Venous thrombo-embolism (VTE) is a major cause of morbidity and mortality during pregnancy. Most of the evidence being used in the management of this condition in pregnancy is extrapolated from the general population. One such intervention is the use of the D-dimer test for the diagnosis of thromboembolism in pregnancy. Although this test has been found to be useful in low-risk non-pregnant patients, its negative predictive value is limited in high-risk patients in the general population to be used as a reliable diagnostic tool. Considering pregnancy as a high-risk state for VTE, we have evaluated the role of D-dimer in diagnosing VTE in pregnancy and proposed a diagnostic algorithm for the management of VTE based on the current evidence available.

Though uncommon, Wolff–Parkinson–White syndrome (WPW) can cause life threatening cardiac rhythm disorders in pregnancy. We examine a case report of a 20-year-old primigravida with WPW referred by her GP at 16 weeks of gestation. After consultation with the tertiary care cardiac treatment centre, she was prescribed flecainide (40 mg twice daily), resulting in a settling of the palpitations and chest pain. In pregnant WPW syndrome patients with tachyarrhythmia, therapeutic strategies should be based on interdisciplinary co-operation (obstetrics, cardiology, and neonatology). With an appropriate management strategy, most pregnant women will have a normal and uneventful pregnancy.

This article discusses the actual practice of the vaginal examination and compare the different methods that commonly are used in Europe, particularly the UK and the north European way. The advantages and disadvantages for the patient and the gynaecologist are described in a comprehensive way explaining why different gynaecological positions may be more efficient for both the patient and the gynaecologist. Emphasis is given on the training validation for the junior doctors and the future general practitioners.

The safety of women undergoing childbirth with prior caesarean delivery is a major public health concern. Most of the earlier studies focused on the success rate of vaginal birth after caesarean section; later focus shifted to maternal and neonatal safety, and presently, each factor that would influence the outcome of trial of labour is being considered on both the success and the safety of vaginal birth following caesarean delivery. The contribution of induction of labour to uterine rupture is not entirely clear. Although large multi-center randomised trials comparing planned elective repeat caesarean delivery vs vaginal delivery following prior caesarean delivery are required for conclusive evidence; current evidence suggests that, in properly selected women, vaginal birth can be safely achieved if adequate facilities to monitor the foetus and immediate caesarean can be performed. Unbiased evidence-based information should be given to patients in making decisions about mode of delivery based on individual characteristics. The purpose of this review is to understand each factor that would influence the success and safety of vaginal birth after caesarean delivery.

For several reasons, surgical training is suffering important reductions in terms of time and opportunities. New approaches to surgical training are required, and new training strategies should be proposed to maintain surgical standards. Affordable technologies allowing digital capture and recording of surgical procedures are now widely available, and we believe that the use of such technologies could play a role in the surgical training. Digital videos are useful to surgeons involved in teaching, because they are much easier to edit and share. In the operating theatre, the use of real-time digitised video during operations performed by trainees has different useful applications. A computer screen, with the use of a mouse cursor, can enhance the interaction between trainees and supervisors and can provide valuable information for observers. Recordings can be used for self-assessment, audit and as a basis for digital logbooks. Finally, digital videos can be sent real-time on network connections, allowing for several different telemedicine applications. Every physician involved with surgical teaching and training should be aware of the potential applications of digital videos and eventually become familiar with them.

