The female reproductive tract can be divided into the lower and the upper genital tracts from a functional and clinical viewpoint.
Lower genital tract
The lower genital tract comprises the vulva, vagina and cervix.
The vulva
Development
In early embryonic development there is a common indifferent stage when the external genitalia of both sexes comprises:
• Two genital swellings
• Two genital folds
• A midline anterior genital tubercle
In the absence of fetal testosterone, these develop in the female into:
• Labia majora
• Labia minora
• Clitoris
During puberty, there is an increase in the size of the labia majora and pubis by the accumulation of fat, and pubic hair develops prior to menarche. Low oestrogen levels after the menopause result in atrophic changes with loss of fat and pubic hair and sometimes narrowing
of the introitus.
Anatomy
The vulva has a rich blood supply from the internal pudendal artery and other branches of the internal iliac artery, and the external pudendal artery which arises from the femoral artery (Fig. A ).
The lymphatics drain to the inguinal and superficial femoral lymph nodes. The pudendal nerves arise from S2, 3 and 4.
The vagina
Development
The upper vagina develops from the paramesonephric duct and the lower vagina forms by canalization of the solid sinovaginal valves. The introitus and the hymen develop from the urogenital sinus. The complete canalization of the vagina does not occur until 6 – 7 months in utero.
Anatomy
The vagina is lined by stratified squamous epithelium. This epithelium is rich in glycogen; a substrate used by the normal commensal lactobacillus. The breakdown of glycogen to lactic acid produces an acidic vaginal pH. This has a protective role in maintaining normal vaginal flora and preventing an overgrowth of pathogenic organisms.
Secretions from the cervical, paraurethral and Bartholin’ s glands and some vaginal transudate form physiological vaginal discharge. Before puberty and after the menopause low oestrogen levels are associated with low levels of glycogen and thinning of the vaginal mucosa.
The blood supply derives from the vaginal artery branch of the internal iliac artery.
The lymphatic drainage from the lower third of the vagina is the same as the vulva but the upper two - thirds drain to the internal iliac, obturator and external iliac nodes.
The cervix
Development
The cervix and the uterus develop from the fusion of the paramesonephric ducts with absorption of the central septum to form a single cavity. The cervix projects into the vaginal vault and the ectocervical portion is covered with the same stratified squamous epithelium as the vagina. By contrast, the endocervical canal has a single layer of columnar epithelium and contains numerous mucus glands. The two types of epithelium meet at the original squamocolumnar junction (SCJ) and in utero, under the effect of maternal oestrogens, this lies on the surface of the ectocervix. The site of the SCJ changes after birth and throughout reproductive life.
The transformation zone of the c ervix
Low oestrogen levels in childhood result in the SCJ retracting into the endocervical canal. During puberty, increasing oestrogen levels increases the size of the cervix with eversion of the anterior and posterior lips of the
cervix. This exposes the columnar epithelium which
appears redder and rougher than the smooth pale squamous epithelium. This is a physiological change called an ectopy or ectropion. The acidic pH of the vagina
promotes active metaplasia of columnar to squamous
epithelium. As a result, the original SCJ junction lies out
on the ectocervix and the area between this and the
new SCJ is known as the transformation zone (TZ). The
endocervix contains many mucous glands and gland
openings can still be seen within the TZ. Cervical mucus
produces most of the vaginal secretions.
The TZ is the area where precancerous and cancerous
changes are most likely to be identified (see Case 10 ) and
this is the area of the cervix that needs to be sampled for
cervical screening. After the menopause, reduced oestrogen levels produce shrinkage of the cervix and retraction
of the SCJ into the endocervical canal.
The cervix receives its blood supply from ascending
branches from the vaginal artery and descending branches
from the uterine artery
The lymphatics drain to the internal and external iliac
and the obturator fossa nodes.
Upper genital tract
The upper genital tract comprises the uterus, fallopian
tubes and ovaries.
The uterus
Development
While the uterus forms by fusion of the paramesonephric
duct, the mesonephric ducts in the female fetus degenerate after the indifferent stage. The upper part of the
paramesonephric ducts remain separate and form the
fallopian tubes. These enter through the thick muscular
walls of the uterus at the cornua and on hysteroscopy the
tubal ostia can be seen at either end of the uterine fundus.
Inferiorly, the upper end of the endocervical canal is
known as the internal os.
Anatomy
The outer surface of the myometrium is covered by peritoneum which runs over the dome of the bladder and
posteriorly to cover the pouch of Douglas behind the
uterus and upper vagina. Lateral to the body of the
uterus, this forms the broad ligament which is simply a
fold of peritoneum which has no supportive function.
The uterus receives its blood supply from the uterine
artery, a branch of the internal iliac artery. It crosses the
ureter and runs a very tortuous course up the side of the
uterus. This allows the large increase in size of the uterus
during pregnancy.
The lymphatics drain to the internal and external iliac
and the obturator fossa nodes.
It is important to know the anatomical course of the
ureter for gynaecological surgery as it passes through the
base of the broad ligament and close to the cervix
ureter for gynaecological surgery as it passes through the
base of the broad ligament and close to the cervix
The endometrium
The inner layer of the uterus is the endometrium. The
basal layer of the endometrium remains throughout the
menstrual cycle and forms tubular glands which penetrate into the myometrium. The endometrial structure
and function is controlled by hormones which vary
throughout the menstrual cycle.
The inner layer of the uterus is the endometrium. The
basal layer of the endometrium remains throughout the
menstrual cycle and forms tubular glands which penetrate into the myometrium. The endometrial structure
and function is controlled by hormones which vary
throughout the menstrual cycle.
• Following menstruation. The basal layer is covered by
necrotic glandular and stromal tissue with the underlying
glands intact.
• Proliferative phase. There is rapid repair of the endometrial glands and stromal metaplasia. Initially, the
surface epithelium is thin but by mid - cycle it is 3 mm in
thickness. The endometrial glands are formed by a single
layer of cuboidal cells with a short straight narrow lumen.
• Following ovulation (early secretory phase). Increasing
oestrogen and progesterone production stimulates secretory activity (the secretory phase of endometrium). The
glands lengthen and become tortuous. This prepares the
endometrium for implantation should the ovum be
fertilized.
• Later secretory phase. Progesterone decidualizes the
endometrial stroma with increased size of the stromal
cells and increased extracellular fluid. If pregnancy does
not occur, the endometrium undergoes apoptosis and
consequently loss of the functional outer 75% of the
endometrium.
The ovary
The ovaries are essential to reproductive function with
ovum production and oestrogen and progesterone production under the control of the hypothalamic pituitary axis.
Development
The primitive gonads first appear at 5 weeks ’ gestation as
a gonadal streak in the mesonephric genital ridge. At this
indifferent stage, they can develop into ovaries or testicles. These contain coelomic epithelium, mesoderm and
primitive germ cells. The primitive germ cells originate
in the endoderm and migrate to the primitive gonad to
develop into oocytes. The stromal cells develop from the
ovarian mesenchyme. The number of oocytes is greatest
in utero before birth and throughout life many oocytes
undergo atresia. The ovum remains in arrested meiosis
and this is not completed unless the oocyte is fertilized
by a sperm.
The gonads descend from the abdominal cavity into
the pelvis in the female, and the scrotum in the male, by
a ligament known as the gubernaculum. This embryological remnant is called the round ligament and has no
supportive structure in the female.
Anatomy
The ovaries are suspended from the back of the cornua
of the uterus by the ovarian ligament and from the broad
ligament by the mesovarian, which contains the nerves
and vessels, and laterally to the suspensory ligament. In
necrotic glandular and stromal tissue with the underlying
glands intact.
• Proliferative phase. There is rapid repair of the endometrial glands and stromal metaplasia. Initially, the
surface epithelium is thin but by mid - cycle it is 3 mm in
thickness. The endometrial glands are formed by a single
layer of cuboidal cells with a short straight narrow lumen.
• Following ovulation (early secretory phase). Increasing
oestrogen and progesterone production stimulates secretory activity (the secretory phase of endometrium). The
glands lengthen and become tortuous. This prepares the
endometrium for implantation should the ovum be
fertilized.
• Later secretory phase. Progesterone decidualizes the
endometrial stroma with increased size of the stromal
cells and increased extracellular fluid. If pregnancy does
not occur, the endometrium undergoes apoptosis and
consequently loss of the functional outer 75% of the
endometrium.
The ovary
The ovaries are essential to reproductive function with
ovum production and oestrogen and progesterone production under the control of the hypothalamic pituitary axis.
Development
The primitive gonads first appear at 5 weeks ’ gestation as
a gonadal streak in the mesonephric genital ridge. At this
indifferent stage, they can develop into ovaries or testicles. These contain coelomic epithelium, mesoderm and
primitive germ cells. The primitive germ cells originate
in the endoderm and migrate to the primitive gonad to
develop into oocytes. The stromal cells develop from the
ovarian mesenchyme. The number of oocytes is greatest
in utero before birth and throughout life many oocytes
undergo atresia. The ovum remains in arrested meiosis
and this is not completed unless the oocyte is fertilized
by a sperm.
The gonads descend from the abdominal cavity into
the pelvis in the female, and the scrotum in the male, by
a ligament known as the gubernaculum. This embryological remnant is called the round ligament and has no
supportive structure in the female.
Anatomy
The ovaries are suspended from the back of the cornua
of the uterus by the ovarian ligament and from the broad
ligament by the mesovarian, which contains the nerves
and vessels, and laterally to the suspensory ligament. In
the front of the ovary lies the fallopian tube with the
fimbrial end close to the ovary.
The blood supply to the ovary comes from the ovarian
arteries directly off the aorta below the level of the renal
arteries. The right ovarian vein drains into the inferior
vena cava and on the left into the left renal vein.
Lymphatic drainage of the ovary follows the course of
the blood vessels to the para - aortic lymph nodes.
The ovaries consist of a central vascular medulla and
outer denser cortex covered with a single layer of cuboidal cells. The outer cortex contains oocyte follicles at
various stages of development. Both the cortex and the
medulla contain stroma which provide support and
structure to the ovary but also synthesize steroid hormones. The majority of the primordial follicles present
at birth undergo atresia and it is the developing follicle
that produces circulating oestrogens. Oestrogen is
synthesized principally from androstenedione and
testosterone to oestradiol by the granulosa cells which
line the follicle.
Reproductive physiology
Puberty
Stimulation of ovarian tissue comes from follicule stimulating hormone (FSH) and luteinizing hormones (LH).
These are produced from the pituitary gland. FSH is suppressed in the fetus by oestrogens from placental and
maternal sources. In childhood, FSH levels are raised
as a result of low oestrogen levels. FSH is centrally
inhibited by gonadotrophin releasing hormones (GnRH)
produced from the hypothalamus. In the 2 years prior to
puberty, pulsatile release of FSH starts and increases in
frequency until it reaches normal adult levels. This establishes the menstrual cycle.
fimbrial end close to the ovary.
The blood supply to the ovary comes from the ovarian
arteries directly off the aorta below the level of the renal
arteries. The right ovarian vein drains into the inferior
vena cava and on the left into the left renal vein.
Lymphatic drainage of the ovary follows the course of
the blood vessels to the para - aortic lymph nodes.
The ovaries consist of a central vascular medulla and
outer denser cortex covered with a single layer of cuboidal cells. The outer cortex contains oocyte follicles at
various stages of development. Both the cortex and the
medulla contain stroma which provide support and
structure to the ovary but also synthesize steroid hormones. The majority of the primordial follicles present
at birth undergo atresia and it is the developing follicle
that produces circulating oestrogens. Oestrogen is
synthesized principally from androstenedione and
testosterone to oestradiol by the granulosa cells which
line the follicle.
Reproductive physiology
Puberty
Stimulation of ovarian tissue comes from follicule stimulating hormone (FSH) and luteinizing hormones (LH).
These are produced from the pituitary gland. FSH is suppressed in the fetus by oestrogens from placental and
maternal sources. In childhood, FSH levels are raised
as a result of low oestrogen levels. FSH is centrally
inhibited by gonadotrophin releasing hormones (GnRH)
produced from the hypothalamus. In the 2 years prior to
puberty, pulsatile release of FSH starts and increases in
frequency until it reaches normal adult levels. This establishes the menstrual cycle.
Ovarian hormone production is controlled by the pituitary and hypothalamus and the menstrual cycle results
if pregnancy is not achieved (Table A ).
Menopause
Even before the perimenopause, FSH levels start to
increase with altered ovarian response. Periods may
become lighter and less frequent or stop abruptly as ovulation ceases. Progesterone production is reduced which
affects luteinization. Despite rising FSH levels, ovarian
follicles fail to respond to gonadotrophins and oestrogen
production falls.
After the menopause, oestrone is found in lower levels
and is mainly produced by peripheral conversion of
androstenidione in adipose tissue.
Support to the pelvic floor and organs
The pelvic floor is formed by the levator ani muscles
which rise in a line running along the lower part of
the pubic bone, the internal surface of the pelvic fascia
and the ischial spine. They insert into the midline, the
wall of the anal canal and the lower part of the coccyx.
The urogenital diaphragm lies below the levator ani
and fills the gap between the pubic rami. The urethra
and vagina both pass through this diaphragm in the
midline.
Another important supporting structure is the perineal body, a condensation of muscle between the lower
third of the vagina and the anal canal. Its boundaries are
the vaginal fourchette to the anus and, superiorly, the
point where the posterior vaginal wall and the rectum
meet. Damage may occur following childbirth from tears
and care needs to be taken to identify any disruption for
repair.
The main supporting structures to the uterus are the
uterosacral ligaments and the transverse cervical ligaments. The uterosacral ligaments are dense fibrous cords
running from the posterior wall of the cervix and the
vaginal vault to the sacrum and can be clearly seen at
laparoscopy. The transverse cervical ligaments insert at
the level of the cervix and vaginal vault and spread out
laterally to the pelvic side wall. These lie under the base
of the broad ligament and cannot be seen unless the
pelvic side wall is opened. Both these pairs of ligaments
transmit sympathetic and parasympathetic nerve supply
to the pelvic organs.
