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 TOG
The Obstetrician & Gynaecologist
The journal for continuing professional development
from the RCOG
The CPD journal from the RCOG ISSN 1467-2561/1744-4667 (online)
http://onlinetog.org http://onlinetog.org

Volume 24 Issue 1 2022

Contents

Editorial 58 Preconception health in the well woman

SBA
3 Editorial Charlotte Brooks, Prasanna Raj Supramaniam, Monica Mittal
Kate Harding

Editor's Pick Education

4 Spotlight on… haemorrhage 67 The blind spot: value-based health care in obstetrics and
Hashviniya Sekar, Lauren Berg, Wai Yoong gynaecology
Osama Naji, Vivienne Souter, Edward Mullins, Jonathan
Gaughran, Yasser Diab, J Edward Fitzgerald, Tom Bourne,
Edward Morris
Commentary
7 TOGadvisor: the role of online feedback in obstetrics and
gynaecology
CPD
Lorraine S Kasaven, Srdjan Saso, Jara Ben Nagi, Karen Joash,
Joseph Yazbek, J Richard Smith, Tom Bourne, Benjamin P Jones 73 CPD questions for volume 24 issue 1

77 TOG ratings
Reviews
12 Female sexual dysfunction
SBA
Victoria Kershaw, Swati Jha MBRRACE-UK update
79 MBRRACE-UK update: Key messages from the UK and Ireland
24 Investigation and management of postcoital bleeding
SBA Confidential Enquiries into Maternal Death and Morbidity 2021
Gemma L Owens, Nick J Wood, Pierre Martin-Hirsch
Marian Knight
31 Cervical cancer in pregnancy: diagnosis, staging and treatment
SBA
Tamara Howe, Kate Lankester, Tony Kelly, Ryan Watkins,
Sonali Kaushik TOG reviewers 2020
40 Accessory cavitated uterine malformations (ACUMs): an 82 TOG reviewers 2020
SBA
unfamiliar cause of dysmenorrhoea
Thulasi Setty, Joel Naftalin, Davor Jurkovic And finally…
50 Pregnancy in underweight women: implications, management 84 Small world?
SBA and outcomes James Drife
Robert Burnie, Edward Golob, Sonji Clarke
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 DOI: 10.1111/tog.12790 2022;24:58–66
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Preconception health in the well woman

Charlotte Brooks MBBS MRCOG,a Prasanna Raj Supramaniam MB ChB MSc MRCOG MAcadMEd,*
b,c

Monica Mittal BSc MBBS MRCOG MDd

a
Locum Consultant Obstetrician and Gynaecologist, Women’s and Children’s, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed
Street, Paddington, London W2 1NY, UK
b
Consultant Gynaecologist, Subspecialist in Reproductive Medicine and Surgery, Women’s and Children’s, Oxford University Hospitals NHS
Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
c
Honorary Senior Clinical Lecturer, Endometriosis CaRe Oxford, Nuffield Department of Women’s and Reproductive Health, University of Oxford,
Oxford OX3 9DU, UK
d
Consultant Obstetrician and Gynaecologist, Subspecialist in Reproductive Medicine, Women’s and Children’s, Imperial College Healthcare NHS
Trust, St Mary’s Hospital, Praed Street, Paddington, London W2 1NY, UK
*Correspondence: Prasanna Raj Supramaniam. Email: prasannaraj@doctors.org.uk

Accepted on 18 December 2020. Published online 19 January 2022.

Key content
 It is important to focus on preconception care in the well woman
because prevention is better than treatment, and interventions
commenced in pregnancy may have limited benefit.
 A lower socioeconomic status is associated with poorer maternal
and neonatal outcomes, including gestational diabetes mellitus
(GDM), preterm birth (PTB), pre-eclampsia (PET), and small-for-
gestational-age babies.
 Poor nutrition contributes to epigenetic dysregulation, which can
alter gene expression and effect phenotypic change. A healthy diet
during pregnancy, high in grains and vegetables, may help to
reduce the risk of obesity, GDM, cardiovascular disease,
hypertension, PET, and maternal anaemia; the benefits to the fetus
include the prevention of low birthweight, macrosomia, PTB
and stillbirth.
 The minimum amount of aerobic activity recommended during
the preconception and pregnancy period is either 150 minutes of
moderate intensity activity per week, or 30 minutes of activity per
day, or 75 minutes of intense activity per week.
 Alcohol is a teratogen that can cause fetal growth restriction and
facial malformations, learning and behavioural challenges and
impairment to the central nervous system. Smoking in pregnancy
can lead to impaired fetal growth and adverse effects on the
immune system.
Learning objectives
 To understand the importance of the preconception period.
 To evaluate key nutritional requirements in the
preconception period.
 To critically evaluate the benefits and disadvantages of vaccination
in the preconception period.
Keywords: infections / nutritional health / preconception health /
pre-pregnancy counselling

Please cite this paper as: Brooks C, Supramaniam PR, Mittal M. Preconception health in the well woman. The Obstetrician & Gynaecologist 2022;24:58–66. https://
doi.org/10.1111/tog.12790

The preconception period can be viewed from three

Introduction
different perspectives:
Preconception care is an important aspect of supporting  Public health: addressing risk factors such as smoking, diet
health improvements for individuals across their reproductive and obesity in the months to years preceding conception.
life.1 The global awareness of preconception health and care is  Individual: planning for a pregnancy in the months
currently low, but most women in low-, middle- and high- before conception.
income countries do plan for a pregnancy.2 This period of  Biological: the weeks to days before
planning provides the opportunity for education and embryological development.
intervention to improve preconception health and Preconception health is important for three main reasons:
subsequently, to reduce the incidence of maternal and  Parental lifestyle during the maturation phase of
neonatal morbidity and mortality. The challenge, however, gametes and embryo development can adversely affect
lies in accurately identifying the women who are most at risk. developmental programming.3
Women who are healthy at the time of conception are more  Maternal motivation is high at this time; therefore,
likely to have a successful pregnancy and healthy child.1 effective changes can be implemented.

58 ª 2022 Royal College of Obstetricians and Gynaecologists.


 Interventions commenced in pregnancy have only
limited benefit.2
Approximately 40% of all pregnancies are currently
unplanned; therefore, health interventions provided once a
woman has already decided to have a child can sometimes be
too late. Many of the interventions are more effective when
implemented throughout the reproductive years of a
population.2,4 These interventions can be categorised into
three groups:5
 Educational: general health advice, education on sexually
transmitted infections, counselling (faith-based groups or
individual counselling), and skills-building sessions.
 Promotion of contraception: education as well as the
distribution of contraception.
 Combination of educational and contraception
promoting interventions.
Programmes adopting multiple strategies (education,
contraception promotion and skill-building sessions), in
contrast to singular interventions have been shown to have a
greater impact.5
In the Australian LIMIT study6 and the UPBEAT UK trial7
for example, a change in dietary behaviour with exercise and
diet interventions in overweight pregnant women was not
correlated with a reduction in any adverse pregnancy
outcomes such as gestational diabetes mellitus (GDM), pre-
eclampsia (PET), preterm births (PTB) or large-for-
gestational-age babies.2 These studies demonstrated that
strategies relying on implementation at the public health
level could take considerable time to reverse obesity. Thus,
better health outcomes are achieved with interventions
instigated at an earlier stage, allowing for physical, mental
health and social issues to be discussed and addressed. This,
overall, helps to empower women in making a more
informed decision about their family planning.8
This article summarises the current advice and
recommendations, along with any specific interventions.
Socioeconomic factors
Preconception advice and the availability of facilities differs
between high and low socioeconomic statuses (SESs).
Overall, however, a lower SES is associated with poorer
maternal and neonatal outcomes, including GDM, PTB, PET
and small-for-gestational-age (SGA) babies.9,10 A Korean
study11 found that 29% of low SES women received
inadequate antenatal care, with fewer antenatal visits and
poorer obstetric outcomes, compared with 11.4% of high SES
women. Women in the low SES group had a higher rate of
abortions (30.1% versus 20.7%, p < 0.001), caesarean
delivery (45.8% versus 39.6%, p < 0.001), PET (1.5%
versus 0.6%, p < 0.001), PTB (2.1% versus 1.4% p < 0.001)
and obstetric haemorrhage (4.7% versus 3.9%, p = 0.017).
These findings were echoed by another study highlighting
ª 2022 Royal College of Obstetricians and Gynaecologists.
Brooks et al.
lower live birth rates per cycle of in vitro fertilisation
undertaken in a socioeconomically deprived cohort.12
Many causative factors other than financial barriers to
health care contributed to the differing outcomes, such as
longer working hours, cost of travelling to antenatal
appointments, smoking, psychological stress and lower
educational standards leading to fewer attendances at
antenatal appointments.11
Environmental health
Environmental hazards are increasingly recognised as risk
factors for poor perinatal outcomes. Chemical hazards such
as lead, mercury, carbon monoxide, pesticides and chlorine
exposure can affect a developing fetus.13 The critical point of
exposure is during fetal development and postnatally, rather
than preconceptually. Table 1 highlights the health effects of
chemicals with strategies to prevent exposure.
Nutritional health
Interactions between genetics, epigenetics and external
factors such as nutrition can affect in utero developmental
processes, which can lead to adverse pregnancy outcomes and
an increased risk of certain diseases in later life.2,16
Nutritional factors and undernutrition are not thought to
cause genetic changes at the DNA level, but are thought to
contribute to epigenetic dysregulation, which can alter gene
expression and effect phenotypic change. In embryogenesis,
DNA is demyelinated and then re-myelinated, during which
time reprogramming and epigenetic hallmarks can occur,
leading to life-long effects. The Dutch famine is an example
of how maternal malnutrition can lead to an increased risk of
obesity in progenies.3,16 This is echoed in animal models
demonstrating a correlation between fetal growth restriction
and obesity in later life.17,18 Furthermore, epigenetic
reprogramming leading to placental insufficiency has been
linked to a reduced expression of insulin-like growth factor 1
(IGF-1) by the liver, which, in turn, is associated
with obesity.19
A healthy diet during pregnancy, which is high in grains
and vegetables, may help to reduce the risk of obesity, GDM,
cardiovascular disease, hypertension, PET, and maternal
anaemia. The benefits to the fetus include the prevention of
low birthweight, macrosomia, PTB and stillbirth.20,21
In many countries, obesity coexists with a continuing
problem of undernutrition and micronutrient deficiencies.
Several studies have highlighted poor nutritional intake in
both women contemplating pregnancy and those who are
currently pregnant, with most not meeting the
recommendations for vegetable, grain, folate, iron, and
calcium intake. Furthermore, 55% are said to exceed the
recommended daily fat intake.20,21 Comprehensive strategies
59
 Preconception health in the well woman

Table 1. Health effects following chemical exposure and strategies to prevent exposure.

Chemical Source Impact on health Prevention strategies

Lead Paint Low levels: cognitive Postpone conception for 3–6 months following exposure
Soil impairment Lead-free paint
Water High levels: aggression
and cognitive dysfunction

Mercury Ocean fish Child deficits in language, Follow the fish consumption guidelines from the
Swordfish attention, and memory Food Standards Agency14
Anxiety

Carbon Cigarette smoking Sudden fetal death Testing in early pregnancy

monoxide Faulty gas or Neurological deficits Smoking cessation of the woman and other members
heating appliances Premature birth in the household
Cars with faulty exhausts Repair/remove faulty items

Organic From ingestion/inhalation/ Lower intelligence quotient (IQ) Organic pollutants are stored in fat tissues; therefore,
pollutants dermal exposure Reduced memory in children aim to achieve a normal body mass index
Contaminated foods (BMI) before pregnancy

Modified from Gardella, 200115 and Ondeck and Focareta, 200913

are therefore needed to both reduce undernutrition and
prevent obesity.21
Overweight/obesity
Globally, the prevalence of obesity in women has risen from
6% in 1975 to 15% in 2014.2 A body mass index (BMI) above
25 kg/m2 has been linked to multiple complications and
causes of maternal mortality, such as hypertensive disorders
of pregnancy, GDM, reduced fecundity and an increased risk
of miscarriages.2,23,24 The intrapartum and postpartum
periods are also complicated by increased anaesthetic risks,
lower success rates from a trial of labour and an increased
risk of infection.24 Fetal and neonatal adverse effects
include macrosomia, stillbirth, low birthweight, congenital
anomalies as well as neonatal hypoglycaemia secondary to
poor lactation.2
Obesity has been shown to adversely affect the
periconception developmental conditioning of the embryo.3
It has been linked to higher concentrations of inflammatory
cytokines, hormones and metabolites, which can accumulate
in the ovarian follicular fluid and affect oocyte development
and maturation. Oocytes from obese women are smaller in
size and have increased triglyceride levels. Mitochondrial
defects and impaired metabolic regulation have been
demonstrated in the oocytes of mice models in the
presence of raised lipid concentrations. The resultant
blastocyst from an oocyte of an obese female expresses
reduced glucose consumption and raised insulin levels
compared with oocytes from healthy individuals, which can
subsequently drive fetal adiposity and growth.3 Furthermore,
the level of oxidative stress rises, with a subsequent increase
in the aneuploidy rate.3 These findings are supported by
studies conducted in donor oocyte cycles, in which poorer
outcomes were seen in recipient women of normal BMI who
received donor oocytes from women with a raised BMI.3
Undernutrition
Approximately 10–20% of all women are underweight; being
underweight is most prevalent in women of South Asian
descent (24% in 2014).2 Stunted growth is often the result of
poor nutrition and famine since childhood. Maternal short
stature heightens the risk for obstructed labour, birth
asphyxia and obstetric fistula formation. Female
undernutrition also contributes to 20% of maternal deaths
and is a significant risk factor for stillbirth, PTB, low
birthweight and SGA babies.24
A maternal protein-deficient diet in the final few days of
oocyte maturation and up to the stage of embryo pre-
implantation is associated with chronic inflammation and
metabolic health in progeny. It can cause a decrease in
pancreatic beta-cell mass and function, leading to glucose
intolerance in adult life.16 This has also been associated with
increased weight, hypertension, and adiposity in later life.3
Interventions and strategies
Preconception weight normalisation is supported by a
population-based cohort study, in which there was a 10%
lower risk of stillbirth, PET, GDM and macrosomia with a

60 ª 2022 Royal College of Obstetricians and Gynaecologists.


