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Answers to questions for volume 9, number 2

The current management of vaginal birth after previous caesarean delivery

In the UK

1 the relative risk of uterine rupture during vaginal birth after caesarean section is under 3%. True 2 a countrywide audit has reported a caesarean section rate of 26%. False 3 over 50% of women attempt vaginal birth after one caesarean section. True 4 over 30% of women with a previous caesarean section achieve a vaginal delivery. True Discussion In the UK, 21.5% of births are currently by caesarean section and 56% of women attempt vaginal birth after one caesarean section, with 66.7% of them succeeding.

With regard to caesarean section,

5 there are no overall cost savings from VBAC compared with elective repeat caesarean. False 6 there is a higher risk of caesarean hysterectomy associated with VBAC compared with caesarean section. False 7 endometritis is more common after failed than successful VBAC. True Discussion There are cost savings from VBAC if success rates of 60–75% are achieved.3 The risk of hysterectomy in VBAC appears to be reduced or unchanged,5,7,8 but the rate of hysterectomy for uterine rupture is increased by 3.4/10 000.17

With regard to the risks of VBAC,

8 epidural anaesthesia masks the pain associated with scar dehiscence. False 9 a baby of more than 4000 g predisposes to failed VBAC, but not to uterine rupture. True 10 the rate of uterine rupture where there is a classical caesarean scar is over 20%. False 11 the maternal mortality rate is 0.02 per 1000. True Discussion Epidural anaesthesia rarely masks scar pain but signs and symptoms of uterine rupture can be confused with acute placental abruption.24 A previous classical caesarean or T-shaped scar has been linked to scar rupture in 4–9% of VBACs.21

With regard to research into VBAC,

12 most of the evidence available today is based on large randomised controlled trials. False 13 a recent statistical model includes antenatal findings to predict the likelihood of success. True 14 one aim of the Caesarean Section Surgical Techniques (CAESAR) trial is to evaluate the effect of uterine closure on future pregnancies. True Discussion The available evidence on VBAC stems from case control or retrospective observational studies, with inherent problems of selection bias and limited comparability between study groups.

Regarding the diagnosis of uterine rupture,

15 cardiotocography (CTG) changes are present in more than 90% of cases. False 16 CTG changes include tachycardia, late decelerations and the disappearance of contractions. True 17 uterine rupture usually leads to fetal death. False Discussion Cardiotocography heralds uterine rupture in 50–70% of cases.21 Uterine rupture is associated with a neonatal death rate of 1.8%.8

With regard to induction in cases of VBAC,

18 the use of oxytocin is associated with rupture precisely at the site of the previous scar. False 19 recent evidence suggests that sequential use of prostaglandin and oxytocin is more hazardous than oxytocin after amniotomy. True 20 one study has reported a >15% increase in risk of uterine rupture with prostaglandin induction. True Discussion Oxytocin is more usually associated with defects remote from the old scar.43

Cardiac disease in pregnancy. Part 2: acquired heart disease

Regarding the management of acute myocardial infarction during pregnancy and the puerperium,

21 coronary angiography is safe. True 22 most deaths occur within 2 weeks of treatment. False 23 thrombolysis is contraindicated. False Discussion Maternal mortality rates of 37–50% have been reported, with most deaths occurring at the time of infarction.15 Thrombolysis can cause bleeding from the placental site but is still indicated in the management of acute myocardial infarction.

In a woman with mitral stenosis,

24 pregnancy increases the risk of atrial fibrillation. True 25 pregnancy is associated with an approximately 10% maternal mortality rate. False 26 pregnancy should be delayed until surgical correction where the symptoms or the stenosis are severe. True 27 treatment with balloon mitral valvuloplasty is required in those with refractory symptoms. True Discussion Mortality among pregnant women with minimal symptoms is less than 1%.

During pregnancy, open heart surgery with cardiac bypass is

28 best avoided. True 29 associated with a 25% maternal mortality rate. False 30 associated with a 16–33% risk of fetal mortality. True Discussion Open heart surgery with cardiac bypass carries a 1.5–5% risk of maternal mortality.11

With regards to peripartum cardiomyopathy,

31 the diagnosis is usually one of exclusion. True 32 the mortality is approximately 20%. True 33 subsequent pregnancies do not carry a risk of relapse if left ventricular systolic function has recovered completely. False Discussion Subsequent pregnancy carries a higher risk if left ventricular systolic function is not fully recovered first and, even with full recovery, some additional risk of relapse remains.24

Cardiac arrhythmias

34 should be treated with amiodarone during pregnancy. False 35 should not be treated with cardioversion during pregnancy. False Discussion Amiodarone is contraindicated, as it is associated with fetal hypothyroidism, growth restriction and prematurity. Electrical cardioversion is safe in pregnancy and necessary in all women with tachyarrhythmias who are haemodynamically unstable.

