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 TOG
The Obstetrician & Gynaecologist
The journal for continuing professional development
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Volume 23 Issue 2 2021

Contents

Editorial 138 Options for acquiring motherhood in absolute uterine factor

SBA infertility; adoption, surrogacy and uterine transplantation
83 Editorial Benjamin P Jones, Niccole Ranaei-Zamani, Saaliha Vali,
Nicola Williams, Srdjan Saso, Meen-Yau Thum, Maya Al-Memar,
Editor’s Pick Nuala Dixon, Gillian Rose, Giuliano Testa, Liza Johannesson,
Joseph Yazbek, Stephen Wilkinson, J Richard Smith
84 Spotlight on… heavy menstrual bleeding and uterine fibroids
Tommy Tang
Tips and techniques
Commentary 148 Manchester repair (‘Fothergill’s operation’) revisited
Dhanuson Dharmasena, Clive Spence-Jones, Rajvinder Khasriya,
86 Networked maternal medicine services in England and the role of
Wai Yoong
the obstetric physician
Lucy Mackillop
CPD
154 CPD questions for volume 23 issue 2
Reviews
89 Acute and chronic pancreatitis in pregnancy
SBA Josie L O’Heney, Rebecca E Barnett, Ruth M MacSwan, 158 TOG ratings
Ashraf Rasheed
94 Breastfeeding and drugs Letters and emails
SBA Sadie Mullin, Christy Burden, Judith Standing, 160 Re: Very advanced maternal age
Francesca Neuberger Maria Woolley, Rhiannon George-Carey, Abha Govind, Wai Yoong
103 Detecting endometrial cancer
SBA Eleanor R Jones, Helena O’Flynn, Kelechi Njoku, Emma J Crosbie
MBRRACE-UK update
113 Life in the laparoscopic fast lane: evidence-based perioperative 161 MBRRACE-UK update: Key messages from the UK and Ireland
SBA management and enhanced recovery in benign gynaecological Confidential Enquiries into Maternal Death and Morbidity 2020
laparoscopy Marian Knight
Alison Bryant-Smith, Sawsan As-Sanie, Jillian Lloyd, Maggie Wong
124 Surgical site infection in obstetrics and gynaecology: prevention
SBA and management And finally…
Emmanuel E Ekanem, Olubunmi Oniya, Hudah Saleh, 164 Doctors and authors
Justin C Konje James Drife
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 DOI: 10.1111/tog.12725 2021;23:89–93
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Acute and chronic pancreatitis in pregnancy

Josie L O’Heney MBBS BSc (Hons) MRCP MRCOG,*a Rebecca E Barnett MBBS MRCS PhD,b Ruth M MacSwan MBChB,c
Ashraf Rasheed MBBCh BAO MD FRCSI FRCS Eng FRCS Gen Surgd
a
Specialist Registrar, Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK
b
Specialist Registrar, General Surgery, Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport NP20 2UB, UK
c
Specialist Registrar, Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health NHS Trust, Leytonstone E11 1NR, UK
d
Consultant in Upper Gastrointestinal and Biliary Surgery, Professor of Surgical Sciences and Technology, Gwent Centre for Digestive Diseases,
Royal Gwent Hospital, Newport NP20 2UB, UK
*Correspondence: Josie O’Heney. Email: j.oheney@gmail.com

Accepted on 14 July 2020.

Key content Learning objectives

 Acute pancreatitis can be a life-threatening condition at any stage
of life. It is seen in up to 3 in 10 000 pregnancies, with high rates of
preterm delivery and maternal mortality rates of up to 3%.
 Diagnosis in pregnancy can be more challenging, and its aetiology
is distributed differently to that of the nonpregnant population.
 When managing pregnant patients, consideration of implications
for the fetus poses an additional challenge.
 Pregnant patients with chronic pancreatitis need careful
assessment, paying attention to nutritional and exocrine needs,
pain management and the development of diabetes mellitus.
 Know the symptoms, signs and causes of acute pancreatitis in
pregnant women, as well as methods of investigation
and classification.
 Understand how to manage acute pancreatitis.
 Appreciate the challenges faced by women with chronic
pancreatitis and how to manage them, including
pregnancy outcome.
Keywords: management / pancreatitis / pregnancy

Please cite this paper as: O’Heney JL, Barnett RE, MacSwan RM, Rasheed A. Acute and chronic pancreatitis in pregnancy. The Obstetrician & Gynaecologist
2021;23:89–93. https://doi.org/10.1111/tog.12725

Chronic pancreatitis has an annual incidence of about five

Introduction
Pancreatitis is inflammation of the pancreas. It can be acute,
with sudden onset, or chronic, caused by repeated
episodes of pancreatic inflammation and the resulting
pancreatic dysfunction.
Outside of pregnancy, the incidence of acute pancreatitis in
the UK is 56 cases per 100 000 people. Fifty percent of cases are
caused by gallstones, 25% by alcohol and 25% by other causes.1
Mortality is high at around 5%, so optimal management is
important. The incidence of acute pancreatitis in pregnancy is
rare, at around 3 per 10 000 deliveries,2 but it could be severe,
with not insignificant maternal and fetal mortality and
morbidity. Maternal mortality from acute pancreatitis in
pregnancy used to be up to 37%.3 However, improved
management across disciplines has greatly reduced this, with
many case series reporting no cases of maternal mortality. In
the past, fetal loss has been up to 60%. More recent data suggest
a rate closer to 3%,2 though it may be higher in those with
hyperlipidaemic pancreatitis.4,5 The first part of this Review
focuses on the management of women with acute pancreatitis
in pregnancy.
new cases per 100 000 population/year. There is a strong
male predominance and age of onset is commonest at 36–55
years,1 so it is rarely encountered in the maternity
population. Chronic pancreatitis is, however, an important
consideration for pregnant women, so the second part of this
Review will guide their management, considering pain,
probable concurrent diabetes and reduced exocrine
(digestive) function.
Symptoms and signs of acute pancreatitis
in pregnancy
The commonest presentation of acute pancreatitis is sudden
onset upper abdominal pain, most often located in the
epigastrium and radiating through to the back.1 It is often
accompanied by anorexia, nausea and vomiting. Examination
findings may include epigastric tenderness, reduced bowel
sounds, fever and tachycardia. These may be more difficult to
elicit in the pregnant abdomen, thus a high index of suspicion
is important to establish the diagnosis. Note that early
low-grade fever is most commonly related to systemic

ª 2021 Royal College of Obstetricians and Gynaecologists 89

 Acute and chronic pancreatitis in pregnancy
inflammatory response syndrome (SIRS) rather than
infection.6 The symptoms and signs in pregnancy are very
similar to those found outside pregnancy, but if the diagnosis is
not considered then it may be delayed. Depending on the
gestation, the differential diagnosis can include hyperemesis
gravidarum, pre-eclampsia, HELLP (haemolysis, elevated liver
enzymes, and low platelet count) syndrome and placental
abruption,2 as well as non-obstetric causes such as biliary colic
or gastritis. Acute pancreatitis is more common with
advancing gestational age and postpartum, which coincides
with the increasing frequency of gallstones in pregnancy.3
Causes of acute pancreatitis in pregnancy
The commonest cause of pancreatitis in pregnancy is
gallstones, which account for over 65% of cases.2,7 Weight
gain and hormonal changes in pregnancy predispose women
to biliary sludge and gallstone formation, and the risk of this
increases with parity.8 The next most common causes are
alcohol (5–10%)3 and hypertriglyceridaemia (4–6%).2 Levels
of triglycerides rise three-fold in the third trimester8–10 and
women with familial hyperlipidaemia will also be
predisposed to developing pancreatitis. Pregnancy-specific
causes are rare but include hyperemesis gravidarum and
acute fatty liver of pregnancy. Other causes are specified
in Box 1.
Diagnosis of acute pancreatitis in
pregnancy
The diagnostic criteria for acute pancreatitis in pregnancy are
the same as those for the nonpregnant patient. Diagnosis of
pancreatitis requires two of three criteria: (1) abdominal pain,
typically epigastric, radiating through to the back; (2) serum
amylase or lipase more than three times the upper limit of
normal (usually >300 U/L, the same as nonpregnant patients);
and (3) characteristic features of pancreatitis on imaging.6,11
Acute pancreatitis can be divided into milder, interstitial
oedematous pancreatitis, and more severe, necrotising
pancreatitis.6 In interstitial oedematous pancreatitis,
Box 1. Causes of acute pancreatitis in pregnancy6
Common
 Gallstones (over 65%)
 Alcohol
 Hypertriglyceridaemia
 Idiopathic
Rare
 Drug-induced (e.g. thiazide diuretics)
 Hyperemesis gravidarum
 Acute fatty liver of pregnancy
 Hyperparathyroidism
 Gene mutations
 Association with severe HELLP-syndrome
90
patients symptoms usually resolve in the first week.12
Development of necrosis of the pancreatic or peripancreatic
tissue, which occurs in 5–10% of patients, happens over a
longer period, with a variable disease course.6
Peripancreatitic necrosis patients have increased morbidity
and a greater need for intervention than those with
interstitial oedematous pancreatitis.13,14
Computed tomography (CT) or magnetic resonance
imaging (MRI) should be used only in patients for whom
there is diagnostic uncertainty, or to evaluate for
complications. Ideally, this should be done after waiting
until at least 5 days from the onset of pain because it takes
several days for hypoperfusion and necrosis to emerge.11,15,16
Ultrasound is the first choice for imaging the pancreas and
gallbladder during pregnancy, but it is not sensitive enough
to detect bile duct stones in most patients, so further imaging
may be required. MRI without gadolinium contrast is
considered safe in pregnancy. An abdominal CT scan
exposes the fetus to a radiation dose of 1.3–35.0 mGy, with
levels <50 mGy considered acceptable in pregnancy.17
Therefore, if CT is clinically indicated, then pregnancy
should not be considered a contraindication.
At diagnosis, the patient should be scored for their risk of
developing severe pancreatitis. For ease of memory, the
Modified Glasgow Score is often used (Box 2), with patients
scoring 3 or more being considered at risk of developing
severe pancreatitis. This is beneficial if repeated at
48 hours.18 Patients with a score of 3 or more should be
referred for critical care input. C-reactive protein (CRP) level
>150 g/L on day three is also prognostic for the development
of pancreatic necrosis.19,20
Normal physiological changes occurring during pregnancy
can trigger an apparently elevated Modified Glasgow Score.
For example, white blood cell count (WBC) can rise during
pregnancy to 16 x 109/L in the third trimester and albumin
can decrease to 25 g/L.10 As far as the authors are aware,
none of the available risk-scoring criteria have been validated
in a pregnant population. Accepting these limitations, there
remains benefit in identifying those at higher risk, so use will
only increase the number of patients who should be under
Box 2. Modified Glasgow Scoring for risk of severe pancreatitis in
the nonpregnant patient
Score 1 point for each parameter present. A score of 3 or more puts
the patient at risk of severe pancreatitis4,5
P – Arterial oxygen saturation (PaO2) <8 kPa
A – Age >55 years
N – Neutrophils white cell count >15 x 109/L
C – Calcium <2.0 mmol/L
R – Raised urea >16 mmol/L
E – Enzymes: lactate dehydrogenase >600 l/L
A – Albumin <32 g/L
S – Sugar glucose >10 mmol/L
ª 2021 Royal College of Obstetricians and Gynaecologists

closer surveillance for development of severe
acute pancreatitis.
At diagnosis, the cause of the pancreatitis must also be
investigated to prevent future episodes (Box 3). Investigation
should include a focused history of alcohol use, family
history of hypertriglyceridaemia or gallstones and current
medications. An ultrasound of the abdomen is required to
check for the presence of gallstones and, if no other causes
have been found, a blood test for lipid profile and IgG4 (to
look for autoimmune disease).
The severity of acute pancreatitis is based on the Atlanta
criteria (Box 4)6 and divided into mild, moderate–severe and
severe, based on the presence and duration of organ failure
and complications.
Management of acute pancreatitis in
pregnancy
The management of acute pancreatitis in pregnancy requires a
collaborative multidisciplinary team approach and is largely
supportive – much the same as for nonpregnant patients. In
more advanced gestations, careful consideration of the
location of management of these patients is required, based
on the availability of both skilled nursing and
fetal monitoring.
Management considerations
1. Intravenous fluids to keep up with third space loss and to
maintain an adequate urine output. Increased vascular
permeability means that third space losses can be
significant; haematocrit can give an indication of these
losses. In early severe acute pancreatitis, fluid requirements
of 150–300 ml/hour would not be unusual – input should
be titrated to aim for a urine output of 0.5 ml/kg/hour.21
2. Analgesia – many patients require opioids as well as
simple paracetamol.
3. Venous thromboembolism (VTE) prophylaxis – this is
required and should be prescribed according to
local guidelines.
Box 3. Investigations in acute pancreatitis
Blood tests: on admission and at 48 hours
 Arterial blood gas
 Full blood count, urea and electrolytes, liver function tests and bone
profile, lactate dehydrogenase, C-reactive protein, glucose
 Daily blood tests only required if parameters abnormal
Imaging
 Ultrasound abdomen to look for gallstones at first opportunity after
diagnosis
 Consider computed tomography (CT)/magnetic resonance imaging
(MRI) after 5 days if concerned about complications (see text)
Other tests
 Lipid profile if no gallstones seen
ª 2021 Royal College of Obstetricians and Gynaecologists
O’Heney et al.
Box 4. Atlanta criteria for severity of acute pancreatitis1-3
 Mild
○ No organ failure
○ No local or systemic complications
 Moderately severe
○ Transient organ failure (<48 hours) and/or
○ Local or systemic complications without persistent organ failure
 Severe
○ Persistent organ failure (>48 hours)
○ Single or multiple organ failure
4. Nutrition – oral intake should be encouraged and
supplemented where necessary, favouring the enteral
route where possible. If the patient is unable to eat, then
passing a nasogastric or nasojejunal tube for feeding is
preferable to total parenteral nutrition, though this is
occasionally required.
5. Referral to critical care for organ support where necessary.
6. Antibiotics, but only for those patients with proven
infections1,22 – the systemic inflammatory response to
pancreatitis can result in a raised WCC and temperature
spikes without an infective source.
7. Imaging for complications, if suspected. This is best done
at least 5 days after the onset of symptoms. CT or MRI are
the usual choices of modality, but should only be
considered in patients who are not improving.
8. Treatment of complications (see below).
9. Modification of risk factors to prevent further episodes –
laparoscopic cholecystectomy, manage lipids, advice
about alcohol.
When pancreatitis has been caused by gallstones, current advice
is for laparoscopic cholecystectomy to be performed during index
admission, or within 2 weeks of discharge,22 at 12–24 weeks of
gestation, or after delivery. However, recent American guidelines
suggest that it can be safely performed at any gestation.23 There is
increasing evidence that endoscopic retrograde
cholangiopancreatography with sphincterotomy and stone
retrieval may be used in selected cases during pregnancy, with
limited fluoroscopy time.24,25 At this time, there is no complete
guideline for the treatment of biliary pancreatitis in pregnancy.
Triglyceride levels will reduce by a period of nil-by-mouth,
or use of a sliding scale.26 Referral to an endocrinologist
is advised.
Management of complications
Complications from pancreatitis can be local (acute
peripancreatic fluid collection, pancreatic pseudocyst, acute
necrotic collection and walled-off necrosis), regional (gastric
outlet dysfunction, splenic and portal vein thrombosis and
colonic necrosis), or systemic (worsening of known
comorbid conditions; for example, ischaemic heart or lung
disease).6 Imaging to look for complications should be
91
 Acute and chronic pancreatitis in pregnancy
prompted by persistence or recurrence of abdominal pain,
signs of sepsis, or organ dysfunction. If complications are
present, referral to the local hepatopancreatobiliary or
general surgical team is advised (if not already involved).
The patient may require discussion or transfer to the regional
tertiary centre.1,22
Pancreatitis and pregnancy outcome
Many case series have been published on pancreatitis in
pregnancy. These demonstrate increased rates of preterm
birth, ranging from 15–32%.2,5,7,27 There is also significant
fetal mortality, mostly within the severe acute pancreatitis
group, ranging from 27–57% in studies stratified by
severity.4,27,28 Of note, these studies with high fetal
mortality are from Chinese hospitals with higher rates of
severe hypertriglyceridaemic acute pancreatitis. A large case
series in a North American population found a fetal mortality
rate of 3.6%,2 which is more likely to be representative of the
population in UK hospitals.
Delivery is not routinely indicated when pancreatitis
occurs. The decision to deliver must consider both the
gestational age and the severity of the pancreatitis. In
addition to usual obstetric indications, delivery should be
considered if there is clinical deterioration despite 24–
48 hours of active treatment in moderate–severe and severe
cases.5 A multidisciplinary approach involving obstetricians,
surgeons and physicians is desirable. Pancreatitis is not a
contraindication to vaginal delivery; mode of delivery should
be based on obstetric factors.
Based on higher premature delivery rates, the use of
steroids for fetal lung maturation should be considered in
cases of severe pancreatitis presenting at viable gestations of
pregnancy. There is also no contraindication to giving a
magnesium sulphate infusion for neuroprotection of the
premature infant, should delivery be required.
Chronic pancreatitis in pregnancy
Chronic pancreatitis is progressive inflammation of the
pancreas, causing irreversible damage of the parenchyma that
leads to endocrine and exocrine dysfunction.29,30 Development
is multifactorial, but the most common causes are alcohol and
recurrent episodes of severe acute pancreatitis.31
Exocrine dysfunction usually manifests as diarrhoea,
bloating, cramping with meals, abdominal pain, steatorrhoea
and weight loss. Faecal elastase can be used to evaluate
pancreatic secretion, but may not detect mild to moderate
insufficiency.32 Alternatively, a trial of pancreatic enzyme
replacement can be used, titrated to clinical symptoms. The
dose of pancreatic enzyme replacement may need to be
92
increased in pregnancy.33 The need for vitamin
supplementation must also be considered; involvement of the
nutrition team is a useful adjunct. Often, the use of a
multivitamin will suffice.
Endocrine insufficiency in chronic pancreatitis is complex.
It is caused by reduced insulin production, increased insulin
resistance, or a combination of the two.34,35 Pregnant women
with a history of chronic pancreatitis should have an oral
glucose tolerance test arranged at booking, if not previously
diagnosed with diabetes. Diseases of the exocrine pancreas can
cause pancreatogenic diabetes mellitus (type 3c).36 The
combination of malabsorption, poor oral intake, chronic
pain and potential ongoing alcohol use, puts these patients at
risk of large variations in blood glucose levels and poor
nutrition.37 Early involvement of a specialist diabetes team is
advised to pay careful attention to the exocrine function of
these patients, who are also very likely to require insulin.38
Abdominal pain is the most common symptom of chronic
pancreatitis,39 often requiring regular opioid analgesia. Eating
may exacerbate pain, resulting in reduced oral intake, so well-
managed pain is important for nutrition, especially in
pregnancy. The stepwise escalation of analgesic therapies is
advised to obtain sufficient pain relief.40 Outside of pregnancy,
tramadol is the preferred opioid analgesic; it may be
appropriate to continue this. Pregabalin has been shown to
be beneficial outside of pregnancy, but its associated risk of
major congenital malformations in the fetus means it should
ideally be discontinued in the pregnant patient.39 The pain
experienced is often chronic in nature, so a multidimensional
scale such as the McGill Pain Questionnaire is a more
appropriate assessment in these patients.41
Abstinence from alcohol and smoking is strongly advised
and has been shown to improve pain.39 The regular use of
opioid analgesia, and related tolerance, may also affect
choices and doses of analgesia in labour. If the mother has
been on regular opioid analgesia, then the neonate will need
to be monitored for signs of withdrawal after birth.
Conclusion
Acute pancreatitis can be a life-threatening, though rare
condition, which can be encountered in pregnancy. The
diagnosis should be considered in any patient with acute
onset upper abdominal pain. The management of pancreatitis
in the pregnant patient echoes that of the nonpregnant
patient, with extra consideration for implications on the fetus.
The early and continued input of obstetric, surgical and
critical care teams is vital to the care of both mother and baby.
Disclosure of interests
There are no conflicts of interest.
ª 2021 Royal College of Obstetricians and Gynaecologists

Contribution to authorship
JLO instigated, researched and wrote the article. REB
researched and wrote the article. RMM edited the article
and wrote the CPD questions. AR provided guidance. All
authors approved the final version.
Acknowledgements
Andy Heeps MBBS, BSc, MRCOG had the original idea for
the article after managing a patient with acute pancreatitis
in pregnancy.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Infographic S1. Pancreatitis in pregnancy
References
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ng104/resources/pancreatitis-pdf-66141537952453].
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Classification of acute pancreatitis – 2012: revision of the Atlanta classification
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Hobbins JC, Spong CY, editors. Protocols for high-risk pregnancies: an evidence-
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11 Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology.
American College of Gastroenterology guideline: management of acute
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of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol
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Leeuwen MS. Update on acute pancreatitis: ultrasound, computed
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Stepping up the quality of its evaluation. JAMA 1995;274:1870–3.
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93
 DOI: 10.1111/tog.12728 2021;23:94–102
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Breastfeeding and drugs

Sadie Mullin MBChB BA,a Christy Burden BSc MRCOG MD MBChB,
b
Judith Standing MBChB MRCOG,
c

Francesca Neuberger MBChB FRCP*d

a
ST4 Academic Clinical Fellow Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol BS10 5NB,
UK
b
Academic Consultant Clinical Lecturer, Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol
BS10 5NB, UK
c
Consultant Obstetrician and Specialist in Maternal Medicine, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol BS10 5NB,
UK
d
Consultant in Acute Medicine and Specialist in Obstetric Medicine, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol BS10
5NB, UK
*Correspondence. Francesca Neuberger. Email: francesca.neuberger@nbt.nhs.uk

Accepted on 7 December 2020. Published online 24 March 2021.

Key content
 Most commonly used medications such as paracetamol, most
antibiotics and inhalers are considered safe for women to use
during lactation.
 Most drugs taken by a breastfeeding woman will be expressed in
small volumes in the breast milk. The amount depends on several
factors, including the drug dose, the size of the molecule, the
protein binding and lipid solubility of the drug, the age of the
infant and volume of milk consumed.
 Data regarding short-term and long-term effects of maternal
medication use on breastfed infants are limited.
 There is no direct evidence of impaired lactation with most
commonly used medications, but some medications, such as
decongestants (pseudoephedrine/phenylephrine), high-dose
diuretics and the combined oral contraceptive pill, may
inadvertently adversely affect maternal milk supply.
 Women need accurate and balanced advice regarding safety of
medication in breastfeeding to avoid early or inappropriate
cessation of medications in the lactation period.
Learning objectives
 Understand the pharmacokinetics of common medications used in
the lactation period.
 Understand the impact of drugs on the breastfed infant.
 Be familiar with the current literature on drug safety and lactation
to enable appropriate counselling.
Keywords: breastfeeding / contraception / drugs / maternal
physiology / postnatal care

Please cite this paper as: Mullin S, Burden C, Standing J, Neuberger F. Breastfeeding and drugs. The Obstetrician & Gynaecologist 2021;23:94–102. https://doi.org/
10.1111/tog.12728

medications and provides clinicians with a practical and

Introduction
Many women choose to breastfeed their infants and most
drugs can be taken safely by lactating mothers. However,
there is a paucity of quality data on the safety of many
prescribed drugs during breastfeeding. Standard reference
texts, such as the British National Formulary,1 are limited in
their usefulness to aid professionals when weighing up the
risk and benefits of prescribing for mother and baby.
Clinicians are put into challenging situations in which they
must advise caution in the use of drugs, not because of any
direct evidence of harm, but simply because of a lack of high-
quality studies. Medication use during breastfeeding has also
been shown to shorten the duration of breastfeeding; this is
often thought to be associated with restrictive advice given by
healthcare professionals and maternal fear of harming their
newborn baby.2,3 This Review summarises the drug safety
data of several key groups of commonly prescribed
structured approach to discussing medication with
breastfeeding women.
Common drugs used in the lactation period
Table 1 shows some preferred commonly used medications
during lactation.
The woman in pain
Analgesia is a routine requirement for women postnatally.
Women are commonly discharged home with analgesia
after caesarean section, instrumental delivery and perineal
tear repair. However, increasingly, complex analgesia
requirements are becoming commonplace antenatally. Pre-
existing chronic back pain, fibromyalgia and symphysis pubic
dysfunction often precipitate prolonged use of opioid

94 ª 2021 Royal College of Obstetricians and Gynaecologists

 Mullin et al.

Table 1. Preferred commonly used medications during lactaction Box 1. Analgesia key messages

Type of drug Preferred drugs Drugs to avoid  Paracetamol and ibuprofen are considered to be safe and are
recommended as preferred analgesics for breastfeeding mothers.
They have no known effect on lactation.
Analgesics Paracetamol Codeine phosphate  Variation in maternal metabolism of codeine renders infant
Ibuprofen exposure unpredictable. It is not recommended for use in
Dihydrocodeine breastfeeding women, but dihydrocodeine is safe to prescribe
short term.
Antibiotics Co-amoxiclav Nitrofurantoin in
Flucloxacillin babies with G6PD
Metronidazole deficiency or <8 days Effects of drug on infant
Ciciprofloxacin (short- old Paracetamol is routinely prescribed to infants from birth.
term use) Evidence regarding the safety of paracetamol and
Antidepressants Sertraline
breastfeeding – although reassuring – is limited and
relatively old. Studies are small, uncontrolled and largely
Antihypertensives Enalapril ACEIs other than single-dose exposure.
Nifedipine/others enalapril
calcium channel Diuretics
blockers Angiotensin receptor Ibuprofen
Labetalol/beta blockers blockers
such as atenolol Pharmacokinetics
Ibuprofen is a nonsteroidal anti-inflammatory drug of the 2-
Drugs for Prednisolone (up to 40
inflammatory mg daily) arylpropionic acid (2-APA) class. The absorption of ibuprofen
disorders Mononclonal antibodies is rapid and complete when given orally.7 It has a short plasma
half-life, which gives a low risk of accumulation.8
AEDs Most AEDs are not Phenobarbital,
considered to not be primidone (caution)
harmful; data are Drug levels in breast milk and infant blood
limited A study of 12 women taking 400 mg of ibuprofen 6-hourly
postpartum showed the drug was undetectable in breast
Contraceptives Progesterone-only pill
Contraceptive injections
milk.9 A further study measured ibuprofen levels in breast
IUD/IUS milk at approximately 0.06% of the typical infant dose of
Combined oral 10 mg/kg every 8 hours.10
contraceptive pill (from
6 weeks postpartum)
Contraceptive patch Effects of drug on infant
The literature reports at least 23 cases of no adverse effects on
infants breastfed by mothers taking ibuprofen.10–12 There is
ACEIs = angiotensin-converting-enzyme inhibitors; AEDs = anti-
epileptic drugs; IUD = intrauterine device; IUS = intrauterine system no known effect of ibuprofen on lactation or ability
to breastfeed.

