoplasmosis is
Enterobacteriaceae and staphylococcus cause lymphadenopathy, which may be accompanied
less severe forms of sepsis. Blankets, air sucked by the presence of glandular fever-like cells in
intothe theatre from other parts of the hospital the blood.The disease affects both sexes and the
and the patient's own skin may also be a source peak incidence isbetween25 and 3 5 years.
of infection. Inexpert and clumsy surgery is Although placental transmission has been
demonstrated in chronically infected mice, in
undoubtedly a contributory factor.
humans congenital infection is believed to
follow primary infection and the prognosis for
Specific infections subsequent pregnancies is good. The risk to the
Toxoplasmosis fejus appears to berelated to the gestational age
Toxoplasmosis is probably unique amongst the at which primary maternal infection occurs,
parasitic diseases of man in that its congenital with transmission being less likely in the fust
form was recognised before the postnatally trimester but if it does occur, resulting in more
acquired form. There is little difference in the severe disease. Infection leading to stillbirth or
prevalence rates between sexes although the neonatal death, or to survival with ocular and
disease is clearly more important and more cerebral involvement, occurs only in the
frequently diagnosed inwomen of childbearing offspring of mothers who acquire primary
age. There are few data from which to derive infectioninthe first or secondtrimester.
morbidity, mortality or case fatality rates. Although transmission rates as high as 33%
Serological surveys show that infection have been reported following primary maternal
with die protozoan parasite Toxoplasma gondii is infection, 72% of the infected newborn were
common and widespread in man. In Nigeria, in a spared overt clinical infection. Such
total of n = 655 screened between 1997 and 1999 asymptomatic infants may suffer no serious
(male 203, female 452), 13 were positive in male consequences or may later develop chorioretinitis,
and 33 positive in female that is 6.4% and 7.3% blindness, strabismus, hydrocephaly or
respectively. The organism is an obligatory
microcephaly, cerebral calcification,
intracellular parasite, elongated or sickle-shaped and
psychomotor or mental retardation, epilepsy, or
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Maternalinfections inpregnancy 313 ÿ

deafness. Children known to have had and because of this women should be screened
congenital toxoplasmosis must therefore be before marriage and during pregnancy.
kept under observation for months or years.
The available data are insufficient to Listeriosis
support or to refute the hypothesis that T. gondii Listeria monocytogenes is one of few pathogens
causes malformations during the period of that can form colonies at 4°C and can survive in
organogenesis. The infected infant should be nature in hay, straw and earth for many months. It
treated with spiramycin or has been isolated from many species of domestic
pyrimethamine/sulphonamide and folinic acid. birds, insects and crustaceans. The infective cycle
There is some evidence that treatment of the is probably based on its survival in soil or
mother who has an acute attack in pregnancy vegetation, multiplication in silage,
with spiramycin decreases the fetal risk. establishment of carrier or diseased state in
Serological tests include the cytoplasm- animals or fowls, and for man, growth in food
modifying (dye) test of Sabin and Feldman, derived from these sources and consumed after
complement fixation, haemagglutination and ' inadequate heating. Its localisation in the genital
florescence inhibition, Enzyme linked tracts of many vertebrates and its transmission to
immunosorbent assay (ELIS A) and enzyme the fetus characterise its importance in obstetrics.
linked immunosorbent agglutination assay are A large outbreak of listeriosis occurred in 1981 in
now widely used, and the IgG avidity test is theAtlantic provinces of Canada, including many
promising as a possible indicator of early perinatal cases, and was attributed to cabbage
acquired infection. The interpretation of fertilised with infected sheep manure. Of 25 cases
serological tests can be very difficult, as latent of maternal and perinatal listeriosis in Nova
infection is so common. Demonstration of a Scotia, 17 infants were bom alive although five
rising litre or the presence of specific IgM died; there were three stillbirths and five
antibody indicates active infection. When it is spontaneous abortions.
not possible to demonstrate a rise, a dye test titre Characteristically, infection in pregnant
of 1:1000 is probably reliable evidence of women is associated with two or more febrile
current infection. episodes. The first, recognised in retrospect as
The risk to the fetus of primary maternal the primary infection, is associated with malaise,
toxoplasmosis is of the order of 50%, some 15% headache, fever, backache, pharyngitis,
in the first trimester and 70% in the third. Inearly conjunctivitis, diarrhoea and abdominal or loin
gestational life abortion is the likely outcome. pain. The • condition may be diagnosed as
Since 1975 in Austria, all women have been pyelonephritis since the kidneys may be
screened for Toxoplasmosis antibody during involved inthe listeric process but the true nature
pregnancy. If seroconversion (primary infection) of the infection will be recognised if the often
occurs the mother is treated. Spiramycin is used if slowly growing L. monocytogenes is actively
infection occurs in the first trimester; otherwise sought in cultures of blood and of other sites,
pyrimethamine and sulphametoxydiazine are such as the genital tract and urine. Resolution of
given. It is believed that congenital infection fever may occur ifantibacterial therapy hasbeen
has been reduced by 50-70% in consequence of given but relapse is likely. Within 1-20 days
these measures. The results of a 20-year follow- of delivery, often of an infected premature
up of those with congenital toxoplasmosis baby, there is a further febrile episode regarded
demonstrated that subclinical infection at as a manifestation of reinfection from the
birth could have severe consequences placenta. In about 40% of cases fever is
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i 314 Obstetrics and Gynaecology

aSillllÿiiljÿ i-lfej- .•. '.'A
r rsv
H ___ Hl'Wfl—ÿ
i

_ * .

not marked at any time; the disease presents as type may be transmitted from the environment
an influenza-like illness or is completely About one-quarter to one-third of babies with
unremarked by the patient. It is suggested to be early-onset disease are born dead; necropsy
a cause of habitual abortion in man as in demonstrates typical appearances of j
domestic or wild animals. Due to difficulties in granulomatosis infantiseptica with miliary '
isolation of the microbe and inthe performance microabscesses and granulomata in the liver.
and interpretation of serological tests, the spleen, adrenal glands, lungs, pharynx.
aetiological diagnosis may be difficult to gastrointestinal tract, central nervous system
substantiate inabortion. and skin. The disease is more frequent in
The incidence of listeriosis infection in the continental Europe than in the BritishIsles and I
perinatalperiod in the UK is about 1 in 30 000 L. monocytogenes is thought to rank third after
births and in the USA in the early 1980s about Escherichia coli and the group B streptococcus
3.7 in 1000 000 population. Neonatal as a cause of neonatal sepsis in France.
septicaemia may occur in epidemic form in Mortality rates of 90% used to be recorded for
cattle and epidemics inman have been reported infantile listeriosis but given early diagnosis
from East Germany and New Zealand. Cross- and prompt treatment with bactericidal agents
infectioninneonatalunitshas also occurred. in high dosage, an overall mortality of 50% is
Listeriosis infection of the newborn occurs
more likely. Ifa surviving infant is more than 36
intwo forms. The early-onset type results from
weeks of gestation at birththere are likely to be
infection in utero, whether by the
adverse sequelae. Combination therapy with
haematogenous transplacental route or
ampicillin and gentamycin is the treatment of
following the inhalation of contaminated
choice, although gentamycin is contraindicated
amniotic fluid, and is manifest as septicaemia
inpregnancy.
within 2 days of birth. There is meconium
staining of the amniotic fluid and the usually
prematurely born infant has signs of respiratory Viral diseases
distress and sometimes a rash. The late form of Some viral diseases in pregnancy are important
the disease presents predominantly as a because of the deleterious effects they may have
meningoencephalitis, sometimes with slow on the developing fetus and inthe newborn. The
hydrocephalusdevelopingafter the fifth day. This main complications of these diseases are shown
in(Table 36.4).

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Maternalinfections inpregnancp:

Virus Potential effect on mother Potential effect on fetus or newborn

Coxsackie A Herpangina, hand and foot and mouth Transplacental transmission; abortion
Coxsackie A, myocardiopathy ?Gastrointestinal defects
Often unnoticeable, aseptic, meningitis, Myocarditis -meningoencephalitis; neonatal
Coxsackie B
Bornholm disease sepsis
B2 and B4 ?Urogenital anomalies
B3 and B4 ?Cardiovascular lesions
B,B3 and B4 Late stillbirth
B,-Bs Nosocomial neonatal sepsis
Cytomegalovirus Usually asymptomatic but sometimes moderate to ; Chronic infection; acute disease; late-onset
high fever in primary infection Sequelae
ECHO virus Rash of ECHO, may resemble rubella; maternal
disease may mimic appendicitis or abruptio Neonatal sepsis; fetal disseminated infectio:
placentae, as in other enterovirus infections (hepatic necrosis); late stillbirth (ECHO IT
Enterovirus Usually non-specific febrile illness; abdominal nosocomia noenatal sepsis (ECHO 5,11,18,19,31
pain. Acute or subclinical disease; flu-like illness; Neonatalsepsis
Hepatitis A
chills and fever; constitutional symptoms and Vertical transmission; nosocomialspread
jaundice; increased severity in pregnancy
Asymptomatic chronic carrier state; acute hepatitis Vertical transmission; chronic carrier state;
Hepatitis B rarely acute or fulminant neonatal hepatitis
Acute hepatitis Vertical transmission as yet little studied
Hepatitis C
Superinfection in those with HBV
Hepatitis D (delta agent) Highmortality in pregnant women
Hepatitis E Oral or genital infection;more severe inpregnancy.
Herpes simplex Abortion following primary infection:
Acceleration of disease; asymptomatic; ?prematurity fetal disseminated infections
HTV AIDS or PGL (HSV2 > HSVI); ?congenitaI malformations;
Adult T-cell leukaemia/lymphoma; tropical Vertical transmission; infantile disease;
Spastic paresis ?central nervous system malformations
Human T-cell leukaemia virus
Increased mortality in pandemics Vertical or perinatal transmisssion and
(HTLW-1) persistent infection leading to ATLL
Influenza ?Increased fetal mortality; ???congenital
Meningitis/meningoencephalitis malformations; ?increase in childhood
Lymphocytic choriomeningitis May be complicated leukaemia
by pneumonia and CCF;
Measles More severe and fatal Congenital disease
No special effect Probably increased mortality; congenital
Asymptomatic; erythema infectiosum measles.
Mumps
Parvovirus Increased fetal mortality; '/endocardial
B19 fibroelastosis
Increased severity and mortality Second trimester abortion; hydrops fetalis
Poliomyelitis Asymptomatic with severe anaemia; vertical transmission
Polyoma No special effect haematological effects following late
Rubella infection in pregnancy.
Often more severe; maternal death Fetal death; late stillbirth; neonatal diseasf
Varicella-zoster ?Increased risk of jaundice
Vaccinia and variola Fetal death; chronic persisting infection;
Increased severity and mortality
Venezuelan and western Meningoencephalitis congenital malformations
equine encephalomyelites Neonatal chickenpox; congenital varicella
syndrome
Infantile zoster
Fetal death; intrauterine or neonatal diseas
Neonatal encephalitis
HSV = herpes simplex virus, HIV = human immunodeficiency virus, CCF = congestive.cardiac failure
Table 36.4 Viral infections during pregnancy resulting in fetal or neonatal disease

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316 Obstetrics andGynaecology

w H

Prince Of Medicine-2014-BSUTH

rate of induction of labour but occasionally may be Bibliography and suggested furthei
used incombinationwith prostaglandins. reading
Misoprostol can also be used for medical
Lawson,J.(1982)Deliveryofthedeadormalformedfetus
induction in intrauterine fetal death.
In:Clinics
inobstetrics andgynaecology, Vol. 9, W.B. Saunders,
London.
e*

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Chapter 38
Anaemia in pregnancy
sickle cell disease
Definition absorption of ingested iron, iron freed from
The World Health Organization's (WHO) effete redblood cells in the reticuloendothelial
recommendation is that anaemia in pregnancy system, and mobilisation of iron from iron
is present when the haemoglobin concentration stores. Iron deficiency develops when the iron
in the peripheral blood is 1 Ig/dl or less. stores are depleted and in such cases the blood
However from practical experience in tropical morphology is that of a hypochromic
obstetrics it is generally accepted that anaemia microcytic anaemia.
in pregnancy exists when the haemoglobin In normal pregnancy iron demand is
concentration is less than lOg/dl or the packed increased many folds: the fetus needs about 350
cellvolume (PCV) is lessthan 3 0 per cent. mg, the placenta about 100 mg, the increased
maternal haemoglobin mass about 350 mg, the
amount lost during delivery and in the lochia
Pathophysiology
about 150 mg and that from lactation about 150
For haemoglobin and red cell synthesis, iron,
mg. In addition the pregnant woman still
folic acid, vitamins B12 and C, and trace
excretes iron, but on the credit side about 225
elements like cobalt and copper are required.
mg of iron is available as a result of the
Erythropoietin produced by the renal
amenorrhoea of pregnancy (i.e. what she would
parenchyma stimulates the bone marrow to have lost in her menstrual flow is saved). The
increase erythropoiesis, which is one of the absorption of dietary iron in pregnancy is about
noticeable physiological changes inpregnancy. 15%. The increased iron requirement is not
Inthe non-pregnant, total body iron is about uniformly spread over the period of pregnancy
3.5-4g; two-thirds of this iron is in but rises as pregnancy advances. From 28
haemoglobin, another one-quarter is in body weeks onward, the increased demand is noticed
stores and the remaining is in the tissue and as a resultant drop in PCV or haemoglobin
plasma. Ironis stored in the liver and spleen as concentration if no iron supplementation had
ferritin and in bone marrow as haemosiderin. been given.
Iron in the serum is bound to transferrin, a (3, Folic acid (pteroylmonoglutamic acid) and
globulin, and transferrin is only one-third vitamin B12 are involved in the synthesis of
saturated with iron. Main sources of iron are deoxyribonucleic acid (DNA). Folates are
meat and liver. A good diet provides about 10 to required for normal maturation of red cells in
15mg of iron per day and only 10% of this is the bone marrow. The entry of folates into the
absorbed. Iron is absorbed mainly in the red blood cell is dependent on vitamin B12 and
duodenum and to some extent in the upper methionine. The blood picture in folate
jejunum. The absorption is influenced by dietary deficiency is macrocytic with occasional
phosphate and phytates, ascorbic acid, sugars nucleated red cells. Daily requirement of folic
especially fructose, hydrochloric acid in the acid in non-pregnant women is about 200 pg per
stomach and three gastric factors-Factors I- III. day. Sources offolic acid are yeast, yeast extract,
Iron is lost in the bile, urine, faeces, sweat and crude liver extracts and vegetables, ana these are
of course during menstruation. It is estimated readily damaged by cooking. Folic acid is
that about 1 -2mg of iron is lost daily. stored in the liver as pteroylpolyglutamates and
Normally,this lost iron is replenished by increased in other tissues as tetrahydrofolate for entry into

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Anaemia in Pregnancy Sickle cell disease 327

the folic acid cycle. It is absorbed by passive volume expansion in normal pregnancy is
diffusion across the duodenal and jejunal Abudu and Sofola have shown that this rather
mucosa as monoglutamates, the intestinal excessive plasma volume expansion in normal
conjugates having reduced the dietary pregnant Nigerians on routine haematinics is
polyglutamates to the mono state. Folic acid is responsible for low packed cell volume in these
excreted in the urine and the excretion is pregnant women. Coupled with this fact is that,
increased in pregnancy. The demand for folic if the WHO definition of anaemia is applied,
acid inpregnancy is very high. which in fact is the case in many previous
The daily intake of vitamin B12 is about 5-15 reports, one can now see why the incidence of
[Xg ina good balanced diet, andanimal products pregnancy anaemia quoted is high, However,
are the main sources. Vitamin B12 is excreted in this argument does not remove the fact that
small amount in the gut and urine. Maternal there are factors as discussed below which
transfer to the fetus is very small, so fetal predispose many pregnant women in
demand in pregnancy is not much compared to the tropics to developing anaemia.
ironand folic acid.Vitamin B12 deficiency state Iron deficiency and folic acid deficiency
in pregnancy is therefore very uncommon anaemias are due to either increased demand
except ifthere is intercurrent intestinal disease. reduced storage, diminished intake, abnormal
absorption or abnormal utilisation of iron and
Incidence folic acid and other essential substances needed
The incidence of anaemia in pregnancy varies inhaemopoiesis.
from place to place even within the same The increased demand for these substances
country depending on the socio-economic has already been discussed but this is further
status andlevel of development. While anaemia aggravated by increased incidence of multiple
in pregnancy is uncommon in the developed pregnancies amongst black women. If the
world, it is very common in the developing intake was adequate or increased according to
countries for obvious reasons which are demand as it should be, there would be a
discussed below. It is claimed that 5 to 50% of balance. But invariably there is undernutrition
pregnant women in the tropics who attend or malnutrition prevalent in many parts of the
antenatal clinics are anaemic as against the developing world as a result of socio¬
prevalence rate of 2% inthe developed world. economic deprivation and sometimes due to
taboos and superstitious ways of preparing
Aetiology foodstuffs like overcooking which destroys the
The reasons for the reported high incidence of nutritional value. Of course there is also the
pregnancy anaemia inthe developing world are problem of storage after cooking. Which there
multifactorial. is no refrigeration the cooked food invariably
One of the most dramatic physiological goes bad. The food consumed in most African
phenomena in normal pregnancy is increased homes has low meat, low vitamin, high
blood volume comprising a larger increase in carbohydrate and high phytate contents which
plasma volume than in red cell volume. This reduce iron absorption. Fresh food rich in high
larger increase in plasma volume is responsible folate content is only available during the
for the well known physiological harvest periodwhich is seasonal so the intake of
haemodilution of pregnancy. However, it folate is invariably seasoned too! Along
appears that the npn-pregnant plasma volume with the poor intake is the factor of poor
of Nigerian women is small and the plasma absorption. Fever due to malaria and bacterial
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ipy

328 Obstetrics andGynaecology

infections resulting in intestinal hurry number between 1,000 and 20,000. They are
interfere with absorption and utihsation of attached to the duodenal mucosa and absorb
nutrients. Excessive morning sickness of blood from the submucous tissues.
pregnancy also interferes with intake and Haemoglobinopathies including sickle cell
absorption of nutrients. disease and variants of thalassaemia and
Many women inthe developing world start haemoglobin CC cause severe maternal
pregnancy with a depleted iron store as a result
anaemia in pregnancy. The problems of sickle
of successive pregnancies at too frequent
intervals while not giving the body time to cell disease in pregnancy are discussed later in
replenish its depleted stores. So with no reserve, this chapter.
poor intake and absorption and high pregnancy
demand, it is no wonder that anaemia often Clinicalfeatures
occurs. Many women with anaemia in pregnancy
Malaria is endemic in the tropics; in early would only be discovered at routine estimation
pregnancy the level of acquired immunity is of packed cell volume or haemoglobin at
lowered especially amongst the primigravidae booking, or during the course of pregnancy.
thus increasingthe incidence of malariaattacks. Some women however, would have symptoms
Anaemia is the most serious effect of malaria especially if they have not had any form of
especially that due to P. falciparum infection. antenatal care. Common symptoms include
The anaemia occurs frequently in the second tiredness,weakness, dizziness, fainting attacks,
trimester and is due to a combination of headaches,breathlessness and swollen legs.
haemolysis, folate deficiency and Absence of conjunctival pallor does not
hypersplenism. Erythrophagocytosis of both
exclude anaemia. Pallor should also be looked
parasitised and non-parasitised red cells coated
with malarial antigen occurs i.e., there is for in the buccal mucosa and the nail beds if
increased red cell destruction or reduced red they are not painted. Simple observation of
cell survival. This phenomenon stimulates pallor is not always a reliable sign on its own,
erythropoiesis, increasing the demand for thus making routine estimation of blood
folates. There is reticulo-endothelial and haemoglobin or packedcell volume mandatory.
lymphoidhyperplasia and sinusoidal dilatation Other signs of moderate to severe anaemia
resulting in splenomegaly. Splenomegaly leads include generalised oedema, jaundice, fever
to increased red celldestruction with pooling of and hepatosplenomegaly especially if there has
red cells into the spleen. This vicious cycle been severe haemolysis and infection. Heart
aggravates the anaemia. failure in severely anaemic patients is not
Acute blood loss in pregnancy as a result of uncommon, and the presence of tachycardia
ectopic pregnancy, antepartum haemorrhage, with water hammer pulse, systolic heart
abortion, ruptured uterus and retained placenta with murmurs and raised jugular venous pressure
postpartum haemonhage may cause anaemia. should warn the clinician of this highly fatal
Chronic bloodloss resulting indepletion of the
complication of pregnancy anaemia.
iron stores and consequently impaired
erythropoiesis may result from hookworm
infestation and chronic duodenal or gastric ulcers. Investigations
Ancylostoma duodenale and Necator americanus The most basic investigation has already been
are the commonest hookworms found inthe tropics. mentioned, i.e., regular estimation of blood
' They are found in the duodenum where they may haemoglobin and/or packed cellvolume inpregnancy.

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Anaemia in Pregnancy Sickle cell disease 333

mothers is about 5 to 10 folds, but this can be recorded or charted. Also where facilities are
reduced if the pregnancy is carefully available, routine ultrasonic biparietal diameter
supervised and the mothers are crises free. of the fetus should be done at about 20 weeks
Crises encountered in sickle cell disease and repeated at 32 weeks.. Further tests of fetal
include haemolytic crisis, thrombotic crisis, monitoring like fetal kick count, and antenatal
bone pain crisis and acute sequestration crisis. cardiotocography should be done in centres
Development of systolic hypertension and where electronic monitoring machine is
proteinuria in bone pain crisis indicates available. Indeedbabies with worsening IUGR
imminent bone marrow embolism. can be identified by these tests and the fetal
umbilical artery wave velocity measurement.
Labour and delivery of these patients are so
Management
hazardous and unpredictable that they must be
Management of pregnancy in patients with managed in a tertiary care institution. On
SCD is not easy. Results would be better if in admission to labour ward, the Hb or PCV must
fact these patients had their SCD diagnosed in be checked on a 2 hourly basis. They must not
infancy and were already attending a sickle cell be allowed to have an unduly long labour,
clinic. This would ensure that they would be in therefore, labour is augmented as necessary. In
a stable state by the time they get pregnant and addition, they must all have at least 2 units of
would have been properly counselled as to the fresh haemoglobin AA blood cross-matched
very high risk of pregnancy. ready when in labour; packed cells would be
These patients need to continue with their preferable. The fetus must be monitored
prophylactic antimalarial (proguanil 100 mg carefully in labour and delivery expedited as
daily), and the folic acid is increased to 5 mg necessary.
t.d.s. They should be seen every two weeks and Operative deliveries should be embarked
later every week antenatally and their upon only for purely obstetric indications, and
haemoglobin concentration or packed cell in such cases a good anaesthetist who is
volume estimated at each visit. Any infection conversant with the problems of SCD and
should be treated vigorously with the requisite anaesthesia should be available. Any post¬
antibiotics. Proteinuria should be investigated operative blood loss must be replaced ml for
and a mid-stream urine specimen should be ml. The same is true for postpartum
tested often to detect asymptomatic urinary haemorrhage.
tract infection. One of the aims of frequent In the immediate postpartum period, their
Hb or PCV tends to fall and this should be
antenatal visits is to ensure good health and to
estimated every 4 hours to detect if blood
keep the haemoglobin at a level not less than 6
transfusion wouldbe necessary.
g/dl or a PCV of 18 per cent. Routine iron
If pseudotoxaemia occurs, the patient
supplement is not given to these patients except if should be given adequate analgesics,
there is proven iron deficiency anaemia. Because transfused accordingly with fresh blood,
SCD patients are in a dynamic state of haemolysis commenced on antibiotics and delivered
without any external bleeding, the body iron is preferably by caesarean section, if undelivered.
conservedandused intime of highdemand. Heparinisation should be commenced two
As IUGR is very common amongst pregnant hours after delivery and continued for at least
patients with SCD, the fimdal height should be four days. The dose of heparin is 10,000 I.U.
measured with a tape and the height in centimetres stat, then 5,000 to 15,0001.U. every 6 hours
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to maintan the clotting time at more than 17 SCD in utero (prenatal diagnosis) by sampling
minutes. the chorionic villus as early as in the first
We do not as a routine advocate repeated trimester. If a diagnosis of SCD is thus
prophylactic blood transfusion or exchange established, the mother could be offered an
transfusion antenatally in pregnant patients abortionwhich is best done inthe first trimester.
with SCD. Where such is the practice, the If however she is opposed to abortion on
wellbeing of the mother is improved and fetal
religious grounds or for any other reasons,
mortality improves marginally butthe problems
repeated counselling sessions from the time of
of morbidity especially IUGR are not
significantly improved. The rationale of diagnosis until the baby is bom would enable
prophylactic transfusion is to keep the Hb at her to appreciate and prepare for the critical
about lOg/dl and to reduce the number of sickled problems posedby an offspring with SCD.
cells so that oxygenation is improved. Sound However with good primary health care
reasoning, but inthe tropics there isthe problem programme, availability of good food, good
of finding donors; also repeated transfusion water for drinking and for other household
increases the risk of abnormal antibodies chores, and good attention to hygiene, the
formation. Moreover, raising the haemoglobin chances of a good life for a patient with SCD
or PCV of a patient with SCD to a much higher will improve but her ability to reproduce
level than she is used to, increases the blood successfully as desired is still questionable.
viscosity which can aggravate the thrombosis A woman with SCD shouldbe advised to limit
that is already present. Abudu and Sofola have her family to a small number as a result of the
advanced evidence to show that there is
various complications discussed above.
decreased or lack of intravascular volume
Contraception using intrauterine contraceptive
expansion in pregnant Nigerian patients with
device is preferable to oral contraceptives which
HbSS and HbSC especially more so inthose who
deliver IUGR babies. It is thought that this poor may predispose to thromboembolism. Sterilisation
plasma volume expansion is a result of thrombi may be offered ifthe patient agrees to this.
blocking the end arteries and arterioles of the
uterinevessels that supply the placenta.
When the haemoglobin or packed cell Bibliography and suggested further
volume inthese patients falls below 6 g/dl or 18 reading
per cent, they are transfused with packed cells
Abudu, O., Macaulay, K., Oluboyede, O.A. (1988) Serial
using fresh cross-matched blood from donors serum ferritin and other haematological parameters in
with normal genotype, HbAA. normal pregnant Nigerianprimigravidae. Int.J. Gynaecol.
Obstet. 26:33-39.
Prognosis
The prognosis is rather poor. The type of care that Abudu, O., Sofola, O.A. (1988) Intravascular volume
expansion and fetal outcome in pregnant Nigerians with
these patients needcan hardly be provided inmost haemoglobin SS and SC. J.. Natl. Med, Assoc. 80:8, 906-
countries in the developing world because of the 912.
prevailing poor socio-economic status, hence the
rather high maternal and fetal mortality. Abudu, O., Macaulay, K., Oluboyede, O.A. (1990) Serial
Recent advances in the field of molecular evaluation of iron stores in pregnant Nigerians with
biology have now made itpossible to diagnose haemoglobin SS and SC. J.Natl. Med,Assoc. 82:1:41-48.

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.
Anaemia in Pregnancy Sickle ceildisease - 335
*' -*

Agboola, A. (1975) Placental changes in patients with a Luzatto, L., Ajabor., L.N. (1972) Pregnancy in
lowhaematocrit. Br.J. Obstet Gynae 82:225-227. homozygous sickle cell anaemia. Br. J. Obstet. Gynae
79:396-409.
Agboola, A. (1979) Effect of type and duration of
anaemia on placental weight and villous histology. J. Piyor, D.S. (1967) The mechanism of anaemia intropical
Natl. Med.Assoc. 71: 1067-1069. splenomegaly. Quarterly Journal of Medicine 36: 337-
356.
Anderson, M., Went, L.N., Maciver, P.G et al (1960)
Sickle celldisease inpregnancy. Lancet2: 516-521. Watson JC, Flerring DW, Borella AJ, Olcott ES, Conrad
RE,Baron RC (1993).Vertical transmission of hepatitisA
Cunningham, F.G, Pritchard, J.A., Masion, R. et al. resulting in an outbreak in a neonatal intensive care unit
(1979) Prophylactic transfusions of normal red blood Journal ofInfectiousDiseases 167:567
cells during pregnancies complicated by sickle cell
haemoglobinopathies. Am. J. Obstet. Gynaecol. Harrison, K.A. (1982) Anaemia, Malaria and Sickle cell
135:994-1001. disease. In Clinics in obstetrics and gynaecology, Vol.
9:3. Philpott, R.H. ed., W.B. Saunders London.
Fleming, A.F. (1969) Iron status in anaemic pregnant
Nigerians.J. Obstet. Gynae. Br. Cwlth. 76:1013. Abudu O., Sofola, O.A. (1985) Plasmavolume innormal
pregnant Nigerian primigravidae. Int. J. Gynaecol.
Harrison, K.A.,Ibeziako, P.A. (1973) Maternal anaemia Obstet. 23: 137-142.
and fetal birthweight. J. Obstet. Gynae. Br. Cwlth. 80:
798-804. Giles, H.M. Lawson, J.B., Sibelas, M., Voller, A., Allan
N. (1969) Malaria, anaemia and pregnancy. Ann. Trap.
Hendrickse, J.P., Harrison K.A., Watson- Williams, EJ., Med Parasitology 63: 245.

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Chapter 39

Severe anaemia in pregnancy

Definition From the study in Zambia the pathological

picture of severe anaemia due to malaria
The accepted definition of anaemia in includes macrocytosis, erythroid hyperplasia,
pregnancy by the World Health Organization neutrophil leucocytosis, monocytosis and the
(WHO) is a haemoglobinless than 1lOg/L. presence of intracellular iron in bone marrow.
Developing countries or sub-Saharan Africa Anaemia of iron deficiency is however
should be guided by this definition and no characterised by less severe anaemia,
longer talk of haemoglobin of lOOg/L now that microcytosis, hypochromia, poikilocytosis,
Africa is striving to eliminate most of the target cells and absence of iron in the bone
marrow.
aetiological factors of anaemia.
AIDS is now becoming frequently seen as a
Africa and developing countries still accept the
cause of severe anaemia in the affected
definitionof haemoglobin of less than 70g/L as
severe anaemia.
developing world of sub-Saharan Africa.
Haematological abnormalities appear to be due
Aetiology to direct retroviral infection of bone marrow
The order of priority of aetiological factors of cells, changes in the regulation of
anaemia in East and southern Africa appears to haematopoiesis, responses to infection and
be different from that in West Africa including autoimmune destruction of cells.
Nigeria. Haematological picture includes leucopenia
and thrombocytopenia while bone marrow
Inmost cases of severe anaemia inZambia, the aspiration may reveal mixed patterns of
aetiological factors are multifactorial but put in hypercellularity, red cell hypoplasia,
order of priority,they are: granulocyte hyperplasia, excess of plasma cells
and lymphocytes, and increasedstainable iron.
a) Malaria mostly due to Plasmodium
falciparum In southern Africa, severe anaemia in
b) Folate deficiency pregnancy is more common with increased
c) Iron deficiency incidence of malaria. It is not uncommon to see
d) Sickle cell anaemia pregnant women with haemoglobin as low as
e) Infections (urinaiy or upper respiratory) 30 g/L. Surprisingly, some of these women do
f) Acquired immunodeficiency syndrome survive with adequate therapy.
(AIDS)
Clinicalfeatures
Folate deficiency is secondary to malarial Symptoms of anaemia in pregnancy have already
haemolysis. Iron deficiency is both nutritional been described earlier in a previous chapter but in
and also due to hookworm infestation. Severe severe anaemia they are more exaggerated. Usually
anaemia due to sickle cell anaemia appears to the affected mothers are young teenagers mostly,
be more common inNigeria and probably West and there appears to be no correlation with
Africa than inZambia. parity except in cases where these teenagers decide
to have babies at very short intervals in an endemic

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Severe anaemia inpregnancy 337

** " .5 * '
mmsmÿHSSeH
malarial area. dosage of 600 mg stat, followed by 300 mg 6
hours later, and then 300 mg daily for 2 days,
For obvious reasons, severe anaemia is making a total of 10 tablets. Due to increasing
encountered more frequently inwomen intheir resistance to chloroquine in many parts of
thirdtrimester than inthe first trimester. Africa, this regime is currently being reviewed
inNigeria.
Apart from severe conjuctival pallor, massive
pedal oedema and probably jaundice, gross Folic acid is usually given as 5mg daily. Only in
hepatomegaly and splenomegaly may be case of vomiting should folic acid be given
significant features. Symptoms and signs of parenterally.
AIDS including lymphadenopathy should also
be looked for inwomen with severe anaemia. There are many preparations in the market
nowadays which contain both iron and folic
Investigations acid in case the anaemia is of a mixed aetiology
Thick blood films in most cases may show of ironand folic acid deficiency.
Plasmodium falciparum asexual forms.
Occasionally, Plasmodium malariae may be seen. Severe anaemia of iron deficiency aetiology is
not as common as that due to malarial infection
Haemoglobin electrophoresis is mandatory as the and folate deficiency in southern Africa.
severe anaemia may bedue to sickle cellanaemia. Ferrous sulphate 200mg t.d.s or ferrous
gluconate 300mg t.d.s provides adequate iron
Stool shouldbeexamined for the ova of hookworm. for replenishment.

Urine microscopy may reveal ova of Schistosoma The use of Total Dose Ironintravenous therapy
haematobium or even bacterial infection. (Iron dextran) as practised in Zambia most
probably has no added advantage over oral iron.
Bone marrow aspiration sample usually shows Dietary supplementation is essential and
eiythroid hyperplasia and myeloid hyperplasia. patient should be de-wormed in case of
Megaloblastic erythropoiesis and myelopoiesis are parasitic infection likehook worm infestation.
typical, and there may be absence of intracellular
iron but malarialpigments may be seen. The use of blood transfusion may be
unnecessary in early pregnancy unless the
Management anaemia is very severe and the patient is in
The management of severe anaemia in incipient cardiac failure or she is a sickler with a
pregnancy very much depends on the stage of haematocritvalue of lessthan 13 percent.
pregnancy at which the diagnosis is made. If in
the first or second trimester of pregnancy, a full Great caution should be taken when blood is to be
investigation of the aetiology is mandatory transfused. The blood should be compatible packed
before commencement of treatment. Most red blood cells and in case of sicklers the
cases due to malaria and folate deficiency will haemoglobin electrophoresis must be AA. Blood is
respond to antimalarials and oral folic acid. transfused slowly with an added fast acting diuretic
Chloroquine is usually given in the normal like frusemide 40-8Gmg for each unit of blood
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' 1
338 Obstetrics andGynaecology

transfused to prevent the patient from going recommended drugs are:

intocardiac failure. a) Quinine sulphate (oral), 600mg 8
hourly for 7 days.
Broad spectrum antibiotics like ampicillin b) Sulphadoxine-pyrimethamine
should also be administered orally at a dosage (fansidar) orally (only in combination
of 250-500mg 6 hourly to prevent infection with quinine when necessary), 3 tablets
even ifno urinary or upper respiratory infection stat as a single dose (1 tablet = 500mg
has been isolated. It must be remembered that sulphadoxine + 25mg pyrimethamine).
women with severe anaemia already have a low
resistance to infection. In severe and complicated malaria or cerebral
malaria with resultant severe anaemia, it is
In the latter part of pregnancy especially in the always advisable to administer quinine (e.g
last four weeks of pregnancy, blood transfusion Adco-quinine dihydrochloride) by the
in the form of packed red cells is normally intravenous route. Loading dose - Quinine
recommended as the patient may go into labour dihydrochloride salt 20mg/ kg body weight,
unexpectedly. With a low haemoglobin and intravenously, in 5% dextrose-saline (5-10
copious blood loss during or after delivery, the ml/kg body weight depending on the patient's
resultant effect could bematernaldeath. fluid balance) over 4 hours.
Blood transfusion to correct blood loss after Maintenance dose - 8 hours after start of the
labour and inthe immediate puerperium should loading dose give maintenance dose of quinine
be given with caution usually ml for ml. A dihydrochloride salt of lOmg/kg in dextrose-
woman who has lost 300ml of blood should saline diluted as above over 4 hours. The
only be transfused with 300ml in return as maintenance dose should be repeated every 8
packed cells to prevent cardiac failure. Booster hours untilthe patient cantake oralmedication.
transfusion couldbe given about 48 hours later
if her condition warrants it. The use of Total duration of treatment is 7 days or until
intravenous ergometrine given to the mother at smears are negative.
delivery is contra-indicated as this may lead to
auto-transfusion from the placental bed and to c) Halofantrine (oral), 500mg 6 hourly for
overloading of her circulation with resultant 3 doses on an empty stomach.
cardiac failure. Treatment dosage is repeated one
week later innon-immune patents.
Prophylactic proguanil lOOmg daily is
Other antimalarials which have been tried include
recommended for all pregnant women in sub-
SaharanAfrica where malariaisendemic. mefloquine and artemisinin especially in quinine
resistant cases but adequate care must betaken.
It is of interest that some strains of Plasmodium are
becoming resistant to chloroquine in some southern Quinine toxicity when given intravenously presents
some problems and patient should be carefully
African countries like Zambia and quinine is now
monitored. These include hypoglycaemia (blood
the best choice of drug in such cases. Sometimes
glucose levelshouldbemeasured before and during
sulfadoxine-pyrimethamine (fansidar) may be
treatment), cinchonism, deafness, cardiac
effective but not as effective as quinine. The
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Severe anaemia inpregnancy 339

anythmias, hypersensitivity, hypertension, of severe anaemia.

visual disturbances, heart block, and oliguria
(urinary output should be measured during Studies from Nigeria have already shown that
therapy). an anaemic woman does not necessarily give
birth to an anaemic infant. The infant being a
Following treatment with quinine as well as clever parasite while inutero drawshis required
other antimalarials, a follow-up blood smear is nutrients from the mother untilhe can obtain no
taken 2-3 weeks after completion of treatment more and it is then that intrauterine death or
to confirm elimination of the Plasmodium perinatalmortality may occur.
parasites. Administration of folic acid should
however, continue. Prognosis: This is a public health problem and
with improved education, increased health
While researches are ongoing in the awareness, eradication of poverty and malaria,
development of a suitable vaccine, there is still improved nutrition and better environmental
probably a longtime to wait. planning, severe anaemia may become an event
Labour: Management of labour of severely of the past in sub-SaharanAfrica. Health policy
anaemic pregnant women should not be makers have a greatjob to do inthis direction.
different from normal labour. Oxygen should be
made available and administered if necessary.
Assisted delivery is usually advocated.
Agboola A. (1974). "Placental-fetal weight ratios and
Abdominal delivery is only indicated for
placental changes in anaemic pregnant Nigerians". M.D.
obstetrical reasons. The use of ergometrine has
Thesis of the University of London. Department of
already beendiscussed above.
Health, Pretoria (1996). Guidelines for the treatment of
malaria.The Government Printer,Pretoria.
Puerperium: Prophylactic broad spectrum
antibiotics should be given as a rule for about 2
Fleming A.F. (1989). The aetiology of severe anaemia in
weeks to prevent infection that may predispose
pregnancy in Ndoia, Zambia. Annals of Tropical
to cardiac failure.
Medicine and Parasitology. 83,37.
The infants delivered by severely anaemic
Fleming A.F. (1990) Malaria, Deficiencies Of Iron And
women are lighter in weight when compared
Folate And Anaemia In Pregnancy In The Guinea
with those of non-anaemic women.
Preterm labour is mostly responsible for this. Savanna of Nigeria. Coiloque NSERM, Herchberg S.,
GalanP., Dupin,Heds., 197,75.
This may be caused by hyperpyrexia of malaria,
which stimulates premature onset of labour
or to the oxytocic action of quinine when
employed to treat malaria, a causative factor

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Chapter 40

Antepartum haemorrhage

Definition 4. Localcauses

Antepartum haemorrhage is bleeding from the 5. Vdsa praevia

genital tract after the 28th week of gestation and Placenta praevia
before the onset of labour.
Aetiology
Some authors have however defined this as The cause of placenta praevia is unknown althou|
haemorrhage occurring after the 24th week of some aetiological factors havebeen suggested.
pregnancy. The latter is applicable more in (i) Faulty implantation ofthe ovum. The fertilisec
developed countries where fetal survival is not ovum may implant low inthe uterine cavity.
uncommon after the 24th week. (ii) Highparity. This condition is morecommon in |
the multigravida than inthe primigravida.
INCIDENCE (iii) Advanced age. It is more common in women
The true incidence of antepartum haemorhage over the age of 3 5 years.
countrywide is difficult to establish with (iv) Uterine fibroid. Multiple submucous fibroids
accuracy in the developing countries due to occupying the upper uterine segment may
lack of reliable data. Ithas however beenshown cause the fertilised ovum to implant in the
that geographical and socio-economic factors lower segment andresult inplacentapraevia.
may affect itsincidence. (v) Large placental surface. Large placenta as
obtained in multiple pregnancy and a
CLASSIFICATION placenta membranacea may encroach on
The bleeding can be classified into five broad the loweruterine segment.
categories. (vi) Previous uterine damage. It has been
postulated that scar in the uterus as in
1. Placentapraevia previous caesarean section may predispose
This iswhenthe placenta is inpart or entirely in to placenta praevia. Other conditions
the lower uterine segment because it is seen include frequent episodes of dilatation and
there at imaging, caesarean section or at curettage, and evacuation of uterus for
examination intheatre (BIT) retainedproducts of conception.

2. Abruptio placentae A diagnosis of Incidence

abruptio placentae is made when there are The incidence of placenta praevia varies from
clinical signs of tense, tender uterus or ifthere is one institution to another. In some western
evidence of retroplacental clot at delivery. countries, it ranges from about 0.2 to 1.0
percent of alldeliveries.
3. Haemorrhage of undeterminedorigin
This embraces other causes of haemorrhage Classification
having excluded placenta praevia, abruptio Placenta praevia can be classified as follows
placentae, and bleeding from the genital tract. Type I- The placenta encroaches on the lower

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# 2 ; s ' "
Antepartum haemorrhage 341

uterine segment but does not reach as far as the

internal os.
Type II- The placenta reaches to the internal os
but does not cover it.
Type III- The placenta covers the internal os by
reaching across to the farther margin but ceases
to do so as the cervix dilates. TYPE TYPE

Type IV - The placenta covers the os to such a

degree that even dilatation of the cervix does
not bring its marginover the cervix, (fig. 40. 1)

Clinical history
The woman complains of slight vaginal
bleeding during the .third trimester of
pregnancy. The bleeding is painless and may be TYPE Hi TYPE IV
repeated after a couple of days. Sometimes it Figure 40.1 Types of placenta praevia
may be severe especially if it occurs in labour
during cervical dilatation. Some women with Investigations
placenta praevia may have experienced The routine investigations include estimation of
"spotting " during the first and second haemoglobin or packed cell volume, full blood
Trimesters of pregnancy. count, haemoglobin electrophoresis, and urine
for microscopy, culture and sensitivity.
Clinical findings
There may be evidence of pallor especially if the The special investigations are carried out with a
patient has had repeated haemorrhages. Shock is view to localise the placenta and confirm the
not uncommon after a heavy bleeding episode. diagnosis: Ultrasound. This method is non¬
Abdominal examination which should be gentle invasive, accurate, safe and may be repealed on
may reveal a high head or presenting part. The lie several occasions.
of the fetus may often be abnormal, oblique or
transverse due to the fact that the placenta (i) Transabdominal ultrasonography
occupies the lower segment. The abdomen is soft, This is the conventional method and is
relaxed, and non-tender, and fetal heart sounds are also widely used inNigeria. A full bladder
audible and regular except in a few cases is customary for a good examination,
complicated by hypovolaemic shock which may (ii) Transvaginal ultrasonography. Withthi s,
cause the fetal heart sounds to be irregular or faint. imaging is better and the patient does not
need a full bladder. It is recommended as a
Pelvic examination at the casualty or emergency confirmatory method if placenta praevia
room at the time of admission is forbidden so as is suspected at transabdominal
not to evoke further haemorrhage. ultrasonography inmid-pre0nancy.
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Magnetic resonance imaging (MRI) This is a obstetricians still needs more trials before it
newer technique that may be superior to routine merits can be accepted considering the side
ultrasonography in terms of quality of imaging. It is effects of ÿ-sympathomimetic drugs.
however, very expensive and probably presently
unffordable by many developing countries. Most authors believethat pregnancy should not
be allowed to progress beyond 38 weeks before
Examination in theatre (EIT) The most
accurate method of diagnosing placenta
termination is undertaken so the patient is taken
praevia is by examination in theatre (previously to theatre at that time for an examination in
examination under anaesthesia) when the theatre (with a double set-up). Inthis procedure.
placenta will be felt in the lower uterine the fornices are first palpated for evidence of a
segment. This procedure is carefully carried out boggy mass followed by a gentle digita
without anaesthesia but not until 38 weeks examination through the cervical os to feel the
gestation whenthe fetus is to be delivered. placenta inthe lower segment.

Treatment For Types Iand IIanterior placenta praevia, the

Expectant treatment: If the bleeding is slight. treatment is artificial rupture of membranes
the patient is admitted to the ward and blood followed by intravenous oxytocic infusion to
transfusion is commenced to replace any blood induce labour and effect delivery.
loss and raise the haeomoglobin to about 80
For Types IIposterior. III and IV, the treatment
percent (11.7 gm). This is very important
because it iswell knownthat a woman who has is caesarean section. Profuse bleeding is to be
had a haemorhage in pregnancy is in danger of expected so at least 2 units of blood must be
further and more serious haemorrhage which made available for the operation.
may result in intrauterine death of the fetus or
even maternal mortality. An initial sedation Active treatment Immediate resuscitation with!
such as pethidine 100 mg is prescribed. blood is mandatoiy if there is massive bleedim
Caesarean section should be carried out promptly
An ultrasonic scan is carried out to make a irrespective of the maturity of the fetus if the baby ]
definitive diagnosis. Ifthe diagnosis of placenta is to be salvaged. It isalso safer for the mother.
praevia is not confirmed, the patient could then
be allowed home and a re-scan arranged later in Asymptomatic placenta praevia. This is
pregnancy. If the diagnosis is however, placenta praevia that is discovered incidental!]
confirmed, the patient remains in hospital until during routine ultrasonic examination anc
delivery. A scan is repeated periodically to look
without prior symptoms ofvagina! bleeding. The
for evidence of placenta rising, and
measurement of the fetal abdominal
teaching in most units nowadays is to repeat th<
scan and if confirmed to treat such patients, ii
circumference as a means of detecting fetal
growth restriction. Fetal anomaly which is not minor placenta praevia. as outpatients and asl
uncommon could also be detected from the them to report in hospital if there is any episode
scan. A late scan at 36 weeks is also considered of bleeding. Such outpatient treatment should bel
necessary to determine further placenta rising. reserved for patients who live within an eas}
reach of hospital should a massive bleeding I
Similarly, the use of tocolytics as advocated by some occur. They should also be advised against I
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Antepartum haemorrhage 343

346 Obstetrics andGynaecology

fibrinogen 4-8 grams is given intravenously. In

I
the oliguric to the early diuretic and finally to
the absence of fibrinogen, triple strength plasma the recovery phase with this regimen.
could be given as an alternative. Triple strength Continuous impairment of renal function
plasma is prepared by mixing the contents however, may require renal dialysis and
(powder form) of three bottles of plasma into one consultation with a nephrolegist.
and constitute the solution. Ifthere is intractable
clotting defect and bleeding persists, it may be Prognosis
worthwhile giving antifibrinolysins although The maternal mortality in abruptio placentae is
they are more effective where an excess of the invariably due to complications such as
fibrinolytic system has been demonstrated. The cerebrovascular accidents following severe
antifibrinolysins commonly used are Trasylol or hypertension, renal failure and haemorrhage.
epsilon aminocaproic acid (EACA). The end While some authors claim no mortality, it is
result of disseminated intravascular coagulation generally believed that maternal mortality may
(DIC) complicating abruptio placentae is a range from 0.5-5.0 percent especially in the
hypofibrinogenaemia, platelet deficiency and a developing countries.
reductionof clotting factors V and VII.
Perinatal mortality in abruptio placentae is
Renalfailure: This may complicate abruptio quite high even in the developed countries
placentae especially the concealed type. Renal where resuscitative measures are readily
failure is confirmed when urinary output is less available. It may be as high as 50-80 percent in
than 30m/ per hour or 600m/ in24 hours. A self- most centres in developing countries. Placental
retaining catheter inserted in the bladder on abruption has a profound impact on stillbirth
admission will enable early detection of this preterm delivery, and fetal growth restriction.
complication. It is usually the result of Sonographic findings of placenta! abruption]
prolonged hypovolaemic shock, hypertension also correlates with fetal outcome.
and DIC. There is every possibility that the
lesion is that of acute tubular necrosis or Local causes
corticalnecrosis. An attempt should be made to
improve renal circulation and promote diuresis. Speculum examination should only be carried I
The patient is put on strict intake and output out after excluding placenta praevia by |
chart. Blood is taken daily for urea, uric acid, ultrasound examination. Local causes ol
creatinine and electrolytes estimation. bleeding from the lower genital tract include:
Cervical erosion.
Administration of a 50ml intravenous bolus of Cervical polyp.
20% mannitol may be useful during the oliguric Carcinoma of thecervix.
phase. Daily fluid intake is restricted to the Varicosities of the vulva or introitus.
amount of urine passed plus the volume of Vaginitis.
vomitus if any in the last 24 hours, plus 1,500 Trauma.
ml, which represents the amount of insensible
Clinical symptoms
loss in the tropics. The fluid is preferably given
The patient presents with vaginal bleeding
as 10% dextrose solution to provide enough
calories for the patient. Electrolyte imbalance which usually scanty.
should be corrected according to the daily Management
electrolyte results. The patient may pass from Bleedingfrom cervicalerosionis usuallyslight and
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will stop without any treatment. Cauterisation Clinically there will be signs of fetal distress
inpregnancy shouldbe avoided. and immediate caesarean section should be
carried out to avoid fetal mortality.
Cervical polyp usually mucous or
fibroadenomatous, should preferably be left
alone unless there is active bleeding when Bibliography and suggested further
gentle avulsion can be performed. Bleeding reading
from the base after removal will usually stop Ananth CV, Berkowitz GS, Savitz DA, Lapinski RH( 1999).
after some hours once pressure is applied. Placental abruption and adverse perinatal outcome. JAMA
Carcinoma of the cervix is usually friable and 282:1646-51.
readily bleeds to touch. Its management is Chan CC, To WW (1999) Antepartum haemorrhage of
discussed elsewhere inthis book. unknown origin - what is its clinical significance? Acta Obstet
Gynecol Scand. 78:186-90.
Varicose veins may rupture and cause some
bleeding. A gentle pressure may be all that is Crane J.M van den Hof MC, Dodds L, Armson BA, Liston R.
necessary to stop the bleeding. Occasionally it (1999). Neonatal outcomes with placenta previa Obstet
may be required to ligate a ruptured vein. Gynecol 93:54 1-4.