Pregnancy involves a number of changes to the maternal
physiology, anatomy and hormonal milieu, to allow for
optimal growth and development of the fetus, protect the
mother through the processes of pregnancy and birth,
and also to allow for nurturing of the newborn baby.
Some of these normal physiological changes may result
in maternal symptoms and changes in the results of clinical investigations which may, in the non - pregnant state,
be associated with disease, and could therefore confuse
clinical assessment.
The placenta
Implantation of the embryo into the endometrium
occurs 8 – 10 days after fertilization. The surface trophoblastic cells of the blastocyst differentiate into the cytotrophoblast and the syntiotrophoblast which proliferate
and penetrate the uterine decidua and go on to form the
placenta. The placenta is an efficient interface between
the fetal vascular surface and that of the mother and
allows the fetus to obtain nutrients, exchange gases and
eliminate its waste products.
The placenta is also a major endocrine organ. It synthesizes and secretes steroid hormones – progestogens
and oestrogens – and a number of other hormones
including human chorionic gonadotrophin, relaxin and
placental lactogen, all of which have profound effects on
both fetal and maternal physiology.
Human chorionic gonadotrophin
This is one of the earliest hormones synthesized by the
chorion. It maintains the corpus luteum in the ovary,
which secretes progesterone and oestrogen, both of
which are essential for maintenance of the pregnancy,
until the placenta takes over the production of these hormones (by about 8 weeks ’ gestation).
Progesterone
This is one of the major hormones that helps maintain
the pregnancy. It appears to decrease the maternal
immune response to allow for the acceptance of the pregnancy, and decreases contractility of the uterine smooth
muscle allowing it to hold the pregnancy until labour and
delivery. A drop in progesterone levels possibly facilitates
the onset of labour.
Its relaxing effects on the smooth muscle are also seen
on the ureters, oesophageal sphincter and the intestines.
These may result in clinical symptoms of reflux, heartburn, delayed gastric emptying, constipation and ureteric
dilatation which may contribute to the increase in urinary
tract infection and/or pylonephrites in pregnancy.
Oestrogen (oestriol, oestradiol and oestrone)
While the placenta is the main source of oestrogen, it
requires certain enzymes that are produced by the fetus
to complete its synthesis. Oestrogen promotes the growth
of uterine muscle to allow it to adapt to the growing
pregnancy. Changes in the breast to allow milk production by increasing duct and alveolar development and to
allow feeding by increasing the size and mobility of the
nipple are also promoted by oestrogen. It increases
protein synthesis, and has effects on blood volume and
coagulation. It causes changes in the cervix including
softening to prepare it for labour.
Relaxin
Relaxin facilitates the birth process by causing a softening
of the cervix and the ligaments of pubic symphysis,
by simultaneously reducing collagen production and
increasing collagen breakdown. The loosening of the
ligaments of the symphysis pubis can result in maternal
discomfort and symphysis pubis diasthesis, especially in
the later stages of pregnancy.
Transfer across the placenta
Feto - maternal exchange across the placenta may be
passive (by simple diffusion, e.g. for water, oxygen,
carbon dioxide, urea), facilitated by a carrier molecule
(e.g. for glucose), active by enzymatic action (e.g. amnio
acids, free fatty acids, water - soluble vitamins) or by
pinocytosis (e.g. immunoglobulin G [IgG] antibodies,
lipoproteins).
Most medications or drugs pass through the placenta
as do nicotine, alcohol and illegal substances such as
cocaine and heroin. This is particularly important in the
first trimester for drugs that may be teratogenic, e.g.
angiotensin converting enzyme (ACE) inhibitors, but
may also be of relevance later on in pregnancy, for
example when there is neonatal withdrawal from opiates.
The embryo and fetus
In humans, the embryonic period begins at fertilization
(2 weeks ’ gestation or about 2 weeks after the last menstrual period in a 28 - day cycle) and continues until the
end of the eighth week of development (10 weeks ’
gestation).
Following fertilization once the zygote is formed, it
travels down the fallopian tube, dividing several times as
it does so, to form a ball of cells called a morula. Further
cellular division is accompanied by the formation of a
small cavity between the cells, resulting in a blastocyst.
The blastocyst reaches the uterine cavity at approximately the fifth day after fertilization. Lysis of the zona
pellucida, the glycoprotein shell around the blastocyst,
occurs, so that it can come into contact with and become
embedded in the uterine endometrium (implantation).
In most successful pregnancies, the blastocyst implants
8 – 10 days after ovulation. The inner cell mass forms the
embryo, while the outer cell layers form the membranes
and placenta. Together, the embryo and its membranes
are referred to as a conceptus, or the ‘ products of
conception ’ .
At this stage, there is rapid growth of the embryo, and
by the end of the embryonic period (10 weeks ’ gestation
or eighth week of development) the beginnings of all
essential structures are in place and the embryo ’ s main
external features begin to take form. This process is called
differentiation, and it results in the varied cell types (such
as blood, kidney and nerve cells). A miscarriage or birth
defects may occur if there are genetic abnormalities in
the developing embryo, or toxic exposures, for example,
to infections (e.g. rubella and cytomegalovirus), alcohol,
certain drugs or nutritional deficiencies (e.g. folate,
which might result in open neural tube defects). In the
vast majority of early miscarriages, however, it is difficult
to determine the causative factor.
The fetal period extends from 10 weeks ’ gestation to
birth and is characterized by growth and elaboration of
the structures and organ systems. Genitals are well differentiated by 12 weeks ’ gestation, and by 19 – 20 weeks
nails appear on toes and fingers and the mother is usually
able to feel ‘ quickening ’ – small fetal movements
(although in parous women, quickening may be felt
much earlier than at 20 weeks).
Some of the factors affecting fetal size and growth in
utero include race, ethnicity, size (body mass index
[BMI]), parity, age of the mother (e.g. teenage mothers
may have small babies), smoking, alcohol and drug
misuse, pre - eclampsia, recurrent antepartum haemorrhages, diabetes (usually causes large babies, but may
result in growth restricted babies with severe disease),
multiple gestation, maternal infections and fetal congenital abnormalities.
Adaptation of the fetus to extrauterine life
The circulatory system of a human fetus works differently from that of adults, mainly because the lungs are
not in use: the fetus obtains oxygen and nutrients from
the mother through the placenta. Blood from the placenta is carried to the fetus by the umbilical vein. About
half of this enters the fetal ductus venosus and is carried
to the inferior vena cava, while the other half enters the
liver. The branch of the umbilical vein that supplies the
right lobe of the liver first joins with the portal vein. The
blood then moves to the right atrium of the heart,
from where most of it flows through the foramen ovale
(opening between the right and left atrium) directly into
the left atrium, thus bypassing pulmonary circulation.
The continuation of this blood flow is then into the left
ventricle, from where it is pumped through the aorta into
the body. Some of the blood moves from the aorta
through the internal iliac arteries to the umbilical arteries, and re - enters the placenta, where carbon dioxide and
other waste products from the fetus are taken up by the
mother ’ s circulation.
Some of the blood entering the right atrium does not
pass directly to the left atrium through the foramen
ovale, but enters the right ventricle and is pumped into
the pulmonary artery. In the fetus, there is a special connection between the pulmonary artery and the aorta, the
ductus arteriosus, which directs most of this blood away
from the lungs.
Once the baby is born and the first breath is taken, the
circulatory and respiratory systems change dramatically.
The pulmonary resistance is reduced, and more blood
moves from the right atrium to the right ventricle and
into the pulmonary arteries, and less flows through the
foramen ovale to the left atrium. The blood from the
lungs travels through the pulmonary veins to the left
atrium, increasing the pressure there. The decreased right
atrial pressure and the increased left atrial pressure results
in the closure of the foramen ovale, which now becomes
the fossa ovalis. This completes the separation of the circulatory system into two halves, the left and the right.
The ductus arteriosus normally closes off within
1 – 2 days of birth, leaving behind the ligamentum arteriosum. The umbilical vein and the ductus venosus close
within 2 – 5 days after birth, leaving behind the ligamentum teres and the ligamentum venosus of the liver,
respectively.
Changes in the pregnant mother
Maternal changes start from very early on in the first
trimester of the pregnancy. Nearly all systems are affected.
Cardiac system
Stroke volume and heart rate both increase resulting in
cardiac output increasing by about 40% (from 4 to 6 L/
min). The pulse rate may increase by 10 – 15 beats/minute.
The increased flow across the heart valves results in
an increase in physiological flow murmurs heard on
auscultation.
There is a decrease in peripheral vascular resistance,
resulting in a fall in blood pressure of about 10 mmHg in
mean arterial pressure (MAP) in the first and second
trimesters. The blood pressure tends to rise again after
about 24 weeks ’ gestation.
The gravid uterus, especially in the later stages of pregnancy, can occlude the inferior vena cava when the
mother lies flat on her back, and cause decreased return
of blood to the heart, hypotension and reduced fetal flow
(supine hypotension). This is why pregnant mothers are
advised not to lie flat on their backs, and labour, delivery
and anaesthesia are managed with the mother propped
up or with a wedge that tilts her back.
Respiratory system
There is increased oxygen requirement in pregnancy,
which results in hyperventilation and deep breathing.
Ventilation is increased by 40% through an increase in
tidal volume (from 500 to 700 mL) rather than in the
respiratory rate. CO2 levels in pregnancy are lower than
in the non - pregnant state; this helps the gradient between
fetus and mother and favours transfer of CO2 from fetus
to mother across the placenta. Mothers may feel dyspnoeic; this may partly be because of the splinting of the
diaphragm by the gravid uterus.
Body temperature
Progesterone is thought to be responsible for the rise in
body temperature of 0.5 – 1.0 ° C during pregnancy. An
increased metabolic rate and peripheral vasodilatation also
result in a warm skin and may cause palmar erythema.
Blood and plasma volume
Blood volume increases by approximately 1200 mL
(40%), while red cell mass increases by 250 – 400 mL
(about 25%). This results in a relative haemodilution and
anaemia, with a drop in haematocrit and haemoglobin
levels.
There is increased blood flow to a number of systems
including the uterus, skin and the kidneys. There is an
increase in the glomerular filtration rate (GFR) from 140
to 170 mL/minute. This results in lower serum urea and
creatinine levels. This needs to be borne in mind when
interpreting blood results in pregnancy, as the normal
range quoted for the non - pregnant state may not be relevant, and an abnormal result may be missed.
There is an increase in extravascular fluid because of
lower plasma colloid osmotic pressure (albumin levels
are lower in pregnancy), and this contributes to the
peripheral odema that may be seen with normal pregnancy. Symptoms of carpel tunnel syndrome of tingling
of the fingers may be caused by compression of the
median nerve under the flexor retinaculum because of
increased extracellular fluid.
The blood may show a mild leucocytosis in pregnancy
(9 – 11 × 109/L compared to 4 – 11 × 109/L) and an increase
in erythrocyte sedimentation rate. Serum iron is lower and
iron requirements are increased because of demands from
the fetus, red cell increase and blood loss at delivery. There
is no consensus as to whether routine iron supplementation is indicated in pregnancy but evidence suggests that a
higher iron level following supplementation does not
improve maternal or neonatal outcomes. Iron supplementation is advised at haemoglobin levels below 10.5 gm/ dL.
Metabolic changes
Metabolic rate is increased to accommodate increased
energy demands from the fetus and for the maternal
changes. Pregnancy is also a diabetogenic state. Glucose
levels are increased as placental hormones are insulin
antagonists and there is an increased insulin resistance in
pregnancy. If sufficient insulin cannot be produced to
counter this resistance, gestational diabetes may occur.
This physiological change also explains why insulin
requirements in known insulin - dependent diabetic
mothers increases during pregnancy.
Coagulation profile
Pregnancy is a hypercoagulable state. This is a protective
mechanism for the mother to be able to minimize blood
loss after delivery of the placenta. There is an increase in
fibrinogen, factor VIII and von Willebrand factor, and a
decrease in anticoagulants such as antithrombin III.
There is also an increase in fibrinolytic activity.
While this hypercoagulable state is protective against
bleeding, it results in an increased risk of thrombosis
during pregnancy, especially when there are other risk
factors present (e.g. increasing age, smoking, high BMI,
operative delivery, prolonged immobilization).
Maternal weight gain
This is around 11 – 12 kg through the pregnancy. Much of
this increase is caused by the extravascular retention of
fluid (approximately 8.5 L), increase in blood volume,
growth of the uterus, breasts and body fat. The fetus
(around 3.5 kg), placenta and liquor (about 0.7 – 0.8 kg
each) account for about 4.5 – 5 kg of the weight gain.
Other changes
There may be thyroid enlargement and a mild goitre in
pregnancy. As there is increased urinary excretion of
iodine and some uptake of iodothyronines by the fetus,
there is a relative iodine deficiency in the mother. This
results in a compensatory thyroid hypertrophy in order
to maintain normal iodide concentrations. Especially in
early pregnancy, blood results may mimic a hyperthyroid
state with low thyroid stimulating hormone (TSH),
but free T3 and T4 remain within the normal range.
In mothers with a known history of hypothyroidism,
thyroid requirements may increase in pregnancy.
Renal changes include anatomical ones (dilatation of
renal pelvis and ureters) brought about by both the effects
of progesterone and pressure effects from the growing
gravid uterus to some extent. Renal function tests change
in pregnancy. Glycosuria may occur in the presence of
normal plasma glucose levels, because of an increase in the
GFR and a change in tubular reabsorption of glucose.
The uterus undergoes both hypertrophy and hyperplasia, and increases from a non - pregnant weight of 0.3 –
0.4 kg to 1 – 1.3 kg at term. Uterine blood flow increases
from 50 to 500 mL/minute.
The narrow isthmus of the uterus between the body of
the uterus and the cervix becomes increasing stretched
and thinned out as the pregnancy progresses, to become
the well - formed lower segment at term. This is the preferred site for the uterine incision at caesarean section,
because of its relative avascularity, quiescence, better
healing and lower risk of scar rupture in a subsequent
pregnancy than an upper segment incision. The lower
segment does not contract during labour.