In pregnant women with mechanical heart valves

36 oral anticoagulation during pregnancy is associated with a rate of maternal thromboembolism of less than 5%. True 37 the use of low molecular weight heparin during the first trimester carries a high risk of fetal embryopathy compared with use in the second trimester. False 38 the fetal mortality rate is approximately 1 in 3. True Discussion Effective anticoagulation is critical and the risks to the mother and fetus need to be carefully balanced; several approaches are available. Substituting low molecular weight heparin for warfarin during the period of organogenesis (6–12 weeks of gestation) abolishes the risk of warfarin embryopathy but doubles the maternal thromboembolism risk to 9%.

With regard to maternal mortality rates in the United Kingdom,

39 valvular disease following rheumatic fever has recently become one of the major causes. True Discussion With increasing immigration from countries where rheumatic fever remains prevalent, valvular heart disease is set to become a significant problem in the UK.

During pregnancy

40 all women with heart valve lesions should be given antibiotics to prevent endocarditis. False Discussion Antibiotic prophylaxis should be given during labour and delivery to all women with valvular lesions except mitral valve prolapse without regurgitation.

Uterine leiomyosarcomas: a review of the diagnostic and therapeutic pitfalls

Uterine leiomyosarcomas

41 are associated with exposure to tamoxifen. True 42 are the commonest uterine sarcomas. True 43 belong to the subgroup of mixed mesodermal tumours. False 44 originate from leiomyomas. False 45 most commonly metastasise to the bones. False Discussion Leiomyosarcomas belong to the uterine sarcomas group. Uterine fibroids are not generally thought to develop into malignant leiomyomas. Leiomyosarcomas commonly metastasise to the lungs.

Regarding the diagnosis of uterine leiomyosarcoma,

46 a frozen section is not beneficial if a leiomyosarcoma is suspected intraoperatively. True 47 the presence of coagulative necrosis is indicative of leiomyosarcoma. True 48 the presence of coagulative tumour cell necrosis is a more accurate diagnostic criterion than mitotic count. True Discussion Intraoperative frozen sections performed for suspicious fibroids are often inaccurate.6

Concerning adjuvant therapy for uterine leiomyosarcomas,

49 adjuvant pelvic radiotherapy has a significant impact on survival. False 50 anthracycline-based chemotherapy has a role in treatment. True Discussion Despite the possible benefit of adjuvant pelvic radiotherapy in reducing local recurrence rates, there has not been a proven significant impact on overall survival.7

With regard to surgical treatment of uterine leiomyosarcomas,

51 bilateral salpingo-oophorectomy is mandatory. False 52 myomectomy is contraindicated. False 53 the role of pelvic lymphadenectomy is unclear. True 54 if the pelvic disease is controlled, resection of a single metastasis may be indicated. True Discussion It may be reasonable to consider ovarian conservation in young women with early-stage disease. A therapeutic dilemma in treating younger women is the discovery of a leiomyosarcoma during histological examination of a myomectomy specimen. Total hysterectomy has been established as the safest surgical procedure for these cases. A conservative approach following myomectomy should only be taken for specific and accurately selected women who strongly desire pregnancy and who are well counselled about the risks involved.

With regard to treatment for uterine leiomyosarcomas,

55 palliative radiotherapy is preferred for advanced unresectable disease. False 56 aggressive surgical cytoreduction at initial operation offers the best long-term prognosis. True

In women with recurrent uterine leiomyosarcomas,

57 more than half have been shown to respond to gemcitabine combined with docetaxel. True

Concerning the prognosis of uterine leiomyosarcomas,

58 the most important factor is tumour size. False 59 staging is similar to that of endometrial carcinoma. True 60 there is a direct relationship between high levels of Ki67 and rapid tumour growth. True Discussion Overall, tumour stage has been confirmed as the strongest prognostic variable.

Obstetric management of women with female genital mutilation

The following statements about female genital mutilation are true:

61 The World Health Organization is working towards its recognition as a violation of human rights. False 62 Under the Female Genital Mutilation Act 2003, it is illegal to perform the procedure in the UK, but a health worker can perform it abroad. False Discussion The World Health Organization has outlawed female genital mutilation.4 Under the Female Genital Mutilation Act 2003 it is an offence for any person to carry out the procedure abroad.

In the UK,

63 the incidence of female genital mutilation has fallen since the introduction of the Female Circumcision Act 1985. True 64 around 7 000 women are still at risk of having genital mutilation. True

Regarding female genital mutilation,

65 girls are being mutilated at increasingly younger ages. True Discussion As the campaign against female genital mutilation in the West increases, parents are bringing down the age of mutilation and are increasingly taking girls abroad for the procedure.