Vaginitis is usually due to trichomonas Green-Thompson, R.W (1982) Antepartum haemorrhage In

infection and this istreated with the appropriate Clinics in Obstetrics and Gynaecology, H.R. Philpott ed, W.B.
medication. Saunders, London, 9:479.

Traumais managed on its own merit. Lawson, J.B. and Stewart, D.B. (1967) Obstetrics and
Gynaecology in the tropics and developing countries, ed,
E.L.B.S. and EdwardArnold, London..
Vasa praevia
Neilson J.P. (1999) Antepartum heamorrhage. In Dewhursfs
Invelamentous insertion of the umbilical cord, Textbook of Obstetrics and Gynaecology for Postgraduates, 6
the cord is inserted on the chorionic membrane ed, Edmonds, D.K.ed, Blackwell Science Ltd,London.
outside the placental margin. Veins from the
Nyberk DA, Mack LA, Benedetti TJ, Cyr DR; Schuman WP
cord could rupture while traversing the
(1987) Placental abruption and placental haemorrhage:
membranes lying below the fetal presenting correlation of sonographic findings with fetal outcome.
part. This conditionwhich is rare istermed vasa Radiology 164:357-61.
praevia.
Rosen DM. Peek MJ (1994). Do women with placenta praevia
The bleeding in this case is of fetal origin and without antepartum haemorrhage require hospitalization? Aust
N.Z.J. Obstet Gynaecol 34:130-4.
fetal blood can be confirmed by the Kleihauer
test or the simple alkali denaturation test. Fetal Taipale P, Hiilesmaa V, Ylostalo P (1998) Transvaginal
exsanguination canoccur rapidly. ultrasonography at 18-23 weeks in predicting placentapreviaat
delivery. UltrasoundObstet Gynaecol 12:422-5

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v 'Chapter *41
| -,

Pregnancy induced hypertension

......
J* •
*.
: v,
*-***ÿ •* ÿ-vv. v*
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•**• -
•
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pre-eclampsia and chronic,hypertension

Hypertension is the most common medical hypertension and proteinuria, which often
problem seen in pregnancy. The hypertensive develops after the 20th week of pregnancy. In
disorders of pregnancy constitute major threats hydatidiform mole, however, it could occur
to maternal life during pregnancy, labour and before the 20th week. The occurrence of PE in
the immediate postpartum period. Since most molar pregnancy suggests that the presence of a
cases inthe developing countries present late in fetus is not essential to the development of the
pregnancy and because there are inadequate disease.
facilities for investigations, it is not easy to
differentiate on clinical grounds between PE is essentially a disease of the primigravida
pregnancy induced hypertension (PIH), and is more common in the age group of <2(
essential hypertension and chronic renal and >35 years. When this condition is present in
disease. Under the general title of hypertensive the multipara it is commonly associated with I
disorders of pregnancy the following multiple pregnancy, essential chronic
classification is acceptable: hypertension and chronic renal disease. It is
also seen in multiparous women in their first
1. Pregnancy induced hypertension (PIH). pregnancy with a new partner.
(a) Gestational hypertension or PIH alone
without proteinuria or other associated features. Hypertension
(b) Gestational hypertension with proteinuria Hypertension is usually defined as a BP of
i.e. pre-eclampsia (PE). 140/90 mmHg and above. This is because
perinatal mortality has been found to be
2. Chronic hypertension (CHT) of any significantly increased above a diastolic BP of
aetiology. This includes essential hypertension 90 mmHg. Ina normal pregnancy, however, the
and chronic renal disease. BP falls gradually untilthe late second trimester
(22-24 weeks) whereupon it begins to rise and
3. CHT with superimposed PE. reaches pre-pregnant levels at term. Thus, the
gestational age at which the BP is recorded
Pregnancy induced hypertension (PIH) should be taken into consideration. Also BP
PIH is the development of hypertension in the readings differ between ethnic groups. A study
second half of pregnancy on two or more done in Ile-Ife, Nigeria, showed that the figure
occasions, about 4 hours apart, in a woman who for 2 standard deviations above the mean BP, of
has previously been normotensive, and inwhom 189 women who were monitored during the
blood pressure (BP) returns to normal within 6 different stages of pregnancy, was 130/80 mm
weeks of delivery. PIH without proteinuria is a Hg. Different mean values and upper limits
relatively benign conditionand usually occurs in should therefore be set for different stages of
the third trimester, during labour or the pregnancy, in different populations. However,
puerperium. Perinatal mortality is usually not since most patients book late in pregnancy in
increased in this condition and it is thus Nigeria, it is necessary to have an absolute value
important to distinguish betweenitand PE. at which monitoring of the patient can be
PEis a multi-systemic disorder characterised by commenced and the figure of 140/90 is thus used.

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Pregnancy inducedhypertensionpre-eclampsia andchronichypertension 349

A change in BP is also used in the definition of the urine as, in dilute urine e.g. specific gravity
PIH. Many pregnant Nigerians have relatively less than 1030, proteinuria of 1+ (0.3g
low BP readings and may develop albumin/ 1) is significant. Before ascribing
complications of PE before their BP reaches the proteinuria to PE, other possible causes such as
absolute level of 140/90 mm Hg. Since diastolic urinary tract infection, vaginal discharge and
BP rises by about 10 mm Hg at the end of chronic renal disease have to be excluded.
pregnancy, it has been suggested that the Examination of a mid-stream specimen of urine
definition of hypertension in pregnancy should obtained after cleaning the vulva with water
include a rise in diastolic BP of at least 25 mm would exclude urinary tract infection and
Hg. The standard definition in Nigeria, vaginal discharge. Proteinuria of chronic renal
however, has been an increase in systolic BP of disease pre-dates the pregnancy and occurs
50 mm Hg above the earliest recorded reading throughout its duration. This, of course, applies
or a diastolic increase of 15 mm Hg. Using this to patients who booked before the 20th week of
definition of a change in BP readings also helps pregnancy. In unbooked patients or patients
who booked late, the distinction may not be
differentiate between borderline essential
made until after pregnancy when the
hypertension and true PIH.
proteinuria becomes persistent. Renal biopsies
are only indicated in cases before 32 weeks
In summary, therefore, hypertension in
where knowledge of the renal lesion would
pregnancy should be defined as a BP of affect management and a steroid-sensitive
mmHg and above, or a rise in systolic BP of 30 lesionis suspected. Insuch cases, the diagnosis
mm Hg or diastolic of 15 mm Hg during the of chronic renal disease becomes obvious.
course of pregnancy. It is important to confirm Orthostatic ('standing straight') proteinuria is an
abnormal readings by rechecking the BP 4 hours uncommon cause of proteinuria and is not
later but a single reading of 110 mm Hg diastolic peculiar to pregnancy. Testing the urine before
BP or more is appropriate for diagnosis. and after activity can make the diagnosis.
Proteinuria in PE is associated with the classic
The Korotkoff sound to be used in measuring the pathological finding of
diastolic reading is also controversial. Phase 4 glomeruloendotheliosis, which is not
(muffling phase) has been used in the past and is permanent but recovers after delivery. The
what most management strategies are based on. occurrence of hypertension and progressive
However, phase 5 (disappearance phase) is more proteinuria increases the poor maternal and
reproducible, correlates better with intra-arterial fetal outcome inPE. Other causes of proteinuria
measurements of diastolic blood pressure, and is inthe tropics likesickle cell disease and malaria
more closely related to outcome. Thus phase 5 is should be considered as differential diagnosis.
beingincreasingly accepted as preferable.
Oedema is now not generally accepted as a
pathognomonic sign ofPE.This isbecauseoedema
Proteinuria
of the feet and hands is present in 50 - 80% of
Proteinuria is usually defined as the presence of
300mg or more of protein in a 24-hour urine normal pregnancy. However, where rapidly
collection or a protein measurement of 2+ (Ig increasing or severe oedema of the fingers, face or
albumin/ 1) or greater ina randomurine specimen. legs is present, the sign of oedema should be taken
Attention should be paid to the concentration of seriously and other features of PE should be

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ÿ 350 0bstefrics andGynaecology

Pregnancy inducedhypertensionpre-edampsiit andchronic hypertension 353

trained and motivated staff are present. hydralazine can also be used in moderate to
Antihypertensives severe hypertension as a second-line drug, for
These drugs should be used to treat those patients who do not respond to
hypertension whether due to non-proteinuric monotherapy with methyldopa alone.
PIH, PE or CHT. This is so as to reduce the risk
of complications of hypertension, especially Beta-blockers are useful antihypertensives in
that of cerebral haemorrhage. However, it is clinical practice but their safety in the fetus is
not so well established. There is suggestion that
established that while these drugs may lower
the BP andreduce maternal complications, they they may cause IUGR when used for long term
in pregnancy. They are thus not recommended
do not prevent the progression of the disease.
for use in pregnancy except in some CHT
The exact level of BP at which to commence
patients who are poorly controlled on other
therapy remains controversial but all agree that
medications.
it is mandatory to treat if the BP goes above or
equal to 170/110 mmHg. In Nigeria where Labetalol is listed as an alpha and beta-
blood pressure levels are slightly lower than in adrenergic blocking agent but in fact contains
Caucasians, it may be wiser to commence more of beta-blocking agent. This drug can be
treatment at lower levels. used intravenously in acute cases to control BP
Methyldopa is the drug of choice for (dose is 100-400mg) or orally in graduated
hypertension in pregnancy. It acts centrally by doses for less severe cases. It has a rapid onset
stimulating ia2 adrenoceptors and reducing of actionbut because of the concern about beta-
sympathetic outflow and has been found not to blockers (see above), it should be restricted to
have any serious side effects on the fetus or short-term therapy inthe thirdtrimester.
children followed up to the age of 7 years. It is
the most commonly used drug for treatment of Calcium channel blockers cause vasodilation
hypertension in pregnancy on a long-term by inhibiting calcium influx into vascular
basis. The dose is 0.5g to 3g daily in divided smooth muscle cells. Nifedipine is commonly
doses. Side effects include sedation, depression, used and oral administration of a 10 mg tablet
nightmares and postural hypotension. The fall in reduces BP within 10-15 minutes, but with the
BP ismaximal after 4-8 hours. slow release tablet, the onset of action is about
60 minutes. Side effects include headache,
Hydralazine is the most commonly used drug for tachycardia and facial flushing. They are useful
the management of severe hypertension. It lowers both for the management of severe
the BP by direct action on the vascular smooth hypertension and also for long-term control of
muscle producing peripheral and central moderate hypertension.
vasodilatation. It improves renal blood flow, may
improve utero-placental blood flow, and produces Alpha-adrenergic blocking agents such as
a reflex tachycardia and increased cardiac output. prazosin have the advantage of reducing
It is given as a slow intravenous injection in doses of peripheral resistance particularly inthe visceral
5mg, repeated every 20-30 minutes as necessary. vascular bed, and increasing blood volume
Its onset of action after intravenous administration without a decrease incardiac output. The initial
is 15-20 minutes. Side effects include dose is 1mgtwice daily, and can be increased to
headache, restlessness and palpitations. Oral a total of 30mg daily as required.
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u 354 Obstetrics and Gynaecology

Diuretics should not be used because they will should receive corticosteroids in order to
aggravate the already depleted plasma volume induce fetal lung maturation.
inpatients with PE. They should only be used in
pregnancy for the treatment of heart failure and Labouranddelivery
pulmonary oedema. These should be well supervised and should
take place in centres with facilities for recourse
Angiotensin-converting enzyme (ACE) to caesarean section. Labour should be induced
inhibitors (e.g. captopril, enalapril) should also when it is desirable to terminate the pregnancy.
not be used in pregnancy because despite being Ifdelivery is to be effected before 34 weeks the
effective hypotensive drugs, they are very chances of success are lower and caesarean
hazardous to the fetus. They cause section may have to be resorted to. Even if
oligohydramnios, renal failure, hypotension induction is successful, emergency caesarean
and there is even a risk of intrauterine death. section may be necessary because of fetal
Women with CHT previously on ACE distress in labour. In cases of mild PE,
inhibitors should be switched over to drugs like pregnancy should not be allowed to go past term
methyldopa. and induction of labour should be performed
In acute severe hypertension, pre-treatment any time after 38 weeks. All patients must be
with intravenous colloids like haemacel or fully monitored in labour. Elective caesarean
humanalbumin solutionis useful for improving section should be carried out on purely obstetric
renal and uteroplacental blood flow as women grounds.
with PE have a reduced intravascular volume.
This line of management can be pursued before Epidural analgesia should be used in these
hypotensive drugs are used and even help to patients as it not only relieves pain but also
helps to control the BP and may improve
reduce the blood pressure. However, no patient
placental blood flow. It can be used for both
should receive greater than 500 ml of colloid as
labour and caesarean section unless delivery is
there is a serious risk of volume overload.
urgent inwhich case general anaesthesia should
be used for caesarean section. However, it is
There is no evidence for the use of sedatives or contraindicated if there is DIC or
tranquilisers in the management of mild to thrombocytopaenia of lessthan lOOx 109/L.
moderate pre-eclampsia.
Labour should be as short as possible and the
Fetal assessment second stage should be augmented with the use
This is as mentionedearlier. The symphysial-fundal of ventouse or forceps as prolonged pushing
measurement is done daily, the daily fetal kick chart raises the BP even further. Ergometrine should
is instituted and where available non-stress also be avoided for the same reason and
antenatal cardiotocography is done daily. Regular syntocinon should be used instead. The
ultrasound measurements should be done every 2 paediatrician should be present at delivery as the
weeks to assess fetal growth. Liquor volume and baby may require intensive care after delivery.
Dopplers can be assessed more frequently if
possible. Where there is evidence that the fetus is in COMPLICATIONS
jeopardy, the baby is best delivered. If delivery is Eclampsia is still one of the major causes of
planned before 34 weeks gestation, women obstetric maternaldeaths and perinatal deaths in
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developing countries and is significant also in Abruptio placentae is commonly associated

developed countries where other causes of with PE. This is more so in patients with
maternal mortality such as haemorrhage, sepsis chronic hypertensionwho have superimposed
and abortion are now very uncommon. PE. Disseminated intravascular coagulation
Eclampsia is thought to be caused by cerebral (DIC) complicates a few cases of PE.
vasospasm leading to ischaemia and tissue
oedema. The reduced plasma oncotic pressure PREVENTION
from the loss of serum protein, and the increase Attempts to prevent PE in the past have been
in capillary permeability, lead to a decrease in disappointing. However, low dose aspirin
plasma volume and an increase in tissue (75mg daily) started early in the second
oedema which affects all organs. Compromise trimester may be useful for patients at risk of
of uteroplacental perfusion is often seen in PE developing severe early onset PE e.g.
and intrauterine growth restriction (IUGR) is a
previous history of early onset PE, chronic
common complication. By the time
hypertensives and patients with renal disease.
hypertension becomes clinically obvious, the
Calcium supplementation also appears to be
disease has already progressed to a stage where
of benefit in women at high risk of PE and in
uteroplacental perfusion is compromised by
about 30-50%. The decrease in plasma volume
those with low dietary calciumintake.
and consequent high maternal haemoglobin
concentration is also associated with an Bibliography and suggested further
increased risk of IUGR. In severe cases, reading
intrauterine death or neonatal death may occur.
Abudu, O. (1988) Low birthweightand perinatal mortality
A study done at the Lagos University Teaching
in Lagos. J Obstet Gynaecol East Centr Afr 7:68-70.
Hospital found that hypertensive disease of
pregnancy was responsible for 11.8% of total Broughton Pipkin, F. (1995) Fortnightly Review: The
perinatal mortality. hypertensive disorders ofpregnancy. BMJ311: 609-6 13.

Acute renal failure can occur in severe cases of Nelson-Piercy, C. (1997) Hypertension and Pre¬
PE and is often due to acute tubular necrosis. eclampsia. In: Nelson-Piercy, C. (ed.) Handbook of
Dialysis may be required in some cases Obstetric Medicine, lsl ed.:IsisMedical Media, Oxford.
although most recover spontaneously. Acute
Okonofiia FE, Balogun JA, Amiengheme NA, O'Brien
cortical necrosis is a more permanent cause of SP (1992) Bloodpressure changes during pregnancy in
failure but is fortunately very uncommon in Nigerian women. Int J Cardiol 37:373-9.
patients with PE.
Robson, S.C. (1999) Hypertension and renal disease in
Pulmonary oedema is another manifestation of pregnancy. In: Edmonds, O.K. (ed.) Dewhurst's Textbook
the generally increased tissue oedema. ofObstetrics andGynaecologyfor Postgraduates. 6th ed.:
Injudicious use of intravenous fluids may also Blackwell Science Ltd, Oxford.
predispose to pulmonary oedema and as such
Walker, JJ. (2000) Pre-eclampsia. Lancet 356:1260-1265.
caution must be exercised when administering
fluids to these patients.

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Zuspan, F. B. (1982) Treatment of severe pre-eciampsia.

vi. HELL? syndrome is a complication of pre¬ InPregnancy Hypertension. Sammour, M. B., Symonds,
eclampsia as well as eclampsia. The syndrome E. M., Zuspan, F. B. and El-Tomi, N eds. Aim Shams
is an association of haemolysis (H), elevated Univerity Press, Cairo.
liver enzymes (EL) and low platelet count (LP).
Robson, S. C. (1999) Hypertension and renal disease in
It may occur in the absence of hypertension. pregnancy. In Dewhurst's Textbook of Obstetrics and
The patient may present with epigastric or right Gynaecologyfor Postgraduates, 6th ed., Edmonds D. K.
upper quadrant pain. Severe pain with tender ed. Blackweil Science, Oxford.

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Chapter 43
Cardiac Disease

Physiology retention.
There are some haemodynamic changes that It has been stated that oestrogens and
occur in pregnancy and these include alteration of prostaglandins including prostacyclin are the
the cardiac output, blood volume, andheart rate. likely mediators of the alterations in
haemodynamics caused by pregnancy.
It has been established that the cardiac output
begins to rise before the end of the first trimester During labour, contraction of the uterus
and reaches the maximum which is 40 percent produces a rise in venous pressure due to
above the nonpregnant level by about 20 weeks increased venous return to the heart. The
gestation. This maximum level is maintained consequence of this is an additional increase in
throughout pregnancy and does not fall until cardiac output and rise in blood pressure. After
some time after delivery. The increase in delivery there is shunting into maternal
cardiac output is caused partly by an increase in circulation from the placental bed. The
heart rate and partly by an increase in stroke rise in blood volume is said to be associated
volume. Fall in systemic vascular resistance with an increase in cardiac output due to
and blood volume increase are also causative increase in stroke volume. The marked increase
factors. in blood volume and cardiac output during this
period may precipitate heart failure in a woman
In pregnancy, both systolic and diastolic
who already has a cardiac disease.
pressures show a slight fall with a decrease in
the total peripheral resistance. However, by Incidence
term they have returned to the pre-pregnancy
value usually. The incidence of cardiac disease in pregnancy
inIour obstetric population is generally low but
While there is no appreciable change in the this varies from one centre to another. For
venous pressure in the arms, that in the legs and example, the incidence may be higher in the
abdominal veins is increased. The pressure in northern part of Nigeria where a certain type of
the inferior vena cava is increased when a pregnancy cardiomyopathy is prevalent.
pregnant woman lies in the supine position.
This is because the gravid uterus compresses Aetiology
the inferior vena cava. There is consequently a
decrease in venous return, a fall in cardiac Generally, the causes of heart disease in
output without concomitant rise in peripheral pregnancy are:
resistance, and as such the woman usually i. Hypertensive heart disease. Essential
experiences fainting attacks.
hypertension and hypertension secondary to
Peripheral oedema occurs in about 50 percent of renal disease may predispose to congestive
pregnant women without an underlying cardiac or cardiac failure in pregnancy. Hypertension is
renal disease. This has been ascribed to sodium encountered more frequently in the urban than in
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I the rural areas. Diabetes mellitus has also been

associated hypertension inthe African.
Cardiac Disease 361

there is endomyocardial scarring which usually

affects one or both ventricles thus restricting
ventricular filling.
ii. Rheumatic heart disease probably ranks
next to hypertensive heart disease in the v. Congenital heart disease - Some cases of this
African. Inadequate treatment and prevention nature have been observed inNigeria and these
of streptococcal infections may be the main include interatrial or interventricular septal
predisposing factors. defects, patent ductus arteriosus and
coarctation of the aorta. Congenital heart
iii. Peripartum dilated cardiomyopathy or
disease couldbe acyanotic or cyanotic.
pregnancy cardiomyopathy. This type of heart
disease was described in Zaria, a town in vi. Anaemic heart disease - Severe anaemia
Northern Nigeria, in 1978. It occurs in the hot of pregnancy which is still seen especially inthe
season and during the last few weeks of rural areas ofAfrica may lead to anaemic heart
pregnancy and the first few weeks after delivery. failure.
The peak incidence is however four weeks post
partum. Its aetiology is linked with vii. Coronary artery disease - This condition is
hypervolaemia from lying on a hot mud bed for probably rare in pregnancy in the developing
about 18 hours a day which is the local custom countries. It causes myocardial infarction
for the Hausa woman. Sometimes the which mostly occurs during late pregnancy or
temperature may reach as high as 40°C, and the peripartum. It has also been associated with
woman is also made to increase her salt intake in administration of oxytocic agents. However,
excess by eating 'Kanwa' salt from Lake Chad. spontaneous coronary artery dissection
This custom is probably now practised only in the resulting in sudden severe chest pain is the
rural areas, with little or no modem obstetric care. commonest cause.

Reports from developed countries where this Classification of heart disease

type of heart disease is rare have supposed its
In the assessment of a pregnant woman with
aetiology to be viral or autoimmune or at least
heart disease, it is more important to assess the
to be contributory factors. Echocardiography is
heart's condition according to the functional
central to diagnosis.
capacity than to the nature of the structural
Pathologically, the heart is pale and flabby with damage.
hypertrophy and dilatation of all chambers.
The degree of functional disability is graded
There may also be focal areas of endocardial according to the New York Heart Association
fibrosis intheventricles. Classification:
iv. Endomyocardial fibrosis (EMF) accounts for
some of the cardiac diseases in pregnancy. This Grade 1:
disease which has been described inAfrica and in There are no symptoms limiting ordinary
the hot wet areas of the tropics presents as cardiac physical activity. There are signs but no
enlargement of no apparent cause. Pathologically, symptoms of heart disease.

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ÿ 362 Obstetrics andGynaecology

Grade 2: Infection should be vigorously treated with

There is slight limitation with mildto moderate antibiotics. Particular attention is paid to the
activity but no symptoms at rest. patient's teeth because of bacteria which may
predispose to subacute bacterial endocarditis
especially in a woman with valvular heart
Grade 3:
disease. The causative organism here is
There is marked limitation with less than Streptococcus viridans which is sensitive to
ordinary activities; also there is dyspnoea or penicillin or broad spectrum antibiotics. As a
pain on minimal activity. Signs of incipient rule, extraction of teeth in a cardiac patient
heart failure are present. should always bedone under antibiotic cover.

Grade 4: Pre-eclampsia may occur and this poses an

additional strain on the heart because of the
There are symptoms at rest or with minimal hypertension and excessive fluid retention.
activity. Symptoms of frank, congestive heart Admission to hospital for effective
failure are present. All cases of previous heart management is mandatory.
failure and atrial fibrillation past or present also
belong to this class. All cardiac patients are advised to have
adequate bed rest. Should cardiac failure set in,
However, this classification is only a rough guide a cardiologist should be consulted for expert
because sudden and unpredictable changes in management. Generally, the main stay of
classification occur during pregnancy. treatment includes bed rest, sedatives, digoxin
and diuretics like frasemide. Details are given
Management in pregnancy ina standardInternalmedicine textbook.

Supervision of cardiac patients in pregnancy It has always been a tradition to admit all
should be done by both the obstetrician and the cardiac cases to hospital in early third trimester
cardiologist but this is not always practicable in as their condition may get worse during this
the rural areas where there are no secondary trimester due to physiological reason. Grades
health care centres or facilities for referral to HI and IV cases may need to spend the greater
tertiary care centres. part of their pregnancy period in hospital. It is
recommendedthat allcardiac patients shouldbe
However, the guideline should be as follows: admitted to hospital two weeks before their
Patients should be seen every two weeks in the expected date of delivery to ensure a smooth
antenatal clinic except for the more severe cases onset of labour. There is no contraindication to
who should preferably be seen weekly. surgery during pregnancy. Various types of
Anaemia shouldbe prevented by giving routine operation that could be considered inpregnancy
haematinics and if present, should be when other measures have failed include closed
vigorously treated. mitral valvotomy in the presence of mitral
stenosis, balloon pulmonary valvotomy for
The weight should be recorded at every visit pulmonary stenosis, balloon aortic valvotomy
and ifthere is excessive weight gain, the patient for aortic stenosis, coronary angioplasty or
isadvised to reduceher diet andsalt intake. coronary bypass for coronary artery disease.
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ConfuteDisease $63

As much as possible, surgery should be delayed not be allowed to bear downbut instead labour
until after the first trimester, though it could be isshortened by forceps or ventouse.
undertaken at any time in pregnancy as an
emergency measure to save the lifeof the woman. The teaching that ergometrine should not be
given to cardiac patients unless there is
In the developing countries, pregnant women postpartum haemorrhage is to prevent shunting
with mechanical heart valves are probably few. of blood from the placental bedinto the general
What is however, recommended is the use of circulation which may overloadthe heart. Ithas
warfarin throughout pregnancy except between 6 even been suggested that shouldthe delivery be
and 12 weeks gestation and after 36 weeks of bloodless, a venesection might be necessary to
gestation when heparin is substituted. Details are prevent onset of pulmonary oedema.
found in Cardiology or Internalmedicine textbooks.
Management in the puerperium
There is no place for induction of labour
because of cardiac disease per se. Surgical The most critical period for a cardiac patient is
induction could even be considered dangerous the first 12 hours after delivery. Signs of
because of chances of infection occurring if pulmonary oedema should be looked for and if
there is prolonged induction-delivery interval. present diuretics and digoxin should be
Prophylactic antibiotics should be given right prescribed. Liberal sedatives should also be
from the onset if artificial rupture of given. Prophylactic antibiotics like ampicillin
membranesisundertaken. are prescribed for two weeks after delivery to
Management in labour prevent infection which may trigger off an
attack of subacute bacterial endocardits.
During the first stage of labour, allcardiac cases Anaemia if present must be promptly treated.
should receive routine antibiotic cover like There is no contraindication to breastfeeding if
ampicillin 500mg 6 hourly. The patients are the patient is fit enough.
propped up in bed and digitalised if the pulse is
rapid, i.e.above 110per minute. Discharge after delivery is at the discretion of the
attending obstetrician and the cardiologist.
Liberal analgesic is prescribed and oxygen is Sterilisation is advisable for patients with Grade
administered if necessary. This stage of labour IV heart disease after a successful deli very. This
does not usually last more than 8 hours. However, should however be delayed until after the
trial of labour is contraindicated to prevent any puerperium. In the meantime contraceptive
stress that may precipitate heart failure. advice is given before discharge from hospital
and this invariably applies to all cardiac patients.
Caesarean section is not contraindicated ifthere
is an obstetric indication but the operation is
Termination of pregnancy
rarely performed for cardiac disease per se. For
this operation, epidural analgesia is preferred to
Termination of pregnancy for cardiac disease is
general anaesthesia especially if hypotension
no longer indicated except invery rare cases like
can beavoided.
Eisenmenger syndrome. Even in the latter,
Duringthe second stage of labour, the patient should successful pregnancy could beachieved inawoman
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364 Obstetrics and Gynaecology

i
already pregnant if she earnestly wants to keep in a majority of the babies as a result of
it, provided she is managed in an excellent reducedplacenta! perfusion.
centre. If termination of pregnancy has to be
performed for cardiac reasons, it is better done Bibliography and suggested further
inthe first trimester by vacuum aspiration. reading
Maternal prognosis Chan, W. S. (1999) What is the optimal management
pregnant women with valvular heart disease in
Maternal prognosis depends on the type of pregnancy: Heamostasis, Suppl. SI: 105.
cardiac disease, the grade, the age of the
patient, the presence of cardiac failure before Heider, A. L., Kuller, J. A. Strauss, R. A. Wells S. R.
(1999) Peripartum cardiomy oppathy: a review of the
pregnancy is embarked upon, and the literature. Gynecol Surv, 54 (8): 526.
supervision received during pregnancy.
Jaiyesimi, F. (1982) Cardiomyopathies in Africa:
Fetal prognosis Dilatedcardiomy-apathy. Postgraduate Doctor, 4, 365.

Oakley, C. M. (1999) Heart disease in pregnancy In

The fetal prognosis is worse in cases of Dewhurst's Textbook of Obstetrics and Gynaecologyfor
cyanotic congenital heat disease than in most Postgraduates, 6* ed., ed D. KeithEdmonds. Blackwell
other cases. Science Ltd.,London.

In general, the perinatal death rate is higher in Oviasu, V. O. (1982) Risk factors for cardiovascular
diseases inAfrica. Postgraduate Doctor,4, 196
patients with cardiac disease because of the
prevalent higher prematurity rate especially
when cardiac failure occurs. Growth restriction
occurs

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mm
Chapter 44
Diabetes mellitus

Definition were already diabetic before pregnancy and are

being managed on diet, insulin or oral
Diabetes mellitus isthe metabolic disease that hypoglycaemic agents.
results from lack of insulin. The WorldHealth
Organisation Expert Committee on diabetes (2) Gestational diabetes mellitus-women in
mellitus defined the disease in terms of blood whom diabetes commences or is recognised for
glucose levels. Ifthe random blood glucose is the first time during pregnancy. A small
equal to or greater than 11.0 mmol/1 ina (non¬ proportion of such women may have hadoccult
pregnant) patient with polyuria, polydipsia, diabetes before pregnancy.
weight loss and occasional glycosuria, that
(3) Impaired glucose tolerance - women whose
patient has diabetes.
blood glucose levels correspond to the values
If a patient without the above symptoms and shown above.
signs has a fasting glucose value greater than Incidence
8.0 mmol//, and/or the 2 hour glucose level The incidence of diabetes in pregnancy in any
following a 75g oral glucose load (OGTT) is obstetric population will vary according to
greater than 11 mmol//, the patient is diabetic. whether diabetic screening is done routinely or
Any patient whose random blood sugar is less not in that population. In a Lagos University
than 8.0 mmol// or fasting levelis less than 6.0 Teaching Hospital study, a prevalence rate of
mmol// does not have diabetes mellitus. about 15 undiagnosed diabetic women per
1,000 antenatal population has been reported.
A diagnosis of impaired glucose tolerance Generally the incidence of diabetes in
(IGT) is made if the fasting level is less than pregnancy is between 0.25 and 2.5 per cent and
8.0 mmol/1 but the concentration 2 hours could be higher in highly specialised units that
after an oral glucose load of 75g is between take diabetic referrals.
8.0 and 10.9 mmol/1.
Screening for gestational diabetes is a
The WHO committee also recommended that controversial issue. Certain risk factors have
the same definition for non-pregnant women traditionally been used to define "potential
be applied in pregnancy so as to achieve diabetics". These factors include a history of
international standardisation. However, it is unexplained stillbirths, history of having had
knownthat the fasting andthe random blood macrosomic babies (> 4kg), family history of
glucose levels in pregnant women are diabetes in a first degree relative, and/or the
significantly lower than in non-pregnant presence of glycosuria in the current pregnancy.
women. Using these criteria alone about as many as 60 per
cent of diabetic patients and those with IGT would
Classification be missed, and a lot of non-diabetics would be
There are three broad categories found in included as there are many other causes of these
pregnancy: clinical factors than impaired glucose tolerance. An
(1) Establisheddiabetes mellitus -women who example is glycosuria which is commonly seen in

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m 366 Obstetrics andGynaecology

pregnancy because of the reduced renal

threshold for glucose. Very few pregnant women
These changes are hormone-dependent.
I
Oestrogen and progesterone facilitate the release
with glycosuria would be found to have diabetes of insulin and thus enhance the peripheral
after an OGTT. However, screening all pregnant utilisation of glucose; fasting hypoglycaemia is
women would be even less sensitive and therefore common in pregnancy. Also glucose
specific, and very expensive. Hence "clinical readily crosses the placental barrier while insulin
risk factor" screening is still "used inmany units, does not. Glucose from the mother is the main
testing the women with the above features using source of energy for fetal anabolic functions; its
blood glucose levels. The definition of diabetes demand by the fetus is such that the glucose
turnover rate in the normal adult is exceeded two
is then based on WHO recommendations, using
or three fold. The net result is the reduction of
the OGTT as described above. Screening may be
blood glucose level to about 0.5 mrnol/l lower
done initially at booking and then repeated at than for non-pregnant women.
about 28 weeks gestation whenthe detection rate
is higher and there is still a chance to treat the Increased production of human placental
woman and improve outcome. lactogen (HPL), Cortisol and prolactin occurs in
pregnancy. These hormones exhibit contra-
Pathophysiology insulin effects especially in late pregnancy. The
Table 44.1 summarises the metabolic effects of normal pregnant woman compensates this
insulin. The absolute or relative lack of insulin relative insulin resistance by producing more
results in hyperglycaemia, protein catabolism, insulin and releasing it at increased rates. This
lipolysis and ketogenesis. These metabolic explains why some pregnant diabetics may require
effects of lack of insulin lead to the major increaseddoses of insulinas pregnancy advances.
findings in diabetic ketoacidosis. In pregnancy,
significant changes in carbohydrate and fat In the diabetic patient, absence of insulin or
metabolism occur which increase the tendency insufficient production of insulinleads to under
for development ofketoacidosis inthe diabetic. utilisation of glucose by the peripheral tissues,
and the liver responds by increased breakdown
Target organ Metabolic effect of insulin of glycogen to glucose, so there is excess
A. Liver Inhibition of gluconeogenesis. glucose (hyperglycaemia) in the circulation.
Enhanced glucose and aminoacid uptake. Hyperglycaemia increasesthe osmotic pressure
Increased glycogen synthesis
Conversion of glucose into fatty acids. in the extracellular fluid space thus causing
Enhanced glucose and aminoacid uptake. intracellular dehydration. Also the
B. Muscle hyperosmotic extracellular glucose in the
Increased glycogen synthesis.
Little or no effect on glucose metabolism. kidney causes diuresis and this leads to
C. Brain extracellular dehydration.
Increased fatty acids synthesis.
D. Adipose tissue Inhibitionof release of fatty acids fromfat
stores. Persistent maternal hyperglycaemia causes fetal
Increasedglucose andaminoacid transport.
Enhanced glucose utilisation by tissues
hyperglycaemia because of the ready movement of
E.All tissues and thus spares fat glucose from mother to fetus. The fetal response is
Inhibition of protein catabolism. fetal pancreatic hypertrophy and increased insulin
Increased protein synthesis. production. It is this hyperinsulinaemia that is
Table 44.1 Metabolic effects of insulin on different tissues thought to cause the fetal macrosomia frequently

Prince Of Medicine-2014-BSUTH

Chapter 45
Hydramnios

Hydramnios (or polyhydramnios) means to maternal or fetal factors.

excess of amniotic fluid (or liquor amnii). The
average volume of amniotic fluid at term is Aetiology
about 800ml (range: 400-1500ml). Any volume Fetal causes
above the upper limit of normal is described as 1. Multiple pregnancy, especially
excessive. Clinically, volumes above 2000ml monochorionictwins.
are palpably obvious as cases of 2. Congenital malformations like
polyhydramnios. anencephaly and oesophageal atresia,
where inability of the fetus to swallow is
Amniotic fluid is of both fetal and maternal responsible for the accumulation of liquor
I origin. The main sources in early pregnancy amnii.
include secretions from the amnion and 3. Hydrops fetalis.
diffusion through the fetal skin. By the time the 4. Chorioangioma of the placenta (rare).
fetal skin loses its permeability at about the 20th
week of gestation, the fetal kidneys contribute Maternal causes
significantly to the production of amniotic fluid 1. Diabetes mellitus, especially in badly
through urine production. The fetus swallows controlled cases. The hydramnios may be
the liquor, which is absorbed from the intestine due to polyuria inthe fetus.
f to enter the fetal plasma. Some liquor is 2. Rhesus isoimmunisation when affected
absorbed by the amnion into the maternal babieshave hydrops fetalis.
plasma. The turn over rate of liquor is rapid and
approaches about 1000ml an hour. Clinical history
The patient may complain of abdominal
When excessive amniotic fluid accumulates discomfort or excessive distension, or that there
gradually and is noticed in the third trimester, is' excessive fetal movement. In acute
this is referred to as chronic hydramnios. Acute hydramnios, she may complain of vomiting,
hydramnios occurs early in pregnancy, usually abdominal pain, indigestion and difficulty with
during the early part of the second trimester, breathing.
and the rate of accumulation is fast. It is less
common than chronic hydramnio-, and the Clinical findings
prognosis is poor if the patient goes into labour The fundal height far exceeds the expected
as the baby is invariably premature. gestational age. The abdomen may be tense and
Monochorionic twins are frequently associated shiny. Fetal parts may be difficult to palpate andthe
with acute hydramnios. fetal heart sounds may be difficult to hear. A fluid
thrill may be present. In acute hydramnios the
Hydramnios is more often seen in multiparous than patient isbreathless and inrespiratory distress. Fetal
in nulliparous women, and the causes may be due

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372 Obstetrics andGynaecology

malpresentation may be present.

1
Where there is serious maternal distress but
the gestational age is far less than 37 weeks
Differential diagnosis and there is no fetal abnormality, abdominal
Multiple pregnancy and other causes of large amniocentesis could be performed. This may
for dates pregnancy like co-existing fibroids or be repeated if necessary. The dangers are
ovarian cyst should be remembered. infection and perforation of a fetal vessel with
Hydatidiform mole, fetal macrosomia and resultant bleeding into the amniotic sac.
wrong dates shouldalso beconsidered. These risks can be avoided if the procedure is
carried out under aseptic conditions and with
Investigations ultrasound guidance. Premature labour is a
definite risk of amniocentesis but the
(1) Ultrasound scan is non-invasive and incidence islow.
would exclude multiple pregnancy, ovarian
cyst, hydatidiform mole, fibroids and fetal
Complications
macrosomia. It would also show fetal
abnormalities if present. An increase in The effects of polyhydramnios on pregnancy
amniotic fluid with a single pool of greater than include preterm labour, prolapsed umbilical
8cm in depth or an amniotic fluid index (AFI) cord following rupture of fetal membranes,
greater than the 95th centile for gestational age abruptio placentae following rapid release of
(the amniotic fluid index is the sum of the the amniotic fluid, malpresentation of the
liquor depth in each of the four quadrants of the fetus, and postpartum haemorrhage as a result
uterus) is diagnostic of polyhydramnios. of uterine atony.

(2) Abdominal X-ray is relatively All the above complications increase fetal
inexpensive and could exclude multiple mortality and morbidity appreciably in cases
pregnancy and show skeletal fetal of hydramnios, even after correcting for fetal
abnormalities. However it should only be used abnormalities that are often associated with
in situations where ultrasound scan is not hydramnios.
available.
Bibliography and suggested further
Management reading
Asymptomatic polyhydramnios needs no
Donald I. (1979) Practical obstetric problems, 5th ed.,
treatment if there is no associated fetal Lloyd-Luke, London.
abnormality.
Insymptomatic cases of hydramnios where the Queenan John T. (1994). Management of High-Risk
gestational age is greater than 37 weeks and Pregnancy, 3rd ed., Blackwell Science, Inc.
there is serious maternal distress, labour can be
safely Induced.

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Chapter 46

Multiple pregnancy

Incidence Eastern countries, about 5 per 1000 births.

Multiple pregnancy is the term used for a Among Caucasians the natural incidence is
pregnancy with more than one fetus. Twin about 1:80 births for twins, 1:1000 births for
pregnancy is the commonest type of multiple triplets and 1:500,000 births for quadruplets.
The twinning rates in Nigeria appear to be
pregnancy. The incidence of multiple
influenced by ethnicity. The twinning rate in
pregnancy has increased worldwide due to
Ibadan and its environs, in the purely Yoruba
increased use of ovulation induction drugs in speaking southwestern Nigeria, is probably the
assisted reproduction techniques. While the highest in the world. On the other hand the
incidence of triplets, quadruplets and other high twinning rate in Lagos, a cosmopolitan city, is
order multiple pregnancy has increased the lowest in Nigeria but the rate is still high,
significantly, the same cannot be said of about twice compared with that of Caucasians.
twinning. Naturally, twinning is greater in the Twinning rates in some Nigerian cities and
black race than in the Caucasians. The towns are shown inTable 46. 1
incidenceis low inFar

Author Place Incidence

Knox andMorley, 1960 Ilesha 53/1000

(Southwestern Nigeria) (1: 19) births
Enugu 357 1000 births
Azubuike, 1982
(Southeastern Nigeria) (1:29)
Lagos 21.1/1000 maternities
Abudu, 1984
(Southwestern Nigeria) (1 in 47)
Ibadan
Nylander, 1971
(Southwestern Nigeria) 52/1000 births (1 in 19)
Rehan and Tafida, 1980 Katsina 40/1000 births
(Northwestern Nigeria) (1 in 25)

Cox, 1963 (a) Ama Achara 55.7/1000 births (1 in 18)

(b) Umuahia 33.5/1000 births
(Southeastern Nigeria) (1 in 30)

Harrison, 1977 Zaria 35.5/1000 births

(North central Nigeria) (I in28)

Abudu 2000 Lagos 28.9/1000(1 in 34.6)

Table 46.1 Twinning rates in some Nigerian cities and towns

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,.s . ...
.v$... ;
ff

'374 Obstetrics andGynaecology

Aetiology and pathophysiology

The following are predisposing factors for

twinning:

(i) Age: There is increasing incidence of

twinning with increasing age, this falls
after the age of 35 years.
(ii) Parity:Incidenceincreases with parity.
(iii) Race: The lowest recorded incidence of
twinning is in Japan and the highest is
among the Yorubas of southwestern Nigeria.

(iv) Familial:There is a well knownbut ill

defined familial tendency to dizygotic
twins, usually a daughter inheriting it
from the mother. diamniol

(v) Constitution: Women who deliver

dizygotic twins tend to betaller and heavier
than those who deliver singletons.
(vi) Diet: Some recent studies have isolated
a clomiphene-like substance in yam, a
stem crop, which is a staple food in
many parts of West Africa.

Dizygotic twins
This is the more common type of twins. The
twins arise from two separate ova that are
fertilised by two separate spermatozoa. They
are therefore ofdifferent genetic make up. They
may be of the same or different sex and
resemblance is not any different from that
within the same family. They have different
placentae, chorion and amnion i.e. dichorionic
and diamniotic. There is no anastomosis
betweenthe two placentae (fig-46.1).
Figure 46.2 Monozygotic twins - monochorionic and
diamniotic

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t Monozygotic twins
Multiplepregnancy 375

have been described in which head, trunk,

Monozygotic twins arise from division of one viscera or limbs may be shared or duplicated.
ovum that has been fertilised by a spermatozoon
i.e. it arises from one zygote. It is claimedthat the Clinical features
incidence of this variety of twins is constant
Early symptoms of pregnancy are usually more
about 1 in 250 births worldwide. Since the twins
have the same genetic constitution they are pronounced in twin pregnancy. If the patient
therefore of identical sex and look very much booked early, a discrepancy in the uterine size
alike physically and mentally. Monozygotic and gestational age may be noted early too.
twins arising from very early cell division e.g. at However, as pregnancy advances the patient
or before the eight-cell stage will have separate herself may complain of excessive large
chorion and amnion i.e. dichorionic and abdomen and fetal movements or discomfort
diamniotic; this occurs in one third of cases. If and even shortness of breath. Anaemia and
division occurs at the blastocyst stage (Day 4 to pregnancy-induced hypertension may become
Day 6) the fetuses will have only one chorionand evident. Severe pedal oedema and proteinuria
two separate amnions i.e. monochorionic and may be present. The incidence of pregnancy
diamniotic (fig 46.2). This accounts for about anaemia and pregnancy-induced hypertension
two thirds of monozygotic twins. Those that is higher in multiple pregnancy than in
result from very late division i.e. just before the singletons.
appearance of the primitive streak have the same On physical examination, the uterus is larger
chorion andthe same amnion i.e. monochorionic than expected from the duration of pregnancy.
and monoamniotic-this is rare and accounts for 1 Polyhydramnios may be obvious and multiple
% of monozygotic twins. Much later after the fetal parts may be palpable. Morethan two fetal
formation of the primitive streak (about 13 days poles may be palpable, e.g. two heads and one
after fertilisation) incomplete splitting of the breech. The fetal head feels smaller thanwould
germinal disc will give rise to conjoint twins. be expected from the size of the abdomen.
There are usually placental and cord
complications wherever there is a single Diagnosis
chorion. The umbilical cords are usually Twins may be suspected from the above clinical
separate but there is almost always a vascular
features. The diagnosis is confirmed by
communication (artery to artery, artery to vein or
ultrasound scan. The scan will also diagnose
vein to vein), in the placentae between the two
twins very early inpregnancy.
fetuses. This may lead to twin-to-twin transfusion
syndrome where the "donor" twin develops
Differential diagnosis
anaemia and growtha restriction, while
polycythaemia, macrosomia and hydrops are found (i) Hydatidiform mole: In early pregnancy.
in the "recipient" twin. This is usually the cause hydatidiform molecould present with the same
of acute polyhydramnios in twin pregnancy. clinical features as multiple pregnancy
Fetus papyraceous results from the early death Estimation of beta-subunit of humanchorionic
of one twin in utero and the dead fetus is retained gonadotrophin (p-hCG) is expected to be
and compressed flat on the membranes, abnormally high in hydatidiform mole. An
hence the terminology. Various types of monsters ultrasound scan in case of a hydatidiform mole

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ÿstetrics ÿnaec°ÿ°s'

shows a "snow storm" appearance, singletons.