As labour progresses, the cervix dilates and effaces
almost completely into the lower segment. When the
placenta is low lying and implanted on the lower segment,
there is an increased risk of postpartum haemorrhage as
the lower segment does not contract effectively after
delivery of the placenta.
As pregnancy progresses, the collagen concentration in
the cervix decreases and there is accumulation of glycosaminoglycans and water. This results in increasing ‘ ripening ’ of the cervix in preparation for labour.
Labour
Labour is the process whereby the fetus is delivered from
the mother; it involves regular uterine activity causing
progressive cervical dilatation and effacement followed
by expulsion of the fetus.
There are no conclusive theories to explain the onset
of labour. A change in the levels of and ratio between
concentrations of oestrogen and progesterone has been
suggested, possibly following a fetal trigger in the form
of secretion of adrenal corticosteroids when it is mature
and ready to be delivered. Prostaglandin concentrations
have been shown to increase prelabour and they are
known to promote cervical ripening and uterine contractility. Oxytocin receptors in the uterus also increase
towards term and oxytocin from the posterior pituitary
is known to be a potent stimulator of uterine
contractions.
The diagnosis of active labour is not always easy and
includes the presence of regular painful contractions with
increasing effacement and dilatation (usually at least
3 – 4 cm) of the cervix. There may be a ‘ show ’ (bloodstained mucosal discharge) associated with the cervical
changes. The first stage of labour is defined as the period
from the start of active labour until full (10 cm) cervical
dilatation.
The second stage includes the time until delivery of the
fetus after full cervical dilatation ( ‘ active ’ second stage is
when the mother is actively pushing with uterine contractions, while ‘ passive ’ second stage is when time is
allowed for the head to descend lower into the pelvis by
uterine contractions alone without maternal effort).
The third stage includes the time from delivery of the
fetus to the delivery of the placenta. The signs of placental separation include lengthening of the cord, a gush
of blood vaginally and sustained contraction of the
uterus.
Puerperium is the period following delivery which lasts
about 6 – 8 weeks, when the body returns to its prepregnant
state. While much of the physiological and anatomical
change is reversed, some changes are lasting (e.g. the presence of stria gravidarum). It is important to remember that
some of the maternal changes of pregnancy (e.g. the hypercoagulable state) remain for some time after delivery and
therefore the risks (e.g. of thrombosis) remain too.
if pregnancy is not achieved (Table A ).
Menopause
Even before the perimenopause, FSH levels start to
increase with altered ovarian response. Periods may
become lighter and less frequent or stop abruptly as ovulation ceases. Progesterone production is reduced which
affects luteinization. Despite rising FSH levels, ovarian
follicles fail to respond to gonadotrophins and oestrogen
production falls.
After the menopause, oestrone is found in lower levels
and is mainly produced by peripheral conversion of
androstenidione in adipose tissue.
Support to the pelvic floor and organs
The pelvic floor is formed by the levator ani muscles
which rise in a line running along the lower part of
the pubic bone, the internal surface of the pelvic fascia
and the ischial spine. They insert into the midline, the
wall of the anal canal and the lower part of the coccyx.
The urogenital diaphragm lies below the levator ani
and fills the gap between the pubic rami. The urethra
and vagina both pass through this diaphragm in the
midline.
Another important supporting structure is the perineal body, a condensation of muscle between the lower
third of the vagina and the anal canal. Its boundaries are
the vaginal fourchette to the anus and, superiorly, the
point where the posterior vaginal wall and the rectum
meet. Damage may occur following childbirth from tears
and care needs to be taken to identify any disruption for
repair.
The main supporting structures to the uterus are the
uterosacral ligaments and the transverse cervical ligaments. The uterosacral ligaments are dense fibrous cords
running from the posterior wall of the cervix and the
vaginal vault to the sacrum and can be clearly seen at
laparoscopy. The transverse cervical ligaments insert at
the level of the cervix and vaginal vault and spread out
laterally to the pelvic side wall. These lie under the base
of the broad ligament and cannot be seen unless the
pelvic side wall is opened. Both these pairs of ligaments
transmit sympathetic and parasympathetic nerve supply
to the pelvic organs.
Pregnancy involves a number of changes to the maternal
physiology, anatomy and hormonal milieu, to allow for
optimal growth and development of the fetus, protect the
mother through the processes of pregnancy and birth,
and also to allow for nurturing of the newborn baby.
Some of these normal physiological changes may result
in maternal symptoms and changes in the results of clinical investigations which may, in the non - pregnant state,
be associated with disease, and could therefore confuse
clinical assessment.
The placenta
Implantation of the embryo into the endometrium
occurs 8 – 10 days after fertilization. The surface trophoblastic cells of the blastocyst differentiate into the cytotrophoblast and the syntiotrophoblast which proliferate
and penetrate the uterine decidua and go on to form the
placenta. The placenta is an efficient interface between
the fetal vascular surface and that of the mother and
allows the fetus to obtain nutrients, exchange gases and
eliminate its waste products.
The placenta is also a major endocrine organ. It synthesizes and secretes steroid hormones – progestogens
and oestrogens – and a number of other hormones
including human chorionic gonadotrophin, relaxin and
placental lactogen, all of which have profound effects on
both fetal and maternal physiology.
Human chorionic gonadotrophin
This is one of the earliest hormones synthesized by the
chorion. It maintains the corpus luteum in the ovary,
which secretes progesterone and oestrogen, both of
which are essential for maintenance of the pregnancy,
until the placenta takes over the production of these hormones (by about 8 weeks ’ gestation).
Progesterone
This is one of the major hormones that helps maintain
the pregnancy. It appears to decrease the maternal
immune response to allow for the acceptance of the pregnancy, and decreases contractility of the uterine smooth
muscle allowing it to hold the pregnancy until labour and
delivery. A drop in progesterone levels possibly facilitates
the onset of labour.
Its relaxing effects on the smooth muscle are also seen
on the ureters, oesophageal sphincter and the intestines.
These may result in clinical symptoms of reflux, heartburn, delayed gastric emptying, constipation and ureteric
dilatation which may contribute to the increase in urinary
tract infection and/or pylonephrites in pregnancy.
Oestrogen (oestriol, oestradiol and oestrone)
While the placenta is the main source of oestrogen, it
requires certain enzymes that are produced by the fetus
to complete its synthesis. Oestrogen promotes the growth
of uterine muscle to allow it to adapt to the growing
pregnancy. Changes in the breast to allow milk production by increasing duct and alveolar development and to
allow feeding by increasing the size and mobility of the
nipple are also promoted by oestrogen. It increases
protein synthesis, and has effects on blood volume and
coagulation. It causes changes in the cervix including
softening to prepare it for labour.
Relaxin
Relaxin facilitates the birth process by causing a softening
of the cervix and the ligaments of pubic symphysis,
by simultaneously reducing collagen production and
increasing collagen breakdown. The loosening of the
ligaments of the symphysis pubis can result in maternal
discomfort and symphysis pubis diasthesis, especially in
the later stages of pregnancy.
Transfer across the placenta
Feto - maternal exchange across the placenta may be
passive (by simple diffusion, e.g. for water, oxygen,
carbon dioxide, urea), facilitated by a carrier molecule
(e.g. for glucose), active by enzymatic action (e.g. amnio
acids, free fatty acids, water - soluble vitamins) or by
pinocytosis (e.g. immunoglobulin G [IgG] antibodies,
lipoproteins).
Most medications or drugs pass through the placenta
as do nicotine, alcohol and illegal substances such as
cocaine and heroin. This is particularly important in the
first trimester for drugs that may be teratogenic, e.g.
angiotensin converting enzyme (ACE) inhibitors, but
may also be of relevance later on in pregnancy, for
example when there is neonatal withdrawal from opiates.
The embryo and fetus
In humans, the embryonic period begins at fertilization
(2 weeks ’ gestation or about 2 weeks after the last menstrual period in a 28 - day cycle) and continues until the
end of the eighth week of development (10 weeks ’
gestation).
Following fertilization once the zygote is formed, it
travels down the fallopian tube, dividing several times as
it does so, to form a ball of cells called a morula. Further
cellular division is accompanied by the formation of a
small cavity between the cells, resulting in a blastocyst.
The blastocyst reaches the uterine cavity at approximately the fifth day after fertilization. Lysis of the zona
pellucida, the glycoprotein shell around the blastocyst,
occurs, so that it can come into contact with and become
embedded in the uterine endometrium (implantation).
In most successful pregnancies, the blastocyst implants
8 – 10 days after ovulation. The inner cell mass forms the
embryo, while the outer cell layers form the membranes
and placenta. Together, the embryo and its membranes
are referred to as a conceptus, or the ‘ products of
conception ’ .
At this stage, there is rapid growth of the embryo, and
by the end of the embryonic period (10 weeks ’ gestation
or eighth week of development) the beginnings of all
essential structures are in place and the embryo ’ s main
external features begin to take form. This process is called
differentiation, and it results in the varied cell types (such
as blood, kidney and nerve cells). A miscarriage or birth
defects may occur if there are genetic abnormalities in
the developing embryo, or toxic exposures, for example,
to infections (e.g. rubella and cytomegalovirus), alcohol,
certain drugs or nutritional deficiencies (e.g. folate,
which might result in open neural tube defects). In the
vast majority of early miscarriages, however, it is difficult
to determine the causative factor.
The fetal period extends from 10 weeks ’ gestation to
birth and is characterized by growth and elaboration of
the structures and organ systems. Genitals are well differentiated by 12 weeks ’ gestation, and by 19 – 20 weeks
nails appear on toes and fingers and the mother is usually
able to feel ‘ quickening ’ – small fetal movements
(although in parous women, quickening may be felt
much earlier than at 20 weeks).
Some of the factors affecting fetal size and growth in
utero include race, ethnicity, size (body mass index
[BMI]), parity, age of the mother (e.g. teenage mothers
may have small babies), smoking, alcohol and drug
misuse, pre - eclampsia, recurrent antepartum haemorrhages, diabetes (usually causes large babies, but may
result in growth restricted babies with severe disease),
multiple gestation, maternal infections and fetal congenital abnormalities.
Adaptation of the fetus to extrauterine life
The circulatory system of a human fetus works differently from that of adults, mainly because the lungs are
not in use: the fetus obtains oxygen and nutrients from
the mother through the placenta. Blood from the placenta is carried to the fetus by the umbilical vein. About
half of this enters the fetal ductus venosus and is carried
to the inferior vena cava, while the other half enters the
liver. The branch of the umbilical vein that supplies the
right lobe of the liver first joins with the portal vein. The
blood then moves to the right atrium of the heart,
from where most of it flows through the foramen ovale
(opening between the right and left atrium) directly into
the left atrium, thus bypassing pulmonary circulation.
The continuation of this blood flow is then into the left
ventricle, from where it is pumped through the aorta into
the body. Some of the blood moves from the aorta
through the internal iliac arteries to the umbilical arteries, and re - enters the placenta, where carbon dioxide and
other waste products from the fetus are taken up by the
mother ’ s circulation.
Some of the blood entering the right atrium does not
pass directly to the left atrium through the foramen
ovale, but enters the right ventricle and is pumped into
the pulmonary artery. In the fetus, there is a special connection between the pulmonary artery and the aorta, the
ductus arteriosus, which directs most of this blood away
from the lungs.
Once the baby is born and the first breath is taken, the
circulatory and respiratory systems change dramatically.
The pulmonary resistance is reduced, and more blood
moves from the right atrium to the right ventricle and
into the pulmonary arteries, and less flows through the
foramen ovale to the left atrium. The blood from the
lungs travels through the pulmonary veins to the left
atrium, increasing the pressure there. The decreased right
atrial pressure and the increased left atrial pressure results
in the closure of the foramen ovale, which now becomes
the fossa ovalis. This completes the separation of the circulatory system into two halves, the left and the right.
The ductus arteriosus normally closes off within
1 – 2 days of birth, leaving behind the ligamentum arteriosum. The umbilical vein and the ductus venosus close
within 2 – 5 days after birth, leaving behind the ligamentum teres and the ligamentum venosus of the liver,
respectively.
Changes in the pregnant mother
Maternal changes start from very early on in the first
trimester of the pregnancy. Nearly all systems are affected.
Cardiac system
Stroke volume and heart rate both increase resulting in
cardiac output increasing by about 40% (from 4 to 6 L/
min). The pulse rate may increase by 10 – 15 beats/minute.
The increased flow across the heart valves results in
an increase in physiological flow murmurs heard on
auscultation.
There is a decrease in peripheral vascular resistance,
resulting in a fall in blood pressure of about 10 mmHg in
mean arterial pressure (MAP) in the first and second
trimesters. The blood pressure tends to rise again after
about 24 weeks ’ gestation.
The gravid uterus, especially in the later stages of pregnancy, can occlude the inferior vena cava when the
mother lies flat on her back, and cause decreased return
of blood to the heart, hypotension and reduced fetal flow
(supine hypotension). This is why pregnant mothers are
advised not to lie flat on their backs, and labour, delivery
and anaesthesia are managed with the mother propped
up or with a wedge that tilts her back.
Respiratory system
There is increased oxygen requirement in pregnancy,
which results in hyperventilation and deep breathing.
Ventilation is increased by 40% through an increase in
tidal volume (from 500 to 700 mL) rather than in the
respiratory rate. CO2 levels in pregnancy are lower than
in the non - pregnant state; this helps the gradient between
fetus and mother and favours transfer of CO2 from fetus
to mother across the placenta. Mothers may feel dyspnoeic; this may partly be because of the splinting of the
diaphragm by the gravid uterus.
Body temperature
Progesterone is thought to be responsible for the rise in
body temperature of 0.5 – 1.0 ° C during pregnancy. An
increased metabolic rate and peripheral vasodilatation also
result in a warm skin and may cause palmar erythema.
Blood and plasma volume
Blood volume increases by approximately 1200 mL
(40%), while red cell mass increases by 250 – 400 mL
(about 25%). This results in a relative haemodilution and
anaemia, with a drop in haematocrit and haemoglobin
levels.
There is increased blood flow to a number of systems
including the uterus, skin and the kidneys. There is an
increase in the glomerular filtration rate (GFR) from 140
to 170 mL/minute. This results in lower serum urea and
creatinine levels. This needs to be borne in mind when
interpreting blood results in pregnancy, as the normal
range quoted for the non - pregnant state may not be relevant, and an abnormal result may be missed.