Codeine

analgesics in the postpartum period. See Box 1 for Pharmacokinetics

summary recommendations.
Paracetamol
Pharmacokinetics
Paracetamol is a non-opioid analgesic, with no anti-
inflammatory action. Its rate of oral absorption is largely
dependent on the speed of gastric emptying.
Drug levels in maternal and infant blood
Levels of paracetamol peak in breast milk approximately
1–2 hours after ingestion.4 Data from studies suggest that
infants are exposed to between 1.1 and 3.6% of maternal
weight-adjusted dose.4–6
Codeine is metabolised to morphine, norcodeine and
codeine-6-glucuronide (80%) via cytochrome P450 2D6
(CYP2D6), and to morphine-6-glucuronide by UDP-
glucuronosyltransferase-2B7 (UGT2B7). Codeine has very
weak analgesic activity; its analgesic properties are provided
by its metabolites. There is considerable genetic variability
among patients in both enzymes required to metabolise
codeine. This can result in varied amounts of the drug in
breast milk.13
Drug levels in breast milk and infant blood
The breast milk of seven mothers who were 1–3 days
postpartum and taking 60 mg codeine every 4–6 hours for

ª 2021 Royal College of Obstetricians and Gynaecologists 95

 Breastfeeding and drugs
an average of four doses was sampled up to 6 hours after a
dose for codeine and morphine concentrations.14 Using the
peak codeine and morphine milk levels from this study, an
exclusively breastfed infant would receive an estimated 1% of
the maternal weight-adjusted dosage. Of relevance is that
codeine’s primary active metabolite (codeine-6-glucuronide)
was not measured in this study, and results probably
underestimate infant exposure.14,15 The plasma clearance of
morphine is prolonged in newborn infants compared to older
infants and children.13,16 The morphine:codeine ratio is
noted to be higher in infant serum.
Effects of drug on infant
A fatal case of morphine toxicity in a breastfed infant
following maternal codeine use has led the Medicines and
Healthcare Products Regulatory Agency (MHRA) and
European Medicines Agency (EMA) to contraindicate its
use in breastfeeding women.17,18 A study investigating the
case found the mother to be an ultrarapid metaboliser
of codeine.19
Maternal codeine use has also been associated with
asymptomatic bradycardia, apnoea and cyanosis in
infants.20,21 A study compared the frequency of drowsiness
in breastfed infants whose mothers took paracetamol and
codeine with that of infants whose mothers took paracetamol
alone. Infants exposed to codeine had a 16.7% frequency of
drowsiness compared with 0.5% of those exposed to
paracetamol alone.
Effects on lactation and breast milk
Codeine can increase serum prolactin. However, the
prolactin level in a mother with established lactation may
not affect her ability to breastfeed.
Dihydrocodeine
Unlike codeine, the analgesic properties of dihydrocodeine
(DHC) are largely attributed to the parent compound and
usually unaffected by an individual’s metabolism.22,23
Although DHC is also metabolised to dihydromorphine via
CYP2D6, this occurs in much smaller quantities. Evidence
shows that even in rapid metabolisers, less than 10% of
urinary metabolites were derivatives of dihydromorphine.24
UK Medicines Information (UKMi) supports the use of
dihydrocodeine in breastfeeding women at the lowest dose
for the shortest duration.25
Aspirin
Pharmacokinetics
Aspirin is rapidly metabolised to salicyclic acid, which is
readily excreted into breast milk at disproportionately
high levels.26
96
Effects of drug on infant
Reye’s syndrome has been associated with aspirin given to
infants for viral infections, but its association with breast
milk is unknown. There are reports that a 16-day-old infant
whose mother was taking 3.9 g/day of aspirin for arthritis
developed metabolic acidosis with a salicylate serum level of
240 mg/L and salicylate metabolites in the urine.27 There are
further reports of thrombocytopenia, fever and petechiae in a
5-month-old breastfed infant after her mother took aspirin
for a fever over 5 days.28 There is no known effect of aspirin
on lactation or a woman’s ability to breastfeed.26
Aspirin is not the pain relief of choice during
breastfeeding; however, the occasional use of low dose
aspirin (75 mg to 300 mg daily) would not be expected to
increase risks to a breastfeeding infant because only small
amounts are known to be detectable in breast milk.26
Tramadol
Pharmacokinetics
Tramadol is centrally acting and structurally related to
codeine and morphine. It contributes to analgesic activity via
several different mechanisms. Tramadol and the metabolite
O-desmethyl-tramadol (M1) are agonists of the mu opioid
receptor. Tramadol also inhibits the reuptake of serotonin
and noradrenaline, which results in inhibitory effects on pain
transmission in the spinal cord. In adults, tramadol has 70–
100% oral bioavailability. Women who are extensive
metabolisers may have increased levels of M1 in breast milk.
Drug levels in breast milk and infant blood
The excretion of tramadol into breast milk is low and even
lower amounts of its active metabolite are detected.29
Effects of drug on infant
The ability of preterm and newborn babies to metabolise M1
is limited.30 A study of 75 breastfed infants whose mothers
were taking 100 mg tramadol 6-hourly for pain relief post
caesarean section were compared with 75 controls. Paediatric
assessment using the Neurologic and Adaptive Capacity score
revealed no difference between the groups.31
Effects on lactation and breast milk
As with codeine, tramadol can increase serum prolactin. In a
mother who has established lactation, an increase in prolactin
may not affect her ability to breastfeed.32
Morphine
Pharmacokinetics
Morphine is metabolised to inactive morphine-3-glucoronide
(60%) and active morphine-6-glucoronide (10%). Peak
ª 2021 Royal College of Obstetricians and Gynaecologists

plasma levels are achieved within 15–20 minutes of
intramuscular and subcutaneous administration, and within
30–90 minutes of oral administration.33 Peak levels are much
lower after oral use owing to extensive first pass metabolism.
Drug levels in breast milk and infant blood
The plasma clearance of morphine is prolonged in very
young infants compared with older infants and children.
Clearance is thought to approach adult levels at about
2 months of age. One study showed that epidural morphine
given as labour analgesia was undetectable in the breast
milk of 80% of participants’ colostrum 24–100 hours post-
epidural.34 Regarding long-term morphine use, a study
followed a group of women and infants who were treated
for opiate dependency with slow-release oral morphine.
Breastfed infants had lower average measures of neonatal
abstinence syndrome, less morphine requirement, shorter
durations of treatment abstinence and shorter length of
admission compared with non-breastfed infants.35
Effects of drug on infant
Therapeutic doses of morphine, for example for
postoperative analgesia, are unlikely to be harmful to the
infant in the short term.36 It is recommended to observe
infants for sedation and poor feeding.
Effects on lactation and breast milk
A national survey compared women who received spinal or
epidural only, spinal or epidural plus another medication,
and other pain medication only and no analgesia. Women
who were prescribed any medications were found to have
approximately twice the risk of delayed lactogenesis (over
72 hours) compared with women who had no analgesia.37
The woman with an infection
Pregnancy is a subtle state of immunosuppression, which is
characterised by a reduction in proinflammatory host
Box 2. Antibiotics key messages
 Tetracyclines are safe in short courses while breastfeeding, although
longer duration of use (for example, for acne treatment) should be
avoided whenever possible.
 Trimethoprim or nitrofurantoin are preferable to ciprofloxacin for
routine urinary tract infection. Nitrofurantoin should be avoided in
the first 8 days of life.
 On occasion, altered gastrointestinal flora in infants, resulting in
diarrhoea and thrush, has been reported with the use of penicillin
antibiotics. They are still considered safe for breastfeeding mothers.
 No special precautions are required when treating breastfeeding
mothers for methicillin-resistant Staphylococcus aureus infection
with vancomycin or teicoplanin.
ª 2021 Royal College of Obstetricians and Gynaecologists
Mullin et al.
responses to infection. It is thought that this state persists
until approximately 3–4 months postpartum.38 Commonly
treated infections in breastfeeding women include caesarean
and perineal wound infection, suspected endometritis,
mastitis and urinary tract infections. See Box 2 for
summary recommendations.
Co-amoxiclav
Co-amoxiclav (amoxicillin and clavulanic acid) is considered
safe as a broad-spectrum antibiotic therapy for use in the
context of breastfeeding.
Pharmacokinetics
Amoxicillin is a b-lactam antibiotic, which inhibits
peptidoglycan synthesis (a key component of the bacterial
cell wall). Clavulinic acid is a b-lactam with an ability to
inactivate some bacterial b-lactamase, thus preventing the
inactivation of amoxicillin.
Drug levels in breast milk and infant blood
An exclusively breastfed infant could be expected to receive
approximately 0.1 mg/kg amoxicillin with a co-amoxiclav
dose of 500 mg three times daily. This is equivalent to
between 0.25% and 0.5% of a standard infant dose.26
Effect of drug on infant
Limited evidence suggests that side effects in infants of
mothers taking co-amoxiclav are uncommon. Occasional
reports of restlessness, diarrhoea and rash exist in
the literature.26
Effect on lactation and breastfeeding
There is no evidence of any significant effect of co-amoxiclav
on lactation or breastfeeding.
Flucloxacillin
Pharmacokinetics
Flucloxacillin is a b-lactam antibiotic with a particular effect
on Gram-positive organisms.
Drug levels in breast milk and infant blood
Limited studies suggest that drug levels in breast milk
are low.
Effect of drug on infant
The literature includes occasional reports of diarrhoea and
thrush in infants with penicillin use, but this has not been
thoroughly investigated.26
Effect on lactation and breastfeeding
Flucloxacillin remains a safe choice of antibiotic for
breastfeeding mothers.
97
 Breastfeeding and drugs
Metronidazole
Pharmacokinetics
Metronidazole is bactericidal by inhibiting nucleic acid
synthesis in bacterial cells. Orally, metronidazole is
absorbed well with more than 90% bioavailability.
Absorption is unaffected by infection.39
Drug levels in breast milk and infant blood
There is no body of evidence regarding topical or vaginal
metronidazole and breastfeeding. After topical
administration, plasma levels are approximately 1% of that
after a 250 mg oral dose.26 Only water or gel-based
preparations are recommended to be applied to the breast
because ointment-based preparations may result in increased
exposure from feeding. Metronidazole is well distributed in
breast milk; infants are exposed to less than the standard
paediatric doses, but hydroxymetronidazole (metronidazole’s
active metabolite) also adds to total infant exposure.26 The
American Academy of Pediatrics recommends withholding
breastfeeding for 12–24 hours after single-dose
administration.40 This is because of concerns regarding
metronidazole-associated carcinogenesis and mutagenesis
in vitro. However, this is not the case in the UK, and the
relevance of these findings has been questioned against the
body of evidence suggesting that metronidazole is well
tolerated in routine clinical practice.
Effect of drug on infant
There are case reports of candidal infections and diarrhoea
associated with metronidazole use. A trial suggested that oral
and rectal colonisation with Candida might be more
prevalent in infants exposed to metronidazole.26
Effect on lactation and breastfeeding
Anecdotally, metronidazole has been said to alter the taste of
breast milk and prevent feeding. However, there are no
published data to suggest that metronidazole negatively
affects lactation or the ability to breastfeed.
Ciprofloxacin
Pharmacokinetics
Ciprofloxacin is a fluroquinolone antibiotic. It works largely
via inhibition of DNA gyrase and topoisomerase IV.
Drug levels in breast milk and infant blood
Topical use of ciprofloxacin, for example as eye or ear drops,
poses negligible risk to breastfeeding infants.26 Ten lactating
women were given 750 mg ciprofloxacin orally for three
doses. Milk levels were measured after the third dose and it
98
was estimated that an infant would receive a maximum of
approximately 0.57 mg daily.41
Effect of drug on infant
Ciprofloxacin has traditionally been withheld during
breastfeeding and not administered to infants because of
concerns regarding effects on developing joints. However, a
systematic review of 1000 infants showed no difference
between those exposed to ciprofloxacin and controls.42 A case
of pseudomembranous colitis in a 2-year-old infant with a
previous history of necrotising enterocolitis was attributed to
maternal self-treatment with ciprofloxacin.43
Tetracyclines
Pharmacokinetics
Tetracyclines are protein synthesis inhibitors and are
bacteriostatic in nature. They inhibit translation by binding
to the 30S ribosomal subunit.
Drug levels in breast milk and infant blood
A group of 10 women were given 100 mg doxycycline orally.
Average peak and trough levels estimated that a solely
breastfed infant would be exposed to approximately 6% of
the maternal weight-adjusted dose.
Effects of drug on infant
It has been previously stated that doxycycline is
contraindicated during breastfeeding owing to possible
staining of infants’ teeth or bone deposition of
tetracyclines. However, available literature suggests that
short-term use is unlikely to be harmful because low levels
are present in breast milk and absorption by the infant is
inhibited by calcium in breast milk.26
Nitrofurantoin
Nitrofurantoin is contraindicated for use directly in infants
under 1 month old or in those with glucose-6-phosphate
dehydrogenase (G6PD) deficiency because of the potential
for haemolysis. Levels of nitrofurantoin are low in breast
milk. It is thought that the time of greatest risk for
haemolysis in term newborns without G6PD deficiency
might be as soon as 8 days after delivery.26 For this reason,
although nitrofurantoin doses in breast milk are low,
alternative antibiotics are preferable for use in mothers of
infants under 8 days of age, or in neonates of any age with
G6PD deficiency. It is thought to be safe to use while
breastfeeding outside these parameters.
Vancomycin and teicoplanin
These antibiotics are the mainstay of treatment for
methicillin-resistant Staphylococcus aureus (MRSA).
ª 2021 Royal College of Obstetricians and Gynaecologists

Although evidence is limited, vancomycin is poorly absorbed
orally and is therefore unlikely to reach the bloodstream of
breastfed infants.26 As a result, no precautions are required.
Teicoplanin is not orally absorbed and is therefore unlikely to
affect breastfed infants.26
The woman with anxiety and depression
Antidepressants
Choice of antidepressant during breastfeeding will largely be
dictated by medication taken throughout pregnancy. As per
antenatally, abrupt cessation or change of medication is not
recommended. Depression is known to have a significant
effect on the likelihood of a woman breastfeeding. An
observational study of 2859 women showed that women who
took antidepressant medication throughout pregnancy were
37% less likely to breastfeed.44 Women who commenced
antidepressants in the third trimester were 75% less likely to
breastfeed.44 Healthcare professionals must recognise this
relationship and reassure and support women whenever
possible. See Box 3 for summary recommendations.
Selective serotonin reuptake inhibitors
Sertraline. Sertraline is the selective serotonin reuptake
inhibitor (SSRI) of choice. There are low levels of sertraline in
breast milk, therefore quantities ingested by the infant are
usually small. Sertraline is not usually detectable in infant
serum, although studies have found its weakly active
metabolite (desmethylsertraline) in small quantities.
Fluoxetine. The average level of fluoxetine is higher in
breast milk than with most other SSRIs. Although there has
been reports of colic and drowsiness in a small number of
infants, no long term adverse developmental outcomes were
reported.45,46 It is not recommended to stop fluoxetine for
breastfeeding, if it is required by the mother. Breastfed
infants should be monitored for side effects and adequate
weight gain.
Effects on lactation and breastfeeding. Mothers taking an
SSRI during pregnancy and breastfeeding may struggle with
Box 3. Antidepressants key messages
 Choice of antidepressant postpartum will largely depend on the
choice of drug used during pregnancy.
 Depression is an independent risk factor for early cessation of
breastfeeding, so these women require enhanced support.
 Sertraline is the medication of choice for breastfeeding mothers.
 As with tricyclic antidepressants outside of pregnancy, the low levels
required for overdose can render other medications preferable.
ª 2021 Royal College of Obstetricians and Gynaecologists
Mullin et al.
breastfeeding. It is difficult to clarify whether this is
associated with their disease state, medication use or a
combination of the two.47
Tricyclic antidepressants
Levels of amitriptyline and its metabolites are low in breast
milk; however, other medications with fewer active
metabolites may be preferred. The literature reports one
outcome of a neonate suffering drowsiness and sedation,
which was attributed to amitriptyline use.48 As with use of
tricyclic antidepressants (TCAs) outside of pregnancy, the
relatively low levels required for overdose can make other
medications preferable.
Other antidepressants
Venlafaxine. The dose transferred to infants in breast milk
is relatively high, although no adverse outcomes have
been reported.26
The woman with high blood pressure
On discharge from hospital, essential and pregnancy-related
hypertension are largely managed in a primary care setting.
See Box 4 for summary recommendations.
Venous thromboembolism and
breastfeeding
Breastfeeding mothers can continue to feed as normal while
taking heparin, warfarin and low-molecular-weight
heparin (LMWH).
Warfarin
Very low levels of warfarin are excreted into breast milk. In
one study, warfarin was not detected in the breast milk of 13
Box 4. Antihypertensives key messages
 First-line treatment for hypertension in women who wish to
breastfeed is enalapril, and nifedipine for women of Black African
or Caribbean family origin.49
 No adverse effects have been reported in infants exposed to
nifedipine in breast milk.26
 Enalapril is poorly excreted in breast milk. As a result, it is not
expected to cause side effects in exposed infants.26
 It is recommended that breastfeeding women avoid diuretics or
angiotensin receptor blockers.49
 Uncontrolled blood pressure (i.e., >150/100) can be managed with
a combination of nifedipine (or amlodipine) and enalapril.
 Adding or swapping atenolol or labetalol to this combination is also
appropriate if the above proves ineffective or is not tolerated.
 When treating hypertension in breastfeeding women, once-daily
regimens should be used when possible.
99
 Breastfeeding and drugs
mothers who were anticoagulated with 2–12 mg daily.50 In
the infants, there was no effect on vitamin K-dependent
clotting factors or any reports of bleeding.50 No special
precautions are required for breastfeeding mothers.
Low-molecular-weight heparin
Owing to its large molecular weight of 2000–8000 Daltons,
enoxaparin is not expected to be excreted into breast milk or
absorbed by an infant.51 There is limited evidence to suggest
there are no adverse effects on breastfed infants.52,53
Direct oral anticoagulants
Direct oral anticoagulants (DOACs) are not currently
recommended as first-line treatment for venous
thromboembolism in pregnant or breastfeeding women
because there is a paucity of safety data. Limited evidence
suggests that a maternal dose of rivaroxaban 30 mg daily is
excreted in low levels in milk.26
The woman with complex medical
problems
Women with complex medical problems often receive
thoughtful and individualised care antenatally, with
specialised input from maternal medicine teams. Without
careful planning for the postnatal period, medication
adherence can fluctuate in women in this group.
Widespread fear of negative effects of medication on the
infant via breastfeeding must be discussed in detail with the
woman antenatally.
Asthma
Beta-2 agonists and steroidal inhalers are safe to use and
continue using while breastfeeding. Montelukast is excreted
in low levels in breast milk and is used therapeutically for
children as young as 6 months of age.26 Breastfeeding can
continue as normal with short courses of high-dose steroids,
for example prednisolone 40 mg.54
Steroids
Prednisolone is thought to be safe to use while breastfeeding
in doses up to 40 mg per day to treat asthma, rheumatoid
arthritis and inflammatory bowel disease. Prednisolone is
extensively bound to plasma proteins, so is poorly excreted
into breast milk. The largest data set comes from the National
Transplantation Pregnancy Registry, which reports 124
women with transplants have taken prednisolone while
breastfeeding 169 infants for periods as long as 48 months,
with no apparent infant harm.55
Monoclonal antibodies
There is a paucity of safety data for many monoclonal
antibody medications; however, their pharmacokinetic
100
profile is reassuring. Monoclonal antibodies exist as large
protein-bound molecules, thus their excretion in breast milk
is likely to be minimal. Absorption is also thought to be
minimal because their structure means they are likely to be
destroyed in the infant’s gastrointestinal tract.56
Furthermore, commonly used drugs including adalimumab
and infliximab have shown no adverse effects in exposed
infants.26 Until more data become available, caution should
be exercised when breastfeeding a newborn or preterm infant.
Antiepileptic drugs
In many reports of anticonvulsant use during breastfeeding,
women studied were taking a combination of drug therapies.
Some anti-epileptic drugs (e.g. phenytoin, carbamazepine)
enhance the metabolism of other drugs, whereas others (e.g.
valproic acid) slow the metabolism of other drugs.26 As a
result, the relationship between the maternal dosage and the
concentration in breast milk is difficult to clarify.26
Levetiracetam
Levetiracetam is excreted in low levels in breast milk and is
considered safe to use during breastfeeding.26 Some evidence
suggests that levetiracetam might reduce the breast milk
supply in some women.57
Lamotrigine
Women taking lamotrigine are encouraged to breastfeed. Infants
have serum concentrations that reflect maternal serum and milk
lamotrigine concentrations.26 Therefore, prompt serum
monitoring and dose adjustments are necessary after delivery
because maternal serum levels can increase postpartum.26
Sodium valproate
In contrast to pregnancy, sodium valproate has a reassuring
safety profile and can be recommenced during breastfeeding.58
Contraception and breastfeeding
Emergency contraception
The levonorgestrel-containing emergency contraceptive pill
carries no special precautions and women are free to
continue breastfeeding with its use. This is similar for the
intrauterine device (IUD), which can be sited from 28 days
postpartum. If ulipristal acetate (ellaOne; Cenexi, Osny,
France) is preferred, the Family Planning Agency advises
women to avoid breastfeeding for 1 week.58 During this
time it is advised to express and discard so as to not
affect supply.
Contraception key messages
Lactational amenorrhoea can be up to 98% effective as a
method of contraception if the following criteria are met:59
 A woman is fully breastfeeding both day and night
ª 2021 Royal College of Obstetricians and Gynaecologists

 An infant is younger than 6 months old
 A woman is amenorrhoeic60
In all other circumstances, contraception is required from
21 days postpartum. Breastfeeding women are safe to use the
following methods from any time after birth:
 Progesterone-only pill
 Contraceptive injection – when using within 6 weeks of
delivery, women are more likely to experience heavy and
irregular bleeding.
From 6 weeks postpartum, breastfeeding women are
eligible to use:
 The combined oral contraceptive pill
 The contraceptive patch
Prior to this, the estrogen component may affect
milk production.
The copper IUD or levonorgestrel-releasing intrauterine
system (IUS; Mirena; Bayer, Whippany, NJ) can also be
fitted within 48 hours of giving birth.
How to tackle medication adherence in
breastfeeding women
 Clinicians must ensure they are confident in counselling
women about the risks of taking medication while
breastfeeding. Hesitance and a limited knowledgebase
can drastically affect a woman’s motivation to take
medication and breastfeed.
 Women with mental health problems need added support
and reassurance, both with the establishment of
breastfeeding and the importance of their medication
when required.
 Women with complex medical problems need a careful
discussion antenatally with regards to the safety of their
medications during breastfeeding.
Box 5 provides some useful resources.
Box 5. Useful resources
Drugs and Lactation Database (LactMed): https://www.ncbi.nlm.nih.
gov/books/NBK501922/
The Breastfeeding Network: https://www.breastfeedingnetwork.org.uk
UK Teratology Information Service: http://www.uktis.org
The British National Formulary: https://bnf.nice.org.uk
National Institute for Health and Care Excellence Clinical Knowledge
Summary – Hypertension in Pregnancy: https://cks.nice.org.uk/hyperte
nsion-in-pregnancy
Royal College of Physicians – Acute Care Toolkit 15: https://www.rc
plondon.ac.uk/guidelines-policy/acute-care-toolkit-15-managing-ac
ute-medical-problems-pregnancy
NHS Start4Life – Breastfeeding: https://www.nhs.uk/start4life/baby/
breastfeeding/
ª 2021 Royal College of Obstetricians and Gynaecologists
Mullin et al.
Conclusion
Most medications are safe to use while breastfeeding.
However, there remains a paucity of safety data for some
new and emerging drugs. A careful risk–benefit discussion
with women is essential to ensure safety and optimal
adherence. Uncertain or inconsistent advice from medical
professionals is likely to affect both medication adherence
and duration of breastfeeding. A holistic and individualised
approach is required to provide the best care for mother
and baby.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
FN instigated, wrote and edited the article. SM researched
and wrote the article. CB and JS edited the article. All authors
approved the final version.
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ª 2021 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12722 2021;23:103–12
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Detecting endometrial cancer

Eleanor R Jones BSc MBChB,a Helena O’Flynn MBChB MPH MRCGP,
b
Kelechi Njoku MBBS MSc MRCP(UK),
c

Emma J Crosbie BSc MBChB PhD FRCOG*d,e

a
Clinical Research Fellow in Gynaecological Oncology, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of
Manchester, St Mary’s Hospital, Manchester M13 9WL, UK
b
NIHR Doctoral Research Fellow and Academic Clinical Lecturer in Primary Care, Division of Cancer Sciences, Faculty of Biology, Medicine and
Health, University of Manchester, St Mary’s Hospital, Manchester M13 9WL, UK
c
Cancer Research UK Manchester Cancer Research Centre Clinical Research Fellow, Division of Cancer Sciences, Faculty of Biology, Medicine and
Health, University of Manchester, St Mary’s Hospital, Manchester M13 9WL, UK
d
Professor of Gynaecological Oncology, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s
Hospital, Manchester M13 9WL, UK
e
Division of Gynaecology, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
*Correspondence: Emma Crosbie. Email: emma.crosbie@manchester.ac.uk

Accepted on 14 July 2020. Published online 27 February 2021.

Key content  To understand the evidence underpinning the current diagnostic

 Endometrial cancer (EC) is the most common gynaecological pathway for EC.
cancer in the UK.  To highlight unique and promising perspectives for EC detection
 Ninety percent of women with EC present with postmenopausal and their potential to transform clinical care.
bleeding (PMB), but less than 10% of women with PMB have a
Ethical issues
sinister underlying cause.
 Current diagnostics for EC are invasive and often painful. There is
 National Institute for Health and Care Excellence guidance advises
an urgent need for high-quality randomised controlled trials to
that symptomatic postmenopausal women undergo urgent
inform effective pain relief options.
investigation; however, guidance is unclear for
 Premenopausal women with suspected EC do not fit criteria for
premenopausal women.
 Current investigations for PMB, including transvaginal ultrasound
urgent investigations. How can we identify those at highest risk to
ensure they are fast-tracked appropriately?
scan, endometrial biopsy and/or outpatient hysteroscopy, have  Novel diagnostic tools hold promise, but they must be robustly
advantages and disadvantages.
 Novel detection tools are in development, which combine
validated before being introduced into clinical practice.
minimally invasive sampling with genomic, proteomic and single Keywords: diagnosis / diagnostic pathway / endometrial cancer /
cell technologies. novel diagnostic tests / risk factors
Learning objectives
 To understand who is at risk of EC and who should be referred for
urgent investigations.

Please cite this paper as: Jones ER, O’Flynn H, Njoku K, Crosbie EJ. Detecting endometrial cancer. The Obstetrician & Gynaecologist 2021;23:103–12. https://doi.
org/10.1111/tog.12722

treatment for women of reproductive age or for those for

Introduction
Endometrial cancer (EC) is the fourth most common cancer
in women in the UK and the most common gynaecological
malignancy. In the UK, there are over 9000 new cases each
year and the incidence has risen by 57% since the early 1990s.
This is attributed to the ageing population, a growing
prevalence of obesity and declining rates of hysterectomy for
benign disease. Survival rates are dependent on stage at
diagnosis, ranging from 95% for stage I cancers to 15% for
stage IV, therefore early diagnosis is essential for good
outcomes.1 Early diagnosis may also enable conservative
whom surgery carries considerable risks, such as the elderly
or morbidly obese.
Risk factors for endometrial cancer
Age and obesity are the strongest risk factors for
endometrioid EC, the most common histological subtype
(Table 1). Both act through estrogen-triggered endometrial
proliferation, which occurs in the absence of progesterone.2
The probability of acquiring mutations in proto-oncogenes
and tumour suppressor genes is increased during

ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. 103
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
 Detecting endometrial cancer

proliferation. Unimpeded by apoptosis, these mutations symptom for EC.11 Over 90% of women with EC present
expand clonally and acquire additional mutations that drive with PMB, but over 90% of women with PMB have a benign
carcinogenesis. Estrogen is produced by adipose tissue underlying cause for their symptoms (Box 1).12,13
through the aromatisation of adrenal androgens. After PMB can be confused with haematuria, triggering urgent
menopause, a lack of endogenous progesterone leaves the urological investigations.14 Vaginal discharge or pyometria is
endometrium unprotected from the effects of estrogen.3 less commonly described. Premenopause, women complain
Thus, obesity confers a higher risk of endometrial cancer,4 of intermenstrual or persistent heavy menstrual bleeding.
with every additional 5 kg/m2 of body mass index (BMI) Late-stage disease presents with abdominal distension, pelvic
associated with a 50% (95% confidence interval [CI] pressure symptoms or pain.15 Cytology-based cervical
40–60%) increased risk.5 Around 85% of EC is diagnosed screening detects atypical glandular cells in up to half of
in women older than 55 years of age.6 In premenopausal women subsequently diagnosed with EC,16 who might also be
women, anovulatory cycles in polycystic ovary syndrome identified incidentally on ultrasound, computed tomography
(PCOS) and obesity are a major risk factor.7 Lynch syndrome (CT) or magnetic resonance imaging (MRI) performed for
is an autosomal dominant inherited condition of defective other reasons.
DNA mismatch repair, which affects the MSH2, MLH1,
MSH6 and PMS2 genes.8 Women with Lynch syndrome have
Referral from primary care
a 25–60% lifetime risk of EC and present at younger ages
than women with sporadic EC.9,10 The 2015 National Institute for Health and Care Excellence
(NICE) suspected cancer guidance (Box 2) recommends that
women with PMB or heavy, irregular bleeding who are over
Red flag symptoms for endometrial cancer
45 years of age should have a full history, pelvic and speculum
Postmenopausal bleeding (PMB), defined as vaginal bleeding examinations and urinalysis performed in primary care.17
occurring more than 12 months after the cessation of Examination is important to exclude a pelvic mass or
menstruation at menopause, is the most common red flag pathology of the lower genital tract. The probability of EC in
women with PMB rises from less than 1% in women under the
Table 1. Risk and protective factors for endometrial cancer age of 50 to 24% in women over 80 years old.18 Women on
hormone replacement therapy (HRT) require special
Risk factors Protective factors consideration. Those with persistent unscheduled bleeding
for more than 6 months after starting HRT should be referred
Increasing age Obesity/insulin resistance for investigation.17 Those with new onset PMB should only be
Obesity/insulin resistance Healthy diet
referred if bleeding continues 6 weeks after stopping HRT.
Obesity Bariatric surgery-induced weight loss
Weight gain in adulthood High levels of physical activity EC should be considered in premenopausal women
Increased waist-to-hip ratio Reproductive with abnormal bleeding, particularly those with obesity,
Taller than average height Parity (versus nulliparity)
Diabetes mellitus Later age at last birth
(Type 1 and Type 2) Late menarche
Hypertension Oral contraceptive use
Reproductive (ever versus never) Box 1. Causes of postmenopausal bleeding
Polycystic ovary syndrome Progestin therapy
Early menarche Continuous combined Malignant:
Late menopause hormone replacement therapy Endometrial cancer
Nulliparity Use of intrauterine devices Cervical cancer
Unopposed estrogen hormone (any type) Vulval cancer
replacement therapy Breastfeeding Vaginal cancer
Genetic Lifestyle/other Ovarian or fallopian tube cancer
Lynch syndrome Smoking (ever versus never) Choriocarcinoma
Cowden syndrome Consumption of coffee Cancer in adjacent organs (e.g. urethra, bladder, bowel)
Family history of endometrial or Increased animal fat intake Pre-malignant:
colorectal cancer Iatrogenic Endometrial hyperplasia
Lifestyle Metformin use (ever versus never) Benign:
Physical inactivity Bisphosphonate use Endometrial polyps
Dietary factors, e.g. Western Atrophy of the vaginal mucosa or endometrium
diet intake Endometritis
Iatrogenic Iatrogenic:
Tamoxifen therapy Unscheduled bleeding in women using hormone replacement therapy
Anticoagulant therapy
Post radiation therapy
No cause identified