10% decrease in pre-pregnancy BMI.2,25,26 Comparable
results were also seen in a study comparing women who
had undergone bariatric surgery 2 years before conception to
those that had not of a similar BMI.2,11,12
The World Health Organization (WHO) has advised all
countries to adhere to the recommended
international/national dietary guidelines, as this will
provide adequate macro and micro nutrition for a healthy
diet. In turn, this will lead to positive effects on pregnancy
and birth outcomes, as well as the future health of the
offspring.1,20 Unfortunately, nonadherence remains an issue
in both high and low socioeconomic countries, with one in
three people experiencing undernutrition, malnutrition,
nutritional deficiencies or obesity.21 Noncompliance has
been attributed to low income, food availability, cultural
traditions, individual beliefs, age, education, environmental
and geographical factors. Older women, who do not smoke
and have a higher level of education were predictors for
better adherence.27
Dietary advice, nutritional education and counselling
during pregnancy have been demonstrated to statistically
reduce excessive weight gain, reduce the risk of anaemia in
late pregnancy by 30%, increase birthweight by 105 g and
lower the risk of PTB by 19%.16,27,28 The overall quality of the
evidence, however, is low.20,27
In 2018, a Lancet review evaluated three strategies aimed at
improving health behaviours and nutrition before
conception: supplementation; cash incentives; and
behavioural changes. The authors concluded that while
food fortification and supplements in pregnancy can
provide the much-needed micronutrients to correct
maternal deficiencies, the reports on benefits to child health
are conflicting.2,29 The supplements were acceptable to the
women, but compliance was poor for the same reasons
previously mentioned. Cash incentives have proven
successful in other settings such as school enrolment, but
no studies have addressed this in the context of health
behaviours. In contrast, studies addressing preconception
behavioural interventions demonstrated no favourable
impact on pregnancy outcomes.30
Undernutrition in low SES settings is more complex.
Broader health strategies over behavioural changes will
be required in the context of food not being as readily
available.30 Health strategies have a greater impact when the
interventions are targeted; for example, by identifying the age
and life phase of the individual. The motivation of the
individual is better recognised in these circumstances.30
Exercise
A combination of aerobic and strength exercises is
recommended during the preconception and pregnancy
period. Moderate intensity activity has not been shown to
ª 2022 Royal College of Obstetricians and Gynaecologists.
Brooks et al.
be detrimental during this time. Contact sports, including
those with the risk of falling, and scuba diving, however, are
contraindicated during this period.25
The minimum amount of aerobic activity recommended is
either 150 minutes of moderate intensity activity per week, or
30 minutes of activity per day, or 75 minutes of intense
activity per week. Women are recommended to be active on
most days of the week, with no session lasting longer than
60 minutes.25
Strength sessions are recommended twice a week, on non-
consecutive days, of 1–2 sets of 12–15 repetitions of each
muscle group.25
Vitamin supplementation
Duckworth (2012)31 highlighted the importance of adequate
levels of the 13 essential vitamins (A, B series, C, D, E and K)
in pregnancy. Here, we focus on folate, iron, and zinc levels.
Folate
Folate (B9) is essential in the manufacture of red and white
blood cells in the bone marrow, for conversion of
carbohydrates into energy and for production of DNA and
RNA. Adequate levels are required for rapid cell replication
during periods of fetal and placental growth. Deficiency can
lead to macrocytic anaemia and reduced oxygen-carrying
capacity of the blood, and subsequently, fatigue, weakness,
and shortness of breath.32 It has also been linked to adverse
fetal outcomes such as neural tube defects and anencephaly,
congenital heart defects, growth restriction, low birthweight
and preterm delivery.25,32
Interventions and strategies
The main intervention has been preconception folic acid
supplementation. Folic acid is converted to folate in the body
and is the more stable product to manufacture and store.
Supplementation with folic acid is internationally
recommended by the WHO for a minimum of 3 months
before conception and until 12 weeks’ gestation.33 It has been
shown to prevent 69–78% of recurrent neural tube defects, as
well as reduce the risk by 70%.2,24,29 Other benefits include
the decreased risk of PET, stillbirth, neonatal death, SGA and
autism in children.2
Interventions have either been targeted at the individual or
through a collective provision of folic acid through food
supplementation and public campaigns.29,34
Iron
Over 40% of women worldwide are anaemic in the
preconception period. This is associated with an increased
risk of maternal mortality. Maternal undernutrition and iron
deficiency account for 20% of maternal deaths worldwide.4 It
is estimated that a population increase in maternal
61
 Preconception health in the well woman
haemoglobin of 1 g/dL could reduce the risk of mortality by
approximately 25%.35
The iron status of a woman has manifold roles in the
reproduction cycle. Anaemia has been shown to
detrimentally affect the birthweight, as well as the woman’s
recovery following delivery.24 Experimental animal models
have demonstrated a 40–50% reduction in brain iron stores
in the postnatal period, with dietary iron restriction
during pregnancy.2
Interventions and strategies
The main intervention includes iron supplementation or
fortification of foods such as flour, rice, sugar, juice, fish or
soy sauce. Iron supplementation has been shown to have a
greater impact on the population than food fortification.
Daily iron supplementation has reduced the incidence of low
birthweight by 20% (relative risk [RR] 0.80, 95% confidence
interval [CI] 0.71–0.90) compared with controls, and iron
deficiency maternal anaemia by 66% (RR 0.44, 95% CI 0.28–
0.68) at term compared with controls.36 The fortification of
foods, however, is more cost effective, with high cost-benefit
ratios given the levels of deficiency in low SES.37
The WHO has recommended weekly iron and folic acid
supplements in reproductive-aged populations, especially
where the prevalence of anaemia is >20%.34 Iron
supplementation programmes, however, are poorly
implemented and have little global impact secondary to
limited access and participation in antenatal care. Between
2007 and 2014, globally only 64% of women completed the
WHO recommended minimum of four antenatal visits for
patients in low- and middle-income countries. In 2016, the
WHO changed its recommendation to eight
antenatal visits.35
Other interventions include delayed cord clamping, which
has been shown to reduce the risk of neonatal anaemia. The
WHO has recommended delaying cord clamping for up to 1
minute, with some evidence suggesting up to 3 minutes is
beneficial in countries where the rates of infant iron
deficiency anaemia are high.38 Furthermore, nutrition
counselling and deworming in high-prevalence countries
have shown some benefit, as hookworms can cause
gastrointestinal bleeding.35
Zinc
Zinc is essential in protein synthesis, nucleic acid
metabolism, cell division and in the immune system.
Deficiency may contribute to intrauterine or systemic
infections, leading to PTB and low birthweight.2,39 The
maternal impact of zinc deficiency includes postpartum
haemorrhage and pregnancy-induced hypertension.40
The WHO estimates that approximately 8% of pregnant
women worldwide have an inadequate zinc intake.39
62
Interventions and strategies
Zinc supplementation has been associated with a 14% (RR
0.86, 95% CI 0.76–0.97) reduction in PTB compared with
controls.40 This was predominantly seen in the low SES
setting and could reflect poor nutrition as a whole. No other
benefits from zinc supplementation have been identified.40
Tobacco use
Smoking in pregnancy can lead to impaired fetal growth and
adverse effects on the immune system. It has been linked to a
28% increased incidence of late stillbirths plus neonatal
mortality. Furthermore, the birthweight has been shown to
be reduced by 170 g in those who smoke.41
Interventions and strategies
Smoking cessation classes alone have been shown to reduce
the self-reported smoking rate by 88%; however, in reality,
none of those questioned had stopped smoking. Written
hand-outs and counselling had little impact in the
short term, but after 12 months, significantly more
individuals remained smoke-free than those in the
control group.29
Individual-level planning, however, is not possible in
unplanned pregnancies; thus, in these circumstances, advice
and action at the public health level is more beneficial. Public
health strategies and education work to reduce risk
behaviours; for example, by increasing taxation and
minimum spend on cigarettes and alcohol purchases.2
Alcohol
The number of women worldwide who are thought to
consume alcohol is in the region of 20%. Ingestion of more
than seven standard units of alcohol per week is said to
increase the risk of developmental and cognitive disability in
the offspring.42 The consumption of more than 5 units of
alcohol in one setting has been shown to increase the risk of
miscarriage, low birthweight and PTB.43 Alcohol
consumption has been linked to reduced absorption of
nutrients contributing to malnutrition.
Fetal alcohol spectrum disorder (FASD) or fetal alcohol
syndrome (FAS) are terms used to describe the effects of
prenatal exposure to alcohol on the brain and body of the
fetus. Alcohol can effectively cross the placenta, meaning that
the level of alcohol in the fetus’ blood will be similar to
maternal alcohol blood levels within minutes of
consumption. Approximately 1% of the population are
thought to be affected by FASD. Alcohol is a teratogen that
can cause growth restriction and facial malformations,
learning and behavioural challenges and impairment to the
central nervous system.44,45
ª 2022 Royal College of Obstetricians and Gynaecologists.
 Brooks et al.

Interventions and strategies Table 2. Maternal and neonatal effects of infections (modified from
Pharmaceutical, psychological, and educational strategies Lassi et al., 201447 and Janakiraman, 200848)
have all been described in the literature. Medications
include: disulfiram; naltrexone, which causes unpleasant Infection Maternal outcomes Neonatal outcomes

symptoms when combined with alcohol; and acamprosate,

which stimulates the inhibitory gamma-aminobutyric Cytomegalovirus None/mild viral infection Hearing loss
acid (GABA) receptors, preventing the sensation of Visual impairment
pleasure usually associated with the consumption of Learning disabilities
alcohol.42 Their safety profile, however, within pregnancy Epilepsy
Congenital
is unknown. malformations
A study comparing the effects of four counselling sessions
with personalised feedback (including a session on Toxoplasmosis None/mild viral infection None to severe
Miscarriage Neurological
contraception), with written information regarding the
impairment
risks of alcohol consumption and women’s health on Retinal lesions
behavioural changes, found a two-fold (odds ratio [OR] Congenital
2.11, 95% CI 1.47–3.03) lower incidence of an alcohol- malformations
Risk of infection
exposed pregnancy up to 9 months after the intervention, in
increases with
the group who received counselling sessions. This outcome, gestational
however, was based on a self-reported change age/severity decreases
in behaviour.29,46 with gestational age
Research on the efficacy of psychological and educational Rubella Miscarriage Birth defects (effects
interventions are limited owing to the heterogeneity of are severe
studies. Results relating to a reduction or total abstinence of <16 weeks’
alcohol were mixed, and there was little evidence that these gestation)
interventions were effective for reducing alcohol Hepatitis B None in pregnancy Transmission of
consumption in pregnancy.42 Long term risk of liver hepatitis
Pregnancy outcomes post-intervention have not been cancer
reported; however, it is plausible that by reducing overall
HIV None if the viral load is Transmission of the
alcohol consumption during pregnancy, this will reduce low disease
adverse neonatal effects.29
Zika Rash/viral Microcephaly
symptoms/headaches
Infections
Syphilis Primary: painless Stillbirth
Preconception counselling regarding infections is important ulcers/sores Congenital syphilis
for two reasons. Firstly, any woman with an infectious disease Secondary: widespread (skin lesions/failure to
rash thrive/seizures/
can often be treated to eliminate or minimise the risk of
If untreated can cause hepatosplenomegaly)
transmission to the newborn; as is the case for example, with long term neurological
HIV, hepatitis B and syphilis. In view of this, all women are problems
offered antenatal screening. Secondly, some pregnant women Miscarriage
are more susceptible to certain infections during pregnancy. Listeria Fever/viral Fetal and neonatal
These can be associated with greater morbidity and mortality symptoms/headaches infections are severe
to either the mother or neonate secondary to changes in the Diarrhoea and vomiting Stillbirth/preterm
immune system, heart, and lungs of the pregnant woman; as Miscarriage delivery
Case fatality of
is the case in influenza, whooping cough, rubella, 20–30%
toxoplasmosis, Zika and listeria.47 Pneumonia/
Table 2 summarises the maternal and neonatal outcomes sepsis/meningitis
from exposure to infections.

Interventions
Vaccinations during pregnancy allow the woman to make
antibodies to specific infections, which can then be passed
through the placenta and/or breast milk to protect the
neonate. Not all vaccinations, however, are safe during
pregnancy and should therefore be administered during the
preconception period. Preconception education on
simple hygiene, lifestyle changes and foods to avoid during

ª 2022 Royal College of Obstetricians and Gynaecologists. 63

 Preconception health in the well woman

Table 3. Infections and interventions (modified from Lassi et al., 201447; Janakiraman, 200848; and, Peyron et al., 201949)

Treatable with medications Vaccine that can be given during

Infection during the preconception period preconception Interventions to prevent infection

Cytomegalovirus No None Education in simple hygiene

Toxoplasmosis Preconception infection: treatment is None Avoid undercooked meat

not indicated Avoid handling cat litter
Periconception infection (1 month
prior to 1 month after conception):
the risk of infection is very low –
discussion with an obstetrician
regarding risk-benefit in performing
a diagnostic amniocentesis

Rubella No Yes No
Mumps/measles/rubella (MMR)

Hepatitis B Anti-virals to reduce viraemia Yes for high-risk individuals Education regarding the transmission of the
preconception disease process with lifestyle/behavioural
modifications

HIV Anti-retrovirals to reduce viraemia None Anti-retrovirals to lower viraemia

preconception Education regarding the transmission of the
disease process with lifestyle/behavioural
modifications

Zika No None Education regarding the transmission of the

disease process with health precautions

Syphilis Yes (penicillin) None Education regarding the transmission of the

disease process with lifestyle/behavioural
modifications

Listeria Not normally required None Avoid luncheon meats/hot dogs unless
cooked until steaming
Avoid pates/unpasteurised milk or cheeses/
cheeses with a mould rind

pregnancy are essential to prevent these infections.47 Table 3
summarises these vaccinations and recommendations.
Conclusion
Improving preconception health will undoubtedly improve
maternal and neonatal outcomes. Table 4 summaries key
areas of concern and highlights potential interventions.
Unfortunately, changing behaviours in pregnancy alone is
often not sufficient. Studies have explored the main
challenges facing preconception health improvement.
Firstly, women believe that conception is a natural event,
which has been successful for generations, thus limiting the
need for medical intervention or attention. Secondly, there is
a lack of awareness of the need for preconception care, or
that this service is available. Thirdly, barriers to the delivery
of this service have been identified, such as limited access to
care because of location or cost and a lack of awareness about
where help can be obtained.50
Individuals must implement and maintain a healthy
lifestyle throughout their reproductive years. This can be
challenging, requiring input at many organisational levels.
Changes and strategies to encourage and improve the health
of individuals must be cultural and societal in nature, driven
at a governmental level. Each SES and country have their own
health behaviours that can be improved; however, the single
largest strategy to create the greatest impact is to improve
access to higher-level education. Improved education
worldwide will subsequently highlight the importance in
reducing ‘risky’ behaviours (such as smoking, alcohol and
drug abuse) and health guideline adherence.22
Interventions in key areas of concern in the preconception
period have proven to improve maternal and neonatal
outcomes. The mainstay of the intervention appears to be

64 ª 2022 Royal College of Obstetricians and Gynaecologists.


Table 4. Summary of key areas of concern and proposed
interventions.
Area of concern in the
preconception period Preconception intervention
High body mass index Combination of aerobic and strength
exercises
Minimum amount of aerobic activity:
 150 minutes of moderate intensity
activity per week, or
 30 minutes of moderate activity per
day, or
 75 minutes of intense activity per week
Strength sessions twice per week on non-
consecutive days
Nutritional status (folate, Folate: Supplementation recommended
iron and zinc levels) for a minimum of 3 months prior to
conception and until 12 weeks’
gestation
Iron: Iron fortification of foods such as
flour, rice, sugar, juice or soy sauce
Zinc: Supplementation taken as a
preconception tablet
Tobacco use Smoking cessation classes
Written hand-outs
Individual counselling
Alcohol use Educational strategies to increase
awareness
Psychological interventions
Pharmaceutical treatment
Written hand-outs
Infections Pre-pregnancy vaccination
Vaccinations during pregnancy
Education on simple hygiene, lifestyle
changes and foods to avoid during
pregnancy
through the dissemination of information about the
consequences and risks associated with risky behaviour to
all individuals of reproductive age. It is also vital to continue
to create awareness of the preconception period, increase the
availability of resources to address this issue, and, overall,
improve care in this period.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
CB reviewed the literature, wrote the manuscript and revised
the final draft after critical appraisal by PRS and MM. PRS
and MM oversaw the development of the manuscript. All
authors approved the final version.
ª 2022 Royal College of Obstetricians and Gynaecologists.
Brooks et al.
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ª 2022 Royal College of Obstetricians and Gynaecologists.
 DOI: 10.1111/tog.12792
The Obstetrician & Gynaecologist
http://onlinetog.org
Pregnancy in underweight women: implications,
management and outcomes
a b
Robert Burnie MRCOG, Edward Golob MRCOG,
a
ST6, Queen Elizabeth Hospital, Woolwich, London SE18 4QH, UK
b
ST6, Kingston Hospital, Kingston upon Thames KT2 7QB, UK
c
Consultant Obstetrician, Guys and St Thomas’ Hospitals Foundation Trust, London SE1 7EH, UK
*Correspondence: Sonji Clarke. Email: sonji.clarke@gstt.nhs.uk
Accepted on 28 December 2020. Published online 18 January 2022.
Key Content
 Despite attention on obesity in pregnancy, within the UK and globally,
many women enter pregnancy underweight. There remains a paucity
of evidence-based guidance on the optimal care of these women.
 Maternal underweight is associated with low birthweight and
preterm birth, both spontaneous and iatrogenic, but appropriate
gestational weight gain may mitigate low body mass index (BMI).
 Although being underweight may be protective against several
antenatal and intrapartum complications, low BMI can be related
to underlying organic disease and/or eating disorders, or there may
be modifiable lifestyle factors that should be addressed
in pregnancy.
 BMI at booking should assist as a screening tool. Body image,
genetic, socioeconomic and cultural factors may affect BMI,
making underweight women a heterogeneous group requiring
individualised assessment.
Learning Objectives
 To understand the associations of low BMI in pregnancy and its
impact on maternal and fetal outcomes.
Please cite this paper as: Burnie R, Golob E, Clarke S. Pregnancy in underweight women: implications, management and outcomes. The Obstetrician &
Gynaecologist 2022;24:50–7. https://doi.org/10.1111/tog.12792
Introduction
Despite the obesity epidemic, within the UK and globally,
many women enter pregnancy underweight. Maternal
underweight can be defined as having a body mass index
(BMI) of <18.5 kg/m2 at the start of pregnancy. A low BMI
may be ‘normal’ for the individual, but it could be associated
with underlying organic disease, psychiatric illness or
socioeconomic and lifestyle factors, which may need
addressing during the course of a pregnancy. While being
underweight can be protective against several antenatal and
intrapartum complications, it is associated with maternal and
fetal adverse outcomes, including low birthweight and
prematurity. Despite this, there remains a paucity of
evidence-based guidance on the optimal care of these
women. Guidance published by the National Institute of
Health and Care Excellence (NICE) on weight management
50
2022;24:50–7
Review
c
Sonji Clarke FRCOG MA FHEA *
 To understand the antenatal care of underweight women,
including nutritional advice and when additional fetal surveillance
is required.
 To understand the heterogeneity of underlying causes of low BMI
in pregnancy and the importance of gestational weight gain.
Ethical Issues
 Beware making assumptions about different ethnicities that will
interfere with offering the most appropriate care.
 Low BMI that is not managed as a risk issue during pregnancy is an
avoidable cause of low birthweight and preterm birth.
 Women presenting with low BMI may have features in their
history, such as certain mental health disorders, that mean they
should be referred for safeguarding as a vulnerable
adult. The unborn child and other children may also
need assessment.
Keywords: comorbidities / low BMI / pregnancy and anorexia /
pregnancy and pre-term delivery / underweight women
before, during and after pregnancy1 specifically excludes
women with a BMI of less than 18.5 kg/m2.
Epidemiology
Approximately 3–4% of women in the UK enter pregnancy
underweight.2 However, worldwide, the burden of
malnutrition lies in low- and middle-income countries. For
example, up to 30% of women of reproductive age, in most
countries in Sub-Saharan Africa, are underweight. Body
image, genetic, socioeconomic and cultural factors affect
BMI, making underweight women a heterogeneous group.
However, large cohort data sets have indicated that
underweight pregnant women tend to be significantly
younger, single, in education, and not in paid employment.
In addition, there is evidence to suggest the prevalence of
smoking is higher in underweight women.2 In an American
ª 2022 Royal College of Obstetricians and Gynaecologists.