There is an increase in extravascular fluid because of
lower plasma colloid osmotic pressure (albumin levels
are lower in pregnancy), and this contributes to the
peripheral odema that may be seen with normal pregnancy. Symptoms of carpel tunnel syndrome of tingling
of the fingers may be caused by compression of the
median nerve under the flexor retinaculum because of
increased extracellular fluid.
The blood may show a mild leucocytosis in pregnancy
(9 – 11 × 109/L compared to 4 – 11 × 109/L) and an increase
in erythrocyte sedimentation rate. Serum iron is lower and
iron requirements are increased because of demands from
the fetus, red cell increase and blood loss at delivery. There
is no consensus as to whether routine iron supplementation is indicated in pregnancy but evidence suggests that a
higher iron level following supplementation does not
improve maternal or neonatal outcomes. Iron supplementation is advised at haemoglobin levels below 10.5 gm/ dL.
Metabolic changes
Metabolic rate is increased to accommodate increased
energy demands from the fetus and for the maternal
changes. Pregnancy is also a diabetogenic state. Glucose
levels are increased as placental hormones are insulin
antagonists and there is an increased insulin resistance in
pregnancy. If sufficient insulin cannot be produced to
counter this resistance, gestational diabetes may occur.
This physiological change also explains why insulin
requirements in known insulin - dependent diabetic
mothers increases during pregnancy.
Coagulation profile
Pregnancy is a hypercoagulable state. This is a protective
mechanism for the mother to be able to minimize blood
loss after delivery of the placenta. There is an increase in
fibrinogen, factor VIII and von Willebrand factor, and a
decrease in anticoagulants such as antithrombin III.
There is also an increase in fibrinolytic activity.
While this hypercoagulable state is protective against
bleeding, it results in an increased risk of thrombosis
during pregnancy, especially when there are other risk
factors present (e.g. increasing age, smoking, high BMI,
operative delivery, prolonged immobilization).
Maternal weight gain
This is around 11 – 12 kg through the pregnancy. Much of
this increase is caused by the extravascular retention of
fluid (approximately 8.5 L), increase in blood volume,
growth of the uterus, breasts and body fat. The fetus
(around 3.5 kg), placenta and liquor (about 0.7 – 0.8 kg
each) account for about 4.5 – 5 kg of the weight gain.
Other changes
There may be thyroid enlargement and a mild goitre in
pregnancy. As there is increased urinary excretion of
iodine and some uptake of iodothyronines by the fetus,
there is a relative iodine deficiency in the mother. This
results in a compensatory thyroid hypertrophy in order
to maintain normal iodide concentrations. Especially in
early pregnancy, blood results may mimic a hyperthyroid
state with low thyroid stimulating hormone (TSH),
but free T3 and T4 remain within the normal range.
In mothers with a known history of hypothyroidism,
thyroid requirements may increase in pregnancy.
Renal changes include anatomical ones (dilatation of
renal pelvis and ureters) brought about by both the effects
of progesterone and pressure effects from the growing
gravid uterus to some extent. Renal function tests change
in pregnancy. Glycosuria may occur in the presence of
normal plasma glucose levels, because of an increase in the
GFR and a change in tubular reabsorption of glucose.
The uterus undergoes both hypertrophy and hyperplasia, and increases from a non - pregnant weight of 0.3 –
0.4 kg to 1 – 1.3 kg at term. Uterine blood flow increases
from 50 to 500 mL/minute.
The narrow isthmus of the uterus between the body of
the uterus and the cervix becomes increasing stretched
and thinned out as the pregnancy progresses, to become
the well - formed lower segment at term. This is the preferred site for the uterine incision at caesarean section,
because of its relative avascularity, quiescence, better
healing and lower risk of scar rupture in a subsequent
pregnancy than an upper segment incision. The lower
segment does not contract during labour.
As labour progresses, the cervix dilates and effaces
almost completely into the lower segment. When the
placenta is low lying and implanted on the lower segment,
there is an increased risk of postpartum haemorrhage as
the lower segment does not contract effectively after
delivery of the placenta.
As pregnancy progresses, the collagen concentration in
the cervix decreases and there is accumulation of glycosaminoglycans and water. This results in increasing ‘ ripening ’ of the cervix in preparation for labour.
Labour
Labour is the process whereby the fetus is delivered from
the mother; it involves regular uterine activity causing
progressive cervical dilatation and effacement followed
by expulsion of the fetus.
There are no conclusive theories to explain the onset
of labour. A change in the levels of and ratio between
concentrations of oestrogen and progesterone has been
suggested, possibly following a fetal trigger in the form
of secretion of adrenal corticosteroids when it is mature
and ready to be delivered. Prostaglandin concentrations
have been shown to increase prelabour and they are
known to promote cervical ripening and uterine contractility. Oxytocin receptors in the uterus also increase
towards term and oxytocin from the posterior pituitary
is known to be a potent stimulator of uterine
contractions.
The diagnosis of active labour is not always easy and
includes the presence of regular painful contractions with
increasing effacement and dilatation (usually at least
3 – 4 cm) of the cervix. There may be a ‘ show ’ (bloodstained mucosal discharge) associated with the cervical
changes. The first stage of labour is defined as the period
from the start of active labour until full (10 cm) cervical
dilatation.
The second stage includes the time until delivery of the
fetus after full cervical dilatation ( ‘ active ’ second stage is
when the mother is actively pushing with uterine contractions, while ‘ passive ’ second stage is when time is
allowed for the head to descend lower into the pelvis by
uterine contractions alone without maternal effort).
The third stage includes the time from delivery of the
fetus to the delivery of the placenta. The signs of placental separation include lengthening of the cord, a gush
of blood vaginally and sustained contraction of the
uterus.
Puerperium is the period following delivery which lasts
about 6 – 8 weeks, when the body returns to its prepregnant
state. While much of the physiological and anatomical
change is reversed, some changes are lasting (e.g. the presence of stria gravidarum). It is important to remember that
some of the maternal changes of pregnancy (e.g. the hypercoagulable state) remain for some time after delivery and
therefore the risks (e.g. of thrombosis) remain too.
HOW TO APPROACH TO THE PATIENTS
The gynaecological patient
Most diagnoses are made from the patient ’ s history and
examination so this should be taken carefully and systematically. At the start of the consultation always introduce yourself, giving your name and position, and ask for
consent whenever examining a patient. This is particularly important if you are going to perform a pelvic
examination (Box A ).
The general structure of a gynaecology consultation
follows that of any other system but there are additional
history sections for relevant important information such
as a menstrual history and past obstetric history. This is
particularly important if the patient is currently pregnant
but will contribute to any gynaecological history.
Presenting complaint
The consultation starts with an open question to determine the presenting complaint. Remember that much of
obstetric and gynaecological practice relates to normality
and promoting good reproductive health. The patient
may be referred for an opinion despite feeling perfectly
well and may not have a complaint as such. The patient ’ s
perception of a problem may be quite different from the
details in the referral letter and it is best to start with open
questions to invite the patient to explain in her own
words what has been happening.
Menstrual history
It is worthwhile at the start to check on the date of the
patient ’ s last menstrual period (LMP).
• The menstrual cycle is represented by the letter
κ = numerator/denominator
• The numerator is the total number of days that she
bleeds for
• The denominator is the length of the menstrual cycle
from the first day of one period to the first day of her
next period
• If the patient does not have a regular cycle, this should
be expressed as a range from the minimum length of the
cycle to the maximum length of the cycle
• κ = 5/28 describes a woman who bleeds for 5 days with
a regular 28 - day cycle
Abnormal v aginal b leeding
It is usual to ask about the age of the first menstruation
(menarche). You need to ask about intermenstrual
bleeding (IMB) and postcoital bleeding (PCB) which is
provoked by intercourse. If the patient is postmenopausal, ask about the date of her last normal period and
if she has experienced any vaginal bleeding since then.
Postmenopausal bleeding (PMB) is bleeding more than
1 year after the last normal period (Table B ).
Heavy m enstrual b leeding
If the patient complains of heavy periods, there are a
number of ways in which the severity is assessed but the
most important aspect is the effect on patient ’ s quality
of life such as whether it disrupts her normal
activities.
Clots
Normal menstrual blood does not clot because of the
local release of prostaglandins. The formation of clots
suggests that the blood loss overwhelms this natural
system. It is important to assess the size of the clots. As
clots often form in the vagina, they tend to be like pieces
of liver.
Sanitary p rotection
It is useful to ask about:
• Sanitary protection, including the strength of absorbency of sanitary pads or tampons
• Frequency of changing pads or tampons
• Double protection (wearing a pad in addition to a
tampon)
• Use of towels or other covers to protect the bed during
the night
Flooding
Flooding means the menstrual loss is heavy enough to
soak through outer clothes but some staining of underwear is considered normal.
Contraception
As part of the menstrual history you should also ask
about her method of contraception and any problems
associated with this.
Cervical smears
In the UK, all women are called on a regular basis for cervical screening but it is worth checking that they have complied with screening and have a smear result within their
last screening round. Remember that the eligible age group
for screening varies in different screening programmes.
Pain
To assist your diagnosis, you need to establish if pelvic
pain is cyclical or non - cyclical and if cyclical, in which
part in the menstrual cycle pain occurs. You also need to
enquire about dysparunia (pain during sexual intercourse). This may be superficial (on penetration) or deep
(within the pelvis). Further information on site, radiation, character, aggravating and relieving factors follows
the same format as other systems.
Past obstetric history
A more detailed past obstetric history would be required
for an obstetric patient. You still require a past obstetric
history from gynaecology patients; it is normal to note
the number of previous pregnancies, the gestation
reached and the outcome for the pregnancy. For patients
with urinary or prolapse symptoms, you will want to
know the mode of delivery and the birth weight.
Sexual history
It is not usual to take a detailed sexual history in gynaecology but a limited sexual history may be appropriate
and this information will determine if a more detailed
history is required.
Social history
The usual details on smoking, alcohol and use of recreational/non - prescription drugs are useful. It is also
important to know about social support and care for
patients returning home after gynaecological surgery,
particularly if the woman is responsible for the care of
young children or elderly relatives.
Many gynaecological conditions are not life - threatening and therefore the impact of any condition on quality
of life needs to be assessed. For example, a woman may
be found to have asymptomatic fibroids or some degree
of vaginal prolapse on attending for a smear test but if
these are not reducing her quality of life, it is perfectly
reasonable not to take further action.
Examination of the gynaecological
patient
Women with a gynaecological complaint require a full
examination but the aspects that are different to routine
examination are abdominal and pelvic examination.
Abdominal examination
It is important to offer the patient privacy to undress and
to expose only the relevant area. The abdomen needs to
be exposed from the xiphisternum down to the symphysis pubis. It is normal to keep the pubic area covered.
Abdominal examination comprises of inspection, palpation, percussion and auscultation.
Inspection
It is normal to look for presence of any obvious distension by a mass, striae and movement with respiration. It
is important to look for scars from previous surgery. If
the patient has a previous low transverse incision, you
need to ensure that the covering sheet is lowered sufficiently to check below the patient ’ s pubic hair line.
Remember to check for any scars inside the umbilicus
from laparoscopy.
Palpation
Before performing superficial and deep palpation, check
with the patient if she has any areas of tenderness. Begin
your palpation in the quadrant away from this and
examine the tender area last. Remember that women of
reproductive age may be referred to gynaecology with
non - gynaecological conditions and you need to examine
the whole of the patient ’ s abdomen including upper
abdomen and renal angles.
If you detect tenderness, check for signs of peritonism;
rebound tenderness and guarding. If you identify
abdominal distension, you need to consider ascites and
check for shifting dullness and a fluid thrill.
If you detect a mass, you should try to determine if it
is abdominal or pelvic in origin. Pelvic masses rise above
the pubic symphysis and the lower border cannot be
palpated. You should be able to describe the mass both
on abdominal and pelvic examination in the terms
described in Table C .
Auscultation
Auscultation for bowel sounds is a normal part of
abdominal examination.
Pelvic examination
Preparing the p atient for a p elvic e xamination
It is essential to have a professional approach to pelvic
examination to reassure the patient and to prevent
unnecessary embarrassment. Before starting the examination ensure that the patient understands the purpose
of the examination and the procedures that you are going
to follow. It is usual to position the patient lying down
supine with her head slightly raised. If she is on a bed or
couch you should ask her to bring her feet up close to
her bottom and let her knees fall out in order for you to
gain adequate access to perform a speculum examination. Many clinics and wards provide a gynaecological
examination couch where the patient ’ s legs are supported
in leg rests. The use of foot pedals allow you to lower or
raise the bed and tilt the patient backwards to aid examination and access for any outpatient procedures or investigations. You need to consider any necessary adaptations
to ensure your patent ’ s comfort, e.g. if she has restricted
mobility.
Inspection
It is important to examine the vulval area with an adequate light source. This will allow you to see if there are
any local lesions such as atrophic changes in the postmenopausal woman, ulceration or obvious prolapse.
Speculum e xamination
The purpose of speculum examination is to examine the
lower genital tract. The vagina has an anterior and a
posterior vaginal wall which are normally in close contact.
Inserting the speculum allows the vaginal walls to be
pushed apart gently so the vaginal wall and the cervix can
be inspected and any relevant procedures, such as taking
a vaginal swab or cervical smear test, can be carried out.
It is important to be familiar with the Cusco speculum
(bivalve speculum; Fig. J ).
Practicalities of e xamining the p atient
• Remember the General Medical Council (GMC)
guidelines (Box A )
• Wash your hands either with soap and water or with
alcohol rub
• Ensure your hands are completely dry before putting
on your gloves; this helps you to put on your gloves
smoothly
• Let the patient know when you are about to begin the
examination and exactly what you are doing throughout
the examination
• If using a metal speculum, ensure it is warm
• Assemble the speculum prior to the examination
(unless you are using a pre - assembled disposable
speculum)
• Apply only a small amount of lubricant jelly to the end
of the speculum (large amounts will be wiped off on
insertion leaving your patient messy)
• If you are obtaining a liquid - based cytology sample for
cervical screening, the lubricant can cause cytolysis and
you can just dip the speculum in normal saline
Speculum t echnique
• If you are right - handed you should hold the speculum
in your right hand, keeping the anterior and posterior
valves of the speculum closed.