104 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

Box 2. National Institute for Health and Care Excellence (NICE)
Suspected cancer: recognition and referral guidance (NG12) for
endometrial cancer17
Two-week wait referral for women aged ≥55 with postmenopausal
bleeding (PMB)
Consider a two-week wait referral for women aged <55 with PMB
Consider direct access transvaginal sonography in women aged ≥55
with:
 Unexplained vaginal discharge who:
○ present for the first time or
○ have thrombocytosis or
○ report haematuria, or
 Visible haematuria and:
○ low haemoglobin levels or
○ thrombocytosis or
○ high blood glucose levels
PCOS, a strong family history or other risk factors. A
systematic review of premenopausal women with abnormal
uterine bleeding found the risk of EC – or its precursor lesion,
atypical hyperplasia – was just 1.31%, with intermenstrual
bleeding being a better predictor than heavy menstrual
bleeding.19 The risk for premenopausal women increases
with BMI and is reportedly five times higher at a BMI ≥30 kg/
m2.7 A retrospective review of two-week wait referrals from
primary care in England between 2006 and 2010 found that
women aged 35–44 years eventually diagnosed with EC were
significantly less likely to be referred urgently than women
aged 65–74 years (odds ratio 0.09, 95% CI 0.07–0.12,
p < 0.001).6 The lack of clear guidance from NICE on which
premenopausal women require urgent review risks diagnostic
delay for those at highest risk.
Diagnostic pathway for endometrial cancer
The most effective diagnostic strategy for the investigation of
PMB remains controversial; there is no evidence-based up-
to-date guidance from NICE, the Scottish Intercollegiate
Guidelines Network (SIGN), or the Royal College of
Obstetricians and Gynaecologists (RCOG). Selective
transvaginal sonography (TVS) for ‘high-risk’ women based
on age, BMI and other risk factors is the most cost-effective
strategy, but risks missing cases.20 The British Gynaecological
Cancer Society (BGCS) recommend TVS as first-line
investigation for PMB, followed by endometrial biopsy,
with or without hysteroscopy, if the endometrium is
thickened (Figure 1).21
One-stop postmenopausal bleeding clinics
One-stop clinics, in which patients are scanned, reviewed by a
clinician and offered endometrial biopsy and/or hysteroscopy
in a single visit, reduce delays, improve patient experience
and are cost-effective.20–22
ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Jones et al.
Transvaginal sonography for investigation of
postmenopausal bleeding
TVS provides a non-invasive assessment of double-layered
endometrial thickness, which can be used to triage women
for further investigations. A recent systematic review of
women with PMB found that women with EC have a mean
endometrial thickness of 16.4 mm (95% CI 14.8–18.1 mm),
compared with 4.1 mm (95% CI 3.5–4.7 mm) for those
investigated but found not to have EC.23 Interestingly, mean
endometrial thickness has increased significantly over time.
The mean endometrial thickness of women with PMB found
not to have EC was 3.5 mm in studies published before 2000,
but 5.7 mm in later studies; this can possibly be attributed to
improved resolution of imaging, increased HRT use, or
higher obesity rates. This influences the clinical utility of TVS
for EC detection, since endometrial thickness cut-offs derived
from historical studies might not be transferable to modern
day populations.
The diagnostic accuracy of TVS for EC detection depends
on the endometrial thickness cut-off used. BGCS guidelines
currently recommend an endometrial thickness cut-off of
≥4 mm. This is based on a systematic review published in
2010,23 which included 13 studies of 2896 patients with PMB,
of whom 259 were diagnosed with EC. A cut-off of ≥4 mm
had a sensitivity of 94.8% (95% CI 86.1–98.2%) and a
specificity of 46.7% (95% CI 38.3–55.2%) for EC
detection.21,24 A more recent systematic review, based on
44 studies from 25 countries, including 17 339 women with
PMB, of whom 1341 were diagnosed with EC, found that an
endometrial thickness of ≥5 mm had 96.2% (95% CI 92.3–
98.1%) sensitivity and 51.1% (95% CI 42.3–60.7%)
specificity for EC detection (Table 2). Based on this
systematic review, increasing the cut-off from ≥4 mm to
≥5 mm in future UK guidance would offer comparable
sensitivity and negative predictive value (NPV) to a cut-off of
≥4 mm, but improved specificity, reducing the need for
invasive diagnostic procedures by up to 17%.23
The character of the endometrium can further define risk
of malignancy by TVS. A heterogenous endometrium with
cystic change is highly suspicious of underlying disease
(Figure 2A).25 A caveat is the benign subepithelial stromal
hypertrophy associated with tamoxifen treatment, which
causes a grossly abnormal endometrial signal and,
consequently, a high false-positive rate.26 This is
particularly challenging because tamoxifen is associated
with a three-fold increased risk of EC and therefore triggers
a high level of clinical suspicion.27 Grayscale and colour
Doppler sonographic features can be useful to distinguish
malignant from nonmalignant endometrial
pathology (Figure 2B).25
Endometrial thickness is of limited utility as a triage test in
premenopausal women, in whom endometrial thickness
105
 Detecting endometrial cancer

2WW referral with unexplained PMB

TVS

Endometrial thickness ≥4 mm Endometrial thickness ≥4 mm,

Endometrial thickness <4 mm
but NOT irregular irregularities or polyp seen

Examination including speculum, Outpatient hysteroscopy

Endometrial biopsy
no biopsy required + endometrial biopsy

Reassure and discharge Inadequate Normal

EC diagnosed
sample result

If low risk of EC and If high risk of EC and/or

TVS not concerning TVS concerning

Figure 1. Diagnostic pathway for women presenting with postmenopausal bleeding. 2WW = two-week wait; EC = endometrial cancer; PMB =
postmenopausal bleeding; TVS = transvaginal sonography.

fluctuates naturally during the menstrual cycle. It is also
technically challenging to accurately measure endometrial
thickness where the uterine cavity is distorted by fibroids and
when body habitus compromises test validity (for example, in
women with a high BMI).
Incidental findings in asymptomatic women
An incidental finding of a thickened endometrium in an
asymptomatic postmenopausal woman is a thorny issue
because there is no consensus as to what endometrial
thickness cut-off requires further investigation. A
prospective study of 81 asymptomatic women referred for
endometrial sampling following an incidental finding of a
thickened endometrium on TVS found EC or atypical
endometrial hyperplasia (AEH) in just four women (4.9%),
all of whom had an endometrial thickness ≥10 mm.28 A
theoretical cohort study combining published and
unpublished data from 10 000 postmenopausal women
found an endometrial thickness cut-off of ≥11 mm
differentiated between women whose risk of cancer was
6.7% and those whose risk was just 0.002%.29 In contrast, a
systematic review of 32 studies and 11 100 women failed to
identify a discriminatory endometrial thickness in
asymptomatic postmenopausal women of sufficient clinical
utility to rationalise further investigations.30
The UK Collaborative Trial for Ovarian Cancer Screening
(UKCTOCS) reported asymptomatic endometrial pathology
in 125 of 36 861 postmenopausal women within 12 months
of TVS and found a cut-off endometrial thickness of ≥5 mm
had a sensitivity of 77.1% and specificity of 85.8% for the
detection of EC or AEH.31 A caveat was the lack of a
standardised protocol for endometrial investigations at the
≥5 mm cut-off; EC diagnoses were made up to 12 months
later, possibly after women developed symptoms, when an
up-to-date TVS may have returned a different endometrial
thickness. With no clear guidance, an incidental finding of a
thickened endometrium is investigated at the discretion of
individual clinicians, taking patient preference and risk
factors into account.
Endometrial sampling
An endometrial biopsy is indicated if a woman presenting
with PMB has a thickened endometrium on TVS. While easy
and quick to perform in an outpatient setting, endometrial
biopsy is an invasive procedure with potential for harm,
including failure (11%), inadequate sample (31%), pain,

106 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
 Jones et al.

that the 30% of women with an inadequate sample could be

Table 2. The diagnostic accuracy of investigations for endometrial
cancer detection safely reassured;35 however, given that 4.5% of women were
diagnosed with EC after an initial inadequate sample in one
Sensitivity Specificity Failure of study,37 this might not be appropriate and emphasises the
(%) (%) procedure
importance of restricting endometrial sampling to women
with a thickened endometrium in the first place. While most
Transvaginal
women tolerate endometrial sampling well, pain is a significant
sonography23
barrier for some.34 Failed endometrial sampling is usually
ET ≥3 mm 96.2 42.1 Very low/not reported associated with pain or cervical stenosis, which are more
common in nulliparous women.38 As a blind procedure,
ET ≥4 mm 95.7 46.0
endometrial sampling has the potential to miss small, localised
ET ≥5 mm 96.2 51.5 cancers.39 Women with benign or inconclusive histology, but
persistent symptoms or suspicious ultrasound findings, should
ET ≥6 mm 85.2 64.0 be offered hysteroscopy.
ET ≥8 mm 88.0 66.2
Hysteroscopy
ET ≥10 mm 78.2 83.7 Hysteroscopy is direct visualisation of the uterine cavity via a
fine bore scope to identify pathology, take directed biopsies
ET ≥15 mm 58.9 94.2
and carry out therapeutic procedures, such as polypectomy.
Endometrial 90–100 98–100 Failed procedure, 11% Hysteroscopy is indicated for women with a thickened,
biopsy32 Inadequate sample, 31% irregular endometrium, or other concerning features on
Total, 42%
ultrasound; those with recurrent or prolonged bleeding; or
Hysteroscopic 86.4 99.2 3.4% for operative where random endometrial sampling has been
opinion41 procedures nondiagnostic.21 A randomised controlled trial comparing
4.2% for ambulatory hysteroscopic resection of endometrial polyps with expectant
procedures
management of PMB found endometrial (pre)malignancy in
6% of women that had been missed by random endometrial
ET = endometrial thickness. sampling.40 This highlights the importance of hysteroscopic
assessment in cases where focal pathology is suspected on
TVS. A systematic review of 65 studies, including 26 346
bleeding, infection and – very rarely – perforation.32 women, reported that hysteroscopy has a sensitivity of 86.4%
Numerous aspirating, brush and cannulation devices are and specificity of 99.2% for EC detection.41 This is the most
available that show similar diagnostic accuracy to traditional recent systematic review at the time of writing, although
dilatation and curettage, but enable outpatient sampling.33,34 modern technology may offer improved accuracy.
The Pipelle aspirator (Pipelle de Cornier Mk II, Eurosurgical Hysteroscopy can be carried out as an outpatient procedure
Ltd., Guildford, UK) is the most commonly used sampling and, when offered as part of a one-stop clinic, this is the most
device, with a sensitivity of 90–100% for EC detection when an cost-effective and efficient way of investigating unexplained
adequate sample is obtained.32,34–36 It was previously thought PMB.42 The risks of hysteroscopy include failure (4.2%),

(a) (b)

Figure 2. Transvaginal sonography images of endometrial cancer. (a) Transvaginal ultrasound image from a patient with endometrial cancer
showing heterogenous endometrium with thickness of 26.5 mm (prior to application of colour Doppler). (b) Transvaginal ultrasound image from
same patient showing increased vascularity of the endometrium when colour Doppler is applied. The presence of colour indicates blood flow and
the colour represents the direction of the flow.

ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. 107
 Detecting endometrial cancer
pain (31%), bleeding, infection (0.25%) and perforation (less
than 0.1%).41,43,44 Although well tolerated by most women, a
significant proportion report severe (13%) or moderate to
severe (31%) pain.44 Women are advised to take standard
doses of nonsteroidal anti-inflammatory drugs (NSAIDS)
1 hour before their scheduled appointment;45 however, this
may be insufficient analgesia for many women. A Cochrane
review of 32 trials and 3304 participants found no evidence
for a clinically meaningful improvement in pain scores
at outpatient hysteroscopy associated with opioid,
antispasmodic, intracervical or paracervical local anaesthetic
administration.46 Vaginoscopic techniques using fine bore
scopes improve procedural tolerance.47,48 It is important that
women are appropriately counselled, provide informed
consent and are offered a choice of analgesia, including the
option to undergo the procedure under general anaesthesia.
Hysteroscopy under general anaesthesia has significantly
lower postoperative pain scores, but carries greater risks and
is much more expensive.49
Magnetic resonance imaging
MRI is usually reserved for the preoperative staging of EC.
On rare occasions, it might be required for more detailed
assessment of a thickened endometrium on TVS where
hysteroscopy fails or is contraindicated.
Diagnostic models
Current approaches to the investigation of PMB do not take
risk factors into account, yet certain groups of women have a
much higher pre-test probability of EC than others. The
integration of clinical parameters and ultrasound findings in
a diagnostic model could support a more sophisticated risk-
based assessment of symptomatic women, which is likely to
be more cost-effective.20 High-risk women could be fast
tracked through urgent invasive investigations, while low risk
women are safely reassured. To date, six diagnostic models
have been developed specifically for women presenting with
PMB.50–55 Predictors used in these models are age, age of
menopause, BMI, parity, recurrent PMB, hypertension,
diabetes, HRT and warfarin use, endometrial thickness,
detailed ultrasonographic findings and serum HE4 levels.
These models are not currently used in clinical practice
because none have been externally validated and their clinical
efficacy has not yet been established.56 In their systematic
review, Alblas et al.56 called for the validation of previously
published models and their extension with new predictors
and biomarkers to build a model for clinical use.
Screening for endometrial cancer
The aim of screening is to identify occult atypical hyperplasia
or EC in asymptomatic women. Detecting cancer at its
108 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
earliest possible stage is expected to improve cure rates,
reduce the morbidity associated with aggressive treatment
and offer uterus-sparing management options for younger
women wishing to preserve their fertility.57 There is currently
no established EC screening programme in the UK, neither
for average-risk nor high-risk populations.
The ideal screening tool is a minimally invasive,
inexpensive and easy-to-perform test that is effective at
detecting pre-invasive and early invasive disease.58 In
average-risk postmenopausal women, TVS has the
advantage of being tried and tested, but the endometrial
thickness cut-off chosen is a trade-off between sensitivity and
specificity. Ensuring cases are not missed might expose large
numbers of women to unnecessary invasive diagnostic tests.31
Cervical cytology has not been explicitly tested as a
screening tool for endometrial cancer. However, according to
a systematic review of 45 studies and 6599 endometrial
cancer cases,16 atypical glandular cells are found in cervical
samples of 77% of women with type II, and 44% of those
with type I endometrial cancers, respectively. Indeed, a
disadvantage of the switch to primary human papillomavirus
(HPV) cervical screening is that most samples do not now
undergo cytological assessment, thus missing the opportunity
to incidentally diagnose EC.
In Japan, endometrial cytology features in an established
screening programme for high-risk women. Such high-risk
women are defined as those attending routine cervical
screening who are nulligravid or postmenopausal and report
abnormal bleeding in the past 6 months.58 Endometrial
cytology requires uterine instrumentation and is
therefore less acceptable as a screening tool; however, it is
associated with much lower rates of inadequate/failed
sampling than endometrial biopsy.59 Screen-detected
endometrial cancers are also identified at an earlier stage and
boast improved survival outcomes compared with women
diagnosed following acute symptomatic presentation.58
Screening high-risk groups for endometrial cancer
Current BGCS guidelines recommend that women with Lynch
syndrome are offered annual TVS, hysteroscopy and
endometrial biopsy after the age of 35 years;21 however, the
evidence supporting this strategy is limited.8 Sceptics question
the benefit of screening when most EC presents at an early stage
and has an excellent overall 5-year survival rate.60 Other high-
risk groups include women with class III obesity referred for
weight loss management, in whom a high prevalence of occult
endometrial abnormalities has been described61 and breast
cancer survivors receiving tamoxifen treatment, although no
screening strategy is currently recommended for either group.
Risk-stratifying women from the general population based on
obesity, insulin resistance, reproductive and genetic
biomarkers might identify other high-risk groups that could
benefit from screening.62
 Jones et al.

Table 3. Novel endometrial cancer detection tools under development

Sampling method Biomarker Advantages Disadvantages

Uterine lavage Genomic – mutations, methylated DNA64,72 Proximal to tumour, therefore rich in Invasive
Proteomic – (MMP9 and KPYM)65 cancer-relevant biomarkers Risk of failed uterine instrumentation
Cannot be done in primary care

Uterine brushings Cytology58 Established screening programme in Invasive

Genomic – mutations,66 methylated DNA67 Japan Risk of failed uterine instrumentation
Fewer inadequate samples than Cannot be done in primary care
endometrial biopsy
Genomic biomarkers have high
sensitivities

Cervical brush Cytology16 Non-invasive Current thresholds insufficiently

Genomic – mutations and copy number sensitive for early (pre)cancer
alterations (PapSEEK)66 detection

Vaginal tampon Genomic – methylated DNA67 Non-invasive Uncomfortable for elderly women
Suitable for self-collection at home

Vaginal swab Metabolomic73 Non-invasive Proof-of-principle pilot data only

Genomic – methylated DNA74 Suitable for self-collection at home
Proteins – CA12575

Urine Genomic – microRNA76 Non-invasive Proof-of-principle pilot data only

Metabolomic77 Suitable for self-collection at home
Spectroscopic78

Blood Genomic – circulating tumour cells, ctDNA79 Routinely available Low concentrations of cancer-specific
Proteins – CA125, HE480 biomarkers in early cancer
Metabolomic81
Spectroscopic82

Developing novel endometrial cancer

detection tools
Current investigations for suspected EC are unpleasant,
invasive and expensive. No single test is sufficient to both
‘rule in’ and ‘rule out’ disease in women presenting with red
flag symptoms, or to identify occult endometrial (pre)cancer
in asymptomatic women with risk factors. Technological
innovation and an improved understanding of cancer biology
have paved the way for novel ways of detecting endometrial
cancer early. The goal is to combine patient-friendly tools for
biofluid collection with EC biomarker discovery to develop
minimally invasive sampling methodologies for screening
and diagnosis (Table 3, Figure 3).63
Uterine samples, including endometrial brushings and
uterine lavage fluid, are an excellent source of cancer-specific
biomarkers, but their collection is invasive and poorly Figure 3. Sampling methods for novel detection tools. (1)
tolerated by some.64,65 The anatomical continuity between Endometrial lavage and brushings. (2) Cervical brush sample. (3)
the upper and lower genital tracts provides the opportunity Vaginal tampon. (4) Vaginal swab. (5) Urine sample. (6) Blood sample.

ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. 109
 Detecting endometrial cancer
for naturally shed tumour debris to pass through the cervix,
enabling collection from the vagina using tampons, brushes
and swabs.66,67 These collection tools lend themselves to self-
sampling, enabling women to collect their own biofluids at
home for postal return to the laboratory. While tampons can
be left in the vagina for several hours to collect a
representative sample, they are uncomfortable for
postmenopausal women to use.68
Urine is the perfect biofluid for non-invasive sampling
because it is easy to collect, with the potential for large
volumes, repeat samples or collection at pre-specified times
of the day. It depends on urinary excretion of systemic cancer
biomarkers, or the reliable contamination of urinary flow
with uterine-shed tumour debris. Initial studies have yielded
promising results.69 Blood biomarkers are also undergoing
development. Cancer antigen 125 (CA125) is elevated in
advanced stage, poor prognosis EC, but its relatively normal
levels in early stage disease precludes its utility as an early
detection tool. A panel of protein biomarkers may have more
value than a single protein biomarker; indeed, studies
combining CA125 with HE4 and other proteins have
demonstrated encouraging proof of concept.70 Circulating
tumour cells (CTCs), circulating tumour DNA (ctDNA) and
microRNA (miRNA) are genomic biomarkers that could
facilitate diagnosis, treatment monitoring and the detection
of relapse, but their low concentration in early stage cancer
limits their applicability at current detection limits.71
Conclusion
Despite its reputation for good prognosis, the rapidly rising
incidence and devastating outcomes from advanced disease
mean that 40% more women are now dying from EC than
they did at the turn of the 21st century.1 Early diagnosis is key
to improving outcomes and there is much interest in the
development of minimally invasive detection tools for the
rapid triage of symptomatic women. Used in combination
with validated diagnostic models, these tools could enable
fast-tracked invasive diagnostics for those at greatest risk,
while avoiding the physical and psychological harms of
investigating healthy women. Such a tool may also be useful
for screening asymptomatic women who are deemed to be
high risk by virtue of age, obesity or hereditary predisposition,
where currently no standardised programme exists.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
ERJ and EJC designed and wrote the article. HO’F and KN
provided expert material and review. All authors provided
critical comment, edited the manuscript, and approved its
final version. EJC is this article’s guarantor.
110 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Funding
ERJ is supported by a grant from the JP Moulton Charitable
Foundation. KN is supported by a Cancer Research UK
Manchester Cancer Research Centre Clinical Research
Fellowship (C147/A25254). HO’F is supported by a
National Institute of Health Research (NIHR) Doctoral
Research Fellowship (DRF-2018-11-ST2-054). EJC is
supported by the NIHR Manchester Biomedical Research
Centre (IS-BRC-1215-20007).
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53 Burbos N, Musonda P, Giarenis I, Shiner AM, Giamougiannis P, Morris EP,
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 DOI: 10.1111/tog.12723 2021;23:113–23
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Life in the laparoscopic fast lane: evidence-based

perioperative management and enhanced recovery in
benign gynaecological laparoscopy
Alison Bryant-Smith MBBS/BA MPH MSurgEd MRCOG FRANZCOG,*a Sawsan As-Sanie MD MPH FACOG,
b

Jillian Lloyd MBChB MRCOG MD,c Maggie Wong MBBS MMed MHlthEth FANZCAd
a
Fellow, Centre for Advanced Reproductive Endosurgery, Sydney 2065, Australia
b
Associate Professor and Director, Minimally Invasive Gynaecologic Surgery and Fellowship, The University of Michigan, Ann Arbor 48109, USA
c
Consultant Obstetrician and Gynaecologist, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
d
Consultant Anaesthetist, St Vincent’s Hospital, Melbourne 3065, Australia
*Correspondence: Alison Bryant-Smith. Email: dr.alison.bryantsmith@gmail.com

Accepted on 15 May 2020. Published online 15 March 2021.

Key content  To understand the importance of preoperatively assessing and

 Enhanced recovery after surgery (ERAS) protocols aim to shorten
the length of hospital stay and expedite recovery, without
increasing complications or readmission rates.
 Implementation of ERAS protocols should be evidence-based,
including when applied to pre-admission clinic (including
preoperative investigations), fasting, antibiotic prophylaxis,
thromboprophylaxis, analgesia, expeditious removal of urinary
catheters and early mobilisation.
Learning objectives
 To understand evidence-based perioperative management of
patients undergoing laparoscopic procedures for benign
gynaecological indications.
 To appraise critically the judicious ordering of
preoperative investigations.
managing each patient’s risk of venous thromboembolism.
 To understand the key components of perioperative management
that decrease surgical site infection(s).
Ethical issues
 Preoperative patient education is a vital component of
perioperative management; written materials should be prepared
in languages other than English to enable all patients to benefit
from the ERAS approach.
 A balance must be found between applying ERAS protocols as a
checklist to ensure all aspects of patient care have been considered
and tailoring those protocols to each patient’s individual needs.
Keywords: benign laparoscopy / enhanced recovery / evidence-
based medicine / perioperative management / same-day surgery

Please cite this paper as: Bryant-Smith A, As-Sanie S, Lloyd J, Wong M. Life in the laparoscopic fast lane: evidence-based perioperative management and enhanced
recovery in benign gynaecological laparoscopy. The Obstetrician & Gynaecologist 2021;23:113–23. https://doi.org/10.1111/tog.12723

The numerous, well-documented benefits of laparoscopy can

Introduction
Perioperative medicine encompasses the period between the
moment surgery is contemplated and the patient’s complete
recovery. Enhanced recovery after surgery (ERAS) pathways
standardise a variety of evidence-based perioperative inter
ventions, ensuring patients are in prime condition for surgery
(thereby minimising postponements and cancellations),
receive optimal individualised and evidence-based care
intraoperatively, and return to their normal lives as rapidly
as possible. ERAS pathways focus on elements that may delay
postoperative recovery, such as gut function, pain
and immobility.
While initially developed for patients undergoing open
colorectal surgery, there is mounting evidence that the ERAS
approach is applicable to benign gynaecological laparoscopy.1
be thwarted by nausea and vomiting, fluid overload,
restricted ambulation, deconditioning and poorly
controlled pain.2 Applying evidence-based ERAS protocols
to benign gynaecological laparoscopy reduces the incidence
of such complications, thereby minimising the physiological
effects of surgery.3 Moreover, ERAS pathways increase
patient satisfaction, decrease intravenous fluid admin
istration, cost and morphine equivalents consumed, and
expedite recovery, all without increasing complication or
readmission rates.4 Most patients undergoing gynaecological
laparoscopy have short hospital stays (e.g. same-day
discharge or overnight admission only). Implementing
evidence-based ERAS pathways enables patients’ length of
stay to be measured in hours, rather than days.5 One study
found that implementation of an ERAS pathway following

ª 2021 Royal College of Obstetricians and Gynaecologists 113

 Life in the laparoscopic fast lane
laparoscopic hysterectomy decreased the average length of
stay from 34 to 20 hours.6
This article provides a chronological outline of evidence-
based perioperative management for benign gynaecological
laparoscopy, from a patient’s preoperative outpatient clinic
appointment, to their postoperative recuperation.
Outpatient preoperative management
Gynaecology clinic
When an operation is booked, surgeons should specify the
operation needed and which surgeon is best placed to
perform that operation, and obtain patient consent. ERAS
information should be conveyed in both verbal and written
forms, encompassing perioperative expectations about
patients’ active involvement in their care.
When pertinent, clinicians should foreshadow how
patients can improve their preoperative condition by
ceasing smoking, optimising weight and managing their
comorbidities (e.g. hypertension and diabetes).
Mounting evidence supports screening for and treating
bacterial vaginosis (BV) prior to hysterectomy. These
recommendations are based on the prevalence of BV, the
efficacy and low cost of treatment and the link between BV
and surgical site infections.7 While such practice is not
routine in the UK, the adoption of BV screening prior to
hysterectomy is evidence-based and recommended.
The authors’ international experience (in the USA and
Australia) confirms the importance of a weekly
multidisciplinary team (MDT) meeting, during which
patients who have surgery booked in the coming month
(and who have not yet been discussed in a previous MDT
meeting) are reviewed. Discussion of patients at this MDT
meeting should be on an ‘opt out’ basis; that is, all patients
are reviewed, except well patients having minor surgery.
Ideally, nonmedical personnel (e.g. pharmacy and nursing
staff) should be involved because MDT discussions often pre-
empt several perioperative challenges.
Pre-admission clinic
Gynaecological, anaesthetic and nursing staff should review
relevant patients at a pre-admission clinic. Pre-admission
clinics aspire to optimise patients’ medical comorbidities and
lifestyle factors. Such assessments have been shown to
significantly lower cancellation rates.8
Behavioural modification
Patients can make several behavioural modifications to
improve their perioperative outcomes. For example,
patients should abstain from smoking tobacco or
consuming alcohol for 4 weeks preoperatively.2
As obesity becomes more prevalent, greater numbers of
increasingly obese women will undergo gynaecological
114
laparoscopy. Resultant anaesthetic challenges include
accurately measuring patients’ blood pressure, obtaining
intravenous access, achieving regional techniques and the
potential for difficult airway management and ventilation.9
In addition to anaesthetic and mobilisation issues, coexistent
cardiac, respiratory and metabolic complications add to the
perioperative challenges presented. An individualised risk–
benefit analysis should be undertaken and nonoperative
alternatives encouraged. Some hospitals have stringent
policies (e.g. no elective surgery if body mass index, BMI,
is greater than 35 kg/m2); others require achievable weight
loss (e.g. 5%) preoperatively.
Data from nongynaecological populations show that so-
called ‘prehabilitation’ (i.e. preoperative exercise and physical
conditioning) improves postoperative outcomes such as
pain, length of stay, and physical function.10
Patient education and expectation management
One vital component of ERAS programmes is preoperative
counselling, which sets realistic expectations regarding
surgical and anaesthetic recovery and postoperative patient
care.2 Preoperative education reduces anxiety, increases
patient satisfaction, reduces pain and nausea and improves
patient wellbeing.2 Some trusts have found that so-called
‘recovery schools’ are an efficient way to impart such
knowledge. Here, classroom-based sessions outline the
benefits of exercise, improved nutrition, the ERAS
approach and preoperative lifestyle modifications (e.g.
cessation of alcohol and smoking).
Management of venous thromboembolism and
bleeding risk
Screen all patients for risk factors for both venous
thromboembolism (VTE) and bleeding using the National
Institute for Health and Care Excellence (NICE) risk
assessment chart (provided as online supporting
information).11
NICE simply states that pharmaceutical throm
boprophylaxis (e.g. 7 days of low-molecular-weight hep-
arin, LMWH) is warranted for patients ‘whose risk of VTE
outweighs their risk of bleeding’.12 Hence, using this
guideline means that surgeons must employ their clinical
judgement and take individual patient factors into account.
Patients on estrogen-containing contraception or hormone
replacement therapy should consider ceasing it 4 weeks
preoperatively; offer advice on alternative contraception or
management of vasomotor symptoms.12
An alternative VTE risk assessment tool is the Caprini
score, as recommended by the American College of Chest
Physicians. As outlined in Figure 1, this scoring system
evaluates VTE risk based on patients’ inherent predisposing
factors (e.g. thrombophilias), modifiable risk factors (e.g.
smoking status) and planned operation (e.g. open versus
ª 2021 Royal College of Obstetricians and Gynaecologists
 Bryant-Smith et al.

1. Patient’s age is:

0–40 years (00 points
points)
41–60 years (11 point
point)
61–74 years (22 points
points)
3 points
75 years or older (3 points)

2. Add 1 point for each statement that applies:

Surgery under general / regional anaesthesia that lasted more than 45 minutes in the last month
Varicose veins (within the last month)
Swollen legs (within the last month)
Heart attack (within the last month)
Serious infection (e.g. pneumonia, cellulitis) within the last month
Inflammatory bowel disease (in the past / currently)
Congestive heart failure (in the past / currently)
Chronic lung disease (e.g. chronic obstructive pulmonary disease), NOT including asthma

3. For women only, add 1 point for each statement that applies:
Currently on hormonal contraception (pills, implants, patches, intrauterine device or injection)
or hormonal replacement therapy
Currently pregnant
Had a baby within the last month
History of unexplained stillbirth, more than three miscarriages, preterm birth with pre-eclampsia, or low
birth weight baby

4. Add 2 points for each statement that applies:

Patient previously told that they have cancer, leukaemia, lymphoma, or melanoma
In the last month, the patient has had a plaster cast or mold that has limited leg bending / walking
normally
In the last month, the patient has had a PICC line, port, or central venous access catheter inserted in their
neck or chest

5. Add 3 points for each statement that applies:

Previous blood clot in legs, arms, abdomen or lungs
Family history of blood clots
Patient has previously been told they have increased risk of clotting based on blood tests

6. Please select the appropriate statement for the patient:

In bed for less than 3 days when unable to walk more than 30 feet (add 1 point)
point
In bed for 3 days or more when unable to walk more than 30 feet (add 2 points)
points

7. Add 5 points for each of these statements that applies:

Hip or knee replacement surgery within the last month
Broken hip, pelvis or leg within the last month
Serious trauma (e.g. multiple broken bones due to fall or car accident) within the last month
Spinal cord injury resulting in paralysis within the last month
Stroke (clot or haemorrhage in the brain, or transient ischaemic attack) within the last month

8. If the patient is scheduled for surgery, please select the most appropriate statement:
Scheduled surgery is under general or regional anaesthesia and is expected to take less than
point)
45 minutes (add 1 point
Scheduled surgery is under general or regional anaesthesia and is expected to take more than
45 minutes, including laparoscopy (add 2 points)

Total score:

Figure 1. Caprini score for venous thromboembolism risk stratification.13

laparoscopic surgery).13 Of note, patients acquire one point
when undertaking laparoscopic surgery of less than 45
minutes’ duration, and two points if longer than 45
minutes’ duration.
The patient’s individualised Caprini score then allocates
them to one of six VTE risk groups (from lowest to highest
VTE risk). Thereafter, this guides their thromboprophylaxis,
as noted in Table 1.14 While this provides more detailed
guidance than NICE and is less reliant on surgeons’ clinical
judgement, it does not take into account patients’
bleeding risk.
If patients require LMWH postoperatively, yet are having
an operation that carries a higher risk of intra-abdominal
haemorrhage (e.g. myomectomy), management should be
discussed with a haematologist. Surgery may need to be
delayed to allow management of modifiable risk factors.
Patients with complex analgesic requirements
Patients with chronic pain syndromes, or who are dependent
on controlled medications or illicit substances, require an
individualised analgesic strategy devised in collaboration with
a pain specialist.15 Studies have found a 20.8–97.4% drop in

ª 2021 Royal College of Obstetricians and Gynaecologists 115

 Life in the laparoscopic fast lane

Table 1. Management of postoperative risk of venous thromboembolism based on patients’ Caprini score

Early Pneumatic Graduated

Caprini Risk frequent compression compression LWMH or
score category VTE risk ambulation devices stockings low dose heparin Duration

0 Lowest Minimal Indicated Optional Optional Not necessary During hospitalisation

1–2 Low Minimal Indicated Indicated Optional Not necessary During hospitalisation

3–4 Moderate 0.7% Indicated Indicated Optional Not necessary During hospitalisation

5–6 High 1.8% Indicated Indicated Indicated Indicated 7–10 days in total

7–8 High 4.0% Indicated Indicated Indicated Indicated 7–10 days in total

≥9 Highest 10.7% Indicated Indicated Indicated Indicated 30 days in total

LMWH = low-molecular-weight heparin; VTE = venous thromboembolism

postoperative narcotic use when ERAS protocols are
implemented.3 Realistic expectations regarding postoperative
pain should be outlined: clinicians should not promise a pain-
free postoperative course; rather, that aggressive analgesia will
lower pain to a tolerable level.
Patients with diabetes
One common comorbidity worth discussing is diabetes –
see Box 1.
Preoperative investigations
Clinicians tend to order excessive tests preoperatively: only
0.0–2.8% of ‘routine’ tests influence patient management.17
Only order tests that are clinically indicated; doing otherwise
causes false positives, further delays and potential harm.
Standardised guidelines for preoperative investigations
should be used that are specific to the patient population
and planned procedure.18 Such guidelines should consider
these key attributes:
 Diagnostic efficacy (whether the test correctly
identifies abnormalities)
 Diagnostic effectiveness (whether the test changes
the diagnosis)
 Therapeutic efficacy (whether the test changes
patient management)
 Therapeutic effectiveness (whether the test changes
patient outcomes).19
The more of these attributes a preoperative test has, the
more worthwhile it is.
NICE guidance outlines that patients having ‘intermediate’
grade surgery (such as laparoscopy), with an American
Society of Anesthesiologists (ASA) status of 1 or 2 should not
routinely have a full blood count (FBC) taken
preoperatively.18 (Those with an ASA status of 3 or 4 plus
cardiac, renal and/or diabetic comorbidities do warrant a
preoperative FBC, however.) A ‘blood group and save’ is not
warranted routinely prior to benign laparoscopy.
Patients with a history (or examination findings suggestive)
of heavy menstrual bleeding warrant a preoperative serum
haemoglobin test. Anaemia is an independent predictive risk
factor for operative complications and death.20 Serum
haemoglobin ( C-reactive protein, CRP) should be tested at
least 1 month preoperatively (in appropriate patients) to
enable treatment, guided by the flowchart in Figure 2. If iron
therapy is indicated, it can be given orally in divided daily
doses; evaluate the response after 1 month of therapy. If oral
iron is contraindicated, poorly tolerated or ineffective,
consider intravenous iron infusion if rapid iron repletion is
clinically important (e.g. less than 2 months until
nondeferrable surgery).21
Preoperative electrocardiograms (ECGs) aim to detect
underlying cardiac disease (e.g. arrhythmia or myocardial
infarction) that will either alter anaesthetic plans and/or
require the postponement of surgery. An ECG is rarely
indicated prior to laparoscopy. NICE suggests that patients
with an ASA of 1 do not need a preoperative ECG, those with an
ASA of 2 do if they also have cardiovascular, renal, or diabetic
comorbidities and those with an ASA of 3 or 4 do need an ECG.18
Chest radiography (CXR) is not recommended prior to
surgery, unless the patient has a history of respiratory disease,
or abnormal findings on respiratory examination. There is no
age cut-off above which CXR is routine prior to
benign laparoscopy.18
Alterations to regular medications
Sparse evidence is available to guide the management of
patients’ regular medications perioperatively. General
principles include:

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 Bryant-Smith et al.