(ii) Wrong dates (v) Antepartum haemorrhage: Placenta
(iii) Macrosomic baby praevia may result from encroachment
(iv) Abdomino-pelvic tumours e.g. fibroids or on the lower segment by the large
ovarian tumours coexisting with pregnancy placenta. Abruptio placentae can
(v) Polyhydramnios complicate pre-eclampsia, which is
common inthis condition.
The ultrasound scan is valuable indifferentiating (vi) Increased pressure effects: Backache,
these conditions from twin pregnancy. varicose veins, haemorrhoids and
oedema offeet are common.
Complications (vii) Increased operative delivery:
Generally twin pregnancy is associated with Malpresentation is common in twin
increased complications for both mother and pregnancy and this leads to increased
the fetuses. operative vaginal deliveries and
Complications in the mother include: caesarean section. Operative deliveries
(i) . Exaggeration of early pregnancy are associated with increased maternal
symptoms: There is increase in morbidity.
early pregnancy symptoms. (Viii) Retained placenta: This may result
Hyperemesis gravidarum is common, from uterine atony (over distension of
(ii) Anaemia: This is commoner in poor the uterus caused by multiple pregnancy
countries. The women in these leads to atony of the uterus in the third
countries usually start pregnancy stage).
with iron and folic acid deficiencies (ix) Post partum haemorrhage: This is as a
because of poor nutrition, malaria result of either uterine atony or bleeding
and worm infestations. The from the large area of the placental bed
increased demand of these found in twin pregnancy. Also in some
micronutrients by the growing cases as a result of encroachment of the
fetuses worsens the already existing lower uterine segment by the large
anaemia. placenta (the lower segment contracts
poorly).
(iii) Polyhydramnios: Acute polyhydra¬
mnios usually in mid-pregnancy is Complications in the fetus include:
common in monozygotic twins and
it isalmost always a complication of (i) Miscarriage: Fetal loss especially very
twin-to-twin transfusion syndrome. early in pregnancy is common i.e. the
It is an important cause of preterm "vanishing twin" phenomenon.
labour and is associated with a very (ii) Prematurity: The mean gestational age
highrate of fetal loss. at birth in twins is about 37.4 weeks
(iv) Pregnancy-induced hypertension compared to 39.7 in singleton
and pre-eclampsia: These tend to be pregnancies. The incidence of preterm
commoner intwin pregnancy than in
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_
Hydramnios 377
t :'>% -
"ÿ
'_
: *t> vj'.f* -

labour intwin pregnancies isabout 40 to perinatal morbidity and mortality. A

60% compared with about 10% in recent study in Lagos shows an
singletons. A recent 10-year review of incidence of 3%, and all the cases
twins at the Lagos University Teaching were "unbooked".
Hospital shows an incidence of 40.6%. (viii) Perinatal mortality and morbidity:
Preterm labour is commoner in These are significantly increased in
monozygotic twins than in dizygotic twins compared to singletons.
twins. Perinatal mortality rate in twins is
(iii) Intrauterine growth restriction: This about four times of that in singletons.
can result from twin-to-twin Low birth weight due to prematurity
transfusion, pre-eclampsia or insertion and intrauterine growth restriction is
of the cord into the membranes responsible for almost 50% of all
(velamentous insertion). perinatal deaths in twin gestation.
Other causes of perinatal deaths
(iv) Low birth weight: The incidence of low
include fetal anomaly, twin-to- twin
birth weight in twin pregnancy is about transfusion syndrome, pre-eclampsia,
10 times that in singletons. The mean and retained second twin due to
birthweight of a twin is usually lessthan mismanagement of twin pregnancy in
2.5kg. Low birth weight results from
labour. Prematurity is the single most
prematurity or intrauterine growth
important contributor to perinatal
restriction or both.
morbidity and mortality.
(v) Twin-to-twin transfusion syndrome: (ix) Lockedtwins: A very rare complication
This may occur in up to 20% of that occurs when the presentation of
monozygotic twins. Complications
the first twin is breech andthat of the
include intrauterine growth restriction,
second twin is cephalic (Fig46.3).
fetal anaemia, hydrops fetalis and fetal
death. At birth the haemoglobin of the
"donor twin" is about 5g/dl less than that
of the "recipient" twin.
(vi) Congenital malformation: Fetal
abnormality is found in about 3.3% of
twins and it is commoner in
monozygotic twins.

(vii) Retained second twin: This should not

occur where twins are properly
managed. It results from poor
management of twin pregnancy in
labour and is associated with high
Figure 46.3 Lockedtwins

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378 Obstetrics and Gynaecology

Management of multiple pregnancy unit. Operative deliveries and low birth weight
babies are common and therefore an
Antenatal care
anaesthetist and a neonatologist/ paediatrician
The objectives of antenatal care are to prevent must also be available.
or recognise the complications of multiple In labour the presentations encountered are
pregnancy. Twin pregnancy is a high-risk cephalic-cephalic 40%, cephalic-breech 40%,
pregnancy i.e. it is associated with increased breech-breech 15%, cephalic-transverse 2%,
perinatal and maternal morbidity and mortality breech-transverse 2% and transverse-
and must therefore be managed in a secondary transverse 1%. The obstetrician, aneasthetist
or tertiary centre where there are obstetricians and the neonatologist must be informed when a
and experienced midwives. Twin pregnancy woman withtwin pregnancy is inlabour.
should not be managed in a primary health care Where the first twin is found to be in
centre. Early diagnosis of multiple pregnancy, transverse lie, caesarean section is indicated.
usually by ultrasound scan, is necessary so that Caesarean section is also indicated if there is
the patient may benefit fully from antenatal care evidence of intrauterine growth restriction and
and this improves perinatal outcome. She must the presentation of the first twin is any other
be warned about all the complications of twin than cephalic. All the contraindications to
pregnancy andadvised on what to do should she vaginal breech delivery are also observed in
notice any warning signs. Frequent visits to the twins.
clinic are mandatory. The first stage of labour is managed in the usual
way except that it is advisable to have an
Complaints like abdominal pain, fever, vaginal intravenous normal saline or 5% dextrose
discharge and abdominal tightening must be infusion set up so that oxytocin can be added if
fully investigated and treated. Prophylactic need be. Epidural analgesia is best for twin
iron, folic acid and malaria chemoprophylaxis labour. Monitoring in labour is intensive.
are given to prevent anaemia. Serial ultrasound Where facilities for electronic monitoring are
scans to assess growth (if facilities are available these should be used; ifmembranes of
available) are performed every 3-4 weeks up to the first twin are ruptured a fetal scalp electrode
28 weeks and 2-weekly from 28 weeks to is applied while an external abdominal
delivery. Admission to hospital for bed rest and transducer monitors the second twin. Progress
observationis only done when there are signs of of labour is monitored using a partograph as in
preterm labour, pre-eclampsia or intrauterine singletons. Fetal distress in any of the twins
growth restriction. Routine admission in late during the first stage of labour is an indication
pregnancy is no longer practised. Patients are for abdominal delivery. The first stage is not
advised to have enough rest during pregnancy unusually prolonged in twins. Indications for
as bedrest is thought to improveplacental blood abdominal delivery at this stage of labour are
flow and so improve fetal growth. similar to those of singletonpregnancy.
Management of the second stage of labour in
Labour twins is not any different except when a
complication arises. The first twin is delivered
Labour in twin pregnancy should always be normally if it is a cephalic presentation, or by
supervised and conducted by an obstetrician in a assisted breech delivery if it is a breech
well-equipped hospital that has a special care baby presentation.
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~w • -I; - :•
Hydramiuos 379
HHRhsMHIH
After delivery of the first twin the cord is even maternal death can result if it is not
divided between the two clamps applied and properly performed.
one of the clamps is left on the maternal end of The chances of survival of the second twin are
the umbilical cord. The mother's abdomen is reduced the longer it is retained. The retraction
palpated to determine the he of the second twin of the uterus after delivery of the first twin
and to ascertain if uterine contractions are still jeopardises the utero-placental circulation and
present. Ifthe lie is any other than longitudinal, causes fetal distress inthe second twin. Also die
it is corrected by external cephalic or podalic cervix closes down if there is undue delay in
version and made longitudinal. Check the fetal delivering the second twin. Delivery of the
heart rate. A vaginal examination is performed second twin should therefore immediately
to determine if the membranes are intact or follow that of the first Prophylactic injectionof
ruptured; if they are already ruptured, cord oxytocin 10 units or ergometrine 0.5mg
prolapse is excluded. Syntocinon 2.5 units is intramuscularly is given immediately after
added to the 500ml of 5% dextrose water or delivery of the second twin. The
normal saline infusion if the uterine
placenta/placentae is/are delivered in the usual
contractions become ineffective or cease
way. To prevent any further bleeding
completely. If the presenting part is high and
postpartum, intravenous infusion of 500ml
membranes unruptured it is important to allow
normal saline containing 20 units of oxytocinis
it to descend well into the pelvis before doing
set up to runfor about 2 hours.
artificial rupture of membranes. This will
prevent cord prolapse. With effective Lockedtwins
contractions the second twin is delivered
normally after rupturing the membranes. If This is very rare, with an incidence of 1:817 twin
there is fetal distress delivery can be expedited pregnancies. It occurs when the presentation of
usingthe ventouse or the obstetric forceps. the first twin isbreech andthat of thesecondtwin
When the presentation of the second twin is is cephalic. Unexplained delay or difficulty in
breech one of the following can be done: delivering the first twin should make one suspect
©external cephalic version and vertex delivery lockedtwins (fig46.3).
(ii) assisted breech delivery (iii) breech When the diagnosis of locked twins is
extraction (this should be done under epidural established the first is most often dead and
analgesia or general anaesthesia). Breech decapitation under anaesthesia is done and the
extraction is only performed when there is fetal free floating head pushed into the uterus to free
distress and there is need for quick delivery. In the head of the second twin, which should be
cases of transverse or oblique lie an alternative delivered, by a forceps or vacuum extraction.
form of delivery is internal podalic version and The decapitated head is then delivered after
breech extraction. This procedure must be grasping the stump of the neck with strong
preformed under anaesthesia by an experienced volsellum forceps and traction applied while
obstetrician, the cervix must be fully dilatedand the operator at the same time inserts a finger in
the membranes must be intact. It should never the mouthto flex thehead.
be attempted, (i) when the uterus isscarred from
previous caesarean section and (ii) when Elective caesarean section in twins
membranes have ruptured and all liquor has
drained out. Serious complications like Indications include:
ruptured uterus, fetal injury and fetal death and 1. Severe pregnancy-inducedhypertension
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380 Obstetrics and Gynaecology

where induction of labour is considered Lagos University Teaching Hospital shows an

unwiseand risky. incidence of 3%, and all the cases were
2. Cases where the mother merits elective "unbooked" and mainly from primary health
section already on account of pelvic care centres and traditional birth attendants.
abnormalities, bad obstetric history, or Retained second twin is associated with high
any other appropriate indication. perinatal and maternal morbidity and
3. Where theFe is preterm labour and the mortality.
babies are presenting by the breech
provided there is an ideal maternity set¬ High order multiples
up with good neonatal intensive care
unit. Some cases of triplets could be delivered
Other indications are similar to those for vaginally, but where the babies are very small I
singletonpregnancy. and incases of high order multiples it is bestt(
deliver them by elective caesarean section to 1
Retained second twin reduce morbidity and mortality. Some
obstetricians however prefer to deliver]
This is a condition commonly seen in places triplets and high order multiples by caesarean
where obstetric care is poor or inadequate as is section as a rule.
found in many developing countries. It is
preventable, it does not occur where twin
pregnancy andlabour are properly managed.
Bibliography and suggested further
Major causes of retained second twin are
reading
uterine atony, abnormal presentation and partial Abudu OO, Agarin M (1983). Twin pregnancy and 1
close downof the cervix after the delivery of the perinatal mortality inLagos.J Obstet Gynae EastAfri ,
first twin. These result from poor management 3:7-11
of twins, i.e. when twin pregnancy and labour Fisk NM (1999). Multiple Pregnancy. In: Edmonds
are managed in a centre that is not well DK (ed) Dewhurst's Textbook of Obstetrics ana
equipped, or where an inexperienced person Gynaecology for Postgraduates 6th ed. Blackwell
conducts the delivery. A recent study at the Science, Oxford, pp298-307.

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Chapter 47
Rhesus red cell isoimmunisation
and ABO incompatibility
Introduction produce either Rh-positive or Rh-negative
offspring with equal frequency in each
Isoimmunisation (maternal blood group pregnancy. Rh isoimmunisation can occur only
Isoimmunisation), a disease of genetic in the pregnancy where an Rh-positive fetus
predisposition, has been a focus of concern for resides, and that fetus will be affected by the
obstetricians for centuries. Sixty one years ago,
maternally produced Rhantibody.
Landsteiner and Weiner first described their
classic experiment inwhich Rhesus monkey red B. Other Rh antigens
cell antiserum was mixed with blood samples
from a selected human population. Levine and A long list of other antibodies has been
colleagues subsequently demonstrated that the described that delineates other Rh antigens and
Rh immune response in a Rh-negative woman argues for a hugely more complex system that
was the primary aetiology for haemolytic the Cc-Dd-Ee antigen loci might suggest.
disease inthe newborn.The identification of the Haemolytic disease of the newborn and fetal
Rhesus antigen and its description in these erythroblastosis are much less common with
classic works are a cornerstone of modern these antigens (Du, C") which were first
immunohaematology. Improved technologies described inTippett and Sanger's classic article.
and the elucidation of the complexities of the Rh The proteolipid Rh antigen chemically
blood group system haveled to the development described by Brown and colleagues in 1983 is
of sensitive screening tests for blood group an essential component of the red blood cell
antibodies. The maternal isoimmunised patient membrane.
and her caregiver now have choices for both
prevention and management of this historically C. Population distribution
difficult problem. In predominantly white national groups,
approximately 15% of the population has been
I. Rhsystem identified as Rh-negative. The distribution is
not homogeneous, however. It appears that the
A. D antigen Basque population of Spain has an incidence of
Although the Rh antigens are grouped in three 30-32% Rh-negativity. The frequency of Rh-
pairs (Dd, Cc, Ee), the presence of the D antigen negative in Asian, Native American and black
determines that the individual is Rh-positive. population is significantly lower.
The Rh-positive individual will be found to be Approximately 8% of American blacks are Rh-
negative. African blacks are significantly less
homozygous for D (i.e., DD) approximately
likely to be Rh-negative.
(45%) of the time. This results from
having inherited D-containing set of alleles These population statistics argue that Rh-
from both parents. The remainder of Rh- negativity was originally confined to the Basque
positive individuals will be heterozygous for population, and that initially all of the races were
the D locus (Dd). A homozygous partner of an entirely Rh-positive. In our series we found out
Rh-negative woman can produce only Rh- that of 1045 male and female screened, 62
positive offspring; a heterozygous partner can patients were Rhesus negative, that is 5.95%.

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382 Obstetrics andGynaecology

II. Aetiology Dia

Blood group isoimmunisation arises from one or Dib
two pathogenetic incidents: incompatible blood Lua
transfusion or fetomatemal haemorrhage. Yt"
Jka
A. Incompatible blood transfusion
Although still the most common cause of non- Jkb
Rhesus blood group immunisation, transfusion Le None
isoimmunisation generally is related to
development of atypical blood group Leb
antibodies. Although the majority of atypical
antibodies are of little clinical consequence,
haemolytic disease of the newborn can be Table 47.1 Atypical maternal blood group antibodies
relatedto a few atypical antibodies (Table 47. 1). andassociatedrisk ofneonatal haemolytic disease.

hemolytic disease was identified in zone 1. gestation should be encouraged to deliver at 37-
Empirical data and evolving prognostic 38 weeks of gestation, provided that lung
accuracy have allowed the evolution of the maturity can be demonstrated. Pregnancies in
associated chart (fig 47.1). The method of which hydrops in noted after 34 weeks of
measurement used, however, seems less gestation represent 20% of all pregnancies.
important than the judgement and experience Such patients should be promptly delivered if
of the personreviewing amniotic fluid results. the Delta OD 450 measurement rises to upper
zone 2 or zone 3. Although evidence of
E. Delivery pulmonary maturity is preferable,
corticosteroid administration may be
Those 50 - 60% of pregnancies immunised for
considered 48 hours prior to delivery.
the Rh antigen in which either amniocentesis
has not been required or Delta OD 450
F. Treatment
measurements have been measured to fall
In those pregnancies where prematurity is
within mid zone 2 or lower should be allowed problematic and where neonatal morbidity and
to deliver spontaneously. The patient in mortality rates may be increased, intrauterine
whom elevation to upper zone 2 as measured treatment becomes the therapeutic mode of
by amniocentesis at 35-37 weeks of

ZUftfB 3

•l."i 4

CLOT"

7£m\

24
Figure 47.1 Modification of Liley graph used to depict degree of sensitisation. The dotted
line represents a linear extrapolation from the original Liley data (solid line)

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386 Obstetrics andGynaecology

Choice. Fetal
Transfusion Exsanguination
The original intrauterine fetal transfusion, an Overtransfusion
Intraperitoneal transfusion technique, was first Cardiac tamponade (intraperitoneal
described by Liley in 1963. With increasing transfusion, primarily)
sonographic sophistication, intravascular Infection
transfusion, providing more immediate
diagnostic and therapeutic endeavours to be Labour induction
employed was described in 1981 via fetoscope Umbilicalvein compression (intrauterine
and vianeedle in 1982. These procedures, either Transfusion, primarily)
intraperitoneal or intravenous transfusion, Maternal
should only be attempted by those skilled at
Infection
ultrasound interpretation and cordocentesis
since intrauterine transfusion carries a distinct Tissue trauma
risk for the fetus (Table 47.3). Fetal - maternal
Further transplacental haemorrhage
Current protocol about Human Anti-D Rh (D)
immunoglobulin (RhoGAM): Table 47.3 Risks of intrauterine fetal
transfusion
(i.) Antenatal prophylaxis: 500 l.U. should be
given to a Rh(D)-negative non-immunised It has been argued convincingly that intrauterine
pregnant woman at both 28 and 34 weeks of transfusion is a legitimate therapeutic modality.
gestation if the husband or partner is Rh(D)- When indicated, premature deliveries are
positive. removed from statistical consideration. The
physical and intellectual development in most
(ii.) Following an incident during pregnancy: transfusion survivors appears normal.
Up to 20 weeks gestation: 250 I. U. . After 20 Although suppression of Rh immunisation by
weeks gestation: 5001. U. These should be various modalities (promethazine,
administered at the time of incident. Such plasmapheresis, intravenous immune serum
incidents include abortion (spontaneous or globulin) remains equivocal, it is obvious that
induced), unless it is shown that the conceptus prevention of Rh immunisation altogether is a
is Rh(D)-negative, external version, or largely attainable goal.
antepartum haemorrhage.
** Postpartum RhoGAM
(iii.) Postnatal prophylaxis: For non-immunised Present recommendations indicate
Rh(D)-negative women who give birthto a Rh(D) administration of Rhesus immunoglobulin
positive infant, 500 l.U. should be administered (RhoGAM, RhIG) to the mother as soon
immediately after birth or within 72 hours of after delivery as cord blood findings indicate
delivery. Human Anti-D immunoglobulin the baby to be Rh-positive and the mother to
injection is administered intramuscularly and the be at risk. Adherence to the dictum that it is
product has been found to be safe. preferable to treat a woman unnecessarily
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Rhesustedceil isoimmunization andABO incompatibility 387

than to fail to treat a woman who then becomes Pathol. 110:127,.

Rh sensitised is sensible. A woman at risk who Kleihauer, E., Braun, H., and Betke, K. (1957).
is inadvertently not given RhIGwithin 72 hours Demonstration von fetalem Haemoglobin in den
of delivery should still receive prophylaxis at Erythrozyten eines Blutrasstriches. Klin.Wochenschr.
35:637,.
least up to two weeks after delivery if
prophylaxis is delayed. It should be understood Landsteiner, K., and Weiner, A. S. (1940). An
that it may not be effective. If there is any agglutinable factor in human blood recognized by
immune sera for Rhesus blood. Proc. Soc. Exp. Piol.
question about the amount of RhIG to be Med. 43:223.
administered after delivery, a Kleihauer-
Betke test should be performed and a Levine, P., Katzin, E. M., and Burnham, L. (1941).
Isoimmunisation in pregnancy: its possible bearing on
calculation of quantity of transplacental the etiology of erythroblastosis fetalis. J.A. M.A.
haemorrhage made. Current recommendations 116:825.
indicate that one vial (300 ug) of RhIG should
Liley,A. W. (1963). Intrauterine transfusion offetus in
be administered if the transplacental haemolytic disease. Br Med. J. 2:1107
haemorrhage is 25ml of blood or less, two vials
(600 ug) if the transplacental haemorrhage is Liley, A. W. (1961). Liquor amnii analysis in
management of pregnancy complicated by rhesus
between25-50 ml, and so forth. immunisation.Am. J.Obstets. Gynecol. 82: 1359,.
Rodeck, C. H. etal (1981). Direct intravascular fetal
** Current protocol about Human Anti-D blood transfusion by fetoscopy in severe rhesus
Rh(D) immunoglobulin. isoimmunisation. Lancet 1:652,.
Tippet, P., and Sanger, R. (1962). Observations on
subdivision of the Rhantigen D. Vox Sang. 7.9.
Bibliography and suggested further
reading Whitfield, C.R. (2000). Rhesus disease: success but
unfinished business In The Yearbook ofObstetrics and
Bowman, J. M. and Pollock, J. M. (1978). Antenatal Rh Gynaecology. O'brieri, P.M.S. ed. RCOG Press,
prophylaxis: 28 week gestation service program. Can. London.
Med.Assoc. J. 18:627.,
Woodrow, J. C. (1970). Rh Immunisation and its
Bowman, J. M., And Pollock J. M., and Pension, L. E. Prevention. In series Hematologia, Vol. Ill
(1986). Fetomaternal transplacental hemorrhage during Copenhagen: Munsgaard.
pregnancy and after delivery. Vox Sang 51:117,.
Zipursky, A., and Isreals, L. G. (1967). The
Brown, P. J., et al. (1983). The Rhesus D antigen. A pathogenesis and prevention of Rh immunisation. Can
dicyclohexylcarbodiimidebinding proteo-lipid.Am. J. Med.Assoc. J. 97:1245.

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Chapter 48
Prenatal diagncisis of inherited diseases
and therapy
Introduction diagnosis have occurred, due in part to other
technological advances including alpha-
Serious birth defects often genetically fetoprotein (AFP) assay technique for detecting
determined, complicate and threaten the lives of neural tube defects, the application of
3 percent of newborn infants. These disorders ultrasound for the diagnosis of physical
account for 20 percent of deaths during the abnormalities and the development of
newborn period and even a higher percentage of fetoscopy for direct visualisation in fetal skin
serious morbidity in childhood. The cost of biopsy and the sampling of blood and the
neonatal intensive care is staggering. Higher increased use of radiological examinations.
still is the cost of rehabilitation programmes for
the severally handicapped. The family tragedy The identification of frequencies inwhich there
is immeasurable. With the growing recognition is an increased chance of a diagnosable fetal
of the frequency and importance of congenital disorder involves a search for general and
disorders and with current social trends towards specific risk factors. The use of the
smaller families and postponement of questionnaire to find out genetic informatioi
has been recommended by some obstetrick
childbearing on account of social and economic
and gynaecologists. Counselling befor<
problems, prenatal diagnosis has an important
prenatal diagnosis is an integral part of
role in the management of many pregnancies
whole process. The central issue is balancing
especially in areas where certain genetic
the risk of an abnormal child against the risk
diseases are endemic like haemoglobinopathies
an investigative procedure. Prospective parent
among others in several developing countries
must understandthat a specific diagnosis can 1
like Nigeria.
excluded or established with a high degree
reliability but not with complete certainty.
Indications for prenatal diagnosis
One of the most important goals of geneti:
Prenatal diagnosis is one of the more counselling is to help patients understand
rapidly developing areas in medicine, not only reproductive options available to them.
with regards to the number of patients Apersoris previous experience, ethnic anc
evaluated, but also in relation to the number of cultural background, and religious beliefs
conditions which may be diagnosed. Prior to affect the acceptability of prenatal diagnosii
the 1960s prenatal diagnosis was made and the choice to be made if an abnormality ii
infrequently. During the 1960s however, diagnosed. Counselling should be non-
techniques for chromosomal and biochemical directive and should concentrate on th«
analysis of amniotic fluid cells were accurate presentation of all the facts
developed, and routine prenatal evaluation options. Common indications for prenat
became a reality. Subsequently, expanded counselling and diagnosis are summarised u
utilisation and application of prenatal Table 48.1
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Prenatal diagnosis ofinheriteddiseases and therapy 389

General riskfactors

Maternal age >35 years at the time of delivery

Elevated or reduced maternal serum alpha-fetoprotein concentration
Results of triple screening: elevated or reduced maternal serum alpha-fetoprotein,
human chorionic gonadotropin and the conjugated oestriol concentrations.

Specific riskfactors
Previous child with a structural defect or chromosomal abnormality
Previous stillbirth or neonatal death
Structural abnormality in the mother or father
Balanced translocation in the mother or father
Inheriteddisorders: cystic fibrosis, metabolic disorders, sex-linked recessive disorders
Medical disease in the mother: diabetes mellitus, phenylketonuria
Exposure to a teratogen: ionizing radiation, anticonvulsant drugs, lithium, isotretinoin,
alcohol
Infection: rubella, toxoplasmosis, cytomegalovirus.

Ethnic risk factors

Disorder Ethnic or racial group Screening marker

Tay - Sachs disease Ashkenazi jewish Decreased serum hexosaminidase

French Canadian concentration

Sickle cell anaemia Black African, Mediterrranean Presence of sickling in haemolysate

Arab, Indian and Pakistani followed by confirmatory
haemoglobin eletrophoresis

Alpha- and Beta- Mediterranean, Southern and Mean corpuscular volume < 80p in3
Thalessaemia Southeast Asian, Chinese followed by confirmatory
haemoglobin electrophoresis.
Table 48.1 Indications for prenatal diagnosis

most of the child-bearing population. Of

Risk factor screening children with Down's syndrome, 30% are born
General risk factors to women over 35 years, but because only half
of these are willing to have invasive testing,
Pregnant women over 35 years old are tested maternal age screening effectively picks up
for fetal karyotype abnormalities, the only 15%. This poor performance had led to
most common of which is trisomy, world wide
search for improved methods. Children of
today.Although older women are individuals at
a higher risk of having fetal karyotype mothers aged 16 years or less have a
abnormalities, (Table 48.2) 70% of children high genetic risk of chromosome aberrations
with Down's syndrome are born to women and almost as high as in maternal age group of
younger than 35 years because they form more than 38 years old. Whether paternal

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390 Obstetrics and Gynaecology

age factor of 45 years andabove plays a role is gestation, the levels of several biochemical
still controversially discussed inEurope since products of pregnancy in the maternal serum
some genetic counselling centres have not differ between those at risk for certain cytogenetic
included it intheir list whether as single factor and structural abnormalities and those that are
or incombination with maternal age factor.
normal. Alpha-fetoprotein, the major circulating
protein of early fetal life is synthesised inthe fetal
Age Risk of Down's Risk of chromosomal liver and yolk sac. Open neutral tube and ventral
syndrome abnormality wall defects are associated with exposed fetal
20 1/1667 1/526 membrane and blood vessel surfaces that increase
the level of alpha-fetoprotein, human chorionic
25 1/1250 1/476 gonadotrophin (p-HCG) and unconjugated
30 1/952 1/385 oestriol used as screening tests, generally as a
35 1/385 combination of alpha-fetoprotein and (3-hCG.
1/202
Urea resistant neutrophil alkaline phosphates
36 1/295 1/162 (NAP), inhibin and pregnancy associated
37 1/227 1/129 placental protein A(PAPP-A) are attracting
38 attention today. The calculation of risk depends on
1/175 1/102
a combination of likelihood ratios. Low levels of
39 1/137 1/82 maternal serum alpha-fetoprotein and
40 1/106 1/65 unconjugated oestriol are associated with trisomy
21 and trisomy 18. The single marker that yields
41 1/82 1/51 the biggest detention rate for Down's syndrome is
42 1/64 1/40 the level of human chorionic gonadotrophs.
43 1/50 1/32 which is significantly elevated when the fetus is
affected by this syndrome. As mentioned earlier.
44 1/38 1/25 the combined use of maternal serum human
45 1/30 1/20 chorionic gonadotrophin level, the unconjugated
46 1/23 oestriol level, the alpha-fetoprotein level
1/16
andmaternal age can identify approximately 60%
47 1/18 1/13 of cases of Down's syndrome, with a false
48 1/14 1/10 positive rate of 3.8% Biochemical screening
49 1/11 allows a more accurate definition of the
1/7
population at risk. Invasive diagnostic tests
According to Hook in these women detect a greater percentage
of infants with Down's syndrome without
Table 48.2. Relationship between maternal age and
the estimated rate of chromosomalabnormalities increasing the number of invasive procedures
carried out. The use of ultrasonography to verify
gestational age reduces the false positive rate to
3.8%. Gestational age must be assessed
Biochemical screening
accurately by ultrasound measurement of the
Serum screening for Down's syndrome has biparietal diameter. Fetal femur length
developed from the finding that at 16- 18 weeks measurements are not used because the femur of

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, .
Prenataldiagnosis of inheriteddiseases andtherapy
-j
391

villus sampling has a 1.7 to 4.6 percent lesser

chance of a successful pregnancy outcome than
a woman assigned to second trimester
amniocentesis. The disadvantages of CVS
(Table 48.5) are:

1. The miscarriage rate is slightly higher

than with amniocentesis
2. CVS carried out too early before 9
completed weeks of pregnancy
may leadto fetal malformation
Figure 48.4 Cordocentesis 3. Ambiguous results may occasionally
occur as a result of mosaicism
Chromosomal mosaicism is the presence of two
Chorionic villus sampling (CVS) or more cell lines with different karyotype in a
Several hundred thousand procedures have single person. This occurs as a result of post
beendocumented worldwide that first trimester zygotic non-disjunction. The observation of
CVS can now be considered as a reasonably multiple cell lines in prenatal sample does not
safe and reliable alternative to amniocentesis. necessarily mean that the fetus has mosaicism.
Chorionic villi may be obtained by aspiration Amniocentesis is recommended in doubtful
through a transcervical catheter or trans¬ cases. Limb reduction defect has been reported
abdominal needle with ultrasound guidance in five infants born among a group of 289
(fig. 48.2&3). The choice is based on the women who underwent chorionic villus
location of the placenta and the operator's sampling 56 to 66 days after the beginning of
preference and experience. The main advantage the last menstrual period. Oromandibular
of chorionic villus sampling over amniocentesis hypogenesis was present in four of the five
is the earlier availability of result, since the infants. The proposed mechanism of the defects
procedure is generally performed between 9/10 is a form of vascular insult leading to
and 12 weeks of gestation. Results based on a hypoperfusion of the fetus. Transverse limb
direct preparation of spontaneously dividing abnormalities after chorionic villus sampling
cells are usually available in 24 to 48 hours and have been cited in other reports. However, the
final results from cultured cells in 10 to 14 days. incidence of limb defect was not significantly
An additional advantage of chronic villus different from the expected rates, and defects
sampling is that more tissue is obtained than by were also observed when the procedures were
amniocentesis. The extra tissue is useful when performed after 66 days (Table 48.6). Although
DNA analysis or enzymatic diagnosis is the incidence of limb defects may be dependent
necessary. Amniocentesis must be used on the timing of the procedure and the
however, for assays for which amniotic fluid experience of the operator may be a factor,
is essential, such as measurement of the causal relationship between chorionic villus
alpha-fetoprotein concentration. Results sampling and limb defects has not been
from randomised studies, showed that the established. We have so far not experienced this
experience of the operator may be crucial in in our small group of patients sampled in
achieving optimal safety because a woman CMUL-NIMR-CVS Lagos-Programme.
assigned to undergo first trimester chorionic
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EH - Obstetrics and Gynaecology

Early amniocentesis even late in pregnancy; as it might allow parents to

Experience has been accumulating with early decide against a caesarean section in case of severe
amniocentesis (performed before 15 weeks of chromosomal abnormalities such as trisomy 18.
gestation). The possibility of this method at 14
weeks or less is being examined. Culture success Percutaneous umbilical blood sampling
is comparable to that with mid-trimester samples, (Cordocentesis)
though the incidence of mosaicism rises because
of the relatively smaller proportion of viable cells The indications for fetal blood sampling are
of fetal origin. Although this procedure is shown in Table 48.1. With high resolution
technically easier to perform than chorionic villus ultrasound guidance, fetal blood can be sampled
sampling, the rates of success of the two from the umbilical cord, the intrahepatic
procedures in obtaining samples are similar. The umbilical vein or the fetal heart, usually after 19
procedure is the same as that of conventional weeks' gestation. Percutaneous umbilical cord
amniocentesis but failure to obtain a sample sampling was developed for the diagnosis of
occurs more commonly. A vaginal approach is
toxoplasmosis. Access to the fetal circulation
feasible but there is only a 17% culture rate permits the prenatal evaluation of many fetal
because of bacterial or fungal overgrowth.
haematological abnormalities, including
iso immunisation, haemoglobinopathy,
The volume of amniotic fluid at 12 weeks thrombocytopenia and coagulation factor
gestation may be as little at 30ml, and the abnormalities. Fetal blood sampling may clarify
proportion removed may therefore be very whether chromosomal mosaicism detected by
high. The effects of this on fetal lung cytogenetic analysis of amniotic fluid or
development are still to be established, but chorionic villi is true. The need for rapid
there is circumstantial evidence that it may karyotyping when congenitial abnormalities are
cause pulmonary hypoplasia. Neonatal suspected is the most common indication for fetal
respiratory distress is more common following blood sampling inUSA. Cytogenetic results from
first trimester amniocentesis than after CVS. short term fetal lymphocyte cultures are usually
The risk of pregnancy loss resulting from early available within 48 to 72 hours. The rate of fetal
amniocentesis is reported as 0.7% miscarriage loss after percutaneous umbilical blood sampling
within 2 weeks of the procedure. is about 2 percent more than the background risk
to the particular fetus. This technique is being
Second and third trimester placentacentesis used for monitoringfetal therapy (fig. 48.4).
The most rapid approach to cytogenetic
analysis throughout pregnancy is direct Fetal biopsy
chromosome preparation from chorionic villi.
Ithas been shown that chorionic villus obtained Fetal biopsy was initially performed at fetoscopy
in the second and third trimesters is usually by but is now performed under ultrasound
the transabdominal route. Another advantage of guidance. Certain genetic skin disease such
placental biopsy is that it can easily be applied as epidermolysis bullosa can now be diagnosed
in cases with poly or oligohydramnios where by DNA analysis of ornithine transcarbamylase
the alternative methods can be difficult. With deficiency. Fetal muscle biopsy has been
few exceptions most perinatologists and used to diagnose Duchenne's muscular
geneticists agree that karyotype is indicated dystrophy in a family in which DNA studies
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Prenatal diagnosis of inheriteddiseases andtherapy 399

were uninformative. It is difficult to assess the Chorionic villus sampling (CVS) vs amniocentesis
(AC)
safety and accuracy of fetal biopsy because
experience with this procedure is limited. This • CVS allows the earliest diagnosis of
is an example of one of the general trends in fetal abnormality.
prenatal medicine that made potentially riskier •Reports of fetal limb defects following
procedures get replaced by techniques that are CVS at 9 weeks' gestation have led to
safer for mother and fetus. Rapid advances in the abandonment of the technique
DNA technology can be expected to elucidate before this time.
the molecular basis of many diseases that now
require fetal biopsy. As such, knowledge is •The chance of the pregnancy resulting
accumulating that the need for this procedure in surviving infant is 4.6% (95% CI1.6 -
will decline. 7.5 P<0.01) less following CVS than
after amniocentesis, according to one
Preimplantation genetic diagnosis study.
"The placenta is not always
The standard approaches to the prenatal
chromosomally identical to the fetus. It
diagnosis of genetic diseases are as mentioned
isderived from the trophectoderm of the
earlier: chorionic villus sampling, blastocyst, while the fetus develops
amniocentesis and more recently percutaneous from the inner cell mass. Discordance
blood sampling. Each of these procedures is (genetic dissimilarity) or mosaicism
associated with obstetric risks to the mother and necessitates repeat sampling in 1% of
to the fetus. And if a genetic anomaly is CVS, three times as frequently as after
detected, the only alternative to continuing the amniocentesis.
pregnancy is an elective termination. For
patients at high risk of a genetically abnormal Transcervical (TC) vs transabdominal (TA)
conception, such as haemophilia, muscular CVS
dystrophy or cystic fibrosis, the possibility as
* The technique of TA CV S may be easier
well as the experience of repeated pregnancy
to learn for those already familiar with
terminations inflicts severe mental trauma. This
ultrasoundguided amniocentesis.
would be avoidable if a genetic diagnosis could
be made prior to implantation. Verlinsky in • The TC route is theoretically more
1987 described such a model. The mapping of likely to introduce infection.
the human genome is expected to be completed
in some few years and as a result molecular
• Pregnancy loss rates are generally
genetic technique is likely to be available for the equivalent at 2% in the most
> experienced hands.
detection of all common monogenic disorders.
Fetal cells in maternal blood Fetal cell •TA CV S inmore painful than TC CV S.
sampling from maternal cells is another way
now and for the future. Recently, research on * Most of the fetal limb defects reported have
fetal cells separated from maternal circulation been associated with TA single needle
has been showing advances and the future of aspiration. The trauma caused by this
this methodology is full of hopes. technique mustbe keptto a minimum.
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mam—

ÿSwSEi -
i
HflNHflRM pi mm
490 Obstetrics andGynaecology
!
*-

_ NHflHHHNHHHHMHi H
Table 4315 Risks and benefits of different sampling techniques

Chorionic villus sampling series

Study 56 to 66 Defect >66 Defect
days* days*
Firth et al. 1 .Transverse limb-reduction
5/289 0/250
defect, 4 combined limb
reduction defects with
micrognathia or microglossia
Burton et alO 4/394 3 finger-and toe-abnormalities
1 finger abnormality

2/2227 2 finger abnormalities

Monne et al. 0/525 —
1/1025 Longitudinal limb-reduction 6/8563 1 longitudinal limb-reduction
MahoneyO defects
defect
5 transverse limb-reduction
Defect
(2 of the 5 were limited to
Fingers or toes)

Jackson etalj 1/2367 Bilateral aplasia of the thumbs 4/10,496 3 transverse limb-reduction
defects, 1 finger abnormality
Schloo et al
1/636 Microglossia and hypodactyly 3,2200 3 finger abnormalities
(2 of the 3 had a family
history of limb defects).

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\ Population - based studies

Prenataldiagnosis ofinheriteddiseases andtherapy 401

Study Defect Incidence

Froster-Iskenius Combination of limb-reduction and
and Baird micrognathia or microglossia
1/75,000
Limb-reduction defects 1/1692
Terminal longitudinal defects 1/2857
1/6250
Terminal transverse defects

Prince Of Medicine-2014-BSUTH

MA Obstetrics and Gynaecology

Fetus between low maternal level of vitamin A and

increased mother-to-child transmission.
Intrauterine growth restricted and low birth Administration of vitamin A to the mother
weight babies are common in this condition. during pregnancy in Africa may be beneficial
Both intrapartum and intrauterine deaths are althoughthis view is still disputable.
also common features.
Infants with low Apgar scores, neonatal deaths, Antimalarial prophylaxisduring pregnancy has
and increased infant mortality are more
also been shown to reduce transplacental HIV
frequently recorded.
transmission and most authors advocate this
Vertical transmission practice especially inAfrica.

This is the term used to express the spread of Labour in affected mothers should be
HTV/AIDS from mother to baby. The methods shortened as much as possible and oxygen
by which this occurs include: should always be available to correct anoxia, as
i) Antepartum, when the infection is many of these womenare invariably anaemic.
probably transmitted from the mother to
the unbornchildviathe placenta, or when The use of elective caesarean section for
HTV infected blood is transfused to the delivery is still controversial. Some authors
mother for anaemia or obstetric reasons. advocate this to reduce viral transmission,
(ii) Intrapartum, when the baby becomes which may occur during normal labour while
infected during delivery while some think that this may leadto an unnecessary
negotiatingthe passage. increase in operative delivery without
statistical difference in transmission rate.
(iii) Postpartum, when the infection is Results of recent randomised trials have
transmitted to the baby during however shown significant reduction.
breastfeeding by an HIV infected mother. Postoperative infection during the puerperium
To reduce antepartum transmission, the isanother militating factor inAfrica.
administration of an antiviral agent like
zidovudine (AZT) which suppresses viral Those who favour normal vaginal delivery
replication to some extent has been advocated. employ the use of irrigation of the vagina with
Oralzidovudine is givenduring pregnancy, and chlorhexidine or other antiviral solutions at the
preferably intravenously in labour. After time of delivery with the aim of reducing viral
delivery, the baby is also given zidovudine for transmission. However, studies from Malawi
about six weeks. Previous trials have shown a have not been very convincing. Administration
reduction of transmission from 25% to 8% of microbicides vaginally or rectally has also
(Connor etal, 1994). been suggested for this purpose.
Blood given to a pregnant woman should be
Transmission to the baby during breastfeeding if
screenedfor HTV before transfusion.
the mother is infected has been considered a
Trials from Malawihavedemonstrated a relationship serious issue. Some studies carried out in Soweto,
SouthAfrica, have shown a reduction from 28.5%
to 18% in babies who were not breastfed by their
infected mothers. The World Health Organization
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HIVandAIDS inpregnancy ,&05:

(WHO) previously advocated that in Africa, Africa is yet to benefit from either of the two
HIV positive mothers should breastfeed their methods of treatment. Infact, monotherapy is
babies in spite of the fear of viral transmission. not even affordable by mostAfrican countries.
It is considered that in Africa, babies who are
not breastfed may succumb otherwise to Some African countries have negotiated with a
diarrhoea, malnutrition, and other infections. few interested big foreign pharmaceutical
Such a policy for Africa should not be accepted companies and succeeded indrastically reducing
whole-heartedly for with increasing level of the cost of these drugs but this is still not within
education and hygiene some of these mothers thereach of many afflicted poor people.
couldbe taught how to sterilise baby's bottles or
feeders effectively. Another argument is the There are ongoing clinical trials to meet the
rampant level of poverty that may make the cost needs of developing countries that are unable to
of formula unaffordable to these women. The implement interventions now standard in the
answer is that any serious government that
industrialised world. Such recent trial results
wants to fight the scourge ofHIV/AIDS must be
suggest that short-course antiretroviral
willing to subsidise the cost of formula or even
regimens could significantly reduce perinatal
supply it free.
HIV transmission.
The WHO has now revised its views and
Atypical regimen includes oral administration of
recommends breast milk substitutes wherever
a combination of zidovudine (a nucleoside
possible.
reverse transcriptase inhibitor) 300mg twice
daily, and lamivudine (a synthetic nucleoside
Vaccine for HIV/AIDS
analogue) 150 mgtwice daily from 36 to 40 weeks
It is being suggested that efforts should be
directed at inventing m effective vaccine of pregnancy. Nevirapine (a non-nucleoside
against HIV/AIDS but this may yet take a long reverse transcriptase inhibitor) is given as a single
time just as scientists are still researching for oral dose of 200 mg at onset of labour or 6 hours
vaccine against malaria. before caesarean section. The mother is not to
breastfeed and the newborn is given Nevirapine
Monotherapy versus combination therapy syrup 2 mg/ kgbody weight daily for 3 days.

The use of zidovudine has beenconsidered to be Screening for HIV/AIDS

largely free of adverse effects but there is the
possibility of drug resistance especially if used It has been suggested that all pregnant women
for a fairly long period in pregnancy. should be offered an HIV test in an effort to
Monotherapy is now considered substandard reduce the rising number of babies bom with the
and combination therapy is the practice deadly vims. If women know they are infected,
especially if the infected pregnant woman has there is a possibility that the risk of mother to baby
been shown to have a high viral load. While the transmission could be reduced from 1 in 6 to less
latter practice may reduce the chances of than 1 in 20. The cost of treating a baby with HIV
resistance, it may unfortunately result inserious far exceeds the cost of screening the pregnant
adverse effects and possible neonatal woman and providing treatment early. Many
mitochondrial toxicity. institutions in Nigeria have also advocated
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406 Obstetrics and Gynaecology

mandatory testing ofpregnant women for HIV.

I
Bibliography and suggested further
The above is good for developed countries but reading
what of developing countries especially Africa Connor, E.M., Sperling, R.S., Gelber, R.etal (1994).
that harbour two-thirds of the world cases of Reduction of maternal-infant transmission of human
HTV/ AIDS? There is very little hope due to immunodeficiency virus type 1 with zidovudine
poverty and lack of funds by various African treatment. New England Journal of Medicine
governments even when the will is there. The 331,1173.
cost of screening and therapy with zidovudine
the most active antiviral drug so far, is very Johnstone, F.D. ed. (1992). HTV infection inObstetrics
exorbitant and claims of cure with herbal and Gynaecology. Bailliere's Clinical Obstetrics and
medicine have not proved authentic or Gynaeco logy 6, (1).
scientifically proven. What can save Africa
presently is a re-direction of sexual attitude. A Johnstone, F. (2000) HTV and pregnancy: national and
random sampling carried out in an urban international perspectives. In The Yearbook of
antenatal clinic in southern Africa, showed an Obstetrics and Gynaecology, ed. O'Brien, PMS,
HIV positivity rate of 30%. If conditions in RCOGPress, London.
most countries in Africa are as gloomy as this,
thenthe continuing building of orphanages and Verkuyl, D.A. A. (1995). Practising obstetrics and
rendering emotional support to the afflicted gynaecology in areas with a high prevalence of HTV
mothers may prove eventually to be only infection. Lancet 346,293 .
cosmetic measures. Counselling no doubt plays
a vital role in this war against HIV/AIDS. For Webb. D. and Fleming A.F. (1996). The essential role
the moment, this disease remains incurable and of antenatal clinics inAIDS control (derived from the
antiviral drugs likezidovudine only prolong the CAB Healthdatabase) 9,4.
lives of the affected women and children for a
relatively short period oftime. WHO InternationalCollaboration Group for the study of
Perhaps we could look forward to a discovery of WHO staging systems (1993). Proposed"WorldHealth
more potent antiviral drugs from ongoing Organisation staging system for HIV infectionand
research efforts or even the possibility of an Disease":
preliminary testing by an internationalcollaborative cross
effective vaccine. sectional study. AIDS, 7,711.
Acknowledgement
Ziegler, J.B.,. (1993). Breast feeding and HIV.Lancet,
Ithank Professor A.F. Fleming for making
302, 1437.
available to me his manuscript onHTV/AIDS.