• Use your left hand to separate the labia so the posterior
fourchette is exposed. The most comfortable way to
proceed is to insert the speculum directly, angling the
speculum slightly down and back until fully inserted.
• The speculum should be inserted and opened slowly
to avoid discomfort to your patient.
• If only inspection of the cervix and/or vagina is
required then you can hold the blades of the speculum
apart.
• If you need to perform any procedures, close the
ratchet on a disposable plastic speculum or rotate the nut
to the top to keep the speculum open.
• Asking your patient to cough can help to relax the
pelvic floor and bring the cervix into view.
Removal of the s peculum
Remember to withdraw the end of the speculum beyond
the cervix before closing the blades together. Remove the
speculum slowly and carefully.
When examining prolapse, a bivalve speculum holds
both walls of the vagina apart. You need to use a Sims
speculum (Fig. K ) with the patient lying in the left lateral
position.
Bimanual e xamination
The purpose of the bimanual examination is to examine
the upper genital tract (uterus and adnexa). You should
follow a systematic approach (Box B ).
It is important to consider this examination in context
as the signs that you are trying to elicit will be different
in a patient presenting with acute pain from the patient
seen in the gynaecology clinic. It is normal to perform a
two finger examination using the index and middle finger
with some lubricating jelly. In postmenopausal women,
you should start with one finger to determine whether a
two finger examination is possible or not.
Pelvic examination
Pelvic examination should not be performed in prepubescent girls or if there is a clinical contraindication . You should
consider either a transabdominal ultrasound scan of the
pelvis or examination under anaesthetic if necessary.
Vaginal e xamination
First feel the cervix:
• In a nulliparous patient, this is smooth, firm and
regular
• In the parous patient, the normal cervix may be bulky,
smoothly irregular with ectopy or formation of Nabothian follicles (blocked mucous glands)
Remember there is a wide normal range related to
physiological changes including oestrogen levels and
childbirth.
Bimanual p alpation
The aim of bimanual examination is to palpate the uterus
and possibly the adnexa between your examining hand
on the lower abdomen and your fingers in the vagina.
Push up on the uterus vaginally with your fingers anterior to the cervix. Push down with the left hand over the
lower abdominal wall. You should feel the uterus between
both hands and note its size. It is usual to compare the
size of the uterus in terms of weeks ’ gestation even in the
non - pregnant patient. If you are unsure of this, try to
visualize it in terms of the size of fruit:
• A small tangerine = 8 weeks
• A small orange = 10 weeks
• A large orange = 12 weeks
• A grapefruit = 14 weeks (and will be palpable just
about the pubic symphysis on abdominal palpation)
If the uterus is enlarged, consider if it is generally
enlarged (such as the bulky uterus of a parous patient or
pregnancy) or if there is an obvious mass involving the
uterus (such as fibroids).
Note if the uterus is anteverted or retroverted. If you
cannot palpate the uterus, it may be retroverted. Note
whether the uterus is mobile or fixed (Table C ).
Examining the a dnexae
Move the tips of your fingers into each lateral vaginal
fornix at the side of the cervix in turn. Also palpate
from above with your abdominal hand on the same side.
Normal ovaries are only likely to be felt in a thin premenopausal woman. Palpation of an adnexal mass
usually indicates that pathology is present. Ascertain
whether any mass is smooth and regular or irregular and
whether it is fixed or mobile (Table C ). Use the bimanual
technique to feel if a mass is attached to the uterus or
separate. Remember that fixed irregular masses in the
adnexa are more likely to be related to endometriosis or
the effects of scarring from chronic pelvic inflammatory
disease than malignancy. It is equally important to note
if there is any tenderness on palpation of the adnexa.
Check for cervical excitation (Box C ).
Following e xamination
First allow the patient to dress herself. The changing area
should give her privacy. Tissues to wipe away excess jelly
and facilities for her to wash her hands should be provided.
Clear away your examining instruments and wash your
hands again. Once you have completed this, you should
discuss your findings with the patient and your proposed
plan for further investigations and management.
The obstetric patient
Most pregnant women are fit and healthy and will remain
‘ low risk ’ through the pregnancy and birth, with the
midwife being the lead caregiver. However, there are some
maternal conditions that predate pregnancy and some conditions arising during the pregnancy that can worsen
maternal and/or fetal outcomes and need additional
medical care. The main aim of antenatal care is to assess
‘ risk ’ to the mother and baby at every stage of the pregnancy
and to offer appropriate investigations, with the overall aim
of achieving a healthy baby and mother at the end of the
pregnancy, and to make the pregnancy and birth a satisfying, fulfilling and happy journey for the parents.
Preconception care
While most women will present when they are pregnant,
care should ideally begin preconception, when a pregnancy is being planned. Folic acid is advised (to reduce
the risk of fetal neural tube defects), as is advice regarding
a healthier lifestyle including reducing or stopping
smoking (see Case 20 ) and a healthy diet.
For some women, preconception care is especially
important: for example, women with insulin - dependent
diabetes (see Case 21 ), epilepsy, hypertension on angiotensin converting enzyme (ACE) inhibitors (see Case 21 )
or those with a previous history of pregnancy affected by
open neural tube defect. In women with epilepsy not on
medication, there is an increased risk of fetal abnormalities (4% vs a 3% risk in the general population), but this
risk is further increased when the mother is on antiepileptic medications such as phenytoin or sodium valproate. These fetal abnormalities include cleft lip and palate,
cardiac and neural tube defects. While the risk with one
drug is around 6 – 7%, this risk increases with the number
of antiepileptic drugs taken. The aim of prepregnancy
care therefore is to achieve good seizure control on a
single drug, if possible.
Similarly, in women who have been seizure - free for
some years there may be the option of discontinuing
antiepileptic medication. However, this must be
considered and implemented only under appropriate
physician or neurological advice and supervision. A
higher dose of preconception folic acid supplementation
of 5 mg is also advised (as in mothers with a previous
pregnancy affected by neural tube defect).
In couples with known genetic problems (e.g. carriers
of cystic fibrosis or sickle cell trait), counselling regarding
the fetal risks of acquiring the disease and the invasive
diagnostic tests (e.g. chorion villus sampling and amniocentesis) that might be available should ideally be discussed preconception.
Care in pregnancy
Dating of the p regnancy
Although pregnancy begins at conception, it is more convenient to date from the first day of a woman ’ s last menstrual period (LMP). Naegele ’ s rule estimates the expected
date of delivery (EDD) from the first day of the woman ’ s
LMP by adding a year, subtracting 3 months and adding
7 days to that date. This approximates to the average
human pregnancy which lasts 40 weeks (280 days) from
the LMP, or 38 weeks (266 days) from the date of fertilization. Counting from the LMP, a term pregnancy
usually lasts between 37 and 42 weeks.
As women may not accurately remember their LMP,
or their menstrual cycles may not be very regular,
dating of the pregnancy by the measurement of the
crown – rump length as determined by a scan in the first
trimester is thought to be more accurate. Determining
the gestational age accurately is important, both in case
the woman labours prematurely and if she goes postdated to help with induction of labour at the appropriate time.
Some o bstetric d efinitions
Gravidity is defined as the number of times that a woman
has been pregnant and parity is the number of pregnancies she has had with a gestational age of 24 weeks or
more, regardless of whether the child was born alive or
stillborn. There is usually a second number added on to
parity which is the number of pregnancy losses before
24 weeks ’ gestation. Therefore, para 0 + 0 is a woman
who has never been pregnant before. Para 1 + 1 implies
one previous pregnancy beyond 24 weeks (live or stillbirth) + one pregnancy loss before 24 weeks (a termination, miscarriage or ectopic pregnancy). A women who
is currently in her first pregnancy is gravida 1 para 0 (G1
P0) and a parous women with three previous term live
births and two 10 - week spontaneous miscarriages and
currently pregnant would be gravida 6 para 3 + 2 (G6
P3 + 2).
• Term gestation is usually 37 – 42 completed weeks ’
gestation
• Preterm is less than 37 weeks ’ gestation
• Mildly preterm is 32 – 36 weeks ’ gestation
• Very preterm is less than 32 weeks ’ gestation
• Extremely preterm is less than 28 weeks ’ gestation
Antenatal appointments
The needs of each pregnant woman should be assessed at
the first booking appointment (which ideally should be
in the first trimester) and reassessed at each appointment
throughout pregnancy because new problems can arise
at any time. A schedule of antenatal appointments should
be determined by the degree of risk identified. In a nulliparous woman with an uncomplicated pregnancy, 10
appointments, and in a parous woman with an uncomplicated pregnancy, a schedule of seven antenatal visits is
usually adequate. Generally, in a parous woman having
gone through at least one previous uncomplicated pregnancy, it is easier to assign risk than in a nulliparous
woman in her first pregnancy (Box D ).
As with any other patient, assessment begins with
taking an appropriate history at the booking visit. The
general principles of approach to the patient are as
described above in the gynaecology section.
History
History includes details of the mother and the current
pregnancy to date including maternal age – young
teenage mothers are at increased risk from preterm
labour, and have an increased incidence of pre - eclampsia
and small for gestational age babies. Scans to monitor
fetal growth, more frequent blood pressure checks and
education as to the signs and symptoms of preterm
labour may be indicated.
With increasing maternal age the risk of chromosomal
abnormalities such as trisomy 21 increases and also the
incidence of hypertension and type 2 diabetes. Invasive
prenatal genetic tests available for confirming fetal karyotype (see Case 20 ) may need to be discussed; regular
monitoring of blood pressure and consideration of an
oral glucose tolerance test are also indicated.
Present p regnancy
What is her estimated gestation from the last menstrual
period (gestational age and viability is best confirmed by
a first trimester scan) and has she has been well thus far
Most diagnoses are made from the patient ’ s history and
examination so this should be taken carefully and systematically. At the start of the consultation always introduce yourself, giving your name and position, and ask for
consent whenever examining a patient. This is particularly important if you are going to perform a pelvic
examination (Box A ).
The general structure of a gynaecology consultation
follows that of any other system but there are additional
history sections for relevant important information such
as a menstrual history and past obstetric history. This is
particularly important if the patient is currently pregnant
but will contribute to any gynaecological history.
Presenting complaint
The consultation starts with an open question to determine the presenting complaint. Remember that much of
obstetric and gynaecological practice relates to normality
and promoting good reproductive health. The patient
may be referred for an opinion despite feeling perfectly
well and may not have a complaint as such. The patient ’ s
perception of a problem may be quite different from the
details in the referral letter and it is best to start with open
questions to invite the patient to explain in her own
words what has been happening.
Menstrual history
It is worthwhile at the start to check on the date of the
patient ’ s last menstrual period (LMP).
• The menstrual cycle is represented by the letter
κ = numerator/denominator
• The numerator is the total number of days that she
bleeds for
• The denominator is the length of the menstrual cycle
from the first day of one period to the first day of her
next period
• If the patient does not have a regular cycle, this should
be expressed as a range from the minimum length of the
cycle to the maximum length of the cycle
• κ = 5/28 describes a woman who bleeds for 5 days with
a regular 28 - day cycle
Abnormal v aginal b leeding
It is usual to ask about the age of the first menstruation
(menarche). You need to ask about intermenstrual
bleeding (IMB) and postcoital bleeding (PCB) which is
provoked by intercourse. If the patient is postmenopausal, ask about the date of her last normal period and
if she has experienced any vaginal bleeding since then.
Postmenopausal bleeding (PMB) is bleeding more than
1 year after the last normal period (Table B ).
Heavy m enstrual b leeding
If the patient complains of heavy periods, there are a
number of ways in which the severity is assessed but the
most important aspect is the effect on patient ’ s quality
of life such as whether it disrupts her normal
activities.
Clots
Normal menstrual blood does not clot because of the
local release of prostaglandins. The formation of clots
suggests that the blood loss overwhelms this natural
system. It is important to assess the size of the clots. As
clots often form in the vagina, they tend to be like pieces
of liver.
Sanitary p rotection
It is useful to ask about:
• Sanitary protection, including the strength of absorbency of sanitary pads or tampons
• Frequency of changing pads or tampons
• Double protection (wearing a pad in addition to a
tampon)
• Use of towels or other covers to protect the bed during
the night
Flooding
Flooding means the menstrual loss is heavy enough to
soak through outer clothes but some staining of underwear is considered normal.
Contraception
As part of the menstrual history you should also ask
about her method of contraception and any problems
associated with this.
Cervical smears
In the UK, all women are called on a regular basis for cervical screening but it is worth checking that they have complied with screening and have a smear result within their
last screening round. Remember that the eligible age group
for screening varies in different screening programmes.
Pain
To assist your diagnosis, you need to establish if pelvic
pain is cyclical or non - cyclical and if cyclical, in which
part in the menstrual cycle pain occurs. You also need to
enquire about dysparunia (pain during sexual intercourse). This may be superficial (on penetration) or deep
(within the pelvis). Further information on site, radiation, character, aggravating and relieving factors follows
the same format as other systems.
Past obstetric history
A more detailed past obstetric history would be required
for an obstetric patient. You still require a past obstetric
history from gynaecology patients; it is normal to note
the number of previous pregnancies, the gestation
reached and the outcome for the pregnancy. For patients
with urinary or prolapse symptoms, you will want to
know the mode of delivery and the birth weight.
Sexual history
It is not usual to take a detailed sexual history in gynaecology but a limited sexual history may be appropriate
and this information will determine if a more detailed
history is required.
Social history
The usual details on smoking, alcohol and use of recreational/non - prescription drugs are useful. It is also
important to know about social support and care for
patients returning home after gynaecological surgery,
particularly if the woman is responsible for the care of
young children or elderly relatives.
Many gynaecological conditions are not life - threatening and therefore the impact of any condition on quality
of life needs to be assessed. For example, a woman may
be found to have asymptomatic fibroids or some degree
of vaginal prolapse on attending for a smear test but if
these are not reducing her quality of life, it is perfectly
reasonable not to take further action.