Box 1. Perioperative management for women with diabetes

The perioperative milieu challenges glycaemic management owing to fasting, counter-regulatory hormones released in response to the physiological
stress of surgery and a slow return to normal diet. Hence, patients often require considerable modifications to their medications. Unfortunately, there is
neither a strong evidence base, nor a generic recipe for doing so: management should be based on national and local guidelines and conducted in
discussion with an endocrinologist.16 The following need consideration:

 Patient’s type of diabetes

 Planned surgery
 Presence or absence of diabetic complications
 Patient’s preoperative HbA1c levels (see below)
 Withholding oral hypoglycaemic agents, which may need to be done for 24–48 hours preoperatively
 Alterations to insulin dosing16
Endeavour to achieve an HbA1c of less than 69 mmol/mol (less than 8.5%) preoperatively.16 Patients with an HbA1c greater than 69 mmol/mol should
be discussed with the diabetes team and, if it is safe to delay surgery, their HbA1c should be optimised. The perioperative risks of proceeding when
HbA1c is suboptimal should be balanced against the urgency of the procedure.
On the day of surgery, patients with diabetes requiring medications should be first on a morning list so as to minimise the duration of fasting:
management becomes more complex as the day progresses. Patients with insulin-controlled diabetes should not undertake carbohydrate loading
preoperatively. Target preoperative capillary blood glucose is 6–10 mmol/L; up to 12 mmol/L may be acceptable.16 Higher blood glucose levels require
measurement of urinary or capillary blood ketones: if urinary ketones are greater than +++, or capillary blood ketones greater than 3 mmol/L, then
surgery should be cancelled and the on-call diabetes team contacted. If ketones are below these levels, administer rapid-acting insulin and recheck the
blood glucose 1 hour later. If surgery cannot be delayed, or if the response is inadequate, commence a variable rate intravenous insulin infusion (‘sliding
scale’).16
Intraoperatively, the frequency of capillary blood glucose level monitoring is determined by clinical circumstances; blood sugar should be measured at
least hourly.16 Aim for a blood sugar level of 8 mmol/L (range 6–10 mmol/L; up to 12 mmol/L may be acceptable).16
Postoperatively, endeavour to maintain blood glucose levels between 6 and 10 mmol/L. Recommence oral hypoglycaemic agents once patients can eat
and drink.

 To continue medications that will not impair the

operation or anaesthesia, but will carry considerable risks
if withdrawn (e.g. beta-blockers)
 To withhold medications that increase surgical or
anaesthetic risk and are not essential for short-term
quality of life (e.g. angiotensin inhibitors)
 If a medication doesn’t clearly fit either category above: to
base decisions on surgical and anaesthetic considerations,
plus the stability of the condition the medication is used
to treat22
When in doubt, discuss the medication in question with
the prescribing clinician.
Perioperative management of antithrombotic agents (e.g.
aspirin, clopidogrel, warfarin) presents contradictory risks:
withholding these medications increases thrombotic risk,
while continuation increases perioperative bleeding. At pre-
admission clinic, discuss such patients with a haematologist
and consult national and local guidelines.23
Goh et al.’s recent review of perioperative management of
women on oral anticoagulants and antiplatelet agents
undergoing gynaecological procedures provides invaluable
guidance to clinicians.24 Of note, the authors classify all day
case and inpatient surgery as carrying a major bleeding risk.
Their recommendations regarding perioperative
management for such ‘high bleeding risk’ patients are
summarised in Table 2.
Surgeons must assess the risk of postoperative haemorrhage
on an individual case-by-case basis.
Immediately preoperative: day before and
day of surgery
Patients should shower or bathe, using soap, on the day
before or the day of surgery, to decrease the risk of surgical
site infection.25
All patients admitted for abdominal or pelvic surgery
should receive mechanical thromboprophylaxis: intermittent
pneumatic compression devices, with/without graduated
compression stockings. This should be continued until
their mobility is no longer considerably reduced from
baseline,12 or as recommended based on their Caprini score
(outlined previously).14
Bowel preparation and fasting
Mechanical bowel preparation (e.g. bisacodyl, sodium
picosulfate) should not be routinely administered, even in
patients with planned enteric resection (e.g. deeply invasive
endometriosis with rectal involvement).26 Data from several
randomised controlled trials (RCTs) show that bowel
preparation is not associated with improved intraoperative
visualisation, bowel handling, or surgical ease and can cause
patient distress and dehydration.27
Regarding fasting, mounting evidence supports solid food
intake up to 6 hours preoperatively and clear fluids (in
particular, a complex carbohydrate drink for patients without
diabetes) up to 2 hours preoperatively.2 These interventions
reduce preoperative thirst, hunger and anxiety and

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 Life in the laparoscopic fast lane

Preoperative history and examination

- Risk factors for anaemia (e.g. heavy
menstrual bleeding)?
- Previous/current iron deficient anaemia?

Yes No

Preoperative blood tests FBC, iron studies

indicated: not indicated
FBC, iron studies
(including ferritin), CRP

Is the patient anaemic? What is the serum ferritin?

i.e. Hb <120 g/L Yes

No
<30 mcg/L 30–100 mcg/L >100 mcg/L
Is ferritin <30 mcg/L?

No Yes
Iron deficiency What is the CRP?
Is Hb expected to decrease Iron deficiency anaemia
≥30 g/L postoperatively? without anaemia - Evaluate possible causes,
Determine cause based on history and
Yes and need for possible examination
No Raised Normal
GI investigations - Commence iron therapy

No iron Consider iron

supplementation supplementation Possible iron deficiency Possible anaemia of chronic
needed preoperatively anaemia disease, or other cause
- Consider clinical context - Consider clinical context
- Consider haematology - Review MCV/MCH
and/or renal advice - Consider ordering:
- Consider possible GI UEC, blood film, B12 and
investigations folate levels, reticulocyte
- Commence iron therapy count, liver and
thyroid function
- Seek haematology
and/or renal advice

Figure 2. Algorithm to guide management of preoperative anaemia.21CRP = C-reactive protein; FBC = full blood count; GI = gastrointestinal; Hb =
haemoglobin; MCH = mean corpuscular haemoglobin; MCV = mean corpuscular volume; UEC = urea, electrolytes and creatinine

postoperative insulin resistance, thereby improving both
patient experience and length of stay.28
The neuroendocrine response to surgery results in sodium
and water retention, leading to a reduction in maintenance fluid
requirements.29 Hence, administration of preoperative intr-
avenous fluids for fasting patients is not routinely indicated.
Pregnancy testing
On the day of surgery, sensitively ask all women of
childbearing potential (from menarche to 2 years after
regular menses) whether there is any possibility they could
be pregnant. Perform a urinary pregnancy test (with the
woman’s consent) if there is any doubt.18 Such screening is
positive in up to 0.4% of tests and fulfils the criteria outlined
in the ‘preoperative investigations’ section.30
Preoperative analgesia
Preoperative analgesia improves postoperative pain levels,
thereby decreasing postoperative opioid use. Administer the
following oral analgesia to all laparoscopy patients, 1 hour

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 Bryant-Smith et al.

Table 2. Commonly used oral anticoagulants and antiplatelet agents and recommendations of perioperative management for laparoscopy.24

Class, examples When should it be stopped preoperatively? When should it be restarted postoperatively?

Vitamin K antagonist

Warfarin 5 days prior to elective surgery, with INR check ideally the day before
surgery (if INR >1.5 phytomednadione should be given) and on the
day of surgery.
Bridging with treatment dose LMWH should be considered in those
with high VTE risk.
LMWH should not be given until 48 hours after
surgery. Restart warfarin when bleeding risk is
minimised. LMWH should be continued until INR in
therapeutic range.

Factor Xa inhibitors

Apixiban, rivaroxaban, Creatinine clearance ≥30 ml/min: stop 48 hours prior Wait 48 hours before re-introducing at the full dose.
edoxaban Creatinine clearance <30 ml/min: stop 72 hours prior If high VTE risk, consider prophylactic dose of
anticoagulation before restarting at full therapeutic
dose.

Dabigatran Creatinine clearance ≥80 ml/min: stop 48 hours prior Wait 48 hours before re-introducing at the full dose.
Creatinine clearance ≥50 to <80 ml/min: stop 72 hours prior If high VTE risk, consider prophylactic dose of
Creatinine clearance ≥30 ml/min to <50 ml/min: stop 96 hours prior anticoagulation before restarting at full therapeutic
dose.

COX inhibitor

Aspirin Continue Continue

P2Y12 inhibitors

Clopidogrel, prasugrel, In patients with recent coronary syndrome or coronary artery stent Restart when haemostasis achieved (12–24 hours
ticagrelor on dual antiplatelet therapy: if possible, postpone the surgery; if not post-surgery).
possible, stop medication 7 days before and continue with aspirin
following liaison with haematologist.

INR = international normalised ratio; LMWH = low-molecular-weight heparin; VTE = venous thromboembolism

preoperatively (unless a contraindication exists): 1 g antibiotics.26 (‘Clean-contaminated’ refers to procedures

paracetamol, 400 mg celecoxib or ibuprofen, and
600 mg gabapentin.2,26
Intraoperative management
Preventing surgical site infections
Surgical site infections (SSIs) are infections that occur within
30 days of an operation, at or near a surgical incision. Two-
thirds of gynaecological SSIs are superficial incisional
infections (e.g. skin or subcutaneous tissues).31
Laparoscopic operations that are not contaminated by the
genitourinary or digestive tracts do not require antimicrobial
prophylaxis; such operations include oophorectomy, ovarian
cystectomy, tubal ligation, salpingectomy, myomectomy
(irrespective of whether the endometrial cavity is breached)
and excision of endometriosis (except with bowel
resection).2,26 Conversely, operations that are expected to
become ‘clean-contaminated’ warrant intravenous
that open a colonised viscous or cavity under surgical
circumstances, thereby allowing the ascent of pathogens.)
Examples of ‘clean-contaminated’ procedures include total
hysterectomy (which incises into the vagina) and excision of
severe endometriosis (which may necessitate contact with
vaginal, vesical, and/or bowel mucosa).
If indicated, prophylactic antibiotics should have a
spectrum of activity covering the most common infecting
organisms and be at adequate concentrations from the time
of knife-to-skin until the operation’s completion. One
evidence-based regimen is to administer 2 g cefazolin or
1.5 g cefuroxime, plus 500 mg metronidazole (all
intravenous) during the hour prior to skin incision
(increase doses in patients with a BMI greater than 30 and/
or weight greater than 100 kg).26,32,33 Broadening coverage
by administering metronidazole (rather than a cephalosporin
alone) decreases SSI following hysterectomy.33 Alternatively,
similar broad-spectrum coverage is achieved with

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 Life in the laparoscopic fast lane
intravenous amoxicillin plus a b-lactamase inhibitor (e.g. co-
amoxiclav, at a dose of 2 g amoxicillin/1 g clavulanic
acid).2,25,30 For patients who are allergic to penicillins or
cephalosporins, administer a combination of clindamycin
and gentamicin, or a quinolone (e.g. ciprofloxacin).26,32
Antibiotics should be repeated if the operative time is longer
than 3 hours and/or blood loss is greater than 1500 ml.32
Regarding skin and vulval or vaginal preparation:
traditionally, povidone-iodine was used in the vagina owing
to concerns about complications attributable to alcohol-
based chlorhexidine. However, compared with povidone-
iodine, chlorhexidine more effectively eliminates vaginal
bacteria and remains effective in the presence of blood.31 In
concentrations of 4% or less, alcohol-based chlorhexidine is
well-tolerated vaginally and its use is supported by the
American College of Obstetricians and Gynecologists.26,34
Hence, surgeons should use alcohol-based chlorhexidine (less
than or equal to 4% alcohol content) for abdominal, vulval
and vaginal preparation.
Adoption of SSI reduction ‘bundles’ decreases the risk of SSI.
Elements of such bundles (which are additive) include
antibiotic prophylaxis, skin preparation, and avoidance
of hypothermia, surgical drains, and perioperative
hyperglycaemia.2
Intraoperative VTE prophylaxis
All patients undergoing laparoscopy should have graduated
compression stockings and/or intermittent pneumatic
compression intraoperatively.12
Maintenance of normothermia and euvolaemia
Heat loss is accelerated intraoperatively owing to abdominal
exposure and preparation and impaired thermoregulatory
responses secondary to general anaesthesia. Actively maintain
normothermia using air blanket devices and warmed
intravenous fluids.
Trendelenburg position and pneumoperitoneum reduce
patients’ cardiac output; hypovolaemia increases the risk of
postoperative acute kidney injury, SSI, sepsis and prolonged
hospital stay.2 Hence, normovolaemia should be maintained,
using stroke volume to guide intravenous fluid administration.
Intraoperative analgesia and wound closure
There are mixed data about the postoperative analgesic
benefits of administering local anaesthetic to the tissue
surrounding laparoscopic port sites. However, given the
limited risks and low cost involved, most surgeons do so.
One recommended regimen is to use 0.25% bupivacaine
(2.5 mg/ml), to a maximum dose of 2.5 mg/kg.35
Skilled wound closure is pivotal to minimising wound
complications. Subcuticular absorbable sutures are most
often used for closing laparoscopic port sites, but so called
‘tissue glue’ can be used as an alternative.36
120
Postoperative: in the recovery bay and/or
ward
Postoperative nausea and vomiting
Postoperative nausea and vomiting (PONV) affects 30% of
all patients following general anaesthesia.37 The Apfel score
assesses four variables (female gender, history of motion
sickness and/or PONV, non-smoker and planned opioid
treatment postoperatively) and assigns one point for each
variable. The probability of PONV for scores of 0, 1, 2, 3, and
4 are 10%, 21%, 39%, 61%, and 78%, respectively.37 Most
women undergoing benign gynaecological laparoscopy are in
the highest risk group (i.e. at almost 80% risk of PONV).37
Hence, PONV should be pre-empted in gynaecological
laparoscopy patients and multifaceted management should
be routinely implemented. This should include avoiding
nitrous oxide and volatile anaesthetics where feasible, using a
continuous target-controlled propofol infusion, utilising
short-acting inhalational agents (e.g. sevoflurance or
desflurane), minimising opioid use and using a lower
neostigmine dose.2 Routine prophylactic anti-emetics
should be administered; a combination of two or more
anti-emetic classes enhances potency (e.g. dexamethasone,
plus aprepitant, ondansetron, midazolam or haloperidol).2
Diet and bowel function
Postoperatively, oral fluids and a regular (‘full ward’) diet can
be commenced immediately.26,38 This approach is safe and is
associated with less nausea, shortened length of stay and
higher patient satisfaction.26
Return to bowel-related functioning is an important factor
indicating return to daily activities. Regular laxative use
reduces the time to first defecation by 24 hours (from 69 to
45 hours).39 Regular administration of laxatives is
reasonable, given their favourable side-effect profile and
low cost.
Postoperative analgesia
Mild pain is common following laparoscopy because carbon
dioxide used to produce pneumoperitoneum can remain
in situ, causing cramps, bloating and shoulder tip pain. These
symptoms should subside within 24 hours, but if pain
worsens thereafter, intra-abdominal complications must
be excluded.40
Benefits of optimising analgesia include earlier
mobilisation (decreasing VTE risk and pulmonary
complications), improved sleep, higher patient satisfaction
and fewer delayed discharges. Multimodal analgesia improves
pain relief, while reducing the side-effects of individual
agents. Administration of regular paracetamol and regular
non-steroidal anti-inflammatory drugs reduces both pain
and opioid consumption.2 A weak opioid (e.g. codeine) can
be added pro re nata.40
ª 2021 Royal College of Obstetricians and Gynaecologists

Opioids are associated with sedation, fatigue, restricted
mobilisation, nausea and ileus, so minimising their use
improves both the patient experience and functional
recovery.2 Evidence-based guidelines founded on patients’
actual opioid use suggest that prescribing 15 x 5 mg
oxycodone tablets after laparoscopic hysterectomy will meet
or exceed 75% of patients’ needs.41 Prescribing any more
than this may contribute to opioid dependence, which is a
growing global problem.
Individual variability in patients’ postoperative opioid
consumption means that clinicians should consider patient
factors such as preoperative opioid use and history of
endometriosis.42 Shared-decision making can further
decrease opioid prescribing, without reducing patient
satisfaction or postoperative pain control.43
Tapentadol (a relatively new medication) may become an
alternative to oxycodone. Some studies have shown similar
analgesic efficacy to oxycodone, with less nausea and
constipation.44 Further studies are needed to determine its
role in post-laparoscopy analgesia.
Early mobilisation
Early mobilisation is key to ERAS: it counteracts the
numerous disadvantges of bed rest, such as VTE and
impaired insulin resistance, pulmonary function and tissue
oxygenation.28 Encourage mobilisation by prescribing
effective multimodal analgesia, eschewing drain tubes and
removing hindrances (e.g. catheters and intravenous
cannulae) as soon as possible.
The pace of resumption of normal activities
postoperatively depends on the operation performed.
Pragmatic advice is, ‘if it hurts, don’t do it’; patients
should notice a daily improvement in the activities they
can undertake without pain.40 Time until return to work
depends on the patient’s operation and occupation: 2 weeks
of leave from a sedentary job after laparoscopy usually
suffices. For 2 weeks postoperatively, patients should avoid
lifting anything heavier than a full kettle and any considerable
pushing and pulling activities (e.g. lawn-mowing,
vacuuming).40 Patients should not drive until they are no
longer using opioids or other sedatives, have sufficient
reaction times and can comfortably apply the brakes forcibly
and check their blind spot.40
VTE prophylaxis
Patients should mobilise as soon as possible postoperatively.
Additional thromboprophylaxis is guided by their
individualised VTE risk assessment, as outlined previously.
If LMWH is indicated, then prior to administering the first
dose, evaluate the likelihood of bleeding by reviewing the
NICE bleeding risk assessment tool, operation notes, output
from drain tubes (if present) and ooze on
surgical dressings.11
ª 2021 Royal College of Obstetricians and Gynaecologists
Bryant-Smith et al.
Any tick in the ‘bleeding risk’ section of the NICE risk
assessment tool should prompt clinicians to consider if the
patient’s higher risk of bleeding precludes LMWH
administration.11 If so, discuss the patient with their
surgeon and a haematologist. Some situations may warrant
unfractionated heparin, which can be quickly reversed
with protamine.
If at low risk of bleeding, administer LMWH within
12 hours postoperatively.45 Consider admitting patients
overnight if they require LMWH; this allows for clinical
observation (subtle signs of intra-abdominal haemorrhage
may not be recognised at home until considerable
morbidity occurs).
If patients fly within 1 month of their operation, it would
be sensible for them to wear graduated
compression stockings.40
Management of urinary catheters
Clinical guidelines regarding the management of urinary
catheters after laparoscopy are sparse. Unless the patient has
had a concomitant incontinence and/or prolapse procedure
and/or has a history of urinary retention, their catheter
should be removed at the end of their operation.
Regarding laparoscopic hysterectomy: guidelines from
neither the UK nor USA provide recommendations on
when to remove the urinary catheter.46,47 An RCT of
immediate versus delayed (18–24 hours postoperative)
catheter removal following laparoscopic hysterectomy
found that 4% of women in the immediate removal group
had voiding dysfunction at 9 hours postoperatively.48 The
authors concluded that the clinical advantages of immediate
catheter removal after uncomplicated laparoscopic
hysterectomy outweigh the risk of urinary retention; this is
consistent with an earlier RCT.49
Patients who have had a minor procedure (e.g. diagnostic
laparoscopy, tubal ligation, ovarian cystectomy, excision of
minimal/mild endometriosis), are at even lower risk of
postoperative urinary retention (POUR). (POUR refers to
impaired voiding after a procedure, despite a full bladder,
which results in an elevated post-void residual, PVR.)50 These
patients do not even need to void prior to discharge, let alone
undertake a formal ‘trial of void’.
Women who have undergone concomitant incontinence
and/or prolapse surgery and/or have a history of urinary
retention, are at higher risk of POUR. These women do
require a formal ‘trial of void’ prior to discharge. This
involves asking the patient to void into a collection device
when they have a strong urge, or after 4 hours have
passed. The voided volume is measured, as is the PVR (by
ultrasound). ‘Success’ is defined as the PVR being 100 ml
or less, or the patient being able to void at least two-thirds
of their total bladder volume (when total bladder volume
= voided volume + PVR).50 If a patient does not pass on
121
 Life in the laparoscopic fast lane
the first attempt, they can try again (when they have
another strong urge or 4 hours later). If they do not pass
on the second attempt, their trial of void is considered to
be unsuccessful. They should be discharged with an
indwelling catheter and the trial of void repeated
1 week later.
Postoperative investigations
Postoperative investigations are rarely indicated. When
necessary, they should be guided by the patient’s
comorbidities and clinical state. An FBC is only warranted
for patients who have symptoms and/or signs of
haemodynamic compromise.51
Advice upon discharge
Discharge patients once they are mobilising, tolerating fluids
and controlling their pain with oral analgesia. Although
desirable, passing urine and flatus and tolerating oral intake
are not prerequisites for discharge.40 Prescribe a softening
laxative (e.g. docusate) to take until their first
bowel movement.
Patients should be advised when to seek clinical review; for
example, if their abdominal pain worsens or if there is
worsening distension; if they are unable to eat, drink, or
mobilise; or if they experience nausea or vomiting, poor
urine output or fever. Of note, almost all fevers that occur on
day one are unexplained, with virtually all resolving by day
four. Such febrile episodes are thought to be associated with
direct tissue trauma and the resultant release of pyrogenic
cytokines. Hence, a ‘less is more’ approach is generally
appropriate. Conversely, fevers beginning three or more days
after surgery often have an infectious aetiology and warrant
investigation (e.g. physical examination, urinalysis, FBC,
urine or blood culture, ultrasound and/or computed
tomography) and broad-spectrum intravenous antibiotics
(if infection is confirmed).52
Conclusion
Evidence-based perioperative management and ERAS should
be the standard of care in gynaecological laparoscopy.15 Such
an approach has many benefits, including decreased
cancellation rates, higher patient satisfaction, fewer
complications and shorter length of stay. Despite the
evidence base supporting an ERAS approach to
gynaecological laparoscopy, diffusion and uptake of many
interventions has been slow. Possible reasons include
clinicians being unaware of, or unwilling to adopt, the
interventions supported by evidence-based literature.
Simple measures that clinicians can implement include
judicious ordering of preoperative investigations, screening
for BV prior to laparoscopic hysterectomy, calculating each
122
patient’s VTE risk and implementing appropriate
management thereafter, minimising preoperative fasting,
only prescribing antibiotic prophylaxis and urinary ‘trial of
void’ when indicated and prescribing multimodal analgesia.
Such interventions will safely enhance patients’ recovery and
allow them to experience life in the laparoscopic fast lane.
Disclosure of interests
ABS has has received training facilitated by Olympus. SAS has
received research support from the National Institutes of
Health (USA), has been a consultant for AbbVie, Bayer,
Myovant and Merck and receives author royalties from
UpToDate. JL and MW have no conflicts of interest.
Contribution to authorship
ABS initiated the idea, performed the literature search, and
co-wrote the article. SAS, JL, and MW co-wrote the article.
All authors approved the final version.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
PDF S1. Risk assessment for venous thromboembolism.
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undergoing gynaecological procedures. The Obstetrician & Gynaecologist.
2020;22:131–6.
25 National Institute for Health and Clinical Excellence (NICE). Surgical site
infections: prevention and treatment. Clinical guideline CG74 London: NICE;
2019 [https://www.nice.org.uk/guidance/cg74/resources/surgical-site-infec
tions-prevention-and-treatment-pdf-975628422853].
26 American College of Obstetricians and Gynecologists (ACOG). Summary:
Perioperative pathways: Enhanced Recovery After Surgery. ACOG
Committee Opinion No. 750. Obstet Gynecol 2018;132:801–2.
27 Zhang J, Xu L, Shi G. Is mechanical bowel preparation necessary for
gynecologic surgery? A systematic review and meta-analysis. Gynecol
Obstet Invest 2016;81:155–61.
28 Crawford RAF, Acheson N, Nordin AJ, Torb
e EJ, Royal College of
Obstetricians and Gynaecologists (RCOG). Enhanced recovery in
gynaecology. Scientific Impact Paper No. 36. London: RCOG; 2013. pp. 36.
29 Pearse RM, Ackland GL. Perioperative fluid therapy. BMJ 2012;344:e2865.
30 Douglas WR, Stacy K, Peter D, Mary HS, Bonnie R, Kathy V, et al. Pre-
operative pregnancy testing (POPT) and the undiagnosed pregnancy rate in
an elective gynaecology surgery population. Clin Obstet Gynecol Reprod
Med 2015;1:43–6.
31 Steiner HL, Strand EA. Surgical-site infection in gynecologic surgery:
pathophysiology and prevention. Am J Obstet Gynecol 2017;217:121–8.
32 Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK,
et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery.
Surg Infect (Larchmt) 2013;14:73–156.
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Bryant-Smith et al.
33 Till SR, Morgan DM, Bazzi AA, Pearlman MD, Abdelsattar Z, Campbell DA,
et al. Reducing surgical site infections after hysterectomy: metronidazole
plus cefazolin compared with cephalosporin alone. Am J Obstet Gynecol
2017;217:187.e1–187.e11.
34 American College of Obstetricians and Gynecologists Women’s Health Care
Physicians, Committee on Gynecologic Practice. Solutions for surgical
preparation of the vagina. Committee Opinion No. 571. Obstet Gynecol
2013;122:718–20.
35 Tam T, Harkins G, Wegrzyniak L, Ehrgood S, Kunselman A, Davies M.
Infiltration of bupivacaine local anesthetic to trocar insertion sites after
laparoscopy: a randomized, double-blind, stratified, and controlled trial. J
Minim Invasive Gynecol 2014;21:1015–21.
36 Buchweitz O, Frye C, Moeller C, Nugent W, Krueger E, Nugent A, et al.
Cosmetic outcome of skin adhesives versus transcutaneous sutures in
laparoscopic port-site wounds: a prospective randomized controlled trial.
Surg Endosc 2016;30:2326–31.
37 Apfel CC, L€a€ar€a E, Koivuranta M, Greim CA, Roewer N. A simplified risk
score for predicting postoperative nausea and vomiting: conclusions
from cross-validations between two centers. Anesthesiology
1999;91:693–700.
38 Pan Y, Chen L, Zhong X, Feng S. Gum chewing combined with oral intake of
a semi-liquid diet in the postoperative care of patients after gynaecologic
laparoscopic surgery. J Clin Nurs 2017;26:3156–63.
39 Hansen CT, Sørensen M, Møller C, Ottesen B, Kehlet H. Effect of laxatives on
gastrointestinal functional recovery in fast-track hysterectomy: a double-
blind, placebo-controlled randomized study. Am J Obstet Gynecol
2007;196:311.e1–311.e7.
40 Blencowe NS, Waldon R, Vipond MN. Management of patients after
laparoscopic procedures. BMJ 2018;360:6–10.
41 Michigan Opioid Prescribing Engagement Network (OPEN). Prescribing
recommendations. Ann Arbor: OPEN; 2019 [https://michigan-open.org/pre
scribing-recommendations/].
42 As-Sanie S, Till SR, Mowers EL, Lim CS, Skinner BD, Fritsch L, et al. Opioid
prescribing patterns, patient use, and postoperative pain after hysterectomy
for benign indications. Obstet Gynecol 2017;130:1261–8.
43 Vilkins AL, Sahara M, Till SR, Ceci C, Howard R, Griffith KC, et al. Effects of
shared decision making on opioid prescribing after hysterectomy. Obstet
Gynecol 2019;134:823–33.
44 Raeder J. Opioids in the treatment of postoperative pain: Old drugs with
new options? Expert Opin Pharmacother 2014;15:449–52.
45 Muntz JE, Michota FA. Prevention and management of venous
thromboembolism in the surgical patient: options by surgery type
and individual patient risk factors. Am J Surg 2010;199 1 Suppl:
S11–20.
46 National Institute for Health and Care Excellence (NICE). Laparoscopic
techniques for hysterectomy. Interventional procedures guidance. London:
NICE; 2007 [https://www.nice.org.uk/guidance/ipg239/resources/laparosc
opic-techniques-for-hysterectomy-1899865344377797].
47 American Association of Gynecologic Laparoscopists (AAGL). AAGL practice
report: practice guidelines for laparoscopic subtotal/supracervical
hysterectomy (LSH). J Minim Invasive Gynecol 2014;21:9–16.
48 Sandberg EM, Twijnstra ARH, van Meir CA, Kok HS, van Geloven N,
Gludovacz K, et al. Immediate versus delayed removal of urinary catheter
after laparoscopic hysterectomy: a randomised controlled trial. BJOG
2019;126:804–13.
49 Alessandri F, Mistrangelo E, Lijoi D, Ferrero S, Ragni N. A prospective,
randomized trial comparing immediate versus delayed catheter
removal following hysterectomy. Acta Obstet Gynecol Scand
2006;85:716–20.
50 Mueller E, Brubaker L, Eckler K. Postoperative urinary retention in women.
UpToDate; 2019 [https://www.uptodate.com/contents/postoperative-urina
ry-retention-in-women].
51 Chamsy DJ, Louie MY, Lum DA, Phelps AL, Mansuria SM. Clinical utility of
postoperative hemoglobin level testing following total
laparoscopic hysterectomy. Am J Obstet Gynecol
2014;211:224.e1–224.e7.
52 Pile JC. Evaluating postoperative fever: a focused approach. Cleve Clin J Med
2006;73:S62–6.
123
 DOI: 10.1111/tog.12730 2021;23:124–37
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Surgical site infection in obstetrics and gynaecology:

prevention and management
Emmanuel E Ekanem MBBCh FWACS MRCOG MRCPI,a Olubunmi Oniya MBBS FRCOG,
b

Hudah Saleh MBBS MD (Arab Board),c Justin C Konje MD MBA FRCOG*d

a
ST4 Trainee in Obstetrics and Gynaecology, Northampton General Hospital NHS Trust, Northampton NN1 5DR, UK
b
Senior Attending Physician, Sidra Medicine, Assistant Professor of Obstetrics and Gynaecology, Weill Cornell Medical College, Doha, Qatar
c
Senior Consultant, Women’s Wellness Research Center, Hamad Medical Corporation, Doha, Qatar
d
Emeritus Professor of Obstetrics and Gynaecology, Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
*Correspondence: Justin Konje. Email: jck4@leicester.ac.uk

Accepted on 14 July 2020. Published online 23 March 2021.