With regards to the practice of female genital mutilation in African countries,

66 it is performed in 28 to 30 countries in Sub-Saharan Africa. True 67 approximately 500 procedures are carried out per day. False Discussion Six thousand girls a day are at risk of having the procedure.

The following are acute complications of female genital mutilation:

68 Retention of urine resulting from pelvic haematoma. False 69 Haematocolpos from retention of menstrual blood. False 70 Faecal incontinence. True Discussion Retention of urine from pain and direct mechanical obstruction is an acute complication; haematocolpos from retention of menstrual blood is a long-term complication.

Regarding obstetric complications from the procedure,

71 there is a significant increase in the rate of infant morbidity from fetal hypoxia. True 72 there is an increased incidence of postpartum haemorrhage. True

In women with type III female genital mutilation, the defibulation procedure

73 should be left until the second stage of labour if it is not performed at 20 weeks of gestation. False 74 should preferably be performed under general anaesthesia to avoid evoking painful memories of the past. False Discussion Defibulation should be offered and performed early in pregnancy, before 20 weeks of gestation, according to the RCOG guidelines.31 The procedure can be performed under local or spinal anaesthesia.

In women with type III mutilation,

75 the labia minora are absent. True 76 difficulty in bladder catheterisation during labour can lead to a prolonged second stage. False Discussion A full bladder can prolong the first stage because of difficulties in catheterising the bladder.

Recent research shows that, where indicated, many pregnant women with genital mutilation

77 prefer to undergo defibulation between 34 and 38 weeks of gestation. False Discussion A recent study shows that a significant number of women prefer to wait until the onset of labour.26

Healthcare professionals caring for women with genital mutilation during pregnancy,

78 should ensure that women have a pelvic examination at the first antenatal visit. False Discussion Digital assessment is not always needed as physical appearance may provide the reassurance that is needed.

Regarding female genital mutilation,

79 defibulation may be necessary if urinary tract infections keep recurring. True

One way in which obstetric services could be improved,

80 would be to ensure that midwives are trained in performing an anterior episiotomy. True

Modern management of miscarriage

In women with threatened miscarriage,

81 the therapeutic role of progesterone in prevention and treatment has not been established. True 82 the use of uterine muscle relaxant drugs improves outcome. False Discussion There is insufficient evidence to support the use of uterine muscle relaxant drugs13 in women with threatened miscarriage.

Regarding non-viable pregnancy,

83 approximately 30% of women will choose expectant management if given the choice. False 84 use of biochemical markers is not a practical consideration when considering the best treatment option. True 85 the incidence of diarrhoea is significantly higher with the use of vaginal misoprostol when compared with oral misoprostol. False 86 nulliparity is a factor that predicts success with misoprostol. True Discussion Up to 70% of women will choose expectant management if given the choice.16 While biochemical markers can predict the likelihood of successful expectant management, they would increase costs. Vaginal misoprostol is as effective as oral misoprostol, with a significant reduction in the incidence of diarrhoea.23

Regarding treatment of miscarriage,

87 the risk of infection is higher with medical treatment than with surgical treatment. False 88 about 50% of women would opt for the same management in the future. True 89 expectant management appears to be the least costly alternative. True 90 filmy intrauterine adhesions may develop following surgical evacuation but not after conservative or medical management. True 91 anti-D should be given to all women with a confirmed miscarriage <12 weeks of gestation. False 92 women who choose their own treatment have been shown to have the best health-related quality of life over time. True Discussion The MIST trial36 showed that the risk of infection is low (2–3%), regardless of treatment modality. Regarding anti-D prophylaxis for Rh-negative women, see Figure 1 in the article.

Regarding early pregnancy assessment units,

93 one of the benefits is a reduction in inpatient admission by an average of 1 day for women requiring no treatment. False Discussion Admission time is reduced from 1.5 days (range 0.5–3.0) to 2 hours for women requiring no treatment.2

Regarding viable intrauterine pregnancy,

94 miscarriage is likely to occur in about 1 in 10 pregnancies where a fetal heartbeat is present. True

Regarding treatment of miscarriage,

95 the duration of expectant management can be up to approximately 2 months. True 96 the low levels of progesterone present in non-viable pregnancy means that prostaglandins can be administered on their own. True 97 research has shown that treatment with vaginal misoprostol can lead to heavy bleeding for about 2 weeks afterwards. False 98 a benefit of using vacuum aspiration is that there is no need for analgesia. False 99 metronidazole may be given as part of a prophylactic antibiotic regime in women with Chlamydia trachomatis before undergoing surgical evacuation. True 100 there are no differences between treatments with regard to long-term conception rates and pregnancy outcomes. True Discussion Following treatment with vaginal misoprostol, mild–moderate bleeding lasts 4–6 days. Analgesia and sedation should be provided as needed for vacuum aspiration.

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