cohort study,3 being underweight pre-pregnancy was highly
correlated with ethnicity. The study describes a disparity of
maternal underweight of 8.6% in the Asian population and
1.9% in the Black American population, drawing into
question the validity of BMI as a measure of wellbeing,
across a multi-ethnic population.
The prevalence of the eating disorders (EDs) anorexia
nervosa (AN), bulimia nervosa (BN) and binge eating
disorder (BED) in the nonpregnant population has been
suggested as 9.2%, falling to between 5.1% and 7.5% during
pregnancy.4 Women with AN are most likely to be associated
with low booking BMI, while women with BN and BED often
have a BMI within the normal range or higher and may be
less likely to be detected during pregnancy.
Body mass index
BMI is the commonest surrogate marker of nutritional status
in studies of pregnancy. BMI was conceived as a tool for
estimating body fat percentage. The ideal BMI range of
18.5–25 kg/m2 is itself based on the evidence of lower, all-
cause mortality in this group. Bhaskaran et al. (2018)5
analysed mortality data from over 3.6 million UK cases and
found the lowest mortality in the BMI range 21–25. They
noted that while the greatest risk was associated with class
2 obesity and above, the projected life expectancy at age 40
for BMI <18.5 was 4.3 years lower than for those with a
healthy weight. Arguably, for an Asian population, the
normal BMI range (19–25 in adults) should be lower. This
would have the effect of reclassifying Asian people with lower
BMI as ‘normal’ and higher BMI as ‘overweight’.6 It may
also contribute to missing pathology affecting weight within
the Asian population, because lower BMI is assumed to
be normal.
The construct of BMI is unable to describe the cause
of a low BMI. Any individual can be under weight for
various reasons; for some it will represent their ‘normal’
genetic potential, whereas for others it will be the result
of a pathological process such as malnutrition, hyperemesis,
EDs or chronic illness. Many authors have drawn
attention to the different confounding factors associated
with extremes of BMI in different communities, including
socioeconomic factors.2,7
Causes of low body mass index
Table 1 summarises the causes of low BMI.
In the initial assessment, treatable causes of low BMI
should be excluded before arriving at a determination of an
idiopathic low BMI. Do not assume that because someone is
oriental or of Asian ethnicity, a BMI less than 19 is normal;
this may miss the fact that EDs and other morbid states
relating to low BMI occur in these populations too.
ª 2022 Royal College of Obstetricians and Gynaecologists.
Burnie et al.
Gastrointestinal conditions leading to malabsorption, such
as inflammatory bowel disease, or conditions associated with
chronic inflammation, such as inflammatory arthropathies,
are not uncommon in the pregnant population and may
coexist with low BMI.
Severe hyperemesis gravidarum often causes weight loss
and poor weight gain and may be particularly detrimental in
individuals who already have low starting body weight.8 It
can also be difficult to distinguish between vomiting in early
pregnancy and symptoms of ED. Inadequate nutritional
intake is – of course – essential to address and the
involvement of dieticians can be useful. Appropriate
nutritional supplementation with thiamine and other
vitamins should also be considered.
The prevalence of ED is steadily increasing and (despite
common belief) female sufferers can conceive. For many
women, pregnancy confers some protection from the effects
of the condition. Poorer pregnancy outcomes have been
reported in women with AN and specialised support should
be provided through an ED service, if relapse of symptoms
occurs during pregnancy.9
BMI usually reflects a combination of genetic potential and
environmental exposure. Yates et al. (2013)10 used data from
population databases in Utah to analyse the rates of low BMI
phenotype among individuals with low BMI relatives. They
found a relative risk (RR) of 2.21 (95% confidence interval
[CI] 2.13–2.28) for adults with BMI <18.5 with a first-degree
relative with low BMI, with a slightly stronger association in
the age range 25–65 years (RR 2.57, 95% CI 2.42–2.72).
The relationship between BMI and socioeconomic factors
is complex. In poorer countries, low BMI has predominantly
been considered a marker of poverty and undernutrition,
while in richer countries there is an association between
lower socioeconomic status and raised BMI.11 This
association does not represent a linear cause, however, as
high BMI for women has been presented as a cause, rather
than the result, of lower socioeconomic status.11 While a
healthy BMI has been associated with higher socioeconomic
status, in their analysis of the UK population Bhaskaran
et al.5 did not find an association between low BMI (<18.5)
and socioeconomic status.
Neonatal outcomes
Pregnancy places increased metabolic demands on the
mother; therefore, maternal nutritional status is thought to
be important in fetal growth. The Dutch famine cohort
study12 demonstrated that periods of starvation in pregnancy
result in an increase in low-birthweight (LBW) babies (<2500
g). The Barker hypothesis (1995)13 argued that these effects
have enduring implications for the future cardiovascular and
metabolic health of the individual. Extremes of bodyweight
are therefore considered to be risk factors for negative fetal
51
 Pregnancy in underweight women

Table 1. Causes of low BMI

Cause of Potential effects on Pregnancy effect on

low BMI pregnancy underlying cause Assessment

Constitutional Consider risk of Should gain weight normally Refer to obstetrician

(normal) growth restriction Positive effect and body image Assess nutritional status, e.g. fat distribution and appearance
and preterm delivery Assess eating habits
Assess mental state and wellbeing
Consider bloods for nutritional screen.
Consider growth scans

Malnutrition Increased risk of fetal Anaemia – mixed pattern Regular blood counts to assess for anaemia
growth restriction Inadequate weight gain Ferritin, B12 and folate levels if haemoglobin falls to provide
Preterm delivery adequate and appropriate replacement
Refer to dietician
Consider fortified drinks and multivitamins
Screen for vitamin D deficiency and provide appropriate
supplementation
Weigh at regular intervals during pregnancy to confirm weight gain
Growth scans

Eating disorder Growth restriction risk All the associations with
Potential risk of malnutrition, observe for
microcephaly in ketonuria and consider renal
toddlers and liver profiles if a
suspicion of laxative abuse
or forced emesis
suspected
Higher risk of osteopaenia
Risk of hypokalaemic alkalosis
with acute kidney injury if
severe purging and forced
emesis.
Regular weighing during pregnancy
Growth scans
Consider referral to eating disorder specialist or perinatal mental
health team
Dietician referral and nutritional supplementation
Refer to for anaesthetic review
Ensure drug doses are adjusted, depending on weight at the time of
prescribing
Refer and recommend bone scan once breastfeeding complete
Communicate concerns with GP

Consider Possible growth Advanced disease if treatment Full blood count, renal and liver profiles
malignancy restriction not considered or declined Tumour markers depending on suspected malignancy
Iatrogenic preterm because of pregnancy Ultrasound/CT/MRI/PET scanning
delivery Difficulty investigating and Multidisciplinary team and specialist surgical/oncology involvement
managing malignancy

Uncontrolled FGR, IUD, PET Treat in conjunction with maternal medicine or endocrine specialist
hyperthyroidism Miscarriage Growth scans
Preterm labour/
delivery

Abbreviations: CT = computed tomography; FGR = fetal growth restriction; IUD = intrauterine death; MRI = magnetic resonance imaging;
PET = positron emission tomography

outcomes, with implications far into adulthood. It is
recognised that fetal outcome follows a U-shaped curve
with respect to maternal BMI, with a BMI between 20 and 25
being associated with the lowest risk of complications.
The most consistently reported effect of low maternal BMI
in the literature is an increased prevalence of LBW babies and
late prematurity (34–37 weeks of gestation). In a large
systematic review published in 2011, Han et al. (2011)7
analysed data from over 1 million pregnancies in both
developed and developing countries. They reported a
statistically significant increase in LBW, in both developed
and developing countries (RR 1.48, 95% CI 1.29–1.68, and R
1.52, 95% CI 1.25–1.85, respectively). Interestingly, the
association with preterm birth was only statistically
significant in developed countries. This could be globally
significant as most preterm births occur in developing
countries and prematurity is responsible for most early
neonatal deaths. Robillard et al. (2018)14 published an
observational cohort study of nearly 60 000 term
pregnancies in R
eunion and argued that, within the normal

52 ª 2022 Royal College of Obstetricians and Gynaecologists.


BMI range of 19–25, the appropriate number of neonates
were born as either large or small for gestational age. With
increasing BMI, the number of larger babies increases, and
with lower starting BMI, there are higher rates of low
birthweight babies. In 2013, Jeric et al. (2013)15 presented
data showing that, on average, babies born to women with a
BMI <18.5 weighed 163 g less. However, the authors make no
comment on whether these babies were growth restricted,
small for gestational age (SGA) or born prematurely.
Knight-Agarwal et al. (2016)16 presented data from
Australia, which associated low BMI with a higher risk of
LBW and late preterm delivery, but without any increase in
neonatal morbidity. Sebire et al. (2001)17 published a
retrospective population study based on maternity records
in northwest London of 200 000 pregnancies. They found an
increase in LBW and late prematurity, but noted that the data
do not allow adequate analysis of potential confounders, such
as socioeconomic status and smoking. Sebire et al.17 also
discuss the clinical significance of this increase in LBW. The
observed shift in a normal distribution of fetal birthweight to
the left, they argue, probably represents a higher rate of
constitutionally small babies rather than growth restriction:
“[this shift in the normal distribution] suggests that intrinsic
maternal control of fetal size correlating with maternal size
occurs in such pregnancies, rather than a higher prevalence of
utero-placental insufficiency resulting in intrauterine
growth restriction”.
Williams et al. (2010)18 demonstrated a reduction in
stillbirth risk with low BMI mothers, correlating with a
reduction in the number of missed cases of fetal growth
restriction. This perhaps intimates that increased surveillance
in this group of women might protect against the risk fetal
growth restriction and, crucially, if growth restriction were to
occur in pregnancy, it is less likely to be missed. These
considerations are important if screening is instituted based
on low BMI as a risk factor.
Healthy weight
Several papers have challenged the association between LBW
and prematurity.19,20 It has been suggested that gestational
weight gain is a better marker of adaptation to the demands
of pregnancy than BMI in isolation. Zanardo et al. (2016)21
showed that pregnant women with normal gestational
weight gain (as defined by guidance published in 2009 by
the Institute of Medicine),22 there was no increase in LBW
but a reduction in both fetal macrosomia and various
maternal complications. If low BMI is the consequence of
chronic malnutrition caused by poverty, then the mother is
less likely to gain adequate weight during the pregnancy
because of the continuing stresses of her environment. The
inclusion of gestational weight gain is another method for
separating cases of ‘healthy’ low BMI women from those
ª 2022 Royal College of Obstetricians and Gynaecologists.
Burnie et al.
who have a low BMI caused by malnutrition or disease. This
challenges the current practice of not routinely weighing
pregnant women, at least at the extremes of the BMI range.
Perhaps monthly weighing for these groups of women
should be considered.
In addition to LBW and late prematurity, there is some
evidence to suggest that suboptimal gestational weight gain
or a low BMI elevates the risk of placental abruption. For
fetal development, some cohort work has suggested an
association between a low BMI and risk of atrial septal
defect, isolated congenital diaphragmatic hernia and
gastroschisis.23,24 Neither causality nor the potential
aetiology of these associations has been established.
Most studies7,21 show a small but significant tendency for
women with a lower pre-pregnancy BMI to have smaller
babies and late preterm deliveries. However, most of these
studies acknowledge difficulties in accounting for the effect of
confounders associated with low BMI, particularly
socioeconomic status. The value of BMI in Asian
populations has been challenged and analysis of low BMI
women in exclusively Asian subgroups has not shown the
same associations as in other groups. The concept of a
constitutionally low BMI, rather than a BMI that is
inappropriately low because of a secondary cause, is also
important in terms of stratifying risk. The 2009 Institute of
Medicine (IOM) recommendations on weight gain during
pregnancy22 provide an adjunct for assessing adequate
nutritional status during pregnancy, rather than relying on
just pre-pregnancy BMI.
Guidance published in 2013 by the Royal College of
Obstetricians and Gynaecologists (RCOG) on SGA25
recognises BMI <20 as a minor risk factor for SGA, but
considers the effect on size to be the same as being
overweight and less than that of being obese.
Maternal implications and associations
Women with a low BMI are not a homogeneous group and
being underweight may reduce the risk of various antenatal
and intrapartum complications.
Antenatally, women with a low BMI are less likely to
develop gestational hypertension, pre-eclampsia and
gestational diabetes.2,17 They are also less likely to deliver
large-for-gestational-age babies and are significantly less
likely to need delivery by caesarean section (whether
emergency or elective). There is some evidence that
postpartum haemorrhage rates are lower, as are rates of
instrumental deliveries. Conversely, tocophobia may be part
of the underlying reason why a woman with low BMI might
request a caesarean delivery.
Antenatal anaemia appears to be commoner in this
group;17 there is also evidence that underweight women are
at higher risk of obstetric anal sphincter injuries (OASI),
53
 Pregnancy in underweight women
although this is not uniformly seen in all cohorts.
Underweight women also have an increased number of
admissions in pregnancy (compared with women of normal
weight), but fewer admissions than obese women.
Change in body shape and weight gain in pregnancy may
trigger relapse for ED. Cohort studies have shown trends
towards an increase in relapse of ED postpartum, especially in
the first 6 months. This group of women is also at higher risk
of postpartum depression and obsessive-compulsive disorder.
Management
General considerations
Management of underweight women in pregnancy should be
holistic and guided by the underlying aetiology of the low
BMI. The BMI at booking should be used as part of the
screen to stratify a woman’s risk and to determine the type of
care she and her baby will need throughout the pregnancy
and beyond.
Where there is an organic cause for being underweight, the
appropriate multidisciplinary team (MDT) should be
involved, with the obstetrician and midwife working with
the teams to provide the best pregnancy outcome.
Appropriate gestational weight gain is important for good
fetal outcomes in underweight women. However, in the
absence of any randomised clinical trial (RCT) evidence of a
beneficial effect on pregnancy outcomes, NICE guidance1
suggests that repeated weight measurements during
pregnancy should be confined to circumstances in which
clinical management is likely to be influenced.
There is debate about the application of the IOM
guidelines22 on appropriate gestational weight gain to a
multi-ethnic population. The guidelines advise an increased
gestational weight gain of 12.5–18 kg for underweight women
compared with 11.5–16 kg for normal weight women and 5–
9 kg for obese women.1
Nutritional advice
Individual energy requirements during pregnancy vary
greatly, so it is difficult to stipulate a rigid calorie intake.
However, dieticians usually recommend an extra 200 kcal
each day in the third trimester of pregnancy for all women.26
Advice on gaining weight safely includes the use of healthy
high calorie foods such as porridge, nuts and whole milk.
This should be given alongside standard advice on what
constitutes a healthy diet, including basing meals on starchy
carbohydrates, the need for five portions of fruits and
vegetables per day, with adequate daily protein intake.
Consideration needs to be given to iron, folic acid, vitamin
D and calcium supplementation, as with all pregnant women.
Additional supplementation of micronutrients is not usually
required and should be dietician-led. Carbohydrate-rich
supplements had surprisingly modest effects on increasing
54
birthweight (less than 100 g in all but one study).19 Women
with very low BMI may benefit from dietician review and a
prescription of fortified drinks.
Fetal surveillance
Given the association with LBW babies, consideration of
additional fetal monitoring is warranted. RCOG guidance25
views BMI <20 as a minor risk factor for an SGA baby and, in
isolation, would not recommend additional growth scans.
However, it may be pragmatic to consider additional growth
scans if the BMI was <19, given the wider clinical context.
Certainly, concerns about poor gestational weight gain would
suggest a benefit of increased fetal surveillance.
Management of women with eating
disorders
Pre-conception counselling should ideally be offered to
women with ED. Women with active EDs should be
treated and in remission before seeking to become pregnant.
Enquiry should be made about the use of appetite
suppressants, laxatives or diuretics, which may be harmful
in pregnancy. EDs can go undetected in primary care and
women with ED may be reluctant to disclose symptoms to
healthcare providers. The first antenatal visit or obstetric
appointment is an opportunity to screen for their presence,
so obstetricians should be aware of the signs suggestive of an
underlying ED. In addition to a low BMI, difficulties
conceiving related to oligomenorrhoea or amenorrhoea, a
lack of weight gain, hyperemesis or psychological problems
might raise suspicion of an underlying ED. Physical
examination may further help to differentiate a
constitutionally thin, healthy woman from one with an
underlying ED. Signs may include nail damage or calluses
across finger joints from induced vomiting, thinning of hair
or fine facial hair (lanugo), dental problems including enamel
erosion, and dry skin. Parotid enlargement (‘hamster sign’)
can also suggest self-induced vomiting.
Ideally, women with a suspected or disclosed ED should
book with an obstetrician with an interest in EDs and be
referred early to a specialist ED service. Liaison for this can
often take place through the local perinatal mental health team.
It is essential to discuss with the woman how she is
responding to her pregnancy and her thoughts about the
effect that pregnancy weight gain may have, and does have,
on her, as an assessment for body dysmorphic disorder
(BDD). Early education is required on expected body shape
changes and the importance of ensuring adequate nutrient
intake for fetal wellbeing. Ceasing harmful behaviours, such
as binge eating, self-induced vomiting, laxative use and
excessive exercise should be encouraged and supported. In
addition, should psychological therapy be required, referrals
should be dealt with quickly, during pregnancy.
ª 2022 Royal College of Obstetricians and Gynaecologists.