Patient mobility and its implications for patient safety become increasingly import throughout the European Union (EU). Before extending cross-border care further, differences in the approaches to similar health problems need to be known. With regard to antenatal care, there are sufficient differences in the national guidelines to produce gaps or an unnecessary, expensive and possibly harmful multiplication of tests for pregnant women. As it was perceived impossible to gain a quick and comprehensive overview of what the recommendations in the member states of the EU are, further investigations were needed to address this. Moreover, a comprehensive review of the content of national guidelines on antenatal care was required to find out whether a common minimum guideline would be beneficial, and what this guideline might contain. A model needed to be developed for integrating existing guidelines to a common minimum guideline to complement national health policies. In a survey, the Ministries of Health and equivalent bodies, as well as the societies of obstetricians and midwives, were asked to fill in a structured questionnaire on their national guidelines for antenatal care. Descriptive analyses identified which and how many states recommend a test and to how many people this applied. The tests which were recommended by more than 50% of the states and applied to more than 50% of the inhabitants of the EU were compared to the measures supported by scientific evidence. Finally, it was explored whether there was a correlation between the gross national product (GNP) and the number of tests recommended. At least one representative of all 25 member states of the EU returned a completed questionnaire. Twenty of the member states were found to have a national guideline, within which, 47 tests were reported and 23 of which are recommended for routine care by more than 50% of the states and apply to more than 50% of inhabitants. Those 23 tests are also supported by scientific evidence. Countries with a GNP below EU average were found to recommend more tests than the others. This study presents in detail what the national guidelines of the member states of the EU recommend for antenatal care. These findings demonstrate for the first time that extracting the measures from national guidelines that are recommended by the majority of states and apply to the majority of inhabitants of the EU leads to the development of a guideline compatible with scientific evidence. On the basis of these findings, a common minimum guideline for antenatal care in the EU should be established.

Genital herpes infections may be caused by either the herpes simplex virus type 1 or 2 (HSV-1 or HSV-2). The changing patterns of HSV-1 acquisition in childhood have meant that many individuals will acquire this disease in adult life when at least one third of such late infections will involve the genital area. In many parts of the world, HSV-1 is the principal cause of acquisition of HSV disease. However, the majority of cases of frequent and severe genital disease remain due to HSV-2. The management of genital HSV infections involves a careful assessment of the impact of the disease upon the patient. Such an assessment must take into consideration not only the severity and frequency of the disease, but also the impact of infection upon the patient’s psychosexual well-being as well as any concerns around the management of transmission to partners or neonates. Antiviral therapy, if indicated, can be carefully tailored to maximize its impact on symptoms, complications or concerns.

The European Society for Human Reproduction and Embryology’s Special Interest Group Early Pregnancy recently published a revised terminology for the description of early pregnancy events as well as evidence-based guidelines for the investigation and medical treatment for patients with recurrent miscarriage (RM). This review, designed for clinicians working in the field of human reproduction, starts with the updated glossary of terms essential for an accurate assessment and documentation of clinical events. The revised terminology is summarized in this article. Many terms used in early pregnancy were old and had persisted before or since the introduction of ultrasound. Based on the data of recently published randomized controlled trials (RCTs) and meta-analysis, recommendations are provided for basic investigations of couples presenting with RM and for proposed therapies. The recommendations are likewise summarized in this article. A large number of therapies mentioned in the literature require more investigations under strict RCT conditions, whilst others are of no proven benefit or are associated with more harm than good.

Haemostatic brace suturing techniques have been used recently for the treatment of massive post-partum haemorrhage due to uterine atony. Placement of these sutures can be considered before embarking on more technically complicated measures such as internal iliac artery ligation or hysterectomy. This article describes different uterine brace compression sutures, their advantages and complications and their place among other treatment modalities.

Vasa praevia constitutes a rare obstetric complication that is potentially lethal for the generally healthy infant. If unrecognized antenatally, the condition carries a higher fetal mortality rate than any other complication in pregnancy. Only in the past two decades have major diagnostic advances led to a dramatic improvement of perinatal survival and lower morbidity rates. Good outcomes depend primarily on prenatal diagnosis and appropriate management. The performance of a caesarean section before rupture of the membranes and the onset of labour is mandatory. Simple modifications of standard screening protocols and the recognition of high-risk patients will allow identification of most cases of vasa praevia.

This article review takes into consideration the multiple symptoms fibroid uterus can cause in pregnancy and summarises the recent treatment options of leiomyomas in pregnancy with emphasis on the possible use of surgery during pregnancy in selected cases.