Key content
 Surgical site infection (SSI) is an important cause of postoperative
morbidity and, in severe cases, mortality.
 The epidemiology of SSIs varies depending on the type of surgery
and the country. It is influenced by patient-related, preoperative,
intraoperative and postoperative risk factors.
 Prevention strategies target these risk factors and include measures
taken before, during and after surgery.
Learning objectives
 To understand how SSIs can be prevented, depending on the type
of wound, especially perioperative measures including antibiotic
prophylaxis, and when to institute repeat antibiotics or
alter dosages.
 To understand the bases of and approaches to perioperative
antibiotics in women with incidental infections (for example,
lower genital and urinary tract) and in women with comorbidities,
such as those who are immunosuppressed or with mechanical
valvar heart diseases.
 To understand what specific measures to take to reduce the risk of
SSIs in special cases in obstetrics and gynaecology, such as in
morbidly obese women, those undergoing cancer surgery, or those
with cardiac conditions or transplants.
Ethical issues
 Should perioperative antibiotics be given to every woman
undergoing surgery?
 What is the risk of antibiotic resistance as a result of
administration of perioperative antibiotics?
Keywords: antibiotics / caesarean section / gynaecological surgery /
preoperative antibiotics / surgical site infection

Please cite this paper as: Ekanem EE, Oniya O, Saleh H, Konje JC. Surgical site infection in obstetrics and gynaecology: prevention and management.
The Obstetrician & Gynaecologist 2021;23:124–37. https://doi.org/10.1111/tog.12730

emergency caesarean section and multiple vaginal

Introduction
After the introduction of antisepsis and antibiotics in the 19th
century, subsequent advances have made surgery even safer.
Some of these advances include good surgical techniques and
safe anaesthesia. Despite this, surgical site infection (SSI) has
remained a problem, with huge implications for patient care and
safety. SSI may lead to severe morbidity and mortality, with
prolonged hospitalisation and enormous economic costs for
both patients and healthcare systems.1 Several advances in
infection prevention practices have made significant
contributions to a reduction in SSIs. These include improved
ventilation in the operating theatre, methods of equipment
sterilisation and use of barriers during surgery. Factors
associated with increased rates of SSIs include antibiotic-
resistant pathogens and chronic disorders such as diabetes,
alcoholism, obesity and immunosuppression.1 In obstetrics,
increased SSIs may be associated with prolonged labour,
examinations. Common pathogens include Gram-positive and
-negative organisms such as Staphylococcus aureus and
Escherichia coli, respectively.
In the UK, SSIs not only increase the length of hospital
stay, but also the cost of care. Estimates of this additional cost
range from £959–1300, depending on the type of surgery and
the severity of infection.2,3 In this review, we discuss and
provide an evidence-based approach to reducing and
managing SSIs in obstetrics and gynaecology.
Definition
SSI is defined as an infection of the superficial or deep skin
incision, or of an organ or space, occurring up to 30 days
after surgery if no implant was left behind, or within 1 year if
an implant was left in place (Figure 1).1 There are specific
criteria for making a diagnosis.

124 ª 2021 Royal College of Obstetricians and Gynaecologists


Figure 1. Cross-section of abdominal wall illustrating the
classification of surgical site infection by the Centers for Disease
Control (CDC). Adapted from Horan et al.,4 with permission. SSI =
surgical site infection.
For superficial wound infection, at least one of
the following:
 Purulent effluent or exudate with organisms identified
 Presence of one of the following: pain, redness, localised
swelling, tenderness or heat
 Diagnosis of a superficial wound infection by a surgeon or
an attending physician1
For deep wound infection, at least one of the following:
 Purulent exudate from a deep wound incision
 Spontaneous dehiscence of a deep incisional wound or a
wound deliberately opened in the presence of pyrexia
>38°C, localised pain, or tenderness
 Evidence of abscess or infection involving deep wound
incisions found on direct examination of the wound,
during re-operation, radiologically or on histology
 Diagnosis of a deep incisional wound infection by a
surgeon or an attending physician1
For organ or space infection, at least one of the following:
 Purulent exudate from a drain placed in the organ or space
via a stab wound
 Organism isolated from the organ or space
 Evidence of abscess or infection involving the organ or
space found on direct examination of the wound, during
re-operation, radiologically or on histology
 Diagnosis of an organ or space wound infection by a
surgeon or an attending physician1
Wounds have traditionally been classified as clean, clean
contaminated, contaminated, dirty or infected (see Box 1).4,5
Epidemiology
The incidence of all SSI varies depending on the population,
risk factors, type and duration of surgery. SSI is estimated to
ª 2021 Royal College of Obstetricians and Gynaecologists
Ekanem et al.
Box 1. Wound classification
Clean: a wound made under sterile conditions where there are no
organisms present and the skin is likely to heal without complications,1
or an incision in which no inflammation is encountered in a surgical
procedure, without a break in sterile technique, and during which the
respiratory, alimentary or genitourinary tracts are not entered (e.g. skin
incision for ovarian cystectomy).5
Clean contaminated: a wound made under sterile conditions but in
which the respiratory, gastrointestinal, genital or urinary tract is
entered under controlled conditions and without
unusual contamination,1 or an incision through which the respiratory,
alimentary or genitourinary tract is entered under controlled conditions
but with no contamination encountered (e.g., skin incision at
hysterectomy or caesarean section).5
Contaminated: typically an open, fresh or accidental wound or an
incision undertaken during an operation in which there is a major
break in sterile technique or gross spillage from the gastrointestinal
tract, or an incision in which acute, non-purulent inflammation is
encountered.1 Open traumatic wounds that are more than 12 to 24
hours old also fall into this category (obstetrics and gynaecology
surgery in which the bowel is opened either deliberately or
accidentally).5
Dirty or infected: a wound with devitalised tissues with organisms
pre-existing in the surgical field before surgery (e.g., laparotomy for
pelvic collection).1
complicate about 2–6% of surgeries in high-income
countries; for example, 2.6% in Italy, 3% in France and
5.4% in Switzerland.6,7 The incidence is lower in high-
income countries than in low-income countries.6
In a 2006 survey of hospitals in the UK, the incidence of
health care-acquired infection was shown to be 8%. SSI was
responsible for 14% of these infections and 5% of patients
who had a surgical procedure developed an SSI.3,5 In
England, an audit of SSI in the National Health Service
(NHS) by Public Health England, which took place in 2017/
18, found a reduction in the incidence of SSI compared with
that in 2016. This also varied according to the type of surgery;
it was highest after large bowel surgery (8.7%); bile duct, liver
and pancreas surgery (6.8%); and small bowel surgery
(6.7%), and lowest after knee replacement surgery (0.5%).
There were 47 SSIs after abdominal hysterectomy, with an
incidence of 1.6%.8 This is much lower than the rates
reported by Rosenthal and colleagues,6 of 2.7% for
abdominal and 2.0% for vaginal hysterectomy. A review of
the SSI rate in England over the 10-year period between 2009/
10 and 2018/19 showed an interesting pattern for SSI
following abdominal hysterectomy. The rate fell from 1.9%
in 2009/2010 to a nadir of 0.9% in 2014/15, then rose steadily
to a peak of 2.5% in 2016/17 before dropping to 1.9% for
2017/18 and 2018/19.9 In the USA, the SSI rate following
hysterectomy was 2.7% in 2013. Two-thirds of these SSIs
were superficial incisional infections, including vaginal cuff
cellulitis,10,11 while 1.1% were deep and organ-space SSIs
(including vaginal cuff abscess, peritonitis and pelvic
abscess).10 In a large study in Sweden, the mean SSI rate
125
 Surgical site infection

was 11.6% for vaginal hysterectomy, 3.79% for abdominal
hysterectomy and 3.76% for lower segment caesarean section
(CS).12 The rates following CS vary worldwide, too, and have
been reported as 3–15%.13-16 Some of the reasons for this
wide variation in SSI rates following CS include the use of
different denominators to capture the data, widely varying CS
rates, the presence of comorbidities, the use of prophylactic
antibiotics, grade of surgeon and surgical techniques.15,16
When some of these factors are included in the studies, the
variation in rates becomes closer, as reported by Wloch
et al.15 (9.8%) and Martin et al.16 (4.9–9.8%). SSI rates are
thus influenced by various risk factors, as shown in Table 1.
Risk factors
Table 1 shows some of the risk factors for SSI in obstetrics
and gynaecology. These factors can be grouped as patient-
related, preoperative or prepregnancy, intraoperative or
intrapartum, and postoperative.
Microbiology
Various organisms are responsible for SSIs, causing
symptoms by inducing changes in several inflammatory
and complement system pathways. Some of these organisms
are endogenous commensals normally found on the skin, in
the gastrointestinal tract and in the genital tract.20 SSIs may
arise as a result of complex interplay between the type and
number of the organisms and their virulence.20
The most common causative pathogens isolated are
enterobacterales (formerly known as enterobacteriaceae),
Staphylococcus aureus and coliforms such as Escherichia coli
and Proteus mirabilis.1,21 In the NHS-wide audit of SSI,
enterobacterales and S. aureus were responsible for 30.2%
and 22.9% of cases, respectively. Others included coliforms
(19.6%) and P. mirabilis (13.3%).2 The proportion of SSIs
associated with S. aureus increased from 22.1% in 2017/18 to
22.9% in 2018/19.9 Infections associated with methicillin-
resistant S. aureus (MRSA) or methicillin-sensitive S. aureus
(MSSA) both increased by 1.0% between 2017/18 and 2018/
19. Coagulase-negative staphylococci (CoNS) remained
stable at 19.4% in 2018/19, but had the greatest per cent
increase from 2009/10, followed by Enterococcus spp. (8.7%
in 2018/19). When restricted to deep or organ/space SSI only,
the species distribution showed a similar picture; however,
CoNS and Enterococcus spp. made up a higher proportion of
cases (21.7% and 9.9% in 2018/19, respectively). The only
gynaecological procedure data included in the national audit

Table 1. Risk factors for surgical site infection in obstetrics and gynaecology1,6,13,15,17-19

Patient factors Preoperative/prepregnancy factors Intraoperative/intrapartum factors Postoperative factors

Age Hypertension in pregnancy Frequent vaginal examination Haematoma

Obesity Gestational diabetes Prolonged rupture of membranes Blood transfusion

Diabetes mellitus Multiple pregnancy Prolonged labour Length of hospital stay

Place of residence – rural Chorioamnionitis

Smoking Previous caesarean section Emergency caesarean section

Immunosuppression – e.g. steroid Skin preparation Prolonged surgery

use, alcohol

Poor nutritional status Hair removal Poor surgical technique

Length of preoperative stay Type I and II diabetes mellitus (glycaemic Surgical drains
control)

Anaemia American Society of Anaesthesiology (ASA) Non-use of antimicrobial prophylaxis

score of a minimum of 3

Pre-hospital stay of minimum of 2 days Primary postpartum haemorrhage

Intrapartum pyrexia

Premature rupture of membranes

Factors in italics apply to both obstetrics and gynaecology, while those in roman type apply to obstetrics only.

126 ª 2021 Royal College of Obstetricians and Gynaecologists

 Ekanem et al.

was SSI following abdominal hysterectomy. Furthermore, the

Table 2. Organisms responsible for surgical site infection in obstetrics
data on causative organisms did not focus on gynaecology as and gynaecology1,20,22
a specialty.
In obstetrics and gynaecology, the microorganisms most Gram-positive Gram-negative
aerobes aerobes Anaerobes
frequently responsible for SSIs are polymicrobial aerobes and
anaerobes, which are often from both the skin and the genital
tract flora.1,22 SSIs complicating abdominal hysterectomy Staphylococcus aureus Klebsiella sp. Clostridium (Clostridioides)
typically involve S. aureus, CoNS, Enterococcus spp. and E. coli sp.
(Table 2).23 These microorganisms may come from the skin or
Enterococcus sp. Escherichia coli Gardnerella vaginalis
ascend from the vagina (if it is opened, as at hysterectomy).
Gynaecological SSIs are therefore more likely to be secondary Group b haemolytic Pseudomonas Fusibacterium sp.
to Gram-negative bacilli, enterococci, group B haemolytic streptococcus aeruginosa
streptococci and anaerobes. In recent years, the presence of
Staphylococcus Proteus sp. Bacteriodes fragilis
MRSA has been implicated in rising SSIs rates, although less so pyogenes
in gynaecological surgery.1 Genital infections such as bacterial
vaginosis, and infection with Neisseria gonorrhoea, Chlamydia Staphylococcus Klebsiella sp. Peptostreptococcus sp.
epidermidis
trachomatis or mycoplasma can lead to ascending infections
following transvaginal or transcervical procedures.24 In Methicillin-resistant Prevotella sp.
gynaecological procedures such as hysterectomy, where the Staphylococcus
wound is normally classified as clean contaminated, organisms aureus (MRSA)
implicated are S. aureus, E. coli and anaerobes. These often
contaminate surgical sites at the time of surgery or come from
the genital or gastrointestinal tract microflora.18 The organism
most commonly responsible for SSI after CS is S. aureus. In a
prospective study of risk factors for SSI following CS in 14 lifestyle changes (smoking cessation, alcohol intake reduction
hospitals in England, Wloch et al.15 found that S. aureus was and maintaining a normal weight before surgery) have been
the most common organism responsible, identified in 40.4% shown to reduce the incidence of SSI.30 Furthermore,
of cases (of which 17.1% were methicillin-resistant). Other adequate glycaemic control, avoiding immunosuppression,
causative pathogens are anaerobic cocci such as E. coli optimising haemoglobin status and good nutrition all
(13.3%) and Streptococcus sp. (7.4%), Enterococcus sp. and enhance wound healing and reduce the risk of SSIs.1 A
Pseudomonas sp.15,25 reduction in preoperative hospitalisation has been shown to
prevent the development of comorbid conditions and also to
reduce the incidence of SSIs.1,30
Prevention
Several strategies have been employed and evaluated in trials
Preoperative factors
to reduce the incidence of SSI and improve patient care and
outcomes. Various guidelines have been developed for the Nasal decolonisation
prevention of SSI, including those from the National Institute S. aureus, especially MRSA from the anterior nares in positive
for Health and Care Excellence (NICE), 7 the American carriers, is associated with an increased risk of SSI,
College of Obstetricians and Gynecologists (ACOG),26 the particularly in cardiac and orthopaedic surgery. Evidence
World Health Organization (WHO),27 the American College from studies has shown a reduction in the incidence of SSI in
of Surgeons (ACS), Surgical Infection Society (SIS)28 and the patients who underwent nasal decontamination with an
Centers for Disease Control (CDC).29 These guidelines antiseptic compared with placebo. NICE recommends that
classify risk factors as ‘modifiable’ or ‘non-modifiable’. The decolonisation with mupirocin should depend on the type of
measures to reduce SSIs outlined in these national and surgery and patient factors such as MRSA status.5 It is
international guidelines, discussed below, cover the pre-, considered good practice to screen for MRSA status and to
intra- and postoperative periods. Table 3 compares some of decontaminate women undergoing surgery in obstetrics
the recommendations from these guidelines. and gynaecology.26

Patient and staff gowns

Patient factors Although there is no evidence to suggest that wearing surgical
Patient factors associated with SSI are detailed in Table 1. gowns by staff and patients decreases the risk of SSIs, it is
Identifying and managing modifiable risk factors such as nonetheless recommended that patients wear clothing that is

ª 2021 Royal College of Obstetricians and Gynaecologists 127

 Table 3. Comparisons of recommendations for preventing surgical site infections between guidelines
128
Recommendation NICE7
Parenteral antibiotics Single dose of antibiotic prophylaxis
intravenously on starting anaesthesia
MRSA Consider nasal mupirocin in
screening/carriers combination with a chlorhexidine
prophylaxis body wash before procedures in
which Staphylococcus aureus is likely
to be a cause of a surgical site
infection
Skin preparation Use alcohol-based solution of
(surgical site chlorhexidine, or aqueous solution of
preparation) chlorhexidine if operating next to
mucous membranes
Alcohol-based solution of povidone-
iodine if chlorhexidine is
contraindicated, or aqueous solution
of povidone-iodine if alcohol-based
solution and chlorhexidine are
contraindicated
Preoperative skin wash Shower or bath using soap, either on
the day before, or on the day of,
surgery
Patient homeostasis Maintain temperature in line with
NICE 2008 guideline
Maintain optimal oxygenation during
surgery; in particular, give patients
sufficient oxygen during major
surgery and in the recovery period to
ensure maintenance of a
haemoglobin saturation of more
than 95%
Vaginal cleansing No mention
Hair removal Do not use hair removal routinely
ª 2021 Royal College of Obstetricians and Gynaecologists
ACOG26
Single dose antimicrobial prophylaxis
Additional intraoperative doses for lengthy
procedures or excessive blood loss
For patients with a history of known MRSA
colonisation, who are undergoing surgery
through a skin incision, use hospital-
recommended MRSA antibiotic prophylactic
protocol or adjustment of the preoperative
prophylactic antibiotic regiment to include a
single preoperative dose of vancomycin
Use alcohol-based agent unless
contraindicated
Chlorhexidine-alcohol is an appropriate
choice
Advise patient to shower or bathe (full body)
with soap (antimicrobial or
nonantimicrobial) or antiseptic agent on at
least the night before abdominal surgery
Implement preoperative glycaemic control
and use blood glucose target of 200 mg/DL
(11 mmol/L) in patients with and without
diabetes
With either 4% chlorhexidine gluconate or
povidone-iodine before hysterectomy or
vaginal surgery
Hair should not be removed routinely unless it
will interfere with the operation, in which
ACS and SIS28
Single dose within 60 minutes of
incision and re-dose based on half-
life of antibiotic and blood loss
Screen and decolonise cardiac and
orthopaedic patient with S. aureus
Use alcohol-based preparations unless
contraindicated
Advise patient to shower or bathe
prior to surgery with plain soap or an
antimicrobial soap
Aim for target blood glucose of 110–
159 mg/DL (6.1–8.8mmol/L)
Pre and intraoperative warming
recommend 80% supplemental
oxygen to be given before operation
(under general anaesthetic)
No mention
WHO27
Single dose within 120 minutes of
incision (taking half-life of antibiotic
into consideration)
Surgical site infection
Nasal carriers of S. aureus undergoing
cardiothoracic or orthopaedic
surgery should be decolonised with
mupirocin 2% ointment prior to
surgery
Consider treatment for known carriers
for other types of surgery
Use chlorhexidine alcohol-based
antiseptic solution unless
contraindicated
Ensure patient showers or bathes
before surgery using either plain
soap or antimicrobial soap
Use protocols for patients with and
without diabetes before surgery (no
targets given)
Warm patient during surgery
Use 80% fraction of inspired O2
intraoperatively and 2–6 hours
postoperatively
No mention
Do not shave but, if absolutely
necessary, use clippers rather than
 Ekanem et al.

comfortable and appropriate for surgery and that provides

In primarily closed surgical incisions in

adequate exposure of the surgical site. Staff who are not

ACOG = American College of Obstetricians and Gynecologists; ACS = American College of Surgeons; MRSA =methicillin-resistant Staphylococcus aureus; NICE =National Institute of Health and
actively engaged in surgery should also wear nonsterile
theatre gowns (clean hospital scrubs) in the vicinity of
the surgery.5,7,31

high risk wounds

Preoperative bathing
Several studies have examined the role of preoperative

No mention
bathing or showering in reducing SSI. A Cochrane review,
WHO27

razors

which included seven randomised trials, showed no

difference in SSI rates when 4% chlorhexidine gluconate
(the most frequently used body wash) was compared with
soap or placebo.32 A subsequent large study showed a
reduction in SSI rate in favour of bathing with 4%
chlorhexidine gluconate over no washing (relative risk [RR]
0.36; 95% confidence interval [CI] 0.17–0.79). In a 10-year
survey of SSI in the USA, it was found that the rate was much
lower among women who used chlorhexidine wash prior to
ACS and SIS28

surgery compared with those who did not.33Additionally,

No mention

Savage et al.34 showed that preoperative showering

significantly reduced the risk of cellulitis after abdominal
hysterectomy (odds ratio [OR] 0.2, 95% CI 0.06-0.7). Based
on these data, preoperative bathing or showering is
case it should be done immediately before

recommended good practice because it reduces skin

colonisation by flora, especially at the surgical site. It is
unclear if bathing with either medicated or a plain soap
surgery, preferably with clippers

reduces the risk of SSI further.5,35–37 Having said that,

patients are recommended to bathe or shower with a plain or
an antimicrobial soap, either the day before or on the day of
surgery.5,6 For procedures in which S. aureus is a likely cause
Care Excellence; SIS = Surgical Infection Society; WHO = World Health Organization
Do not use razors

of SSI, this should preferably be with chlorhexidine. In

obstetrics and gynaecology, this will be in those identified as
No mention

carriers of MRSA for who decontamination has been

ACOG26

offered.5 ACOG guidelines recommend that patients

undergoing major abdominal gynaecological surgery should
take a shower or bathe their full body using soap
If hair has to be removed, use electric

caesarean section to reduce the risk

clippers with a single-use head on

(antimicrobial or nonantimicrobial) or an antiseptic agent

Consider using sutures rather than

of superficial wound dehiscence

High risk women – for primarily

on the night before surgery. NICE similarly advises that

staples to close the skin after

patients should shower or have a bath using soap the day

closed surgical incisions

before or on the day of surgery.5 This recommendation

applies to all major abdominal surgeries.
the day of surgery
Do not use razors

Hair removal
Previously a common practice in obstetrics and gynaecology,
NICE7

hair removal is now increasingly less common. Hair removal

can be achieved by shaving with a razor, clipping or using
depilation cream. Several randomised controlled trials
Table 3. (Continued)

Recommendation

(RCTs) that have evaluated different methods of hair

Negative pressure
wound therapy

removal compared with no hair removal in reducing the

Skin closure

incidence of SSI have reported no advantage of any one

technique over another. This finding has also been validated
by a Cochrane review.38 Despite this, WHO recommends
that, if it is absolutely necessary, hair removal should be

ª 2021 Royal College of Obstetricians and Gynaecologists 129

 Surgical site infection
carried out using a clipper. Shaving should be strongly
discouraged.6 NICE discourages routine preoperative hair
removal because it is not considered cost effective and does
not prevent SSI. However, NICE advises that if hair removal
is necessary, it should be done using electric clippers with
single-use heads rather than razors because razors have been
shown to increase the risk of SSI.5 With regards to the timing
of shaving, a Cochrane review concluded no significant
difference in SSI rates between shaving or clipping the day
before surgery or on the day of surgery. However, the studies
from which this conclusion was made were small, so further
research is needed.38
Antimicrobial prophylaxis for caesarean section
Antibiotics are central to the prevention of SSI and their use
has been appraised in several RCTs. With regards to CS, a
Cochrane review of 95 trials on prophylactic antibiotics and
SSI post-CS found that, for elective and emergency CS, the
SSI rate was 68 per 1000 with antibiotics and 97 per 1000
without antibiotics. Compared with the control arm, the use
of prophylactic antibiotics was shown to reduce the rate of
wound infection by 61% (RR 0.39, 95% CI 0.32–0.48),
endometritis by 62% (RR 0.38, 95% CI 0.34–0.42) and
serious maternal infectious complications by 69% (RR 0.31,
95% CI 0.19–0.48). For women undergoing elective CS only,
it was noted that prophylactic antibiotics also reduced the
incidence of wound infection by 38% (RR 0.62; 95% CI 0.47–
0.82) and endometritis by 62% (RR 0.38; 95% CI 0.24–0.61).
The review concluded that antibiotics reduce the incidence of
SSI, endometritis and serious maternal infectious
complications by 60–70%.39 The administration of first-
generation cephalosporins reduces the risk of postoperative
wound infection by 62% (RR 0.38; 95% CI 0.28–0.53) and
endometritis by 58% (RR 0.42; 95% CI 0.33–0.54).39 With
regards to the timing of antibiotics, a Cochrane review of 10
studies, which included 5041 women, showed that
intravenous (IV) antibiotics administered within
60 minutes of a CS decreased the composite maternal
infectious morbidity by 53% (RR 0.57; 95% CI 0.45–0.72),
endometritis by 56% (RR 0.54; 95% CI 0.36–0.91) and
wound infection by 41% (RR 0.59; 95%CI 0.44–0.81)
compared with those who received IV antibiotics after
neonatal cord clamping.40 Furthermore, IV amoxicillin-
clavulanic acid (Augmentin) given prior to CS has been
shown to increase the risk of neonatal necrotising
enterocolitis.41 It is therefore recommended that routine
antibiotics should be given prior to starting the CS, but if
Augmentin is to be used, it should be given after
cord clamping.
Antimicrobial prophylaxis for hysterectomy
Several trials, and a Cochrane review of 37 RCTs comparing
antibiotics and placebo preoperatively in women undergoing
130
abdominal hysterectomy, showed that prophylactic
antibiotics significantly reduced postoperative infections
(RR 0.38; 95% CI 0.21–0.67) and abdominal wound
infections (RR 0.51; 95% CI 0.36–0.73). The overall effect
of prophylactic antibiotics was to decrease the risk of
postoperative infection from about 16% to 1–6%. This was
also true for vaginal hysterectomy.42
It is recognised that optimum tissue concentrations of
antibiotics before surgery are critical for reducing the risk of
SSI, yet the recommendation on timing of the administration
of antibiotics varies between different guidelines. Achieving
optimum concentration depends on pharmacokinetic
properties such as the half-life and minimum inhibitory
concentration (MIC). Most antibiotics are given at two-to-
four half-life intervals, thus achieving therapeutic levels only
intermittently.43 Cefuroxime, for instance, has a half-life of
1–2 hours and the MIC is usually achieved between 20 and
90 minutes of administration.44 In obstetric and
gynaecological surgery, prophylactic IV antibiotics are
recommended to be administered within 60 minutes of the
skin incision.5,45 NICE recommends a single dose of IV
prophylactic antibiotics at induction of anaesthesia for
surgical procedures.5 The type(s) of antibiotic usually
depends on individual hospital policy. Prophylactic
antibiotics are usually recommended for surgeries with
clean, clean contaminated and contaminated wounds.
Where the wound is infected, antibiotics must be more
than prophylactic (prolonged).7 Table 4 shows our suggested
list and doses of generally recommended standard
perioperative antibiotics for SSI prevention in obstetrics
and gynaecology.
Prolonged surgery is associated with a higher rate of SSI. Studies
have reported an SSI rate of 6.3% for surgery of less than 1 hour
duration, and 28% for surgery lasting more than 2 hours.30
Similarly, where the blood loss at surgery is significant (more than
1500 ml), the MIC of prophylactic antibiotics is reduced, resulting
in lower efficacy. Redosing is therefore recommended if:
 Surgery is prolonged (>3 hours)46,47 and
 Blood loss is more than 1500 ml47,48
For morbidly obese women, consideration should be given
to administering a higher – or indeed double – the standard
dose of prophylactic antibiotics.5,49 For example, the
standard dose of cefazolin is 2 g, but for those who weigh
more than 120 kg, this should be 3 g.46
In special cases, such as obstetrics and gynaecology patients
with cardiac conditions, thoracic valves and transplants,
surgical prophylactic antibiotics regimens are not
usually different.50,51
While it is good practice to offer prophylactic antibiotics, it
must be remembered that these are not recommended in
clean, non-prosthetic, uncomplicated surgeries, such as
diagnostic laparoscopy, ovarian cystectomy (for
uncomplicated simple cysts) or laparoscopic sterilisation.5
ª 2021 Royal College of Obstetricians and Gynaecologists
 Ekanem et al.