Advice on portion size, having regular structured meals
and not missing breakfast may be required. Longitudinal
work in women with ED has found an increase in anaemia
associated with deficiencies in vitamin and mineral intake, so
additional nutritional supplements should be considered,
depending on the anaemia and nutritional screen.
Women with a dual diagnosis
Pregnant women with an ED who have a dual diagnosis, such
as a coexisting substance misuse disorder or other mental
illness, present additional management challenges.
Frequently encountered comorbidities include depression,
anxiety disorder and obsessive-compulsive disorder, alcohol
and substance misuse. It is therefore extremely important to
ensure that appropriate note is taken of the Whooley
questions27 for these women as a screening tool for
accompanying mood disorders. The use of the AUDIT-C
alcohol screening tool28 may also be indicated from the
history and presentation.
Rates of substance misuse in individuals with EDs can be
as high as 50%. There is a clear need to screen and, if
substance misuse is suspected, consent should be sought
from the woman for urine toxicology or hair strand testing.
Women with a dual diagnosis have poorer treatment
outcomes, increased complications, longer recovery times
and higher relapse rates.29 Caffeine, stimulants including
amphetamines, laxatives, and thyroid medication may be
used for appetite suppression, to aid weight loss or provide
energy. In addition, alcohol and other psychoactive
substances may be used for emotional regulation or in the
context of impulsive behaviours. Although the literature
suggests separate aetiologies for ED and substance misuse
disorders, any shared common risk factors should be
explored; for example, traumatic childhood experiences.
Dual diagnosis may also include BDD, a condition in
which the sufferer considers part or all of their body to be
flawed, leading to anxiety and behaviours that focus on the
perceived flaw. This presentation would warrant referral to
the perinatal mental health service for further psychological
input and management with psychological support or
medication – often antidepressants.
Common to these disorders is potential resistance to
treatment and a reluctance to divulge symptoms because of
feelings of guilt or shame. Obstetricians and midwives must
be prepared to ask difficult questions and be open to explore
these issues without judgement.
Other management challenges can include which service to
lead care (for example, substance misuse agencies or perinatal
mental health). Effective communication between members
of the multidisciplinary team is crucial.
Tocophobia may present as part of this constellation of
symptoms. This psychological comorbidity should be
ª 2022 Royal College of Obstetricians and Gynaecologists.
Burnie et al.
managed with appropriate psychological input and requires
careful handling. Elective caesarean section is not necessarily
the most appropriate treatment and individualised
assessment and management is key in these cases.
There is very limited good-quality evidence in management
approaches for comorbid disorders. However, current
literature suggests that the disorders should be treated
simultaneously, addressing underlying factors that are
common to both, such as difficulties with emotional
regulation (personality disorder), through a multidisciplinary
approach.30 Treatment may need to involve medical
stabilisation in cases of severe ED, concurrently with
psychological treatments including cognitive behavioural
therapy (CBT) and psycho-education. Antidepressants may
have a limited role and should not be used in isolation.27
An extreme manifestation of AN can be hypokalaemic,
alkalotic renal failure, related to forced emesis accompanied
by laxative misuse. This will require MDT management with
appropriate physician input as well as the ED team.
Investigations
Table 2 summarises the investigations that may be required
for low BMI.
Table 2. Investigations for low BMI
Parameter Investigations
Baseline tests for Full blood count, renal profile, bone profile, liver
low BMI profile
In presence of Ferritin, vitamin B12, folic acid (methyl malonic
anaemia acid)
(haemoglobin
<105 g/L)
Low threshold Vitamin D assay
Low potassium ECG  chest X-ray – risk of cardiac arrhythmia
BMI <19 Consider regular weight minimum once each
trimester or monthly
Urinalysis Ketonuria may suggest purging and forced
emesis or starvation
Arterial or venous Look for alkalosis, high pH and low potassium
blood gas
Postnatal bone Consider suggesting this to GP beyond 3 months
scan postnatal to assess bone density and risk of
continuing osteopaenia/osteoporosis
Abbreviations: BMI = body mass index; ECG = electrocardiography;
GP = general practitioner
55
 Pregnancy in underweight women

‘Healthy Start’ vouchers are available to all pregnant women

Weight loss in pregnancy
Very occasionally, true weight loss is seen during pregnancy;
however, this is very rare, even with women with ED. Weight
loss can occur as part of the somatic signs and symptoms of
depression, but organic causes should be excluded. With the
reproductive age shifting to the higher end of the range,
investigations to exclude cancer in pregnancy may be
necessary. Stage 4 bowel cancer can occur in women of
normal reproductive age and has been described
during pregnancy.
Other chronic conditions associated with weight loss, for
example, inflammatory bowel disease (IBD), can present for
the first time in pregnancy.
Safeguarding
Depending on the aetiology, women with a low BMI may be
vulnerable adults who will require additional input from
safeguarding teams and social care to ensure that they and
their unborn children are protected from abuse, harm or
neglect. An appropriate level of enquiry is needed to
determine the wider socioeconomic context of their
pregnancy. For example, a pregnant woman with housing
issues might not have anywhere to cook. Women with
limited access to their own financial means, perhaps because
of unemployment, poverty or in the context of abusive
relationships, might find it difficult to buy food. In the UK,
under the age of 18 and to those over 18 who are in receipt of
state benefits. These can be spent on milk, fruit or vegetables.
Healthy Start vitamins for pregnant women (containing folic
acid and vitamins C and D) are also available. Women with
limited access to healthcare because of immigration status or
language barriers also represent a vulnerable population
requiring additional input to ensure their nutritional needs
are met. These may be overlooked if it is assumed that their
low BMI is associated with ethnic origin; indeed, this can be
considered a form of systematic racism.
Postnatal care
Table 3 summarises the care that should be given to women
with low BMI postpartum.
Conclusions
Women with a low BMI are a complex, heterogeneous group.
Booking BMI should be considered a screen for organic
disease, EDs and other mental health issues, and used to
highlight women requiring additional, or multidisciplinary
antenatal care, related to their complexity. An appropriate
level of enquiry into the socioeconomic context of their
pregnancy is essential.
While there is risk associated with low birthweight,
appropriate gestational weight gain may be more important

Table 3. Postnatal care

Expected neonatal
Presentation birthweight Level of postnatal care

Low booking BMI but Neonatal birthweight Normal postnatal care

appropriate weight most likely in normal
gain in pregnancy range

Low BMI (or weight Likely normal neonatal Support from primary care and multidisciplinary team managing cancer diagnosis.
loss) and malignancy birthweight Support breastfeeding until cancer treatment makes untenable

Low BMI and eating Increased risk of LBW Enhanced postnatal support such as early intervention health visiting31
disorders Assist with breastfeeding32
Observe for deterioration of mental health, particularly obsessive-compulsive
disorder/postnatal depression
Risk of resurgence of eating disorders33,34
Consider a MARF to social care/early intervention health visitor

Low BMI and Increased risk of LBW MARF to social care/involve no recourse service, if applicable
malnutrition Early intervention health visiting
Provide supplements and vitamins and fortified drinks
Communicate concerns to primary care
Postnatal depression related to social complexity

Abbreviations: BMI = body mass index; LBW = low birthweight; MARF = multi-agency referral.

56 ª 2022 Royal College of Obstetricians and Gynaecologists.


in determining fetal outcomes and may help clinicians to detect
women who would benefit most from serial growth scans.
Pregnancy and comprehensive antenatal care act as a window
to explore and address both medical and lifestyle factors related
to a low BMI that might otherwise remain hidden and provide
a means of referral to other services and specialties most
appropriate to help and treat women with low BMI.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
SC instigated and edited the article. RB researched and wrote
the article; EG wrote and researched the article. All authors
approved the final version.
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Washington, DC: National Academies Press; 2009.
23 Rankin J, Tennant PW, Stothard KJ, Bythell M, Summerbell CD, Bell R.
Maternal body mass index and congenital anomaly risk: a cohort study. Int J
Obes (Lond) 2010;34:1371–80.
24 Lam PK, Torfs CP, Brand RJ. A low prepregnancy body mass index is a risk
factor for an offspring with gastroschisis. Epidemiology 1999;10:717–21.
25 Royal College of Obstetricians and Gynaecologists (RCOG). The investigation
and management of the small-for-gestational-age fetus. Green-top
guideline no. 31. London: RCOG; 2013.
26 Royal College of Obstetricians and Gynaecologists (RCOG). Information for
you. Healthy eating and vitamin supplements in pregnancy. London: RCOG;
2014.
27 Gregorowski C, Seedat S, Jordaan GP. A clinical approach to the assessment
and management of co-morbid eating disorders and substance use
disorders. BMC Psychiatry 2013;13: 289.
28 UK Government. Alcohol use disorders identification test for consumption
(AUDIT C). London; 2017 [https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/684823/
Alcohol_use_disorders_identification_test__AUDIT_.pdf].
29 Courbasson CMA, Smith PD, Cleland PA. Substance use disorders, anorexia,
bulimia, and concurrent disorders. Can J Public Health 2005;96:102–6.
30 Klopfer K, Woodside D B, Substance abuse in women with bulimia nervosa:
prevalence of comorbidity and therapeutic approaches. Psychiatric Times
2008; 25: SE1
31 Stein A, et al. An Observational Study of Mothers with Eating Disorders and
Their Infants. Journal of Child Psychology and Psychiatry 1994; 35:4:
733–48
32 Larrson G, Andersson-Ellstro €m A. Experiences of pregnancy-related body
shape changes and of breast-feeding in women with a history of eating
disorders. European Eating Disorders Review 2003; 11:2: 116–24
33 Kouba S et al. Pregnancy and Neonatal Outcomes in Women with Eating
Disorders. Obstetrics and Gynaecology 2005; 105:2: 255–60.
34 Mazzeo SE et al. Associations among postpartum depression, eating
disorders, and perfectionism in a population-based sample of adult women.
Eating Disorders 2006; 39:3: 202-11.
57
 DOI: 10.1111/tog.12787
The Obstetrician & Gynaecologist
http://onlinetog.org
Accessory cavitated uterine malformations (ACUMs): an
unfamiliar cause of dysmenorrhoea
Thulasi Setty MBChB MRCOG,
a
* Joel Naftalin MBChB MRCOG MD,
a
Clinical Research Fellow in Gynaecology Ultrasound, Institute for Women’s Health, University College Hospital, London, UK
b
Consultant Gynaecologist, Institute for Women’s Health, University College Hospital, London, UK
*Correspondence: Thulasi Setty. Email: thulasi.setty@nhs.net
Accepted on 4 January 2021. Published online 18 January 2022.
Key Content
 Accessory cavitated uterine malformations (ACUMs) are isolated
cavitated lesions within the lateral aspect of the myometrium,
inferior to the attachment of the round ligament.
 They are a rare M€ ullerian anomaly and are increasingly recognised
as a cause for severe dysmenorrhoea and pelvic pain.
 ACUMs can be diagnosed with ultrasound and magnetic
resonance imaging, where they appear as well-defined lesions
with a central cavity containing haemorrhagic content,
surrounded by a myometrial mantle. On histological
examination, the cavity is lined by functional endometrial glands
and stroma.
 Recognised treatments include hormonal suppression,
destruction of the endometrial lining by alcohol sclerotherapy,
or complete surgical excision, which has demonstrated
curative results.
Please cite this paper as: Setty T, Naftalin J, Jurkovic D. Accessory cavitated uterine malformations (ACUMs): an unfamiliar cause of dysmenorrhoea. The
Obstetrician & Gynaecologist 2022;24:40–9. https://doi.org/10.1111/tog.12787
Introduction
Accessory cavitated uterine malformations (ACUMs) are
increasingly recognised myometrial lesions. They are
considered a rare but significant cause of severe
dysmenorrhoea, often in young women. ACUMs are
isolated cavitated lesions located within the lateral aspect of
the myometrium, inferior to the attachment of the round
ligament of the uterus. They are considered to be of
embryological origin.1 The earliest description of an ACUM
was by Oliver2 in the early 20th Century: a patient presenting
with dysmenorrhoea underwent surgical excision of a
tumour from the broad ligament, which was described as
“a globular-shaped closed sac, containing chocolate-coloured
fluid, thick-walled and lined by cuboidal epithelium, which
resembled very closely the stroma of normal
endometrium” (Figure 1).2
Until 2010, there had only been occasional case reports in
the literature describing this phenomenon. Then, Acien
et al.1 published a literature review of ACUMs alongside a
40
2022;24:40–9
Review
b
Davor Jurkovic FRCOG MD
b
Learning Objectives
 To know what ACUMs are and recognise them as a cause of
dysmenorrhoea and pelvic pain.
 To be able to diagnose an ACUM with the use of ultrasound, MRI
and histological findings if surgically excised.
 To be able to counsel patients with ACUMs on the different
management options, including conservative, medical and surgery.
Ethical issues
 All women with ACUMs are currently offered surgical excision,
but is it appropriate to offer this, to patients as young as 13 years
old, with no long-term data on the effect of surgery on
future fertility?
Keywords: accessory cavitated uterine malformation (ACUMs) /
dysmenorrhoea / juvenile cystic adenomyoma / M€
ullerian
anomaly / painful periods
series of four of their own cases. In 2012, the same authors
coined the term ‘ACUM’ to describe these lesions, which –
until then – had no agreed name.3 Subsequent advances in
imaging have allowed more detailed examinations of uterine
architecture – more specifically, the myometrium – thereby
increasing visualisation of this important but relatively
unknown pathology. This review summarises the existing
literature on ACUMs, in particular demographics, clinical
presentation, diagnostic imaging and available treatment
options, to increase knowledge and aid better detection of
ACUMs in everyday clinical practice.
Epidemiology
Currently, the literature on ACUMs is limited to case reports
and case series and there have been no formal prospective
studies of the condition. The prevalence is therefore
unknown, although, based on the scarcity of reported cases,
it is probably a rare abnormality. Possible reasons for the
paucity of evidence include poor recognition of the condition
ª 2022 Royal College of Obstetricians and Gynaecologists.