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Chapter 50
Low birth weight and intrauterine
growth restriction
Definition suffered IUGR. These definitions are
World Health Organization (WHO) currently
retrospective, however, as they refer to birti.
recommends that any baby that weighs less than weight. The diagnosis of IUGR can only be
2.5kg at birth is a lowbirthweight (LBW) baby. made in-utero by serial cephalometry anc
abdominal circumference measurements usint
This definition includes babies born too early ultrasonography. In that case, where a standarc
(before 37 completed weeks of gestation, i.e. curve for a population is already established
preterm babies), babies with intrauterine IUGR can be identified when the biparieta
growth restriction, and babies that are both diameter or the head-abdominal circumference
preterm and growth restricted. However, babies ratio of a baby measured on two consecutive
who are born at term and above 2.5kg but have occasions about two weeks apart, is found to be
lower birth weights than appropriate for below the 5th percentile for that population.
gestational age, are not included in this
definition even though they may be susceptible Incidence
to similar problems as those below 2.5kg. The incidence of low birth weight varies from 4 tc
45% in different populations. It is estimated that the
Inthis chapter we shall discuss low birthweight world incidence of low birth weight is about \1°A
in general and intrauterine growth restriction in and more than 90% occurs in developing countries
particular. The term 'growth restriction' is now In Nigeria today, the incidence of low birth weigh
preferred to 'growth retardation' because of the as reported in hospital based studies ranges betweei
implications of the word retardation (as in 8 and 12 %. A study done in Enugu showed ;
mental retardation). Preterm labour is significantly higher incidence in low birth weigh'
discussedelsewhere inthis book. babies in 1998 as compared with the incidence ii
Intrauterine growth restriction (IUGR) A fetus 1984. The babies were an average 183 gram
with IUGR is one that has failed to reach its heavier in 1984 than in 1998. This was felt to be as
genetic growth potential. This should not be result of the decline in socioeconomic status c
confused with the small-for-gestational age Nigerians as a whole within this period. Inthe UK
(SGA) baby as some of the latter are the incidence of low birthweight is 6%.
constitutionally small but normal. An SGA
baby is one that isbelow the 5th percentile of the Aetiology
expected weight for its gestational age. Most There are various factors that affect the baby
babies that are born after 37 completed weeks weight and are referred to as baby weigl
of gestation and weigh less than 2.5kg suffered determinants.
intrauterine growth restriction. If a graph of
gestational age against birth weight is plotted, Baby weight determinants include:
most babies whose birth weights are below the 1. Genetic constitution.
5th percentile of their expected weights for that (a) Sex of the infant
period of gestation would be deemed to have (b) Height and weight of the mother

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Prince Of Medicine-2014-BSUTH

488 Obstetrics andGynaecology

(c) Race of parents. Caucasian babies are 6. Drugs used by mother e.g. Betel chewing
generally heavier than those of the among Indians. Smoking, though prevalent
NegroidandMongoloidraces. amongst the women in the developed world
2. Environmental factors. is less of a problem amongst ruralwomen in
(a) Social class of parents, which is developing countries. Chronic alcoholism
indirectly relatedto the nutritional and hard drug addiction are also relatively
status of the pregnant woman. uncommon.
(b) Parity of the mother. Women of
higher paritybeing predominantly 7. Multiple gestation. Prevalence of low birth
from low socio-economic class weight is higher amongst multiple births
and hence closely related to 2(a) than singleton. A study reported from the
above. University College Hospital, Ibadan in
(c) Geographical factors. Bantu
1997 showed the incidence of low birth
pygmies and North Arctic
Eskimos produce lighter babies. weight among twins to be 53.9% as
High altitude is also associated opposed to 11.8% among singletons.
with low birthweight babies. Pathology
3. Placental factors are mainly reflective The pathology of preterm labour is discussed
of vascular diseases inthe mother, e.g. elsewhere in this book.The placenta plays a very
chronic renal failure, sickle cell important role in the fetus with IUGR. It supplies
disease, hypertensive diseases, the fetus with oxygen and all the essential
diabetes mellitus, diseases nutrients required for growth. In fact, a state of
complicating pregnancy e.g. chronic hypoxia is synonymous with growth
pregnancy induced hypertension and restriction and eventually fetal death if the fetus is
antepartum haemorrhage. not removed from the hostile environment or if
Malformations of the placenta e.g. the state of hypoxia is not corrected. Therefore,
single umbilical artery and factors that affect the maternal blood supply to the
haemangioma are rare, so also is placenta (uterine vessels), resulting in decreased
extrachorial placenta. These perfusion pressure (i.e. flow of blood in the
conditions are however significantly intervillous space, trophoblast and fetal
associated with low birth weight capillaries), will cause IUGR.However,placenta!
babies. factors account for only a small proportion of
IUGR babies. The cause or pathology of IUGR in
4. Congenital malformation of the fetus a large number of cases is yet unknown.
with loss of potential for growth in
utero. Identification of LBW/IUGR babies
The consequences of IUGR can be severe thus it is
5. Infections in mother and/or babies.
Organisms such as Toxoplasma gondii important that mothers at risk of having IUGR
rubella and cytomegalovirus are babies are identified early in pregnancy so that the
greatly implicated. In the tropics, pregnancy can be closely monitored and action
chronic malaria and trypanosomal taken as necessary if the situation worsens. Table
infectionsaffect thebirthweight. 50.1 shows the list of mothers at risk of having low
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Low birth weight andintrauterinegrowth restriction 499

birth weight babies. Most of the women who 6. Maternal diseases

deliver IUGR babies do not have any antenatal Chronic renal disease
risk factors, therefore the identification of these Sickle cell disease
babies depends on the standard of antenatal care Chronic hypertensive
and availability of biophysical methods (e.g. disease
ultrasound cephalometry). Diabetes mellitus
Traditionally, fetal growth is monitored 7 Multiple pregnancy
antenatally by palpation of the height of the 8. History of smoking
fundus and occasionally by the measurement of 9. History of drug addiction
the maternal abdominal girth. The limitations 10. Unknown-By far the largest number
of the traditional method of fundal height (> 50%)
palpation are well known.Tape measurement of
the fundal height from a fixed point (i.e. the Table 50.1 Mothers at risk of having low birth weight
pubic symphysis) is more reproducible than the babies
traditional method although it varies widely in
sensitivity and specificity. Serial rather than However, as a rule of thumb, the tape fundal
single measurements should be used to height measurement in centimetres is equal to
determine growth restriction. the gestational age from about 26 weeks ± 2
(i.e. 26 ± 2cm=26 weeks) where a standard
Various formulae have been given to correlate reference curve is not available. It is
the fundal height measurement with the preferable though that IUGR is identified as
gestational age. It is of course better to define a early as the twentieth week of gestation so
standard curve for one's particular obstetric that actions can be taken if possible, in order
population and use that as a reference. In that the baby can achieve its optimal growth
constructing such a reference standard curve, it potential and development.
is essential that a high number of normal It is now knownthat IUGR canbe of two varieties:
pregnant women with the fetus lying
longitudinally are used. (a) Symmetrical growth restriction in
whichthe baby is proportionally small
1. Parity - Primigravidity
and is usually of fetal origin.
Grandmultiparity(> 5)
(b) Asymmetrical growth restriction in
2. Age - <20 years
which a head sparing effect occurs,
>35 years
the fetal head shows a smaller loss of
3. Low socio-economic class
growth rate than the body. This is
4. Previous maternal history of:
Miscarriage
thought to be due to poor placental
Incompetent cervix
perfusion.
Premature rupture of
fetal membranes Because of these differences, serial ultrasound
5. Complications of pregnancy: measurements of the biparietal diameter, the fetal
Antepartum haemorrhage head circumference (cephalometry) and the
Pregnancy induced measurement of the circumference of the fetal
hypertension abdomen (abdominal circumference), give a more

Prince Of Medicine-2014-BSUTH

Prolongedpregnancyendskoukierdystÿm4l£i ]
- & •
•

Computed cardiotocogram(CTG), which Complications and prognosis

may be superior to conventional CTG
It has beenshown by Walker as far back as 1954
that a progressive fall inthe percentage level oi
11. The use of umbilical artery Doppler
oxygen saturation in the umbilical vein occurs
ultrasound. The two methods above are
from 60 percentjust before term to 30 percental
awaiting evaluation by randomised
controlled trials before they can be said to 43 weeks gestation. Fetal hypoxia therefore
be effective ways of monitoring. posesa great probleminthis condition.

Ill Maximum vertical pool depth (MVPD) of Prolonged labour may occur possibly due to
the amniotic fluid volume can be assessed factors like failure of good moulding of the
by the ultrasound. Since amniotic fluid head, frequent occurrences of malposition ol
volume falls after term, the question is, the head such as occipitoposterior position,and
what value should be taken as critical and uterine inertia
indicating a hazard in prolonged
pregnancy. The suggested critical values Shoulder dystocia may occur due to a large
are 4.2cm. 3.0cm and 2.1cm respectively, baby (macrosomia) but this condition could
but there is yet no consensus of opinion as also occur ina normal sized baby.
to the most accurate of the three values to
be taken as signifying adverse perinatal Caesarean section rate may be slightly increased.
outcome inprolonged pregnancy. From our
experience, the criticalvalue of 3.0cm may Increased perinatal mortality rate has been
be mostaccurate. demonstratedandthis is a definite risk factor.

Management There is also an increasedrate of stillbirth.

Once it iscertain that pregnancy has progressed Shoulder dystocia
beyond 42 weeks, most obstetricians will prefer
Definition
to proceed to induce labour and deliver the
baby. If vaginal examination reveals an unripe This simply means difficulty in delivering the
cervix, prostaglandin pessary or tablet could be shoulders following the delivery of the head o
inserted inthe posterior fornix to ripenit prior to the baby. It may involve both shoulders usualb
artificial rupture of membrances and oxytocin in an anteroposterior position, or only th<
infusion. Some obstetricians however adopt the anterior shoulder which in this case is lodgec
conservative method and may even allow above the pubic symphysis while the posterio
pregnancy to progress beyond 43 weeks shoulder has already entered the pelvis.
provided effective monitoring as described
above is employed. There may be some merit in Incidence
this since the day of conception is not known for
certain and uncertain dates of last menstrual IjTiC ixlCiu6nC6OI'uUS wuuiuGulStjuOK»toTxwwii
period are not uncommon especially in our own
populationinruralparts ofAfrica.
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0.15 percent and 2.0 percent of all vaginal impression is always that of obstructed
deliveries. labour which is common in our environment
especially with unbooked cases.
Aetiology
V. Failure of the head to descend in second
stage of labour.
It is easy to assume that its aetiology is linked
with macrosomia (big baby) but this is not vi. A long second stage of labour. This should
always correct For example, non-diabetic not be allowed but could occur in
ÿ

women in Saudi Arabia are known to deliver unbooked cases.

big babies but the incidence of shoulder
dystocia is not necessarily increased. vii. Assisted vaginal deliveries. Shoulder
dystocia has been found to be more
When considering the aetiology of this common in instrumental deliveries than in
obstetric emergency, it is the risk factors that spontaneous vaginal deliveries.
play a prominent role.
Prevention
Risk factors
It is always wise to prevent the phenomenon of
i. Fetalmacrosomia (big baby) shoulder dystocia ratherthan having to face it as
A baby weighing more than 4.0kg couldbe an emergency management.
considered macrosomic in the tropical
countries, where the average weight of a Elective caesarean section
Nigerian baby at term isabout 3 .2kg. It has
Caesarean section at term is the rule for
however been shown that shoulder
dystocia may occur in over 50 percent of diabetics with macrosomic babies. Elective
caesarean section for mothers with macrosomic
babies weighing lessthan 4.0kg.
ii. Maternal diabetes. babies could be difficult to decide as the
Itis aknownfact that diabetic mothers tend diagnosis of macrosomia both clinically and by
to deliver macrosomic or big babies. Some
ultrasound cannot be always accurately
of these babies could weigh over 4.5kg. predicted.
For such women, elective caesarean
section atterm istherule. Emergency caesarean section
Inour environment it is probably better to allow
iii. Ahistory of shoulder dystocia ina previous a woman with mare suspected big baby to
delivery. This could occur again and the labour first and watch her progress in labour. If
attendant should always bear this in mind there is an arrest before full cervical dilatation,
and be prepared. or there is failure of the head to descend in
second stage of labour, this will necessitate are-

after 7cm cervical dilatation. This phenomenon decision may then be appropriately made to
is not strange in tropical Africa as the first terminate labour by caesarean section.

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Prolongedpregnancy andshoulder dystocia 415

Induction of labour
The policy of elective induction of labour for using the above procedures.
suspected macrosomia has not been widely
accepted for it tends to increase caesarean vi. If the above measures fail, an attempt
section rate for failed induction, and without should now be made to deliver the posterior
necessarily reducing the incidence of shoulder arm and shoulder. The attendant passes his
dystocia. This has been documented by some hand up to the fetal axilla and the posteror
earlier authors. shoulder is hooked down. Effort is made to
reach the cubital fossa and backward
Emergency management pressure on it will disengage the arm which
As soon as shoulder dystocia is diagnosed at is then brought down by getting hold of the
delivery, it becomes an emergency measure hand and sweeping it across the chest.
which should only be handled by an Having delivered the posterior shoulder,
experienced obstetrician. the anterior shoulder is easily disimpacted.
i. Help should be summoned vii. If the above manouvre should fail, then
immediately by the attendant. internalrotation of the posterior shoulder is
resorted to. The posterior shoulder is
i Make a generous episiotomy. This will rotated 180" in a cockscrew fashion
provide greater access to the pelvis for any towards its back so that the impacted
manoeuvre that may beundertaken. anterior shoulder can be released (Woods'
iii. Correct positioning of the mother's legs is screw manouvre). Normal delivery of the
-crucial and the McRobert's manouvre is baby is then completed by gentle neck
advocated. traction and maternalpushing.
In this position, the maternal hips are
abducted, flexed and rotatedoutward. Two Cleidotomy
assistants are required to maintain this This little operation which involves breaking
position. Thus the lumbosacral angle is one or both clavicles of the baby and allowing
straightened and the pubic symphysis is the shoulders to be delivered is perhaps still
rotated superiorly. Maternal pushing and being practised as a last resort in some
appropriate lateral neck traction is now developing countries. Usually the clavicles heal
restarted. spontaneously after a couple of days.

iv. An assistant places the flat of the hand behind Prognosis

the anterior shoulder and applies lateral
Shoulder dystocia carries a higher perinatal
suprapubic pressure. When properly mortality in inexperienced hands more so as it is an
performed, the shoulder is dislodged from unexpected emergency which deserves immediate
the pubic symphysis. It is mandatory for the treatment. A regular training programme is
assistant to stand on the same side as the fetal recommended for allobstetric practitioners in order

twins must be excluded. Factors that prevent proper fitting of the

Diagnosis is by abdominal examination where presenting part predispose to cord prolapse.
the uterus is long on the transverse axis, These include low birth weight, premature
symphysis to fundal height may be less than birth, multiparity, breech and shoulder
gestational age. The suprapubic region is empty presentations, multiple pregnancy,
and the head is felt in one or other flank. With cephalopelvic disproportion and
exclusion of placenta praevia, pelvic polyhydramnios.Diagnosis may beheralded by
examination may reveal other pelvic tumours sudden fetal distress in labour or mostly at
and exclude gross cephalopelvic disproportion. vaginal examination, which is confirmatory. If
The dorsum is frequently anterior. Delivery is not diagnosed in time, fetal heart sounds may
usually by elective caesarean section. In the become absent, or a non-pulsating cord may be
presence of intact membranes and no visible at theintroitus.
contraindication, eternal cephalic version may Management of cord prolapse depends on
be attempted. In labour, membranes tend to the state of the fetus and cervical dilatation.
rupture early andthe umbilicalcord and/or hand
Where the cord is non-pulsating, it is no longer
may prolapse. Where the fetus is dead, a skilled
an emergency and labour is allowed to progress
obstetrician may do a decapitation with Blond
normally. An emergency situation exists where
Heidler saw if this is acceptable to the patient,
the cordis pulsating. Ifthe cervix is fully dilated
otherwise acaesarean sectioniscarried out.
and presentation is suitable, delivery should be
effected with the forceps forthwith. The
Compound presentation
ventouse is also an alternative.
It occurs where the hand, or foot, presents Cord prolapse in the first stage of labour
alongside the head or breech. Usually there is presents an anxious situation especially in
pelvic disproportion or tumour preventing the tropical obstetric practice where decision-
engagement ofthe presenting part. The diagnosis intervention interval could be long. The danger
is rarely made before the membranes are is of cord compression between the presenting
raptured. Often times, the hand can be pushed part and the pelvic wall or cord spasm from
above the head. Where this fails, expectant temperature changes.
approach is the norm, as with further uterine Umbilical cord protruding through the
action, the head advances and the limb recedes. introitus should be replaced, while the patient is
At full cervical dilatation, delivery may be
placed in the knee-chest or Trendelenburg's
effected by the ventouse or forceps after the arm
position thus preventing the head or presenting
is dislodged. In the presence of cephalo pelvic
part from compressing the cord. Immediate
disproportion, pelvic tumour or fetal distress,
caesarean section should be arranged. Bladder
caesarean section isthe treatment of choice.
filling with normalsaline has been advocated to
Cord presentation push away the presenting part from the cord.
This has the additional advantage of inhibiting
A cord presentation occurs when the umbilical
cord is felt between the presenting part and the uterine contractions. Furthermore, ultrasound
fetal membranes. When the membranes assessment of patients with prolapsed, non-
rupture, it becomes cord prolapse. It pulsating and absent fetal heart sounds is
complicates about Iin500 deliveries. advocatedwhere feasible to avoid any doubt.
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422 Obstetrics and Gynaecology

Bibliography and suggested further

reading

(i) 32-33 Weeks: At this stage of gestation there causative factors.

are still significant risks of RDS and other Hospital admission is useful for bed rest and
problems like intraventicular haemorrhage in investigations to identify any associated
some of the neonates. Thus, where the facilities treatable causal factors. This requires a good
exist there should be determination of the L/S history and clinical examination and other
ratio to assess lung maturity. When it is not investigations. Aggressive treatment of
possible to test for lung maturity, treatment associated factors like urinary tract infection,
should be offered to accelerate fetal lung malaria etc rapidly leads to suppression of the
maturity with corticosteroids as previously preterm contractions and subsequent
described for the preterm remote from term. continuation of the pregnancy.
The other treatment with intravenous tocolysis
and antibiotics as already described should also (ii) Specific treatment: This strictly depends on
be administered for the added reason of helping the gestational age of the pregnancy.
to prolong the pregnancy. The route for delivery
is per vaginam except for breechwhich is better (a) Previable threatened preterm labour (less
delivered by caesarean section. than 24 weeks)
The principle here is to suppress the
(ii) 34-36 Weeks: At this stage of gestation the contractions with tocolysis often begun with the
several risks of preterm birth are considerably intravenous route and later maintained orally.
reduced and the neonate can easily stand the There is often no need for other adjunctive
stress of extrauterine life. The standard treatments. At times, this problem may occur in
treatment is to allow the labour to progress to a woman with cervical incompetence. In such a
delivery supervising the progress with the circumstance when contractions have been
partograph. When the labour shows any successfully suppressed and the uterus is
evidence of slow or abnormal progress, quiescent for over one week, cervical cerclage
oxytocin infusion may be used to facilitate the may be considered if the gestational age is less
process. The route for delivery is always better than 26 weeks and there is still a good measure
vaginally except there are other antecedents in of cervix on vaginal assessment. Such late
the pregnancy or labour that contraindicate cerclages have their own dangers and may be
vaginal delivery for which emergency caesarean performed with tocolysis maintained
section should be performed. Breech perioperatively till 48 hours postoperative.
presentation at this gestation has a good outcome Several previable threatened preterm labours
with a well conductedassisted breech delivery. respondto treatment.
Threatened preterm labour (b) Threatened preterm labour remote from
When the diagnosis is threatened preterm labour term (24 - 3 1 weeks) weeks and near term (32 -
(i.e uneffaced cervix, undilated cervical os and 33 weeks)
intact membranes) the outcome of attempts to
suppress the contractions and ensure the The management here is the same as in the genuine
continuation of the pregnancy is often better.The preterm labour in which all the adjunctive treatments
management consists of the following: of antibiotics, tocolysis and corticosteroids are
used. Response is usually much better since in this
(i) Admission and treatment of the associated situation the cervix is not yet effaced or cervical os
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Pretermlabour andpremature rupture of membranes 427

dilated to the critical line of 3 cm and the Diagnosis: Women with spontaneous rupture
membranes are intact. Failure of treatment in of membranes present with a history of
this range is often related to the degree of drainage of fluid per vaginam. The drainage
cervical dilatation, (c) Threatened preterm may be continuous or intermittent especially
labour (34 - 36weeks). In the majority of cases with any amount of straining. In the obvious
this threat will subside and pregnancy will cases this is confirmed on Sterile speculum
continue to term. Often there is no need for examination with observed pooling of liquor in
suppression of the contractions. the posterior fornix. The presence of vernix
caseosa makes the recognition of liquor easy. In
PREMATURERUPTURE OFMEMBRANES doubtful cases, the vaginal fluid may be tested
with nitrazine yellow paper which turns black
Definition in alkaline medium (liquor is alkaline) or with
This refers to the spontaneous rupture of fetal red litmus paper which turns blue in alkaline
membranes at any gestational age before the medium. False positive occurs with the
onset of labour. It is more appropriately called presence of vaginal infections or even water
prelabour rupture of membranes. It may occur baths. When the duration of rupture is over 12
preterm (before 37 completed weeks) or at term hours, there may already be clinical features of
(beyond 37 weeks). In some 5-10% of chorioamnionitis like fever, purulent vaginal
discharge, maternaland fetal tachycardia and in
pregnancies, it is now known that labour may
extreme cases, uterine tenderness. Usually at
begin first with spontaneous membrane rupture
the speculum examination, swabs are taken
but followed rapidly within 15 minutes to one
from the fluid inthe posterior fornix for culture
hour by contractions which are associated with
and sensitivity of any identified organisms, the
progressive cervical os dilatation. In these
absence of cord prolapse is ascertained and the
circumstances, the diagnosis is labour. If it state of the cervical os, whether dilated or not is
occurs at term it is term labour or preterm labour noted.Also full clinical assessment is performed
if it occurs before 37 completed weeks. The to establishthe actual gestational age.
spontaneous rupture of membranesthat is being
discussed in this section is the variety that Management
occurs at any gestational age that is not This depends on the established gestational age
followed by uterine contractions. This non- of the pregnancy.
contractile spontaneous rupture of membranes
is what is best called prelabour membrane Term:
rupture when it occurs at term or preterm The ideal treatment is to administer an oxytocic to
prelabour membrane rupture when it occurs generate uterine contractions that will be sustained
before 37 completed weeks. and effective enough to ensure delivery. When
digital examination confirms a favourable Bishop
Causes of spontaneous prelabour membrane score, oxytocin titration is usually effective to
rupture: generate the appropriate contractions. With an
Vaginal infection unfavourable Bishop score, although oxytocin
Cervical incompetence titration still succeeds in several instances, it is better
Defect inthe fetal membranes to use misoprostol tablet vaginally in doses of 50 -
Idiopathic 100 micrograms.Adequate monitoring isessential to

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Prince Of Medicine-2014-BSUTH

428 Obstetrics and Gynaecology

ensure safety when oxytocics are used to At this gestational age there is the twin problem
manage labour. of extreme preterm birth and its complications
and fetomaternal infections and resultant
Pretermprelabour rupture of membranes: morbidity. The chances of survival if delivered
The management here depends on the gestational in most centres in the developing countries are
age. very low because of poorly equipped special
care preterm birth units. The principal strategy
(i) Preterm membrane rupture near term
of management is to maintain the pregnancy a
(32 -36) weeks
little longer as a way of reducing the dangers of
When membrane rupture is confirmed at this extreme preterm births. Only speculum
gestation the principle is to give oxytocics to examination should be allowed when liquor is
generate uterine contractions to effect delivery. to be sampled.
With gestational ages 34 weeks and beyond,
Adjunctive treatment consists of
oxytocics are administered without further corticosteroids in conjunction with potent
delay to effect delivery since the risk of preterm antibiotics and tocolysis for 48 hours. These
birth problems is much less and any delay drugs induce accelerated lung maturity, reduce
increases the chances and severity of infections and help prolong the pregnancy. This
fetomaternal infections. However, in the form of management often succeeds with cases
gestational age of 32-33 weeks, there is still near 30-31 weeks while those cases that are
some substantial risk of preterm birth problems more premature easily get complicated with
like RDS etc. Hence, it is usual to treat with progressive contractions which may end in
corticosteroids and potent antibiotics for 48 delivery. The tocolysis which is begun by
hours to accelerate lung maturity. Tocolysis is infusion may be maintained by the oral route
often used in addition to prevent or reduce the after 48 hours till the 34th week in those with
contractions so as to allow for the full benefit of good response. The antibiotics are only given
the adjunctive corticosteroids and antibiotics. for one week while the corticosteroid is
Insome cases the pregnancy may continue after administered for 48 hours without the need for a
the critical 48 hours for which the treatment to repeat administration no matter how long the
induce lung maturity was administered. Insuch pregnancy is prolonged. However, antibiotics
instances, the pregnancy should be terminated should be recommended or maintained during
at 34 weeks with the administration of
labour andthe postpartum period.
In the cases in which there are no contractions
oxytocics as a way of reducing further
even at 34 weeks and there is evidence of
fetomaternal infections andresultant morbidity.
infection, expectant treatment should be
In all these instances, once oxytocics are
stopped and oxytocic administered to effect
administered to effect delivery in all the near delivery. In those without any covert or overt
term preterm membrane rupture, antibiotics evidence of infection, the pregnancy may be
must be administered intrapartum and allowed to progress to term without any further
continued into the postpartum period. Also the interference full monitoring to exclude
neonate must be screened for sepsis and potent infection and ensure fetal wellbeing should
antibiotics administered. however be continued.
(ii) Preterm membrane rupture remote from
term (24-31) weeks (iii) Previable membrane rupture (under 24 weeks)

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Preterm labour andpremature rupture ofmembranes 429

This situation is actually an inevitable second For breech presentation, caesareari-section

trimester miscarriage. In those that are is best for those of gestational age 30-33
associated with uterine contractions or overt weeks to reduce the risk of birth asphyxia. In
evidence of infection or severe cases of gestational age 34 weeks andabove a
oligohydramnios, the safe treatment is good outcome is often associated with a well
oxytocic infusion to expedite the evacuation conducted assisted breech delivery. With the
of the uterus with potent antibiotics cover. In very preterm breech at 29 weeks and less the
other cases with no contractions and no vaginal route is "preferred because of the
evidence of infection expectant treatment considerably reduced chance offetal survival
may be considered with absolute bed rest and in most units for which a caesarean section is
regular monitoring of feto-maternal vital inappropriate. In practice every delivery by
signs. There are few cases in which this caesarean section in these extremely
management option succeeds even to the premature cases does not significantly
point that the loss of liquor becomes improve the chances of survival. Inany case it
considerably less and the pregnancy is then is good practice often to discuss the options
prolonged into the viable gestational age that and outcome with the woman who should be
may be remote or at times near term. Often guided to choose the best option.
there are serious complications mainly due to
considerable loss of liquor and ascending
infection for which the expectant treatment is Bibliography and suggested further
promptly terminated. reading
Dudley, D. J. (1999) Dystocia. IN Clinical Obstet,
Mode of delivery with preterm membrane Gynaecol 40. Pp 459-548
rupture Symonds, E.M. (1998). Essential Obstetrics and
Excluding other confounding clinical Gynaecology. Churchill Livingstone, Publisher.
circumstances, the mode of delivery for the O' Driscoll,K.,Meagher, D (1980). The active management

fetus in cephalic presentation is vaginal even of labour. London, Saunders.

in the very premature cases that are still Spencer, J. A.D (1991) Fetal monitoring. Oxford Medical
remote from term. The labour and delivery Publications, Oxford University Press.
should be carefully monitored to end in Calder, A. A. (1999) Induction and augmentation of labour.
spontaneous vertex delivery without the need InDewhurst's textbook ofObstetrics andGynaecology
for any elective instrumental delivery. Even for Postgraduates. 6th ed. Edmonds,D.K.ed.Blackwell
episiotomy once thought to be an essential science.
part of a well conducted delivery for any Definition
preterm birth is now no longer considered
essential except ina few instances.

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Chapter 54

Induction of labour

Induction of labour is the artificial initiation of Term gestation with bleeding in early
labour after 28 weeks in a parturient with intact pregnancy
fetal membranes and without active phase Severe abruptio placentae with dead fetus
labour contractions. It is the aim in induction of Abnormal fetus that is incompatible with
labour to achieve vaginal delivery in an ideal life
time interval of not less than 3 hours and not Elderly primigravida at term
more than 16 hours in a pregnancy where the Idiopathic pruritus of pregnancy at term
risk of continuation of pregnancy to the fetus is Stabilising induction at term
adjudged to be greater than the risk of Medical
extrauterine life. This definition encompasses Known hypertensives
the fact that induction of labour will have an Diabetes mellitus
indication and aims to achieve vaginal delivery Chronic renal disease
with the avoidance of precipitate and prolonged Chronic liver
labour. Based on this definition, failed induction disease Social
is failure to achieve vaginal delivery in a Patient's convenience
parturient that was induced whatever may be the Obstetrician's convenience
specific indication for the caesarean section. Long distance from hospital
Incidence: This is highly variable and the range Table 54.1: Indications for induction of labour
is from 3-20% and depends on the capacity to
monitor and diagnose antenatal fetal problems. The indications are all self-explanatory with the
exception of a few. Stabilising induction is
Indications performed for women with unstable lie of fetus
Indications for induction of labour must also be at term. In unstable lie the fetal lie may have
justifiable for a caesarean delivery and hence been varying at different examinations between
induction must not be performed for any trivial oblique, transverse and longitudinal in the
reason. The common indications are as listed in absence of any pelvic tumour occupying the
the table. lower uterine segment. With the strategy of
Obstetric stabilising induction, artificial rupture of
Prolonged pregnancy membranes (ARM) is performed when the lie is
Pre-eclampsia/eclampsia longitudinal and presentation cephalic either
Antepartum haemorrhage at term spontaneously or after ECV (from oblique or
Rhesus isoimmunisation transverse), after generating uterine contractions
Intrauterine growth restriction of 3 in every 10 minutes with oxytocin infusion.
Previous intrauterine fetal death at term The release of a substantial volume of liquor
Decreased fetal movement at term following the ARM stabilises the head at the brim
especially with poor or non reactive non- and the rest of the induction process can then
stress test, on CTG tracing. progress normally. Stabilising induction is an
Previous precipitate labour important specialised obstetric procedure which helps to
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- r s |pp
Induction of labour
431

substantially reducethe caesarean section rate. above situation but with careful attention to the
In developing countries there is almost no oxytocin base mixture, the oxytocin dose end
place at all for induction of labour for social point and oxytocin incremental intervals ol
reasons of either patient's or obstetrician's over 3 0 minutes as a way of reducing the risk of
convenience. The only exception is where a ruptureduterus.
woman stays far away from hospital with (B) - Multiple pregnancy
difficult transportation problem especially in an Breech presentation
emergency situation. A planned induction of Elderly primigravida
labour to resolve such a social problem is Previous infertility
reasonable. Long birth interval of over
eight
Contraindications: These are usually situations years.
inwhich a vaginaldelivery is contraindicated.
The fear inthe above situations isslow progress
(a) Contracted pelvis confirmed by X-ray
and therefore prolonged labour and sequelae.
pelvimetry. ÿ These problems are easily avoided by ensuring
(b) Previoils ruptured uterus/classical a favourable cervix pre-induction, careful
caesarean section. supervision of labour progress with the
(c) Two or more previous caesarean sections. partograph which will easily identify
(d) Major degree of placentapraevia. parturients who may require highdose oxytocin
(e) Pelvic tumour preventing the engagement for sustained progress until delivery.
of the presenting part like ovarian cyst,
horseshoe kidney or pedunculated fibroid. Conditions to be fulfilled before induction of
(f) Persistent oblique/transverse lie labour
(g) Abnormal presentation likebrow or face In order to ensure success from induction of
mento-posterior. labour, the conditionsbelow mustbe satisfied:
(h) Invasive cancer of the cervix, (i) 1. A good indicationfor the inductionof labour.
Previous successful repair of vesicovaginal 2. Fetal maturity assessment. A review of the
fistula (WF) or stress incontinence, (j) last menstrual period (LMP), early
Patient's refusal inspite of appropriate and ultrasound scan before the 20th week of
adequate explanation. gestation, and early symphysis-fundal
height (SFH) measurement. Where facilities
Cases for extreme caution during induction. are available L/S ratio may bedetermined.
These are situations inwhichthere are fears that 3 .Pelvic assessment to confirm the adequacy oi
some complications may arise from the induction the pelvis and in doubtful cases X-ray
Process: pelvimetry shouldbe performedto exclude
(A) - Grandmultiparity contracted and abnormal pelvic shape.
One previous caesarean section 4. Exclude all contraindications to vaginal
without wound dehiscence and delivery especially dangerous previous
with an adequate pelvis. scars like classical caesarean section,
In these cases the great fear is for rupture of the hysterotomy and uteroplasty scar.
uterus to complicate induction. Nowadays, 5. The parturient and her husband have been
induction of labour is commonly performed in the adequately counselled to accept the induction

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having explained the purpose, benefits This system signifies the readiness or nearness
and risks. of uterus to spontaneous onset of contractions
6. Adequate staff in the labour ward to monitor and cervical os dilatation, characteristic of
thelabour such that one nurse is assigned to spontaneous active phase labour onset. A low
an induced parturient and physicians are score signifies unreadiness or difficulty with
available round the clock to take decisions initiating contractions andcervical os dilatation
and intervene when necessary. Above all, while a high score signifies readiness or great
there must be ready facilities for ease with initiating contractions and cervical os
intervention with instrumental delivery or dilatation. Hence by this system, parturients in
caesarean section in response to spontaneous active phase have a bishop score of
complications. 13 points. By normal expectation pregnancies
7. Adequate knowledge of how induction of that are not yet at term should have a low Bishop
labour as a procedure can be safely score while those at term or beyond, should
conducted. This is an important condition have varying Bishop scores that are expected to
because ever so often induction of labour is be high reflecting their nearness to spontaneous
performed when the appropriate knowledge active phase labour. However, this expectation
of the essentials that will guarantee success is does not invariably follow the gestational age,
unknownor poorly understood. as often pregnancies that are at term or even
8. The pre-induction cervical status must be beyondmay have a low Bishop score depending
favourable based on the assessment by the on their nearness to spontaneous active phase. It
Bishop score system. This is a score system
is true that any pregnancy not yet at term that is
associated with a high Bishop score is very near
designed by H.P Bishop (1964)which entails
or has imminent preterm spontaneous active
tallying points for five different factors. The
phase labour.
total score ranges from 0-13 points

The Table below shows the Bishop score system.

SCORES
FACTORS 0 1 2 3

1 POSITION POSTERIOR MID-POSITION ANTERIOR

CONSISTENCY FIRM MEDIUM SOFT
2
EFFACEMENT % 0-40 40-60 60-80 OVER 80
3 (LENGTH INCM) 3-2 2-1.5 1.0 0.5 or Less
4 STATION OF THE 0-3
PRESENTING PART -2:- 1 0 + 1.-+2
5 0 1 -2 3-4
CERVICAL OS 5+
DILATATION (CM)

TOTAL SCORE 13
0-5 UNFAVOURABLE SCORE;
6-13 FAVOURABLE SCORE
Table 54.2 inducibility rating (Bishop 1964) of the cervix

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The failure rate following induction of labour aspect of the thigh slightly under tension. Fetal
with an unfavourable Bishop score is high but heart rate is auscultated with other vital signs
low with favourable scores. It is often essential for about one hour after which the woman is
that parturients with an unfavourable cervix allowed to go back to bed in the lying-in ward
should have some prior treatment that will where she is regularly observed. The following
transform this into a favourable cervix so that the morningwhich will be after 12 hours, the woman
risk offailed induction of labour will be reduced. is brought back to the labour ward and a repeal
sterile vaginal examination is performed. If the
Methods of ripening the cervix
catheter is still in situ, it is deflated and removed
Concern about induction of labour when the and Bishop score assessed. At times the catheter
cervix is unfavourable is very high because may have fallen out with the bulb intact
studies have confirmed that when induction of (suggesting that the cervix may have been
labour is performed with Bishop score 0 - 4, the further substantially effaced and dilated) or in
caesarean section rate is about 33%, the mean some 5% of cases spontaneous labour may have
duration of labour is about 15 hours, maternal begun long before the 12-hour period. Generally
pyrexia occurs in over 30% and a low Apgar there is usually substantial improvement in the
score of 4 or less inthe first minute of the baby's Bishop score with increases of 2-4 points.
extrauterine life occurs in over 20%. With a In some cases the Bishop score will still be
favourable cervix the caesarean section rate unfavourable with little or no change. In such
falls to under 10%, the mean duration of labour cases the catheter is removed and passed again
is about 8 hours, maternal pyrexia occurs in less after 12 hours rest (i.e by the followingevening)
than 5% and low Apgar score of 4 or less in the and the procedure may be repeated again and
first minute of the baby's extrauterine life again till favourable transformation occurs if
occurs in only 4%. Hence it is a compelling there is no serious urgency for the induction.
requirement that an unfavourable cervix be Very rarely, membrane rupture may occur while
ripened first before the induction procedure the catheter is still in situ. In such cases the
using any of the following: catheter is removed instantly and the case is
1. Intracervical Foley catheter balloon managed as prelabour membrane rupture at term.
overnight Failure of the Foley catheter to induce a
favourable cervix may occur whenthe catheter is
This is the method commonly used in most units not appropriately placed (placement into the
in the developing countries because it requires vagina instead of endocervical canal is common)
only a Foley catheter with at least 30 - 50 ml or bulb capacity inflated with less than 30ml o'
balloon bulb capacity which is available water or the catheter balloon has stayed for a
everywhere. The insertion is performed usually in duration of less than 12 hours. For success inthis
the labour ward using aseptic technique the simple procedure, the catheter must be well
evening preceding the day of the planned placed and adequate balloon size selected. The
induction.A sterile speculum is used to expose the catheter should not stay beyond 12 hours for an>
cervix which is held with sponge forceps. The reason in order to avoid untoward problems.
Foley catheter is then passed up into the There are no known complications except
endocervical canal. The bulb is inflated with at rupture of membranes which may be more
least 30ml sterile water and strapped to the inner commonincases requiring repeated insertions.

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434 Obstetrics and Gynaecology

(2) Prostaglandin pessary Methods of induction of labour

The standard methods of induction of labour
Prostaglandin E2 in pessary form and doses of consist of the following:
1.5mg or 2mg is commercially available for
ripening of an unfavourable cervix by insertion (i) Forewater amniotomy and oxytocin
into the posterior fornix of the vagina using titration
aseptic technique. It is usually veiy effective in
ripening an unfavourable cervix but nearly half Nowadays the method of induction combines
of the women so treated go into spontaneous oxytocin infusion in escalating doses with
labour especially when the 2.0 or 2.5mg dose is forewater amniotomy hence it is no longer
used. Establishing in spontaneous labour is a fashionable to discuss medical and surgical
disadvantage when it is only intended to ripen methods separately. The pioneering work of
the cervix because such labour may often occur Turnbull and Anderson in 1968 has greatly
at the most unfavourable part of the night when popularised this method which is known as the
the best of staff are not around. One advantage conventional approach to labour induction. It is
of induction of labour is that it is usually a the age-long and tested method that has
planned day time event when the best of staff survived throughout the world. By this
and equipment are in an optimal working state. procedure forewater amniotomy is performed
Hence when a case that is on treatment for the synchronously with the oxytocin infusion in
ripening of the cervix is pushed into established escalating doses. The amniotomy is only
labour, the advantages of the planned day light described as synchronous with the oxytocin
obstetrics may be lost or substantially reduced. titration if the two procedures are performed at
Theother problems of Prostaglandin E2 the same time andthere is not more than 2 hours
pessary for ripening the cervix is the cost and between the time of amniotomy and
very limited availability especially in commencement of the oxytocin infusion
developing countries. However, where it is
Forewater amniotomy (ARM)
available and affordable prostaglandin E2
1.5mg pessary is the best for ripening of the This is a surgical procedure which should be
cervix with a low failure rate and low risk of performed only in the labour ward using full
establishing inspontaneous labour. aseptic techniques of cleaning and draping the
woman in lithotomy position followed by
(3) ©estradiol gel
catheterisation to ensure an empty bladder.
17-peta ©estradiol gel is available for ripening With the gloved hand a vaginal examination is
sf an unfavourable cervix. It is simply placed carried out. First, there should be a good
into the posterior vaginal fornix using aseptic membrane sweep and when the forewater
technique. It is usually effective in ripening a bulges it is ruptured ideally with the amniohook
cervix with a high Bishop score without (if available) or special amniotomy forceps
inducing labour. Ithas very limited availability after excluding a cord presentation.
and is also very expensive hence it is almost Although in most units a Kocher's forceps is
unknownindeveloping countries. commonly used for the ARM, it is not the ideal
instrument to use for this purpose because of the

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MHI lactate.
Induction oflabour 435

high risk of fetal scalp injury and tears of the

endocervix. The ARM should be followed by Infusion is begun at a specific flow rate and
slow release of the liquor which should be after a defined interval, the flow rate is
inspected for vernix caseosa, meconium and increased either in arithmetic or geometric
blood stain . If a significant amount of vaginal proportion until a desired end point is attained
bleeding occurs at ARM, cord transection or or until some maximum flow rate isachieved. If
the desired end point has not been achieved

Prince Of Medicine-2014-BSUTH

Chapter 55

Prolonged labour
*
_ flffiH
---.. . "-"tlSS £X_ r* to

Problems of labour
Labour is the act of expulsion of the fetus and part of the fetus and the maternal pelvis at term
placenta through the vagina to the outside which can clinically be elicited in late
world. It is a frequent and common occurrence, pregnancy and in labour. The most frequent
which ends up normally in many women leading part of the fetus at term is the head and
especially when the pregnancy is at term. The when there is a misfit involving the head of the
characteristics of labour (which typically are fetus and maternal pelvis it is known as
the onset of painful, palpable and regular cephalopelvic disproportion (CPD). However,
contractions of increasing frequency and the leading part of the fetus may be the breech
intensity associated with progressive and when involved in a misfit with the maternal
effacement, dilatation of the cervical os and pelvis, this is referred to as fetopelvic
descent of the leading part till expulsion of the disproportion (FPD). A disproportion involving
fetus and placenta per vaginam) are mostly the head is more easily elicited at term than if it
clinical entities, by which the course of labour is involves the breech in which clinical
monitored so that a normal course can easily be assessment is more difficult. Some cases- of
distinguished from an abnormal one. gross CPD have obvious distinguishing
features atterm before labour begins which may
The main factor that determines the outcome of make the diagnosis easily recognised or
labour is uterine contractions which when suspected. However, with several cases of CPD,
strong, regular and progressive easily drive the the diagnostic features may be blurred and not
leading part to efface and dilate the cervical os recognisable until this misfit manifests in
to full capacity. This then allow for the passage labour with failure of labour to progress in the
of the fetus to the outside world. Also, it is presence of good and strong uterine
strong contractions that will initiate the contractions associated with evidence of early
separation and expulsion of the placenta per fetomaternal squeeze like caput or moulding.
vaginam. However, problems may arise when
there is disharmony between the factors Incidence
involved in labour such as uterine contractions
(the leading force), the fetus (as the passenger) CPD has a worldwide occurrence although it is
and the birth canal (as the passage). The more common in socio-economically deprived
problems of labour are often specific and communities such as we have in most
peculiar although the characteristics may not developing countries especially in the tropics
often be specific or pathognomonic of the and subtropics, where there is also a prevalence
problem. This is why different labour problems of nutritional deficiency diseases.
may have the same clinical characteristics or
It is also very common in areas where there are
features and hence considerable experience is child marriages in which pregnancy may occur
required to recognise the specific problem. before the pelvis matures to the full adult size.
There are several problems of labour but the
commonones inclinical practice are as follows: Aetiology
(A) Disproportion Table 56. 1 shows the possible causes of CPD which
This simply refers to a misfit between the leading may either be from the birthcanal or the fetus.
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Prince Of Medicine-2014-BSUTH

Problems oflabour 443

Pelvic factors Fetal factors

(i) Generally contracted pelvis (0 Big fetus such as diabetic or
from poor nutrition or prediabetic states.
immature pelvis of child
marriage.

(ii) Abnormal pelvic shape (ii) Abnormal fetus

eg. - platypelloid (flat) pelvis eg. - hydrocephalus
- android pelvis - conjoined twins
- anthropoid pelvis - monsters.
- fetus with abnormal tumours
(iii) Pelvic deformity viz. (iii) Malposition of the fetal head
- childhood poliomyelitis eg - occipitoposterior position
- childhood rickets
- kyphoscoliosis from TB spine Malpresentation of the fetus -
brow.
-face mentoposterior.

Table 56.1: Causes of CPD: faults in the birth canal and faults in the fetus.

Diagnosis of cephalopelvic disproportion (CPD)

The diagnosis of CPD is often possible in late pregnancy from antecedents in
the history and the presence in the present pregnancy of predisposing or
associated aetiological factors as listed inTable 56.2
Historical antecedents:
- Child parturients
- Pelvic deformity
- Trauma involving the pelvic bones
- Previous prolonged labour
- Previous difficult instrumental deliveries
- Babies with birth asphyxia after difficult deliveries
- Previous big babies of birth weight 4500 gm or
more
- Previous histoiy suggesting diabetes mellitus
- Childhood rickets

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444 Obstetrics and Gynaecology

Predisposing factors:
- Small and short stature with a height
of less than 152cm.
- Abnormal gait
- Spinal and pelvic asymmetry
- Uterine overdistension with big baby
- Polyhydramnios suggesting abnormal fetus
- Abnormal pelvic shape on pelvimetry
- Already diagnosed fetal monster or hydrocephalic fetus
- Malposition like occipitoposterior position
- Malpresentation like brow and face mentoposterior
- Abnormal head fitting test at term
Table 56.2: Historical antecedents and predisposing factors to
CPD in current pregnancy.

Prince Of Medicine-2014-BSUTH

448 Obstetrics and Gynaecology

A good number of cases of CPD diagnosed in Postoperative management will often be

labour are inparturients inwhom the pelvis was dependent on the extent of accompanying
presumed adequate for the fetus either from complications. For instance, prolonged
previous baby's birth weight or clinical catheterisation is instituted for a case of
assessment but yet in labour the combination of prolonged obstructed labour in order to avoid
slow cervical os dilatation and good fistula formation. Also, caesarean section will
contractions reveals that there is CPD. The real be required if there is suspected or confirmed
challenge in contemporary obstetrics is uterine rupture even ifthe fetus were dead.
recognising the early features of CPD as
described. Having missed or failed to recognise (b) Symphysiotomy
this early manifestation, CPD is more This is only mentioned here in order to achieve
commonly diagnosed in the context of completeness of this discourse because this
obstructed labour. procedure is no longer acceptable in
contemporary obstetric practice. It is an
(ii) Prolonged labour
operation by which the symphysial joint is
This refers to first stage active phase duration divided with a scalpel to widen the diameter of
labour of over 12 hours with consequent the pelvis.
spirally fetomatemal complications. When the (c) Craniotomy
CPD features of slow cervical os dilatation rate
and good contractions are not recognised early This is a destructive operation undertakenwhen
enough, this slow labour progress will mature to the fetus is dead. It is prudent to perform this
clinical prolonged labour. Thus, presenting in operation when there is aversion to caesarean
the form of prolonged labour, the CPD is often sectionandwhen it is feared that the woman may
then associated with perhaps other not return for skilled care in subsequent
complications like maternal exhaustion, confinements. Also, this operation is preferred in
dehydration and at times fetomatemal distress. situations where with the dead fetus there is
The puerperium later is also morbidwith genital severe genital sepsis which may be spread into
and neonatal sepsis. the abdomen at an emergency caesarean section.

(iii.) Obstructed labour However, craniotomy requires special

instruments and prior adequate skill. Moreover,
Management of CPD before craniotomy is performed, the cervical os
must be fully dilated and the bladder
When CPD is diagnosed in labour with its completely emptied to prevent damage to both
various manifestations of slow labour progess the cervix and bladder. After the procedure
or prolonged labour, the treatment consists of
there must be exploration of the uterine cavity
the following: and cervix to exclude any injury or rupture
(a) Emergency caesarean section which may often occur from fragments of fetal
bones. If the circumstances of CPD and its
This is the usual and safest option in most cases sequelae resulting in a dead fetus are such that
especially ifthe fetus is still alive after appropriate the skill for craniotomy is lacking it is better to
and adequate resuscitation of the mother. perform a caesarean section to relieve the CPD.

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Problems of labour 449

Trial of labour progress in a trial of labour is with cervical os

dilatation rate of 1cm per hour or more by
A trial of labour is the conduct of labour in a which the graph of cervical os dilatation plotted
primigravida in whom mild CPD is suspected on the partograph will remain to the left of the
with the hope that good and sustained uterine Alert line.
contractions will cause good head flexion and
moulding which in combination with the slight If the graph of cervical os dilatation crosses the
widening of the pelvic girdle (the pelvic give) Alert line on the partograph, this means that there
induced by the strong contractions will allow is slow labour progress (cervical os dilatation
vaginal delivery to occur either spontaneously rate of less than 1cm per hour) which if allowed
or assisted with instrument. The course of the to persist, will translate to clinical CPD with
pregnancy however, should have been associated caput formation and moulding. Hence
associated with no complication as this may in a trial of labour, as soon as the Alert line (not
make the trial fail. The best chance for a Action line yet) is crossed, oxytocin
successful trial is for the labour to begin augmentation is started to immediately correct
spontaneously at term and be established in the uterine inertia. Uterine inertia is a very
active phase and for the contractions to be common problem in primigravid labour and
usually manifests with failure of cervical os
strong and sustained throughout the first stage
dilatation at the rate of 1cm per hour. The
of labour. However, if the pregnancy becomes
prolonged in a parturient already earmarked for appropriate treatment for uterine inertia is
trial of labour, labour could be induced. Here, oxytocin augmentation to which there is
the chances of success are still highprovided the response with improved cervical os dilatation of
at least 1cm per hour. It is with the view to
induced labour is well managed. A trial of
labour is however, contraindicated if there are
diagnosing uterine inertia at the earliest onset
that the vaginal examination in a trial of labour
complications in the pregnancy e.g.
should be at intervals of 2 hours during the active
malpresentation, hypertensive disease states,
phase. A vaginal examination interval of over
cardiac disease, diabetes, thyrotoxicosis or
two hours may lead to a late recognition of
haemoglobinopathies.
uterine inertia at which time it may have become
Conduct of trial of labour complicated with clinical CPD (slow labour
progress associated with caput and moulding in
The best chance of success is when the labour spite of presumed good contractions).
begins spontaneously. Since there may be resort
to abdominal delivery if the trial fails, It is hereby emphasised that as paradoxical as it
compatible blood should have been grouped may appear, oxytocin augmentation should be
and cross-matched and a paediatrician and an instituted to improve the quality of uterine
anaesthetist placed on the alert. As soon as contractions in a trial of labour with uterine
vaginal examination confirms establishment in inertia (as already defined) even when the
active phase labour, further monitoring should contractions are clinically assessed to be strong.
be with the composite partograph on which the Uterine inertia is inherently a disease of primigravid
Alert and Action lines have been constructed labour andwhatever uterine contractions that do not
and vaginal examinations repeated at two- translate to a cervical os dilatation of at least 1cm
hourly intervals till advanced first stage. Good per hour in active phase are not adequate. In

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450 Obstetrics andGynaecology

comtemporary obstetric practice, before a (B) Occipitoposterior position

diagnosis of CPD is entertained in a Occipitoposterior position refers to a situation
primigravid labour, oxytocin augmentation in which the fetal occiput presents posteriorly
must have beenused to eliminate uterine inertia instead of anteriorly creating an unfavourable
even when,the contractions are deemed condition for spontaneous vaginal delivery. At
adequate. Uterine inertia and CPD are two term, the fetal head engages in the lateral
problems that are commonly encountered in diameter of the pelvis with the occiput
primigravid labour and that are both associated obliquely anterior in 90% of cases but posterior
with slow labour progress in the presence of in only 10%. When the occiput is posterior, the
uterine contractions that are deemed clinically outcome of labour depends on the shape of the
adequate. Uterine inertia is a more frequent pelvis, state of flexion or deflexion of the head
cause of slow labour in the primigravid labour
andthe strength of uterine contractions.
than CPD and even when CPD is genuinely With a normal gynaecoid pelvis, good uterine
present, there is still always associated with the contractions and flexion of the head, the occiput
CPD in labour, uterine inertia. To compound being the foremost part of the skull to hit the
this, the contractions associated with the inertia pelvic floor rotates through 3/8lh of a circle to the
may not always be weak or hypotonic as would front into the open space beneaththe pubic arch.
be expected ininertia.
In some cases of inertia the associated This occurs in over 65% of cases and the
contractions may be hypertonic or inco-ordinate suboccipito bregmatic diameter of 9.5cm
which on clinical assessment by the palpation presents to the pelvis with easy vaginal
method may be deemed adequate hence in such delivery. However, even with some normal
cases the inertia will manifest with slow labour pelvic shapes, the occiput may rotate through
the short l/8lh of a circle posteriorly (instead of
progress and good uterine contractions just like in
anteriorly through 3/8* of a circle) to a
CPD. Thus the only sure way of confirming a
persistent Occipitoposterior position. With a
diagnosis of CPD in a primigavid labour is to
roomy normal pelvic shape and good uterine
exclude uterine inertia first with oxytocin
contractions, the head may be delivered as
augmentation in which situation the slow direct Occipitoposterior, face to pubis, with the
progress due to CPD will manifest with more fetal skull diameter of 11.3cm instead of 9.5cm
caput and moulding over 2-4 hour duration. distending the perineum and causing more
perineal damages. With abnormal pelvic
The trial of labour is continued as long as there is shapes, like android and anthropoid which have
good progress and there is no fetal distress. If more room posteriorly with narrowing
progress slows down and in spite of appropriate anteriorly, there is usually deflexion of the head
and effective use of oxytocin augmentation, and posterior rotation to cause persistent
progress does not improve or fetal distress occurs, Occipitoposterior position and the much wider
the trial will be terminated by recourse to fetal skull occipitofrontal diameter of 11.3cm.
caesarean section. When such happens, With the usual funnel shape of the pelvis in
subsequent deliveries might also be by planned android pelvis, CPD may readily occur.
caesarean section. A successful trial of labour
confers so much of obstetric advantage that Much more commonly with these abnormal pelvic
everything shouldbe done to prevent a failed trial. shapes, is that, the rotation of the head through the
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Problems of labour 451

378th of a circle is arrested midway by the very loss of fetal curvature,

prominent ischial spines to result in what is (iii) Multiple fetal limbs anteriorly on
called deep transverse arrest which commonly palpationwhile the back of the fetus
causes delayed second stage labour. The deep may be felt toward the flanks,
transverse arrest may also occur with these (iv) The occiput is felt to be deeper than
abnormal pelvic shapes on account of the fetal the sinciput on suprapubic palpation.
head remaining in the oblique diameter of the (v) Fetal heart beats are best heard
pelvis without rotating to the front or back. near the flanks or midline.