Table 4. Suggested recommended prophylactic antibiotics for obstetrics and gynaecology surgery46-49

Indication Antibiotics+ dose Comments

Caesarean section Cefazolin 2 g or cefuroxime 1.5 g+ metronidazole If penicillin-allergic, then clindamycin 400 mg IV +
500 mg gentamycin 5 mg/kg

Abdominal hysterectomy IV cefazolin 2 g or cefuroxime 1.5 g+ metronidazole If penicillin-allergic, then clindamycin 400 mg IV +
500 mg or co-amoxiclav 1.2 g gentamycin 5 mg/kg

Vaginal hysterectomy IV cefazolin 2 g or cefuroxime 1.5 g+ metronidazole If penicillin-allergic, then clindamycin 400 mg IV +
500 mg or co-amoxiclav 1.2 g gentamycin 5 mg/kg

Perineal procedures: IV cefuroxime 1.5 g+ metronidazole If penicillin-allergic, then gentamycin 5 mg/kg +

500 mg or co-amoxiclav 1.2 g, followed by oral metronidazole 500 mg, followed by oral clindamycin
co-amoxiclav 625 mg 8-hourly for 5 days 300–460 mg 6-hourly for 5 days

MRSA-positive patients IV teicoplanin 400 mg IV + gentamycin 5 mg/kg

IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus

effective, especially in poor resource settings.5 When incise

Intraoperative factors
Hand washing
Hand decontamination with chlorhexidine or povidone
before surgery has been shown to reduce the load of
resident skin flora, with a subsequent reduction in the
incidence of SSI. In this respect, alcohol rubbing and
scrubbing with povidone-iodine have been shown to be of
similar efficacy.52,53 Surgical teams are recommended to wash
their hands with an antiseptic solution and single-use nail
brush before the first operation. After this, the hands can be
washed with either an antiseptic surgical solution or an
alcoholic hand-rub for subsequent operations, but if the
hands become soiled, they should then be washed with an
antiseptic solution.5,53 Hand-scrubbing for a minimum of
3 minutes has been shown to reduce colony-forming units of
microorganisms over hand-scrubbing for just 2 minutes.53
Gloves
There is inadequate evidence to suggest that single- or
double-gloving affects the incidence of SSI differently;
nevertheless, the use of double gloves is recommended to
protect the surgeon. Furthermore, double-gloving reduces
the risk of needle-stick injuries to the surgeon.7,54,55
Gowns and drapes
Although there is insufficient evidence that surgical gowns
reduce the rate of SSIs, their use is recommended good
practice because they reduces contamination of the surgical
field with possible sources of infection.8 Evidence from
various RCTs has confirmed no difference in the incidence of
SSI with the use of disposable or reusable drapes; both are
recommended.56 Reusable drapes are particularly cost-
drapes are used, the non-iodophor-impregnated ones should
not be routinely used because they have been shown to
increase the risk of SSIs. Iodophor-impregnated incise drapes
are therefore recommended, unless the patient is allergic
to iodine.5,6
Skin preparation
The skin harbours resident microflora and contamination of
the surgical site with these organisms increases the risk of SSI.
Skin antiseptics have been shown to reduce the number of
microflorae, especially those not removed by soap and water.
Chlorhexidine has been widely used for skin antisepsis and is
said to be bacteriostatic, while alcohol-based preparations are
bactericidal and evaporate quickly.5 Several RCTs have
compared various skin antiseptics used before CS, namely
chlorhexidine alone, chlorhexidine with alcohol, and
povidone-iodine alone or with alcohol.13
An RCT of 1147 women undergoing CS compared skin
preparation using 2% chlorhexidine gluconate with 70%
isopropyl alcohol, and 8.3% povidone-iodine with 72.5%
alcohol. The study reported a reduction in SSI rate in the
chlorhexidine group (4.0%) compared with the povidone-
iodine group (7.3%).57 Regardless of the indications for the
CS, chlorhexidine in alcohol was found to be superior to
povidone-iodine.58 In a Cochrane review of preoperative skin
antiseptics for preventing surgical wound infections after
clean surgery, it was found that 0.5% alcohol-based
chlorhexidine led to a reduction in the risk of SSI
compared with alcohol-based povidone-iodine (RR 0.47;
95% CI 0.27–0.82).59
For abdominal hysterectomy, the use of chlorhexidine
gluconate in alcohol has also been associated with a 30%

ª 2021 Royal College of Obstetricians and Gynaecologists 131

 Surgical site infection
reduction in SSI compared with povidone-iodine.30 In a
randomised trial of 849 adult patients undergoing clean
contaminated surgery (including hysterectomy), Darouiche
et al.60 compared preoperative skin preparation with 2%
chlorhexidine gluconate with 70% isopropyl alcohol (409)
and 10% povidone-iodine (440). They showed an almost
50% reduction in the overall rate of SSI in the chlorhexidine-
alcohol group compared with the povidone-iodine group
(9.5% versus 16.1%; p = 0.004; RR 0.59; 95% CI 0.41–0.85).
Chlorhexidine-alcohol was significantly more protective than
povidone-iodine against both superficial incisional infections
(4.2% versus 8.6%, p = 0.008) and deep incisional infections
(1% versus 3%, p = 0.05), but not against organ/space
infections (4.4% versus 4.5%).
These findings have therefore led NICE and others to
recommend skin preparation with alcohol-based
chlorhexidine before skin incision and, furthermore,
ensuring that alcohol-based solutions dry by evaporation if
diathermy is used. Alcohol-based povidone-iodine is
recommended as second-line if chlorhexidine is
contraindicated.5 Waiting for 3 minutes for the skin
preparation to dry has been shown to reduce the load of
colony-forming units of bacteria on the anterior abdominal
wall compared with waiting for 1 minute or 5 minutes.61 The
application of skin antiseptics should be guided by the
manufacturer’s instructions. Usually, however,
chlorhexidine-alcohol should be applied (using gentle back
and forth strokes) for 2 minutes for moist sites (inguinal fold
and vulva) and 30 seconds for dry sites (abdomen) and
allowed to dry for 3 minutes.26
Authorisation for marketing in the UK is currently for
0.5% chlorhexidine in 70% alcohol solution (HydrexTM Pink,
[Ecolab, Watford, UK], HydrexTM Clear [Ecolab], Prevase
[Ecolab]) for preoperative skin disinfection prior to minor
surgical procedures; 2.0% chlorhexidine in 70% alcohol
(ChloraPrep [BD, Franklin Lakes, NJ, USA]) for disinfection
of the skin prior to invasive medical procedures (e.g.
hysterectomy and CS); 4.0% aqueous chlorhexidine
(Hibiscrub [M€ olnlycke, Gothenburg, Sweden]) for
preoperative and postoperative skin antisepsis for patients
undergoing elective surgery and 4.0% aqueous chlorhexidine
(Hydrex Surgical Scrub [Ecolab]) preoperative skin
preparation (both in the form of body wash, i.e. before the
person enters the operating theatre to surgery). Iodine
preparations available are 10% povidone-iodine alcoholic
solution (Videne alcoholic tincture [Ecolab]) and 10%
povidone-iodine as antiseptic skin cleanser for major and
minor surgical procedures; 10% iodine antiseptic solution
(Videne Antiseptic Solution [Ecolab]) to disinfect intact
external skin or as a mucosal antiseptic; 7.5% povidone-
iodine surgical scrub solution (Videne Surgical Scrub
[Ecolab]) for preoperative hand disinfection by the surgical
team, or for disinfecting the site of incision prior to elective
132
surgery; and 7.5% povidone-iodine for preoperative
scrubbing and washing by surgeons and theatre staff and
preoperative preparation of patients’ skin. In addition, 10%
povidone-iodine solution is available as a preoperative and
postoperative antiseptic skin cleanser for major and minor
surgical procedures and is indicated for quick-drying
preoperative skin disinfection.5
NICE recommends alcohol-based chlorhexidine as the
first-choice option for antiseptic skin preparation. If surgery
is next to a mucous membrane (as for vaginal surgery), then
an aqueous solution of chlorhexidine should be used. If
chlorhexidine is contraindicated, then an alcohol-based
solution of povidone-iodine should be used and an
aqueous solution of povidone-iodine used where an
alcohol-based solution and chlorhexidine are unsuitable.5
Vaginal preparation
The vagina, just like the skin, harbours several
microorganisms with the potential to contaminate surgical
wounds and cause infections. Using antiseptics to clean the
vagina may therefore reduce the risk of SSI caused by vaginal
flora. A Cochrane review of seven randomised trials
comprising 2635 women on the impact of pre-surgery
vaginal cleansing with povidone-iodine on post-caesarean
infectious morbidity concluded that vaginal preparations
immediately before CS significantly reduced the incidence of
post-caesarean endometritis from 8.3% in control groups to
4.3% in vaginal cleansing groups (RR 0.45; 95% CI 0.25–
0.81). The risk reduction was significantly greater for women
who were already in labour at the time of the CS (7.4% versus
13.0%; RR 0.56; 95% CI 0.34–0.95) and for women with
ruptured membranes (4.3% versus 17.9%; RR 0.24; 95% CI
0.10–0.55).62 Despite these reductions in morbidity, NICE63
and others have not yet recommended this practice. This may
be associated with several concerns, including exposure of the
fetus to iodine-based substances, vaginal staining and allergy
to iodine.64 In a more recent systematic review and meta-
analysis, Martin et al.65 concluded that vaginal preparations
(not specified) reduce the risk of endometritis by 55%, but
had no effect on wound infections. The PREPS study will
hopefully provide more evidence to inform the most
appropriate recommendation, but until then it would seem
sensible to consider this approach prior to CS.65
ACOG guidelines recommend vaginal cleansing with either
4% chlorhexidine gluconate or povidone-iodine before
hysterectomy or vaginal surgery, although only the latter is
approved by the Food and Drug Administration (FDA).
Because of concerns about irritation, chlorhexidine with high
alcohol concentrations (e.g., 70% used for skin preparations)
should be avoided in vaginal cleansing. Instead, 4%
chlorhexidine gluconate soap containing 4% alcohol is well
tolerated and should be used in those who are allergic to
povidone-iodine.26
ª 2021 Royal College of Obstetricians and Gynaecologists

Skin incision
Several studies have evaluated the effect of the type of skin
incision on the incidence of SSIs in obstetrics and
gynaecology. The most studied incisions are the lower
transverse straight line (Joel Cohen) and the curved
(Pfannenstiel) incision. Cochrane reviews comparing the
two incisions have shown that the Joel Cohen incision is
associated with less postoperative pain, fever, analgesic
requirement and blood loss, as well as shorter operating
time and hospital stay.66 However, with regards to SSI,
Martin et al.16 did not find any difference between surgical
incisions. There is no difference between other incisions, such
as the Maylard incision (a transverse skin incision 5–8 cm
above the pubic symphysis and extended through to cut the
rectus muscle transversely) and the Pfannenstiel incision in
terms of wound infection and febrile complications.67
Negative pressure wound therapy
Negative pressure wound therapy (NPWT) is a wound
management technique in which a vacuum dressing is
applied to promote healing. It involves using a sealed
wound dressing attached to a pump, which creates a
negative pressure environment in the wound. This increases
blood flow to the area and draws out excess fluid from the
wound. It provides continuous negative pressure of 80–
125 mmHg over a 5–7-day period and allows for even
distribution of pressure over the wound. NPWT has been
shown to stimulate formulation of granulation tissue,
increase blood flow, reduce oedema, improve wound
contraction and protect against external contamination.
PICOTM (Smith-Nephew, Watford, UK) is an example of
an NPWT system that is being used in obstetrics, especially in
obese women. High-quality evidence has shown that NPWT
reduces bacteria contamination and increases vascular
perfusion and lymphatic clearance around surgical sites.68
A meta-analysis of three RCTs comprising 1187 patients with
closed laparotomy wounds showed a lower SSI rate with
NPWT compared to standard wound care (12.4% versus
27.1%, OR 0.25; 95% CI 0.12–0.52).69 Its use has been shown
to reduce the rate of SSI in patients at increased risk, such as
the morbidly obese; smokers; and those of advanced age, with
underlying illnesses or with diabetes. It is recommended
by NICE.70,71
Intra-caesarean section procedures and surgical site
infection
Closure of the uterine incision and peritoneum
Closing the uterus in either one or two layers has not been
shown to influence the rate of SSIs or endometritis.72 An
RCT and a Cochrane review showed that closure or non-
closure of the peritoneum has no impact on the risk of
ª 2021 Royal College of Obstetricians and Gynaecologists
Ekanem et al.
wound infection or endometritis.67,73 Attention to
haemostasis and the use of drains has been shown to
reduce intra-abdominal collection and hence
pelvic abscess.13,14
Subcutaneous tissue closure
A Cochrane review showed that closure of subcutaneous (SC)
fat is associated with a reduced rate of haematoma or seroma
formation compared with non-closure (RR 0.52; 95% CI
0.33–0.82) and also of ‘wound complication’ (haematoma,
seroma, wound infection or wound separation; RR 0.68; 95%
CI 0.52–0.88).74 This is only beneficial if the SC fat is more
than 2 cm deep.5,75
Wound closure and dressing
Sutures and staples are mainly used for wound closure and a
review of RCTs found that subcuticular closure is associated
with less wound infection compared with the use of staples.
This is thought to be associated with better wound
apposition, with a decrease in the rate of wound
separation.76 With regards to the type of suture material
used, antimicrobial coated sutures such as triclosan may
reduce the risk of SSI, particularly in abdominal surgeries,
compared with plain sutures.5,6
Wound dressing serves to absorb wound exudates, reduce
postoperative pain, provide a moist environment and reduce
exposure of the wound to pathogens. RCTs have found no
statistically significant difference in non-wound cover and
type and duration of wound dressing in reducing SSI.5 NICE
advises against the use of staples to close the skin after CS and
recommends the use of appropriate interactive wound
dressing.5 This dressing promotes wound healing by
creating and maintaining a warm and moist environment
underneath the dressing.5
Special circumstances
Gynaecological oncology
A significant number of patients undergoing gynaecological
oncology surgery are immunocompromised, so minimising
the risk of SSI is vital. The principles to consider are similar
to those with any gynaecological surgery. The use of ‘surgical
site infection reduction bundles’ has been demonstrated, just
as in nongynaecological cases, to reduce the risk of SSI. The
elements of this bundle include antimicrobial prophylaxis,
skin preparation, avoiding hypothermia and surgical drains
and reducing intraoperative hyperglycaemia.77 With regard
to antibiotics, in addition to the approach above, anaerobic
coverage is recommended where the bowel is entered during
surgery. Dosing should be weight-based and re-dosing
considered based on duration of surgery and blood loss.77
Intraoperative hypothermia is associated with an increase in
SSI and cardiac events, especially in patients with
133
 Surgical site infection
comorbidities. Maintenance of normothermia at the time of
surgery is therefore recommended. With regards to drains
and tubes, there is insufficient evidence to recommend their
routine use as part of the SSI reduction bundle; they may
indeed cause harm as these foreign bodies can act as a
conduit for bacteria. Similarly, the use of nasogastric tubes
has been shown to increase the risk of postoperative
pneumonia without reducing SSIs.77
Immunocompromised patients
Immunocompromised patients undergoing surgery should
usually be offered prophylactic antibiotics in line with
standard recommendations. It is, however, critical that
these patients are screened for opportunistic and
asymptomatic infections that would require treatment to
reduce the risk of SSIs.78
Co-existing lower genital tract infections
Minimising avoidable factors that increase SSI and therefore
postoperative morbidity should be routine for patients
undergoing elective surgery. Coexisting infections should
therefore be treated prior to surgery; however, where the
surgery cannot be postponed, the risks of the infections must
be discussed with the patient and, in addition to routine
antimicrobial prophylaxis, a full treatment course for the
infection should be offered. In case of incidental bacterial
vaginosis diagnosed prior to surgery, it is advisable to treat
for 5–7 days. Where the treatment encroaches onto scheduled
surgery, it should be continued to complete the course after
surgery. It is, however, not considered a contraindication
for surgery.26
Postoperative factors
With regard to wound care following surgery, an aseptic non-
touch technique should be used for changing or removing
dressings. Furthermore, wound cleansing should be done
with sterile saline for up to 48 hours after the surgery.
Patients should be advised to shower safely 48 hours after
surgery. If the wound has separated, or has been surgically
opened to drain pus, tap water should be used to clean it
after 48 hours.5
RCTs have shown that prolonging the use of prophylactic
antibiotics postoperatively does not reduce SSIs compared
with a single preoperative dose (OR 0.89; 95% CI 0.77–1.03).
Indeed, prolonging postoperative prophylactic antibiotics is
associated with the development of antimicrobial resistance,
antibiotic-related morbidity and increased healthcare
costs.5,30 It is therefore not recommended, unless there are
specific indications.
An important risk factor for SSI is immobilisation and
prolonged hospitalisation. The introduction of enhanced
early recovery post-surgery has primarily been aimed at early
134
discharge from hospitals. In fact, various care bundles
incorporating individual aspects of SSI prevention have
been developed to reduce SSI rates. These enhanced recovery
after surgery (ERAS) care bundles incorporate SSI prevention
guideline recommendations, such as perioperative
antibiotics, good glycaemic control and early mobilisation.
In a meta-analysis of 27 RCTs assessing 329 patients who
underwent abdominal or pelvic surgery, a lower SSI rate was
seen in those enrolled into ERAS programmes than those
undergoing conventional care (5.1% versus 6.8%, RR 0.75;
95% CI 0.58–0.98).79,80
Management of surgical site infection
Typically, SSIs develop within 4–7 days postoperatively,
especially after a CS.13 The presence of postoperative SSI
can be heralded by symptoms of fever, purulent discharge
and other signs of inflammation. Clinically, superficial
wound infection may be suggested by erythema and
tenderness with induration at the site of infection.
Endometritis may present as abdominal pain, heavy lochia,
abnormal vaginal discharge and/or purulent discharge. A
high index of suspicion based on history, a clinical
examination and a review of vital signs is crucial. Any fever
>38°C on at least two occasions, at least 4 hours apart more
than 24 hours after surgery should be evaluated for infection.
Not every SSI requires treatment with antibiotics; minor or
superficial infections may only require removal of sutures,
abscess drainage and topical antisepsis.7 After taking
necessary microbiological swabs from the wound and
vagina, blood cultures, complete blood count and a C-
reactive protein (CRP) assay, the use of antibiotics (broad-
spectrum in most cases) is the mainstay of treatment. These
tests should not normally delay the commencement of
antibiotic treatment. A review of antibiotic treatment is often
warranted in the face of clinical progress of the patient and
availability of microbiological culture results.5
Imaging may also be required to exclude intra-abdominal
collection; this is usually in the form of a transabdominal or
transvaginal ultrasound scan. A CT scan may be more
informative when ultrasound is inconclusive. It can also
exclude nongynaecological causes of infections, such bladder,
ureteric or bowel injury.33 Imaging should be considered in
the presence of a persisting fever (which has not responded to
48 hours of treatment with antibiotics) occurring more than
24 hours after surgery and with no identifiable source, or
suspected pelvic/intra-abdominal collection (clinically or
from signs). If a venous thrombosis is also considered as a
differential diagnosis, then imaging to exclude this
is indicated.
The first line antibiotics regimen is typically a combination
of a penicillin, such as co-amoxiclav (amoxicillin and
clavulanic acid), or a cephalosporin and metronidazole
ª 2021 Royal College of Obstetricians and Gynaecologists

given in the absence of severe penicillin allergy (which must
be excluded in the history). This combination covers S.
aureus and anaerobes, which are the most common causes of
SSI. Clindamycin or vancomycin can be given if there is
severe allergy to penicillin; however, these do not provide as
broad a spectrum cover as co-amoxiclav. For infections with
which the patient remains febrile after 24–48 hours of
antibiotics, gentamycin can be added.14 Prior to this, renal
function must be assessed.
Following hysterectomy, the common SSIs are vaginal cuff
and pelvic cellulitis and pelvic abscess. Patients with vaginal
cuff cellulitis usually present with fever and a purulent
discharge. Examination may reveal erythema, hyperaemia
and oedema at the vault, with evidence of a purulent
discharge. It might not require antibiotic treatment because it
is sometimes self-limiting.33 For patients requiring
antibiotics, penicillin-based preparations such as co-
amoxiclav is usually sufficient, or clindamycin for those
with penicillin allergy.33
In obstetrics and gynaecology, superficial incisional SSI in
the form of wound infection is most commonly caused by S.
aureus and presents as cellulitis. It is best treated with a
penicillin-based preparation, such as flucloxacillin. In
patients who are allergic to penicillin, clindamycin or
vancomycin may be a substitute.13
Deep-seated SSIs, such as pelvic cellulitis (lateral extension
of the vaginal cuff cellulitis into the parametrium) and pelvic
abscesses, may need surgical exploration of the wound and
drainage of the abscess, as well as a peritoneal saline wash
with the insertion of a drain – particularly for large pelvic
collections.13,22,30 Radiological drainage can be done in
patients with risk factors against repeat laparotomy or
surgical exploration, especially women with multiple
comorbidities.13,14,22 Since most of these tend to be
multiloculated, these percutaneous approaches may
be unsuccessful.
Wound management should, where appropriate, be in
collaboration with the tissue viability team. Although the
evidence is sparse, negative pressure dressing has been used
with good results in patients with complete abdominal
incisional wound dehiscence. Some wounds may require
debridement and secondary closure.7,13
Necrotising fasciitis
Necrotising fasciitis is an uncommon SSI that has been
reported to occur in about 1.8 in 1000 cases following CS.81 It
is commonly caused by polymicrobial organisms; aerobic,
anaerobic or mixed. Three common distinct necrotising
fasciitis syndromes are Type I, or polymicrobial; Type II, or
group A streptococcal; and Type III gas gangrene, or
clostridial myonecrosis. Type II is the most common in
obstetrics and gynaecology. Organisms associated with
necrotising fascitis include bacteriodes, Clostridium sp.,
ª 2021 Royal College of Obstetricians and Gynaecologists
Ekanem et al.
Peptostreptococcus sp., enterobacterales, coliforms, Proteus
sp., Pseudomonas sp., Klebsiella sp. and MRSA.82 The
organisms most commonly associated with CS and
gynaecological surgery are group A streptococci and
coliforms. Type II necrotising fasciitis is common in
patients with immunosuppression, diabetes, vascular
insufficiency or chronic alcoholism, or who have
undergone transplant or are on steroids. A high index of
suspicion is critical to diagnosis; prognosis is determined by
early diagnosis and timely interventions. Though
uncommon, typically, the patient will present with pain
that is not commensurate with clinical signs.80 The clinical
features that should raise suspicion post-surgery include
cellulitis that fails to respond to antibiotics, oedema beyond
the area of erythema, the development of ecchymosis or
vesicles over an area of cellulitis and the presence of gas in
tissues, as demonstrated by palpation (crepitus).19 Imaging
will be diagnostic, particularly CT, MRI or plain X-ray
showing the presence of gas in soft tissues, as well as defining
the extent of the inflammation. This condition is rapidly
progressive; the mainstay of treatment is antibiotics (possible
regimens including a combination of penicillin G and an
aminoglycoside if renal function is normal, as well as
clindamycin to cover streptococci and staphylococci, gram-
negative bacilli and anaerobes) therapy and
surgical debridement.13,19
Conclusion
Surgical site infection presents a huge burden on healthcare
systems and the patient. Despite advances in antibiotic
prophylaxis and treatment with improved wound care, SSI
remains a perisurgical problem. The key to reducing the
incidence and burden lies in prevention, which includes
modification of patient-related factors, preoperative
optimisation, peri- and intraoperative measures, aggressive
postoperative vigilance and treatment of heralding infections.
Disclosure of interests
JCK is Lead CPD Editor for The Obstetrician & Gynaecologist;
he was excluded from editorial discussions regarding the
article and had no involvement in the decision to publish.
EEE, OO and HS have no conflicts of interest.
Contribution to authorship
JCK instigated the article. EE researched and wrote the first
draft article. OO and HS edited the draft. All authors
approved the final version of the manuscript.
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137
 DOI: 10.1111/tog.12729 2021;23:138–47
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Options for acquiring motherhood in absolute uterine

factor infertility; adoption, surrogacy and uterine
transplantation
Benjamin P Jones BSc (Hons) MRCOG,*a Niccole Ranaei-Zamani BSc (Hons),a Saaliha Vali BSc,b
Nicola Williams BA MA PhD, Srdjan Saso PhD MRCS MRCOG,d Meen-Yau Thum MRCOG MD,e
c

Maya Al-Memar MRCOG PhD,f Nuala Dixon RCN,g Gillian Rose FRCOG,h Giuliano Testa MD FACS MBA,i
Liza Johannesson MD PhD,j Joseph Yazbek MRCOG MD,k Stephen Wilkinson MA DPhil,l
k
J Richard Smith MD FRCOG
a
Clinical Research Fellow, Department of Surgery and Cancer, Imperial College London, Du Cane Road, London W12 0NN, UK
b
Specialty Trainee in Obstetrics and Gynaecology, Queen Charlotte’s & Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
c
Research Associate in Ethics, Department of Politics, Philosophy and Religion, Lancaster University, Lancaster LA14YQ, UK
d
Gynaecology Oncolology Subspecialty Trainee, Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK
e
Fertility Specialist, The Lister Fertility Clinic, London SW1W 8RH, UK
f
Specialty Trainee in Obstetrics and Gynaecology, Queen Charlotte’s & Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
g
Clinical Nurse Specialist, Queen Charlotte’s & Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
h
Consultant Gynaecologist, Queen Charlotte’s & Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
i
Transplant Surgeon, Baylor University Medical Center, Dallas, Texas 75246-2088, USA
j
Gynaecology Oncology Surgeon and Medical Director of Uterus Transplant, Baylor University Medical Center, Dallas, Texas 75246-2088, USA
k
Consultant Gynaecologist, Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK
l
Professor of Bioethics, Department of Politics, Philosophy and Religion, Lancaster University, Lancaster LA14YQ, UK
*Correspondence: Benjamin Jones. Email: benjamin.jones@nhs.net

Accepted on 4 August 2020. Published online 19 March 2021.