The second half of the last century saw remarkable changes in the delivery of maternity care services, with the introduction of antibiotics and safe anaesthesia. This was associated with a continued decrease in maternal and perinatal mortality and some were quick to establish a cause-and-effect relationship. However, this was challenged by statisticians and technological developments have also been challenged later by some, though embraced by others. An initial study of midwives’ practice and perception of risk had demonstrated not only a slight link between higher intrapartum intervention rate and higher perception of risk but also an over-pessimistic evaluation of the chances of normal women to progress normally and an over-optimistic risk perception of the outcomes associated with interventions. Known variations in obstetric practice and caesarean section rates suggested that this study might benefit from replication in other European Union member states. The replication of the initial English study aimed at comparing the intrapartum care provided by midwives in the Belgian Flanders and the French regions of Alsace and Lorraine, as well as their intrapartum risk perception for the outcomes of spontaneous labour of nulliparous women suitable for midwifery-led care. A survey by questionnaire was administered to midwives in England, Belgium and France. In England, the midwives were selected on the basis that they worked in maternity units that made their maternity data available centrally on an annual basis. This enabled the analysis of the level of intrapartum interventions for healthy nulliparous women suitable for midwifery-led care and the subsequent comparison of the level of recommended intrapartum care and risk perception by midwives working in maternity units classified as either “lower” or “higher” intrapartum intervention units. The opportunities to replicate the study in Belgium and France were limited to the survey of midwives’ recommended intrapartum care and perception of risk, without the comparison of the actual intrapartum care and outcomes of the maternity units where they practise. All midwives working in the 11 relevant maternity units in England were surveyed. In Belgium, midwives attending the annual Flemish midwives’ conference were surveyed, whereas in France the collaboration of two midwifery schools meant that all midwives involved in intrapartum care in two regions – Alsace and Lorraine – were surveyed. The computerised St Mary’s Maternity Information System data were subjected to systematic data reduction to analyse the data of healthy Caucasian women at term of a healthy pregnancy and in spontaneous labour. The remaining data were then subjected to descriptive statistics to examine the rate of various intrapartum interventions and to establish an intrapartum score that was used to categorise maternity units as either “lower” or “higher” intrapartum intervention units (Mead and Kornbrot, Midwifery 20(1):61–71, 2004). The midwives’ surveys were subjected to descriptive statistical analysis. Major differences in midwifery practice were observed in the three countries: English midwives were more likely to monitor the maternal condition than French and Belgian midwives but less likely to use continuous electronic fetal monitoring, restrict maternal nutrition or recommend epidural analgesia. They were also generally more pessimistic about women’s ability to progress normally in labour. If the variations in methods of delivery observed in England parallel those of France and Belgium, the midwives in all three countries systematically overestimated the benefits of intrapartum intervention and, in particular, epidural analgesia. There are major differences in midwifery practice and in obstetric outcomes in these three countries. It is unlikely that the practices alone can explain the variations in outcomes and, in particular, the differences in caesarean section rates. More research is necessary to examine how the health care systems, perception of risk and attitudes to risk aversion may affect midwifery and obstetric practices and maternity services outcomes.

Premenstrual syndrome (PMS) can be a source of real distress and discomfort to menstruating women. There is a spectrum of severity from one end where women have mild symptoms to the severe end that is premenstrual dysphoric disorder. These symptoms may be so severe that they disrupt the normal functioning, quality of life and interpersonal relationships. It is critical to note the cyclical nature of the condition. The definitive aetiology of PMS remains obscure though it appears to be directly related to the ovarian hormone cycle. The management of PMS is based on the principles of ovulation suppression or correction of the neurotransmitter deficiency, which is considered to be responsible for the cyclical symptoms. There are numerous studies evaluating the various treatment options available. Apart from conservative management involving lifestyle and diet changes, these are followed by other options like hormonal and non-hormonal drug treatment, particularly selective serotonin re-uptake inhibitors that are available as effective alternatives. Further treatment measures like medical oophrectomy with GnRH analogues and surgical oophrectomy are considered for severe cases.