When the contractions are not strong (as may (b) In labour
often occur with occipitoposterior positions on This is often when a confident diagnosis of
account of the poor application of the head to occipitoposterior position can be made. The
the cervix) deflexion and posterior rotation may common features are:
occur resulting in CPD even when the pelvis is (i) The first stage.
of normal shape. Also, poor contractions may - Floating head at brim
predispose to deep transverse arrest and cause - Early rupture of membranes
delayed second stage labour. Borderline or abnormal pelvic shape on
pelvic assessment in labour Slow labour
Aetiology progress with cervical os dilatation rate
Commonly the occipitoposterior position may of lessthan 1cm per hour
be associated with the following: In late first stage labour, when cervical
(i) Extension attitude of the fetus such as
os is 7cm or more, a common vaginal
will occur with cord round the neck or
examination finding is the ease with
neck tumours or poor fetal tone, which the anterior fontanelle is felt
(ii) Anterior implantationof the placenta,
under the pubic symphysis especially
(iii) Abnormal pelvic shape especially when the head is deflexed. When there
android and anthropoid,
is a well flexed head, the posterior
(iv) Primary brachycephaly of the fetus.
fontanelle is felt posteriorly.
(v) Unexplained, in situations with normal
placenta, pelvic shape and fetus.
- The free border of the fetal ear when felt
points posteriorly towardthe occiput.
Presentation (ii) The second stage.
The presenting features of occipitoposterior position May be delayed in duration with slow
of the fetus can be inlate pregnancy or in labour. descent of the head in spite of maternal
pushing efforts during contractions. If
(a) In late pregnancy delay in second stage is due to arrest of
The following may cause suspicion of head at the brim with caput and
occipitoposterior position in late pregnancy: moulding, this signifies CPD. Ifarrest is
(i) Fundal height which is bigger thandates at the midcavity this may be due to deep
(ii) On inspection, there is obvious transverse arrest which requires some
periumbilical flattening because of the intervention.
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452 Obstetrics and Gynaecology

Management perineum threatens to tear. If there is

maternal exhaustion or fetal distress, assist
Occipitoposterior position only requires the second stage with either vacuum
management when it occurs and persists in extraction or Kielland's forceps delivery,
labour from the time that it is discovered.
(ii) Deep transverse arrest
Usually as soon as the findings in labour This isresolvedby one of three methods:
indicate establishment in active phase labour, (a) Head may be displaced upward and
these are recorded on a composite partograph manually rotated to occipitoanterior
with Alert and Action lines and vaginal position, followed by forceps delivery.
examinations are done at 2-4 hourly intervals. (b) The delivery can be with Kielland's
forceps rotationand delivery.
The options in management are as follows:
(a) Good contractions and good progress: (c) The delivery can be with vacuum
This may suggest that the occiput may extraction which will cause auto-
have rotated to the anterior position and rotation with the delivery.
progress may be sustained till
spontaneous vertex delivery. Complications

(b) Slow labour progress with cervical os (i) Prolonged labour: Commonly i
dilatation of less than 1cm per hour i.e. Occipitoposterior position is undetected until
progress on the partograph is to the right there is slow progress and when this is not I
of the Alert line. This may suggest effectively treated with appropriate oxytocin
persistent Occipitoposterior and there augmentation, labour may continue to be slow j
andthenend up beingprolonged.
may have been either early rupture of
membranes or uncoordinated (ii) Inefficient and incoordinate uterine
contractions. For such cases oxytocin is contractions from the poor application of the
begun to improve the contractions and head to the cervix and lower uterine segment.
cervical os dilatation rate. Generous When there is good application of head to the
pain relief measure is offered for which cervix, there is reflex stimulation and
epidural is ideal. If good contractions enhancement of contractions. The reflex j
are maintained throughout, delivery uterine contraction enhancer .: is lacking I
may end up as a direct face to pubis with with Occipitoposterior position hence the I
generous episiotomy. common poor am; '
>r

(c) " :ed second stage labour: This is (iii) F.arh or prematir -ur1 " •' ,r- v .1 I
• : kn
a hat directs attention to the
membranesdue to the r e •»
he-.d j
p -Ms'erce of the Occipitoposterior
at tne pt ic brim 'a- a •
: u'n , I
r it ioii ,nd management then depends
i
allows m v c; .c 1
-
fore -a ic;
nil .he findings.
(i - posterior: Here, encourag .
5 ontractions and when the
• •
wn assist rieih en wT

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Problems of labour 453

occipitofrontal diameter of 11.3cm to present to Obstructed labour is also commoner in the

the pelvis which may cause CPD. primigravida than in the multigravida.
(v) Arrest offetal headrotation inthe midcavity Causes
with deep transverse arrest and delay in second These may be due to maternal or fetal factors
stage labour. as shown in Table 56.3

(vi) Eventual delivery as direct occipitoposterior (A) Maternal factors

which causes overdistension of the vulva with
consequent perineal laceration. (1) Contracted pelvis which may result
(vii) Increased need for intervention in labour from the followings:
with oxytocin infusion and obstetric i. Generally contracted pelvis (when
instrumentsandtheir consequences. all pelvic dimensions are reduced)
(viii) Increasedtentorial tear of the falx cerebri. From malnutrition From
child marriages and
(C) Obstructed labour pregnancy
Obstructed labour is a labour in which progress ii Contracted pelvis from disease states e.g
has come to a complete halt in the presence of
good and adequate uterine contractions. When Childhood rickets
the presenting part in such a labour is the head, Osteomalacia
there will be evidence of fetal head squeeze Childhood poliomyelitis
manifested by excessive caput and moulding. causing pelvic asymmetry
Apart from the head, the presenting part in an
obstructed labour may be the breech, shoulder, iii. Abnormal pelvic shapes e.g
head and hand in a compound presentation or
locked heads intwin delivery.
- Android
- Anthropoid
- Platypelloid
Incidence
The incidence is highly variable but is very (2) Pelvic tumours
common indeveloping countries where there is
a high prevalence of undernutrition, poverty, - Uterine fibroid
poor environmental sanitation and poor health - Ovarian cyst
care. In such situations, there is a high - Horse-shoe shaped kidneys
prevalence of poorly grown and abnormal
(3) Cervical stenosis inwhichthere is inability
pelvic types. In the developed countries, the
. of the cervix to dilate because of cervical
public health measures have generally
scarring from previousoperations e.g
eradicated several preventable diseases and
malnutrition. These with adequate health care - Cone biopsy
facilities for maternal health services, have - Amputation of the cervix
made obstructed labour become very rare.

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m
Prince Of Medicine-2014-BSUTH

454 Obstetrics and Gynaecology

\
Manchester repair in which Most of the factors listed in Table 56.3 will
cervical amputation generally cause obstructed labour in first
was performed
pregnancies while relatively few will cause
obstructed labour in subsequent pregnancies.
Cautery of the cervix
This is the main reason why obstructed labour
(4) Abnormalities of the vagina e.g. tends to be more common in the primigravida
Transverse vaginal septum than inthe multigravida
Longitudinal vaginal septum
Clinical presentation
(5) Tight perineum especially in the primigravida
and direct' occipitoposterio'r position (face to Obstructed labour has its own peculiarities
pubis delivery) inall parities. according to the causal factor but the most
challenging situation is when obstructed labour
(B) Fetal factors occurs in the context of a cephalic presentation
whether it is in a normal or abnormal position.
(1) Malposition inwhichthere iswider When obstructed labour occurs with abnormal
fetal skull diameter presented to the pelvis lie or non-cephalic presentation or maternal soft
e.g - Occipitoposterior position tissue anomaly or pelvic tumour, the clinical
Arrest of fetal head rotation in features are usually dramatic and these often
midcavity causing deep make the diagnosis easy. The discussion
transverse arrest. henceforth, is for obstructed labour in cephalic
presentation and other situations of obstructed
(2) Malpresentations e.g. labour will be appropriately discussed in
relevant chapters.
Face mentoposterior
Brow
When obstructed labour occurs with a cephalic
Shoulder presentation whether in a normal or abnormal
Compound position, the clinical presentation depends on
- Breech with: the parity of the woman:

(i) Impaction due to big baby (a) Primigravida: As a pathognomonic feature,

obstructed labour in a primigravida is often
(ii) Extended arms associated with a cervical os dilatation rate of
less than 1cm per hour. At the time the features of
(iii) Arrested after-coming head obstructed labour occur, the cervical os is usually
of hydrocephalus or deflexed head not yet fully dilated even when contractions are
augmented with oxytocin. This is the reason why
(3) Locked twins commonly, obstructed labour in a primigravida
is associated with prolonged labour (active
phase labour duration of over 12 hours)
Table 56.3 Causes of obstructed labour
because at the time when a confident diagnosis of

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Problems of labour 455

obstructed labour is made, the slow progress level of the umbilicus to now become what is
may have caused prolonged labour. known as the pathological retraction ring or
Bandl's ring. With the continued contractions,
When the obstructed labour is not relieved the thin lower uterine segment becomes
immediately, the uterine contractions compress ballooned out, and the myometrium becomes
the head against the pubic symphysis in front oedematous and bruised. The bladder is also
and sacral promontory behind to cause pressure drawn up into the abdomen and with continuing
necrosis of the cervical tissues (since the cervix pressure of the fetus against the pubis, the
is not usually fully dilated.) The result is often bladder becomes oedematous.
fistula formation (in the front as WF and
behind as RVF) and severe nerve compression The next event in neglected obstructed labour in
to cause foot drop. When the obstruction is on the multigravida, is rupture of the uterus in
for a much longer time, the necrosis may lead to which typically, the rent begins in the thin lower
sloughing off of the cervix or even the lower uterine segment and extends laterally on both
uterine segment and a severely compressed sides down into the vagina and upward into the
dead fetus with grossly moulded head may be fundus of the uterus. With the rupture, the fetal
delivered. Typically, the lower segment in a presenting part may remainjammed inthe pelvis
primigravida does not thin out to cause a to prevent severe haemorrhage from the torn
rupture but rather the soft tissues of the cervix uterine vessels or the fetus may be expelled into
and lower segment become necrosed and the peritoneal cavity with severe haemorrhage
slough offto allow for expulsion of the baby. intraperitoneally and per vaginam. Sometimes,
(b) Mjiltigravida: Usually labour in the the bladder will also rupture especially if it is
murtigravida even when obstructed is associated adherent to the lower uterine segment following
with normal cervical os dilatation rate of at least a previous caesarean section.
lcm per hour until full dilatation. The common
The summary of the explanations above is that
evidence of obstruction is the failure of descent of in the primigravida, obstructed labour is often
the head in spite of good and adequate contractions.
preceded by slow cervical os dilatation rate of
However, in the obstructed labour of some less than lcm per hour even when contractions
multigravidae, the cervical os dilatation rate may be are enhanced with oxytocin augmentation to
lessthan 1cm per hour (as inthe primigravida) inthe become efficient and obstruction typically
active phase of first stage labour but full cervical os occurs with a yet to be fully dilated cervical os.
dilatation will still eventually occur when the With neglected obstruction, fistula formation
obstruction then becomes evident, with marked from pressure necrosis results, whereas
caput and moulding. v.
obstructed labour in the multigravida is often
When the obstruction us not relieved, the strong associated with a normal cervical os dilatation
contractions will continue to cause greater rate and a fully dilated os. However, neglected
fetomatemal squeeze resulting in severe fetal head obstruction in the multigravida does not
compression culminating in fetal asphyxia and cause pressure necrosis with fistula formation
cerebral birth trauma. In addition, retraction and rather it makes the lower uterine segment to thin
thinning of .the lower uterine segment continue so and balloon out and eventually to end in a
that the junction ring between the lower and upper rupture. While obstructed labour may be
uterine segments rises progressively often to the recognised in the primigravida as slow labour
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456 Obstetrics and Gynaecology

progress in the presence of adequate is halted at full cervical os dilatationandthere is

contractions, in the multigravida, obstruction is then progressive build up of caput and
not associated with slow progress but rather moulding. This is genuine obstructed labour in
there is poor head descent with progressive the multigravida. The obstructed labour, if
caput formation and moulding in the presence relieved at this point will not be complicated by
of good progress and adequate contractions. any fetal or maternal factors.
Aside from the above peculiarities of obstructed Genuine obstructed labour is the common form
labour based on the parity of the woman, there are in which cephalopelvic disproportion is
clinical forms of obstructed labour which present reconised in all parities especially the
with some specific features: pimigravida whose labour is being managed in
a hospital setting. In primigravid labour,
(1) Genuine or uncomplicated
obstructed labour cephalopelvic disproportion is not easily
diagnosed when there is slower than 1cm per
In a cephalic presentation, obstructed labour is hour cervical os dilatation and worsening of
simply an active phase first stage labour in caput and moulding until good contractions
which in spite of good and adequate uterine have been further generated with oxytocin
contractions labour progress (rated in the form augmentation to eliminate uterine inertia. The
of head descent and cervical dilatation) has result of such a common intervention in the
come to a halt due to a significant misfit primigravida is the finding of a static cervical os
between the head and pelvis. In the dilatation and worsening of caput and
primigravida, this misfit inactive phase, is often moulding. This finding is no longer ordinary
associated with slow labour progress and cephalopelvic disproportion, but obstructed
formation of caput and moulding in the labour. It is the same thing in multigravid
presence of good contractions. With continued labour, where commonly cervical os dilatation
labour in the presence of the above findings rate is normalandthere is no headdescent inthe
(including situations in which oxytocin presence of good contractions. More time is
augmentation is carried out to improve usually allowed in clinical practice for the good
contractions) the cervical os may not dilate contractions to push the head down for some
further but ratherthere is worsening of the caput hours. Further assessment after the elapsed
formation and moulding. This situation in the time, usually reveals no further headdescent but
primigravida is obstructed labour de novo in worse caput formation and moulding i.e
which the obstruction due to the cephalopelvic genuine obstruction and not any longer
disproportion is picked up at the earliest point. cephalopelvic disproportion.
There will usually not be any complication either
to the mother or fetus when the obstruction is In the primigravida, cephalopelvic disproportion
immediately relieved at this point. clinically is to be diagnosed when there is
slow labour progress and minimal caput
In the multigravida, the gross misfit in the active and moulding in spite of good contractions.
phase is usually associated with normal labour In the multigravida, cephalopelvic disproportion
progress in the presence of good contractions and clinically is when the active phase is ass ociated
then full cervical os dilatation. However, in spite with normal labour progress and poor or no head
of the normal cervical dilatation rate in response decent with minimal caput and moulding in the
to the good contractions, the head descent presence of adequate contractions. It is failure
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Problems of labour 461

(c) Obstructed labour complicated by Management

prolonged labour
This depends on the clinical state of the patient
and the presence of complications. In most
This is a situation in which obstructed labour is
cases of obstructed labour, there will be the
not relieved for whatever reason and active
need for general resuscitation before specific
phase labour duration now extends beyond 12 treatment isinstituted.
hours or an active phase labour duration of over
12 hours now gets complicated by obstructed General treatment
labour. The clinical state is such that obstructed
labour features of severe pain, exhaustion and The patient will require intravenous fluids for
anxiety are now added to the features of rehydration. Her blood is taken for grouping and
prolonged exposure to active phase distressful cross-matching and packed cell volume (PCV)
duration of over 12 hours like dehydration, estimation. Potent antibiotics are commenced
ketoacidosis, gross hypokalemia and oliguria. and bladder catheterisation performed. A sample
The picture is commonly that of neglected of her urine is sent for bacteriological studies and
labour like tiredness, dehydration, pyrexia, the stomach is emptied with a nasogastric tube
especially in the unbooked patient with serious
tachycardia and shock.
complications. The distress of painful
A classical case of a parturient with obstructed contractions should be treated with potent
labour complicated by prolonged labour is a analgesics.
primigravida with no antenatal care and a
history of several days inlabour.
Specific treatment
The treatment of obstructed labour is operation
Examination reveals features of tiredness and but the type depends on the cause of obstruction
dehydration. Abdomen is distended with atonic and extent of complications. The operation may
bowel. Uterine contractions will either be either be vaginal or abdominal.
hypotonic or be very strong and painful with
poor relaxation between contractions. The (i) Abdominal operation
liquor may have drained away and the uterus
moulded around the fetus. The fetal heart rate For cases of uncomplicated obstructed labour from
may be irregular or absent. The bladder is cephalopelvic disproportion which in most cases
distended with retained urine and oedematous would be in a hospital care setting, the specific
from compression. Catheterisation may be treatment is lower segment caesarean section after
difficult and occasionally it may be required appropriate resuscitation. The same is applicable
when the obstructed labour is from transverse or
that the jammed headbe first displacedupward.
oblique lie, breech or compound presentation as
Because the bladder is drawn up, the catheter
long as the obstructed labour is uncomplicated by
may have to pass a long distance to reach the
prolongation and its sequelae. However, lower
bladder and the urine is often blood stained.
segment caesarean section is still the best treatment
Vaginal examination may show vulval oedema in prolonged obstructed labour from whatever cause
from prolonged bearing down effort and a if the fetus is still alive. Considerable experience is
cervix that is not fully dilated. There is required in the resuscitation and eventual
excessive caput and moulding. performance of a lower segment caesarean
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462 Obstetrics and Gynaecology

section for obstructed labour with (b) Symphysiotomy

complications like impacted oblique or
This is indicated when there is mild cephalopelvic
transverse lie. Similarly, caesarean section is
disproportion. It is not easily recommended for
still the choice in cases with uterine rupture
modern day obstetric practice.
even when the fetus is dead. Although
caesarean section is often avoided in obstructed (c) Destructive operation
labour inwhich the fetus is dead, lower segment
caesarean section may still be the safest option There are several varieties of destructive
with the dead fetus if the cervix is not fully operations which can be performed to relieve
dilated especially in the presence of an oblique obstructed labour when the fetus is dead in
or a transverse lie. order to avoid a caesarean section scar. A
destructive operation can only be performed
(ii) Vaginal operations when the cervix is fully dilated. It is
There are varieties of vaginal operations that contraindicated when there is uterine rupture
may be performed to relieve obstruction. or ballooning out of the loweruterine segment
from the obstructed labour. The types of
(a) Instrumental delivery operations are:
Forceps delivery may easily be used to relieve (i) Craniotomy
obstructed labour associated with deep
transverse arrest. The delivery may also be This is for the dead fetus in obstructed labour
achieved with the vacuum extractor. This has with cephalopelvic disproportion in which
the advantage that it will rotate and deliver at the head is not more than three-fifth palpable
the same time. Furthermore, the vacuum above the brim. Ifthe head is higher than this,
extractor is an easier and safer instrument to use then the cephalopelvic disproportion is too
by the young and inexperienced. However, gross and even a craniotomy may not
extreme care should be exercised in cases of successfully deliverthe fetus.
deep transverse arrest where the cervix is not
fully dilated because there may be more gross (ii) Decapitation
cephalopelvic disproportion involved than can This is indicated in a dead fetus in transverse
be clinically appreciated especially in a or oblique lie with prolapsed arm. It requires
primigravida. Whenever the vacuum extractor considerable experience to perform.
is being used, the rule of the three pulls must be
adhered to. The first pull must dislodge the head (iii) Cleidotomy
from its arrested position,the second must bring
the head to the pelvic floor and the third pull This is indicated for cases of impacted
must deliver or at least crown the head. Ifany of shoulders after delivery of the head. It involves
the pulls does not achieve its purpose then, the use of a pair of long scissors to break both
further traction must be resisted and an clavicles so as to allow for their delivery.
alternative method of delivery used. If there is (iv) Embryotomy
fetal asphyxia already with the transverse
arrest, delivery by the abdominal route is often This is rare but often performed in conjunction with
the best option. other procedures like craniotomy, and cleidotomy,
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Problems of labour 463

to allow for the delivery of a large fetus. It severe tissue compression from the
involves getting out the fetus piecemeal. gross cephalopelvic disproportion
causing necrosis and sloughing of
(v) Drainage of a hydrocephalic head tissues in the lower uterine segment and
This may be done either in a cephalic cervical area. It may be reduced or
presentation or in the after-coming head of a prevented by prolonged catheterisation
breech presentation. It involves perforating the to rest the bladder.
head with any sharp instrument. This releases (4) Puerperal sepsis Cases of prolonged
the cerebrospinal fluid, the head collapses, and
obstructed labour are usually septic from
spontaneous delivery follows.
the intrapartum period. Sepsis is a
After any destructive operation, an assessment common cause of the maternal mortality
must be done to exclude any injury to the cervix associated with obstructed labour.
or uterus. Also, continuous bladder drainage
should be done for up to 10 days in cases of (5) Osteitis pubis This presents with
severe compression of maternal tissues to pyrexia, pubic pain and inability to
reducethe chances offistula formation. walk following prolonged obstructed
j labour. It is due to infection of the pubic
Complications bone from damage to the periosteum
and cortex by severe pressure necrosis.
These are common when the obstructed labour
is prolonged and further compounded by (6) Foot drop This is due to traumatic neuritis
prolonged active phase duration. of the sciatic nerve, a result of pressure on
the lumbo-sacral trunk by the fetal head in
(1) Primary postpartum haemorrhage This
prolonged obstructed labour.
occurs inprolonged labour complicated
by dehydration and electrolyte
(7) Acquired gynaetresia This is due to
imbalance causing uterine hypotonia. massive sloughing of vaginal tissue
The third stage in obstructed labour following necrosis from prolonged
shouldbe managed with oxytocics. pressure, and eventually resulting in
contracture of the vagina.
(2) Ruptured uterus This is common with
multigravida who had prolonged (8) Prolonged amenorrhoea There are a
obstructed labour that was not number of reasons that have been
immediately and adequately managed. suggested as the cause of this phenomenon:
It usually leads to severe fetomaternal
(i) Itmay be due to the psychogenic shock and
morbidity and mortality.
inhibition of the hypothalamic- pituitary
(3) Fisula formation This is a common axis caused by the difficult labour.
complication of prolonged obstructed labour (ii) More likely is the severe primary
in the primigravida and it often occurs with postpartum haemorrhage which follows
the cervix not fully dilated. It is due to the obstructed labour resulting in anterior

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—
Prince Of Medicine-2014-BSUTH

EH •*"

pituitary necrosis manifesting as Sheehan's and small statured women tend to have!
syndrome in which only amenorrhoea contracted pelves. Also, a special note should!
occurs without affecting other pituitary be made of past history of difficult labour. I
functions. This is why the menstrual periods difficult instrumental deliveries and prolonged!
often return when the general state of health labour since any of these may suggest that there I
has been improved, particularly after may be a pelvic factor. A vaginal examination!
successful repairs offistulae. should be routine at booking and about 3~1
(iii) weeks to assess for abnormal pelvis, vaginal I
stenosis or septa and pelvic tumour. Also, the I
At times the amenorrhoea may be due to head fitting test should be regularly performed I
severe endometritis and consequent and in those with abnormal head fit, X-ray I
intrauterine adhesions (synechiae). pelvimetry should be arranged. When there is I
abnormal pelvis and asymmetry or gross pelvic I
(2) Prevention contraction, an elective caesarean section will I
be ideal. Women with borderline pelvis I
Obstructed labour when diagnosed early and especially primigravidae should have a I
treated appropriately can be prevented from carefully conductedtrial of labour.
getting complicated. The causes of obstructed
labour are problems in the environment and Labour course and progress should nowadays I
community but the complications of obstructed be documented on the composite partograph on I
labour occur because of late diagnosis and which is constructed the Alert line depicting I
treatment. The prevention can be discussed cervical os dilatation of 1cm per hour as the I
under general and specific factors. normal progress in the active phase. This will I
facilitate the easy recognition of slow labour I
progress in the active phase and when this is I
General factors
associated with early caput formation and I
General factors include improving the socio¬ moulding in the presence of good contractions I
economic status of the populace and (with or without oxytocin augmentation), I
implementing several other preventive measures cephalopelvic disproportion should be
that will ensure clean, disease-free environment, diagnosed and labour terminated by caesarean
good nutrition and proper growth. Sufficient section long before obstructed labour occurs.
investment in education should be encouraged to
ensure a sizeable literate women population When the partograph is used to monitor active i
whose horizon will resist harmful cultural phase labour, slow labour is often easily
practices and above all, appreciate the importance recognised when the graph of cervical os
of antenatal care and institutional delivery. dilatation touches or crosses the Alert line at
which early time, corrective measures can still
Specific factors be instituted. When these corrective measures
are successful (i.e. slow labour progress is I .
These pertain to the role of antenatal and improved), prolonged labour is prevented. This I t
intrapartum care in preventing obstructed labour. is why the partograph is an ideal clinical tool 1 i
During the antenatal period, special attention should be for early recognition and treatment of slow i
paid to screening for height and shoe size because short labour progress. Also, special note should be (

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Problems of labour 465

taken of prolonged second stage in which there illiteracy rate and poor or no maternal health
is progressive caput formation and moulding care services especially in the rural areas where
especially in the multigravidae in which prior the majority live. The incidence of ruptured
cervical os dilatation was normal as this may uterus in most developing countries is 1 in 200
suggest cephalopelvie-disproportion or early deliveries but in the developed countries the
obstructedlabour. incidence is 1in4000 deliveries.

All the antenatal and intrapartum care should (A) Ruptured uterus in pregnancy
not be restricted to the secondary or tertiary care
centres alone. It should be integrated into the As a general rule, this event is rare inpregnancy
services obtained at a basic health post or except inthe following special situations:
dispensary. The staff may be a midwife or (1) Previous classical caesarean section A
midwife auxiliary who may be trained to refer woman who has had a delivery with a
these cases to higher level care. classical caesarean section incision may
rupture her uterus in pregnancy. This
The management of labour with the partograph commonly occurs about the 32nd - 36th week
is not a sophisticated procedure that should be of gestation. A classical caesarean section
used only in the secondary and tertiary care incisionis made inthe upper segment of the
centres. In its evolutionary history, the uterus which would typically heal poorly
partograph, as recorded by R.H. Philpott in because this segment is subject to changes
1972, was designed to be used in small
from uterine involution in the puerperium,
peripheral units from where women in labour
moreso if there has been any degree of
whose cervical os dilatation graph crosses the
puerperal infection. Pregnancy in a woman
Alert line, are transferred to higher level care for
more appropriate and specific treatment. In the
with a previous classical caesarean section
new approach to preventing obstructed labour,
scar is usually planned for elective lower
midwives at the small peripheral units shouldbe segment caesarean section at 37 weeks
I taught the use of the partograph to supervise because the classical scar cannot withstand
! labour in order for them to recognise slow the stress of labour and uterine rupture may
, labour progress early. occur any time from 32weeks without any
sign of labour. This is why it is a good
(D) Rupture of the uterus practice to routinely admit these women for
close observation from the 32nd week of
This is a disaster which may complicate gestation so that if a ruptured uterus should
pregnancy, labour or delivery with fetomaternal still occur, it may be discovered early for
mortality. As an obstetric event, it has become appropriate treatment. The other reason for
veiy rare in the developed countries where such routine admission at 32 weeks is to
there are accessible, affordable, efficient ensure sufficient rest for the woman which
and effective maternal health care services may reduce the chances of a ruptureduterus.
even in the most remote rural areas. In
most developing countries, ruptured uterus (2) Pregnancy in an accessory horn of a double
is still a common obstetric problem because uterus A pregnancy in the accessory horn of
of widespread poverty, high women a double uterus may be complicated by

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466 Obstetrics and Gynaecology'

spontaneous rupture from as early, in Greatly feared that these scars were
pregnancy as late second trimester or even generally weak and may result in uterine
thirdtrimester like 26- 32 weeks with severe rupture in labour, elective caesarean
haemorrhage. The uterine anomaly may not section used to be generally advised for
havebeenknown before the pregnancy until these cases. Emerging knowledge has
presentation with the features of rupture. revealedthat such scars under reference, in
The fetal mortality is often 100 per cent and a non-pregnant uterus, heal usually
maternal mortality is also very high. The excellently well because the uterus is not
rupture occurs because the thin wall of the subject to any contraction or involution
accessory horn cannot withstand the stress which in a pregnant or puerperal state
of further distension as the pregnancy would slow down the healing process.
grows. Nowadays, the scars are regarded as strong
(3) Uterine manipulation in late pregnancy and good enough to withstand labour
with any previous scar A late pregnancy which should however be closely
(36-39 weeks) manipulation like external monitored for early diagnosis of a rupture.
cephalic version (ECV) for breech The risk of uterine rupture in labour
presentation may become complicated by following previous myomectomy is much
uterine rupture in any woman with a lower than a previous caesarean section
previous lower segment caesarean section. buttherisk still exists.
This isthe reason why this procedure should
be attempted only by those with the (b) Previous classical caesarean section scar:
requisite experience. In any woman with This scar may rupture in early labour even
other scars like previous myomectomy or when it is in the latent phase. If a woman
hysterotomy, uterine manipulation may be with known previous classical caesarean
complicated by uterine rupture. It should be section achieves term, the delivery is
noted that uterine rupture may complicate always by elective caesarean section at 37
an ECV in a grandmultipara without any weeks before labour begins. However, the
previous uterine scar especially if problems are in the cases where it was not
considerable force isused. known that the previous scar was a
classical one until ruptureduterus occurs.
(B) Ruptured uterus in labour
This is the more common time for uterine (c) Two or more previous lower segment
rupture to occur and the causes depend on caesarean section scar: Women with these
whether there is a previous uterine scar or not: scars are usually planned for elective caesarean
(1) Uterus with previous scar section at 38 weeks but some women may
default and therefore, come in labour. At times
(a) Previous scar in a nonpregnant uterus: This such labours may have been complicated by
refers to the women in whom the previous uterine rapture at the time of admission.
scar on the uterus is due to myomectomy in
which the cavity was opened or those who
(D) One previous lower segment caesarean
had a hysterotomy or Strassman's operation
section scar Women with one previous
for the correction of a bicomuate uterus.
lower segment
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Problems of labour 467

caesarean section performed for a in this circumstance are as follows:

nonrecurrent cause like antepartum
haemorrhage or fetal distress whose (a) Obstructed labour:
wound had healed well are usually Obstructed labour in a multipara may
allowed to go into labour when the easily get further complicated by uterine
pelvis is assessed to be adequate and the rupture. This is a common feature of the
course of the pregnancy has been obstetric practice in the developing
uneventful. However, such labours are countries. Commonly obstructed labour
usually carefully monitored with the in a multipara may occur from
partograph to facilitate early diagnosis cephalopelvic disproportion due to
of slow labour progress which is a contracted pelvis, big baby,
common antecedent to obstructed malpresentation, malposition or
labour. Obstructed labour in a woman abnormal lie. When the obstruction is
not relieved quickly enough, uterine
with a previous caesarean section
rupture will occur because the uterus in
should be relieved instantly to prevent
a multipara on encountering
uterine rupture.
obstruction, continues to increase its
Labour in a woman with a previous caesarean contractions to overcome the
section scar from a non-recurrent cause may on obstruction until rupture occurs. This
partographic monitoring develop slow labour behaviour is in sharp contrast to the
primigravid uterus which on
progress due to uterine inertia (which may
encountering obstruction may develop
manifest as hypo- or hyper- or inco-ordinate
secondary uterine inertia and hence,
uterine action or various combinations of all
uterine rupture is not common. Also, in
these). The approach to managing such slow
a multipara especially a grandmultipara,
labour is to individually and carefully assess the the uterus contains more fibrous tissues
I pelvis to exclude cephalopelvic disproportion than muscles hence with relatively
and significant caput and moulding. When small resistance from cephalopelvic
there is no cephalopelvic disproportion, the disproportion the uterus may rupture
uterine inertia can be treated with oxytocin easily. This is why extreme care should
augmentation to improve contractions that will be exercised when oxytocin infusion is
result in normal labour progress of at least 1cm used to treat slow labour in the
per hour cervical dilatation and sustained until grandmultipara.
delivery. Careful monitoring will thus
eliminate the fear of ruptured uterus. (b) Injudicious use of oxytocin infusion:
A known complication of oxytocin infusion
In cases of women who are unbooked and with a in parturients is uterine rupture in the
previous caesarean section scar, and admitted with absence of cephalopelvic disproportion
slow labour or obstructed labour, the best approach especially in women of high parity. When
is emergency caesarean section because in such there is cephalopelvic disproportion in a
situations further delay may lead to uterine rupture. multipara which has been missed, and
oxytocin infusion treatment is used in such
(2) Unscarred uterus a circumstance, the cephalopelvic
The situations inwhich uterine rupture may occur disproportion will manifest as obstructed
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468 Obstetrics and Gynaecology

labour and finally uterine rupture will occur avoided and precipitate labour, ruptured
when the obstructed labour is neglected. uterus and other sequelae will not occur.
However, uterine rupture may occur in a (c) Traumatic rupture ofan intact uterus in
multipara in labour, in the complete absence of labour;
cephalopelvic disproportion from the This refers to a situation in which an
injudicious use of oxytocin. intact uterus is ruptured in labour as a
result of some manipulations or
Exposure of the uterine muscles (myocytes) to procedure to effect delivery. The
oxytocin excess will easily occur when situations are as follows:
oxytocin incremental dose interval is as short as
(i) Kielland'sforceps delivery:
15 minutes especially in the grandmultipara.
Kielland's forceps may be used to effect
With such a short interval, the response of the
delivery when the fetal head descent is
myocytes to the initial oxytocin doses is not yet arrested in the mid cavity by prominent
optimal before subsequent dose increases. This ischial spines-a condition known as
creates a situation in which the myocytes deep transverse arrest. If there is
respond to three or more doses at once in a rapid insufficient skill inthe use of this special
summation effect. Such rapid summation forceps, ruptured uterus is one
response manifests as hyperstimulation, complication that may arise.This is why
precipitate labour, fetal distress and uterine exploration of the uterus after Kielland's
rupture in the absence of cephalopelvic forceps delivery is usually carried out
disproportion. This constitutes the commonest especially if there was considerable
variety of injudicious use of oxytocin infusion difficulty during the forceps delivery.
in current practice. The safe approach to (ii) Destructive operation:
oxytocin infusion treatment whether for During any destructive operation,
induction of labour or augmentation is a traumatic rupture of the uterus may
titration regimen of at least 30 minutes occur either from the instrument
incremental interval in the multipara up to Para accidentally or from fragments of bone
4, and 45 minutes incremental interval in the that may incisethe uterus.
grandmultipara. With these longer intervals, the
(iii) Internalpodalic version: This is when a
myocytes, whose response to any oxytocin dose
fetus in transverse or oblique lie is
may be delayed for 30 to 40 minutes, have turned into a breech and immediately
sufficient time to respond to each oxytocin followed by a breechextraction as a way
dose. These intervals also allow the observer, of ensuring a fast delivery in an
sufficient time to observe and assess the uterine emergency. The circumstance in which
response to each oxytocin dose before deciding this could happen in current practice
on the next incremental dose if the observed is in the delivery of a second twin which
response is not yet the desirable end point. In is in oblique or transverse lie with
this way oxytocin excess to the myocytes is intact fetal membranes after delivery
of the first twin vaginally. The
standard procedure is to rupture the
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Problems of labour 469

membranes, perform an internal on whether or not it is in pregnancy, labour or

podalic version and breech extraction. post delivery period.
This can easily be complicated by
uterine rupture especially in the (1) Inpregnancy: The diagnosis of ruptured
grandmultipara. uterus inpregnancy is oftenvery easy. The
feature is sudden severe abdominal pain
Types of uterine rupture with tenderness in a parturient with a
When uterine rupture follows an obstructed previous uterine scar. This may be
labour, the rupture often begins in the lower followed by collapse and haematuria. The
segment if there was no previous caesarean above features may have followed a
section scar but when there is a previous performed procedure and occur either
caesarean section scar the rupture may be along immediately or be delayed by a few hours
the previous scar line and the bleeding is or days. These features also apply in
usually much less. spontaneous rupture.
With obstructed labour, the pattern of rupture is (2) In labour: The diagnosis of ruptured
usually as follows: uterus in labour could be very difficult in
(a) The rupture most commonly affects the certain instances particularly when the
anterior wall in the lower segment and rupture is small andthe fetus is not extruded
the directionis transverse with a vertical
into the abdominal cavity. The cardinal
extension sometimes. The bladder
features of uterine rupture in labour are:
could be involved in an anterior wall
rupture of the uterus. - Continuous uterinecontraction instead of
(b) The next common rupture involves the the normal intermittent contractions of
lateralwall of the lower uterine segment labour.
which may extend upward to the fundus Lack of labour progress
or downward to the uterine vessels and Uterine tenderness
the vagina. Altered uterine contour when part of the
(c) The posterior wall of the lower segment fetus has already beenextrudedinto the
i s least commonly affected in uterine abdominal cavity.
rupture from obstructed labour and the As a rule uterine rupture must be suspected
directionis often transverse. when these features are found especially in the
grandmultipara with obstructed labour, or a
(d) At times the rupture may be multiple woman with previous caesarean section scar,
affecting the anterior, lateral and fetal malpresentation, and malposition. When
posterior walls simulating almost a
the fetus is extruded into the peritoneal cavity
detached uterus.
after a rupture, the diagnosis may be very easy
Diagnosis because of the following peculiar features:
(i) Continuous instead of intermittent
The diagnosis of uterine rupture may not always be labour pains,
easy. However, the difficulties indiagnosis depend (ii) Uterine contour is now altered because

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470 Obstetrics and Gynaecology

the tense uterus no longer fills the centre vaginal and urethral bleeding are
of the abdomen invariably absent. The findings at
caesarean section will confirm absence
(iii) The uterus may be felt separate from the
of uterine rupture.
fetus whose parts are easily palpable.
(iv) There may be generalised abdominal (ii) Severe abruptio placentae: In this
tenderness condition, are present shock, bleeding
(v) There may be fluid thrill and shifting per vaginam, tense and tender uterus
dullness when there is massive and absent fetal heartbeats. The
intraperitoneal haemorrhage. distinguishing feature is lack of
(vi) There is significant vaginal bleeding. prolonged labour and the cervical os is
closed on vaginal examination.
(vii) Catheterisation is easy and urine
is blood-stained. (iii) Term extrauterine pregnancy: This
(viii) In some instances the placenta may be rare condition may be confused with
extruded per vaginam, though uterine rupture. With extrauterine
commonly it is extruded into the pregnancy, the fetus is easily palpable
peritoneal cavity with the fetus. just as in ruptured uterus whenthe fetus
is extruded into the peritoneal cavity but
there will be no history of labour.
(3) Post delivery diagnosis: The diagnosis
of uterine rupture post delivery is also not Treatment
easy. Ruptured uterus should always be
suspected in the following circumstances: Initial resuscitation is done with intravenous
fluid, blood transfusion and analgesics.
Antimalarial drugs and at times antitetanus
(i) Profound shock post delivery especially serum (ATS) are also administered. The
when response to intravenous fluid and definitive treatment is laparotomy and the
bloodtransfusion is poor. procedure may be:
(ii) Severe abdominal pain
(iii) Features of abdomino-pelvic sepsis inthe (a) Repair of the rupture and tubal ligation
especially when the woman is a
puerperium especially if delivery was grandmultipara.
traumatic or parturient had obstructed
labour or previous caesarean section scar. (b) Subtotal hysterectomy: When the rupture
Differential diagnosis is massive and the woman cannot
withstand prolonged anaesthesia.
The differential diagnosis includes the
foliowings: (C) Total abdominal hysterectomy: This is
the best procedure when there is
(i) Obstructed labour without uterine adequate resuscitation for the parturient
to withstand the anaesthesia and there is
rupture: This condition may present with
the skill for this procedure.
features simulating uterine rupture Hysterectomy is often reserved for
especially when there is intrapartum sepsis, multiple tears where repair is not
dehydration and electrolyte imbalance. advisable.
When there is no ruptured uterus present, Prevention
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Problems of labour 471

Uterine rupture is a preventable problem when

the following are adhered to: diagnosis and treatment of uterine

(a) All elective repeat caesarean sections rupture. Prognosis

should be performed at 38 weeks latest,
. because over half of pregnant women will This depends on the cause of the rupture, the
be inlabour after 3 8 weeks. location of the woman at the time of rupture,
extension of the rupture to other surrounding
(b) Early diagnosis of malpresentation and organs and availability of expert care. When
malposition which may easily cause treatment is delayed or unavailable, the
cephalopelvic disproportion and mortality is usually total for mother and fetus.
obstructed labour. When obstructed labour
is diagnosed early and relieved in the
multipara, prolonged obstructed labour
Bibliography and suggested further
which may lead to uterine rupture can be
prevented. reading

Dudley, D. J. (1999) Dystocia. In Clinical Obstet,

(c) Extreme care should be exercised with the Gynaecol 40. Pp 459-548
use of oxytocin to manage labour
especially with a previous caesarean Symonds, E.M. (1998) Essential Obstetrics and
section scar, and in the multipara. In all Gynaecology. Churchill Livingstone,Publishers.
such instances, before the oxytocin is O' Driscoll, K., Meagher, D (1980) The active
applied to manage the labour, management of labour. London, Saunders.
cephalopelvic disproportion must be
excluded. Spencer, J.A.D (1991) Fetal Monitoring. Oxford
Medical Publications, Oxford University Press.
(d) Extreme care should be exercised with
Calder, A. A. (1999) Induction and augmentation of
version procedures. labour. In Dewhurst's Textbbook of Obstetrics and
Gynaecology for Postgraduates. 6th ed. Edmonds,
(e) The cervix and uterine cavity should be O.K. ed. Blackwellscience.
explored after Kielland's forceps delivery
anddestructive operations to facilitate early

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Chapter 57
Local abnormalities and pelvic tumours
in pregnancy
A. Congenital uterine and vaginal prolapse is also a feature in labour. Where the
abnormalities placenta is partially or totally inserted on a uterine
septum, there is increased risk of the placenta
The uterine abnormalities seen in clinical being retained during the third stage of labour.
practice are due to some abnormal
embrvological development of the Diagnosis
paramesonephric (Mullerian) ducts that form Diagnosis is often based on a high index
the Fallopian tubes, uterus and upper two-thirds suspicion. Recurrent early or lateabortions ma;
of the vagina. Some of these seen in pregnancy be the first hint of congenital uterii
take the form of failure of fusion of the ducts, abnormality. The presence of vaginal septum
which if total results in complete duplication of double vagina during the antenatal period ma]
the uterus, cervix and vagina with one Fallopian further confirm the suspicion. Ultrasonic sra
tube leading to each uterus. Partial fusion may can be very useful in detecting the abnormality ii
give rise to duplication of uterus and cervix but pregnancy, but quite often diagnosis is made
one vagina, or comual duplication of the uterus caesarean section or manual removal of placent
with one lower uterine segment, cervix and In some cases the issue can only be resolvi
vagina. Failure of median septum loss may give postpartum with hysterosalpingogram 01
rise to septate uterus of varying degrees and hvsteroscopy. Intravenous urogram should
may be associated with incompetent cervix. • always follow these investigations as renal
abnormalities are often associated with1
Presentation in pregnancy and labour congenital abnormalities of the Mullerian system.
In the first trimester, uterine septum may be
associated with early miscarriages. Congenital Management
fundal abnormalities and congenital cervical The management in pregnancy is dealing
incompetence increase the risk of second with the complications associated with the
trimester abortions and preterm labour. During various abnormalities, as any reconstructive
the third trimester, about 1-3% of preterm surgery can only be done postpartum in
labours are associated with uterine most cases. Abortions due to cervical
abnormalities. Malpresentations are also incompetence can be prevented by a timely
common at this time. Nidation of the fertilised cerclage operation. Where a longitudinal
ovum in a poorly vascular uterine septum can vaginal septum prevents the fetal head
lead to poor placental development with from descending in labour, this can be safely-
consequent intrauterine growth restricted divided during delivery. A thick transverse
(IUGR) fetus. In labour, incoordinate uterine vaginal septum cannot be divided in labour. The
action is a feature of these abnormalities baby should always be delivered abdominally.
leading to prolonged labour and, therefore, However, a thin transverse septum may rupture
high surgical intervention rate. Because of spontaneously in labour to allow descent of the
increased incidence of abnormal lie, cord head or require little assistance by way of a
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Local abnormalities andpelvic tumours inpregnancy 473

cruciate incision at full cervical dilatation. will differentiate these.