Key content Learning objectives

 Following the diagnosis of absolute uterine factor infertility
(AUFI), women may experience considerable psychological harm
as a result of a loss of reproductive function and the realisation of
permanent and irreversible infertility.
 Adoption enables women with AUFI, and their partners, to
experience social and legal parenthood, also often providing
benefits for the adopted child.
 Surrogacy offers the opportunity to have genetically related
offspring. Outcomes are generally positive in both surrogates and
the children born as a result.
 Uterine transplantation is the only option to restore
reproductive anatomy and functionality. While associated
with considerable risk, it allows the experience of gestation
and the achievement of biological, social and
legal parenthood.
 To gain an understanding of the routes to parenthood available for
women with AUFI experiencing involuntary childlessness, such as
adoption, surrogacy and, most recently, uterine transplantation
 To consider a suggested management plan to facilitate counselling
in women with AUFI who experience involuntary childlessness.
Ethical issues
 In the UK, while the number of children requiring adoption continues
to increase, the number being adopted from care is decreasing.
 Some cultures may hold ethical or religious beliefs that surrogacy is
unacceptable, and its legal position in many jurisdictions
is problematic.
 Restrictive selection criteria and high costs may limit future
availability of uterine transplantation
Keywords: adoption / infertility / surrogacy / transplantation / uterus

Please cite this paper as: Jones BP, Ranaei-Zamani N, Vali S, Williams N, Saso S, Thum MY, et al. Options for acquiring motherhood in absolute uterine factor
infertility; adoption, surrogacy and uterine transplantation. The Obstetrician & Gynaecologist 2021;23:138–47. https://doi.org/10.1111/tog.12729

Rokitansky–K€ uster–Hauser (MRKH) syndrome; acquired,

Introduction
Absolute uterine factor infertility (AUFI) is a form of
infertility whereby conception and/or maintenance of
pregnancy is impossible owing to uterine absence or
dysfunction. AUFI may be congenital, such as in Mayer–
following hysterectomy; or from the development of
uterine pathology, such as severe Asherman’s syndrome.
Regardless of aetiology, the diagnosis of AUFI is often sudden
and unexpected, coming after investigation for primary
amenorrhea, hypomenorrhea, or following urgent or

138 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.

unplanned hysterectomy. Others, such as those with severe
Asherman’s syndrome, may be diagnosed after years of poor
reproductive history, often following numerous unsuccessful
hysteroscopic procedures. After diagnosis, women with AUFI
experience the loss of reproductive function and the
realisation of permanent and irreversible infertility, which is
associated with considerable long-term emotional burden.1,2
Management of AUFI thus requires an integrated,
multidisciplinary approach, involving gynaecologists,
psychologists and clinical nurse specialists.3 Additionally,
particularly in conditions such as MRKH, when the diagnosis
commonly occurs during adolescence, counselling and
patient support groups can be particularly beneficial.4
After a diagnosis of infertility, many women experience
anxiety, depression, low self-esteem, loss of gender identity, a
decrease in their quality of life and an enduring sense of
incompleteness and grief.5–8 Worse psychological outcomes
arise in women experiencing infertility who fail to conceive
after assisted reproductive technology (ART) treatment than
in those who are successful.9 In low income and/or strongly
pronatalist cultures and societies, there may also be
associated socioeconomic implications arising from an
infertility diagnosis, including a negative effect on social
status and worsening marital discourse.10
While childlessness, or remaining ‘child-free’, is a choice
increasingly made by both genders,11 most women still expect
to acquire motherhood by conceiving without medical
assistance, carrying a pregnancy themselves and giving birth
to their own children. However, women with AUFI who seek
parenthood have – until recently – had no option but to
change their reproductive plans and either accept involuntary
childlessness or acquire parenthood through adoption or
surrogacy. After more than 70 uterine transplantation (UTx)
procedures worldwide and at least 18 live births,12 women
with AUFI may soon be able to access an alternative route to
parenthood that would allow them to conceive, gestate and
give birth to their own children. However, despite the
additional benefits it promises, UTx is associated with
considerable risk and currently necessitates conception via
in vitro fertilisation (IVF), a highly medicalised pregnancy
and delivery by caesarean section.
This review explores the options available for women with
AUFI to acquire motherhood, discusses the advantages and
disadvantages of each option and provides a suggested
management algorithm for women with AUFI who
experience involuntary childlessness, based on individual
reproductive aspirations.
Adoption
Adoption is the permanent transfer of parental rights and
responsibility from a child’s birth parents to adoptive
parents, creating a new family unit that will raise the child.
ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Jones et al.
For women with AUFI who seek parenthood, adoption
benefits include social and legal parenthood and an
opportunity to enhance the lives of children whose genetic
parents are unable to care for them.13 In the UK, the number
of children defined as being under the care of local
authorities has increased every year since 2013. This is
primarily associated with an increased number of care orders,
resulting in 78 150 children in care in 2018/19. In contrast to
this rise, the number of children who are adopted from care
continues to decrease, with just 3570 adoptions in the
same period.14
While adoption is usually a mutually beneficial
arrangement for both parents and their adopted children, it
is often associated with several challenges or attachment-
related difficulties that require consideration for prospective
parents. Of all children who are looked after by local
authorities, 63% have previously experienced abuse or
neglect.14 Adopted children are more likely to be diagnosed
with emotional, behavioural and relational difficulties
and15,16 to access mental health services in the future,13 and
fare worse in terms of academic attainment17 compared with
children under the guardianship of their birth parents.
Adverse outcomes extend into adulthood.18 However,
successful placements with adoptive families have resulted
in better psychological development and wellbeing outcomes
for previously looked-after children, especially when adopted
at a younger age.19–21
Potential adopters may find adopting a daunting prospect.
It can be a very lengthy process, typically including a formal
evaluation process involving references, background checks
and home visits, before a training period and a more detailed
assessment, while the adoption agency seeks a good match
between child and potential adopters. In the UK, this
matching process can take up to 2 years22 and is by no
means guaranteed. There is the additional insecurity that the
child may not even subsequently be relinquished from their
birth parents. Initial reports portrayed outcomes for adoptive
parents to be inferior to biological ones, with suggestions of
increased anxiety, anger, grief and inability to bond.23,24
However, more recent studies have suggested positive
outcomes for parents following adoption, with three-
quarters of adoptive parents reporting a positive effect on
their family.25,26
The realities of adoption are undoubtedly associated with
numerous challenges. This is exemplified by a recent
unpublished survey from almost 2700 adopters, undertaken
in collaboration with Adoption UK.27 More than one-quarter
of parents responding to this survey described serious effects
on the wider family, or that their wider family relationships
were at risk or had already been disrupted. Around half of
respondents found it challenging but stable and one-quarter
purported it to be fulfilling and stable. Despite almost two-
thirds reporting aggressive behaviour towards them from
139
 Motherhood in uterine factor infertility
their child, most (88%) were glad that they adopted. Another
study identified that 9–13% of adoptions broke down and
21–25% were finding it difficult,28 further highlighting the
challenges faced by adoptive families. Unrealistic
expectations, particularly with regards to subsequent
academic achievement, have also been identified as factors
affecting adjustment.29 From a psychological perspective,
adoptive parents have reported similarly positive depression,
self-esteem and wellbeing scores when compared with
biological parents.30
Cross-border adoption entails the legal adoption of
children born in other countries. These account for
approximately 30 000 adoptions worldwide per year. Cross-
border adoption offers the opportunity for vulnerable
children, mostly from low-income, undeveloped countries,
to be raised in a wealthier country, with better healthcare,
education and opportunities. However, whereas there is
unquestionable opportunity for great benefit, considerable
challenges remain in relation to safeguarding and
exploitation, including the potential for the illicit
movement of vulnerable children who have been illegally
separated from their families. Further issues stimulating
debate relate to the cultural identity of children following
cross-border adoption.31
Surrogacy
Surrogacy is the process whereby a woman (the surrogate)
gestates and gives birth with a pre-arranged plan of giving the
child to another person or couple: the ‘intended’ parents.
Surrogacy arrangements can be paid (‘commercial’) or
unpaid (‘altruistic’). They are also commonly divided into
‘full’, or ‘straight’ or ‘traditional’, surrogacy arrangements,
and ‘host’, or ‘gestational’, surrogacy. In full surrogacy, the
surrogate provides her own eggs, so is genetically related to
the child. In host surrogacy, she does not; the eggs may come
either from the intended parents or an egg donor. The
occurrence of AUFI provides a strong prima facie
justification for utilising surrogacy.32 In such women,
gestational surrogacy is considerably more prevalent than
full surrogacy because, subject to satisfactory ovarian reserve,
it allows them to be biologically related to their children.
Thousands of children have now been born using surrogacy
arrangements.33 However, some cultures or families may still
hold ethical or religious beliefs that surrogacy is
unacceptable. Furthermore, surrogacy’s legal position in
many jurisdictions is problematic.
Surrogacy regulation varies internationally and between
US states, as represented in Figure 1. Paid, commercial
surrogacy is permitted and legally enforceable in certain
countries including Russia, Ukraine and Georgia. In other
countries, only unpaid, altruistic surrogacy is permitted, with
paid arrangements and their brokerage being forbidden.
140 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Countries where this applies include the UK, Australia,
Canada, Brazil, India and South Africa. In many areas of the
world, including most of Western Europe, China, Japan,
Pakistan, Turkey, Saudi Arabia and some areas of North
America, restrictive legislation explicitly or effectively forbids
all forms of surrogacy. Thus, it is excluded as a possibility for
more than one-third of the world’s population. A recent
survey orchestrated by the International Federation of
Fertility Societies (IFFS), which included respondents from
65 countries, reported that surrogacy was permitted by
statute or guideline in just 38% of the countries represented,
and prohibited in 56%.34
Although the UK was one of the first countries to
introduce a regulatory framework for ART, subsequent
legislative reforms have received criticism.35 The Surrogacy
Arrangements Act 1985 was heavily influenced by
recommendations from the Committee of Inquiry into
Human Fertilisation and Embryology 1984, referred to as
the Warnock Report.36 The Warnock Report highlighted
concerns about the potential use of financial incentives in
surrogacy commercialisation to exploit vulnerable women.
Central to the Surrogacy Arrangements Act 1985 was the
prohibition of commercial surrogacy. However, no
safeguards were put in place to protect intended parents or
surrogates and the welfare of subsequent children was not
addressed. Such safeguards were not put in place until the
enactment of the Human Fertilisation and Embryology Act
1990, which provided a legal framework for transfer of
parental rights from surrogates to the intended parents and
incorporated a welfare principle.
Surrogacy is permitted in the UK, but surrogacy
agreements are not legally enforceable. This means that
the surrogate will be the child’s legal mother at birth,
regardless of the origin of the gametes that created the
embryo. If the surrogate is married, then her husband,
who is biologically unrelated to the child, would
automatically be considered the legal father. The
surrogate can then transfer legal parenthood to the
intended parents 6 weeks after birth of the child.
Although cases in which surrogates decide not to
relinquish the child are rare, this legal position carries
some risk for the intended parents. The possibility of the
surrogate not cooperating with the transfer of parental
rights after birth may generate anxiety and make surrogacy
less appealing as a reproductive option.37 For the
surrogate, there is also a risk that intended parents may
renege on the agreement, leaving her to take care of the
child, especially in the event that the child is born with a
disability or medical conditions. In disputes between
intended parents and the surrogate, the courts will decide
based on the child’s best interests; the child’s rights are
deemed to be paramount in such cases, in line with the
Children Act 1989 (England and Wales). However, at the

Figure 1. International variation of surrogacy law.
time of writing, there is increasing pressure within the UK
to review legislation so that genetic parents assume legal
rights at birth.38
While domestic surrogacy rates in the UK have remained
relatively stable in recent years, a growing minority of
prospective parents are utilising cross-border surrogacy.35,37
This increase has been attributed to less restrictive, or clearer,
regulations abroad, in addition to the difficulty of finding a
surrogate domestically, especially when payment is limited or
prohibited.39,40 However, utilising international surrogates
does not bypass UK surrogacy legislation. Not only may
issues surrounding the child’s legal recognition complicate
attempts by the intended parents to travel home, but they are
still required to apply for a parental order upon their return
to the UK to become the child’s legal parents.41 Critics have
also suggested that, from an ethical standpoint, cross-border
commercial surrogacy from low-income countries is
particularly problematic. Concerns centre around the
surrogates’ autonomy and wellbeing, in addition to the
potential for such arrangements to be exploitative. Major
worries expressed here are that surrogates from low-income
countries may be ‘coerced by poverty’, which invalidates their
consent, and they are likely to be underpaid and maltreated
by intended parents or commercial intermediaries.41,42
However, some cross-border surrogates have reported
positive experiences. It could even be argued that surrogacy
ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Jones et al.
is a less exploitative and less harmful means of earning
money than other available opportunities.43
UK surrogates may be compensated with reasonable
expenses only. A 2018 report by Surrogacy UK stated that
the mean average compensation for domestic surrogacy at
that time was £10,694.13; the highest reported in this survey
was £23,500.44 Higher amounts were made for some
international surrogacy arrangements between the USA and
the UK, with one involving a payment of £96,000.44 So far,
courts have usually taken a permissive view of relatively high
expenses payments, with legal parenthood often being
granted provided that it is perceived to be in the child’s
best interests. A recent cross-sectional study suggests that the
average cost of surrogacy in the UK is approximately £25,000.
However, the costs associated with surrogacy vary
dramatically internationally; in the USA, the median
associated cost was found to be £120,000.39
When considering the long-term outcomes in children
born to surrogates, a recent systematic review revealed similar
perinatal outcomes to IVF with oocyte donation.37 Moreover,
there are no major differences in psychological development
compared with children born to nonsurrogates.37 A 10-year
prospective study in the UK showed that families usually
maintain good relationships with surrogate families. Most
children were aware how they were conceived and did not
suffer negatively as a consequence.45
141
 Motherhood in uterine factor infertility
The outcomes in surrogate mothers are also largely
encouraging, with most reporting positive experiences.
Analysis of 16 studies assessing long-term psychological
outcomes found no long-lasting, serious psychopathology.37
However, some surrogates found it difficult to relinquish care
of their born child to the intended parents.46 One study, in
particular, demonstrated that more than one-third (35%) of
surrogate mothers had such difficulties, although this
reduced to 6% after 12 months.46 Similarly, when
considering long-term psychological outcomes of intended
mothers and their relationships with their children, no major
differences were shown when compared with mothers who
conceive naturally.37
Uterine transplantation
UTx entails transplantation of the uterus, including the
cervix, as well as the surrounding ligamentous tissues and
supplying and draining blood vessels. UTx is the only
therapeutic intervention that restores reproductive anatomy
and functionality in women with AUFI. It not only enables
the experience of gestation, but allows biological, social and
legal parenthood, thereby avoiding some of the potential
problems with surrogacy discussed above.
In 2014, the first live birth following UTx was achieved in
Sweden.47 This was achieved after a series of nine UTx
procedures, which demonstrated the procedure’s feasibility
using living donors.48 Eight live births have since been
reported from this pivotal study,49 the success of which has
paved the way for UTx procedures to be undertaken globally.
The first live birth following UTx using a deceased donor was
subsequently achieved in Brazil in 2017.50 While the details
from several cases remain unpublished, a recent review of 45
UTx cases reported at least 18 live births12 and at least double
this figure has been reported in the media, demonstrating
that UTx is unquestionably feasible. However, more than
one-quarter of cases required emergency hysterectomy and
an additional 10% suffered complications necessitating
further surgical intervention, thus highlighting the
considerable associated risk involved.12
UTx can be undertaken using either living or deceased
donors. Each donor type presents differing advantages and
disadvantages,51 and has distinct ethical implications.52,53
Using living donors has organisational advantages, including
plentiful time to assess the recipient and donor
preoperatively, as well as arrange the highly skilled
multidisciplinary team required to undertake the operation.
While it is currently not possible to evaluate clinical and
reproductive outcomes in UTx cases between donor type,
evidence shows that clinical outcomes in other solid organ
transplants are better when living donors are used.54
However, the major advantage of using deceased donors is
that risk to the donor is completely removed. In cases of
142 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
living donor UTx so far, more than 1 in 10 donors have
suffered a complication necessitating further surgical
intervention,12 which highlights the risk involved when
using living donors.
Immunosuppression after UTx is essential and intensive
follow-up is required to assess recovery, while monitoring for
rejection and immunosuppression-related complications.
Histological assessment of cervical biopsies is currently the
only reliable method to detect rejection.48,55,56 After 6–
12 months, following stabilisation on a nonteratogenic
immunosuppression regimen, embryo transfers can be
commenced.57 Using a single euploid blastocyst is
recommended to optimise the probability of IVF success,
while reducing the risk of multiple gestation.12 Following
conception, high-risk pregnancy care should ensue, with
expert maternofetal medicine input, with a view to deliver by
caesarean section at 37 weeks of gestation, unless clinically
indicated sooner. While consideration should be given to the
risks of late preterm/early term delivery, such as transient
tachypnoea of the newborn (TTN) and potentially inferior
cognitive outcomes,58,59 the potential for painless labour
brings potentially greater – albeit difficult to quantity – risk,
with concerns regarding the structural integrity of the graft
and how the vascular anastomoses would fare, following
onset of contractions. Following birth, depending on
reproductive plans and clinical condition, further embryo
transfers can take place, or completion hysterectomy should
be carried out. Following graft removal, transplant-related
medications and immunosuppression can be stopped,
thereby reducing long-term immunosuppression morbidity,
such as infection and neoplasia.60,61
UTx integrates complex bioethical debates from the fields
of organ transplantation and assisted reproduction.62,63
Topics examined have included the welfare of children
born through UTx,64,65 the values of reproductive autonomy
and gestational parenthood,66,67 comparisons between
surrogacy and UTx68,69 and broader questions surrounding
publication, institutional requirements and research ethics.70
UTx has also attracted criticism because alternative pathways
to motherhood exist.71 Some argue that if alternatives, such
as adoption and surrogacy were presented and viewed more
positively, then fewer women would seek UTx. It is also
claimed that by providing UTx, undesirable attitudes towards
parenthood might be reinforced and discriminatory social
biases perpetuated; specifically, pronatalism (bias in favour of
reproduction), gestationalism (bias in favour of gestational
parenthood) and geneticism (bias in favour of genetic
parenthood).72 These criticisms have also been specifically
deployed against publicly funding UTx in countries with
socialised medical care73,74 and in insurance-based or mixed
systems.75 In this context, it has been argued that UTx
improves on other options, such as surrogacy, only by
satisfying personal desire to experience gestation and

childbirth and that these are insufficient to justify the high
financial cost associated with UTx, which has been estimated
at almost €100,000 in European economies.76
These arguments, however, can be challenged. Firstly, it is
not possible to generalise about how suitable adoption and
surrogacy really are for women with AUFI. Their
appropriateness depends on individual circumstance,
taking account of personal values, religious and/or cultural
background and the legal context. In most countries, even if
not prohibited, surrogacy remains socially and legally
complex. In such circumstances, despite the considerable
associated risk, UTx may be a reasonable preference.77
Secondly, concerns about discriminatory social bias look
more like a critique of reproductive medicine in general
than a specific reason to not offer UTx. That said, UTx is
presently more difficult to justify than IVF owing to the
comparatively high costs and risk level.62,63 Finally, it is
difficult to ascertain why the mere existence of alternatives
dictates the necessity to stop providing UTx. Interventions
such as pinnaplasty, breast reconstruction after mastectomy
and scalp cooling for chemotherapy are performed to
enhance quality of life and protect people from hostile
treatment for not conforming to prevailing norms.
Arguments for UTx can be made on similar grounds and,
even with alternatives available, UTx can be justified if it is
in the woman’s interests.78
Perceptions of UTx among women with AUFI already
appear very positive, despite the relative infancy of the
procedure. A UK study demonstrated that 97.5% of women
with AUFI would choose UTx over surrogacy and adoption,
despite being aware of the additional risks posed by UTx.3
Another study, specifically assessing perceptions in women
with MRKH, showed that almost two-thirds of participants
were motivated to undergo UTx, even after becoming aware
of the associated risks.79 This is similar to the findings of a
questionnaire in 60 women with AUFI in France, which
found that 58.3% would partake in a UTx clinical trial.80
Given the additional risks associated with UTx, current
selection criteria for a continuing UK research trial using
deceased donors (Investigational Study Into Transplantation
of the Uterus; INSITU) ensure recipients are aged 24–38,
have a BMI <30 kg/m2 and normally functioning ovaries.81
Exclusion criteria include already having children, poor
fitness and health or significant medical or psychiatric
comorbidity, major or multiple previous abdominal
surgery, or severe endometriosis.81 Moreover, potential
recipients with a previous history of cancer must have been
in remission for at least 5 years, owing to the risk of
recurrence during this high-risk period82 when
immunosuppression is commenced. Ethical and legal
reasons mean it is likely that many of these selection
criteria will be alleviated following transition into clinical
practice;83,84 nevertheless, the selection criteria utilised to
ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Jones et al.
optimise success and safety will continue to restrict UTx
availability among potential recipients.
Management
In most cases, the diagnosis of AUFI is unexpected and can
be highly traumatising, particularly when a woman has not
yet completed her reproductive plans. Women with
congenital causes, such as MRKH or other uterine
anomalies, are often managed in specialist tertiary referral
centres, where team members are experienced at sensitive
diagnosis disclosure, arranging appropriate counselling and
psychological support and offering management to optimise
sexual function in those with suboptimal vaginal length.85,86
Given the rapid progress and demand for UTx among
women with AUFI, and considering the anticipated
transition into clinical care, the potential impact of the
vaginal restoration method on future suitability for UTx
should be contemplated. While dilator therapy,86 or the
Vecchietti procedure,87 would create a physiologically
functioning mucosal vagina, the creation of a neovagina
using skin, peritoneum or intestine would probably create a
dysbiotic environment that might affect future clinical and
reproductive outcomes following UTx.88 As such, some UTx
programmes currently exclude women with intestinal
neovagina from undergoing UTx.81
MRKH is traditionally considered a sporadic condition,
owing to previously reported discordance between identical
twins89 and the fact no females with MRKH have been born
from surrogate pregnancies using oocytes from women with
MRKH.90,91 However, familial cases have more recently been
reported involving both males and females.92,93 Recent
advancement in sequencing technologies has revealed the
partially genetic makeup of MRKH.94-96 As such, genetic
counselling is essential for women who wish to undergo
surrogacy or UTx. In suspected familial cases, exome
sequencing, or adoption, should be considered.
Women with acquired causes of AUFI who have not yet
completed their family, such as cases of emergency
hysterectomy or development of Asherman’s syndrome,
require similar reproductive counselling to those with
congenital causes. It is essential to explore reproductive
aspirations and to fully inform such women at the earliest
opportunity so that realistic reproductive plans can be made
in the context of their options. A suggested – albeit simplified
– management algorithm is demonstrated in Figure 2. All
women should receive extensive reproductive counselling
about the options available to them, considering the
advantages and disadvantages (as summarised in Table 1),
including the associated legal and financial implications.
Women who do not desire biologically related offspring
ought to consider adoption. For those for whom biological
relation is important, surrogacy and UTx should be primarily
143
 Motherhood in uterine factor infertility
pursued, considering the limitations associated with
surrogacy and the extensive selection criteria and risks
involved with UTx. In such women, the implications of age
upon ovarian reserve should be discussed, considering oocyte
or embryo cryopreservation before the physiological decline
in oocyte quality and quantity,97 to optimise future chances
of success.
Conclusion
At present, nearly all women with AUFI face a choice between
involuntary childlessness and acquiring parenthood through
adoption or surrogacy. The need for adoption continues to
rise, with an annually increasing number of children in need
of a permanent home. However, while undoubtedly beneficial
Diagnosis of AUFI and desire for parenthood
Yes
Consider surrogacy or
uterine transplantation
Desire for
gestation?
Yes No
Consider uterine transplantation
Extensive counselling including
assessment of availability,
consideration of suitability
based upon selection criteria,
and informed decision after
consideration of success rates
and risks involved.
Available, suitable and
consents to proceed?
Yes
Pre-operative evaluation to
determine suitability, including
proceed after consideration
extenstive physical and
psychological evaluation
Figure 2. Suggested management algorithm for options to acquire motherhood in women with absolute uterine factor infertility. AUFI =
absolute uterine factor infertility
144 ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
for most adopted children and parents, the absence of a
biological relationship, along with potential emotional,
behavioural and relational issues, mean that prospective
parents must think carefully about this option. Surrogacy
offers a chance to have biologically related offspring, its
outcomes are generally positive and multiple attempts are
possible, thereby opening up the possibility for siblings in the
future. However, in many jurisdictions, its legal position is
problematic, which can cause uncertainty for, or make it
difficult to commission, surrogates without going overseas. In
addition, some cultures or families may reject surrogacy
because of ethical or religious beliefs that surrogacy is
unacceptable. More than 70 UTx cases have now been
undertaken and, following at least 18 live births after
successful procedures, UTx is now considered a feasible
Desire for
biological relation?
No
Full counselling including realistic
awareness of length and
Consider adoption complexity of process, probability
of finding a suitable child to adopt,
and consideration of outcomes in
No both children and parents
Suitable, available
and desirable?
Full counselling including realistic
expectation of finding a surrogate,
Consider surrogacy consideration of psychosocial impact,
legal ramifications, financial
implications and religious context
No No
Suitable and happy to Proceed with
Yes
of alternatives?
uterine transplantation
 Jones et al.

Table 1. Advantages and disadvantages of the options for parenthood in women with absolute uterine factor infertility

Option for
parenthood Advantages Disadvantages

Adoption
 Acquires social and legal parenthood
 Provides opportunity to enhance the life of a less fortunate child,
with subsequent better psychological outcomes, especially if
adopted earlier19-21
 Generally positive outcomes; three-quarters of adoptive parents
report adoption had a positive effect on family25,26
 Lengthy process involving extensive
formal evaluation22
 Potential for increased anxiety if not able to bond
with child23,24
 Challenging process: approximately 1 in 10
adoptions report breaking down and one-quarter
report finding it difficult28
 Risk of disruption to current family unit

Surrogacy  Ethical/cultural/religious barriers

 Allows biological relation to child
 Following successful completion of parental order, legal
parenthood is obtained
 Excellent perinatal and long-term psychological outcomes in
children, comparable to oocyte donation37,45
 Excellent outcomes for intended parents, with similar
psychological outcomes compared with natural conception37
 More than one child can be attained, if relationship with surrogate
remains positive, with the possibility of a second sibling
 Legal prohibitions in many countries
curtail availability34
 In the UK, the surrogate is legally recognised as the
mother at birth despite origin of the gametes and
contractual agreements
 Small transient risk of surrogate finding
relinquishing care difficult46
 Increased anxiety for intended parents: potential
for surrogate not transferring parental rights after
birth of child
 High costs: UK £25,000; USA £120,00039

Uterine transplant
 Restores reproductive function, enabling the woman to
experience gestation and childbirth
 Allows biological relation to child
 Automatically considered legal parents
 Widely accepted across the main cultural/religious groups
 More than one child can be attained with the possibility of a
second pregnancy
 Significant surgical risks related to 3–4
open surgeries
 Immunosuppression risks related to transient use
while graft in situ
 Risk of failure: one-quarter require
emergency hysterectomy12
 Exposure of additional risk to a second individual if
using a living donor
 Strict selection criteria curtail availability
 High financial cost: Europe €100,00078

fertility-restoring treatment for women with AUFI. However,

it is associated with considerable surgical and
immunosuppressive-related risk and, based on cases
performed so far, a >25% risk of unplanned hysterectomy.
The choices faced by women with AUFI are complex and
sensitive. Women’s beliefs and preferences regarding
parenthood are often rooted in, and engage with, deeply
held aspirations and values. Extensive reproductive
counselling is therefore essential for women with AUFI, in
the context of collaborative multi-disciplinary care, to raise
awareness of their options to acquire motherhood and the
associated advantages and disadvantages each option presents.
Disclosure of interests
ND sits on the Ethics Board of Surrogacy UK. JRS is the
Chair of Womb Transplant UK.
Contribution to authorship
BJ instigated and wrote the manuscript. NRZ, SV, NW and
SW assisted in writing the manuscript. MYT, MAM, ND, GR,
GT, LJ, JY and JRS provided guidance and helped revised the
final draft. All authors approved the final version of
the manuscript.
Acknowledgements
Funding: NW is funded by a Leverhulme Early Career
Research Fellowship in Arts and Humanities (grant no:
ECF-2018-113). SW is funded by a Wellcome Trust
Senior Investigator Award (grant no: 097897/Z/11/Z). The
funder had no role in study design or writing of
the manuscript.

ª 2021 The Authors. The Obstetrician & Gynaecologist published by John Wiley Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. 145
 Motherhood in uterine factor infertility
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41 Whittaker A, Inhorn MC, Shenfield F. Globalised quests for assisted
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50 Ejzenberg D, Andraus W, Baratelli Carelli Mendes LR, Ducatti L, Song A,
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51 Lavoue V, Vigneau C, Duros S, Boudjema K, Lev^eque J, Piver P, et al. Which
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55 Johannesson L, Enskog A, Mo €lne J, Diaz-Garcia C, Hanafy A, Dahm-K€ahler P,
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69 Testa G, Koon EC, Johannesson L. Living donor uterus transplant and
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70 Brannstro €m M, Wranning CA, Altchek A. Experimental uterus
transplantation. Hum Reprod Update 2010;16:329–45.
71 Lotz M. Uterus transplantation as radical reproduction: taking the adoption
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72 Petropanagos A. Pronatalism, Geneticism, and art. Int J Feminist Approach
Bioethics 2017;10:119–47.
73 Wilkinson S, Williams NJ. Should uterus transplants be publicly funded? J
Med Ethics 2016;42:559–65.
74 Sandman L. The importance of being pregnant: othe healthcare need for
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75 Blake VK. Financing uterus transplants: the United States context. Bioethics
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76 Peters HE, Juffermans LJM, Lambalk CB, Dekker JJML, Fernhout T, Groenman
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77 Robertson JA. Other women’s wombs: uterus transplants and gestational
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78 Wilkinson S, Williams NJ. Public funding, social change and uterus
transplants: a response to commentaries. J Med Ethics 2016;42:572–3.
79 Chmel R, Novackova M, Pastor Z, Fronek J. The interest of women with
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80 Gauthier T, Garnault D, Therme JF, Piver P, Essig M, Pichon N, et al.
Transplantation uterine: une demande reelle? Gynecol Obstet Fertil
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81 Jones BP, Saso S, Yazbek J, Smith JR. Uterine transplantation: past, present
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€m C, Granath F, Edgren G, Smedby KE, Wilczek HE. Overall and
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83 Hammond-Browning N. UK criteria for uterus transplantation: a review.
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84 Jones BP, Saso S, Quiroga I, Yazbek J, Smith JR. Re: UK criteria for uterus
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85 Valappil S, Chetan U, Wood N, Garden A. Mayer–Rokitansky–K€ uster–Hauser
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86 Edmonds DK, Rose GL, Lipton MG, Quek J. Mayer-Rokitansky-Kuster-Hauser
syndrome: a review of 245 consecutive cases managed by a multidisciplinary
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87 Fedele L, Busacca M, Candiani M, Vignali M. Laparoscopic creation of a
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88 Jones BP, Saso S, L’Heveder A, Bracewell-Milnes T, Thum MY, Diaz-Garcia C,
et al. The vaginal microbiome in uterine transplantation. BJOG
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89 Duru UA, Laufer MR. Discordance in Mayer-von Rokitansky-Kuster-Hauser
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et al. Exome and copy number variation analyses of Mayer-Rokitansky-
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147
 DOI: 10.1111/tog.12724 2021;23:148–53
The Obstetrician & Gynaecologist
Tips and techniques
http://onlinetog.org

Articles in the Tips and techniques

Manchester repair (‘Fothergill’s section are personal views from
experts in their field on how to
carry out procedures in obstetrics
operation’) revisited and gynaecology.

a b c
Dhanuson Dharmasena MRCOG, Clive Spence-Jones FRCS FRCOG, Rajvinder Khasriya PhD MRCOG,
Wai Yoong MD FRCOG*d
a
ST6 Trainee in Obstetrics and Gynaecology, North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
b
Consultant Obstetrician and Urogynaecologist, Whittington Hospital, Magdala Ave, London N19 5NF, UK
c
Urogynaecology Subspecialist, Whittington Hospital, Magdala Ave, London N19 5NF, UK
d
Consultant Obstetrician and Gynaecologist, North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
*Correspondence: Wai Yoong. Email: waiyoong@nhs.net

Accepted on 4 June 2020. Published online 17 March 2021.