To diagnose scar endometriosis when an abdominal wall mass is found near the scar from a previous operation requires a high degree of suspicion. Pre-operatively, ultrasound and fine needle aspiration can be of help. Awareness of diagnosis avoids delay in diagnosis, treatment, and unnecessary referrals to other specialities. We reviewed five cases of scar endometriosis presenting to our unit in the last 5 years and included a literature review.

Pre-pregnancy planning in chronic renal patients has relied mainly on information gleaned from case reports, small series and variable registries. Nevertheless, guidelines have emerged to help clinicians in the care of their patients, so that as with other chronic medical conditions, it is becoming recognised as part of the traditional organisation of care associated with pregnancy. Nevertheless, most chronic renal patients do not plan their pregnancies with their health care team, and this complex behaviour is affected by the quality of the relationship with the team and by the woman’s attitude to her health and beliefs. The basic components of pre-pregnancy counselling should be analysis of risks, provision of health education and advice, and then making specific helpful interventions. Such ‘active preparation for pregnancy’ should be individualised to each woman’s needs and involve her partner. The ethical controversies associated with the need to understand the psychology of women who pursue parenthood, despite substantial risk to their own health and that of their unborn baby, should not be underestimated.

The concept of clinical governance and the philosophy of quality-centred care are being implemented throughout the National Health Service in England. Clinical governance integrates the behaviours, systems, processes and mechanisms necessary to ensure high quality and safe care. It also demands high standards, rigorous assessment and meaningful staff and patient engagement. Continuing Professional Development (CPD) is a principal component of the clinical governance quality framework. Appropriately skilled and competent obstetricians and gynaecologists, working in integrated, multidisciplinary, teams are fundamental to the delivery of safe and high quality care centred on the needs of women, their families and communities. Clinical governance and CPD are a means to the same end: quality assuring patient safety and care.

This chapter describes the basic steps in a systematic review to evaluate causality. These steps are illustrated using a published review concerning the hypothesized mechanism by which homocysteine could lead to preeclampsia. The first and most important step is to specify the problems to be addressed in the form of well-structured questions (Step 1). This step is pivotal as all other aspects of the review follow directly from these questions. The next step is to conduct a thorough literature search to identify studies with the potential to be relevant to the questions you have posed (Step 2). This is necessary to make the review systematic. The third step involves assessing the quality of the relevant studies (Step 3). Furthermore, the study characteristics and results are summarized and any differences between studies are explored (Step 4). Metaanalysis, where possible, should be employed to collate results. Finally, interpretation of the results allows recommendations for practice to be made, in conjunction with discussion of the relevance of the findings (Step 5).

The aim of audit is to improve patient care by examining practice and unmasking areas requiring improvement. It is endorsed by professional bodies and health service management, and often linked, albeit perhaps indirectly, with further professional development. Audit utilizes significant health care resources; therefore, its use ought to be subject to critical evaluation and demonstrable effectiveness. To influence change, audit is inevitably linked to a method of feedback and motivation. Despite the long history and many published studies, there remains considerable debate and uncertainty as to its effectiveness and, consequently, cost–benefit. Published literature suggests the need for further research to determine in which areas audit will be beneficial and also to determine what factors influence the efficacy of audit and feedback. Given this uncertainty, the role of audit in continuous professional development remains speculative.

The information explosion has affected the medical as well as the lay press. Sources of literature have never been so diverse, and freedom of information legislation globally has empowered all and sundry to voice their views on all matters. This freedom is exercised with regard to medical literature in general and Women’s Health publications in particular. The implicit requirement for clinical practice to be informed by evidence (evidence-based medicine) has placed the onus on the readership of clinical literature to acquire skills in appraising such literature. The need to sift out relevant information from the burgeoning obstetrics and gynaecology literature has mandated the acquisition of skills in critical literature appraisal. This review outlines how to critically appreciate and evaluate literature generally, and as it relates to obstetrics and gynaecology.