Figure 1. A schematic demonstration of a uterus and ACUM within the right broad ligament from the original description published by Oliver
et al. in the Lancet in 1912.(2) B.L = broad ligament; F.T. = fallopian tube; R.L. = round ligament.
among gynaecologists, radiologists and sonographers;
variable quality of ultrasound, which remains the primary
diagnostic tool in gynaecology; and challenges in reaching
a diagnosis.
Some authors have proposed that ACUMs can only be
diagnosed in women under the age of 30 years.3,4 However,
while 84% (78 out of 93 cases) of the reported cases are in
women under the age of 30 years, there are published cases of
ACUMs in older women.1–3,5–8
The literature reveals a preponderance of cases in Japan,
with 16 out of 93 (17%) cases published by authors from
Japan.4,9–14 This probably reflects increased clinician
awareness of the condition in Japan rather than a genuine
increased prevalence of the condition within this population.
Nomenclature
Various terms have been used to describe what we now call
‘ACUMs’. These include ‘juvenile cystic adenomyoma’,4,9,13–
24
‘isolated cystic adenomyoma’,5,10–12,25,26 ‘uterine-like
mass’,27,28 or ‘accessory uterine cavity’.2,29,30 In 2010, Acien
et al. reviewed the literature to determine how many
published cases represented true ACUMs. Eighteen clinical
cases met their proposed criteria, as outlined in Box 1.1
Initially termed as an ‘accessory cavitated uterine mass’,3
Box 1. Diagnostic criteria of ACUMs
Location:
 Solitary lesion located in the lateral myometrium or broad ligament
 No communication with uterine cavity or fallopian tubes
Morphology:
 A cavitated lesion containing functional endometrium surrounded
by a myometrial mantle
Histology:
 Cavitated lesions filled with dark brown haemorrhagic content
 Lined with functional endometrium
 Myometrial mantle has concentric organisation of smooth muscle
ª 2022 Royal College of Obstetricians and Gynaecologists.
Setty et al.
other authors have expressed concern that the term ‘mass’
can have sinister connotations for patients. The term
‘malformation’ has been proposed as a more specific and
appropriate alternative, which might avoid unnecessary
worry for what is, in fact, a benign lesion.8
Aetiology
It has been suggested that the early occurrence of pain
symptoms after menarche is evidence that ACUMs are a
congenital rather than acquired malformation.13 While the
precise origin of ACUMs remains uncertain, all authors agree
that they represent a M€ ullerian duct abnormality.1,3 There are
two theories about how they develop: that they represent an
isolated M€ ullerian duct malformation, or a dysfunction of
the female gubernaculum.1
During the fifth and sixth weeks of embryological
development, the genital system is indifferent and exists as
two pairs of genital tracts: the mesonephric (Wolffian) ducts
and paramesonephric (M€ ullerian) ducts. Absence of
testosterone cause the Wolffian ducts to regress in female
embryos. The M€ ullerian ducts persist, fuse at the caudal end
and extend cranially with a central cavity, eventually forming
a functional uterus.31 The unfused lateral arms form the
fallopian tubes.31 Remnants of the M€ ullerian ducts can lead
to congenital uterine anomalies, thus supporting the theory
that the origin of ACUMs might be associated with the
duplication and persistence of a M€ ullerian duct segment at
the level of the attachment of the round ligament.1
The embryological female gubernaculum persists as the
round ligament of the uterus.32 Acien et al.32 hypothesise
that the female gubernaculum is probably formed by muscle
fibres that are not derived from either the mesonephric or
paramesonephric ducts. They believe the attachment of the
gubernaculum to the M€ ullerian ducts induces the fusion and
normal development of the uterus. The fact that all published
cases of ACUMs describe their location in the insertion area
or pathway of the round ligament substantiates this theory
that ACUMs derive from maldevelopment of
the gubernaculum.1,3,13,32,33
41
 Accessory cavitated uterine malformations
Clinical presentation
Severe dysmenorrhoea is the commonest presenting
symptom for women with ACUMs.3,7,12,13,15,23,34,35 The
pain can be central or ipsilateral to the side of the ACUM
and may be accompanied by chronic pelvic pain.1,3,8,21,28,34
The pain is thought to be caused by an accumulation of
menstrual fluid from the functioning endometrium lining the
ACUM within what is an enclosed space. This would lead to
increased pressure within the ACUM and subsequent
stretching of the cavity.3,9,13,19,26,27 Pain often persists or
even increases after the onset of menstruation.34 Other
symptoms reported by patients diagnosed with ACUMs
include dyspareunia1,4 and hypogastric pain,1,3 although it is
uncertain whether the ACUM was the primary cause of these
symptoms. Currently, there are no descriptions of
asymptomatic ACUMs in the literature. Potential reasons
for this might include challenges to diagnosis, and the
combination of a perceived requirement for histology to
confirm diagnosis alongside the lack of an indication to
excise an asymptomatic lesion. Nevertheless, asymptomatic
ACUMs are feasible and future prospective observational
studies might confirm that a proportion cause no pain. There
are no published data to suggest that ACUMs are associated
with menorrhagia or subfertility, and ACUMs have been
diagnosed in parous women. Some authors have described a
clinically palpable, tender mass on bimanual vaginal
examination, which could be mistaken for a fibroid or
ovarian cyst.1,13,25
Investigations
Ultrasound
Transvaginal ultrasound (TVUS) remains the first-line
imaging tool in gynaecology, so it is particularly important
to increase awareness of the ultrasound features of ACUMs.
ACUMs appear on ultrasound as well-circumscribed,
spherical, cavitated lesions, with a myometrial mantle and
echogenic fluid content (Figure 2).8,24,36 They are
characteristically located in one of the lateral aspects of the
anterior myometrium, inferior to the presumed insertion site
of the round ligament.8 The fluid content can either be
‘ground glass’ in nature, like the typical appearance on
ultrasound of the contents of endometriomas, or
hyperechoic.3,4,7,8,14 The contents, being fluid, should be
avascular on Doppler examination, and the blood flow in the
myometrial mantle should be no different to the Doppler
assessment of the surrounding myometrium.8 ACUMs can be
mistaken for obstructed congenital uterine anomalies, so two
normal interstitial portions of the fallopian tubes must be
visualised to confirm diagnosis. If TVUS is a relative or
absolute contraindication, a transrectal ultrasound scan
42
(TRUS) is an acceptable alternative. This is usually well
tolerated and has comparable image quality to TVUS.37
While some authors have described only requiring TVUS
to make the diagnosis,8 quality of ultrasound remains highly
variable. This is reflected in the literature, where most
authors routinely use additional imaging modalities to
confirm the ACUM diagnosis.34,36
Magnetic resonance imaging
Most published case reports and cases series of ACUMs have
been investigated using magnetic resonance imaging (MRI).
MRI examinations include axial, coronal and sagittal T2-
weighted turbo spin echo images, T1-weighted spin echo
images and axial fat suppressed T1-weight images with 3–4-
mm section thickness. This ensures exclusion of M€ ullerian
anomalies by clearly visualising both cornua.34 Peyron et al.34
concluded that all ACUMs could be identified on MRI as ‘a
functioning and non-communicating accessory horn, present
within the external myometrium or broad ligament in an
otherwise normal uterus’. All ACUMs were found to have a
central cavity, each surrounded by a well-defined ring with
low T1 and T2 signal enhancements, which is similar to that
of the junctional zone.34 The surrounding cyst wall or
myometrial mantle is seen as thickened and hypointense
tissue on T2-weighted images, which demonstrates
myometrial hypertrophy (Figure 3).26 In addition, the
cavities had a thin inner lining that moderately enhanced
after gadolinium contrast and appeared hyperintense on T2-
weighted images, indistinct from endometrium.34 The
internal content of the cavities displayed high T1 signal
intensity, which remained after fat saturation and is
indicative of haemorrhagic content.4,19,26,34,36 Some lesions
also displayed T2 shading, which is similarly seen
with ovarian endometriomas, again confirming the
haemorrhagic content of ACUMs.34 All cases had normal
uterine cavities and no concomitant uterine or renal
tract anomalies.1,3,26,34,36
Assessment of uterine morphology
Many authors have stated that an ACUM diagnosis can only be
made in the presence of a normal uterine cavity and once an
obstructive congenital uterine anomaly has been excluded.1,3,4
Both hysterosalpingography (HSG) and hysteroscopy have
been used to confirm a normal uterine cavity and fallopian
tubes in this population.4,7,10,12,13,15,21,34,38 Nevertheless,
numerous other imaging modalities can be used to assess
the uterine cavity, including 2D and 3D ultrasound,
saline infusion sonohysterography (SIS), hysterosalpingo-
contrast-sonography (HyCoSy), MRI, and laparoscopy and
dye test.39,40 Where there is no clear evidence to determine
superiority of imaging modality, local preference will
determine the choice.
ª 2022 Royal College of Obstetricians and Gynaecologists.
 Setty et al.

(a) (b)

(c) (d)

(e)

Figure 2. Location and anatomy of ACUM. Transverse transvaginal ultrasound image of uterus and an ACUM in the left lateral myometrium (a).
The ACUM (yellow arrow) can be seen lateral and inferior to the interstitial portion of the left fallopian tube (red arrow) and uterine cavity (white
arrow). Note the echogenic contents of ‘ground glass’ appearance within the ACUM. (b) Hyperechoic cavity content within the ACUM (yellow
arrow) on transverse transvaginal ultrasound image. (c) Transvaginal ultrasound image of a Doppler examination of an ACUM. Note the presence
of vascularity within the myometrial mantle, but absence within the cavitated part of the lesion. The structure of an ACUM is illustrated in images
(d) and (e), showing a central cavity ’C’, hyperechoic internal lining – similar to that of endometrium (yellow border) and a surrounding myometrial
mantle (MM, red border).

Intraoperative diagnostic features

Figure 3. MRI of an ACUM. T2- weighted axial high-resolution MRI
image showing the presence of an ACUM in the left lateral
myometrium of the uterus (yellow arrow) with a normal uterine
cavity (white arrow).
Diagnosis of an ACUM is rare and often delayed. There are
documented cases of women with ACUMs undergoing
numerous diagnostic laparoscopies to investigate symptoms
of severe dysmenorrhoea and pelvic pain that failed to
diagnose the ACUM.1,8,17,27 ACUMs can be difficult to see
and are often missed if not actively looked for, with the
uterine contour being described as being entirely normal at
laparoscopy or even during laparotomy in some cases.11 In
most cases, an ACUM appears as an asymmetrical, often
subtle enlargement on the right or left lateral aspect of the
uterus, inferior to the insertion of the round ligament and
classically contains altered blood, which appears as dark
brown fluid.1,3,8,15,34 Intraoperative ultrasound examination
can successfully locate the ACUM and aid excision from the
surrounding myometrium.8,10,11

ª 2022 Royal College of Obstetricians and Gynaecologists. 43

 Accessory cavitated uterine malformations

Histology modalities such as high-resolution TVUS and pelvic MRI, it

Macroscopically, ACUMs have a ‘uterus-like’ organisation,
with a central cavity lined by endometrium and surrounded by
a myometrial mantle.13 The largest case series to date8 reported
the mean outer cavity diameter of the ACUM to be 22.8 mm
(95% confidence interval [CI] 20.9–24.8 mm) and the mean
internal cavity diameter of the ACUMs to be 14.1 mm (95% CI
12.2–16.1 mm). These measurements are consistent with other
studies reporting similar dimensions.4,34
Microscopically, the cavity is lined with glands and stroma,
which positively stain for CD10, estrogen receptors (ER) and
progesterone receptors (PR) – indicators of normal
endometrial tissue.4,34 Peyron et al.34 describe a well-
ordered concentric orientation of smooth muscle fibres in
their surgically resected ACUM cases, which differentiates
them from cystic adenomyosis, where the smooth fibres are
more disordered.8 Many authors report small foci of
adenomyosis within the myometrial mantle.1,3,4,10,14,36
Differential diagnoses
Diagnosing ACUMs can be challenging, primarily because
there is unfamiliarity among clinicians, but also because of
various differential diagnoses. Despite advances in imaging
can be difficult to differentiate ACUMs from other more
common pathologies. The presence of a morphologically
normal uterine cavity is one defining feature of an
ACUM.1,3,4,34 This is to differentiate ACUMs from
obstructive and non-obstructive congenital uterine
anomalies, such as unicornuate uteri with a rudimentary
horn (Figure 4), or Robert’s uterus, which is defined as a
septate uterus with a noncommunicating hemi-cavity.
ACUMs can be difficult to differentiate from fibroids
located in the lateral aspect of the myometrium when they
have altered central contents; for example, if they have
undergone cystic, haemorrhagic or fatty degeneration
(Figure 5).19,34 However, central degeneration rarely occurs
in fibroids of a similar size to ACUMs. Furthermore, fibroids
that have undergone haemorrhagic degeneration can be
distinguished from ACUMs on MRI, because accumulation
of methaemoglobin in the obstructed veins at the periphery
of a fibroid with haemorrhagic degeneration produces a rim
that is hypointense in both T1- and T2-weighted images.19
Up until 2010, many ACUMs were termed ‘juvenile cystic
adenomyomas’ and treated as a rare form of adenomyosis.
There are, however, features that distinguish ACUMs from
true cystic adenomyomas, with regards to clinical

(a)
(b)

(c)
(d)

Figure 4. Differentiating an ACUM from a unicornuate uterus. These images demonstrate the difference between a unicornuate uterus with a
functioning, non-communicating rudimentary horn and an ACUM. (a) A 3D-rendered coronal view of a right unicornuate uterine cavity (UC) with a
functional, non-communicating rudimentary horn (RH) with haematometra secondary to obstructed outflow. This can also be seen on 2D
transvaginal imaging (b). This is in contrast with a normally shaped uterine cavity with two interstitial portions (I) of the fallopian tube seen on a 3D
rendered coronal view of the uterus containing an ACUM in the lateral myometrium (c) and on a 2D ultrasound transverse view of the uterus (d).

44 ª 2022 Royal College of Obstetricians and Gynaecologists.

 Setty et al.

(a) (b)

Figure 5. Differentiating an ACUM from a uterine fibroid. Transverse view of the uterus on transvaginal ultrasound sound showing a subserous
fibroid on the left lateral aspect of the uterus (orange arrow in image (a)). In comparison to the ACUM in image (b) (yellow arrow), there is an
absence of cavitation with a hyperechoic lining depicting endometrium and lack of myometrial mantle.

(a) (b)

Figure 6. Differentiating an ACUM from a cavitating adenomyoma. This is a sagittal view of an anteverted uterus on transvaginal ultrasound scan
demonstrating a cavitating adenomyoma in the anterior myometrium (orange arrow in image (a)). In comparison to the ACUM in image (b)
(yellow arrow), there is a lack of myometrial mantle, it is contiguous with the endometrial-myometrial junction (EMJ) of uterine cavity (white arrow)
and its location is in the central, anterior aspect of the uterus in contrast to the lateral location of the ACUM.

presentation, ultrasonographic appearance, surgical findings

and histopathology (Figure 6, Table 1).1
Congenital uterine cysts, another differential diagnosis of
ACUMs, are epithelial-lined myometrial cysts. Unlike
ACUMs, they contain simple fluid that appears anechoic
on ultrasound, rather than blood, and their location
within the myometrium is variable. They also lack a
haemosiderin rim on histological examination, whereas
ACUMs are lined with endometrium and have
haemorrhagic content.19,41
ACUMs can be mistaken for ovarian endometriomas,34
particularly because endometriosis is a diagnosis actively
sought in young women presenting with severe
dysmenorrhoea and pelvic pain. An endometrioma within
an ovary adherent to the lateral aspect of the uterus (a not
uncommon finding in endometriosis), could easily be
mistaken for an ACUM. There are, however, characteristic
features to distinguish ovarian endometrioma, including the
presence of surrounding follicles within the ovarian cortex
and the absence of a thick peripheral ring of muscular
tissue (Figure 7).34
Treatment
Expectant
Currently, all published research confirms the benign nature
of ACUMs and, in asymptomatic women, they can be
managed expectantly. However, the natural history of
ACUMs is not known because most reported cases were
managed by excisional surgery. Prospective observational
studies are required to gain a greater understanding of the
natural history of the condition.
Medical
Given that pain is the primary symptom of ACUMs, simple
analgesics such as nonsteroidal anti-inflammatory drugs
(NSAIDs) can be used. Many authors, however, describe
these as being inadequate for controlling pain.4,13,15,17,21,34,38
The use of suppressive hormonal treatments have been
described, including continuous use of the oral contraceptive
pill,19,20,29,42 levonorgestrel-releasing intrauterine system
(Mirena)8 or gonadotrophin-releasing hormone
(GnRH).4,10–13,20,24,34 Naftalin et al.8 found most patients

ª 2022 Royal College of Obstetricians and Gynaecologists. 45

 Accessory cavitated uterine malformations

Table 1. Differences between ACUMs and true cystic adenomyomas.

Characteristics ACUMs True cystic adenomyoma

Demographics Tend to affect younger, nulliparous women. Tends to affect older, multiparous women7

Clinical presentation Severe menstrual pain and no association with heavy periods Heavy, painful periods1

Concomitant pathology Tend to be isolated lesions3 Usually found alongside other features of adenomyosis

Macroscopic histopathology Distinct border between myometrial mantle and Irregular and poorly defined borders47
findings surrounding myometrium34

Microscopic histopathology Concentric organisation of smooth muscle around cavity Surrounding myometrium lacks organisation
findings Endometrial glands and stroma seen to line cavity8 Absence of internal epithelial lining of cystic cavity7

Location In the lateral myometrium, inferior to the insertion of the Variable location within the myometrium,
round ligament and separate and distinct from often within or contiguous with the
the endometrial-myometrial junction34 endometrial-myometrial junction47

(a) (b)

Figure 7. Differentiating an ACUM from an ovarian endometrioma. (a) Transverse view of a uterus with an enlarged left ovary adherent to the
lateral aspect containing a unilocular cyst (orange arrow) with echogenic ‘ground glass’ content. The cyst is surrounded by normal ovarian tissue as
illustrated by the presence of follicles. There is also an absence of a myometrial mantle as seen with an ACUM (yellow arrow) on image (b).

in their cohort wanted to avoid surgery in the first instance,

with 10 out of 17 patients opting against primary surgery. Six
of these patients chose hormonal treatments, with most
achieving sufficient pain relief to defer or avoid surgery.
ACUMs are often diagnosed in young teenage girls for whom
surgery may not be the best primary treatment option.
Branquinho19 and Fissea42 both describe teenage patients
presenting with severe cyclical pelvic pain, who were found to
have a cystic, haemorrhagic lesion within the lateral
myometrium meeting diagnostic imaging criteria for an
ACUM. They were both treated with continuous oral
contraceptives, which achieved adequate pain relief at 6-
and 12-month follow-ups.
Other authors have reported similar success with
hormonal treatments, specifically the oral contraceptive pill
and GnRH treatments. However, many patients experienced
recurrence of symptoms when the treatment
stopped.3,4,10–13,15,24,33,34,38
Sclerotherapy
Reports on TVUS-guided aspiration and sclerotherapy for
ovarian cysts, including endometriomas, have been published,
with varied results.43,44 Alcohol sclerotherapy can be an
alternative to surgery, or be indicated where medical treatments
have failed. However, with this approach, patients must be made
aware it is not curative. They should also be counselled on the
risks of symptom recurrence and the probable need for further
intervention. It is, however, less invasive and does not carry the
same risks as laparoscopy or laparotomy.
Sclerotherapy aims to destroy the cavity lining, resulting in
inflammation and fibrosis with eventual obliteration.45
Ethanol (95–99% concentration), in particular, has been
shown to combine cytotoxic damage, hypertonic cellular
dehydration and coagulation and thrombosis in the presence
of blood products.45 Naftalin et al.8 used sclerotherapy as a
primary treatment for ACUMs in four patients and described

46 ª 2022 Royal College of Obstetricians and Gynaecologists.