Postpartum, abnormalities like double uteri or
septate uterus can be corrected by the Management
Strassman's operation. A rudimentary horn An indwelling catheter is inserted to
should be excised after the puerperium. decompress the bladder while the woman is
Subsequent deliveries after these made to lie in a semi-prone position. In most
reconstructive procedures should be by cases the retroversion is corrected within 48 to
caesarean section. 72 hours. Rarely is manipulation under general
anaesthesia required to disimpact the uterus.
B. Uterine retroversion
It used to be thought that pregnancy occurs less C. Fibroids in pregnancy
often in retroverted uterus because of the Fibroids are the most common benign tumour
unfavourable situation of the cervical os in this of the female uterus. They are more prevalent
condition. However, pregnancies do occur and with advancing age and more common in the
more often than not go to term without any Negroid race. Estimates have it that 20% of all
incident. With time, the gravid uterus rises out women of reproductive age have one or more
of the pelvis into the abdomen as pregnancy fibroids in the uterus. They are rare before the
progresses, usually between 12 and 16 weeks. menarche and prevalence increases up to the
Ina few cases this correction does not occur and
menopause when regression may occur in size
the developing uterus fills the pelvic cavity and but not innumber.
becomes impacted - incarceration of the
retroverted gravid uterus. With time this leads Diagnosis
to acute retentionof urine. Before the advent of the ultrasound, diagnosis
of fibroid in pregnancy has not been easy.
Diagnosis
Fibroid can be confused with rudimentary horn
A woman with impacted retroverted gravid
uterus usually presents inearly secondtrimester
of the uterus, ectopic pregnancy and ovarian
with lower abdominal pain and retention of tumours. In late pregnancy it can be confused
urine. On examination a tender cystic mass is with the head of a second twin. With
felt in the lower abdomen. The uterus will be improvement in ultrasound resolution, fibroid
palpable in the posterior fornix with the cervix masses not smaller than 2cm in diameter can
displaced upward and behind the pubic accurately be located in pregnancy and the
symphysis. emergence of magnetic resonance imaging (MRI)
has further improved the ease of diagnosis. In the
Differential diagnosis developing world where scanning inpregnancy is
Conditions that may be confused with impacted not routine, most fibroids are diagnosed prior to
retroverted uterus include pelvic haematocele, pregnancy because of sub-fertility, recurrent
but here the patient is usually very pale and in the pelvic symptoms, or during bimanual pelvic
first trimester of pregnancy. A posteriorly placed examinations for some other causes such as
ovarian cyst or pedunculated subserous fibroid
menstrual disorders or chronic pelvic pain. Most
impacted in the pelvis may be difficult to fibroids in pregnancy in this group are diagnosed
distinguish from retroversion. An ultrasound scan
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474 Obstetrics andGynaecology

late in pregnancy because of the complications management of fibroids in pregnancy except in

of the fibroids such as torsion, red degeneration extreme circumstances such as intrapartum
or a uterus larger thanthe dates would suggest. haemorrhage caused by ruptured vessels on
subserous fibroids. Red degeneration should
Complications always be treated conservatively. Myomectomy
Fibroids cause a variety of complications in in pregnancy can be very dangerous, the only
pregnancy often related to their position, size exception being the case of a pedunculatec
and the fact that fibroids grow bigger in subserous fibroid with a long thin pedicle.
pregnancy. Submucous fibroids, for instance, Caesarean delivery is advisable in situatioi
lead to miscarriages due to poor placentation on where fibroid isthe cause of obstruction or poor i
the fibroid and compromise of uterine cavity if uterine action. In such situations efforts must
the fibroid is large. Retained products of made to avoid incising areas containing fibrok
conception are more likely after such abortion. masses as this may leadto torrential bleeding.
In successful pregnancies retained placenta is
quite common as a result of poor placentation D. Carcinoma of the cervix
(villi invading the surface of the fibroid). Other
complications associated with fibroids include: Although the prevalence of carcinoma of the
abruptio placentae, premature rupture of the cervix inpregnancy ranks behind breast cancer.
membranes (PROM), premature labour, lymphoma and malignant melanoma, the pre-
malpresentations and red degeneration malignant stage in women of reproductive age
(necrobiosis). Rupture of engorged large is on the increase. Screening for pre-malignan:
vessels that course over a large subserous disease of the cervix should be undertaken
fibroid may cause massive intraperitoneal during the antenatal period whenever possible
haemorrhage necessitatinglaparotomy. as about one-third of pre-malignant cervical
lesions will progress to malignancy.
Management
Management of fibroids in pregnancy is mainly
medical. In red degeneration there are pain, (i) Cervical intraepithelial neoplasia
fever, and a raised white cell count. The case (ON)
responds to non-steroidal anti-inflammatory
The above is the name given to the pre-
agents but in severe cases pethidine may be
malignant cervical neoplasia. Aetiologically,
required. Pain due to red degeneration should
there is proven association with the human
resolve intwo weeks. Thoughts have been given
papillomavirus.
to the use of prostaglandin synthetase inhibitors
such as mefenamic acid in fibroid related pains, Attempts should be made to obtain a cervical
butthis poses the danger to the fetus of premature smear at the first antenatal visit. If this is
closure of the ductus arteriosus. The use of suspicious, the mother should be referred for
fibroid-size shrinking drugs such as LHRH, colposcopy. If the lesion turns out to be non
Danazol, mifepristone, and gestrinone are Invasive, a conservative approach should then
inappropriate inpregnancy and would be of very be adopted until after pregnancy as there is no
little benefit. There is no place for surgical
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Prince Of Medicine-2014-BSUTH

Localabnormalities andpelvic tumours inpregnancy 475

evidence that pregnancy accelerates delivered preferably by the vaginal route. There
progression to a higher grade. However, is no evidence that abdominal delivery offers a
colposcopy should be repeated at 24 and 34 better prognosis, but the option is there.
weeks gestation and again at 8 and 12 weeks Alternatively, radical caesarean hysterectomy
postpartum. If the diagnosis is still confirmed, could be performed. Whatever option is
local destructive procedure with cryosurgery, decided upon, it must be followed by radiation
diathermy or C02 laser should be carried out therapy.
and patient is followed up. For the older woman
who has completed her family, hysterectomy Prognosis
may be offered. This is discussed in detail With modern approach, the prognosis is similar
elsewhere inthis book. for both pregnant and non-pregnant women.
Neither is there any difference between those
(ii) Micro-invasive carcinoma treated by radiotherapy and those treated with a
combination of radiation and surgery.
For this condition a cone biopsy is done to
exclude invasive disease. Occasionally this E. Ovarian tumours
may evoke serious bleeding that may require Ovarian tumours are uncommon in pregnancy.
haemostatic stitches to control. Vaginal When they occur they are revealed as a result of
delivery should be allowed and the patient complications such as torsion, haemorrhage
followed up as above. and rupture. Routine abdominal scan in
pregnancy could also detect an ovarian tumour
(iii) Invasive carcinoma hitherto unsuspected.
The incidence of carcinoma of the cervix in Incidence
pregnancy is put at about 1 in 250 to 1 in 5000. The incidence of ovarian tumours in pregnancy
Thirty to 60% are asymptomatic and about 50% is put at about 1 in 80 to 1 in 300 pregnancies,
are detected by cervical smear. Vaginal and the incidence of malignancy is put at about
bleeding is usually the commonest symptom 1in8 -20,000.
followed by vaginal discharge. Rarely is pain
the leading symptom. If the condition is The common types encountered in pregnancy
diagnosed before 24 weeks of pegnancy more include, follicular and corpus luteum cysts,
specifically in the first trimester, external beam followed by cystic terratoma (dermoid) and
radiotherapy should be given and this usually mucus cystadenoma. At times germ cell tumours
are found, especially in the younger mothers.
leads to abortion of the fetus. However, if in the
second trimester, it is advisable to first remove
Diagnosis
the fetus surgically before radiation. Some
Inearly pregnancy diagnosis may not be difficult
surgeons may prefer radical hysterectomy and
as it is often easy to palpate the cy&t separate
pelvic lymphadenectomy followed by radiation.
from the uterus. It becomes more difficult as
If the pregnancy is older than 24 weeks
pregnancy advances and the uterus fills the
conservative measures should be adopted until
abdomen. Differential diagnosis includes
about 32 weeks when the baby should be
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476 Obstetrics and Gynaecology

ectopic pregnancy, fibroids, retroverted uterus, should be taken from the apparently normal
rudimentary horn of the uterus, twins and pelvic side. The postoperative period should be
kidney. The ultrasound can be very valuable but normal, but tocolytic agents could be
at times may miss a posteriorly situated tumour. administered in the event of premature
contractions supervening. If a malignant
Complications ovarian tumour were encountered,
Complications that may occur include torsion, management would depend on the stage and
haemorrhage, infection and rupture. Torsion is age of the pregnancy. Advanced disease should
most likely early in pregnancy when the cyst is be treated by debulking after termination of the
being pulled out of the pelvis and during the pregnancy by hysterotomy or caesarean
puerperium when the involuting uterus pulls section, followed by chemotherapy. Where the
the cyst down into the pelvis. During labour an disease is not advanced fetal viability should be
ovarian cyst that is lodged in the pelvis may awaited before intervention. Adjuvant
prevent the fetal head from descending, causing chemotherapy is particularly useful in the
an obstruction. management of highly malignant germ cell
tumours except dysgerminoma. This regime not
Management only improves the survival rates but also has the
If the cyst is diagnosed early in pregnancy, it is advantage of allowing younger women to
always advisable to wait until about 14 to 16 continue childbearing.
weeks before attempting to remove it. This not
only reduces the chances of abortion, especially Bibliography and suggested further
if the cyst is of the corpus luteal variety, but
reading
allows time for it to regress if it is of the
functional type. Cysts found after 16 weeks West, CP (1992) "Uterine fibroids, clinical presentation
should be removed immediately as it becomes and diagnostic techniques" In:Uterine fibroids, time for
more difficult to do so as the pregnancy gets review, Carnforth, Lancashire: Pathenon Publishing
bigger. There is also the danger of torsion, Group, pp 34-45.
rupture, infection, haemorrhage and malignant
Phelan, JP (1995) "Myomas and pregnancy" In:
change. Ovarian cystectomy should be Obstetrics and Gynaecology Clinics of North America,
performed and oophorectomy only if there is no pp801 -5.
ovariantissuethat can be preserved. Abiopsy
Shingleton,HM, Orr J.W. (1983): Cancer complicating
pregnancy. In Cancer of the cervix, diagnosis and
treatment, Churchill Livingstone, Edinburgh, pp!93 -
206.

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Chapter 58

Maternal injuries
Cervical laceration lower uterine segment. Once a full assessment
The laceration of the cervix is one of the causes has been made the lips of the cervix should be
of primary postpartum haemorrhage and long-
grasped with sponge holders, pulled down, and
the rent repaired with interrupted No.2 catgut
term maternal morbidity if not properly
sutures starting from the apex of the laceration.
treated.Causative factors include:
Perineal tear
i. application of the forceps before the
cervix is fully dilated, Perineal tears are classified into three:
ii. spontaneous delivery through a cervix
that is not fully dilated, First degree - The tear involves the anterior
iii. precipitate labour, part of the perineum and posterior wall of the
iv. delivery of the after coming head of the vagina.
breech through incompletely dilated
Cervix, Second degree - The tear involves the
v. improper application of the ventouse perineum including the perinea! body and the
such that the cervix is trapped between posterior vaginal wall.
the fetal head and the cup.
vi. destructive operation, especially Third degree - This is the most serious of the
Craniotomy. tears and involves the anal sphincter and the
Vii. improper use of the Kielland's forceps. anal canal. Extension into the rectal canal
makes it a fourth degree tear. This type of tear
Management: leads to faecal incontinence.
Haemorrhage can be very severe when the
cervix is lacerated from any cause. It should be Causes
routine practice to inspect the cervix carefully
Perineal tears are often due to attempts at
after any operative vaginal delivery. Even delivery procedures or vaginal delivery under
where the bleeding is not severe enough to call conditions that are not so conducive. They can
attention, an unrepaired cervical tear may lead be avoided in most cases. Some of the causes
to shortness of the cervix and incompetence. include rigid perineum, shoulder dystocia,
Where the injury is a slight abrasion andthere is breech delivery, occipitoposterior position of
no significant bleeding, the vagina should be the fetal head, precipitate labour, macrosomia,
packed and the patient kept under observation and inappropriate use of the forceps.
for about 24 hours.Where the laceration is deep
and there is bleeding, a thorough inspection Management
with a good light should be carried out. In some
cases this may have to be done under general All perineal lacerations, except for very minor
anaesthesia as some tears may extend into the abrasions must be repaired as soon as possible with
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478 Obstetrics and Gynaecology

attention paid to good apposition of damaged complications of (he third stage of labour. Most
tissue. Chronic perineal and pelvic pain in later times it develops insidiously, attention being
life, incontinence of flatus and at times urine called when the woman collapses with shock or
and faeces in women have beentraced to badly groans inpain long after her vaginal delivery.
repaired perineal lacerations. They should be
repaired in good light and in the case of third Causes include:
degree, general anaesthesia may be required. Poorly repaired episiotomies
The first degree tear is repaired in layers using Rupture of varicosities of the vulva
2/0 chromic catgut or dexon preferably on an Tear of the submucosal vessels of the lateral wall
atraumatic needle. The vaginal wall is sutured of the vagina following normal or instrumental
continuously from the apex of the wound down delivery.
to the perineum.
The second degree involves the perineal The site of occurrence varies, but it is
muscles. The vagina is sutured and the deep commonest in the subcutaneous tissue of the
perinealmuscles are apposedwith deep through labia majora but may track down to the
and through sutures to obliterate every dead perineum and the ischiorectal fossa. At times it
space, and then the superficial perineals are forms at a higher level, occluding the vagina.
sutured, followed by the closure of the skin.
More recently it has been advocated that the The presenting symptoms are pain and
skin be left without any stitches. It heals better swelling, On examination, the patient is in
and is associated with less residual pain. It is severe distress and inspection of the vulva will
best done under local infiltration with 0.5% or reveal an oedematous swelling on one side. At
1% xylocaine without adrenaline. The repair of times it is so large that it extends up the vagina
the third degree tear should be carried out under andoccludes it
general anaesthesia and in good light. The first
step is to repair the anal and rectal mucosa with Management
interrupted 2/0 chromic catgut This is followed
Except for very small ones, most vulval
by approximation of the torn anal sphincter
haematomata will need to be evacuated.
with interrupted no 1 chromic catgut. The Because some of them may contain a lot of
vaginal wall is then closed followed by the
blood, it is always advisable to make blood
repair of the perineal muscles. The levator ani available. The evacuation should be carried out
may be strengthened at this time. The under general anaesthesia. The swelling is
superficial perineals and the skin are then incised near the introitus. Blood clots are
closed. Post operatively, the patient should be evacuated and any obvious bleeding vessels are
placed on low residue diet for about 4 to 5 days ligated. Where possible, as much of the
and then slowly weaned to normal diet. It is dead space is closed and a corrugated rubber
advisable to perform routine episiotomies at drain inserted. The vagina should be packed to
subsequent vaginal deliveries. reduce the chances of further bleeding.
The drain is removed after 24 -48 hours. The
Vulval haematoma use of a broad spectrum antibiotic may
Vulval haematoma is one of the serious reduce the risks of infection. Where infection

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Prince Of Medicine-2014-BSUTH

Maternal injuries 479

has already set in, a vulval abscess is usually the viii. When the second stage of labour is
result. This should be drained after initial prolonged due to a rigid perineum.
treatment with antibiotics and a drain inserted ix. In certain cases of abnormal pelvic
as described for the acute condition. bone configuration like the android
pelvis. In this situation there is the
Episiotomy tendency for the fetal head to push
Episiotomy is an incisionmade inthe perineum back on the perineum for enough
to enlarge the introitus when the baby is about space. Timely episiotomy may
to be delivered. prevent a severe laceration.

Indications Technique
Some form of anaesthesia sould be used. Local
Episiotomy is often performed: infiltration with about 10 ml of 0.5 -1 %
i. When there is fetal distress and the xylocaine will suffice. There are three types of
presenting part is already on the incisionthat may be used: the medio-lateral, the
perineum. An episiotomy will thus median and the lateral. Of these, the medio-
facilitate rapid delivery with the lateral appears to be the most popular because it
forceps or ventuose. is less likely to extend down the middle of the
ii. -In most cases of forceps or ventuose perineum. The lateral is off the thrust of the
delivery. presenting part and does not always prevent a
iii. When the perineum is very stretched and perineal laceration. Besides, it heals badly. The
about to tear during normal median is the most anatomically correct, but
delivery. tends to extend down into the perineum,
iv. To assist with breech delivery. Here causing severe perineal lacerations whenever
the perineum does not have the time extra pressure occurs during procedures. The
to stretch, as with cephalic medio-lateral is an oblique incision starting
presentation, and runs a risk of from the midpoint of the fourchette and carried
tearing. downward in the direction of the lateral margin
v. Inoccipitoposterior position of the of the anal sphincter. It has the advantage that in
head. the event of an extension, this iswell away from
vi. During the delivery of preterm the perineal body and anus.
babies, to reduce pressure on the
tender skull and hopefully avoid The repair of episiotomy is as described for
intracranial injury. second degree perineal tear.
vii. To avoid injury to scar tissues and
avoid jagged lacerations and The complications of episiotomy include
possible recurrence in mothers who haemorrhage and infection. Haemorrhage can
had previously beentreated for third be avoided by repairing the incision as soon as
degree perineal tears, stress possible after delivery. Infectionusually occurs
incontinence, prolapse and low when there is delay in repair. This situation is
vesicovaginal fistula. common with deliveries inhealth centres that
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fr 4S0 Obstetrics and Gynaecology'

are far from secondary health facilities. Bibliography and suggested further
Where infection supervenes, repair should be reading
deferred untilthe sepsis has settled, usually on
antibiotics. This may mean waiting for some Donald I (1979), Practical Obstetric ProblemsA ed.
days. LloydLuke Ltd, London.

Signorello LB, Harlow BL, ChekosAK, Repke JT (2000)

Midline episiotomy andanal incontinence: retrospective
cohort study.BMJ, 320: 86 - 90.

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Chapter 59

Postpartum haemorrhage

Definition sustained uterine contraction during the

third stage of labour. Delayed or incomplete
Postpartum haemorrhage (PPH) is said to occur expulsion of placenta and membranes.
if bleeding of 500ml or more ensues from the
birth canal after complete delivery of the baby Injury to the genital tract
or the resultant bleeding compromises the 2.
clinical condition of the parturient. The second
3. Failure of normal blood coagulation
segment of this definition is especially
important in certain circumstances where blood
Uterine atony
loss of more or less than 500ml is more
This is the commonest cause of primary
applicable because of the resultant compromise
postpartum haemorrhage and accounts for
of the patient's clinical condition. Such include:
about 66% of postpartum haemorrhage in this
patients who are heavy inweight andhave more country and up to 80% in most developed
blood volume, whose system can cope with countries. Here, there is an inefficient uterine
more blood loss than their average weighted contraction following the delivery of the
counterparts and women with contracted blood placenta. This results in unremitting bleeding
volume, as in pre-eclampsia and dehydration into the uterus from open blood vessels at the
and women with low haemoglobin status, as in placental site. Several predisposing factors and
anaemia and sickle cell disease whose status clinical conditions have been associated with
will be disturbed by less blood loss. Postpartum this situation. A preceding excessive uterine
haemorrhage is one of the commonest causes of distension such as in multiple gestation or
maternal deaths in the world. This is especially polyhydramnios or macrosomic baby is an
so in less developed countries where lack of obvious example. Prolonged labour, in excess
delivery facilities and poor health status of of 14 hours and precipitate labour of less than
women prevail. Postpartum haemorrhage is an three hours also predispose to postpartum
important obstetric emergency and demands haemorrhage. Use of some valuable drugs in
prompt diagnosis and treatment. There are two obstetrics may also predispose to postpartum
haemorrhage. These include: magnesium
categories of postpartum haemorrhage;
primary, if it occurs within 24 hours of delivery; sulphate used for management of pre¬
eclampsia/ eclampsia; anaesthetics like
and secondary if bleeding in excess of normal
halothane, chloroform or ether and beta-
lochia occurs after 24 hours of delivery but sympathomimetic drugs used for uterine
before the end of the puerperium. relaxation. Existence of uterine fibroids,
submucous or intramural, a preceding abruptio
Primary postpartum haemorrhage placentae or placenta praevia will predispose to
This is by far the more frequently encountered postpartum haemorrhage. Multiparity and a
and the most severe inconsequences. Its causes previous history of postpartum haemorrhage
can be due to: may predispose to postpartum haemorrhage.
1. Uterine atony: failure of prompt and Poor management of the third stage of labour is a

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4S2 Obstetrics and Gynaecology

common cause of retained placenta, which or absent endometrial basalis. The

causes postpartum haemorrhage. Poor uterine detection of abnormal placental adherence
contraction may also result from retained is usually unpredictable, presenting
pieces of placenta, retained cotyledon, initially simply as retained placenta that
membranes or a succenturiate lobe. Morbid resists simple techniques to deliver.
adherence or excessive adherence of the Presence of surgical scars on the uterus
such as from previous caesarean deliveries,
placenta to the uterine decidua or myometrium
myomectomy, metroplasty, is also
cancause postpartum haemorrhage.
associated with increased tendency to
RetainedPlacenta: Complete separation and retained placenta and postpartum
expulsion of the placenta and membranes haemorrhage.
from the uterus within 3 0 minutes of delivery
of the baby is consistent with a normal third 2. Injury to the genital tract
stage of labour. Non-realisation of this This is the second common cause of
constitutes the clinical condition "retained primary postpartum haemorrhage. In this
placenta" which could be a result of non- country it accounts for about 32% of the
separation of the placenta, partial or causes of postpartum haemorrhage. Injury
to the birth canal can take the form of
complete placental separation and non-
expulsion; or separated and expelled laceration of the vulva, perineum, vagina,
placenta with retained pieces. Retained
cervix or uterus (uterine rupture). It may
also take the fonn of a hacmatoma, where
placenta complicates about 0.8 -1.2% of
the injury involves the rupture of blood
births worldwide. Poor management of third
vessels with resultant concealment of the
stage of labour is the most frequent cause of
haemorrhage. This may be haematoma of
retained placenta. This may be the result of
the vulva (bulges from the vulva), the
(1) fiddling with the uterus before placental
vagina (protrudes into the vagina) and the
separation is evident by vaginal bleeding retroperitoneum (bulges into the pelvic
during expectant care of the third stage of peritoneum). Bleeding may also result from
labour; (2) use of pressure on the uterus (3) unsutured episiotomy. These injuries are
tugging at the cord before placental predisposed to by primigravidity, previous
separation or excessive traction on the cord. genital tract injuries or surgeries and
Placenta accreta: Morbid or excessive precipitate, manipulative or operative
adherence of the placenta to the uterine deliveries.
decidua or myometrium could be
3. Failure of normal blood coagulation
responsible for retained placenta. Placenta
Coagulation failure as a cause of postpartum
may be unduly adherent when it is called haemorrhage accounts for about 2% of causes
placenta accreta. Placenta may invade the of postpartum haemorrhage in this country.
myometrium when it is called placenta Coagulation plays a vital role in the prevention
increta. The placenta may perforate the uterus of haemorrhage during normal delivery.
when it is called placenta percreta. The cause Immediately after the placenta site vessels are
of these conditions remains unclear but shut by the uterine contraction that
previous endometrial infection, or surgical accompanies placental detachment and
denudation is suspected to predispose to a thin expulsion, the tissue thromboplastin initiates
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Postpartum haemorrhage 483

blood clot formation that eventually plugs them females. Typically it is detected in i.Tr .;s
and prevents haemorrhage. There are, however, _\leu women at delivery, when it
abnormal clinical situations where this iria.'nlv:st> Wj'i prolongedhieedingtime
haemostatic mechanism is deranged and .!:.<(./. i, ...;. V.i activity, decreased
haemorrhage becomes inevitable. Such lavtoi Vlll rekiL-u anhAii and decreased
disturbances could be in form of consumptive \b;:\Vi:!cbiv;i;d" ;.Ur.r
coagulopathy, pharmacological inhibition of
coagulation or congenital deficiency of clotting Other causes ot postpartum haemorrhage
factors. The increased consumption of normal Inversion of the uterus
blood clotting factors, which complicates Inversion of (he uterus is a * ui'Jition thai
abruptio placentae, pre-eclapmsia/eclampsia, involve U-'. i..-k:-,...;i"i ..A ... '
prolonged retention of dead fetus and amniotic uterus into iLs eaviiy It u\u,\L\Avii'p..\ ate. a
fluid embolism ar; issociated with coagulation fundally inserted !)lAr:;n:.a v.hich may "x:
failure andpostpartum haemorrhage. The high partially or non-scpaniuu at Uie ,iniL r!' the
tissue phospholipids associated with these incident. Inversion of the uterus complicates an
disorders activate the clotting mechanism on a estimated 1 in 2,000 deliveries. It can manifest
in an acute or subacute manner. The former
large scale, leading to massive consumption of
presents with haemorrhage and pelvic pains and
the clotting factors. A simultaneous activation occasionally shock. Physical examination of
of the degradation of the formed clots results in the uterus often reveals a uterine size that is less
the circulation of fibrin degradation products than expected and replacement of the usual
(FDP), which worsens the bleeding by globular uterus by a depression. When
impairing normal platelet function and clot ultrasonography is available the diagnosis is
formation. The most useful clinical means of readily confirmed as a telescoping of
determining the severity of disseminated intra¬ the uterine fundus into the cavity. The inversion
vascular coagulation (DIC) include the serum is described as incomplete if the fundus is
platelet count and fibrinogen level. Patients simply depressed into the cavity and complete,
with any of the earlier stated disorders should id! le ct n-pus passes through the cervix. In a
always have their clotting profile monitored as suhacutc varici\, the entire uterus becomes
well as receive prophylaxis against postpartum turned inside out and contracted. Unnecessary
haemorrhage. Anti-coagulants such as heparin application of fundal pressure or traction on the
cord during (he third stage of labour in order to
and warfarin could be indicated in treating
deliver (he placenta, is considered to predispose
pregnancies complicated by severe sickle cell
to this condition.
disease or deep vein thrombosis. In
circumstances where the dosage is excessive or Its management involves icsu::/!( inonoT
there is lateness in the reversal of their effects, the patient and inunuJiuv: ijstoiaumi w 'lie
haemorrhage will complicate childbirth. The uterine anatomy by himimual i.iaiii'nil.ttioM
use of dextran infusion also calls for caution, as using a tocolyuc or unJcr genera! Ajae.viiesia.
it is capable of provoking postpartum The placenta is delivered alter the uterus has
haemorrhage. Von Willebrands disease is nn beenrestorcd.Occa.vonaSSy.a.-iin:i' ! \ .:Av.
autosomal dominant inherited disease that is atlaparotor:\:i A !. iiV: ;. y usually administered
capable of causing haemorrhage in males and io sustain th'j rcsioredm-;: iue form.
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484 Obstetrics and Gynaecology

Amniotic fluid embolism over 1500ml. The knowledge of these estimates

This is one of the most fatal disorders of is valuable in prognosticating and
pregnancy. It is fortunately rare complicating 1 characterising the resuscitation of the patient.
in 30,000 deliveries. Its occurrence has been On account of the emergency nature of
associated with labours that involve postpartum haemorrhage and the fact that its
polyhydramnios, intrauterine fetal death, cause isbest determined by exclusion, it isusual
chorioamnionitis, and multiparity. Amniotic to adopt a flow chart approach (Fig. 59. 1) for its
fluid, including fetal squames and lanugo hair, management. This affords a step-ladder process
escape from within the amniotic cavity into the that integrates investigations, treatment and
venous channels of the uterus and are conveyed monitoring of the patient, with minimal loss of
through the right cardiac chambers to the time. Uponsuspicion of excessive bleeding in a
pulmonary arteries, where they impact and patient in the third stage of labour, it is
cause pulmonary hypertension. Consequently advocated that the uterine cornua be massaged
this syndrome manifests with respiratory in order to stimulate an efficient contraction.
distress, central cyanosis, cardiovascular The urinary bladder should be emptied by
collapse, haemorrhage and a rapiddevelopment voiding or catheterisation.
of coma. Disseminated intravascular Further bleeding will necessitate a blood cross¬
coagulation is a usual complication of this match, verification of the clotting profile and
disorder. The fatality associated with this commencement of intravenous infusion. An
disorder is over 50% hence the need for oxytocic is also administered intravenously, if
immediate institution of intensive care on any this had not been given earlier, otherwise it
patient who is suspected to have it. This care should be repeated. At this stage, if the placenta
includes: maintenance of the airway by has not been delivered, a controlled cord
endotracheal intubationand careful monitoring traction should be performed to do so, failing
of intravenous fluid therapy by central venous which a manual removal should be instituted
pressure (CVP) monitoring. The use of under general anaesthesia. Accumulated
inotropic drugs and vasopressor agents has evidence now suggests that injection of 0.9%
been found to be beneficial. The development saline solution plus oxytocin into the umbilical
of disseminated intravascular coagulation will vein of a retained placenta is a more effective,
necessitate the transfusion of whole blood and safer and simpler means of treatment than the
fresh frozen plasma. manual removal. Where the placenta has been
previously delivered, it should be carefully
Management of primary postpartum inspected for completeness. In the event of an
haemorrhage uncertainty of the completeness of the placenta
It is often difficult to accurately quantify blood loss an ultrasound scan may be performed to detect
at childbirth. Most midwives rely on their residual placental tissue, which will necessitate
experiences to make estimates. The clinical features a uterine evacuation. Persistence of bleeding
exhibited by a patient are useful indicators of the will require the attention of an obstetrician who
volume of blood loss at this time. In normal is expected to examine for and repair any
parturients, blood loss of less than 1000 ml rarely genital tract laceration. The suspicion of rupture
alters the patient's vital signs. On the other hand, a of the uterus will indicate a laparotomy. The
patient in circulatory shock would have already lost persistence of bleeding at this stage shouldbe
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Postpartum haemorrhage 485

Excessive bleeding

Massage uterus / Empty bladder

Still bleeding

Retained placenta
Placenta delivered

C.C.T. / Manual removal

Complete Uncertain

Examine for genital trauma USS

Repeat clotting profile, ultrasonograpy

Evacuation
Repair

Coagulation failure Normal Coagulation

Fresh frozen plasma or cryoprecipiate Laparotomy

Ligation of ascending uterine artery Ligation of internal iliac artery Hysterectomy

Fig 59. 1 Flow chart for the management of postpartum haemorrhage

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486 Obstetrics andGynaecology

managed with a bimanual compression of the Adherence 10 partographic ideals in the care of
uterus while oxygen is administered and the first stage of labour serves to prevent
prosuidandin F2a is injected into the uterine prolonged labour, a predisposing factor to
fundus. The clotting profile should be repeated postpartum haemorrhage. The use of
at this stage, in the absence of a coagulopathy a episiolomy or resort to instrumental delivery
laparotomy should he performed, at which should be only when indicated. Recent analysis
ligation of the ascending branches of the uterine of accumulated evidences suggests that active
arteries or the hypogustric artery or a management of third stage of labour is superior
hysterectomy may he performed. If to "expectant management" in terms of blood
disseminated intravascular coagulation is loss, postpartum haemorrhage and other serious
confirmed a haematologist will have to be complications of the third stage of labour and is
involved and the transfusion of fresh frozen recommended for use on all women expecting
plasma or cryoprecipitate and fibrinogen to deliver in a maternity hospital. Active
shouldbe given . management involves administration of a
prophylactic oxytocic before delivery of the
Prevention of Primary postpartum placenta, curly cord clamping and controlled
haemorrhage cord traction of the umbilical cord.
Syntometrine (combination of syntocinon and
The adage, prevention is better man cure, finds
ready application in postpartum haemorrhage. ergometrine) is the most preferred oxytocic for
The institution of preventive measures on this purpose because it has been shown to be
patients who are prone to developing this associated with reduced risk of postpartum
disorder has been one of the major haemorrhage when compared to oxytocin use
achievements of modem midwifery, It draws its alone. Syntometrine is also associated with less
strength from patient's attendance to prenatal side effects of vomiting and hypertension,
care where risks of developing postpartum which accompany ergometrine use. Expectant
haemorrhage are determined from the past and management of the third stage of labour
present obstetric history and the characteristics involves allowing the placenta to deliver
of the current pregnancy. These considerations spontaneously or aiding by gravity or nipple
include high parity, previous haemorrhage, stimulation. A thorough inspection of the
existing anaemia, multiple gestation, placenta and membranes, usually held under
polyhydramnios, and placenta praevia. running water, ss very valuable for the earliest
The prevention process starts with diagnosis of retained placenta! tissue. Prompt
risk identification and proceeds to patient and skillful repair of episiotomies is always
counselling, blood group determination,
protective against postpartum haemorrhage.
correction of anemia before onset of labour,
The strict observance of maternal rest in the
and patient's assessment at 36 weeks of
fourth stage of labour, coupled with close
gestation to determine the best mode of
delivery. The process continues inlabour with its monitoring of her vital signs and sanitaiy pad
supervision being made by a skilled attendant count during the period is reassuring and
(doctor, midwife or muse), early presentation in proraotive of early detection of a haemorrhage.
labour, request for a blood cross-match, and an Another preventive measure against postpartum
intravenous infusion inthe first stage of labour. ihaemorrhage is the continuation of syntocinon
infusion throughout the fourth static of labour.

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Postpartum haemorrhage 487

Secondary postpartum haemorrhage of maternal death especially in the developing

A secondary postpartum haemorrhage is said m countries. For each patient that dies from this
occur when there is vaginal bleeding in excess disorder, .scores of others survive but with
of expected lochia, after 24 hours but within 42 various complications. One of the most dreaded
days of delivery. complications of postpartum haemorrhage is
For the first few days following
circulatory shock. Blood loss exceeding about
1500 ml predisposes to this and a failure to
childbirth, (here is a rapid diminution of vaginal
bleeding in quantity and colour. By the fourth
promptly address further bleeding and correct
the fluid deficit with fluid infusion and blood
day, this lochia rubra (red lochia) transits into
transfusions readily cause a chain of
the serosa (pink lochia). The latter usually lasts
complications. The development of a
for between two and three weeks after, which it
cardiopulmonary failure rapidly leads to
changes to iochia alba (white lochia).
maternal death. In less dramatic situations
Any bleeding in excess of this pattern is
impaired vascularity of the kidneys may result
regarded with suspicion and should be in acute renal failure which manifests with
investigated for retained placental tissues, oliguria or anuria
endometritis or secondary bleeding from a Immediate resuscitation the patient may
recent surgical wound (caesarean section scar), be sufficient to restore function, failing which,
or submucous leiomyoma. administered of high doses of frusemide may
Additional clinical features of uterine have to be administered. Poor response to these
sub-involution or sepsis are helpful in making measures will necessitate the use of dialysis. A
these distinctions. Very rarely secondary severe hypotension can result in impairment of
haemorrhage may be due to the development of the vuseuiarity of the pituitary gland and its
choriocarcinoma following normal delivery. consequent necrosis. This is Sheehan's
Ultrasonography, where available, serves syndrome, which could manifest in the
as a valuable investigatingtool. puerocrium with poor lactation and
Treatment of secondary postpartum subsequently with nmenorrhoca and infertility.
haemorrhage calls for resuscitation of the In severe cases the production and effects of
patient while specific treatment depends on the other nkrJi.ary hormones may be impaired. The
cause. The presence of retained placental tissue management of this disorder is by replacement
will require a uterine evacuation, which can be therapy with each of the deficient hormones.
performed by Manual vacuum aspiration (M Postpartum haemorrhage caused by retained
VA) or blunt uterine curettage with sponge placental tissue or which necessitates surgical
holding forceps under anaesthesia. Uterine Intervention to treat, may be complicated by
curettings should always be sent for genital tract infections including endometritis,
histological examination to exclude pelvic inflammatory disease andtheir sequelae.
choriocarcinoma. Endometritis should he Resuscitation and parenteral
heated with appropriate antibiotics. Oxytocics administration of appropriate antibiotics ,are
are also useful in checking further bleeding needed to containthese.
once the primary cause has beenaddressed. It is pertinent to not that the inappropriate use
of the sharp uterine curette to treat retained
Complications of postpartum haemorrhage placental tissue could result in the immediate
Postpartum haemorrhage remains a leadingcause of uterine perforation or subsequently.
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m 488 Obstetrics and Gynaecology

uterine synechiae or adhesions (Asherman's The Prevention and Management of Postpartum

Haemorrhage: Report of a technical working group.
syndrome), which manifest as Geneva (1989). WHO/MCH/90.7
hypomenorrhoea, amenorrhoea, or
successive pregnancy wastages. The Prendiville WJ, Elboume D; Macdonald S. Active
existence is usually confirmed at versus expectant management in the third stage of
hysterography or hysteroscopy and is labour (Cochrane review) In: The Cochrane Library
Issue 4 (2000), Oxford; Update Software.
treated by adhesiolysis at hysteroscopy.
Thereafter, oestrogen therapy is given to Carroli G, Bergel E. Umbilical Vein injection for
restore endometrial capacity of the uterus. Management of Retained Placenta (Cochrane
review) In: The Cochrane library Issue 4, (2000),
Oxford; Update software.
Bibliography and suggested
Metin Gulmezoglu A; Jose Villar eds. (2001). The
further reading WHO Reproductive Health Library No.4. Software
W.H.O. Geneva.
Benedetti T.J. (1991) Obstetric Haemorrhage. In:
Obstetrics Normal and problem Pregnancies Gabbe,
S.G, Niebyl J., Sampson, J.L.: Eds. Churchill livingstone
Publishers,New York, 573-605.

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Chapter 60

Instrumental delivery
It is defined as vaginal childbirth with the aid of pelvic curve. The shank connects the blade to
mechanical devices. The use of mechanical the handle. A lock is situated on it which helps
devices in achieving vaginal delivery of the in holding the two halves together. The handle
fetus has remained an important aspect of the is that part of the instrument which is grasped
obstetrician's duties. The frequency of use of by the accoucheur and depending on the type of
instruments to assist vaginal delivery varies forceps, itmay have a serrated surface, grooves,
from country to country, and within country, or finger lugs.
varies from one obstetric unit to another. In our Forceps can be grouped into two depending
unit at the Jos University Teaching Hospital, it on whether they are used for traction or
constitutes about 7% of deliveries. Worldwide, rotation.The Neville Barnes forceps is atypical
it varies from 2% to 15%. These varying rates
example of a traction forceps while Kielland's
are related to the different ways labour is
forceps is that of rotation.
managed inthe obstetric units. For example, the
Forceps designed for rotation of the fetal
use of active management of second stage with
head such as Kielland's forceps are
syntocinon can reduce the rate of instrumental
delivery. characterised by the absence of a pelvic curve.
In this chapter, three types of instrumental Fig 60. 1shows the different types of forceps.
delivery will be discussed viz. (i) Forceps (ii)
Ventouse and (iii) Destructive.

Forceps delivery
The obstetric forceps is a tool designed to
provide traction, rotation or both to the fetal
head when the unaided expulsive efforts of the
mother cannot or are insufficient to accomplish
vaginaldelivery.
The first forceps was designed and used by
the Chamberlen family in the 17th century in
England.
Design of obstetric forceps
The obstetric forceps has two blades, which are Figure 60.1 Shows the different types of forceps
introduced separately into the vagina. Each half of FromL-R.(Wrigleys, Neville-Barries, Kieliands's)
the forceps consists of three component parts viz. (i)
the blades (ii) the shank and lock and (iii) the Forceps operations may be classified according
handle. The blades are designed to encase the fetal to the stationand positionof the fetal headat the
head and to lie within the pelvic cavity. They are time the forceps is applied.
therefore, fenestrated andconsist of a cephalic and

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490 Obstetrics midGynaecology

High forceps: Inthis application, the fetal head (5) Adequate analgesia shouldbe provided.
is not engaged and the vertex is above the level Outlet forceps can be performed under
of the ischial spines. 'I 'here is noplace for such pudendal nerve block and local
application inmodemobstetric practice. infiltration. Rotation with Kielland's
forceps requires epidural or spinal
Mid-forceps: The fetal head is in the mid- anaesthesia.
cavity with the vertex at or near the level of the (6) Uterine contractions must be present.
ischial spines. Rotation may be required in Uterine atony in second stage in the
some cases. absence of disproportion, should be
Low forceps: The head is at or near the pelvic treated with syntocinon before forceps
floor. It is visible at the introitus although delivery. This avoids immediate
perineal distension does not occur with postpartum haemorrhage if forceps
contractions. delivery is done in the presence of
uterine atony.
Outlet forceps: The vertex has reached the (7) Episiotomy is necessary.
pelvic floor- the sugittal suture is in the
anteroposterior diameter. Only maternal soft Indications for forceps delivery
tissues and possibly the coccyx ;ire impeding
the delivery of the head. The indications for forceps delivery may be
classified as maternal or fetal.
Conditions for forceps delivery
Maternal: The commonest maternal indication
To embark on forceps delivery, the is a delay in the second stage of labour due to
following conditions must be fulfilled: either abnormal uterine action or failure of the
fetal head to rotate adequately. Maternal
( 1) The bladder must be empty. It is routine obstetric (pre-eclampsia and eclampsia), and;
to drain the bladder by catheterisation medical (cardiac and pulmonary diseases),
before a forceps delivery isdone. conditions in which strenuous pushing in the
(2 The cervix must be fully dilated. second stage of labour is hazardous to the
(3) The membranes must be ruptured. The mother, arc indications for forceps delivery.
presence of intact membranes may
retard the descent of the presenting part. Fetal: Fetaldistress is a common indication for
Rupture of membranes sometimes forceps delivery. Also, forceps isusedto control
removes the indication for the forceps the delivery of the after-coming head in a
delivery. vaginal breech delivery and to assist in the
(4) Delivery must be mechanically feasible. delivery of the fetal head at caesarean section.
This should be done by a careful
assessment of the level of the presenting Complications of forceps delivery
part, absence or presence of molding
and adequacy of the pelvis. The fetal The complications of forceps delivery may be
head must be engaged. The station and maternal or fetal.
position or the head must he Maternal: Forcible rotation or traction may cause
determined. damage to maternal soft tissues. The damage ranges
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Postpartum haemorrhage 491

from abrasions to severe lacerations of the birth canal. This is timed with uterine
uterus, cervix, vagina and perineum. contractions. If the baby is not delivered with
Vesicovaginal and rectovaginal fistulae may three pulls within twenty minutes, the
also develop.
procedure shouldbe abandoned.
Fetal: Improper application of the forceps may
result in bruising of the face of the fetus while
excessive force at rotation and traction may
cause injury to fetal scalp, cranium or
underlying brain resulting in
cephalhaematoma, scalp lacerations, skull
fractures and intracranial haemorrhage.
Neonatal jaundice could arise from the
breakdown of blood trapped in
cephalhaematoma.

Ventouse delivery

The ventouse or vacuum extractor is an

instrument that employs a suction cup applied
to the fetal head to produce traction which aids
the maternal expulsive effort to effect vaginal Figure 60.2 Ventouse extractor
delivery. James Yonge, a Royal Navy surgeon
devised the earliest vacuum extractor in 1705. Conditionsfor ventouse delivery
His attempt at delivering a primigravida ended
in failure. James Young Simpson developed the The requirements for ventouse delivery are the
first device that proved useful. The apparatus same as those for forceps delivery with the
consists of the following: cup, rubber tube, following exceptions:
pump, vacuum bottle and traction chain (Fig
(1) The cervix need not be fully dilated as
60.2).
The cup is applied to the scalp and air is for forceps delivery. A minimum of 8cm
sucked out by means of the pump and rubber cervical dilatation is acceptable for
tube. A vacuum is created which the fetal scalp, ventouse delivery. Here, small suction
forming a "chignon" quickly fills. The air that cups are used.
has been sucked out from the cup passes The ventouse cup does not occupy space
(2)
through a vacuum bottle which has two uses adjacent to the fetal head, and
viz. (i) it has graduations inkg/cm2 from which
the level of vacuum can be estimated and (ii) episiotomy is less often necessary when
any fluids or secretions along with air are comparedwith forceps delivery.
deposited here. This protects the pumping (3) Analgesia is not oftenrequired.
system. The cup should be applied to the
posterior fontanelle or as close to it as possible. Indications for ventouse delivery
A pressure of not more than 0.8 kg/cm2 is
produced. A perpendicular traction force is The indications for vcuiouse delivery are similar to
applied to the cup in the direction of the
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492 Obstetrics and Gynaecology

those for forceps delivery. The ventouse in (6) It requires less training.
Disadvantages of the ventouse over forceps delivery
addition may be used in delivery for fetal
distress in first stage of labour. The ventouse (1) It usually takes longer to assemble and
must not be used for delivery of fetuses apply.
presenting by the face or breech. (2) It requires maintenance and careful
handling.
Contraindications to ventouse delivery
(3) It is less portable.
(1) The ventouse is contraindicated in
In many countries, the ventouse has
preterm delivery since the fetal head
and scalp are prone to injury from the virtually replaced forceps in instrumental
suction cup. vaginal delivery. Despite this, their use should
(2) The ventouse must not be used in face be seen as complementing eachother.
and breechpresentations. Destructive operations
(3) The ventouse must not be used on the
fetal scalp where active bleeding has A destructive operation is defined as a surgical
complicated a fetal blood sampling site. procedure performed on a dead fetus in order to
allow vaginal delivery. Prolonged obstructed
Complications of ventouse delivery labour is still prevalent in many developing
countries. Fetal death usually occurs while
(1) Vaginal lacerations resulting from
maternal dehydration and sepsis complicate
entrapment of the vaginal mucosa
prolonged obstructedlabour. As a result of these
between the suction cup and the fetal
head.
complications, and because caesarean
(2) Fetal scalp injuries including
deliveries are culturally unacceptable,
destructive operations become imperative.
subaponeurotic haemorrhage and scalp
laceration may occur as a result of Conditions for destructive operations
prolongeduse of the ventouse.
(3) Inadvertent application of the suction (1) The fetus must be dead.
cup to face presentation may result in (2) The bladder should be empty
serious eye damage. (3) The cervix should be fully dilated
(4) The patient should be fully resuscitated
Advantages of ventouse over forceps delivery (5) Anaesthesia is required
(6) Uterine rupture must be excluded
(1) The ventouse is easier to apply. (7) The operator must be skilled in its
(2) It occupies less space in the pelvis performance
(3) It encourages autorotation in
malpositions of the fetal head. This is Types of destructive operations
usually achieved by correct placement
of the suction cup in the midline close The common types of destructive operations include
to the posterior fontanelle. (i) Craniotomy (ii) Decapitation (iii) Cleidotomy
(4) It requires little or no analgesia. and (iv) Embryotomy.
(5) It is safer for both mother and fetus.
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Postpartumhaemorrhage 493

(i) Craniotomy obstruction due to an impacted transverse lie

with or without a prolapsed arm. In this
This refers to the operation where a hole is
operation, the neck of the fetus is cut through
created in the presenting fetal head allowing with a special saw and the fetal headand rest of
cranial contents to be extruded with subsequent the fetal body are delivered separately. The
collapse of the fetal head. This reduces the popular instrument used in this operation is the
diameter of the fetal head and the fetus is then Blond-Heidler Saw and thimble. Embryotomy
delivered by traction of the collapsed head. scissors can also be used in the operation. The
Craniotomy is indicated when there is operation of decapitation can be very tricky and
obstruction in a cephalic presentation or after requires a skilled operator.
coming head in a breech presentation. It is
important that the presenting part (fetal head) is (iii) Cleidotomy
fixed and reasonably accessible to allow for a This operation is indicated when there is
safe craniotomy. The instrument commonly impaction of the fetal shoulders. Cleidotomy
used for the operation is the Simpson's refers to the operation in which the size of the
perforator. It is used for perforation while shoulder girdles is reduced by cutting the
Morris' bone holding forceps, vulsella, or clavicles with a pair of stout scissors.
Kocher's forceps are used for traction of the
collapsed fetal head (Fig60.3). (iv) Embryotomy
Craniotomy is the commonest destructive This operation isdone usually as a complement
operation performed in our obstetric unit at Jos to craniotomy and cleidotomy when the fetus is
UniversityTeaching Hospital. large. In this operation, incisions are made into
the thorax or abdomen of the fetus to empty the
contents andreducethe size of the fetus to allow
delivery.

Complications

The instruments used in these operations are

dangerous in the hands of unskilled operators.
Postpartum haemorrhage is common after
destructive operations. This usually is due to
injury to the genital tract during these
operations. Lacerations of the cervix, vagina
Figure 603 Instrumentsfor destructive operations FromL-R.
and perineum are common and rupture of the
(Embryotomy hook, Embryotomy hook, Cranioclast, uterus can occur. Injuries to the bladder
Embryotomy scissors, Simpson's perforator) anteriorly and rectum posteriorly are common
and may be complicated later by vesicovaginal
(ii) Decapitation
and rectovaginal fistulae.
This operation is commonly performed for reliefof Complications can be reduced by careful
selection of cases and performance of these
operations by skilled operators.
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494 Obstetrics andGynaecology

Bibliography and suggested further

reading
Giwa-Osagie O., Azzan B. (1987): Destructive
Operations. In Progress in Obstetrics and Gynaecology. Livingstone Vol. 18.
StuddJed. ChurchillLivingstone Vol. 16pp.211-221.
OGrady J, Gimorsky M. (1993). Instrumentaldelivery.A
Turnbull A, Chamberlain G (1989). Forceps delivery/ lost art? In Progress in Obstetrics and Gynaecology.
VacuumExtractor. Obstetrics. ChurchillLivingstone. Studd J, ed. Churchill Livingstone.

Carter J. (1990). The vacuum extractor. In Progress in Akinkugbe A. (1996). Instrumentaldeliveries. Textbook
Obstetrics andGynaecology. Studd J, ed. Churchill ofObstetrics andGynaecolog. Evans Brothers Ltd.

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Chapter 61

Caesarean Section
This is an operation performed through the Indications
abdomen for delivery of the fetus. It involves
two incisions, one through the abdominal wall (a) Maternal-Feta!
and the other through the uterine wall. In Fetopelvic disproportion
rupture of the uterus following obstructed Failure to progress in labour
labour in the multigravida or in advanced
extrauterine pregnancy, the fetus already lies (B) Maternal
free in the abdominal cavity and its removal is Maternal disease
not covered by the definition above. Eclampsia/ pre-eclampsia
The origin of the term "caesarean Diabetes mellitus Cardiac disease
section" is uncertain. It may have been derived Cancer of cervix/ovaiy
from the Latinword Caedere, "to cut" although
it hasalso been suggested that it is derived from Previous uterine surgery
the "Lex caesarea", a decree which operated Previous classical caesarean section
during the reign of Julius Caesar. This decree Two previous lower segment
required that the fetus be removed from the caesarean sections
uterus of any woman dying during late Previous myomectomy
pregnancy, before burial of the mother. Previous uterine rupture
The operation is now widely performed Strassman's operation
inboth developing and developed countries. Its Cornual resection for ectopic gestation
safety has largely been due to improved
anaesthetic techniques and availability of Previous vaginal injuries/surgery
blood transfusion and antibiotics. The Vesicovaginal fistula Rectovaginal
incidence of caesarean section varies among fistula Acquired gynaetresia
countries and within a country, varies from
hospital to hospital. The high rate of caesarean Others:
section in the U.S.A. is related to the small Elderly primigravida
family size and probably the fear of medico¬ Long history of primary or secondary
legal repercussions if not performed. The high infertility
rate of caesarean section inthe tropics isrelated
to fetopelvic disproportion and obstructed (C) Fetal
labour. The teaching hospitals, for example in Fetal distress
Nigeria, have a (c) higher caesarean section Cord prolapse
rate because they serve as referral centres and Malpresentations - brow, transverse lie,
therefore have the high risk patients breech, face
concentrated in them. The rate in some of the Erythroblastosis fetalis
teaching hospitals is as high as 18 per cent.

