The diagnosis of venous thromboembolism requires objective testing, which can be done safely throughout pregnancy.
Low molecular weight heparin is the most suitable agent for both prophylaxis and treatment of venous thromboembolism in pregnancy.
Once labour has commenced, heparin should not be administered.
It is recommended that anticoagulants be resumed 4–6 hours after vaginal delivery and 6–12 hours after caesarean delivery.
Learning objectives: To be able to choose the most appropriate diagnostic tests for venous thromboembolism in pregnancy. To be able to prescribe the most appropriate anticoagulants. To be able to manage women on anticoagulants appropriately during the different stages of pregnancy.
Ethical issues: The risks to the fetus of anticoagulant therapy are outweighed by the health benefits to the mother. Women of reproductive age on oral anticoagulants should know about warfarin embryopathy.
Please cite this article as: Asghar F, Bowman P. A clinical approach to the management of thrombosis in obstetrics. Part 2: diagnosis and treatment of venous thromboembolism. The Obstetrician & Gynaecologist 2007;9:3–8.
]]>Overactive bladder syndrome is a highly prevalent symptom complex that can be extremely distressing to women.
It is associated with co-morbidities and reduced quality of life.
Treatment involves behavioural therapy, physiotherapy and pharmacotherapy.
There is robust and convincing evidence that anticholinergic agents are effective drug treatments.
Possible adverse effects include disruption of cognitive function, dry mouth, constipation and blurred vision.
Learning objectives: To know about the pharmacokinetics and pharmacodynamics of anticholinergic medications. To be able to prescribe them appropriately. To know about the differences in effectiveness between the newer anticholinergic drugs.
Ethical issues: How much information should women be given about possible adverse effects?
Please cite this article as: Munjuluri N, Wong W, Yoong W. Anticholinergic drugs for overactive bladder: a review of the literature and practical guide. The Obstetrician & Gynaecologist 2007;9:9–14.
]]>Heart disease is now the most common indirect cause of maternal death in the United Kingdom.
Neonatal morbidity and mortality from fetal growth restriction and prematurity are markedly increased in women with heart disease.
Women with congenital heart disease should ideally have a planned pregnancy managed by a multidisciplinary team which includes obstetricians, cardiologists, anaesthetists, neonatologists and midwives.
Learning objectives: To understand the changes to cardiovascular physiology during pregnancy. To recognise the risk factors for poor pregnancy outcome in cardiac disease. To understand the general management principles for women with cardiac disease in pregnancy.
Ethical issues: Should we be recommending termination of pregnancy in women with high risk cardiac lesions? How do we manage women who become pregnant against medical advice? What is the role of surrogacy in women with high risk cardiac lesions?
Please cite this article as: Gelson E, Johnson M, Gatzoulis M, Uebing A. Cardiac disease in pregnancy. Part 1: congenital heart disease. The Obstetrician & Gynaecologist 2007;9:15–20.
]]>Pregnancy has significant effects on the periodontal tissues and pregnancy gingivitis is a common manifestation of this.
The host response and oral flora are affected and tooth surface loss and mobility may develop.
Further research is required to establish the association between periodontal health and adverse pregnancy outcome.
Learning objectives: To identify the main dental manifestations of pregnancy. To be able to advise pregnant women on how to maintain good dental health. To be aware of the need for effective communication between the dental and medical disciplines to ensure that pregnant women receive the best care possible for oral, obstetric and general health.
Ethical issues: The treatment of gingivitis and periodontitis during pregnancy is safe and effective in treating gum disease.
Please cite this article as: Pirie M, Cooke I, Linden G, Irwin C. Dental manifestations of pregnancy. The Obstetrician & Gynaecologist 2007;9:21–26.
]]>Pregnancy in women with inherited bleeding disorders requires specialised and individualised care using a multidisciplinary approach with obstetricians, midwives, haematologists and anaesthetists.
Childbirth presents an intrinsic haemostatic challenge in these women and obstetricians may be the first to encounter haemorrhagic complications.
An understanding and awareness of these disorders and close collaboration between obstetricians and haematologists are essential in ensuring a successful outcome.