Box 2. Transvaginal sclerotherapy procedure for ACUMs
 Perform under general anaesthetic
 Under continuous transvaginal ultrasound guidance, insert an 18-
gauge needle through the anterior vaginal wall and myometrium,
into the ACUM
 Aspirate intracavitary fluid (usually 2–3 mL) and send for cytological
analysis
 Instil 99% ethanol into the cavity
reduced pain in the immediate follow-up. Two patients,
however, later required surgical resection when pain
resumed. Box 2 outlines the TVUS-guided sclerotherapy
procedure for ACUMs. Recognised risks of sclerotherapy
include peritoneal leakage of the instilled alcohol; however,
this is unlikely with ACUMs because the cavity is surrounded
by myometrium.44
There are currently no long-term follow-up data on the
success of sclerotherapy of ACUMs. Data extrapolated from
its use in the treatment of ovarian endometriomas suggests
recurrence rates of 0–62.5% in a meta-analysis of 1102
patients over 15 studies with follow-up of 1–24 months. Rate
of recurrence was largely influenced by the time of ethanol
washing, with risk of cyst recurrence significantly higher in
those with ethanol washings lasting less than 10 minutes.44
Surgery
Nonsurgical treatments are important in the treatment of
symptoms secondary to ACUMs, not least because they are
less invasive and carry fewer risks than surgical excision.
Nevertheless, most published cases of ACUMs have been
treated surgically with high success rates. All published cases
of surgery for ACUMs have reported almost complete
resolution of pain, with many patients remaining pain free
until completion of follow-up.1,3,4,8,34,38 Excisions have been
performed both laparoscopically and by laparotomy. Acien
et al.1,3 described performing a laparotomy for all eight of
their cases up until 2012. The operations were either excision
of the ACUM, or hysterectomy in those women with separate
indications for hysterectomy. They described the advantage
of open surgery as being greater surgical precision, allowing
better enucleation of ACUMs that can have indistinct surgical
planes.1,3 Given that ACUMs are close to important
structures such as the uterine artery, urinary bladder and
endometrial cavity, surgical precision of excision is of crucial
importance.33 Other authors, however, showed that
sufficiently precise enucleation of the ACUM can be also
achieved at laparoscopy because of the image magnification
and the use of fine dissection instruments. Combined with
bidirectional blunt and sharp dissection, they achieved
complete excision without spillage.33 Laparoscopic
enucleation of ACUMs has usually been favoured over
ª 2022 Royal College of Obstetricians and Gynaecologists.
Setty et al.
open surgery, for reasons including quicker recovery with
reduced postoperative pain and the reduced incidence of
adhesions.8 However, this requires advanced laparoscopic
skills, including the ability to suture laparoscopically.
Nevertheless, with more hysterectomies and myomectomies
being completed laparoscopically, more gynaecological
surgeons should be sufficiently skilled to perform
laparoscopic ACUM excision.
Dividing the round ligament has been proposed as a means
to clearly identify the ascending branch of the uterine artery to
reduce the risk of inadvertent injury.4,19,33,34 Dissection of the
uterovesical fold has also been cited to facilitate safe access to
the laterally placed ACUM.33 Vasopressin infiltration into the
uterine–ACUM serosal interface to aid with haemostasis has
been reported by almost all authors.4,6,7,10,11,13–17,38,46 The
overlying serosa is incised with monopolar energy4,6 and
ACUM enucleation is performed in a circumferential manner
along the ACUM–myometrial interface with the use of bipolar
energy; in contrast to a myomectomy, where dissection
advances along a pseudocapsule.6 If the boundaries of an
ACUM are unclear, intraoperative ultrasound has been
described to facilitate delineation of the lesion and to aid
excision.8,13 Intraoperative ultrasound can also help to avoid
inadvertent breach of the uterine cavity. Peyron et al.34
concluded that the mean distance of the ACUM from the
uterine cavity was 6 mm on MRI, illustrating how easily a
uterine cavity can be breached during surgical excision. While
no studies have reported this complication, theoretical
sequelae would include intrauterine adhesions, development
of adenomyosis, and increased risk of future intrapartum
uterine rupture. Authors have described intraoperative
assessment of the integrity of the uterine cavity post-excision
using methylene blue dye chromopertubation.18,29,33,34
ACUMs are benign lesions, so there is no recognised
danger in spillage of the ACUM contents. They rarely exceed
35 mm in mean diameter. Various techniques have been
described for specimen retrieval, including the use of
colpotomy,4 morcellation10,15,23,46 and specimen
7,8,16,33
retrieval bags.
Follow-up
There is currently limited evidence to guide us on
appropriate follow-up of these patients. Both the natural
history of ACUMs and the long-term impact of surgical
excision remain unknown. Prospective longitudinal studies
are therefore required to further our understanding on
whether they change with time, what impact they have on
pregnancy and whether surgical excision has longer term
sequelae. Future research questions include how surgical
resection may affect fertility or pregnancy outcomes, and
whether a trial of labour is a safe option for these women.
47
 Accessory cavitated uterine malformations
Ethical issues
Surgical excision is curative, so this approach is currently
offered to all women diagnosed with this M€ ullerian
abnormality. However, this raises the ethical question as to
whether it is appropriate to offer a treatment option with no
long-term data on future fertility. This condition has been
shown to affect patients as young as 13 years of age, so
surgery as first-line treatment may not be suitable.
Conclusion
ACUMs are an underdiagnosed M€ ullerian anomaly in women
with refractory dysmenorrhoea. Further work is required to
establish the true prevalence of ACUMs within the population,
their long-term effects on women’s health, and to carry out
comparative studies of different treatment options.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
TS researched and wrote the article. JN instigated and edited
the article. DJ edited the article. All authors approved final
version of the article.
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49
 DOI: 10.1111/tog.12783 2022;24:31–9
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Cervical cancer in pregnancy: diagnosis, staging and

treatment
Tamara Howe MBBS MRCOG PGDipMedEd (Merit),a* Kate Lankester BM BCh MRCP FRCR PhD MAClinEd,b
Tony Kelly FRCOG, MD,c Ryan Watkins BMedSci BM BS MRCPCH,d Sonali Kaushik MBBS MRCOG MDe
a
Consultant in Obstetrics and Gynaecology, Division of Women’s and Children’s Health, Frimley Park Hospital, Portsmouth Rd, Frimley,
Camberley GU16 7UJ, UK
b
Consultant Oncologist, Sussex Cancer Centre, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
c
Consultant in Obstetrics and Gynaecology, Division of Women’s and Children’s Health, Royal Sussex County Hospital, Eastern Road, Brighton
BN2 5BE, UK
d
Consultant Neonatologist, Division of Women’s and Children’s Health, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
e
Consultant in Gynaecological Oncology, Division of Women’s and Children’s Health, Royal Sussex County Hospital, Eastern Road, Brighton BN2
5BE, UK
*Correspondence: Tamara Howe. Email: tamara.howe@nhs.net

Accepted on 12 April 2020. Published online 20 December 2021.

Key Content
 Cervical cancer is the commonest gynaecological malignancy
diagnosed in pregnancy.
 Cancer symptoms may mimic complications of pregnancy, thus
delaying diagnosis.
 Staging of cervical cancer in pregnancy is essential to determine an
individual management plan.
 Treatment of cervical cancer in pregnancy is complex and depends
on the stage of cancer and the gestation of the pregnancy.
 Involvement of a multidisciplinary team is essential in the care of a
woman with cervical cancer in pregnancy.
Learning Objectives
 To understand how to diagnose, stage and treat cervical cancer
in pregnancy.
 To know the risks to the fetus in each trimester, with regard to the
various surgical and chemotherapeutic options available to treat
cervical cancer in pregnancy.
 To understand the psychological effects on a woman of a cancer
diagnosis in pregnancy.
Ethical Issues
 How should maternal and fetal risks be balanced while
investigating and treating cervical cancer in pregnancy?
 Consideration of termination of pregnancy to allow timely
treatment, alternatively risking delay in treatment and progression
of disease.
Keywords: cervical cancer / diagnosis / psychological impact /
staging / treatment

Please cite this paper as: Howe T, Lankester K, Kelly T, Watkins R, Kaushik S. Cervical cancer in pregnancy: diagnosis, staging and treatment. The Obstetrician &
Gynaecologist 2022;24:31–9. https://doi.org/10.1111/tog.12783

Introduction
All cancers in pregnancy are rare, and individual clinicians
will see very few during their careers. Despite advances in
cancer management for pregnant women, many important
questions remain unanswered by evidence-based
information. In most countries, obstetric and oncology
registries are not linked, making it a challenge to estimate
the incidence of all types of cancer in pregnancy. It is for
these reasons the International Network on Cancer, Infertility
and Pregnancy (INCIP) was launched in 2005. With the
support of world experts, INCIP have generated
comprehensive protocols and effective guidance for
pregnant cancer patients and their healthcare providers.1
Epidemiology
Cancer of the cervix is the commonest gynaecological
malignancy diagnosed in pregnancy, with an incidence rate
of 0.1–12.0 per 10 000 pregnancies.2 The epidemiology of
cervical cancer is anticipated to change with the introduction
of the human papilloma virus (HPV) vaccination for school
children in 2008. Consequently, the predicted reduction in
cervical cancer rates is as high as 55% in women aged 25–29
years, with the peak age of cancer diagnosis shifting from 25–
29 years in 2011–2015 to 55–59 years in 2036–2040.2 By
extrapolating these population models of incidence trends,
rates of cervical cancer within pregnancy will probably
also reduce.

ª 2021 Royal College of Obstetricians and Gynaecologists 31

 Cervical cancer in pregnancy
The relative risk of cervical cancer is lower during
pregnancy than in nonpregnant women. This indicates a
delay in diagnosis or detection, a true lower risk, or a healthy
mother effect. Solid data on how pregnancy affects the
outcome of gynaecological cancers is missing, although a few
reports have shown a poorer prognosis for patients diagnosed
with cervical cancer during pregnancy.3,4
Diagnosis of cervical cancer in pregnancy
Presenting symptoms
Early-stage cancer of the cervix may be asymptomatic and
detected after an abnormal smear. The symptoms of cervical
cancer in pregnancy do not differ between pregnant and
nonpregnant women. Cancer-related symptoms, such as
painless vaginal bleeding, pelvic and lower back pain and
urinary frequency, can resemble other common conditions
related to pregnancy.5
Signs and symptoms of cervical cancer can include
anomalous vaginal bleeding and discharge, dyspareunia
and/or an abnormal appearance of the cervix. Local
extension to the pelvic organs may cause other symptoms
including haematuria, urinary incontinence, lower limb
oedema and changes to bladder and bowel habit. More
distant metastases may present with bone pain, or systemic
symptoms such as loss of appetite, weight loss or fatigue.
Ureteric obstruction can cause flank or loin pain, with
subsequent oliguria or anuria as a result of renal failure.5
Examination and referral pathway
All women presenting with bleeding in pregnancy should be
examined and the cervix visualised. If a suspected cervical
abnormality is identified, then they should be urgently
referred to an experienced colposcopist or gynaecologist
under the ‘two-week’ rule.6
Cervical screening in pregnancy
Routine recall and test-of-cure (TOC) smear tests in pregnancy
can be deferred until 3 months after delivery. Pregnancy itself is
not a contraindication to a smear test. For women who require
follow-up after treatment of cervical glandular intraepithelial
neoplasia (CGIN) or cervical intraepithelial neoplasia (CIN) 2
and 3, with involved or uncertain margins, cytology should not
be delayed until after pregnancy.6
Colposcopy and excisional biopsy in pregnancy
Colposcopy is safe during pregnancy. The aim of colposcopy,
where possible, is to exclude invasive disease and defer biopsy
until after the woman has delivered. Colposcopic assessment
during pregnancy requires a high degree of skill and should
be undertaken by an experienced colposcopist.6 The
physiological effects of pregnancy can make it more
challenging to accurately assess the cervix. These effects
32
include increased cervical mucus, cervical hyperaemia, gland
prominence and eversion of the columnar epithelium.7
Pregnancy itself does not influence cervical lesions, and
progression of pre-invasive to invasive disease during
pregnancy is rare (0.0–0.4%).8
If invasive disease is suspected at colposcopy, an adequate
biopsy to make a diagnosis is crucial. It is important to
understand that a punch biopsy diagnosing CIN cannot
reliably exclude invasion.6 The risk of haemorrhage with a
diathermy loop is approximately 25%,9 so such biopsies should
only be undertaken in clinics or operating theatres where
appropriate facilities to manage haemorrhage are available.6
Staging of cervical cancer in pregnancy
Cervical cancer invasion occurs locally, affecting the vagina,
parametrium and uterosacral ligaments as the first site of
spread. The bladder, rectum and pelvic and para-aortic lymph
nodes may also be involved.10 Lymph node involvement is
associated with a worse prognosis.11 The lymph nodes affected
can include the obturator, external and internal illiacs, presacral
and the para-aortic lymph nodes. Distant metastatic spread to
the bones, lungs and liver may also occur.10
The International Federation of Gynaecology and
Obstetrics (FIGO) 2018 staging system for cervical cancer is
shown in Box 1.12 It is primarily based on clinical
examination and can be employed for the staging of
pregnant women.12
Magnetic resonance imaging
Pelvic magnetic resonance imaging (MRI) is the first line for
staging of cervical cancer in pregnancy. It is safe in pregnancy,
at any gestation, as there is no ionising radiation. Therefore, if
distant metastases are suspected, assessment by abdominal MRI
can be considered. Pregnancy may pose challenges when
interpreting MRI. These difficulties can include dilated pelvic
veins being misinterpreted as pelvic adenopathy, or a reduction
in image quality occurring because of fetal movements.13
The use of contrast is not essential in the staging of cervical
cancer. Gadolinium and iodinated contrast mediums can
cross the placenta and be excreted into the amniotic fluid
from the fetus. Despite this, there is no evidence of
teratogenic or adverse fetal effects.14
Computed tomography
Computed tomography (CT) scans are usually contraindicated
during pregnancy to avoid a dose of radiation to the fetus.
Therefore, CT should be considered as a second choice to
MRI. However, it may be necessary to fully stage the patient;
for example, if there is a high suspicion of lung or pleural
spread. In such a case, the benefits would outweigh the risks to
the fetus. If a CT scan (or X-ray) is required, then all efforts
should be made to limit fetal exposure to radiation and to not
ª 2021 Royal College of Obstetricians and Gynaecologists