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496 Obstetrics and Gynaecology

(d) Placenta! and oxytocin administered if necessary.

Placenta praevia Caesarean section is indicated in severe pre¬
Abruptio placentae eclampsia or eclampsia if the cervix is not ripe
or if there isdoubt about adequacy of the pelvis.
The indications for caesarean section have
Long inductions shouldbe abandoned in favour
continued to widen over the years. The of caesarean section.
operation is being increasingly performed for
failure to progress in labour and fetal distress.
Diabetes mellitus
with improvement in fetal monitoring
technique. Elective caesarean section is also The fetus in diabetic women is usually
performed for HIV infection inpregnancy. oversized and tends to die in utero before term.
Caesarean section may be indicated in these
Fetopelvic disproportion women to avoid traumatic delivery. Even in
well controlled diabetes, labour may sometimes
This is the commonest indication for be terminated by caesarean section in the
caesarean section in most hospitals inNigeria. interest of the fetus. Long inductions must be
Gross pelvic contraction or a large fetus, may avoided inthese patients.
result in fetopelvic disproportion requiring
caesarean section. Malpositions Cardiac disease
(occipitoposterior, mentoposterior) of the
fetal head, even in the presence of adequate Cardiac disease on its own is not an indication
pelvis may result indisproportion. for caesarean section but this operation is
indicated if other obstetric complications exist.
Failure to progress in labour
Gynaecological malignancy
In the presence of good uterine contractions Where carcinoma of the cervix or ovary is
and a cephalic presentation, the cervix is discovered during pregnancy, caesarean section
expected to dilate at a rate of 1cm per hour in should be performed and this should' be
the active phase of labour. With the use of the followed by appropriate treatment for the
partogram, a failure of the cervix to dilate over cancer. A classical uterine incision should be
a 4-hour period is considered a failure to performed to avoid cutting through the tumour
progress and is an indication for caesarean inthe cervix.
section. The active management of labour has
been accepted in principle in most labour Previous uterine surgery
wards in this country and more caesarean
sections are being done for failure to progress Certain operations of the uterus pose a problem
in labour. Failedinduction of labour is also an in subsequent pregnancies as these scars on the
indication for caesarean section. uterus weaken the uterine wall and predispose
the uterus to rupture. These operations include
Pre-eclampsia/eclampsia myomectomy especially if the uterine cavity
was entered during the operation, Strassman's
The aim is usually for vaginal delivery if other operations for congenital malformations of the
conditions are favourable. Amniotomy is performed uterus and cornual ectopic gestation.

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Caesarean Section 497

Previous vaginal injuries/surgery prolapses before the cervix is fully dilated.

One of the late complications of obstructed Breech presentation
labour is injury to the urinary tract from
pressure necrosis. This results in vesicovaginal Vaginal delivery should be tried only if the
and/or recto vaginal fistulae. If pregnancy pelvis is adequate and the estimated fetal
occurs before or after successful repair of these weight is average. Caesarean section is
fistulae, caesarean section should be performed indicated for fetuses less than 2.5kg or more
electively at termto deliver the baby. than 4kg and inborderline pelvis.
After a repair of ruptured uterus, bilateral
tubal ligation is usually performed. However, Malpresentations
in selected cases, subsequent pregnancy may be
allowed but the fetus should be delivered by Transverse lie, oblique lie, or brow
elective caesarean section near term. presentations may also cause disproportion.

Obstruction to birth canal Erythroblastosisfetalis

Tumours of the pelvis may also cause Although this condition is rare in Nigeria,
obstruction if not detected in early pregnancy. caesarean section is preferred to induction of
Ovarian tumours should be detected during labour where early delivery of the fetus is
pelvic examination at the booking clinic and indicated because of a high risk of intrauterine
removed in early pregnancy. Leiomyomata of fetal death ifpregnancy is allowed to continue.
the cervix should be detected and an elective
caesarean section planned at term. Antepartum haemorrhage

Other indications: Major types of placenta praevia should be

Not infrequently caesarean section is indicated delivered by caesarean section. In abruptio
for the following: placentae, caesarean section is indicated if the
(i) Elderly primigravida. fetus isalive and the cervix is not fully dilated.
(ii) Long history of primary or secondary
infertility. Types of caesarean section

Fetaldistress This operation may be performed as an

emergency procedure (the decision to perform
When fetal distress is diagnosed by the Pinard the operation is taken during labour) or as an
stethoscope or fetal monitor, before labour or elective procedure (the decision is taken before
during early 1st stage of labour, caesarean or during the pregnancy and operation planned
section is indicated. In the later part of the 1st for term or near term).
stage or in the 2nd stage of labour, a vacuum
extraction or forceps delivery should be Two types of caesarean sections are
performed. recognised based on the type of incisions
placed on the uterus (Fig61.1a);
Prolapse of the umbilical cord
Caesarean section is indicated ifthe umbilical cord (i) Lower segment caesarean section (here the
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498 Obstetrics and Gynaecology

uterine incision is transverse and made make and can sometimes be bloody. The
on the lower uterine segment). ÿ
subcutaneous tissue is dissected and the rectus
°4sheath is freed from the underlying muscles.
(ii) Classical caesarean section (here a Haemostasis is achieved by securing the
vertical incision is placed on the upper perforating branches of the inferior epigastric
uterine segment). vessels. It is important to ensure adequate
haemostasis at every step. The rectimuscles are
(i) Lower segment caesarean section: then, separated in the midline and then the
peritoneal cavity is opened. The Pfannenstiel
This isthe commonly performed procedure. incisionhas gained popularity over the past few
Compared to the classical variety, it involves years inthis country.
less blood loss, lower risk of infection, lower
risk of rupture in subsequent pregnancy and
also lower risk of postoperative peritoneal
adhesions. •

Classical
Technique

As part of the preoperative preparation, the

hair over the lower abdomen from the level of
the umbilicus to a level just below the mons Transverse
Lower Segment
pubis is cleanly shaved.
After administration of . appropriate
anaesthesia on the operating table, the operative Types of Caesarean Section
field is cleaned with antiseptic solution and then Figure 61.1a Types of caesarean section
covered with sterile drapings leaving only the
area where the abdominal incision is to be
made. Two types of abdominal incisions are in
commonuse (Fig 6 1.Ib ).
The midline,subumbilical, vertical incision
is quick to make and is less bloody. It is the
favoured incision in this country, and causes
less problems when repeat caesarean sections
are performed. The length of the incision would
depend on the estimated size of the fetus. The
abdominal cavity is entered by going through
the subcutaneous tissue, the rectus sheath and
the peritoneum. The other abdominal incision is
the transverse, suprapubic (Pfannenstiel) Figure 61. Ib Types of abdominal incisions
incision. This incisionhas a cosmetic advantage, (a) Midline subumbilical incision
probably healsbetter but is certainly not quick to (b) Transverse (pfannenstiel) incision
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Uterine incision 0.25mg of ergometrine intravenously with the

delivery of the head. After the delivery of the
Irrespective of the type of abdominal incision
baby, the umbilical cord is divided between
used, once the abdominal cavity is entered, the
clamps. Nextthe placenta is delivered manually
uterus is carefully palpated to determine its or carefully delivered if it is already separated
direction and degree of rotation. It is brought spontaneously. The placenta is inspected and
into the midline and each lateral peritoneal also the uterine cavity is cleaned out, with
gutter is packed with a moistened intra abdominal pack.
abdominal pack. This is to absorb amniotic fluid Closure of uterine incision: The upper and
and blood that will escape from the opened lower uterine flaps are picked up, with Green
uterus. A Doyen's retractor is inserted in the Armytage (haemostatic) forceps (Fig. 61.2d).
lower half of the incision and this retracts the The angles of the wound could be held with
bladder behind its lip and keeps the bladder Green-Armytage forceps if necessary. The
from trauma during subsequent procedures (Fig wound is closed in two layers using continuous
61.2a). The lower uterine segment is identified. 2 chromic catgut. The first layer, which is the
The serous coat of the anterior wall of the uterus inner halfof the uterine muscle layer, is sutured
continuously with chromic catgut, care being
is loosely applied over this area of the uterus,
taken to avoid the decidua. The second layer,
this loose peritoneum is continuous over the
which is the outer half of the uterine muscle
b)adder-(Fig. 61.2b). The loose peritoneum is layer is also sutured with continuous chromic
grasped with a pair of forceps and incised with a catgut. Where bleeding occurs after closure,
pair of scissors. It isthen incised transversely in figure of "8" or mattress sutures may be applied
a curved direction with the concavity towards to achieve haemostasis. The cut edges of the
the upper uterine segment (Fig. 61.2c). The peritoneum overlying the uterus andbladder are
Doyen's retractor is readjusted so that the lower sutured with a continuous 2/0 chromic catgut
flap of the loose peritoneum and the bladder are suture. The peritoneal cavity is then cleaned
heldbehindthe lip of the retractor. Using a clean carefully to remove blood, blood clots and
knife, a small transverse incisionis made in the amniotic fluid. Closure of abdominal wall: The
lower uterine segment in the midline. Care is peritoneum is closed with 2/0 chromic catgut.
taken to enter the uterine cavity without injuring The rectus sheath is closed with No. 1 chromic
the underlying fetus. This incision is then catgut. The fat layer usually does not need to be
extended laterally with scissors. The assistant sutured. In obese patients interrupted 2/0 plain
catgut is applied. The skin is closed with
must continue with suction inthe operative field
interrupted silk sutures or subcuticular vicryl or
as the fetal membranes are fncised if not already
nylon sutures.
ruptured. The retractor if, removed and the
operator slips his hand into the uterine cavity
betweenthe symphysis pubis and the fetal head Classical caesarean section
and the head is gently elevated with the fmgers
and palm through the incision. A Wrigley's The indications for this operation are few and
include: -
forceps may also be used to deliver the fetal head
at this stage. Theanaesthetist is requested to give 1. Situations where the lower segment cannot

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500 Obstetrics and Gynaecology

k tÿ.4

Fig. 61.2a Doyen retractor in place

Fig. 61.2d Upper and lower uterine flaps picked up with

Green armitage forceps.

be exposed or entered safely, as after

repeat caesarean section, where the
bladder is densely adherent to the scar; or
when the lower uterine segment wall is
riddled with fibroids and there isnowhere
to place the incisionor premature delivery
withpoorly formed lower segment.
2. Transverse lie of the fetus with
Fig. 61.2b Loose peritoneum over lowers segment membranes ruptured and shoulder
impacted.
3. Placenta praevia with large vessels in
the lower uterine segment
4. Carcinoma of the cervix
5. Postmortem caesarean section.

Technique
The abdominal incision and entry into the
peritoneal cavity is similar to that described
under lower segment caesarean section. Once
the peritoneal cavity is entered, the uterus is
brought to the centre, a Doyen's retractor is put,
in place and the lateral peritoneal gutters are
packed with abdominal packs. A vertical
incision is made in the upper uterine segment
using the scalpel. The incision is carried through
the myometrium until the uterine cavity is
Fig. 61.2c Loose peritoneum cut transversely entered, when the fetal membranes are

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Caesarian Section 561

seen to bulge. The vertical incision is then hysterectomy is similar to that described in most
extended with a pair of scissors. The gynaecological textbooks. Extra care must be
membranes are ruptured and the fetus taken to identify and avoid injury to the ureters.
delivered. Ergometrine is given and the
placenta is delivered as described under the Preoperative care for caesarean section
section on lower segment caesarean section.
The uterine wound is repaired in three layers. (i) Patient should have nothing by mouth
The inner third of the myometrial thickness, is for at least 8 hours before the operation.
sutured with chromic catgut excluding the In emergency cases, a nasogastric tube
.decidua. The middle and outer thirds of the may be passed to aspirate gastric contents.
myometrium are sutured with-chromic catgut, Magnesium trisilicate (15 ml) should
as the second and third layers, the bites taken on be given orally to neutralise acidity of
either side of the myometrium should be deep to gastric contents,
prevent the suture from tearing through the (ii) A haemoglobin or haematocrit value is
uterine wall. Once good approximation of the mandatory. A sickling test or preferably
wound is achieved, bleeding usually stops. The a haemoglobin genotype should be done.
peritoneal cavity is cleaned out and tubal Two units of cross-matched blood should
ligation is done. The operation is completed as be available,
described under the section on lower segment (iii) Foley catheter should be passed and left
caesarean section. in situ and urinalysis done.
(iv) The abdomen and perineum should be
Caesarean hysterectomy
Prepared.
The indications for this operation are few and (v) An intravenous system using a
include: cannula should be set up.
(i) Severe intrauterine infection (rare), (ii) (vi) Premedication with atropine 0.4mg is
Markedly hypotonic uterus that has optional.
failed to respond to oxytocics, (iii)
Placenta increta or percreta; placenta Postoperative care
accreta (occasionally), (iv) Ruptured (i) Patients should have nothing by mouth for
uterus following obstructed labour. the first 24 hours. Intravenous fluids should
be continued, giving 2,500 to 3000m 1 of
dextrose saline in 24 hours. If there is
Most of the caesarean hysterectomies done in preoperative dehydration, as in prolonged
this country havebeen for ruptured uterus. Total obstructed labour, electrolyte replacement
hysterectomy is preferable but subtotal should be guided by the results of urea and
hysterectomy is sometimes easier since careful electrolyte estimation. Early ambulation is
and extensive dissection is required to get encouraged.
below and remove the uterus and cervix. In (ii) The Foley catheter shouldbe removed within
some parts of developed countries, caesarean 24 hours of surgery unless after obstructed
hysterectomy is done for sterilisation. This iabour or surgical trauma to bladder.
seems only justifiable if carcinoma of the cervix (iii) Pain should be relieved as required.
or other pathology of the cervix provides an added
Pethidine lOOmg should be prescribed six
indication. The technique for subtotal or total hourly when necessary.
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502 Obstetrics and Gynaecology

(iv) Vital signs should be monitored lA hourly be drained continuously for 5-7 days
until stable, then 4 hourly. postoperatively to prevent fistula formation,
(v) Haemoglobin or haematocrit measurements should which is often preceded by haematuria.
be obtained on the second post operative day.
(vi) Prophylactic antibiotics are recommended (v) A long term complication is dehiscence or
in all patients in the developing countries. rupture of the uterine scar in subsequent
In developed countries, prophylactic delivery. Sepsis may prevent sound healing of
antibiotics shouldbe reserved for women at the scar and such a scar may not be able to
risk of infection, for example, those in withstand labour and may easily rupture.
prolonged labour or with premature
rupture of membranes. Repeat caesarean section
Complications of caesarean section The practice in Nigeria and the United
Kingdom is to perform a caesarean section
InNigeria,these complications are not different electively after two previous caesarean
from those encountered following any
sections. This is different from the attitude and
abdominal or pelvic surgery, and they include:
practice inthe USA. where the dictum is "Once
(i) Primary haemorrhage. This may be due to a caesarean section, always a caesarean section
poor haemostasis during operation. ". The small family size and the safety of the
operation in the developed countries may
(ii) Shock: Haemorrhage may lead to shock explain the attitude to previous caesarean
especially when the indication for caesarean sections inthe USA.
section is a major degree of placenta praevia. It Repeat caesarean section is almost required
may also follow haemorrhage resulting from if the indication for the previous operation was
incision of the lower uterine segment in the obstructed labour due to pelvic contraction.
presence of marked venous varicosity on the There was a history of a young woman in the
surface. labour ward inZaria, NorthernNigeriawho had
(iii) Sepsis: This is a common complication had a caesarean section performed on her for
especially when the operation is performed for obstructed labour at a tender age of 14 years.
prolonged or obstructed labour as seen in many She was now admitted in labour ward, in her
developing countries. Sometimes peritonitis second pregnancy at the age of 19 years. The
and paralytic ileus may result and a "suck and labour ward nurses were preparing for
drip"prophylactic measure is often advised caesarean section when she delivered vaginally
postoperatively. (baby weighed 3.5kg). The mother had grown.
So hadher pelvis!
(iv) Haematuria is not an uncommon complication Repeat caesarean section may be done as an
especially following caesarean section for elective procedure or as an emergency. In
obstructed labour. This is due to damage to the elective procedures, the operation is usually
bladder as a result of prolonged compression by the planned for any time after the 37th completed
fetal head. It is recommended that the bladder weeks of gestation preferably 38 weeks.
Determination of gestational age can be a
problem ifthe date of the last menstrual period
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Caesarean Section 503

is uncertain. This is a common problem in be carefully monitored and lower abdomen

Nigeria and in most developing countries. must be palpated for tenderness, (iv) fetal
The problem is further compounded in heart rate and maternal pulse must be
Nigeria where majority of the patients report carefully monitored, (v) second stage of
at the booking clinic in the second and third labour should be shortened by forceps if not
trimesters. Symphysis-fundal height may rapid enough.
help to determine maturity. Ultrasonography
if done before 30 weeks can be useful in the
Maternal and fetal mortality
determination of gestational age. Lung
maturity of the fetus can be determined by the Maternal mortality is usually due to the
foam test or lecithin sphingomyelin ratiodone indications for the caesarean section rather
on amniotic fluid obtained under ultrasound thanthe operation itself. The rate is lessthan 5
guide. per 1000 in Nigeria. A patient dehydrated and
infected from obstructed labour may survive
Subsequent vaginal delivery the operation and die a few days later from
septicaemia. Also a patient might inhale
Vaginal delivery can be permitted after a gastric contents during induction of
previous caesarean section if the indication anaesthesia and die later from aspiration
for the previous caesarean section is non¬ pneumonitis.
recurrent. One major consideration, in Fetal mortality is also usually related to
allowing such trials of scar ,is the integrity of the underlying reason for the caesarean
the previous uterine scar. Weakness in a section. Perinatal mortality varies from 45 to
previous uterine scar may be suspected if the 60 per 1000 in Nigeria and largely recorded
caesarean section was followed by puerperal after emergency caesarean sections. Maternal
sepsis especially uterine sepsis. This and fetal mortality are much lower in
information is usually available if a careful developed countries.
previous obstetric history is taken. In
pregnancy, these patients should be seen
regularly at the antenatal clinic and carefully Bibliography and suggested further
assessed. A clinical pelvimetry should
be done and followed by X-ray pelvimetry
reading
if necessary. If the pelvis is adequate and Donald, I. (1979): Practical Obstetric Problems. 5th ed.,
the fetus is of average size, labour can Lloyd-Luke Publishers London.
be allowed but the following conditions
should be met: (i) labour must be conducted Adeleye, J.A. (1980) Caesarean section in the University
ina unit with provisions for caesarean section College Hospital, Ibadan. Tropical J. Obst Gynae. 2,67

at short notice, (ii) blood must be

cross-matched and available, (iii) labour must

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Chapter 62

Abnormal puerperium
The puerperium, which begins from the time a practice of early patient discharge within 48
woman delivers the placenta andends six weeks hours of delivery and the liberal use of
after, represents a period of rapid physiological antibiotics with the earliest indications of
and psychological changes and may be
•
infection. Fever during labour is not uncommon
complicated by serious disorders. Where and is usually due to increased metabolism and
pregnancy and labour are complicated these associated dehydration. The fever often
usually predispose to complications in the subsides spontaneously a few hours after
puerperium. In developing countries, factors delivery. It should be noted, however that
such as illiteracy, poverty, and the paucity of infection could be present in the absence of a
health care facilities and personnel further rise in temperature. Whenever a fever occurs in
compound the problem. It has been shown that the puerperium, malaria should be considered
unbooked women form the bulk of the inendemic areas.
casualties as a result of puerperal complications Puerperal infections may arise in the
further buttressing the case for proper antenatal
genital, gastrointestinal, urinary and respiratory
care.
tracts and the breast.
The common complications of the
puerperium include puerperal infections,
breast, thromboembolic and mental disorders. Genital tract infection: The most common
Puerperal infection represents a significant puerperal infections originate from the uterine
cause of maternal mortality and morbidity, endometrium. Most cases of genital sepsis are
especially inthe developing countries. ascending infections from the vagina to the
placental site aided generally by factors
Puerperal infection resulting in a fall in maternal immunity and
inoculation of the genital tract following
This is defined as bacterial infection of the operative vaginal deliveries and frequent
genital tract after delivery. This is the vaginal examinations (Table 62. 1).
commonest complication of the puerperium.
Fever is the main clinical signal of puerperal a. General
infection. All fevers occurring in the o Anaemia
puerperium are not necessarily due to infection
alone, as all puerperal infection may not be due
0 Poor nutrition
to genital tract infection alone. A definition of 0 Unbooked patients
puerperal pyrexia or puerperal morbidity is o Obesity
therefore necessary.
Puerperal pyrexia is defined as a temperature • Low socioeconomic status
rise of 38°C or more occurring on any two of the • Sexual intercourse during pregnancy
first 10 days of the puerperium after the first 24
hours. This temperature should be taken orally at b. Labour events
least four times a day. A large number of women •Prolonged rupture of membranes
with puerperal infections do not meet this or any
• Chorioamnionitis
other definition of morbidity that is based solely
• Intrauterine fetal monitoring
on temperature criterion due in part to the current
• Number of vaginal examinations
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Abnormalpuerperium SOS

9
Harmful traditional practices (e.g. present. Tenderness and bagginess of the vaginal
gishiri cut) fomices are found in the presence of a pelvic
abscess, which often complicates genital sepsis.
c. Delivery Special laboratory investigations required
include: (i) full blood count (ii) blood culture
° Haemorrhage (iii) endo-cervical swab for culture and
®Manual removal of placenta
sensitivity and (iv) urine culture.
° Episiotomy The choice of antibiotic therapy depends on
• Genital tract lacerations the microorganism responsible for the infection.
d. Operative risk factors
However, antibiotics should be empirically
* General anaesthesia administered before culture results become
° Caesarean section available. High doses of parenteral antibiotics
should be administered to achieve adequate
° Operative technique blood antibiotics levels. Intravenous ampiclox 1
° Forceps/ventouse delivery gram 6 hourly and metronidazole 500mg 8
° Emergency operations hourly are a common combination that is used to
inhibit bacterial activity until culture results are
Table 62.1 Risk factors for genital tract infection obtained. Gentamycin can also be included in
severe infections. In rural areas where these
The organisms commonly implicated in genital antibiotics may not be available or affordable,
sepsis include: haemolytic streptococci (group streptomycin and penicillin may be given
B); Gram-negative bacilli (E.coli, klebsiella, parenterally. Protection against tetanus with
proteus, pseudomonas), Gram positive antiserum 1500 i.u. subcutaneously should be
anaerobes (peptostreptococci and peptococci), administered unless it is certain that the patient
Clostridia and staphylococci. Organisms such as hadbeenimmunised antenatally.
Chlamydia trachomatis are a source of concern. With appropriate antibiotic therapy, an
Its long latent period often results in a pelvic improvement inthe patient's conditionshould be
infection developing late in the puerperium (13 observed in 48 hours. If no appreciable
to 38 days postpartum). The infection may pass improvement is noticed, a thorough review of
unnoticed resulting in sequelae that would the patient should be carried out and pelvic
compromise future fertility. Patients with collection, retained products, or other foci of
genital sepsis often develop fever which may be infection should be sought and treated
accompanied by rigors and sweating a few days appropriatelyÿ In addition to antibiotics and
after delivery. The patients may complain of analgesics, correction of anaemia and
abdominal pain, which couldbe easily mistaken malnutritionshould be aimed at.
for postpartum contractions (after pains). Adequate antenatal care with aseptic
Physical examination often reveals raised techniques employed in the labour room is an
temperature and tachycardia. Lower abdominal important measure in the prevention of puerperal
tenderness is usually present and may be infection. Prophylactic antibiotics especially for
generalized with rebound tenderness if infection operative vaginal deliveries and cases of prolonged
has spread beyond the uterus to involve the rupture of membranes should be the rule, to reduce
peritoneum. Vaginal examination often reveals the incidence of genital tract infections and its
foul smelling, purulent discharge. Cervical complications. The complications of genital tract
motion tenderness andtender bulky uterus may be infections (Table 62.2) are often long term and
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506 Obstetrics and Gynaecology

capable of interfering with the woman's Urinary tract infection: This is second only to
reproductive life and happiness. genital tract infection as a cause of puerperal
Septicaemia pyrexia. It often results from frequent or
° prolonged catheterisation during labour and
o Pelvic abscess
o Chronic pelvic infection puerperium. It is also common in patients who
Ectopic pregnancy have had operative vaginal deliveries and
• caesarean sections. Urinary tract infection
o Chronic pelvic pain
Menstrual disorders occurs postpartum in 3% to 7% of pregnant
©
women who have asymptomatic bacteriuria.
© Secondary amenorrhoea
The clinical features include: fever with chills
o Infertility
and rigors, loin and suprapubic pain and
o Intestinal obstruction
dysuria. Tenderness may be found over the loins
© Psychiatric disorders
and suprapubic area. A specimen of mid stream
Table 62.2 Complications of genital tract urine for culture and sensitivity should be
infection obtained to identity the. causative organism,
which is a coliform inabout 95% of cases.
Gastrointestinal tract infection: Poor food Treatment would consist of antibiotic
hygiene, defective sanitary and over crowded therapy with a sulphonamide. Other drugs that
living conditions are responsible for the high could be used include amoxycillin,
incidence of diarrhoeal diseases in the tropics. erythromycin and cephalosporins. Liberal oral
Herbal concoctions administered to women in fluids should be encouraged.
labour may result in diarrhoea in the
puerperium. Most diarrhoeal diseases are self- Respiratory tract infection: This occurs more
limiting and usually require no treatment other commonly in patients who have had general
than oral rehydration. anaesthesia in labour. The complaint is usually
Amoebic dysentery may occur during the fever associated with pleuritic chest pain. The
puerperium. The patient presents with bloody cough may be productive of yellowish sputum.
diarrhoea, fever and anaemia, and abdominal Decreased air entry and crepitations may be
distension may be found on examination. A heard on auscultation of the lung fields. A chest
stool microscopy done in a side laboratory X-ray should be performed and sputum
usually reveals active trophozoites. obtained for culture and sensitivity. Acid-fast
Metronidazole is the drug of choice. Fluid and bacilli should also be looked for to exclude
electrolyte imbalance shouldbecorrected. tuberculosis which is more common now with
Typhoid fever may present with diarrhoea increasing incidence of HIV/AIDS in
in the puerperium. The disease usually begins
pregnancy. Treatment is with a broadspectrum
inpregnancy and continues undiagnosed in the antibiotic which should be changed
puerperium. The offending organism can
appropriately once culture result has been
usually be detected from a stool, urine, or blood
obtained. Physiotherapy may also be required.
culture. Treatment can be effected with
amoxycillin or septrin. Ciprofloxacin, though
highly effective, should be used with caution in Breast disorders
lactating mothers. In all cases of diarrhoeal Disorders of the breast occur usually as a
diseases in the puerperium, vaginal and rectal result of faulty techniques of breastfeeding. These
examinations may rule out pelvic abscess. disorders include engorgement of breast, cracked
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Abnormalpuerpermm 597

nipples, mastitis and breast abscess. expressed with the milk. The symptoms are
Engorgement of breast: This condition similar to those described previously. In both
develops when the amount of milk produced is varieties, the causative organism is usually
in excess of the amount that is being removed. Staphylococcus aureus.
This occurs commonly in the first few days of Treatment is with ampiclox 1 gram 6 hourly
lactation and is usually due to inadequate for 5 to 7 days. Analgesics are given to relieve
suckling. Clinically, the breasts are enlarged, pain. A warm compress applied to the breast
tender, and hard. The patient may have a fever. encourages milk flow. Breast feeding should be
Treatment comprises frequent emptying of the stopped ifadenitis is found but not for cellulitis.
breasts by manual expression to relieve the Abscess: An abscess usually develops as a
tension and then frequent suckling should be complication of an untreated mastitis. There is
encouraged. Analgesic and well-fitting usually a large collection of pus within the breast
brassieres should be employed. A warm tissue, which causes a persistent fever, and the
compress to the breasts with a towel dipped in patient often appears toxic. Treatment comprises
warm water is quite soothing. incision and drainage under general anaesthesia.
Cracked nipples: This is a situationwhere a
sore develops on the nipple in the process of Thromboembolic disorders
suckling. The cause of a sore or cracked nipples These disorders are a result of the increased
is incorrect positioning and attachment of the coagulation and impaired fibrinolytic activities in.
baby to the breast, causing the baby to suck pregnancy. They occur in about 0.5 to 1% of
directly on the nipple instead of the areola. Flat pregnancies but mostly occurring in the
or inverted nipples contribute to the problem of puerperium. The disorders include:
positioning and attachment. The condition is thrombophlebitis, deep venous thrombosis
best managed by teaching the mother correct (DVT) and pulmonary embolism.
positioning and attachment of the baby to the Thrombophlebitis is inflammation of a vein
breast. Lanolin or even breast milk can be with thrombosis. It may occur in the superficial
applied to the nipple after feeding andthe breast veins of the hand and forearm after an intravenous
exposed to air. Taking the baby off the breast cannula has been in situ for a long period of time.
should be discouraged as this could lead to The skin over the superficial veins is inflamed and
engorgement. Flat and inverted nipples can be tender. The condition is self-limiting and not life
corrected by manual manipulation or wearing threatening but if not treated promptly the
of a Waller's shell. inflammatory process may extend to the deep
veins. Septic pelvic dirombophlebitis rarely
Mastitis: This is an inflamation of the breast complicates puerperal pelvic infection. In this
tissue. There are two main types viz non- state, the venous channels in the pelvis become
epidemic cellulitis and epidemic adenitis. In infected and thrombosed. The ovarian vein is
non-epidemic cellutitis, the connective tissue in usually thrombosed. The patient may present 2 to
between the breast lobes becomes inflammed 5 days after delivery complaining of lower
and infected. The clinical features are fever, pain abdominal pain and fever and may have signs of an
in the breast and general malaise. On acute abdomen. The diagnosis is often made by
examination the breast is tense, tender, and warm exclusion, a laparotomy having been done for
to touch. No pus can be expressed from the ducts. suspected appendicitis, ovarian torsion or pelvic
In epidemic adenitis, the lactiferous system is abscess.Treatment is with heparin and antibiotics.
infected resulting in pus formation which can be
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588 Obstetrics andGynaecology

Deep venous thrombosis (DVT) is important reassurance and support from family, friends
because the risk of embolisation is high. It occurs and medical personnel. Sedation at night is
commonly following operative delivery such as a helpful.
caesarean section though other risk factors have In some patients, neurotic depression,
been associated with this condition. These schizophrenic and manic-depressive reactions
include age greater than 35 years, immobility, may occur. The clinical presentations in these
obesity, pre-eclampsia, parity greater than 4, patients are similar to those of the non-pregnant
previous DVT andsickle cellanaemia. state. They may include restlessness, agitation,
The clinical features include leg pain or confusion, fear, suspicion, sleeplessness,
discomfort, swelling, tenderness, increased hallucinations and delusions. Delusions about
temperature and oedema. Lower abdominal herself and the baby are common in
pain may be present. schizophrenia.
Investigations such as compression or In the tropics, it is important to exclude
Doppler ultrasound and X-ray venography may aid severe infections and ingestion of toxic
diagnosis. Treatment with an anticoagulant such as traditional medicines or concoctions as cause
heparin is the main stay of management. Low of the confusional state. History of depressive
molecular weight heparin e.g. enoxaparin has been illness in previous pregnancy or in the non¬
found to be more effective in the treatment of DVT. pregnant state shouldbe sought.
Early ambulation and postoperative heparin have Patients who have suffered perinatal loss
been found to be useful as prophylaxis especially tend to have more severe psychological
in highrisk patients. reactions and such patients require support with
Pulmonary embolism usually results from the management of grief.
deep venous thrombosis in up to 80% of cases. In the treatment of these reactions, the
Fatality associated with this condition is very sendees of a psychiatrist should be obtained for
high in the absence of early diagnosis and proper evaluationandinstitution of therapy.
treatment. It remains a common cause of
maternaldeath indeveloped countries while the
incidence inthe tropics is unknown as maternal Bibliography and suggested further
death occurs before diagnosis is made. reading
Prevention is by recognition of the
( 1) Ellison J., Walker I.D., Greer I.A (2000).
predisposing factors to DVT, and selective Antenatal use of enoxaparinfor prevention and
prophylaxis inhigh-risk patients. treatment of thromboembolism in pregnancy. Br.
I. Gbstet. Gynaecol. Vol. 107:1116-21.
Mental disorders
(2) EschenbachDA.,Wager G.P.( 1980). Puerperal
The psychological reactions to the Infections: Clinical Obstetrics and
Gynaecology. Vol.23, 1003-35.
physiological readjustments occurring in the
puerperium vary from mild depression to frank (3) Harrison K.A., Lawson J.B. (200 1). Puerperal
psychosis. The most common psychological disorders. In Maternity Care in Developing
reaction is a state of mild depression in which Countries. Lawson J.B., Harrison K.A.,
Bergstrom S. eds. RCOG Press.
the patient is tearful, anxious, restless and
unable to sleep. This state has been referred to (4) De Swiet. M. (1984). Medical disorders in
as "maternity blues" or "postpartum blues". Obstetric Practice. Blackwell Scientific
The state is transient and is overcome with Publications.
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514 Obstetrics and Gynaecology

characteristically exhibit hypotonicity, painful, so that an analgesic concentration can

hypoactivity, and impaired temperature be built up inthe blood.Inhalationterminates as
regulation and metabolic response to cold stress. soon as the pain wears off. Although it does not
The phenothiazine derivative adversely affect the progress of labour and
promethazine (phenergan) has been used in delivery, the inteimittent inhalational analgesia
labour. It relieves anxiety, controls nausea and is not a particularly effective method of pain
vomiting and reduces the narcotic relief.
requirements during labour.

Inhalationalanalgesics: Here, sub-anaesthetic

concentrations of inhalational agents are
administered through special equipment to
parturients in first and second stages of labour
to provide analgesia. Common agents
employed include nitrous oxide,
trichloroethylene and methoxyflurane. A
mixture of trichloroethylene and air was
administered by handheld inhalers, available in
two models - Tecota (Temperature
compensated trilene air) and Emotril (Epstein
Macintosh Oxford trilene) to provide 0.35
volume% or 0.5 volume% trilene in air and
provided adequate analgesia. Unfortunately its
toxic metabolites caused it to be abandoned.
Methoxyflurane was dispensed from a
temperature compensated Cardiff Inhaler to Figure 63.1EntonoxApparatus
provide the agent in a concentration of 0.35
volume %. Methoxyflurane is highly lipid Regional analgesia: This refers to a variety of
soluble and eliminated very slowly from fat nerve blocks designed to provide relief of
reservoirs in the mother and newborn. High labour pain without loss of consciousness. They
output renal failure associated with overdosage include local infiltration, pudendal block,
contributed to the decline inits use. Entonoxis a paracervical block, epidural block and spinal
pre-mixed mixture of 50% nitrous oxide, and block.
50% oxygen under pressure inone cylinder. The
Entonox analgesic apparatus consists of two main
Local infiltration: This involves the local
parts (Fig 63.1). (i) A cylinder of premixed gas
infiltration of the perineum with 10 to 20 ml of
coloured blue with white bands at the shoulder and
local anaesthetic solution (1% lignocaine is
(ii) Inhalation unit comprising a pressure regulator
usually preferred). This procedure is used'
and demand valve. It is self administered under
before an episiotomy is performed. It is also
supervision and safety is maintained because if
used after delivery at the sites of lacerations to
consciousness is lost, the mask falls from the
be repaired.
patient's face. Administration is usually
intermittent, the patient applies the face mask at the
ÿ

- - •

start of uterine contraction before it becomes Pudendal block: It provides analgesia of the

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_* . ÿ
I
'Analgesia; andanaesthesia in obstetrics V 515
• »ÿ i®H
5 RR—ÿ ÿ ÿÿBHHHI
— MW

vaginal introitus and perineum. The block is chloroprocaine 1-2%, and bupivacaine 0.0625
easy to accomplish and there is relatively little to 0.5%. The addition of opioids to dilute
systemic absorption and little direct effect on concentrations of epidural local anaesthetics
the fetus. In the transvaginal approach, the has proven to be quite effective in the relief of
ischial spine is first identified. Through a guide, labour pain as both visceral and somatic pains
a needle is insertedinto the vagina and directed are relievedby the combination.
laterally and posteriorly to the ischial spine. A Before an epidural analgesia is induced,
submucosal weal is made and the needle is an intravenous infusion is commenced and
advancedinto the sacrospinous ligament where baseline vital signs are recorded. All necessary
resistance is felt. As the needle passes the resuscitation equipment and drugs should be
readily available in case of an emergency. The
ligament, a loss of resistance is felt. The needle
patient is positioned on her side (lateral
has now entered the pudendal canal which position) on the delivery bed with both knees
contains the pudendal nerve and associated and neck flexed. Under aseptic conditions, a
vessels. After a negative aspiration for blood, 3- size 17 or 18 gauge Tuohy needle is then
5 ml of localanaesthetic solutionis injected and inserted at the L. 3-4, L 4-5, or L 2-3 interspace
the needle is advanced another 0.5-1 cm. If after a skin weal is raised with local analgesic
aspiration is againnegative 5-7 ml of solutionis agent. The epidural space (Fig 63.2) is
injected.A total of 10ml is injected on eachside. identified using either the "loss of resistance" or
Drugs commonly used are lignocaine 1%, "hanging drop" techniques. Most physicians
chloroprocaine l%-2% or bupivacaine 0.5%. prefer the loss of resistance technique as one
The procedure usually works well if properly with less risk of penetration of the dura. A test
done. It is used for vaginal operative delivery. dose of the local analgesic is injected up the
Complications of the procedure include needle, a catheter is then gently inserted in a
intravenous injection of drug which may cause cephalad direction for a distance of 2-3cm
systemic toxicity and rarely severe infection within the epidural space and the needle
leading to retropsoas or subgluteal abscess. withdrawn over the catheter. This catheter is
securely taped in place and provides an avenue
Paracervical block: Inthis procedure, about 5- for intermittent or continuous injection of local
anaesthetic agents or opioids.
10 ml of local anaesthetic is injected
The indications for lumbar epidural
transvaginally just lateral to the cervix on each
analgesia include (i) labour pain (ii)
side. It anaesthesises the sensory nerves of the management of patients with hypertensive
uterus (T. 10 to L. 1) andrelieves pain associated disease in pregnancy (iii) management of
with uterine contractions andcervical dilatation. labour in persons with certain cardiac disease
It is a relatively easy procedure to perform but (iv) management of breechdelivery.
has been associated with high incidence of fetal Absolute contraindications include (i)
bradycardiaand acidosis. patient's refusal (ii) infection at the anticipated
Lumbar epiduralanalgesia: Continuous lumbar site of puncture and (iii) absence of
epidural analgesia isthe most effective technique of resuscitation equipment. Relative
pain relief in all stages of labour and delivery. contraindications include (i) fever (ii) pre¬
Analgesia is effected by blocking the spinal nerves existing C.N.S. disease (iii) severe anaemia (iv)
as they lie in the space between the dura mater hypovolemia (v) severe hypertension or
and the vertebral canal. The most commonly used hypotension (vi) extreme obesity (vii) lack of
local anaesthestic agents are lignocaine 1-2%, experience by the anaesthetist (viii) precipitate
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labour and (ix) blood coagulation defects. caesarean section delivery because of use of
The main advantages of lumbar epidural longer acting agents such as bupivacaine
analgesia include (i) parturient remains awake (marcain) and tetracaine (pontocaine) which
and co-operative (ii) low incidence of enable a single injection to suffice for the
complications where technique is used duration of surgery. The main disadvantages of
spinal anaesthesia are post-spinal headache and
correctly and (iii) it can be used to provide hypotension. Post-spinal headache (post-dural
analgesia and anaesthesia for a vaginal delivery puncture headache) is due to seepage of
or acaesarean section delivery. cerebrospinal fluid through the puncture hole in
The disadvantages and complications the dura mater and its incidence can be greatly
include (i) possibility of poor perineal reduced if a fine needle (especially pencil
analgesia (ii) presence of "hot spots" where point) is used. Hypotension is common and
analgesia is insufficient (iii) delayed onset of reflects hypovolemia. Adequate fluid preload
action (iv) technical difficulty and possible and careful lateral displacement of the uterus
minimises hypotension but when severe, may
failure (v) intravenous injection following be corrected by rapid intravenous infusion of
puncture of epidural blood vessels (vi) balanced salt solution (Hartman's solution) and
accidental dural puncture and (vii) hypotension vasopressors such as ephedrine, methoxamine
and associated nausea, vomiting, restlessness andphenylephrine.
and confusion.
General anaesthesia
Dura
General anaesthesia is used for caesarean
Arachnoid
section when the patient refuses regional
Subarachnoid analgesia or has a contraindication to regional
space
Extradural analgesia or when a need exists for rapid
space delivery because of fetal distress, cord
Ligamentum prolapse, shoulder dystocia or maternal
fiavum
haemorrhage.
Interspinous The main risks associated with general
ligament
Superaspinous
-
anaesthesia are (i) airway control difficult or
ligament failed intubation and (ii) aspiration of gastric
Skin contents.

Aspiration of gastric contents: The patient is

at increased risk of aspirating acidic gastric
Figure 63.2 Cross section of spine showing the contents under general anaesthesia. This is due
epidural space to delayed gastric emptying in pregnancy,
resulting in full stomach and increased
Spinal block: This involvesthe injection of a incidence of gastroesophageal reflux.
small amount of local anaesthetic through a
spinal needle placed in the L 3-4 interspace Inhalation of solid food causes immediate
into the subarachnoid space. It is an airway obstruction resulting inhypoxia and death
excellent technique for pain relief shortly by suffocation whilst aspiration of acidic liquid
before delivery but has become less popular for gastric contents results in aspiration pneumonitis
vaginal delivery since epidural analgesia has or Mendelson's syndrome. This syndrome is
increased in use. Spinal block is popular for characterised by bronchospasm with

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m
Analgesia andonoesikesia in obstetrics 517 ÿ

' ~i. . V '

ÿ'*
•. ÿ

-
mmmm HSR

wheezes and rhonchi, dyspnoea, tachypnoea, no positive pressure ventilation prior to

cyanosis, tachycardia, hypotension and insertion of the endotracheal tube to
pulmonary oedema. Mortality from prevent distension of the stomach with gas.
Mendelson's syndrome is high and death is
usually due to progressive hypoxia which is (ix) Cricoid pressure (Sellick's manoeuvre)
difficult to reverse inspite of intermittent during inductionwhich is maintained until
positive pressure ventilation (IPPV) with 100% endotracheal tube placement in the trachea
oxygen. It is safer to prevent Mendelson's has been confirmed and the cuffof the tube
syndrome by the following general precautions: inflated. Cricoid pressure occludes the
(i) Avoidance of general anaesthesia by use of oesophagus thus obstructing the path of
regionalanalgesia (epidural or spinal) when regurgitation.
feasible.
Suggested sequence of general anaesthesia for
(ii) The parturient should have nil by mouth caesarean section:
from the onset of labour and a 12-hour fast
before :elective caesarean section is (i) Ensure good intravenous access, antacids
recommended. and left lateraltilt.
(ii) Take baseline vital signs.
(iii) Prophylactic use of non particulate (clear)
oral antacids such as 0.3 Molar sodium (iii) Pre-oxygenation with 100% oxygen by
citrate or sodium bicarbonate 30 ml by face mask for at least 3 minutes.
mouth before induction of general
(iv) Always use a "rapid sequence induction"
anaesthesia or 15 ml by mouth 2 hourly
during labour.
by bolus injections of an intravenous
induction agent (commonly thiopentone),
(iv) Use of specific antiemetics - according to the patient's weight. As
metoclopramide 10 mg intravenously to consciousness is lost, a competent assistant
hasten gastric emptying. applies and maintains cricoid pressure
until successful intubation is performed,
(v) H2-receptor antagonists - ranitidine 150 the cuff of the endotracheal tube inflated
mg orally or 50 mg intravenously to reduce
and respirations havebeenauscultated.
gastric secretions and acidity. Cimetidine
serves the same purpose but is less (v) Intubation is facilitated by use of
favoured due to drug interactions. suxamethonium, without positive pressure
Glycopyrrolate reduces both salivary and ventilation with face mask prior to
gastric secretions. intubation.
(vi) A large bore nasogastric tube to drain the (vi) Laryngoscopy and intubation, inflation of
stomach may be passed if it is an emergency cuff of endotracheal tube and auscultations
with significant risk of full stomach. of respirations.
(vii) Supine position with left lateral tilt will (vii) Release of cricoid pressure by assistant.
minimise any increase in intragastric pressure.
(viii) General anaesthesia is maintained with a
(viii) The use of "rapid sequence induction" will mixture of equal parts of nitrous oxide and
protect the airway and prevent aspiration. oxygen, a low dose of an inhalational agent
This involves pre-oxygenation prior to (such as halothane 0.5%) and an IPPV
inductionthen institutedwith the aid of a non-depolarising
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ÿ5ZS Obstetrics snd Gynaecology

(competitive) muscle relaxant. A Bibliography and suggested further

concentration of halothane higher than reading
0.5% is not advisable as it causes uterine
Ciliberto C.F., Mane G.F. (1998) Physiological changes
relaxationand postpartumhaemorrhage.
associated with pregnancy. Update inAnaesthesia.World
(ix) After the delivery of the baby, nitrous Anaesthesia 9:1-6.
oxide concentration may be increased to
70% and narcotics given intravenously to Hughes S.C. (1992) Analgesia methods during labour
supplement the anaesthesia. Midazolam and delivery. Can. J.Anaesth. 39:18.
may be used to decrease the risk of
Faure E.A (1991): The pain of parturition. Semin.
maternalrecall or awareness.
Perinatol.: 15:342.
(x) Patient must be monitored closely
throughout the operation (Bloodpressure Fishburne J.I. (1999) Obstetric analgesia and
measurement at least every 5-10 minutes anaesthesia. In Danforth's Obstetrics and Gynaecology.
andpulse measurement continuously). 8 ed. Lippincott. Williams and Wilkins (Publishers)
PhiladelphiaPp. 111-128.
(xi) At the end of surgery, residual muscle
paralysis is reversed using atropine and Moir D.D. (1979). Obstetric anaesthesia and analgesia.
neostigmine. InRecentadvances in anaesthesia and analgesia. Hewer
(xii) After several minutes of breathing 100% C.L., Atkinson R.S. eds. Churchill Livingstone
oxygen at high flow, and adequate Edinburgh,London,NewYork.
maternal response to commands is Crawford J.S. (1980) Obstetric analgesia. In General
ascertained, the patient is extubated Anaesthesia. Gray TC, Nunn JF, Utting JE eds. 4Ih ed.
while on the lateralside and inheaddown Vol. 2. Butterworth, London. Pp. 1391 -1402.
position, as vomiting and aspiration can
also occur at extubation.

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Chapter 64
Psychiatric aspects of obstetric

In spite of the general belief that significant spontaneous abortion which is notoriously
psychiatric disorders and specifically suicide common during this trimester. If conception
are rare during pregnancy, there is little doubt was presumed to be the grace from a fecundity
that for a majority of women, in any culture, deity appeased to by ritualisation after a period
pregnancy could to an extent be an emotionally of infertility, this first trimester Could be
distressing experience inthat conflict and stress welcomed with- a variety of responses such as
could be generated through the interaction of joy fulness, or uncertainty regarding the
changes in hormonal system, changes in body viability of the fetus and incomplete or failed
image, activation of unconscious psychological compliance to ritual conditions /may evoke
processes specific to pregnancy and mental expectations of morphological abnormalities in
organisation related maternal roles. The nature the baby as retribution from the deity. A teenage
and intensity of these psychological forces are unmarried,expectant mother without a reliable
difficult to predict, however, their manifest male partner may have to face the stress of
behaviour and effect depend significantly on parental rebuke andalso the uncaring neglect of
the pregnant women's personality, resources her partner. The shame and embarrassment
anddie adequacy of support available to her. arising from the condemnatory societal attitude
and its moral overtones towards illegitimate
Psychological changes in pregnancy pregnancy are all too wellknown.
The knowledge of the usual emotional changes
In some women, severe early signs of
during pregnancy is crucial to the identification pregnancy such as vomiting, salivation,
of psychopathology, and the proffering of lethargy, and body weakness will compound
specific counselling. These changes vary in any pre-existing emotional difficulties making
quality and severity from one trimester to the whole pregnancy experience most
another but some occur with considerable unpalatable.
frequency in a particular trimester. In the first
trimester, a notable emotional phenomenon is During the second trimester, quickening stands
ambivalence, a word which connotes an out as a milestone of psychological import It
experience whereby one's feeling is mixed and reassures the mother that the fetus is grossly
could be contradictory. For instance, there viable and reaffirms her own reproductive ability!
could be vacillation between feelings of a sense Realising the fear emanating from the possibility
of genetic disorders such as sickle cell anaemia.
of well being, joy fulness, and acceptance of
and rhesus incompatibility in the baby conk'
pregnancy on one hand, and anxiety,
arouse considerable tension and despair.
uncertainty or low spirit on the other hand. Most
women also feel the need to be protected and In the latter part of the second trimester.
cared for by significant others in their the uterus is usually enlarged enough to restrici
immediate environment and this need may be a woman's social, and occupational activities
exaggerated by some immature women in form more so in the face of persistent vomiting,
of making unrealistic demands for support. salvation and other pregnancy changes.
A common unpleasant feeling relates to the The low income mothers are particularly
fear and pessimism about the possibility of saddled with the anticipated financial
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520 Obstetrics andGynaecology

responsibilities relating to purchase of baby's classical grief.

materials and other maternity items. The Apparently the level of distress would depend
"Alaanu" fund being operated by the medical on the perceived significance of the lost
social welfare services of the Lagos pregnancy to the woman interms of her level of
University Teaching Hospital, had assisted gravidity, age and number of surviving children
some penurious pregnant women in acquiring if any. It is therefore important not to be
some of these items and the hospital's
concerned exclusively with the physical
department of psychiatry gives 'exemption-
from-fee' concession for the prescriptions of recovery from spontaneous abortion but to
haematinics and vitamin supplements of monitor the woman's emotional and behavioural
deserving women. stages inthe periodfollowing the abortion.