Learning objectives: To understand the basic principles in the obstetric management of women with inherited bleeding disorders. To know the options available for prenatal diagnosis. To be aware of the increased risk of haemorrhagic complications in these women and their offspring.
Ethical issues: Advances in prenatal diagnosis and treatment of inherited bleeding disorders create complex dilemmas for families affected by these disorders.
Please cite this article as: Chi C, Kadir RA. Management of women with inherited bleeding disorders in pregnancy. The Obstetrician & Gynaecologist 2007;9:27–33.
]]>Painful bladder syndrome is a chronic disabling condition that mainly affects women.
The aetiology is uncertain, but is almost certainly multi-factorial and presents as a triad of pain, urinary urgency and frequency.
The most common diagnosis made is interstitial cystitis. Diagnosis is based on history and examination and supplemented by clinical investigation.
Learning objectives: To be able to identify the clinical features of interstitial cystitis and arrange appropriate diagnostic tests. To know how to manage interstitial cystitis using non-pharmacological, dietary and behavioural treatment, as well as pharmacological and surgical therapy.
Ethical issues: How much information should women be given about possible adverse effects?
Please cite this article as: Jha S, Parsons M, Toozs-Hobson P. Painful bladder syndrome and interstitial cystitis. The Obstetrician & Gynaecologist 2007;9:34–41.
]]>Risks are measured in various ways by epidemiologists and portrayed with varying degrees of accuracy by the media.
Doctors should examine their motives for explaining risks. These may include the wish to avoid litigation or to persuade women to take a specific course of action.
Communicating risk requires a background knowledge of how risk is measured and a relationship of trust between doctors and women.
Words and numbers are useful in communicating risk and decision aids are now available to help this process.
Understanding the woman's view is essential – remembering that it may change during pregnancy – and there are techniques for learning this skill.
Learning objectives: To understand how risks are measured and how they are perceived by women. To be aware of the importance of the doctor's attitude to risks. To know the prerequisites for communicating risk and the range of techniques for doing so effectively.
Ethical issues: Does the doctor's opinion bias the information he or she gives? When a woman finds it difficult to take a decision herself, should the doctor do this for her?
Please cite this article as: Drife J. Putting risk into context. The Obstetrician & Gynaecologist 2007;9:42–47.
]]>Clinical guidelines help to standardise and improve patient care.
Development of a valid clinical guideline requires resources and skills.
Local adaptation of a national guideline provides a cost-effective approach to guideline introduction.
A formal consensus process allows local stakeholders to adapt a national guideline.
The adapted guideline combines the rigour of national development with the acceptability engendered by local consensus.
Learning objectives: To gain an overview of the fundamental principles of clinical guideline development. To learn how to adapt national guidelines for use by local NHS organisations or by groups of clinicians in non-UK settings.
Ethical issues: Guideline introduction diverts scarce resources from direct clinical care. Evidence indicates that guidelines result in only modest to moderate improvements in patient outcomes. Clinicians wishing to introduce clinical guidelines should adopt an approach that minimises resource use.
Please cite this article as: Penney GC. Adopting and adapting clinical guidelines for local use. The Obstetrician & Gynaecologist 2007;9:48–52.
]]>Blueprinting is a good tool to ensure that the MRCOG examinations cover the right areas of knowledge and skills required for the specialty in an appropriate way.
Examination weaknesses can be identified to ensure that these are covered by different assessment tools.
The addition of considering domains as well as subjects increases the utility of blueprinting.
Making the outline of the blueprint open to candidates will greatly assist their preparation for examinations.
Analysis of the domains covered by the new Core Curriculum and by the whole MRCOG show a close match, indicating that the MRCOG is very fit for its purpose and corresponds well with the content of the new curriculum.
Learning objectives: To understand the concept of blueprinting. To be aware of alternative approaches to blueprinting. To be aware of how blueprinting has affected the RCOG Membership examinations.
Ethical issues: Thorough blueprinting of the coverage of summative assessments contributes to setting standards to protect women's health.
Please cite this article as: Hodges P. Blueprinting the RCOG examinations. The Obstetrician & Gynaecologist 2007;9:53–57.
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