Box 1. 2018 FIGO staging of carcinoma of the cervix12
Stage I:
The carcinoma is strictly confined to the cervix uteri (extension to the
corpus should be disregarded).
 IA Invasive carcinoma that can be diagnosed only by microscopy,
with maximum depth of invasion <5 mm
○ IA1 Measured stromal invasion <3 mm in depth
○ IA2 Measured stromal invasion ≥3 mm and <5 mm in depth
 IB invasive carcinoma with measured deepest invasion ≥5 mm
(greater than stage IA) lesion limited to the cervix uteri
○ IB1 Invasive carcinoma ≥5 mm of stromal invasion and <2 cm in
greatest dimension
○ IB2 Invasive carcinoma ≥2 cm and <4 cm in greatest dimension
○ IB3 Invasive carcinoma >4 cm in greatest dimension
Stage II:
The carcinoma invades beyond the uterus, but has not extended onto
the lower one-third of the vagina or to the pelvic wall.
 IIA Involvement limited to the upper two-thirds of the vagina
without parametrial involvement
○ IIA1 Invasive carcinoma <4 cm in greatest dimension
○ IIA2 Invasive carcinoma ≥4 cm in the greatest dimension
 IIB With parametrial involvement but not up to the pelvic wall
Stage III:
The carcinoma involves the lower third of the vagina and/or extends to
the pelvic wall and/or causes hydronephrosis or non-functioning kidney
and/or involves pelvic and/or paraaortic lymph nodes.
 IIIA Carcinoma involves the lower third of the vagina, with no
extension to the pelvic wall
 IIIB Extension to the pelvic wall and/or hydronephrosis or non-
functioning kidney (unless known to be due to another cause)
 IIIC Involvement of pelvic and/or paraaortic lymph nodes,
irrespective of tumour size and extent
○ IIIC1 Pelvic lymph node metastasis only
○ IIIC2 Paraaortic lymph node metastasis
Stage IV:
The carcinoma has extended beyond the true pelvis or has involved
(biopsy proven) the mucosa of the bladder or rectum. A bullous
oedema, as such, does not permit a case to be allotted to stage IV.
 IVA Spread of the growth to adjacent organs
 IVB Spread to distant organs
compromise the baby’s health. Radiologists should aim to plan
scans in advance, monitor and minimise the length of
scanning time and offer abdominal shielding and low-dose
radiation where possible.15
Ultrasound
Ultrasound may be used to assess maternal hydronephrosis.
It is considered safe for both mother and fetus if both
the thermal and mechanical index are kept as low as
possible. However, as clinicians, we must remember that
compression of the gravid uterus on the ureters and the
relaxation effect of progestogen on smooth muscle may
result in physiological hydronephrosis being exhibited in
90% of pregnancies.16
ª 2021 Royal College of Obstetricians and Gynaecologists
Howe et al.
Radiographs
A chest radiograph may be considered to assess for lung
metastases. Owing to the minimal risk to the fetus in
pregnancy, the British Thoracic Society recommends an X-
ray of the thorax for the same indications as a
nonpregnant woman.17
Laparoscopic lymphadenectomy and sentinel lymph
node biopsy
Accurate nodal staging is essential to the prognosis and
treatment of cervical cancer. For women with stage I disease,
laparoscopic lymphadenectomy may allow for risk
stratification, with the aim of identifying whether or not a
‘safe’ pregnancy-saving policy can be undertaken. Positive
lymph nodes would denote a need for urgent treatment, with
surgery not being the first-line option.18 Negative lymph
nodes may allow time for fetal maturation. However,
performing a nodal resection after the 22nd week of
gestation is not recommended owing to the insufficient
number of nodes retrieved, the size of the gravid uterus and
overall risks of the surgery.1 There is no consensus on what
period of delay is deemed safe and it is important to
remember the risk of tumour progression is always present.19
The sentinel lymph node (SLN) is the first regional lymph
node that directly drains the lymph from the primary
tumour. The benefits of SLN detection are to gain
information on prognosis and reduction in unnecessary
surgery, hence reducing overall morbidity. While the utility
of SLN biopsy in early-stage cervix cancer has been proven
and taken up by some oncology centres, there is insufficient
data for its use in pregnant women with cervical cancer. At
present, SLN biopsy is not recommended in this population
and more trials are needed to clarify safety issues surrounding
SLN biopsy in pregnancy.20
Treatment of cervical cancer in pregnancy
Treatment of stage IA1 without lymphovascular
space invasion
Most stage IA cancers are diagnosed after excisional
treatment, so diagnosis is unlikely to be made during
pregnancy. Provided there is no lymphovascular space
invasion (LVSI), a stage IA1 cancer may be treated with a
cone biopsy. The optimum gestation for this treatment is
between 14 and 20 weeks. The depth of invasion and margins
can be more accurately assessed from a single specimen with
minimal heat artefact. Therefore, a knife or laser cone is
advocated by some for this treatment. If the margins are
positive, then a second treatment should be considered.21
Women should be encouraged and supported to aim for a
vaginal birth if there are no obstetric contraindications.
The risk of pelvic lymph node metastases in stage IA1
squamous cell carcinoma is 1% or less; this risk increases to
33
 Cervical cancer in pregnancy
3–6% for stage IA2.22 The involvement of a specialist
gynaecological pathology review will increase the detection
of LVSI and tumour volume. This may be beneficial in
determining the need for pelvic lymph node dissection in
early-stage disease.
Treatment of stage IA1 with LVSI, IA2 and IB1
The gold-standard treatment for stage IB1 and IB2 cervical
cancer is radical hysterectomy and bilateral salpingectomy,
with or without bilateral oophorectomy (dependent on
future fertility wishes) with bilateral pelvic
lymphadenectomy. Therefore, women must be fully
counselled about the possibility of a higher oncogenic risk
should they choose a different treatment.23 In early
pregnancy, women should be made aware of the option to
terminate the pregnancy and the likely outcomes for the fetus
should premature delivery occur. When deciding a treatment
pathway, the size of cervical lesion and the gestation of the
pregnancy are important considerations.1
As previously discussed, for women who are under 22 weeks
of gestation, a staging lymphadenectomy should be performed.
If the pelvic lymph node dissection (PLND) is positive, then a
termination of pregnancy should be considered. For women
who wish to continue with the pregnancy, neoadjuvant
chemotherapy (NACT) may help treat the disease (although
only after completion of the first trimester). If the lymph nodes
are negative, then a trachelectomy or delay in treatment until
after delivery can be discussed.1 It is important to acknowledge
the risks associated with a trachelectomy requiring appropriate
patient counselling and multidisciplinary team (MDT)
discussion.19 After the 22nd week of gestation, treatment may
include NACT, with the alternative option of delaying
treatment until after delivery.1
Trachelectomy and cervical cerclage
A simple trachelectomy is surgery to remove the cervix. This,
compared with a radical procedure, involves removal of the
cervix, parametrium and upper vagina. When a gynaecological
oncologist is undertaking a vaginal, laparoscopic or robotic
radical trachelectomy, cervical cerclage is routinely performed
as part of the procedure.19
Women who have undergone an antenatal trachelectomy
are at high risk (20–30%) of preterm delivery.23 A recent
systematic review recommended serial ultrasound scans to
monitor for isthmic shortening or funnelling.23 However, it is
important to acknowledge the practical difficulties of
performing such scans and the paucity of evidence in this
area. Fortnightly urine and genital screening have also been
recommended from 16 weeks of gestation, with a consideration
for prophylactic antibiotics. Steroid injections for fetal lung
maturation should be discussed at 24 weeks of gestation, with
the theoretical advice of limited activity in the second half of
their pregnancy, minimising strain on the cerclage.23
34
Overall, there is mounting evidence that radical
trachelectomies result in higher rates of obstetric and
surgical complications and should not be undertaken
during pregnancy. This being said, the 2020 British
Gynaecological Cancer Society (BGCS) guidance on cervical
cancer in pregnancy discourages performing even simple
trachelectomies during pregnancy. Once again, this is a
consequence of the blood loss and poor fetal outcomes
associated with such a procedure.19
Stage IB2: <22 weeks of gestation
In this scenario, a large loop excision of the transformation
zone (LLETZ) or a radical trachelectomy may not be an
effective treatment option because of the size of the tumour.
For women who wish to continue with the pregnancy, NACT
may help to shrink and manage the disease (although only
after completion of the first trimester). If she opts for a
termination, then a radical hysterectomy and pelvic
lymphadenectomy can be performed with the fetus in situ.19
Stage IB2: >22 weeks of gestation
For women over 22 weeks of gestation, consideration
should be given to allow time for fetal maturation; NACT
will help provide this opportunity. Delivery should be by
caesarean section at an appropriate gestation. Once the baby
has been safely delivered, a radical hysterectomy and pelvic
lymph node dissection should be undertaken. If the woman
chooses to not undergo chemotherapy while pregnant, an
observational approach could be employed until delivery,
when surgical treatment can be undertaken
simultaneously.24
Stage IB3 and above
For women with cervical cancer at stage IB3 and above, NACT
can help manage the disease. However, its efficiency has been
investigated in only a few trials and further research is
warranted.25 The role of staging lymphadenectomy is
controversial26 and follow-up without NACT is not
recommended because it is likely to compromise the
prognosis.1 Once fetal maturation is achieved, delivery by
lower segment caesarean section (LSCS) would be followed by
either surgery or radical chemoradiation (depending on initial
stage and response to chemotherapy treatment). Women with
advanced metastatic disease have a poor prognosis. The
intention of treatment at this stage becomes palliative with the
aim of controlling the disease rather than cure.
Figure 1 summarises cervical cancer management
during pregnancy.
Chemotherapy
Chemotherapy is contraindicated in the first trimester of
pregnancy. Interference with organogenesis has been
associated with a 10–20% risk of major malformations.
ª 2021 Royal College of Obstetricians and Gynaecologists
 Howe et al.

Figure 1. Flow chart summarising cervical cancer management during pregnancy.1 AC = adjuvant chemotherapy; DTAD = delayed treatment after
delivery; gw = gestational weeks; MRI = magnetic resonance imaging; NACT = neoadjuvant chemotherapy; NEG = negative; PLND = pelvic lymph
node dissection; POS = positive; ST = simple trachelectomy; TOP = termination of pregnancy.

Treatment after 14 weeks of gestation is considered safe,
with a fetal malformation rate comparable to the general
population.27 No significant long-term effects to the fetus
have been noted from the use of chemotherapy after this
gestation; however, it is important to acknowledge that there
are no large trials of chemotherapy in pregnancy.28 In this
situation, correct dating of the pregnancy is essential.
Platinum agents (cisplatin and carboplatin) and taxanes
(such as paclitaxel) have efficacy in cervical cancer. The
carboplatin and paclitaxel regime is favoured over cisplatin
and paclitaxel; it is better tolerated and there is less
nephrotoxicity and ototoxicity.27,29 Carboplatin and
paclitaxel can be given as a weekly or 3-weekly regimen.27
An advantage of the 3-weekly regimen is that it allows for
closer patient monitoring. Where necessary, this enables
chemotherapy and anti-emetic dose adjustment. Close
collaboration between the oncology and obstetric teams is
required. The timing of the caesarean section is important, to
ensure the patient is not neutropenic. A 3-week gap between the
final dose of chemotherapy and the caesarean section is
recommended. This allows time for maternal (and fetal) bone
marrow recovery.30 Chemotherapy is not recommended beyond
35 weeks of gestation to reduce the risk of spontaneous labour
occurring when a patient might be neutropenic.27
Box 2 summarises recommendations for systemic
treatment and supportive medication.
Possibly, because of the physiological changes that occur
during pregnancy, the bioavailability of chemotherapy agents
may be altered. Despite the increase in maternal cardiac output,
as well as hepatic and renal perfusion,31 no studies have
demonstrated that standard dosing is too low in pregnancy.
Importantly, no difference in survival has been observed.32
Histopathological considerations
Of all cervical tumours, 85% are squamous cell in origin,
with the second commonest type being adenocarcinoma.
There is an association between adenocarcinoma of the cervix

ª 2021 Royal College of Obstetricians and Gynaecologists 35

 Cervical cancer in pregnancy
Box 2. Recommendations for systemic treatment and supportive
medication for patients undergoing cancer treatment in
pregnancy1
 Dosing of chemotherapeutic drugs during pregnancy should be
based on actual weight.
 The same dose/m2 or dose/kg2 should be used as in nonpregnant
patients.
 Chemotherapy is contraindicated in the first trimester of gestation
to avoid interference with organogenesis; fetal benefit of treatment
delay should be balanced against maternal risk.
 After 14 weeks of gestation, administration of several anticancer
drugs is feasible, including taxanes, platinum agents, anthracyclines,
etoposide and bleomycin,
 Chemotherapy is not recommended beyond 35 weeks of gestation;
it is important to give a 3-week window between the last cycle of
chemotherapy and delivery to allow both maternal and fetal bone
marrow to recover.
 Until safety data is available, target therapies should be avoided
during pregnancy.
 Metoclopramide, 5HT3 antagonists, ranitidne, proton pump
inhibitors, methylprednisolone, prednisolone, or hydrocortisone
can be used if necessary.
and ovarian metastases, so it is therefore important to
consider a bilateral salpingo-oophorectomy at the time of
radical hysterectomy. The decision for ovarian conservation
must be explored thoroughly with the patient.33
High-risk types of invasive cervical cancers include small
cell endocrine and clear cell carcinoma of the cervix. A
detailed discussion of rare histological subtypes of cervical
cancers and their treatment is beyond the scope of this
article. Despite this, it is important to acknowledge that
these cancers are more aggressive, metastasise early and
have a worse prognosis than squamous cell and
adenocarcinomas. For these reasons, treatment should
not be delayed, as this will offer the best chance of survival
to these women. Their care should involve a dedicated
expert gynaecological oncology pathologist with a
supraregional team being considered to provide their
overall treatment.19
Multidisciplinary team
Treatment of women with cervical cancer in pregnancy
should be undertaken by cancer experts in a cancer centre.
The specialists must be well informed and experienced,
ensuring that the physiological changes of pregnancy,
which can make diagnosis and staging more challenging,
are not detrimental to the patient’s care and final
prognosis.32 The MDT should comprise a gynaecological
oncology surgeon, medical and radiation oncologist,
radiologist, histopathologist, neonatologist, psychologist,
specialist cancer nurse, midwife and fetal–maternal
medicine specialist.1
36
Radiotherapy, fertility preservation and
premature menopause
Detrimental effects of pelvic radiotherapy on the
uterus
For women who require pelvic radiotherapy following their
caesarean section (cancer at stage IB3 and above), it may be
appropriate to seek advice from a fertility specialist. There is
little evidence that an irradiated uterus can successfully and
safely carry a pregnancy. Uterine radiation-induced damage
may occur by various mechanisms and involving different
tissues. These processes include reduced blood flow within
myometrial and endometrial vessels caused by radiation-
induced fibrosis, as well as damage to muscle fibres and
reduced pelvic floor muscle function.34
Detrimental effects of pelvic radiotherapy on the
ovaries and ovarian transposition
Ovarian injury as a consequence of uterine radiation-induced
damage depends not only on a patient’s age but also on the
total radiation dose and site of irradiation. Ovarian
transposition may be performed prior to pelvic radiation
with the aim of preserving ovarian function. Transposing the
ovaries above the pelvic brim and outside the planned
radiotherapy field will allow subsequent retrieval of oocytes
for in vitro fertilisation and minimise the risk of premature
menopause. Consideration of a bilateral salpingectomy at the
time of surgery is important. The primary benefit of this is to
reduce the risk of epithelial cancers in the future; however,
additional benefits may include improved mobilisation of
adnexae, avoidance of tubal damage and formation of
hydrosalpinx from radiation therapy and
postoperative adhesions.35
It is important to counsel these women appropriately,
because the uterus will not support a pregnancy after a radical
course of pelvic radiotherapy. Surrogacy, although only legal
in certain countries, would be the only option for these
women to have a biologically related child. Even after
successful transposition, transient or permanent ovarian
failure might occur. This might be secondary to
devascularisation at surgery, scatter radiation or gonadotoxic
chemotherapeutic agents. The decision to perform such a
procedure will depend on the patient’s age, ovarian reserve,
desire for future pregnancies, willingness to take hormone
replacement therapy (HRT), comorbidities and prognosis.36
Obstetric care
Timing and mode of delivery
For patients who have undergone a trachelectomy, delivery
should be by planned or prelabour caesarean section. This is
to prevent uterine rupture and massive haemorrhage and to
reduce damage to reconstructive procedures.37 Traditionally,
ª 2021 Royal College of Obstetricians and Gynaecologists

a vertical midline upper segment incision was
recommended;38 nowadays, if the lower segment is
sufficiently developed, there is growing evidence on the
safety of the transverse incision. The surgery may be
technically difficult, with haemorrhage anticipated. For
these reasons, an experienced surgeon is recommended to
be present.37
If a pregnancy preservation and NACT treatment plan is
employed, then the aim should be to continue the pregnancy
until fetal maturation has taken place. The appropriate
gestation is considered to be at 34–36 weeks, with the aim of
minimising the complications of iatrogenic prematurity.
However, if earlier delivery was considered to be in the best
interests of the mother, this could be supported following a
discussion with a neonatologist.1
Mode of delivery on the oncological outcome of cervical
cancer is controversial. All options must be discussed with
these women, including obstetric contraindications to vaginal
delivery. This being said, risks of vaginal delivery include the
possibility that a tumour may obstruct the birth canal or
cause excessive bleeding at delivery.39 In addition to this,
studies have shown tumour recurrence occurs more
frequently at episiotomy scars than abdominal wall
incisions. It is for these reasons that caesarean section is
usually deemed a safer mode of delivery for these women. It
is important to note that if the tumour itself is very large,
consideration to a wound-protective system or corporeal
uterine incision would be beneficial. In this circumstance,
performing a classical caesarean section is likely to reduce
blood loss.19
Corticosteroid cover should be given for fetal lung
maturation, as per National Institute for Health and Care
Excellence (NICE) guidance,40 with the baby being
delivered at an appropriate neonatal unit, dependent on
local neonatal network arrangements. Melanoma,
haematopoietic and lung cancers are currently the only
cancers reported to metastasise to the placenta and fetus.
However, in such a scenario, it would be good practice to
send the placenta for histology to confirm no evidence
of spread.41
Breastfeeding
Chemotherapeutic agents are known to cross into breast
milk. It may cause neonatal leucopenia, increasing the risk
of infection to the baby, so breastfeeding is contraindicated
while undergoing chemotherapy. Advice from a pharmacist
should be sought prior to the decision to breastfeed, with a
minimum period of 14 days from the last chemotherapy
session before breastfeeding is commenced. This will allow
time for clearance of the drug from the breast milk.42 There
is evidence to suggest a period of lactation following a
stressful pregnancy can be of psychological benefit to
the woman.43
ª 2021 Royal College of Obstetricians and Gynaecologists
Howe et al.
Psychological and ethical concerns
Psychological impact of a cancer diagnosis in
pregnancy
Both pregnancy and cancer are life-changing events. If they
occur simultaneously, emotional and psychosocial stressors
are likely to be amplified, so women diagnosed with cancer in
pregnancy are extremely vulnerable. While the physical
wellbeing of a woman is of high priority, it is equally as
important to address the psychological aspect of her
experience. Box 3 summarises recommendations for
psychosocial caregivers treating pregnant cancer patients
and their families. Specialist cancer nurses are fundamental in
building and maintaining an open dialogue with women; this
enables patients to process the information given, while
allowing the specialist to assess their risk of depression.44
One qualitative study utilised semi-structured interviews to
explore psychological experiences of women with a diagnosis
of gestational breast cancer. Two major themes identified were
anxiety and conflict. These related, in particular, to the
woman’s concerns for the baby’s wellbeing, her own health
and the delivery of the child. Women who were already
mothers felt conflict between protecting the fetus versus the
need for treatment. Treatment would likely offer them a better
chance of survival, enabling them to see their other children
grow up. There was a natural tendency for women to think
about the fetus rather than themselves.45
Henry et al.46 investigated the long-term distress associated
with a cancer diagnosis in pregnancy. Women remained
‘clinically distressed’ nearly 4 years after diagnosis compared
with 15% of women at 1-year post diagnosis who received a
nonpregnancy related diagnosis.46 The following factors were
associated with increased risk for long-term distress: preterm
birth, receiving fertility assistance to conceive during this
pregnancy, not producing sufficient milk to breastfeed, being
Box 3. Recommendations for psychosocial caregivers treating
pregnant cancer patients and their families1
 Psychologists should be included in the interdisciplinary team of
caregivers for pregnant cancer patients.
 Counselling should be offered to both the affected woman and her
partner.
 Extensive education should be provided about the necessary medical
steps and their implications on the outcome of the pregnancy, and
the long-term effects on the physical and cognitive health of the
offspring.
 Contact with other families who have experienced cancer during
pregnancy should be encouraged because this might help patients
and their families to cope more easily with their own emotions,
thoughts and concerns.
 In gynaecological cancers, hysterectomy and bilateral oophorectomy
can be performed. Thus, the interdisciplinary team should be aware
of the possible psychological effects of this surgery, including
depression, loss of sexual pleasure and future child-bearing ability.
37
 Cervical cancer in pregnancy
advised to terminate the pregnancy, having a caesarean
section for delivery and undergoing cancer surgery post
pregnancy. The research suggested that women affected by
these risk factors should be referred for additional
psychosocial support.46
Conclusion
A diagnosis of cancer in pregnancy has a considerable effect
on women, requiring both physical and psychological
support. Over the last 2 years, both the BGCS and the
European Society of Medicine1 have published guidelines
encompassing cervical cancer in pregnancy.1,19 With bodies
like INCIP working to advance cancer care for pregnant
women, the hope is that over time, our knowledge will
continue to increase, enabling us to offer more effective and
evidence-based care.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
SK instigated and edited the article. TH researched, wrote
and edited the article. KL wrote and edited the article. TK
wrote and edited the article. RW wrote and edited the article.
All authors read and approved the final version of
the manuscript.
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39
 DOI: 10.1111/tog.12780 2022;24:24–30
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Investigation and management of postcoital bleeding