Please cite this paper as: Dharmasena D, Spence-Jones C, Khasriya R, Yoong W. Manchester repair (‘Fothergill’s operation’) revisited. The Obstetrician &
Gynaecologist 2021;23:148–53. https://doi.org/10.1111/tog.12724

The Manchester repair was first described in 1908 by

Introduction
Anatomical uterine prolapse affects 14% of postmenopausal
women,1 and an estimated 175 000 apical compartment
surgeries are performed annually in the USA.2 In England,
approximately 29 000 prolapse repairs were performed
between 2010 and 2011, at a cost of £60 million. With an
aging female population, this number will probably increase.3
Furthermore, 1 in 10 women will need at least one surgical
procedure, with the rate of recurrence being as high as 19%.4
While vaginal hysterectomy (VH) remains the best known
and most practised procedure worldwide for uterovaginal
prolapse,5–7 there is a demand for minimally invasive and
robotic surgery, and many patients now prefer uterus-
preserving procedures.8 Reasons for this include the desire to
maintain future fertility, a belief that the uterus affects sexual
function or sense of identity and surgical concerns about
vaginal hysterectomy. Several recent studies have shown that
uterus-sparing techniques lead to shorter hospital stay and
less morbidity than VH.9,10 The landscape of surgery in
urogynaecology has changed dramatically over the last
decade,5 with the use of mesh for prolapse and
incontinence surgery coming under much scrutiny by NHS
England. Members of the public are currently more mesh
averse owing to the high media profile raised by
complications and litigation cases. Clinicians must therefore
be able to advise patients about alternative non-mesh
options. This may lead to a revival of historic techniques,
such as Manchester repair, which utilises autologous tissue.
The British Society of Urogynaecologists (BSUG) and
National Institute for Health and Care Excellence (NICE)
have recently developed a decision aid, which includes the
Manchester repair as a choice.11
Professor Donald, from Manchester,12 and later modified by
his colleague Professor Fothergill13, from the same city. The
Manchester repair involves excision of the elongated cervix
and approximation of the cardinal ligaments anterior to the
cervix to elevate and retract it so that the uterus is both
anteverted and supported.
Originally designed for women with second and third-degree
uterine descent, the Manchester repair has a short operating time,
is associated with low morbidity and has the possibility of day
case discharge.14,15 The procedure had become ‘unfashionable’
for some years, but recent studies by Tolstrup and co-authors
have shown it to be superior to VH.10,11 The alternatives to this
procedure include sacrospinous hysteropexy, mesh or suture
hysteropexy and hysterectomy with vault suspension; these are
beyond the remit of this article and are not covered here. The
authors have included an edited video of the procedure, which is
provided as online supporting information (Video S1).
Indications
The indication for Manchester repair includes patients:
 with cervical elongation
 with second and third-degree uterine prolapse who wish to
retain their uterus/reproductive function.
It may also be a safe option for patients who are mesh averse,
or for those who have considerable adhesions from previous
pelvic surgery because the peritoneal cavity is not breached.
Decision aids provided by NICE and BSUG16 can help the
patient to decide which surgical approach they prefer, in
conjunction with discussions after a urogynaecology
multidisciplinary team (MDT) meeting. Contraindications
are listed in Box 1. Patients must be made aware of possible

148 ª 2021 Royal College of Obstetricians and Gynaecologists


Box 1. Contraindications of uterine-preserving surgery
 Abnormal or postmenopausal bleeding
 Endometrial pathology
 History of recent or current cervical dysplasia
 Tamoxifen therapy
 Hereditary nonpolyposis colonic cancer (40–50% lifetime risk of
endometrial cancer)
 Familial cancer BRAC1 and BRAC2 (increased ovarian cancer risk and
theoretical risk of fallopian tube and serous endometrial cancer)
 Unable to comply with routine gynaecology surveillance and follow-
up
Box 2. Complications of Manchester repair
 Haemorrhage
 Bladder/bowel injury
 Infection (urinary tract infection)
 Cervical stenosis (leading to haematometra/pyometra)
 Cervical incompetence (leading to preterm labour/miscarriage)
 Dyspareunia
Box 3. Simplified steps of Manchester repair
1. Cervical dilatation and endometrial biopsy
2. Circumferential cervical incision
3. Securing cardinal complex
4. Amputation of the cervix
5. Insertion of Sturmdorf suture, plication of cardinal ligament
followed by Fothergill suture
Anterior and posterior colporrhaphy if required
perioperative complications (see Box 2), such as haemorrhage
and injury to the bladder or rectum, and urinary tract or
localised infection. Late complications include cervical stenosis
(leading to haematometra), dyspareunia, cervical
incompetence and dystocia. Clinicians must also emphasise
that Manchester repair is not suitable for women who have yet
to complete their family; data for pregnancy outcomes
following this procedure are limited to small case series17-20
and prophylactic cervical cerclage may be required to support
future pregnancy.21
Patient position and anaesthesia
As with similar vaginal procedures, the patient should be
placed in the lithotomy position, with buttocks just
overhanging the edge of the operating table. A self-
retaining vaginal retractor such as the Lone Star retractor
(Cooper Surgical Inc., Trumbull, USA) is often useful to
maximise exposure to the surgical field. The procedure can
be carried out under general or regional anaesthesia.
ª 2021 Royal College of Obstetricians and Gynaecologists
Dharmasena et al.
Procedure
Intravenous antibiotics (for example, co-amoxiclav 1.2 g) at
induction are usually administered and an indwelling Foley
catheter may be inserted, depending on surgeon’s preference.
The steps of this procedure are summarised in Box 3. The
anterior and posterior lips of the cervix are grasped with
Vulsellum tissue forceps and a uterine sound used to assess the
cavity length. The cervical os is then dilated using a Hegar
dilator (up to H8) to facilitate subsequent uterine drainage and
help prevent cervical stenosis following the procedure. A
secondary advantage of dilating the cervical canal is to facilitate
the passage of the needle at the time of the Sturmdorf and
Fothergill sutures. It is also prudent to perform an endometrial
curettage to obtain an endometrial sample.
The vaginal skin is infiltrated with 20 ml of bupivacaine
0.5% (w/v) and adrenaline 1: 200 000 to effect vasoconstriction
and to create a plane of dissection.
A circumferential incision is made around the cervix and
the bladder carefully mobilised (Figure 1) to prevent
inadvertent injury during subsequent cervical amputation.
Ensure that the anterior incision is deep enough to expose the
cervix. The elongated cervix can be further skeletonised and
cleared of pericervical tissue by blunt dissection using the
surgeon’s index finger (wrapped with a gauze swab) to push
gently in the direction of the bladder (Figure 2). When
skeletonising the cervix, it is important to stop at the
uterovesical fold and not to breach the peritoneal cavity.
Unnecessary dissection beyond this level increases the risk of
bleeding and of inadvertently entering the myometrium.
Posteriorly, the cervical incision is continued and the vaginal
skin and rectum are similarly freed using sharp and blunt
dissection (Figure 3). An assistant can facilitate this step by
applying traction to the posterior cervical lip in an
upwards direction.
To display the field of surgery, assistants should use
Langdon lateral wall retractors to create good exposure. The
uterosacral–cardinal ligament complex can be palpated as a
narrow band of dense tissue traversing the lateral side of the
cervix. The cardinal ligament and the descending branch of
the uterine artery are secured bilaterally with a 1-0 absorbable
polyfilament polyglactin 910 (1-0 Vicryl; Ethicon, Somerville,
NJ, USA) suture (Figure 4). The cervix is now amputated
from the uterus using a scalpel or cutting point diathermy
(40W) (Figure 5). The authors suggest mobilising vaginal
skin anterior to the point at which the cervix is amputated so
that the cardinal ligament can later be easily reattached as
part of the Fothergill suture.
A Sturmdorf suture (using 1-0 Vicryl; Ethicon) is used to
re-epithelise the posterior portion of the excised cervix while
leaving the cervical canal open, thus ensuring adequate
drainage. The suture passes from the posterior vaginal skin
on one side to the inner aspect of the cervical canal. The
149
 Manchester repair
Figure 1. Anterior cervical incision made at the level of the vaginal
rugae.
needle is then driven to secure the mid-portion of the
posterior vaginal wall and then passes back to the cervical
canal and posterior vaginal skin on the contralateral
side (Figure 6).
The cut ends of cardinal ligaments are brought across the
anterior surface of the cervix remnant and sutured using an
interrupted 0-0 delayed absorbable monofilament polydioxan
suture (0-0 PDS; Ethicon); this has the effect of supporting
and anteverting the uterus. The Fothergill suture (Figure 7)
allows the vaginal skin to cover the anterior portion of the
Figure 2. The anterior cervical incision must be sufficiently deep, and blunt dissection is used to mobilise the bladder.
150
amputated cervix and also approximates the incised cardinal
complex to help suspend the uterus.
The pubocervical fascia is dissected off the vaginal mucosa
and later plicated in the midline using interrupted 2-0
delayed absorbable monofilament polydioxone sutures (2-0
PDS; Ethicon). The redundant portion of the vaginal mucosa
is excised and the margins are reconstructed using 2-0
absorbable polyfilament polyglactin 901 sutures (2-0 Vicryl,
Ethicon). If other compartment defects are noted during the
procedure, these can be corrected concurrently.
With enhanced recovery techniques, the Manchester repair
is suitable as a day case, in which case the indwelling catheter
is removed at the end of surgery and no vaginal pack is left
in place.
Discussion
The current tendency for patients to prefer non-mesh
surgical options for pelvic organ prolapse (POP) has led
clinicians to revisit historic repair techniques using native
tissue, such as Manchester repair. The 2016 systematic review
by Tolstrup and colleagues9 compared the efficacy of
Manchester repair with VH for the treatment of POP.
Although the data were predominantly retrospective and
unmatched, the authors assessed the outcomes of nine
studies of Manchester repair versus VH (cumulative total:
2674 Manchester repair versus 3671 VH cases). They noted
that symptomatic POP recurrence was higher after VH (9%–
13%) compared with the former procedure (3%–10%).
Furthermore, there were no statistical differences in sexual
function, quality of life or urinary dysfunction between the
two procedures, with the Manchester repair group having less
need for blood transfusion (3% versus 6%). In their 2018
ª 2021 Royal College of Obstetricians and Gynaecologists

Figure 3. Applying upward traction to the posterior cervical lip, a similar incision is made on the posterior vaginal skin.
(a)
Figure 4. Securing (a) the right and (b) the left cardinal complexes.
cohort control study of Manchester repair (n = 295) versus
VH (n = 295) cases matched for age and preoperative POP
stages, Tolstrup and co-authors10 also confirmed that the rate
of recurrent or de novo POP in any compartment was higher
following VH (18.3% versus 7.8%; 95% CI 1.3–4.8), which
was also associated with more perioperative complications
(2.7% versus 0%; p = 0.007) and postoperative
intraperitoneal bleeding (2% versus 0%; p = 0.03)
compared with Manchester repair. There is therefore some
level II evidence (Canadian Task Force Levels of Evidence) to
indicate that outcomes following Manchester repair may be
superior to VH and that this less invasive procedure should
be preferable to VH if there are no other indications
for hysterectomy.
ª 2021 Royal College of Obstetricians and Gynaecologists
Dharmasena et al.
(b)
The inherent risk of developing future uterine pathology
following Manchester repair can be mitigated by performing
a routine preoperative ultrasound scan or endometrial biopsy
at the time of surgery. A retrospective Turkish study followed
204 premenopausal women over a median follow-up time of
five years after Manchester repair and reported no cases of
endometrial neoplasm.15 Similarly, Engelbredt, Glavind and
Kjaerdgaard22 published a case series of 299 women who
underwent Manchester repair and reported no evidence of
cervical or uterine malignancies after a mean follow-up of
7.8 years. Arguably, the rate of preinvasive cervical neoplasia
would be lower than in the baseline population because the
squamocolumnar junction would probably have been
surgically removed during the Manchester procedure. By
151
 Manchester repair
Figure 5. The skeletonised cervix (left) is amputated from the uterus.
Figure 6. Sturmdorf suture to re-epithelise the posterior portion of
the excised cervix. Figure created by Dhanuson Dharmasena.
Figure 7. Fothergill suture to plicate the cardinal complex and
approximate anterior vaginal skin. Figure created by Dhanuson
Dharmasena.
contrast, the rate of endometrial cancer/hyperplasia is
unaffected because the uterine corpus is not involved in the
procedure. Any postmenopausal bleeding after Manchester
repair would warrant an urgent gynaecological referral,
although post-procedure cervical stenosis means this may
be missed in occult cases.
Being a uterine-sparing option, Manchester repair patients
can potentially conceive afterwards, but there are risks during
the pregnancy. There are, in fact, very few published data on
fertility rates and pregnancy outcomes following the procedure
152
because most case series and systemic reviews relate to
postmenopausal women. A 1951 case series of seven women
of child-bearing age (range: 23–37 years at time of surgery) who
underwent Manchester repair revealed reduced fertility and
increased rates of pregnancy loss, as well as intrapartum
complications.17 In 1970, Tipton and Atkins18 reported two
successful births in five women planning pregnancy after the
procedure, but did not specify outcomes or mode of delivery.
Rouzi et al. (2009)19 published a series of seven women (mean
age 32.4  5.2 years) with prolapse who underwent
Manchester repair because they wanted to conceive. Of the
seven, two became pregnant (28.6%) and had vaginal births
with episiotomy, but no further details were provided as to why
the remaining five failed to conceive. More recently, Jasonni,
Matonti and Alfieri (2017)20 described four women who
conceived following Manchester repair (age range 33–
37 years), culminating in two vaginal births at 35 and 36
weeks of gestation and two caesarean sections at 35–37 weeks of
gestation. More contemporary data on conception, which
could be comparable, was published by Kim and co-authors,21
who reported 10 pregnancies in 36 patients following vaginal
radical trachelectomies (RT) for early stage uterine cervical
carcinoma. They concluded that preterm labour and preterm
prelabour rupture of membranes (PPROM) were serious
complications and, despite prophylactic insertion of cerclage at
the time of RT using nylon suture, only six of the 10 women
delivered after 24 weeks of gestation. Thus, Manchester repair
is more suitable for women who have completed their family. If
future pregnancy is contemplated, patients should be
counselled about the risk of preterm labour, PPROM and the
need for elective cervical cerclage.
Although Manchester repair has declined in popularity over
the last half a century, this minimally invasive procedure is
relatively safe, with a shallow learning curve and good surgical
outcomes. The current pause in mesh-associated procedures
ª 2021 Royal College of Obstetricians and Gynaecologists

and the increase in patient preference for uterine-preserving
surgery means that this operation should be offered as an
option in appropriately selected patients. Despite this,
Manchester repair is not included in Urogynaecology and
Vaginal Surgery Advanced Training Skills Modules, or even in
the subspecialty training curriculum.
Given the paucity of long-term data on Manchester repair,
it is crucial that surgeons intending to perform this
procedure upload their surgical data onto the online BSUG
Audit database so that clinicians can reflect on surgical
outcomes and improve patient care.
Disclosure of interests
WY is an Associate Editor of The Obstetrician &
Gynaecologist. He was excluded from editorial discussions
regarding the paper and had no involvement in the decision
to publish. The other authors have no conflicts of interest.
Contribution to authorship
DD performed the literature search, edited the video and
wrote the article. RK co-wrote the article. CSJ and WY
initiated the project, performed the procedures and co-wrote
the manuscript.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Video S1. A demonstration of the Manchester repair.
References
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2 Brown JS, Waetjen LE, Subak LL, Thom DH, Van den Eeden S, Vittinghoff E.
Pelvic organ prolapse surgery in the United States, 1997. Am J Obstet
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hospital-episode-statistics-admitted-patient-care-england-2010-11].
ª 2021 Royal College of Obstetricians and Gynaecologists
Dharmasena et al.
4 National Institute for Health and Care Excellence (NICE). Urinary
incontinence and pelvic organ prolapse in women: management. NICE
guideline [NG123]. London: NICE; 2019 [https://www.nice.org.uk/guidance/
ng123].
5 Jha S, Cutner A, Moran P. The UK National Prolapse Survey: 10 years on. Int
Urogynecol J 2018;29:795–801.
6 Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of
surgically managed pelvic organ prolapse and urinary incontinence. Obstet
Gynecol 1997;89:501–6.
7 Vanspauwen R, Seman W, Dwyer P. Survey of current management of
prolapse in Australia and New Zealand. Aust N Z J Obstet Gynaecol
2010;50:262–7.
8 Korbly NB, Kassis NC, Good MM, Richardson ML, Book NM, Yip S, et al.
Patient preferences for uterine preservation and hysterectomy in women
with pelvic organ prolapse. Am J Obstet Gynecol 2013;209:470.e1–6.
9 Tolstrup CK, Lose G, Klarskov N. The Manchester procedure versus vaginal
hysterectomy in the treatment of uterine prolapse: a review. Int Urogynecol J
2017;28:33–40.
10 Tolstrup CK, Husby KR, Lose G, Kopp TI, Viborg PH, Kesmodel US, et al. The
Manchester-Fothergill procedure versus vaginal hysterectomy with
uterosacral ligament suspension: a matched historical cohort study. Int
Urogynecol J 2018;29:431–40.
11 National Institute for Health and Care Excellence (NICE). Surgery for uterine
prolapse. Patient decision aid. London: NICE; 2019 [https://www.nice.org.
uk/guidance/ng123/resources/surgery-for-uterine-prolapse-patient-dec
ision-aid-pdf-6725286112].
12 Donald A. Operation in cases of complete prolapse. J Obstet Gynaec Brit
Emp 1908;13:195–6.
13 Fothergill W. The end results of vaginal operations for genital prolapse. J
Obstet Gynaecol Brit Emp 1921;28:251–5.
14 Dharmasena D, Spence-Jones C. The outcome of Manchester-Fothergill
operation for uterine prolapse. BJOG 2018;125:4–80.
15 Ayhan A, Esin S, Guven S, Salman C, Ozyuncu O. The Manchester operation
for uterine prolapse. Int J Gynaecol Obstet 2006;92:228.
16 British Society of Urogynaecology (BSUG). Pelvic floor repair using
Manchester technique without the need for hysterectomy. Patient
information leaflet. London: BSUG; 2017. https://bsug.org.uk/budcms/inc
ludes/kcfinder/upload/files/info-leaflets/Manchester-repair-BSUG.pdf.
17 Fisher JJ. The effect of amputation of the cervix uteri upon subsequent
parturition: a preliminary report of seven cases. Am J Obstet Gynecol
1951;62:644–8.
18 Tipton RH, Atkins PF. Uterine disease after the Manchester repair operation.
J Obstet Gynaecol Br Commonw 1970;77:852–3.
19 Rouzi AA, Sahly NN, Shobkshi AS, Abduljabbar HS. Manchester repair. An
alternative to hysterectomy. Saudi Med J 2009;30:1473–5.
20 Jasonni VM, Matonti G, Alfieri S. The case of pregnancies after Manchester-
Fothergill operation. J Surg 2017:166. https://doi.org/10.29011/JSUR-166.
000066.
21 Kim M, Ishioka S, Endo T, Baba T, Akashi Y, Morishita M, et al. Importance
of uterine cervical cerclage to maintain a successful pregnancy for patients
who undergo vaginal radical trachelectomy. Int J Clin Oncol
2014;19:906–11.
22 Engelbredt K, Glavind K, Kjaergaard N. Development of cervical and uterine
malignancies during follow-up after Manchester-Fothergill procedure. J
Gynecol Surg 2020;36:60–4.
153
 DOI: 10.1111/tog.12738 2021;23:154–8
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 23 issue 2

CPD credits can be claimed for the following questions The diagnostic criteria for acute pancreatitis in
online via the TOG CPD submission system in the RCOG pregnancy include,
CPD ePortfolio. You must be a registered CPD participant of
10. abdominal pain, typically in the
the RCOG CPD programme (available in the UK and
epigastrium radiating to back. ThFh
worldwide) in order to submit your answers.
11. serum amylase/lipase more than two times
Participants can claim 2 credits per set of questions if at
the upper limit of normal. ThFh
least 70% of questions have been answered correctly. CPD
12. characteristic features of pancreatitis
participants are advised to consider whether the articles
on imaging. ThFh
are still relevant for their CPD, in particular if there are
more recent articles on the same topic available and if The following would be recommended in the management
clinical guidelines have been updated since publication. of acute pancreatitis in pregnancy,
Please direct all questions or problems to the CPD Office.
Tel: +44 (0)20 7772 6307 or email: cpd@rcog.org.uk. 13. intravenous fluids to maintain urine output
The blue symbol denotes which source the questions >0.5 ml/kg/h. ThFh
refer to including the RCOG journals, TOG and BJOG, and 14. analgesia including opiates. ThFh
RCOG guidance, such as Green-top Guidelines (GTGs) and 15. venous thromboembolism prophylaxis. ThFh
Scientific Impact Papers (SIPs). All of the above sources are 16. antibiotics. ThFh
available to RCOG Members and Fellows via the RCOG Regarding chronic pancreatitis in pregnancy,
website. RCOG Members, Fellows and Associates have full
access to TOG content via the TOG app (available for iOS 17. endocrine and exocrine dysfunction are
and Android). recognised sequelae. ThFh
18. the diagnosis of exocrine dysfunction is
suggested by an elevated faecal elastase. ThFh
TOG Acute and chronic pancreatitis in 19. women not already diagnosed with diabetes
pregnancy mellitus should have an oral glucose
tolerance test arranged at booking. ThFh
Regarding acute pancreatitis in pregnancy,
20. it is commonly caused by recurrent severe
1. gallstones are the most common cause. ThFh acute pancreatitis. ThFh
2. hormonal changes in pregnancy increase
the risk. ThFh
3. 25% of cases are caused by hyperemesis. ThFh TOG Breastfeeding and drugs
4. hypertriglyceridaemia is a
With regard to analgesia during breastfeeding,
predisposing factor. ThFh
5. the incidence in pregnancy is approximately 1. the concentration of active metabolites of
10 per 10 000 deliveries. ThFh codeine in breast milk is not affected by
6. HELLP syndrome is a differential diagnosis. ThFh genetic variation in the mother’s ability to
metabolise codeine. ThFh
Acute pancreatitis in pregnancy,
2. the analgesic properties of dihydrocodeine
7. most commonly presents with sudden onset are largely due to the parent compound. ThFh
upper abdominal pain radiating to the back. T h F h 3. plasma clearance of morphine is slower
8. if associated with low grade fever is in newborns. ThFh
suggestive of infection. ThFh 4. therapeutic doses of morphine (e.g. for
9. is more likely to present at postoperative analgesia) are unlikely to be
advanced gestations. ThFh harmful to the infant in the short term. ThFh

154 ª 2021 Royal College of Obstetricians and Gynaecologists


With regard to antibiotics in breastfeeding mothers,
5. metronidazole alters the taste of breast milk. T h F h
6. nitrofurantoin is safe to use from birth. ThFh
7. special precautions are required when treating
mothers with vancomycin for methicillin-
resistant Staphylococcus aureaus. ThFh
Regarding antidepressants and breastfeeding,
8. sertraline is the drug of choice for mothers. T h F h
9. tricyclic antidepressants are considered safe
due to the high levels required for overdose. T h F h
10. depression is an independent risk factor for
early cessation of breastfeeding. ThFh
Regarding hypertension and breastfeeding,
11. because enalapril is poorly excreted in
breast milk, it is not expected to cause side
effects in exposed infants. ThFh
12. in black African or Caribbean women who
wish to breastfeed, nifedipine is a first-
line treatment. ThFh
13. several minor adverse effects have been
reported in infants exposed to nifedipine
in breastmilk. ThFh
With regard to anticoagulation in breastfeeding women,
14. direct oral anticoagulants are safe.
15. warfarin is contraindicated.
16. enoxaparin is not excreted into breastmilk.
With regard to contraception in breastfeeding women,
17. lactational amenorrhoea is an effective
method up to 1 year postpartum.
18. before 12 weeks postpartum, any estrogen
component in contraception is likely to
affect milk production.
19. the intrauterine device is an option if
inserted within 48 hours of giving birth.
With regard to drugs in breastfeeding women with complex
medical problems,
20. sodium valproate is contraindicated.
TOG Detecting endometrial cancer
With regard to endometrial cancer,
1. over 95% of cases occur in women over the
age of 55. ThFh
2. every 5 kg/m2 increase in body mass index
increases the risk by 50%. ThFh
3. women with Lynch syndrome have a 25–
60% lifetime risk. ThFh
ª 2021 Royal College of Obstetricians and Gynaecologists
CPD
4. late menarche increases the risk. ThFh
With regard to the clinical features of endometrial cancer,
5. the risk in women presenting with
postmenopausal bleeding is around 15%. ThFh
6. women with postmenopausal bleeding
continuing for more than 1 month after
starting hormone replacement therapy
should be referred immediately for
further investigations. ThFh
National Institute for Health and Care Excellence Suspected
Cancer Guidance recommends that,
7. women aged over 55 with unexplained
vaginal discharge should be offered a pelvic
ultrasound scan. ThFh
8. women with haematuria and a raised blood
glucose should be given direct access to
transvaginal sonography. ThFh
With regard to the diagnostic pathway for women with
postmenopausal bleeding,
9. those with an endometrial thickness less than
4 mm and normal ultrasound and speculum
examinations should be reassured. ThFh
10. a heterogenous appearance of the
endometrium and increased vascularity on
ThFh
transvaginal scan are features associated
ThFh
with endometrial cancer. ThFh
ThFh
11. those with an endometrial thickness of
8 mm but no other irregularities should be
offered hysteroscopy and endometrial
biopsy as first-line investigations. ThFh
ThFh
12. those presenting with class III obesity and
an irregular, thickened endometrium
(20 mm) should be offered hysteroscopy
ThFh
and endometrial biopsy. ThFh
13. an endometrial thickness cut-off of
ThFh
greater than or equal to 4 mm has a
sensitivity of around 90% and specificity
of around 50% for the detection of
endometrial cancer. ThFh
ThFh
14. the sensitivity of endometrial sampling with
a Pipelle aspirator for endometrial cancer
detection ranges from 90–100% when an
adequate sample is taken. ThFh
15. twenty percent of endometrial samples are
insufficient for adequate
histological assessment. ThFh
16. the sensitivity of hysteroscopy for detection
of endometrial cancer is over 90%. ThFh
17. the overall risk of serious complications
from hysteroscopy is less than 0.3%. ThFh
155
 CPD
With regard to endometrial cancer screening,
18. an incidental finding of an endometrial
thickness of 7 mm in a premenopausal
woman requires further investigation. ThFh
19. in Japan, cervical cytology is used as a
screening and diagnostic tool for
endometrial cancer detection. ThFh
With regard to novel detection tools for endometrial cancer,
20. novel genomic tests on minimally invasive
samples are expensive. ThFh
TOG Life in the laparoscopic fast lane:
evidence-based perioperative management
and enhanced recovery in benign
gynaecological laparoscopy
In managing patients with diabetes perioperatively,
1. aim for an HbA1c of <69 mmol/mol
(<8.5%) preoperatively. ThFh
2. a blood glucose of >12 mmol/L immediately
preoperatively is an indication for testing
for ketones in urine. ThFh
3. aim for a blood glucose of 6 mmol/L (range
4–8mmol/L) intraoperatively. ThFh
With regard to immediate preoperative management of patients,
4. evidence supports intake of solid food up
to 6 hours before surgery. ThFh
5. a complex carbohydrate drink prior is
recommended up to 2 hours before surgery. T h F h
With regard to venous thromboprophylaxis,
6. consider ceasing estrogen-containing
hormones 4 weeks preoperatively. ThFh
7. low dose aspirin should be stopped for 7
days preoperatively. ThFh
8. patients having a diagnostic laparoscopy
only do not need to have intermittent
compression devices fitted. ThFh
9. if low-molecular-weight heparin is
indicated, it should be given within
6 hours postoperatively. ThFh
For patients having a laparoscopic myomectomy,
10. antibiotic prophylaxis is not indicated even
if the endometrial cavity is breached. ThFh
Postoperatively,
11. giving patients fifteen 5 mg oxycodone
tablets upon discharge after laparoscopic
156
hysterectomy will meet or exceed 75% of
patients’ needs for pain control. ThFh
12. one definition of a successful ‘trial of void’
is having a post-void residual of ≤100 ml,
or the patient being able to void at least
two-thirds of their total bladder volume. ThFh
Enhanced recovery after surgery has been shown to,
13. have no effect on incidence of surgical
site infections. ThFh
14. decrease length of hospital stay after surgery. T h F h
15. lower the cost of consumed opioids. ThFh
With regard to preoperative management of women in
outpatient treatment who are scheduled for surgery,
16. screening and treating for bacterial
vaginosis have not been shown to reduce
surgical site infections after a hysterectomy. ThFh
17. recommending stopping alcohol for 4
weeks preoperatively improves
perioperative outcomes. ThFh
18. an electrocardiogram is indicated for any
woman aged above 60 years of age who is
undergoing laparoscopy. ThFh
With regard to preoperative bowel preparation,
19. there is evidence from randomised trials
that it is associated with improved
intraoperative bowel handling. ThFh
20. administration of bisacodyl is
recommended for patients with planned
enteric resection (such as those with deeply
infiltrating endometriosis. ThFh
TOGSurgical site infection in obstetrics and
gynaecology – prevention and
management
Surgical site infections (SSIs) include,
1. infection of either the superficial or deep skin
incision or of an organ within 6 weeks of
an operation. ThFh
2. infection of organs (e.g. the uterus) within 1
year of surgery if there is an implant in situ. T h F h
In the Public Health England Audit of Surgical Site
Infections 2017/2018,
3. large bowel surgery had the highest rate of SSIs. T h F h
4. rates following gynaecological surgery were
similar to those after liver and
pancreatic surgery. ThFh
ª 2021 Royal College of Obstetricians and Gynaecologists

5. rates following abdominal and vaginal
hysterectomy were similar. ThFh
With regard to the prevention of SSIs,
6. nasal decolonisation of positive
Staphylococcus aureus carriers has not been
shown to reduce the rate. ThFh
7. there is evidence that wearing sterile gowns
reduces the rate. ThFh
8. the National Institute for Health and Care
Excellence recommend routine preoperative
hair removal. ThFh
9. prophylactic antibiotics should ideally be
given at the time of surgery (knife to skin)
for gynaecological procedures. ThFh
10. re-dosingshouldbeconsideredincaseswhere
theestimatedbloodlossismorethan1.5litres. ThFh
11. prolonged surgery has been shown to
increase the risk by more than four-fold. ThFh
Evidence-based steps to reduce SSIs include,
12. wearing surgical masks. ThFh
13. skin preparation with alcohol-
based chlorhexidine. ThFh
14. cleaning the vaginal with povidone iodine. ThFh
At the time of surgery, a reduction in surgical infection
rate is enhanced by the use of,
15. intraperitoneal and subcutaneous drains. ThFh
16. interrupted skin stitches. ThFh
17. subcutaneous fat stitches on obese women. ThFh
Concerning post-caesarean section management of SSIs,
18. the first-line antibiotic combination consists
of a cephalosporin and gentamycin. ThFh
19. S. aureus is the most common pathogen. ThFh
20. treatment with antibiotics is recommended
once a diagnosis is made. ThFh
TOG Options for acquiring motherhood in
absolute uterine factor infertility; adoption,
surrogacy and uterine transplantation
Regarding adoption in the UK,
1. the number of children under the care of local
authorities has decreased every year since 2013. ThFh
2. better outcomes have been demonstrated in
children who are adopted at a younger age. ThFh
3. almost two-thirds of children who
are looked after by local authorities have
previously experienced abuse or neglect. ThFh
4. three-quarters of adoptive parents report a
positive impact on their family. ThFh
ª 2021 Royal College of Obstetricians and Gynaecologists
CPD
Concerning surrogacy in the UK,
5. the surrogate is the child’s legal mother at
birth, regardless of the origin of the
gametes that created the embryo. ThFh
6. surrogacy arrangements ensure that in the
event that the child is born with disability,
the intended parents cannot renege on
the agreement. ThFh
7. undergoing the process internationally
bypasses UK legislation, thereby negating
the need to arrange a parental order. ThFh
8. there are no major differences in
psychological development between
children born from this and those born
to non-surrogates. ThFh
9. the outcomes in surrogate mothers
are mostly positive. ThFh
With regard to uterine transplantation,
10. around one-quarter of the procedures have
resulted in emergent hysterectomy. ThFh
11. spontaneous conception has been reported
following the procedure. ThFh
12. more than 70 live births have been reported
following the procedure. ThFh
13. rejection is assessed by histological
assessment of cervical biopsies. ThFh
14. lifelong immunosuppression is
essential after. ThFh
15. the cost has been estimated to
be almost €100,000. ThFh
16. potential recipients with a previous history
of cancer need to be in remission for at
least 10 years before being considered for
the procedure. ThFh
17. caesarean section is the recommended
approach to delivery following a
successful pregnancy. ThFh
Regarding management of women with absolute uterine
factor infertility,
18. those with congenital causes, such as
Mayer–Rokitansky–K€ uster–Hauser
syndrome, should be managed in tertiary
referral centres. ThFh
19. vaginal restoration techniques such as
the Vecchietti procedure create a
physiologically functioning mucosal vagina. T h F h
20. Mayer–Rokitansky–K€ uster–Hauser
syndrome is inherited in an autosomal
recessive pattern. ThFh
157