With advanced pregnancy in the third Stillbirth: Until very recently, attitude to
trimester limitations of physical activity due stillbirth was casual and the experience often
to increased body weight and the reality of regarded as a minor event. Very frequently, the
pending motherhood are psychologically dead fetus was disposed of without sighting by
significant. An important recurring theme is the mother with consequent probability of
uncertainty of coping with labour pains, the impaired grief. And the reaction of the nursing
intensity and quality of which are often and medical staff was no more than brief
influenced by various misconceptions, some expression of concern and sympathy. However,
of which are picked up in the antenatal clinic it is now believed that there is need for a more
waiting area or at informal street discussions. active intervention in that stillbirth carries a
Despite the modern day availability of risk of affective disorder and considerable
effective analgesics, some pregnant women distorted bereavement process could occur.
are terribly scared of labour pain to the extent
of their insistence on elective caesarean The appropriate management is to assist mother
section with attendant anaesthetic risk. These to come to terms with her situation in loss- ?
psychologicalchanges do not necessarily lead focused counselling session by full acceptance
to frank mental disorder but may be of the loss, adequate expression of emotions,
significant enough to justify appropriate instillation of hope and reassurances that greater
psychological support for some women. surveillances would be shown in subsequent
pregnancy. It shouldbe helpful for the mother to
Psychological reactions to pregnancy
briefly see the dead fetus with the hope that
outcome denialwould beminimised or even avoided.
Spontaneous abortion: There is some
consensus that the vast majority of spontaneous
Abortion (therapeutic termination of
abortions are due to chromosomal abnormalities pregnancy): There are no absolute psychiatric
or anatomical defect which implies that indications for therapeutic abortion. A personal or
psychological distress is more likely to be a family history of a major mental illness should be
complication of the abortions rather than the noted and serve as additional surveillance in joint
converse. Some women have been observed to antenatal care but does not by itself constitute valid
experience significant anxiety and depression basis of abortion. Advocacy for abortion if
and other emotional changes very similar to amniocentesis analysis reveals a chromosomal
changes associated with reaction to stillbirth or defect or other genetic disorder (e.g sickle cell

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anaemia) has not been successful on ethical and which is useful in the treatment of mania and
humanistic ground. However, the option is left prophylaxis of bipolarmanic-depressive disorder
open to parents after due counselling. can cause fetal cardiac malformation if taken
Generally it is believedthat there is littlerisk of during the first trimester. The unclear safety
psychiatric disorder shortly following abortion status of lithiumjustifies avoidance of pregnancy
and psychological problems may even abate or during the duration of lithiumtreatment!
diminish inintensity after termination moreso if Carbamazepine (Tegretol) useful for its anti-
the continuance of the pregnancy would manic effect though generally used as an anti¬
aggravate pre-existing economic (poverty) or convulsant had been associated with
social (large family size) disadvantages. Denial developmental delays and defects when taken
of termination is associated with risk of during the first trimester.
depression and suicidal ideation and can result Neuroleptics e.g the phenothiazines
in conduct disturbances in the emergent child. (chlorpromazine as prototype) and the
The long term risk of psychological disorder butyrophenones (eg haloperiodol) can produce
after abortion is small. Notwithstanding it neurotoxicity in the newborn and their use in
should be bome in mind that guilt, shame and pregnancy should be minimised or totally
self-denigration may occur if secondary avoided except in acute psychotic episodes.
infertility is diagnosed several years following There are no definite information on the newer
abortion invulnerable women. neuroleptics eg risperiodone and clozapine
consequently the rule of avoidance safety
Psychotropic drugs, tobacco, alcohol and should be adhered to.
pregnancy
Anti-depressants: The reported teratogenic
The placental membrane allows relatively free effects of tricyclic antidepressants (eg
passage of many psychotropic drugs form the amitriptyline and imipramine) have been
maternal blood to the fetal circulation. refuted though there hadbeenanecdotal reports
Unfortunately with many of these drugs the on the occurrence of convulsion in newborn
potential for teratogenicity had not been firmly babies of women on these drugs during
established hence the justification for pregnancy. The fear of secretion of some
emphasising avoidance of their use during metabolites of some anti depressants in the
pregnancy, particularly in the first trimester. breast milk with risk of neonatal toxicity is not
However, there are some clinical states during well founded nor their use linked with
pregnancy for which withholding of a increased risk of obstetric complications. Nc
psychotropic drug would be improper or even demonstrable adverse effects have beer
dangerous. Examples of such states include reported for the newer antidepressants such as
persistent sleeplessness, severe anxiety and the selective serotonin re-uptake inhibitors eg
suicidal depression. In such conditions, the risk fluoxetine (Prozac), sertraline (Zoloft) and 2
of fetal health should be weighed against the monoamine oxidase inhibitor (MAO-B) e.£
need to protect maternal welfare. Some of the moclobemide (Aurorix).
psychotropic drugs which could be injurious to
pregnancy wouldbe briefly mentioned. Tobacco smoking: There is ample evidencethai
heavy cigarette smoking is associated with a high
Lithium: There is some evidence that lithium salt risk of lowbirthweight, increased morbidity,and

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j 522 Obstetrics andGynaecology

perinatal mortality of the newborn. For the Electro-convulsive therapy (ECT) and
mother, the risks of placenta praevia, abruptio pregnancy: There are no known definite
placentae, premature rupture of membranes hazards of ECT to the pregnant mother and her
and increased abortion rate are significantly baby and the indications for ECT are the same
higher than for non-smokers. for the pregnant and non-pregnant
Bidiazepam Diazepam: This widely used psychiatrically disturbed women. However,
benzodiazepine when administered to the some clinicians have voiced caution in the
mother can cause brief hypotonia in her infant. administration of ECT to women at risk of
Associated complications include muscle premature labour, cervical incompetence and
twitching, feeding difficulties, low Apgar score antepartum haemorrhage. There is a need for
and convulsion. Similar pathogenic effects close obstetric monitoring in women that
have developed with barbiturate abuse in require ECT.
pregnancy.
Psychiatric disorders inthe pureperium
Fetal alcohol syndrome: This syndrome is a
cluster of physical malformations and mental Significant clinical changes in mood, thought
retardationobserved inthe offsprings ofwomen and behaviour often occur during the perperium
who drank excessive alcohol during pregnancy. and various terms 'postnatal', 'puerperal',
Writing on the subject of alcohol consumption 'maternal' have been used inter changeably to
and infant health dates back to the time of refer to a variety of groups of these changes.
Aristotle who observed that drunken women Two problems have been encountered in the
often gave birth to young children who were description of these psychiatric disorders
feeble minded. The gin epidemic in England during the puerperium.
during the 18th century lent weight to the adverse Firstly, the length of time after childbirth during
consequences of prolonged in-utero exposure to which a psychiatric disturbance could be
alcohol. Among the protean features of the confidently associated with pregnancy hadbeen
syndrome are growth restriction, microcephaly, variable althoughthe puerperium is taken to last
shortened palpebral fissures, hypotonia and 6 weeks after childbirth. Secondly, psychiatric
cardiac abnormalities.The most serious of these disorders during the puerperium are not distinct
features is mentalretardationwhichcould occur clinical entities. Consequently, there had been
in the absence of the grossly visible physical considerable problem of classification.
abnormalities. A number of hypotheses have Generally three fairly distinct clinical varieties
been formulated to explain the patho¬ of postnatal psychiatric disorders are well
physiology of the syndrome. The pendulum of recognised. They are the maternity blues,
opinion swings insupport of a direct teratogenic postpartum psychosis and postpartum
effect of alcohol on the fetus although depression.
secondary factors such as concomitant use of
other harmful substances e.g tobacco, Maternity blues: This is a condition estimated
malnutrition, maternal ill-health, andemotional to be experienced by upto 70-80% of women with
stress could play a role either singly or in onset during the one week after childbirth and
conceit. characterised by brief, mild mood disturbance

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Psychiatric aspects ofobstetric practice 523

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usually but not invariably depression. Due to its the concept of puerperium and failure of some
wide prevalence it could be considered to be workers to exclude toxic-infective states as are
statistically normal and it rarely persists beyond common in the developing countries. The
the first week. If it is prolonged beyond two longer the duration of puerperium adopted, the
higher the incidence figure. A seemingly
weeks, a diagnosis of depression should be accurate rule is that an illness occurring during
entertained.The precise aetiology is not known, the first three months postpartum is likely to be
but biological factors are widely believed to be precipitated by childbirth. However, in
causatively important in view of the absence of ordinary obstetric practice the six-week period
valid association with psycho-social difficulties which marks the involution of the uterus is
such as conflictual relationship with a spouse, normally applied incase definition.
the characteristic sudden onset after childbirth Typically, the illness has an abrupt onset
and the hormonal changes of pregnancy. The after a few postpartum days of apparent
normality. The symptoms are mixed and they
condition does not require any specific
vary rapidly inquality from one form to another
intervention apart form giving reassurances to and the important and highly prevalent ones are
the patient and her next of kin. However, it enumerated as follows:
should be helpful to forewarn the patient and
her spouse during pregnancy on the possibility Mood: Depression, despondency, suicidal
of its later occurrence. The benign nature of the ideation, elation, anxiety, and perplexity.
condition should not give rise to a false sense of Thought disorder: Talkativeness, pressure of
security because severity of mood state couldbe speech, incoherence and flight of ideas.
difficult to assess clinically, therefore there is Delusions (which unfortunately may include
need for careful observation such that a deep faulty perception of the child with consequent
rootedsuicidal depression is not missed. infanticidal tendencies) and diminished sense
of maternalskill.
Postpartum psychosis: The old designation,
puerperal psychosis had been dropped because Sensory perception: Visual and auditory
of the absence of discrete well-defined hallucinations, disturbance of body image.
psychotic syndromes specific to the Other features include confusional state,
puerperium. The scheme of the International disorientation, intermittent disturbance of
Classification of Diseases (ICD Ninth edition) short-term memory, insomnia, disruptive
recommends that the psychiatric illness behaviour, aggression, social withdrawal and
occurring soon after birth be described psychomotor slowing.
according to the predominance of clinical Available evidence indicates that biological
features of a particular functional psychosis. factors are more important than psychological
Therefore the diagnosis ranges form ones in the aetiology of the disorder. The
schizophrenic illness to hypomania, depression argument infavour of this hypothesis rests onthe
and organic brain syndrome. sudden onset of symptoms, absence of
association with obstetric difficulties
The incidence is generally taken to be 1 in 600 and psychosocial adversity such as
live births ifthe 6 week postnatal period istaken disturbed relationship with spouse, constitutional
to define the puerperium and comparability of predilection as suggested by personal or family
epidemiological data is hampered by difference in history of psychiatric illness andthe generallygood

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524 Obstetrics and Gynaecology

response to physical treatments. Current diazepam (valium) and barbiturates should be

thinking indicts sudden oestrogen withdrawal avoided and the use of large doses of other
andits effect on dopaminergic brain sites. psychotropic drugs call for caution with balance
weighting of therapeutic benefit against risk of
Diagnosis: The sudden onset, mixed picture of
undesirablereactions.
the symptomatology, occurrence in the
puerperium, family history of psychiatric Ifdrugs are contraindicated or are not effective,
illness are the key diagnostic features. and certainly with life threatening presentation
However, malaria parasitaemia, drugs e.g.
(e.g suicidal behaviour) electro-convulsive
steroids, alcohol abuse during pregnancy can
therapy (ECT) should be administered
precipitate or aggravate psychosis during the
puerperium. Bacterial infection and sepsis irrespective of diagnostic axis. Infact, ECT may
which are still major factors in puerperal be considered as the first treatment of choice for
morbidity inAfrica should be considered, more quick results as may be desirable with shortage
so if the mother did not attend antenatal clinic, of beds or other administrative constraints. If
there was a delay in seeking medical attention patient is not violently aggressive and
after onset of labour, there was prolonged infanticidal and with adequate psychiatric
labour or the childbirth took place at home. nursing staff, the baby should be admitted and
These exogenous factors should be excluded. kept by the mother's bed. This arrangement is
generally presumed to be reassuring to the
Treatment: For treatment, the emphasis is on mother and may help to accelerate response to
quick control of the acute symptoms with the treatment and enhance mother-child bonding.
choice of physical treatment methods Following recovery, medication should be
depending on the predominant clinical features. continued for a further 6 month period and
In depressive clusters, tricyclic antidepressant thereafter withdrawn gradually. Pregnancy
for example amitriptyline (tryptizol) lOOmg should be delayed for at least 3 years and need
daily or imipramine (tofranil) 150-200mg daily be collaboratively supervised by an obstetrician
preferably in single night dose or two doses and a psychiatrist till the end of the puerperium.
daily administered until there is clinical
improvement which is usually observable Postnatal depression: During the postnatal
within 3 weeks! These drugs are however, period, there could be an emotional disorder
contraindicated in women with pre-existing which presents predominantly as a depressive
cardiac disease in which case a newer mood state of a mild to moderate intensity and
antidepressant with minimal or no cardiotoxicity
which characteristically clears spontaneously
such as fluoxetine (Prozac) or sertraline (Zoloft)
after a few weeks of its onset. It is not a
may be administered. For schizophrenic core
symptoms, neuroleptics such as chlorpromazine,
psychotic condition butits precise delineationis
haloperiodol or thioridazine shouldbe given. Itis still not clearly achieved. In most women, the
important to add that the use of psychotropic condition may be related to some important
drugs immediately following childbirth should stresses associated with childbirth and, its
be with some caution in view of increasing aftermath. These include fatigue, increased
concern for their excretion in breast milk with demand for baby's feeding, blood loss,
attendant risk of neonatal neurotoxicity (tremors, lack of support from spouse, painful breasts,
twitching, convulsion and coma). Lithium, awareness of the deficiency inmothering skills,
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7
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Psychiatric aspects ofobstetricpractice
"ÿÿÿÿ

insomnia etc. Any of these could precipitate a Bibliography and suggested further
depressive reaction, the quality of which is reading
nonspecific to the postnatal period. The
treatment of the condition is no more than Abel, Ernest L (1980). Fetal alcohol syndrome;
behavioural teratology. Psychological Bulletin, 87( 1),
giving reassurances and continuing support
29-50.
for the mother and her next-of-kin. Two other
forms of depressive illness have been Granville-Grossman, K. (1971). Recent Advances in
described. Firstly, there could be a prolonged Clincial Psychiatry: J & A Churchill. London pp 266-
310.
depressive disorder which is masked in that
the typical mood change is overshadowed by Jansson, B (1964). Psychic insufficiencies associated
anxiety, irritability, and diminution in ability with childbearing. Acta Psychiatrica Scandinavica 39.
Suppl. 172,1.
to cope effectively with routine chores. Sleep
and appetite are disturbed and somatic Kumarr, MclvorJandDavies. A (1997). Mental illness in
complaints are common. The likely childbearing women. The Essentials of Postgraduate
consequences of such a disorder on psychiatry. Editedby Murray R, HillP & McGufEn P. 3rd
edition. Cambridge University Press.Pp466-476.
interpersonal relationship particularly
marriage, bond formation with the infant and Kumar, R. Robson. K. (1978). Mental Illness in
long-term social adjustment of mother could Pregnancy and the Puerperium. Sandier, M.e<L Oxford
University Press, Oxford. \
be serious. They include child battering and
antisocial conduct in later childhood. Pitt, B (1975). Psychiatric illness following childbirth.
Secondly, there could be a classical form of Contemporary psychiatry. British Journal of Psychiahy
SpecialNo.9,409-415.
severe depression, which should respond to
antidepressant medication and Robin. A. A (1962). The Psychological changes of
electroconvulsive therapy (as described normal parturition. Psychiatric Quarterly 36,129-150.
above). Snaith; R.P(1983). Pregnancy-relatedpsychiatric disorder.
British Journal of Hospital Medicine 29(5), 450-456.
The practice whereby the care of the newborn
is undertaken with substantial support from
members of the extended family would tend
to diminish the prevalence of postnatal
depression inmany parts ofAfrica.

Imaging in obstetrics and gynaecology

There has been a rapid development in the An idea of the shape of the pelvis can bemade
imaging techniques available in obstetrics and especially the anterior curvature of the
gynaecology. The most rapid development has sacrum. The generally accepted average
been in the area of ultrasonography, which has
measurements inpelvimetry are as follows:
almost taken over the area of investigative w rszn: A*
%8/303T
obstetrics and gynaecology. The other imaging 14! 17:» •' '
5. s; m v-eiw'iv

techniques include; Radiography, Computed yatoiz 2

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Tomography(CT) and Magnetic Resonance "jar 2 .99

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Radiography
Prior to the application of ultrasonography,
radiography was largely used in investigative
obstetrics and gynaeclogy. The hazardous effects
of radiation to the fetus and the germ cells of the
.
r
t'
- >•
ÿ
-i ÿÿ r
ovary limited its use in certain periods of the
menstrual cycle and pregnancy. In obstetrics, % "f f--
-
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radiography was traditionally used in the "lis

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diagnosis of fetal maturity, intrauterine fetal ÿ<3> t>/0
5

death, fetal abnormality, multiple pregnancy, Figure 66.1 Computed tomography (CT) lateral
presentation and position of the fetus and pelvimetry
localisation of the placenta. These roles are now
better served by diagnostic ultrasonography. Antero-posterior diameter of inlet 11.5 cm
Pelvimetry remains the area of investigative Antero-posterior diameter of midcavity 12.5
obstetrics, where radiography has superiority cmAntero-posterior diameter of outlet 11.5 cm.
over ultrasonography. Pelvimetry is usually
carried out in the radiology department and The critical measurements could be taken as:
provides an accurate measurement of the pelvic Antero-posterior diameter of inlet 10.0 cm
Antero-posterior diameter of midcavity 11.5 cm
diameters. The standard views that are taken
Antero-posterior diameter of outlet 11.0cm.
include erect-lateral, antero-posterior, outlet and
supero-inferior or Thorn's view. The erect-lateral In gynaecology, patency of the Fallopian tubes can
view (Fig 66. 1) whether by radiography or CT isthe stillbestbe determined by the radiographic techique
single view that can provide most informationand is of hysterosalpingogram (HSG). This is superior to
also attended by the least radiation hazard. It ultrasonography where normal Fallopian tubes
cannot usually be visualised. The procedure ofHSG
provides information of the measurements of
anterior-posterior diameter of the inlet, midcavity
and outlet

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Imagingin obstetrics andgynaecology $33

is performed in the radiology department and encounter different acoustic densities and at
outlines the uterine cavity and Fallopian tubes each interface some of the sound waves are
(Fig. 66.2 a, 2 b). It involves the injection of reflected back, while some pass on to deeper
contrast medium through the cervical canal tissues depending on the density and acoustic
into the uterus and Fallopian tubes. HSG impedance of the medium. Ultrasonography
remains a standard procedure for the uses transducers, . which are objects that can
determination of tubal patency in some centres convert one form of energy to another and in
in this country. Laparoscopy and dye test is this case mechanical (sound) to electrical
however superior to HSG especially when energy or vice versa. These transducers, which
combined with hysteroscopy inassessing tubal are made of piezoelectric crystals send out
patency. sound waves, usually focused ultrasound beam,
in a series of pulses into the tissues and can
Ultrasonography receive or sense returning waves or echoes from
different interfaces converting them to
This represents the principal imaging electrical pulses (piezoelectricity), which are
technique in obstetrics and gynaecology in displayed on the screen. There are essentially
most centres in developed and developing three modes of displaying signals in an
countries. This technique utilises sound ultrasound procedure; (i) Amplitude or A-
frequencies beyond human hearing (20 Hertz mode; (ii) Brightness or B-mode and; (iii) Time
(Hz) to 20 kilohertz (KHz) and is called Motion or M-mode. Grey scale records the
ultrasound. The frequencies in use in medical quality of echoes as shades of grey. In
diagnoses are inthe range of 1 to 15 megahertz abdominal scanning, the probe is placed on the
(mHz) while those in use in obstetrics and
gynaecology are in the range of 3.5 to 7.5
megahertz (mHz). The basic principles relate
to the passage of sound waves through the body
tissue. When sound waves pass through body
tissues, they

Figure 66.2b Hysterosalpingogram.Delayed film

showing hydrosalpinx

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S34 Obstetrics mdGynaecology

skin, after application of a layer of ultrasound

jelly. The jelly applied to the abdomen
prevents air between the abdomen and the
probe because of the poor conduction of
sound through air.A full bladder is requiredto
serve as a window to the uterus in the pelvis.
In transvaginal sonography, because of the
proximity of the probe to the uterus, the filling
of the bladder is unnecessary.
Diagnostic ultrasound equipment have been
in use for many years in developed countries.
In developing countries, these equipment
have become available in government and
private hospitals. In Nigeria, several centres
around the country have the equipment.
Training is required as the skill of the operator
is an important determinant inobtaining good
ultrasound images. Probes or transducers in
use in this country include the linear array
probe andthe transvaginal probe. Figure 66.4 The Ultrasound machine

Figure 66.3 Two probes. Top — Transvaginal. Bottom — Curved linear array
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Imagingm obstetrics andgynaecology 535

Fig. 66.3 shows two probes in use in our centre surtace of the skull and at the level of the
while Fig 66.4 shows the ultrasound equipment . thalamus and demonstrating the cavum
(Phillips SD 240E) inuse inour centre. septum andthe sylvian fissure.
The measurement is usually taken from the
The development of Doppler ultrasound outer edge of the anterior surtace to the inner
technology has also made it possible to study edge of the posterior surtace. When BPD is
qualitatively blood flow inthe major fetal blood taken between the 15th and 26th weeks, the
vessels. After many years of scanning, it has accuracy of prediction of gestational age is
been shown that ultrasound scanning is safe for about ±7 days. Other measurements that have
bothmother and fetus. Although it is advised that been correlated with gestational age include
since it can cause bio-effects on cells by head circumference (HC), femur length
inducing heat, unnecessary prolonged exposure
(FL),(Fig. 66.7), abdominal circumference
in pregnancy should be avoided. Obstetric
(AC), (Fig. 66.8) and occipitofrontal
applications of ultrasonography include;
(1) diagnosis of pregnancy; diameter (OFD) (Fig. 66.9).
(2) determination of gestational age;
(3) diagnosis of multiple pregnancy;
(4) localisation of the placenta;
(5) fetal growth surveillance;
(6) sex determination;
(7) diagnosis of fetal abnormality.
1. Determination of gestational age In early
pregnancy, gestational sac diameter, crown-
rump length and biparietal diameter
measurements are commonly used. Gestational Figure 66.5a Ultrasound scan of the uterus
sac is usually the first to be seen at ultrasound in longitudinal plane showing
examination. At 5 weeks, using the transvaginal early gestation sac
probe, the gestational sac can be identified with
a mean diameter of about 10 mm. At about 7
weeks the embryo is identified and fetal heart
beat is present. (Fig. 66.5a-c). Crown-rump
length (CRL) measurement when taken properly
between 6 and 12 weeks will give an estimate of
gestational age. Efforts must be made to obtain
the maximum length to reduce errors. After 12
weeks, CRL is not reliable because of flexion
and extension of the fetus. The accuracy of
predictionbefore 12weeks is ± 14.7 days.
Biparietal diameter is a measurement between the
parietal bones of the fetal cranium (Fig. 66.6). It is Figure 66.5b Ultrasound scan of the pelvis
showing early gestation. Note:
taken in the axial plane, preferably from the lateral the fetal echo within the gestation sac
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Figure 66.5c Pelvic ultrasound showing intrauterine

gestation at 9 weeks
Figure 66.8 Fetal ultrasound scan showing the
abdominal circumference

Figure 66.6 Ultrasound scan of fetus showing the

fetal head biparietal diameter
Figure 66.1Gd Twin gestation in which CRL
measurements have been taken.

2. Multiplepregnancy
Ultrasound scan is very useful in the diagnosis
of twin pregnancy especially in early
pregnancy when two gestational sacs are in
identified (Fig. 66. lOa-d).
In later pregnancy, the display of two heads on
Figure 66,7 . The fetal at 34 weeks the same viewis helpful (Fig. 66.11)
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Figure 66.10d Twin gestation in which CRL

measurements have been taken.

Figure 66.11 Diamniotic twin. Note the dividing

Figure 66.10b Diamniotic twins. Note the separating membrane between the fetuses
membrane between the two fetuses
3 .Localisation ofplacenta
The placenta is easily identified at ultrasonography.
In late pregnancy, the placenta shows uniform
echogenicity and white echo demarcating the
cotyledons. Localising the placenta has improved
the management of antepartum haemorrhages as
placenta praevia and abruptio placentae can easily
be identified. Anterior placentae are easier to
identify than posterior placentae. The relative
position of the placenta varies on serial scan from
the second to the third trimester. This has been
referred to as "migrating placenta" but this is due to-
development and growth of the lower uterine
Figure 66.10d Twin gestation at 8 weeks 5 days segment ratherthan actual migration. The presence

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538 Obstetrics endGynaecology

of the placenta in lower segment in the third 8. Biophysicalprofile

trimester (placenta praevia) can also be diagnosed. This is a test that checks fetal health. It
combines a non-stress test (NST) with a careful
ultrasoundexamination. It is usually done after
28- week of the pregnancy. Four different
indicators are checked at ultrasound. These are:
(i) fetal breathing movement
(ii) gross body movements
(iii) fetal tone
Figure 66.12 Ultrasound scan of fetus showing the (iv) qualitative amniotic fluid volume.
base of the skull, cervival and throacic The additional observation (NST) is,
spines
(v) recording reactive fetal heart rate.
4. Fetal abnormality These indicators are scored from 0 to 2 in
A routine scan at 18 and 22 weeks allows for addition to the non-stress test. The scores are
detection of any structural abnormality of the
then added up for a combined maximum of 10.
fetus. At this scan, every organ and structure in
the fetus is carefully examined (Fig. 66.12). Gynaecologic application of ultrasonography
Hydrocephalus, anencephaly, spina bifida, includes:
exomphalus and renal agenesis are some of the (1). diagnosis of early pregnancy
abnormalities commonly detected. disorders (miscarriages, missed
abortion, ectopic pregnancy).
5. Fetal weight
The fetal weight can be derived at ultrasound (2) diagnosis of polycystic ovary
from BPD and abdominal circumference (AC) disease, follicle tracking in ovulatory
measurements. Mostmodemmachines allow this infertility and ovarian cyst.
derivation bycomputing the values of BPD andAC. (3) diagnosis of uterine and ovarian
pathology.
6. Sex determination
The fetal sex can be determined at ultrasound and 1.Earlypregnancy disorders A blighted ovum
this usually will require a skilledultrasonographer. is diagnosed at ultrasound when there is a
gestation sac without an embryo. It is called
7. Amniotic fluid ' volume Abnormally low
anembryonic gestation. In threatened
(oligohydramnios) or high (polyhydramnios)
amounts of amniotic fluid are associated with
miscarriage, ultrasound can be done to confirm
poor fetal outcomes. The amniotic fluid index intrauterine pregnancy with demonstration of
(AFT) is the sum of all maximumvertical pool fetal cardiac activity and a closed internalcervical
of amniotic, fluid measurements in four Os. This usually helps to reassure the patient.
quadrants of the uterus. It is a measure of fetal Ultrasonography will also demonstrate the
wellbeing. presence of retained products of conception in
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Imaging in obstetrics and gynaecology 539

incomplete miscarriage.
Failure to demonstrate cardiac activity within a
fetal pole is suggestive of a missedabortion.
Ultrasound impression of an ectopic pregnancy
can be made by identifying any of the following:
(i) a gestation sac (with or without a fetal
pole) outside the uterus,
(ii) an adnexal mass in association with a
bulky but empty uterus
(iii) an adnexal mass in association with
free fluid in the pelvis. Figure 66.13a Ultrasound scan of the pelvis showing
a normal uterus in longitudinal section
2. Ovarian ultrasonography The ovary is usually
visualised at bothsides of the uterus. Inpolycystic
ovaries, the ovaries are usually larger thannormal
and have multiple small cysts that form a ring
round the ovaries. Follicle tracking is done
sonographically in ovulatory infertility. Follicles
on the ovary are identified, measured and
continually monitored from 3-5 mm diameter up
to 18-20 mm on average at the time of ovulation.
The follicles appear as echo-free structures
amidst the more echogenic ovariantissue. Where
a follicle attains a diameter of 24 mm and above,
follicular failure should be suspected. Follicle Figure 66.13h Pelvic scan showing a normal uterus in
transverse plane
tracking is also very useful in IVF/ET
programmes to determine the number of mature
follicles. 3. Uterine sonography The uterine
muscles usually show homogenous low to
moderate echogenicity. The endometrium is
shown as a linear echo of moderate to high
amplitude. The uterus is usually visualised in the
longitudinalandtransverse sections (Fig. 66. 13 a-
b). Fibroid is a common benign tumour of the
uterine myometrium. It is usually identified as a
discrete circular structure within the myometrium
(Fig.66.1 Figure 66.14a Transverse diameter of uterus
showing uterine fibroids

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Prince Of Medicine-2014-BSUTH

j 540 Obstetrics and Gynaecology

higher radiation in the areas that are scanned.

Computed tomography has been used in the
evaluation of all organ systems in obstetrics
and gynaecology. Cranial C.T scanning has
been useful in the evaluation of acute
haemorrhage in epidural, subarachnoid or
subdural spaces. Computed tomography
pelvimetry has been used to evaluate pelvic
Figure 66.14b Pelvic ultrasound showing multiple
bony dimensions.
uterine fibroids
In gynaecology, C.T. has been used in the
diagnosis of prolactin secretory adenoma of
the pituitary gland. It has also been found
useful in assessing extension of pelvic
cancer. It can identify lymph nodes adjacent
to pelvic vessels. It is expensive and has
been used in few centres in developing
countries. Fig.66.15 shows a normal C.T.
image ofthe female pelvis.
Figure 66.14c Ultrasoundscan of the Pelvis showing
uterine fibroids. Notethe enlarged A- MAGNETIC RESONANCE IMAGING
P diameter of the uterus (MRI)

4a-c). It may also present as an irregular

contour in the anterior or posterior uterine
wall.

Cryptomcnorrhea, 108 Fimbriae, 7

-biopsy, 134-135
Cystometry, 56 -cycle, 26-27 - ovarica, 7
Cytomegalovirus infections, 318 Endometrial carcinoma. 189-191 Follicle stimulating hormone
(FSH),21
Cystoscopy, 56 Endomctriomata (Endometrioid),
Cystourethroscopy, 236-237 202-203 Follicular phase, 25
Endometriotic cysts, 163 Forceps delivery, 419,489-491
Endometrium, 5 Forewater amniotomy (ARM), 434-
Decapitation, 462-463,492 Endomyocardial fibrosis (EMF). 361 435
Delayed puberty, 28 Engorgement of breast, 507 - oxytocin titration, 434
and
Demographic details, 258-259 Episiotomy, 479-480 For thergill or Manchester opera¬
Destructive operation, 462-463,468, Examination in theatre (BIT), 340,342 tion, 35
492 Excisional methods, 172-173
Development of External
- the external genital organs, - cephalic version (EC V), 418- Gall bladder disease in pregnancy,
16 419 275
-the ovary, 14-15 - genital organs Gastrointestinal tract infection, 506
-the vagina. 14 - anomalies of, 17 General analgesics ,513,516
- uterus and fallopian tube, - genitalia, 1 Genetic
12-14 - defects, 98
Diaphragm and cervical cap and -theories, 123
sponge, 152 Face presentation, 420
Genital
Diarrhoea diseases in pregnancy, Failure of normal blood -folds, 16
276-277 coagulation,
-herpes, 84-86
Dilatation 481-482
-andCurettage(D&C), 103, Fallopian tubes, 6 - tract infection, 504-506
False Labour, 284 -warts, 86-87
130
Family Genuine
-and Evacuation (D&E), 100
Domestic violence, 245 - and social history, 258,260 - preterm labour, 424
Doppler, 29 1 -292 -planning programmes, 145 - stress incontinence (GSI),
Female 53-55
Down's syndrome, 389-392
Dysfunctional uterine bleeding -circumcision, 245 Germ Cell Tumours, 206,208-209
(DUB;, 106,116-119 -condoms, 152 Gonadal
Dysmenorrhoea, 106,119-121 - genital tract - dysgenesis, 107
- congenital anomalitics of, -ridge, 14
16-17 -sex, 238
Early embryonic or fetal demise, - infanticide, 245 Gonadotrophin releasing hormone
97-98 - Pseudo hermaphroditism (GnRH),2 1
Early pregnancy disorders, 538-539
241-243 Gonadotropins, 21-22
-sexual slavery, 244 Gonorrhoea, 75-76,80-82
Eclampsia
-sterilisation, 152-153
-
types of, 356
- urinary tract,
Granuloma inguinale, 87-88
Ectopic pregnancy, 68,95,1 ) 1-104
Fetal
Eisenmcngcr syndrome, 363
Electrocautery, 140
- alcohol syndrome, 522 Head Filling test, 446
-biopsy, 398-399
-
Electro convulsive therapy (ECT)
-macrosomii, 414
Health education, 261
and pregnancy, 522 HELLP syndrome, 351-352,359
Fetoniaternal haemorrhage, 382-383
Electronic fetal monitoring, 292 Fibroid polyp, 167 Hepatitis viruses. 320-321
EL 1 SA tests, 90 Heipes simplex, 318-319 "
Fibroids in pregnancy, 473-474
Embryo transfer (E.T), 137- 1 39 Fibroma and fibromyoma. \63 History of present pregnancy, 25*» ; ; •

Embryotomy, 462-463,492-493 Fibromata, 203 260

Endometrial Fibromyoma (fibroid myoma), Hormonal
Uft -as 4
-Assays. 114-115
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Prince Of Medicine-2014-BSUTH

Index 545

- deficiency, 98 Instrumental delivery, 462 Legal abortion, 99

--theories,
sex (phcnotypic sex), 238-239 Internal Ligaments of the uterus, 6
Hormone
124 - genital organs, 4-8 Lilcy graph, 384-385
Replacement Therapy - podalic version, 468 469- Listeriosis, 313-314
(HRT),30 International Labour Organisation, Lithium, 521
Host - parasite interactions, 310-311 244 Local infiltration, 514
Human immunodeficiency vims Interstitial cystitis, 60 Locked twins, 377,379
nrrv),78,89 Intracervical foley catheter Loop electrosurgical excision
-AIDS, 68,151,173 balloon procedure (LEEP), 172
-counselling, 91 overnight, 433 Lumbar epidural analgesia, 515-516
- infections, 244,402-406 Intrahepatic cholestasis of Luteal phase, 26
-screening, 261 pregnancy, 275 Lutein cysts, 197
- virus, 89-92 Intramural part, 6 Luteinising hormone (LH), 21
IJydatiform mole, 218-220 Intrapartum, 356,404
Lymphatic drainage of the genital
Hydrocephalic head Intrauterine contraceptive devices
organs, 10
-drainage of, 463 (IUDs), 150-151
Lymphogranuloma venereum
llydrotubation, 144 Intrauterine fetal transfusion, 386
(LGV), 83-84
Hymen, 2 Intravenous urogram (IVU), 56,186
Hypertension (in pregnancy), 348- Invasive
349 - carcinoma, 475 Magnetic resonance imaging
Hypertensive disorders of pregnancy, -mole, 2 18,220-221
In - vitro fertilisation (IVF), 137-139 (MRI), 342,473,532,540-541 Male
348
Involuntary sterilisation, 136,153 Malignant
Hypnosis, 512
- abortion, 245 tumours, 163-166,189-192
Hypothalamus, 19
- prostitution, 244 -of the vulva, 157
Hysterectomy, 173
- sterilisation, 245 Malnutrition, 244
Hystcrosalpingogram (HSG), 132,
14! Iron deficiency anaemia, 329 Malpresentation, 439
Hystcroscopy, 142,235-236 Isthmus, 6 Management of labour, 287-295
Hysterotomy, 100 -
Marshall - Marchetti Krantz, 57
Mastitis, 507
Jaundice in pregnancy, 274 Maternal
Idiopathic dctnisor overactivity - Ketoacidosis, 367
(IDO),58 -mortality, 527-530
Illegal abortion, 99 Kielland's forceps delivery, 468 - Ratio (MMR), 526-527
Immunodiagnosis of Ovarian Kleihaner - Bctke test, 387 Maternity blues, 522-523
Cancer, 210 Klinefelter syndrome, 239 Mauriceau - Smellie - Veil Method,
Immunological 419 i

-abnormality, 98 Mechanism of labour, 286 - 287

-theories, 123 Labia Melanoma, 162,166
Inclusion cysts, 1 63 - majora, 1 Menopausal distress and other
Induction of labour -minora, 1 perimenopausal disorders,
- methods of, 434-437 Lactation, 305-306 248-249
InfundibuJum, 6 - Amenorrhoea method Menopause, 29-30
Inhalation analogies, 514 (LAM), 154 Menorrhagia, 117
Inhibin, 23 Laparoscopic Menstrual
Injectable -history. 258-259
contraceptives, 148-M9 •myomectomy, 189
jury to the genital -surgery, 144 -phase, 26-27
Innervation of the birthtract,
canal,
481-482
5| pf Laparoscope 142,234-335 Metrorrhagia, 117-118
J JI o Large loop excision of the transfor¬ Micro-invasive carcinoma, 475
mation zone (LLETZ), 172 Microsurgery
F, .
ÿ

Latent phase labour, 283

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Prince Of Medicine-2014-BSUTH

_* ill Ob.ucli re* ,im/ • >'t tuiveiiblpy

- principle* "f. I 10-140

Mifuniiijiifiil iiwioiineiiK HO- I'll - (;|)lÿ?lHi i|l|0|| Hi, 2.00' hi powimn-y, 500-110
Minium! Acce** Noigiov (MAN), 204 IMnaid r.|ei|inÿnpu, 2.0 1
2.14,2.17 - (OlnlfeiO OuiHIHH, 204 PiiMMaiy, 21 •J.. .
Mi.sopioilol. 410-4 .17 205 fdwema
Miscarriage. 0 5-0II nlliii'iniiniunjlliy, 310 •fin. nmviilliilf!, 207
i)Vf»ty iikmbintinega, 207
Monitoring orfelo! Wc'llhelng, 70I •

Monozygotic (Wins, I'M-.17 7 cOilgMiiilal ailoiiMlifi, 1/ - pokvia, 440 343-

Moris pubis. I
i Ivet flow InruiiliMHirÿ 53 50, IV i - cin-penliifjala, 207
Ivtllallon UmIiiHIiIii dings, 1/t - types of, 20/
Moils Veneris. I
Mucinous cvsladeiiunia, 202-20J
'
» Ivtlhiluty phase, 23=20 Placental trigger, 450
Mollerian iliicl symliome, 740
i hyioeiu nitgmciifalitni, VII 1,402, pnlyhyrlraimiiof, 30/ , .
Mullerinii (iihercle, 12 440 frilypwHHhy, HOI ,, ..
i hyfoeln llliailun proi edum, 443 Pnsl- 'filial 'nnOacapOiH), 150
i i
Mm It (gravida, VIM VII i/l.15
Mycoplasma! iitfiM-lioiis, 114 Posltiaial
Myometrium, 5
-depression, 524ÿ525
INiO test, 30 -muimiualiou, Mil
I'nlii reiki In ImImmm, 3 1 V Pusfpailiim, 13r,/t04
Papilloma, !o i r psychosis, 324-524
Narcotics, 5 I I
Nci ve supply lo (lie genital
Paraecivieal block, 3 1 3 Ptiiiufi of Douglas, 4
Patlograpli, 203 III!) Piecu' lutis puhufly, 2M-2.0
organs. 0 10
Neuroleptics. 37 1
Parvovirus, 121 Premature rupture of membranes,
Past 427 420
Non- contractile false labour, 2113
medical oi' stugleal hisloiy, Pienicnsiiiial muslon fityniJromÿ
- insulin dependant tlinhclic (PTH), 240-24H
23 II-2 30
patients (MINI >M), loll
obsleblc liNlmy, 7510250 Pranalal diagnosis, .188-389
- nncculir drugs, 11 '1-5 14
Paternal l(!) slams, III I Pelvic- Prhnigravida, 284-285,454-455 '
- pharmacological IllctllOih
(of pnin re lieI), .5 IV
- contamination Hmmm y, 200 Pilmilive gonad, 14 . i-
ÿdiaphragm, I Progesterone, 22-2 |
- specific infections In
pregnancy, 3 IV - Illlliiniilialoiv disease (I'll I), Progestogen only pills (POP), M7-
Ol'OHJIImlH/ I4K
Normal mcnztiiml cycle, V'/ Ofgan prolapse <|iialiiicalioil holmiin inhibiting liormono (PHI),
(POPt7),4 I 21
* lubmeiilosls, oil Pr nllhnalivc phase, 20
Obstetric palsy, 44-45 PetUilaMeous umldlh'al lilood Pffilnnggd lahour
Obstructed Inbuilt, 45.4-47 1 «aniplln«P3ada»einesh), 104 -causes of, A 40-440
- complication of, 404 - 404 Pcilnatal inoilahly, 3 10 3 11 Pmslaglandln
- iMjulry complex, 43 I'mJ nea I » 1(2,4 15-4)0
OcciplfoposleHoi position, 4.50-43;1 -hotly, 2-4 -pcssaiy, 444
Oeslrogen leaf, 4 /7-4 /11 Prolalnufia, .140*.150
-
fiMicfions of, 22
OJJgomenorrhoeft, 100
Peiiwum, V Psyehialric dihiadcrs in ihc
Ptojmmlnal hulking ageiM, 'III purpaiium, 322-325
Oral eottfract pllves, 145 Plan oncological ttirdltorln 0)1 pain Psychological
Ovarian 317-310 char ics m piegnaiH-y. 5l9r
-cycle, 25-20 Pbaimaeolberapv, 37 320
- cyst In|07-
pmgnHOoy, 210 Physiological - nun lions lo hysicHvih'iiiy.
-cysfs 1VV changes
<• 240 251
-Screening, 215 mlilijeel iitiplhidlon i)fff
-oum/ms, l#0,47M7l? * icai'lioiis lo ptcgnancy
51(1-311
miioomtt 320-522
Psychophysiologu al diaordcr. 24- 1

240
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Prince Of Medicine-2014-BSUTH

Index547

244-2.15 - determining gene, 238 Trasylol or epsilon aminocaproic

psychosocial issues,lobaceo,
psychoimpic drugs, - hormone binding globulin acid (EACA), 346 -
alcohol and pregnancy, 521- (SHBG},22 Trichomoniasis, 73-74
522 - hormones, 3 Tubal
I'Lihciiy, 27-2H Sexual -insufflation, 132,134
pudeiidiillilock,5 14-5 15 -education, 91 - surgery
. -types of, 143-144
puerperal -history, 129
-wfrclion, 504-506 -violence, 244-245 Tubocornual
- sepsis and wound infec¬ Shoulder presentation, 420-421 -anastomosis, 143-144
tions 312 Sickle cell disease, 331 - implantation, 143
Sling operations, 57-58 Tubotubal anastomosis, 143-144
Sonographic screening for Tumour markers, 215
Quinacrine sterilisation, 153 anatomical defects, 392-393 Turner's syndrome, 239
Spermicides, 152 Twin-to-twin transfusion syndrome,
Spinal block, 516 377
Racial and ethnic risk factors, 392 Spontaneous abortion, 520
Radiography, 532 - 533 Stages of labour, 283-287
Rectovaginal fistula (RVF), 44,*50- Stanley operation, 58 Ultrasonography, 103-104,205,324,
51 Sterilisations, 152-153 393,533-540
Regional analgesia, 514 Stillbirth, 520 Umbilical
Relaxin.23 Stress incontinence, 53 - artery Doppler ultrasound,
Respiratory tract infection, 506 Subdermal progrestogen contra¬ 413
Retinopathy and nephropathy, 367 ceptives, 149-150 -Cord
Retrognulemenstruation / implanta¬ Suction evacuation, 100 - abnormalities of, 271
tion theory, 122-123 Surgical methods, 100 Ureterovaginal fistula (ureteric
Jih system, 3H J Syphilis, 79-80 fistula), 48-50
Rokitansky - Kuster - Hauser Symphysiotomy, 448,462 Urethral
syndrome, 17 -caruncle, 59
Round ligaments of the litems, 6 - diverticulum, 59
Rubella (in pregnancy), 3 16-318
Rupture of (lie uterus, 465-47 1
Tension - free vaginal tape (TVT), - prolapse, 60
58 - sphincter incompetence, 53
Termination of pregnancy, 99 Urinary
Salpingolysis, 143
Testicular feminisation, 240 -
incontinence, 53
-syndrome, 106-107 - tract disorders (in pregnancy),
Salpingoscopy, 142- ] 43 Therapeutic abortion, 99 280-282
Sarcoma, 166 Third stage of labour, 286,294 - symptoms of, 53
-of the vulva, 162
Scrolling for HIV/AIDS, -105-406 Threatened preterm labour, 424-427 - tract infection (LTH), 44
.
econd stage of labour,
285-286
Thromboembolic disorders, 507-508
Tobacco smoking, 521-522
Uterine
-
and Fallopian tubes, 16
secondary amenonboea
Secretory phase, 26 4S Total Dose Iron intravenous therapy -atony, 481-482
Selective abort.on, 245 (Irondextran), 337 - inertia,440
ÿ"'lc vaginitis, 76 Toxoplasmosis, 312-3 13 - involution, 303-304
202-203
Transabdominal ultrasonography, - prolapse, 3 1
341 - reuoversion,473
1.14' "|!iÿ5s,erone estimation, Trancutaneous electric nerve stimu¬ - rupture
Sex lation (TENS), 512 - types of, 469-471
lYansitionsl cell (Brenner) tumours, -sarcoma, 191
Jdstromal TumoiJrs. 206- 202-203
Transvaginal ultrasonography, 341
-sonography, 539
Uterosacral ligaments,6
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Prince Of Medicine-2014-BSUTH

5 IS Obsfertrics and Gynaecology

Vnginn, 17
-common anomalies of. 17
Varicocelectomy, 136 -
Vulval excoriation, 44
Vaginal
Vasa pracvia, 347 - hacmatoma, 478-479
-breech deli very, 4 1 8-419
Vaso - vasostomy, 136 Vault - Intraepithelial Neoplasia
prolapse, 3 1,33 (VIN), 157
-cytology, 134-135
Ventouse delivery (or vacuum Vulvovaginal candidiasis, 71-73
-hysterectomy, 1 88
extractor), 491-492 Vulvovaginitis, 61-63
- and pelvic lloor
Repair, 35
Vesicovaginal fistula (VVF), 39-51
Vestibule, 1-2
-
in children, 76-77
- intraepithelial neoplasia Vidcocystourcthrography (VCU), 56
(VAIN). 173
Viral
-myomectomy, 188 Western blot test, 90
- operations, 462-463 - diseases (in pregnancy), Window period, 90
278-280,314-315
-prolapse, 3 1 Varicella
zoster, 319-320
- -hepatitis, 274-475
Voiding
X-ray pelvimetry, 445-446
- mechanism of, 52

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Prince Of Medicine-2014-BSUTH

Textbook of Obstetrics and Gynaecology

For Medical Students
This book is written primarily for undergraduate medical students in Nigeria
andother parts ofAfrica, as well as the tropical and developing countries since
disease patterns are related in these regions. It integrates basic sciences and
clinical materials to aid undergraduates in getting a thorough understanding of
the underlying disease processes in the tropics. This omnibus and revised
edition, previously in two volumes, now comprises sixty-six chapters and
deals with comprehensive topics inObstetrics and Gynaecology.

The pool of contributors has been enlarged to include a few more distinguished
teachers and consultants from teaching and specialist hospitals. The contri¬
butorshave all enrichedthe volume with their varied clinical experience.

ISBN 978 129 934 7

['E'Bjf Heinemann EducationalBooks (Nigeria) Pic

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