Examination of the gynaecological
patient
Women with a gynaecological complaint require a full
examination but the aspects that are different to routine
examination are abdominal and pelvic examination.
Abdominal examination
It is important to offer the patient privacy to undress and
to expose only the relevant area. The abdomen needs to
be exposed from the xiphisternum down to the symphysis pubis. It is normal to keep the pubic area covered.
Abdominal examination comprises of inspection, palpation, percussion and auscultation.
Inspection
It is normal to look for presence of any obvious distension by a mass, striae and movement with respiration. It
is important to look for scars from previous surgery. If
the patient has a previous low transverse incision, you
need to ensure that the covering sheet is lowered sufficiently to check below the patient ’ s pubic hair line.
Remember to check for any scars inside the umbilicus
from laparoscopy.
Palpation
Before performing superficial and deep palpation, check
with the patient if she has any areas of tenderness. Begin
your palpation in the quadrant away from this and
examine the tender area last. Remember that women of
reproductive age may be referred to gynaecology with
non - gynaecological conditions and you need to examine
the whole of the patient ’ s abdomen including upper
abdomen and renal angles.
If you detect tenderness, check for signs of peritonism;
rebound tenderness and guarding. If you identify
abdominal distension, you need to consider ascites and
check for shifting dullness and a fluid thrill.
If you detect a mass, you should try to determine if it
is abdominal or pelvic in origin. Pelvic masses rise above
the pubic symphysis and the lower border cannot be
palpated. You should be able to describe the mass both
on abdominal and pelvic examination in the terms
described in Table C .
Auscultation
Auscultation for bowel sounds is a normal part of
abdominal examination.
Pelvic examination
Preparing the p atient for a p elvic e xamination
It is essential to have a professional approach to pelvic
examination to reassure the patient and to prevent
unnecessary embarrassment. Before starting the examination ensure that the patient understands the purpose
of the examination and the procedures that you are going
to follow. It is usual to position the patient lying down
supine with her head slightly raised. If she is on a bed or
couch you should ask her to bring her feet up close to
her bottom and let her knees fall out in order for you to
gain adequate access to perform a speculum examination. Many clinics and wards provide a gynaecological
examination couch where the patient ’ s legs are supported
in leg rests. The use of foot pedals allow you to lower or
raise the bed and tilt the patient backwards to aid examination and access for any outpatient procedures or investigations. You need to consider any necessary adaptations
to ensure your patent ’ s comfort, e.g. if she has restricted
mobility.
Inspection
It is important to examine the vulval area with an adequate light source. This will allow you to see if there are
any local lesions such as atrophic changes in the postmenopausal woman, ulceration or obvious prolapse.
Speculum e xamination
The purpose of speculum examination is to examine the
lower genital tract. The vagina has an anterior and a
posterior vaginal wall which are normally in close contact.
Inserting the speculum allows the vaginal walls to be
pushed apart gently so the vaginal wall and the cervix can
be inspected and any relevant procedures, such as taking
a vaginal swab or cervical smear test, can be carried out.
It is important to be familiar with the Cusco speculum
(bivalve speculum; Fig. J ).
Practicalities of e xamining the p atient
• Remember the General Medical Council (GMC)
guidelines (Box A )
• Wash your hands either with soap and water or with
alcohol rub
• Ensure your hands are completely dry before putting
on your gloves; this helps you to put on your gloves
smoothly
• Let the patient know when you are about to begin the
examination and exactly what you are doing throughout
the examination
• If using a metal speculum, ensure it is warm
• Assemble the speculum prior to the examination
(unless you are using a pre - assembled disposable
speculum)
• Apply only a small amount of lubricant jelly to the end
of the speculum (large amounts will be wiped off on
insertion leaving your patient messy)
• If you are obtaining a liquid - based cytology sample for
cervical screening, the lubricant can cause cytolysis and
you can just dip the speculum in normal saline
Speculum t echnique
• If you are right - handed you should hold the speculum
in your right hand, keeping the anterior and posterior
valves of the speculum closed.
• Use your left hand to separate the labia so the posterior
fourchette is exposed. The most comfortable way to
proceed is to insert the speculum directly, angling the
speculum slightly down and back until fully inserted.
• The speculum should be inserted and opened slowly
to avoid discomfort to your patient.
• If only inspection of the cervix and/or vagina is
required then you can hold the blades of the speculum
apart.
• If you need to perform any procedures, close the
ratchet on a disposable plastic speculum or rotate the nut
to the top to keep the speculum open.
• Asking your patient to cough can help to relax the
pelvic floor and bring the cervix into view.
Removal of the s peculum
Remember to withdraw the end of the speculum beyond
the cervix before closing the blades together. Remove the
speculum slowly and carefully.
When examining prolapse, a bivalve speculum holds
both walls of the vagina apart. You need to use a Sims
speculum (Fig. K ) with the patient lying in the left lateral
position.
Bimanual e xamination
The purpose of the bimanual examination is to examine
the upper genital tract (uterus and adnexa). You should
follow a systematic approach (Box B ).
It is important to consider this examination in context
as the signs that you are trying to elicit will be different
in a patient presenting with acute pain from the patient
seen in the gynaecology clinic. It is normal to perform a
two finger examination using the index and middle finger
with some lubricating jelly. In postmenopausal women,
you should start with one finger to determine whether a
two finger examination is possible or not.
Pelvic examination
Pelvic examination should not be performed in prepubescent girls or if there is a clinical contraindication . You should
consider either a transabdominal ultrasound scan of the
pelvis or examination under anaesthetic if necessary.
Vaginal e xamination
First feel the cervix:
• In a nulliparous patient, this is smooth, firm and
regular
• In the parous patient, the normal cervix may be bulky,
smoothly irregular with ectopy or formation of Nabothian follicles (blocked mucous glands)
Remember there is a wide normal range related to
physiological changes including oestrogen levels and
childbirth.
Bimanual p alpation
The aim of bimanual examination is to palpate the uterus
and possibly the adnexa between your examining hand
on the lower abdomen and your fingers in the vagina.
Push up on the uterus vaginally with your fingers anterior to the cervix. Push down with the left hand over the
lower abdominal wall. You should feel the uterus between
both hands and note its size. It is usual to compare the
size of the uterus in terms of weeks ’ gestation even in the
non - pregnant patient. If you are unsure of this, try to
visualize it in terms of the size of fruit:
• A small tangerine = 8 weeks
• A small orange = 10 weeks
• A large orange = 12 weeks
• A grapefruit = 14 weeks (and will be palpable just
about the pubic symphysis on abdominal palpation)
If the uterus is enlarged, consider if it is generally
enlarged (such as the bulky uterus of a parous patient or
pregnancy) or if there is an obvious mass involving the
uterus (such as fibroids).
Note if the uterus is anteverted or retroverted. If you
cannot palpate the uterus, it may be retroverted. Note
whether the uterus is mobile or fixed (Table C ).
Examining the a dnexae
Move the tips of your fingers into each lateral vaginal
fornix at the side of the cervix in turn. Also palpate
from above with your abdominal hand on the same side.
Normal ovaries are only likely to be felt in a thin premenopausal woman. Palpation of an adnexal mass
usually indicates that pathology is present. Ascertain
whether any mass is smooth and regular or irregular and
whether it is fixed or mobile (Table C ). Use the bimanual
technique to feel if a mass is attached to the uterus or
separate. Remember that fixed irregular masses in the
adnexa are more likely to be related to endometriosis or
the effects of scarring from chronic pelvic inflammatory
disease than malignancy. It is equally important to note
if there is any tenderness on palpation of the adnexa.
Check for cervical excitation (Box C ).
Following e xamination
First allow the patient to dress herself. The changing area
should give her privacy. Tissues to wipe away excess jelly
and facilities for her to wash her hands should be provided.
Clear away your examining instruments and wash your
hands again. Once you have completed this, you should
discuss your findings with the patient and your proposed
plan for further investigations and management.
The obstetric patient
Most pregnant women are fit and healthy and will remain
‘ low risk ’ through the pregnancy and birth, with the
midwife being the lead caregiver. However, there are some
maternal conditions that predate pregnancy and some conditions arising during the pregnancy that can worsen
maternal and/or fetal outcomes and need additional
medical care. The main aim of antenatal care is to assess
‘ risk ’ to the mother and baby at every stage of the pregnancy
and to offer appropriate investigations, with the overall aim
of achieving a healthy baby and mother at the end of the
pregnancy, and to make the pregnancy and birth a satisfying, fulfilling and happy journey for the parents.
Preconception care
While most women will present when they are pregnant,
care should ideally begin preconception, when a pregnancy is being planned. Folic acid is advised (to reduce
the risk of fetal neural tube defects), as is advice regarding
a healthier lifestyle including reducing or stopping
smoking (see Case 20 ) and a healthy diet.
For some women, preconception care is especially
important: for example, women with insulin - dependent
diabetes (see Case 21 ), epilepsy, hypertension on angiotensin converting enzyme (ACE) inhibitors (see Case 21 )
or those with a previous history of pregnancy affected by
open neural tube defect. In women with epilepsy not on
medication, there is an increased risk of fetal abnormalities (4% vs a 3% risk in the general population), but this
risk is further increased when the mother is on antiepileptic medications such as phenytoin or sodium valproate. These fetal abnormalities include cleft lip and palate,
cardiac and neural tube defects. While the risk with one
drug is around 6 – 7%, this risk increases with the number
of antiepileptic drugs taken. The aim of prepregnancy
care therefore is to achieve good seizure control on a
single drug, if possible.
Similarly, in women who have been seizure - free for
some years there may be the option of discontinuing
antiepileptic medication. However, this must be
considered and implemented only under appropriate
physician or neurological advice and supervision. A
higher dose of preconception folic acid supplementation
of 5 mg is also advised (as in mothers with a previous
pregnancy affected by neural tube defect).
In couples with known genetic problems (e.g. carriers
of cystic fibrosis or sickle cell trait), counselling regarding
the fetal risks of acquiring the disease and the invasive
diagnostic tests (e.g. chorion villus sampling and amniocentesis) that might be available should ideally be discussed preconception.
Care in pregnancy
Dating of the p regnancy
Although pregnancy begins at conception, it is more convenient to date from the first day of a woman ’ s last menstrual period (LMP). Naegele ’ s rule estimates the expected
date of delivery (EDD) from the first day of the woman ’ s
LMP by adding a year, subtracting 3 months and adding
7 days to that date. This approximates to the average
human pregnancy which lasts 40 weeks (280 days) from
the LMP, or 38 weeks (266 days) from the date of fertilization. Counting from the LMP, a term pregnancy
usually lasts between 37 and 42 weeks.
As women may not accurately remember their LMP,
or their menstrual cycles may not be very regular,
dating of the pregnancy by the measurement of the
crown – rump length as determined by a scan in the first
trimester is thought to be more accurate. Determining
the gestational age accurately is important, both in case
the woman labours prematurely and if she goes postdated to help with induction of labour at the appropriate time.
Some o bstetric d efinitions
Gravidity is defined as the number of times that a woman
has been pregnant and parity is the number of pregnancies she has had with a gestational age of 24 weeks or
more, regardless of whether the child was born alive or
stillborn. There is usually a second number added on to
parity which is the number of pregnancy losses before
24 weeks ’ gestation. Therefore, para 0 + 0 is a woman
who has never been pregnant before. Para 1 + 1 implies
one previous pregnancy beyond 24 weeks (live or stillbirth) + one pregnancy loss before 24 weeks (a termination, miscarriage or ectopic pregnancy). A women who
is currently in her first pregnancy is gravida 1 para 0 (G1
P0) and a parous women with three previous term live
births and two 10 - week spontaneous miscarriages and
currently pregnant would be gravida 6 para 3 + 2 (G6
P3 + 2).
• Term gestation is usually 37 – 42 completed weeks ’
gestation
• Preterm is less than 37 weeks ’ gestation
• Mildly preterm is 32 – 36 weeks ’ gestation
• Very preterm is less than 32 weeks ’ gestation
• Extremely preterm is less than 28 weeks ’ gestation
Antenatal appointments
The needs of each pregnant woman should be assessed at
the first booking appointment (which ideally should be
in the first trimester) and reassessed at each appointment
throughout pregnancy because new problems can arise
at any time. A schedule of antenatal appointments should
be determined by the degree of risk identified. In a nulliparous woman with an uncomplicated pregnancy, 10
appointments, and in a parous woman with an uncomplicated pregnancy, a schedule of seven antenatal visits is
usually adequate. Generally, in a parous woman having
gone through at least one previous uncomplicated pregnancy, it is easier to assign risk than in a nulliparous
woman in her first pregnancy (Box D ).
As with any other patient, assessment begins with
taking an appropriate history at the booking visit. The
general principles of approach to the patient are as
described above in the gynaecology section.
History
History includes details of the mother and the current
pregnancy to date including maternal age – young
teenage mothers are at increased risk from preterm
labour, and have an increased incidence of pre - eclampsia
and small for gestational age babies. Scans to monitor
fetal growth, more frequent blood pressure checks and
education as to the signs and symptoms of preterm
labour may be indicated.
With increasing maternal age the risk of chromosomal
abnormalities such as trisomy 21 increases and also the
incidence of hypertension and type 2 diabetes. Invasive
prenatal genetic tests available for confirming fetal karyotype (see Case 20 ) may need to be discussed; regular
monitoring of blood pressure and consideration of an
oral glucose tolerance test are also indicated.
Present p regnancy
What is her estimated gestation from the last menstrual
period (gestational age and viability is best confirmed by
a first trimester scan) and has she has been well thus far
(any history of bleeding, nausea, vomiting or urinary
symptoms)? Is there any particular presenting complaint? Is she on folic acid?
symptoms)? Is there any particular presenting complaint? Is she on folic acid?
Box D An example of schedule of routine antenatal care
First contact with a health care professional
(ideally should be preconception)
Evaluate history/risk factors
Discussion should include:
• Folic acid supplementation
• Food hygiene, including how to reduce the risk of a
food-acquired infection
• Lifestyle advice, including smoking cessation, recreational
drug use and alcohol consumption
• All antenatal screening, including risks and benefits of the
screening tests
Booking appointment (ideally by 10weeks)
• Evaluate ‘risk’ (including evaluation of social and domestic
circumstances) and women who need additional care and
plan pattern of care for the pregnancy
• Offer early ultrasound scan for gestational age assessment
• Check blood group and rhesus D status
• Offer screening for haemoglobinopathies (if indicated),
anaemia, red cell alloantibodies, hepatitis B virus, HIV,
rubella susceptibility and syphilis infection
• Offer screening for asymptomatic bacteriuria
• Inform pregnant women younger than 25years about the
high prevalence of Chlamydia infection in their age group
and offer screening
• Offer screening for Down’s syndrome
• Offer mid-trimester ultrasound screening for structural
anomalies
• Measure height, weight and calculate body mass index
• Measure blood pressure and test urine for proteinuria
• Offer screening for gestational diabetes (in the ‘at risk’ group)
• Evaluate mood to identify possible depression
16weeks
• Discuss the results of all screening tests undertaken
• Investigate a haemoglobin level below 110g/L and
consider iron supplementation if indicated
• Measure blood pressure and test urine for proteinuria
18–20weeks
Mid-trimester anomaly scan if the woman chooses to have this
24–25weeks (for nulliparous women)
• Measure symphysiofundal height
• Measure blood pressure and test urine for proteinuria
28weeks
• Offer a second screening for anaemia and atypical red cell
alloantibodies
• If haemoglobin level below 105g/L, consider iron
supplementation, if indicated
• Offer anti-D prophylaxis to rhesus-negative women
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
31–32weeks (nulliparous women)
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
34weeks
• Discussion of antenatal classes in preparation for labour
and birth, including pain relief in labour and the birth
plan
• Offer a second dose of anti-D to rhesus-negative women
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
36weeks
• Discuss vitamin K prophylaxis and newborn infant
screening tests, postnatal care, awareness of baby blues
and postnatal depression
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
• If baby in the breech presentation, offer external cephalic
version
38weeks
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
• Information of prolonged pregnancy including its
management
40weeks
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
41weeks
For women undelivered by 41weeks:
• A membrane sweep should be offered
• Induction of labour should be offered
• Measure blood pressure and test urine for proteinuria
• Measure symphysiofundal height
At each visit, ‘risk’ (including that relating to domestic abuse,
mood changes) must be assessed and care planned
accordingly
Previous o bstetric h istory
A careful history for each of the woman ’ s previous pregnancies should be sought. This includes details of the
antenatal course, gestation at and mode of delivery, birth
weight of the baby and his/her condition at birth.
Antenatal c omplications
Details of antenatal complications including pre -
eclampsia, antepartum haemorrhage, preterm prelabour
rupture of membranes, venous thrombosis, cholestasis of
pregnancy, intrauterine fetal growth restriction (IUGR),
stillbirth and congenital abnormality are important. In a
woman with the same partner who has had pre - eclampsia
in her first pregnancy there is an approximate 8 – 10% risk
of recurrence. In women with early onset severe pre -
eclampsia or those with severe fetal growth restriction,
especially if recurrent, the option of low dose aspirin could
be discussed. With a previous history of cholestasis of
pregnancy, the recurrence risk might range around 40 –
80% (with a 30 – 40% risk of having pruritus while on the
oral combined contraceptive pill) and plans to monitor the
clinical symptoms, liver function tests including bile acid
estimations and fetal well - being can be put in place.
Labour and d elivery
Details regarding the labour and delivery including
whether the labour was induced or spontaneous, gestation at delivery; a previous preterm labour puts a mother
at a higher risk of this again. If the labour was quick and
painless (or it was a second trimester painless pregnancy
loss), the differential diagnosis of an ‘ incompetent ’ cervix
should be borne in mind. Cervical assessment with ultrasound in the second trimester may be indicated, with the
option of insertion of a cervical suture if the cervix shows
signs of funnelling or shortening. Similarly, with a history
of recurrent preterm labours there might be a place for
prophylactic administration of steroids for fetal lung
maturity at a reasonable gestation before the anticipated
start of labour (although this is not easy to predict).
Mode of d elivery
See Case 23 .
Details of the t hird s tage
Details of the third stage including any history of postpartum haemorrhage (PPH), third degree tears, manual
removal of the placenta under an anaesthetic should be
sought. Some of these have a higher risk of recurrence
(especially if they have occurred on two or more occasions) and prophylactic third stage management with
oxytocin or syntometrine may be indicated.
Details of the n eonate
Details of the neonate including birth weight and condition at birth, especially if requiring admission to the neonatal unit, should be sought.
Puerperium
A history of any problems in the puerperium should be
sought including sepsis, secondary PPH and depression.
Especially with postpartum depression/psychosis, plans
should be in place for careful assessment of the woman ’ s
mood both antenatally and postnatally, with access to
adequate support and help.
Medical and s urgical h istory
This is an important aspect of an antenatal history as
there may be conditions that affect the pregnancy or that
the pregnancy could change with either deterioration
(e.g. cardiac disease) or improvement (e.g. some autoimmune disorders) or an alteration in treatment or dosage
might be indicated (e.g. with ACE antihypertensives, or
with thyroxine replacement in hypothyroidism where
often an increase in dose through the pregnancy is
required). Multidisciplinary team care, involving the
cardiologist, haematologist, rheumatologist and endocrinologist as the case demands, may need to be planned
for. A complete drug history (including over - the - counter
prescriptions) is also essential (e.g. high dose vitamin A
may be teratogenic in the first trimester).
Gynaecological h istory
• This should include the menstrual history – the regularity and pattern of previous menstrual cycles, the LMP
• Previous contraceptive use
• Cervical smear history – if a smear is due this can be
performed in early pregnancy, but it might be preferable
to wait till past the puerperium if there has no previous
concerning smear history
• Any other relevant history (e.g. of pelvic inflammatory
disease, sexually transmitted disease)
Family h istory
A history of consanguinity, of genetic or familial syndromes, is important to be able to organize appropriate
counselling and tests if available. Some conditions such
First contact with a health care professional
(ideally should be preconception)
Evaluate history/risk factors
Discussion should include:
• Folic acid supplementation
• Food hygiene, including how to reduce the risk of a
food-acquired infection
• Lifestyle advice, including smoking cessation, recreational
drug use and alcohol consumption
• All antenatal screening, including risks and benefits of the
screening tests
Booking appointment (ideally by 10weeks)
• Evaluate ‘risk’ (including evaluation of social and domestic
circumstances) and women who need additional care and
plan pattern of care for the pregnancy
• Offer early ultrasound scan for gestational age assessment
• Check blood group and rhesus D status
• Offer screening for haemoglobinopathies (if indicated),
anaemia, red cell alloantibodies, hepatitis B virus, HIV,
rubella susceptibility and syphilis infection
• Offer screening for asymptomatic bacteriuria
• Inform pregnant women younger than 25years about the
high prevalence of Chlamydia infection in their age group
and offer screening
• Offer screening for Down’s syndrome
• Offer mid-trimester ultrasound screening for structural
anomalies
• Measure height, weight and calculate body mass index
• Measure blood pressure and test urine for proteinuria
• Offer screening for gestational diabetes (in the ‘at risk’ group)
• Evaluate mood to identify possible depression
16weeks
• Discuss the results of all screening tests undertaken
• Investigate a haemoglobin level below 110g/L and
consider iron supplementation if indicated
• Measure blood pressure and test urine for proteinuria
18–20weeks
Mid-trimester anomaly scan if the woman chooses to have this
24–25weeks (for nulliparous women)
• Measure symphysiofundal height
• Measure blood pressure and test urine for proteinuria
28weeks
• Offer a second screening for anaemia and atypical red cell
alloantibodies
• If haemoglobin level below 105g/L, consider iron
supplementation, if indicated
• Offer anti-D prophylaxis to rhesus-negative women
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
31–32weeks (nulliparous women)
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
34weeks
• Discussion of antenatal classes in preparation for labour
and birth, including pain relief in labour and the birth
plan
• Offer a second dose of anti-D to rhesus-negative women
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height
36weeks
• Discuss vitamin K prophylaxis and newborn infant
screening tests, postnatal care, awareness of baby blues
and postnatal depression
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
• If baby in the breech presentation, offer external cephalic
version
38weeks
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
• Information of prolonged pregnancy including its
management
40weeks
• Blood pressure and urine for proteinuria
• Measure symphysiofundal height, check lie/position of
baby
41weeks
For women undelivered by 41weeks:
• A membrane sweep should be offered
• Induction of labour should be offered
• Measure blood pressure and test urine for proteinuria
• Measure symphysiofundal height
At each visit, ‘risk’ (including that relating to domestic abuse,
mood changes) must be assessed and care planned
accordingly
Previous o bstetric h istory
A careful history for each of the woman ’ s previous pregnancies should be sought. This includes details of the
antenatal course, gestation at and mode of delivery, birth
weight of the baby and his/her condition at birth.
Antenatal c omplications
Details of antenatal complications including pre -
eclampsia, antepartum haemorrhage, preterm prelabour
rupture of membranes, venous thrombosis, cholestasis of
pregnancy, intrauterine fetal growth restriction (IUGR),
stillbirth and congenital abnormality are important. In a
woman with the same partner who has had pre - eclampsia
in her first pregnancy there is an approximate 8 – 10% risk
of recurrence. In women with early onset severe pre -
eclampsia or those with severe fetal growth restriction,
especially if recurrent, the option of low dose aspirin could
be discussed. With a previous history of cholestasis of
pregnancy, the recurrence risk might range around 40 –
80% (with a 30 – 40% risk of having pruritus while on the
oral combined contraceptive pill) and plans to monitor the
clinical symptoms, liver function tests including bile acid
estimations and fetal well - being can be put in place.
Labour and d elivery
Details regarding the labour and delivery including
whether the labour was induced or spontaneous, gestation at delivery; a previous preterm labour puts a mother
at a higher risk of this again. If the labour was quick and
painless (or it was a second trimester painless pregnancy
loss), the differential diagnosis of an ‘ incompetent ’ cervix
should be borne in mind. Cervical assessment with ultrasound in the second trimester may be indicated, with the
option of insertion of a cervical suture if the cervix shows
signs of funnelling or shortening. Similarly, with a history
of recurrent preterm labours there might be a place for
prophylactic administration of steroids for fetal lung
maturity at a reasonable gestation before the anticipated
start of labour (although this is not easy to predict).
Mode of d elivery
See Case 23 .
Details of the t hird s tage
Details of the third stage including any history of postpartum haemorrhage (PPH), third degree tears, manual
removal of the placenta under an anaesthetic should be
sought. Some of these have a higher risk of recurrence
(especially if they have occurred on two or more occasions) and prophylactic third stage management with
oxytocin or syntometrine may be indicated.
Details of the n eonate
Details of the neonate including birth weight and condition at birth, especially if requiring admission to the neonatal unit, should be sought.
Puerperium
A history of any problems in the puerperium should be
sought including sepsis, secondary PPH and depression.
Especially with postpartum depression/psychosis, plans
should be in place for careful assessment of the woman ’ s
mood both antenatally and postnatally, with access to
adequate support and help.
Medical and s urgical h istory
This is an important aspect of an antenatal history as
there may be conditions that affect the pregnancy or that
the pregnancy could change with either deterioration
(e.g. cardiac disease) or improvement (e.g. some autoimmune disorders) or an alteration in treatment or dosage
might be indicated (e.g. with ACE antihypertensives, or
with thyroxine replacement in hypothyroidism where
often an increase in dose through the pregnancy is
required). Multidisciplinary team care, involving the
cardiologist, haematologist, rheumatologist and endocrinologist as the case demands, may need to be planned
for. A complete drug history (including over - the - counter
prescriptions) is also essential (e.g. high dose vitamin A
may be teratogenic in the first trimester).
Gynaecological h istory
• This should include the menstrual history – the regularity and pattern of previous menstrual cycles, the LMP
• Previous contraceptive use
• Cervical smear history – if a smear is due this can be
performed in early pregnancy, but it might be preferable
to wait till past the puerperium if there has no previous
concerning smear history
• Any other relevant history (e.g. of pelvic inflammatory
disease, sexually transmitted disease)
Family h istory
A history of consanguinity, of genetic or familial syndromes, is important to be able to organize appropriate
counselling and tests if available. Some conditions such
as diabetes, pre - eclampsia and cholestasis are seen more
often in women who have a familial history of these.
Social h istory
A history of smoking, alcohol use and any other substance misuse should be probed as these could affect
pregnancy. Excessive alcohol use could cause fetal effects
spanning the spectrum of fetal alcohol syndrome from
mild to severe (e.g. microcephaly, midface hypoplasia,
flat philtrum, cardiac abnormalities, learning and developmental delay). Opiate and cocaine substance misuse
increase the risk of preterm labour, IUGR, antepartum
haemorrhage, fetal distress and neonatal abstinence syndrome, with cocaine especially increasing the risk of placental abruption. With intravenous drug use there is also
the higher incidence of maternal infections such as hepatitis B and C and of venous thrombosis.
This group of vulnerable women require targeted
multidisciplinary antenatal care involving the substance
misuse services to stabilize drug use (mostly with prescribed oral methadone), prevent substance withdrawal
(which increases the risk of preterm labour and fetal
distress), screening for infections and surveillance of the
baby.
It is also an important part of antenatal assessment to
evaluate if the baby will be going into a safe and appropriate environment and if additional help is needed to
achieve this.
Antenatal appointments should include measuring
body mass index (BMI) at the booking appointment and
blood pressure (BP) and testing urine for proteinuria and
ketones. The offer of the following screening tests should
be made:
• Early ultrasound scan for confirming viability, gestational age and whether a singleton or multiple
pregnancy
• Blood group and rhesus D (RhD) status
• Screening for anaemia, red cell alloantibodies, hepatitis
B virus, HIV, rubella susceptibility and syphilis infection
• Screening for asymptomatic bacteriuria
• Screening for Down ’ s syndrome
• Ultrasound screening for structural anomalies (20 s)
For certain women additional tests may be offered; for
example, Chlamydia testing in the under 25s, a haemoglobinopathy screen in those of African or Mediterranean descent (to look for sickle cell or thalassaemia
carriers). At around 28 weeks repeat red cell alloantibody
screening and a haemoglobin recheck are offered. Screening for gestational diabetes varies from centre to centre
and may include a random glucose check on all women
at some point in the early third trimester to an oral
glucose tolerance test (OGTT) when risk factors are identified in the history (e.g. previous large for dates baby,
family history of diabetes, Asian origin, increased BMI)
or examination (e.g. polyhydramnios, large baby or
recurrent glycosuria in current pregnancy; see Case 21 ).
Women should be informed about the purpose of any
screening test before it is performed, and should have the
option to accept or decline a test (Box E ).
often in women who have a familial history of these.
Social h istory
A history of smoking, alcohol use and any other substance misuse should be probed as these could affect
pregnancy. Excessive alcohol use could cause fetal effects
spanning the spectrum of fetal alcohol syndrome from
mild to severe (e.g. microcephaly, midface hypoplasia,
flat philtrum, cardiac abnormalities, learning and developmental delay). Opiate and cocaine substance misuse
increase the risk of preterm labour, IUGR, antepartum
haemorrhage, fetal distress and neonatal abstinence syndrome, with cocaine especially increasing the risk of placental abruption. With intravenous drug use there is also
the higher incidence of maternal infections such as hepatitis B and C and of venous thrombosis.
This group of vulnerable women require targeted
multidisciplinary antenatal care involving the substance
misuse services to stabilize drug use (mostly with prescribed oral methadone), prevent substance withdrawal
(which increases the risk of preterm labour and fetal
distress), screening for infections and surveillance of the
baby.
It is also an important part of antenatal assessment to
evaluate if the baby will be going into a safe and appropriate environment and if additional help is needed to
achieve this.
Antenatal appointments should include measuring
body mass index (BMI) at the booking appointment and
blood pressure (BP) and testing urine for proteinuria and
ketones. The offer of the following screening tests should
be made:
• Early ultrasound scan for confirming viability, gestational age and whether a singleton or multiple
pregnancy
• Blood group and rhesus D (RhD) status
• Screening for anaemia, red cell alloantibodies, hepatitis
B virus, HIV, rubella susceptibility and syphilis infection
• Screening for asymptomatic bacteriuria
• Screening for Down ’ s syndrome
• Ultrasound screening for structural anomalies (20 s)
For certain women additional tests may be offered; for
example, Chlamydia testing in the under 25s, a haemoglobinopathy screen in those of African or Mediterranean descent (to look for sickle cell or thalassaemia
carriers). At around 28 weeks repeat red cell alloantibody
screening and a haemoglobin recheck are offered. Screening for gestational diabetes varies from centre to centre
and may include a random glucose check on all women
at some point in the early third trimester to an oral
glucose tolerance test (OGTT) when risk factors are identified in the history (e.g. previous large for dates baby,
family history of diabetes, Asian origin, increased BMI)
or examination (e.g. polyhydramnios, large baby or
recurrent glycosuria in current pregnancy; see Case 21 ).
Women should be informed about the purpose of any
screening test before it is performed, and should have the
option to accept or decline a test (Box E ).
Box E Conditions increasing maternal and/or
fetal risks
Examples of conditions in pregnant women increasing
their pregnancy risks, with obstetric and/or medical care
indicated:
• Cardiac disease
• Hypertension
• Renal disease
• Endocrine disorder or diabetes requiring insulin
• Psychiatric disorder (on medication)
• Haematological disorder, including thromboembolic
disease
• Autoimmune diseases such as antiphospholipid
syndrome
• Epilepsy requiring anticonvulsant drugs
• Severe asthma
• Drug use such as heroin, cocaine (including crack
cocaine) and ecstasy
• HIV or hepatitis B virus infection
• Obesity (BMI of 35 or more at first contact) or
underweight (BMI less than 18 at first contact)
Women who have experienced any of the following in
previous pregnancies
• Recurrent miscarriage (three or more consecutive
pregnancy losses) or a mid-trimester loss
• Severe pre-eclampsia, HELLP syndrome or eclampsia
• Rhesus isoimmunization or other significant blood group
antibodies
• Uterine surgery including caesarean section,
myomectomy
• Antenatal or postpartum haemorrhage on two occasions
• Retained placenta on two occasions
• Puerperal psychosis
• Grand multiparity (more than six pregnancies)
• A stillbirth or neonatal death
• A small for gestational age infant (<5th centile)
• A large for gestational age infant (>95th centile)
• A baby weighing <2500g or >4500g
• A baby with a congenital anomaly (structural or
chromosomal)
fetal risks
Examples of conditions in pregnant women increasing
their pregnancy risks, with obstetric and/or medical care
indicated:
• Cardiac disease
• Hypertension
• Renal disease
• Endocrine disorder or diabetes requiring insulin
• Psychiatric disorder (on medication)
• Haematological disorder, including thromboembolic
disease
• Autoimmune diseases such as antiphospholipid
syndrome
• Epilepsy requiring anticonvulsant drugs
• Severe asthma
• Drug use such as heroin, cocaine (including crack
cocaine) and ecstasy
• HIV or hepatitis B virus infection
• Obesity (BMI of 35 or more at first contact) or
underweight (BMI less than 18 at first contact)
Women who have experienced any of the following in
previous pregnancies
• Recurrent miscarriage (three or more consecutive
pregnancy losses) or a mid-trimester loss
• Severe pre-eclampsia, HELLP syndrome or eclampsia
• Rhesus isoimmunization or other significant blood group
antibodies
• Uterine surgery including caesarean section,
myomectomy
• Antenatal or postpartum haemorrhage on two occasions
• Retained placenta on two occasions
• Puerperal psychosis
• Grand multiparity (more than six pregnancies)
• A stillbirth or neonatal death
• A small for gestational age infant (<5th centile)
• A large for gestational age infant (>95th centile)
• A baby weighing <2500g or >4500g
• A baby with a congenital anomaly (structural or
chromosomal)
Examination
General e xamination
It is good practice to start with a general examination,
remembering the normal physiological changes that do
occur from very early on in the pregnancy. Checking for
pallor, peripheral odema, jaundice and dehydration if
there is increased vomiting, and where indicated for varicose veins, thyroid enlargement and tendon reflexes are
important.
Blood pressure in pregnancy should be measured
appropriately. The woman should be relaxed, semi -
recumbent at about a 30 ° angle and the blood pressure
should be measured with an appropriately sized cuff (the
width of the cuff should be 40% of the arm circumference) from her right arm at the level of the heart. Women
with a high BMI may need a larger cuff. While systolic
blood pressure is when the Korotkoff ’ s sounds are first
heard, there has been much controversy as to whether
the muffling or disappearance of sounds should be taken
for diastolic blood pressure. The general consensus from
obstetricians based on careful analysis of the evidence is
that disappearance of sounds (fifth phase) is the most
accurate measurement of diastolic pressure, with the
proviso that in those rare instances in which sounds
persist to zero the fourth phase of muffling of sounds
should be used.
Abdominal e xamination
General e xamination
It is good practice to start with a general examination,
remembering the normal physiological changes that do
occur from very early on in the pregnancy. Checking for
pallor, peripheral odema, jaundice and dehydration if
there is increased vomiting, and where indicated for varicose veins, thyroid enlargement and tendon reflexes are
important.
Blood pressure in pregnancy should be measured
appropriately. The woman should be relaxed, semi -
recumbent at about a 30 ° angle and the blood pressure
should be measured with an appropriately sized cuff (the
width of the cuff should be 40% of the arm circumference) from her right arm at the level of the heart. Women
with a high BMI may need a larger cuff. While systolic
blood pressure is when the Korotkoff ’ s sounds are first
heard, there has been much controversy as to whether
the muffling or disappearance of sounds should be taken
for diastolic blood pressure. The general consensus from
obstetricians based on careful analysis of the evidence is
that disappearance of sounds (fifth phase) is the most
accurate measurement of diastolic pressure, with the
proviso that in those rare instances in which sounds
persist to zero the fourth phase of muffling of sounds
should be used.
Abdominal e xamination
 |
| Figure M Mid-sagittal view of mother with baby in utero. The fundal height is determined by measuring the distance from the pubic symphysis to the highest part of the uterus. A 33-week baby should measure 33cm (+/- 3cm) |
As with any other examination, a structured approach
is best.
Inspection includes determining the degree of distension of the abdomen and to see if it generally appears
appropriate to the period of gestation (e.g. does it appear
overdistended with umbilical eversion – this might be
seen with multiple pregnancy, polyhydramnios or fetal
marcosomia), for any fetal movements that may be
obvious, the presence of old or new striae gravidarum
and linea nigra, and for any scars of previous surgery (of
previous caesarean section, laparotomy, laparoscopy or
appendicectomy).
Before palpating, it is good practice to enquire if the
woman has been in any pain. The fundus of the uterus is
palpated with the ulnar border of the hand by gradually
palpating down from the xiphisternum until the fundus
is reached. The symphysiofundal height (SFH) is then
measured from the upper border of the symphysis pubis
to the fundus, in centimetres (Fig. M ).
This is routine screening for fetal growth problems;
generally, +/- 3 cm from the period of gestation, especially in the third trimester, may indicate a large for dates
or a small for date fetus, respectively. This needs to be
confirmed by a fetal growth scan in most cases as SFH is
not a very sensitive or specific examination tool.
Fundal palpation may help to determine if the fetal
breech or head is at the fundus. Lateral palpation helps
determine the lie (longitudinal, oblique or transverse) of
the fetus and where the back and limbs might be. Both
hands are placed flat on either side of the abdomen and
the fetus is gently balloted between the two to feel the
fetal back and limbs. An attempt must be made to assess
the liquor volume – in oligohydramnios fetal parts may
be very clearly felt while with polyhydramnios the opposite is the case (Fig. N ).
The presenting part is then palpated with both hands
on either side of the lower pole of the uterus to confirm
if it is the head or the breech presenting and then to
determine if it is engaged (widest presenting part through
the pelvic inlet). This is also commented on as how many
fifths of the head can be felt per abdomen – generally
when a head is engaged with it is palpable two - fifths or
less per abdomen.
The fetal heart is then heard through a Doppler Sonicaid or, increasingly less so these days, with a Pinard
stethoscope. The site for the most appropriate check of
the fetal heart is easier if the lie of the fetus, its back and
presenting part are clearly identified with the abdominal
palpation.
Uterine tenderness on palpation may be elicited in
cases of chorioamnionitis (see Case 19 ), placental
abruption (see Case 18 ) and degeneration of uterine
fibroids. There may be epigastric pain and tenderness
over the liver in HELLP (haemolytic anaemia, elevated
liver enzymes and low platelet count; see Case 16 ). There
may be other non - obstetric causes of painful abdomen
including reflux, urinary tract infection, appendicitis,
torsion of an ovarian cyst and gall stones, and appropriate history, examination and investigations should be
evaluated to make a diagnosis. The pregnant uterus could
alter some classic clinical signs; for example, tenderness
over the McBurney point or rebound tenderness in
appendicitis may not be elicited because of displacement
of the appendix from its normal position.
When examining for uterine contractions in labour,
the strength of the contraction (mild, moderate, strong),
the frequency (how many contractions in 10 minutes)
and if the uterus is relaxing well between contractions
must all be taken into account. A uterus that is contracting more than five times in 10 minutes without adequate
relaxation between contractions (with each contraction
lasting more than 1 minute) can be described as having
tachysystole, and if this is associated with fetal heart rate
abnormalities it is labelled as hyperstimulation (hyperstimulation also includes a sustained uterine contraction
≥2 minutes). These features are especially important
when monitoring for side - effects of prostaglandin induction of labour and oxytocin augmentation of labour.
 |
| Figure N Abdominal palpation. (a) Fundal palpation to ascertain the fetal part at the fundus. (b) Lateral palpation to determine the lie (longitudinal, oblique or transverse). (c) Palpation to determine whether presenting part engaged in maternal pelvis.
|
Vaginal e xamination
Vaginal examinations are not very often indicated antenatally, although they are very important in labour to
assess progress. Some of the indications for an antenatal
vaginal speculum examination are as follow:
• To confirm preterm premature rupture of membranes
(PPROM; see Case 19 )
• To look for local causes of antepartum bleeding after
a scan has ruled out a low - lying placenta (see Case 17 )
• To perform swabs when there is a history of symptomatic vaginal discharge
• Where there may be a threatened miscarriage or
preterm labour
• Occasionally, to perform a cervical smear
A digital examination may be indicated to:
• Confirm cervical changes of labour – both in preterm
and term labour
• Evaluate the ripeness of the cervix (Bishop ’ s score; see
Case 14 ) to determine if prostaglandin ripening is indicated when induction of labour is planned
• For sweeping of membranes in postdated pregnancies
prior to formal induction of labour
• Evaluate progress in labour (see Case 14 )
All the principles of performing an intimate examination and the techniques are as described above in the
section on the gynaecological patient. Generally, in pregnancy the cervix looks somewhat different from that in
the non - pregnant state; it is softer, appears larger and
more vascular, and may have a large ectropion (usually
a normal physiological change of pregnancy). The internal os may be more difficult to visualize especially as the
pregnancy progresses as a result of the growing uterus
altering its normal position, and there may be a greater
amount of the normal physiological vaginal discharge.
In conclusion, good antenatal care involves risk assessment; this has to be ongoing through the pregnancy as
the level of risk could change at any stage (and during
labour, delivery and puerperium). Risk assessment is
based on a combination of past obstetric and maternal
medical, surgical, family, social and drug history, maternal demographics such as age and BMI, the results of
routine examination (e.g. increase in BP suggesting pregnancy induced hypertension or pre - eclamptic toxaemia,
or a lower SFH suggesting IUGR) and the results of antenatal screening tests.
References
Antenatal care: routine care for the healthy pregnant woman.
NICE Clinical Guideline CG62. March 2008 .
GMC Guidelines on Intimate Examination: Maintaining Boundaries. November 2006 .
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