Gemma L Owens BSc (Hons) MBBCh MRes PhD MRCOG,a,b* Nick J Wood MBBS MD MRCOG,
c

Pierre Martin-Hirsch MBChB MD, FRCOGc

a
ST6 in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Lancashire Teaching Hospitals NHS Foundation Trust,
Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK
b
NIHR Clinical Lecturer in Gynaecological Oncology, Division of Cancer Sciences, Faculty of Medicine, Biology and Health, University of
Manchester, Oxford Road, Manchester M13 9PL, UK
c
Consultant Gynaecological Oncologist, Department of Obstetrics and Gynaecology, Lancashire Teaching Hospitals NHS Foundation Trust,
Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK
*Correspondence: Gemma L Owens. Email: gemma.owens@manchester.ac.uk

Accepted on 7 December 2020. Published online 20 January 2022.

Key Content Learning Objectives

 Postcoital bleeding is a common gynaecological symptom affecting
up to 9% of women.
 Postcoital bleeding is commoner in women with invasive cervical
cancer than the general population; however, most women with
postcoital bleeding will not have an underlying malignancy.
 Knowledge of how to investigate and manage postcoital bleeding is
imperative to provide optimal care and ensure patient safety.
 It is essential that all gynaecologists are aware of referral pathways
for suspected cervical malignancy.
 To review causes of postcoital bleeding.
 To appreciate the importance of diagnostic tests in the assessment
of postcoital bleeding.
 To understand the management options for women with an
identifiable cause of their postcoital bleeding and the management
of recurrent or persistent postcoital bleeding in the absence
of pathology.
Keywords: cancer / cervical pathology / postcoital bleeding

Please cite this paper as: Owens GL, Wood NJ, Martin-Hirsch P. Investigation and management of postcoital bleeding. The Obstetrician & Gynaecologist
2022;24:24–30. https://doi.org/10.1111/tog.12780

presenting with postcoital bleeding, in the absence of a

Introduction
Postcoital bleeding is defined as nonmenstrual bleeding or
spotting occurring immediately after sexual intercourse.
Estimates of the prevalence of postcoital bleeding in the
community range from 0.7 to 9.0%, with an annual
cumulative incidence of 6% in premenopausal women.1
Although postcoital bleeding is considered a cardinal
symptom of cervical cancer, its positive predictive value is
low. Of those who present to primary care with postcoital
bleeding, only 1 in 44 000 women aged 20–24 and 1 in 2400
women aged 45–54 will have cervical cancer.2 Nevertheless,
the principal aim of investigating women with postcoital
bleeding is to exclude cervical cancer.
A coroner’s inquest into the death of a 49-year-old woman
diagnosed with cervical cancer in 2017 identified key failings
in the management of her case. These included failure to
report the smear test accurately and failure on two further
occasions to recognise a clinically obvious cervical cancer.
Sadly, this case highlights inconsistencies in the investigation
and management of postcoital bleeding within the UK. The
purpose of this review is to outline common causes of
postcoital bleeding and to provide a framework for history
taking, examination and initial investigation of women
national guideline.
Assessment of women with postcoital
bleeding
Postcoital bleeding typically arises from contact with lesions
on the cervix, vagina or vulva, whereas endometrial
pathology usually leads to intermenstrual or heavy
menstrual bleeding. Often, postcoital bleeding and
intermenstrual bleeding coexist. Causes of postcoital
bleeding are outlined in Box 1. Most women with
postcoital bleeding will have a benign condition, such as a
cervical polyp, ectropion, urogenital atrophy or cervicitis
secondary to chlamydial infection. However, postcoital
bleeding can also be associated with cervical cancer and,
understandably, causes anxiety in women presenting with
this symptom. It is therefore essential that women are
carefully assessed to exclude serious pathology.
There are clear guidelines on which women warrant an
urgent referral to secondary care (Table 1).3,4 Colposcopy
referral for every case of postcoital bleeding is unfeasible,
expensive and – most of all – distressing for the women
concerned.5 The cervical screening programme guidelines

24 ª 2021 Royal College of Obstetricians and Gynaecologists

 Owens et al.

History
Box 1. Causes of postcoital bleeding
A thorough clinical history and examination can help to elicit
Benign conditions risk factors and signs suggestive of underlying pathology. The
 Urogenital atrophy history should enquire about:
 Benign vascular tumours of the genital tract, e.g. haemangiomas, A-
V malformation  The patient’s age
 Cervical or endometrial polyps  The duration, frequency and amount of bleeding
 Cervical ectropion
 Menstrual history, including normal bleeding pattern and
 Cervical endometriosis
last menstrual period
Infection  The presence of other gynaecological symptoms, such as
 Vulvovaginitis secondary to candidiasis or trichomonas
 Cervicitis secondary to chlamydia or gonorrhoea vaginal discharge, pelvic pain and dyspareunia
 Endometritis in presence of intrauterine coil device (IUCD)  Contraceptive history and use of other hormonal therapy
Vulval
(for example, hormone replacement therapy, tamoxifen)
 Vulval dermatoses, e.g. lichen sclerosus  History of human papilloma virus (HPV) immunisation
 Genital warts  Cervical screening history, including date and result of last
 Genital ulcers, e.g. herpes, chancroid screening test
 Syphilis
 Lymphogranuloma venereum
 Details of any previous colposcopy and treatment
 Sexual history, including any previous history of sexually
Malignancy
transmitted infections (where appropriate)
 Vulval cancer
 Vaginal cancer  Relevant past medical and surgical history, including
 Cervical cancer bleeding disorders
 Endometrial cancer  Current medications, particularly use of anticoagulants
Other  Other relevant risk factors, such as smoking status.
 Trauma and genital piercings
 Bleeding disorders A sexual risk assessment is particularly pertinent in women
 Foreign bodies aged 25 years or younger, in whom there is a higher prevalence
 Sexual abuse of chlamydia. Further guidance on this is available via the
 Pregnancy-related
 Female genital mutilation (FGM)
British Association for Sexual Health and HIV (BASHH).6 All
patients should be screened for domestic and/or sexual abuse
because trauma to the genital tract can result in postcoital
bleeding. Fear or embarrassment may mean that women do not
Table 1. Indications for referral to secondary care
volunteer this information, so the question needs to be asked.
The ‘HARK’ questions are a simple way to sensitively enquire
Urgency of about intimate partner violence (Table 2).7 Specific guidance
Situation referral
on identifying and responding to disclosures of domestic abuse
has been developed by the Department of Health and
Women presenting with symptoms of cervical Within 2 weeks Social Care.8,9
cancer (e.g. unexplained postcoital bleeding or
persistent vaginal discharge) Examination
Women presenting with postcoital bleeding should have an
Abnormal appearance to cervix or vaginal on Within 2 weeks
speculum examination abdominal examination and careful inspection of the vulval
skin before proceeding to a speculum examination. Vulval
inspection may identify vulval dermatoses, excoriation,
ulceration, fissuring, female genital mutilation or genital
piercings. A Cusco speculum should be used to inspect the
recommend that women presenting with postcoital bleeding vaginal walls for atrophic changes, lacerations, prolapse or
should first be examined by a gynaecologist who is ulcerated lesions. Note any vaginal discharge or the presence
experienced in the management of cervical disease, and of a foreign body. Visual inspection of the cervix may identify
then referred on to colposcopy if cancer is suspected.3 a cervical ectopy or a polyp. Most invasive cancers causing
Women with a clinically suspicious cervical lesion should postcoital bleeding are clinically apparent on speculum
ideally be referred directly to colposcopy, although this may examination.10 Findings suggestive of cervical cancer
vary depending on local service demands. A diagnostic include ulceration, friable tissue, contact bleeding or a
pathway for women presenting with postcoital bleeding is craggy irregular mass. The examination should be
outlined in Figure 1. concluded with a bimanual examination to palpate the

ª 2021 Royal College of Obstetricians and Gynaecologists 25

 Investigation and management of postcoital bleeding

Postcoital bleeding

History and physical examination

Microbiology swabs Cervical screening test Clinically Normal cervix but

if overdue abnormal cervix persistant PCB or
coexisting IMB

If positive, treat
infection and refer Abnormal result
onto GUM for Consider
contact tracing transvaginal USS
+/- pipelle biopsy
Colposcopy +/- hysteroscopy

Figure 1. A diagnostic pathway for investigation of postcoital bleeding. Abbreviations: GUM = genitourinary medicine; IMB = intermenstrual
bleeding; PCB = postcoital bleeding; USS = ultrasound scan.

infection. If gonorrhoea is suspected, an endocervical swab for

Table 2. ‘HARK’ questions to screen for intimate partner violence
‘HARK’ In the last year. . .
Humiliation Have you been humiliated or emotionally abused in
other ways by your partner or ex-partner?
Afraid Have you been afraid of your partner or ex-partner?
Rape Have you been raped or forced to have any kind of
sexual activity by your partner or ex-partner?
Kick Have you been kicked, hit, slapped or otherwise
physically hurt by your partner or ex-partner?
cervix, assess uterine size and adnexal lesions and evaluate for
cervical excitation – a clinical feature of pelvic
inflammatory disease.
Initial investigations
It is important to exclude pregnancy in any woman of reproductive
age presenting with abnormal bleeding. Cervicitis secondary to
chlamydial infection is a common cause of postcoital bleeding in
young women,1 thus a vulvovaginal swab should be taken for
nucleic acid amplification tests (NAATs) in those at risk of
antimicrobial sensitivity testing should be taken in addition to the
vulvovaginal swab. These tests do not need to be repeated if they
have already been completed in primary care.
A cervical screening test can be taken if the patient is aged
25 years or older and has not been screened within the normal
screening interval. This is a screening rather than a diagnostic
test: it is not appropriate in patients with a suspicious cervix on
examination; these women require urgent colposcopic
assessment. Rarely, endometrial pathology can present with
postcoital bleeding. If the cervix is clinically normal, consider a
transvaginal ultrasound, pipelle endometrial biopsy and/or an
outpatient hysteroscopy to exclude endometrial pathology,
especially in women with coexisting intermenstrual bleeding.
One advantage of a diagnostic hysteroscopy is the ability to
visualise the endocervical canal; however, this procedure is
usually reserved for women with an irregular or thickened
endometrium on scan, or with persistent symptoms in the
absence of other pathology.11
When is referral to colposcopy indicated?
The national cervical screening programme has now
introduced HPV primary testing in England, Scotland and
Wales. If high-risk HPV is detected, cytology will then be
performed to check for abnormal cells. Women require
onward referral to colposcopy if they are found to have

26 ª 2021 Royal College of Obstetricians and Gynaecologists


abnormal cytology, including borderline changes, low-grade
dyskaryosis, high-grade dyskaryosis, possible invasive cancer
or glandular changes. Women also require colposcopy if they
have two sequential inadequate tests, or the cervix cannot be
identified on speculum examination.3 In the context of
postcoital bleeding, women require a colposcopic assessment
within 2 weeks if the appearance of the cervix is suspicious
on examination. The NHS cervical screening programme
advocates women with persistent postcoital bleeding or
vaginal discharge in the absence of other pathology to be
“referred for examination by a gynaecologist experienced in
the management of cervical disease (for example, a cancer
lead gynaecologist)”. Gynaecologists may refer these women
on for symptomatic colposcopic examination outside the
cervical screening programme if cancer is suspected.3
Causes and management of postcoital
bleeding
Cervical ectropion
A cervical ectropion is a normal physiological finding.
Cervical eversion results in the friable, mucus-secreting
glandular epithelium of the endocervix being exposed on
the ectocervix. It classically appears as a red disc around the
external cervical os. It is often seen after menarche, during
pregnancy and in women taking the combined oral
contraceptive pill, arising as a result of cervical remodelling
in response to estrogen. Exposure to the vaginal milieu
eventually transforms the glandular epithelium into
squamous epithelium in a process called squamous
metaplasia. The exposed columnar epithelium is susceptible
to trauma and contact bleeding during intercourse or
examination. Women with cervical ectopy may present
with increased mucopurulent vaginal discharge and
postcoital bleeding, or may be asymptomatic.12 On
speculum examination, a cervical ectropion may cause
contact bleeding, making it difficult to exclude significant
disease without colposcopy referral.
Women should be informed regarding the physiological
nature of the condition. Given this reassurance, the patient
may decide not to have any further treatment. If applicable,
changing the combined oral contraceptive to the
progestogen-only pill may resolve symptoms. Women with
persistent or troublesome symptoms can be offered
cryocautery or diathermy to the cervix. However, the risk
of recurrence should be highlighted, especially in the context
of exogenous hormones. In addition, women should be
informed of potential side effects to treatment, including
copious vaginal discharge until healing is complete and
cervical stenosis.13 If the woman has had regular and negative
cervical screening and the doctor is satisfied with the
diagnosis of an ectropion, then cryocautery should be
performed in the gynaecology clinic. If in any doubt, a
ª 2021 Royal College of Obstetricians and Gynaecologists
Owens et al.
cervical biopsy should be performed and treatment delayed
until the histology is known.
Cervical polyps
Cervical polyps are usually asymptomatic and found
incidentally on speculum examination but can also
present with bleeding after intercourse. On examination,
they appear as pedunculated fleshly lobular structures and
can arise from the endocervical canal, ectocervix, or from
an endometrial polyp prolapsing through the cervical
canal. They are friable and easily bleed on contact.
Polyps are thought to arise from chronic inflammation
or after an atypical response to hormonal stimulation.
They most frequently present in perimenopausal and
postmenopausal women.14
Symptomatic polyps and cases with coexisting abnormal
cervical cytology should be removed and sent for histological
examination to exclude malignancy.15 Most cervical polyps
measure less than a few centimetres in diameter and can be
avulsed during speculum examination. The polyp should be
grasped at its base using polyp forceps and twisted off.
Haemostasis can usually be achieved with silver nitrate.
Larger or broad-based polyps may require removal with loop
diathermy at colposcopy.
Symptomatic cervical polyps can be associated with
endometrial polyps and hyperplasia, particularly in
perimenopausal and postmenopausal women. Endometrial
abnormalities have been reported in up to 55% of
postmenopausal women with cervical polyps, advocating
that these women should be offered hysteroscopy and
endometrial sampling, in addition to avulsion of the
polyp.16 The risk of dysplasia or malignancy in cervical
polyps is estimated to be 0.0–1.7%,15 thus conservative
management may be appropriate in asymptomatic women.
Cervicitis, endometritis and pelvic inflammatory
disease
As mentioned above, postcoital bleeding in younger women
is more likely to arise from cervicitis secondary to a sexually
transmitted infection (STI). Chlamydia is the commonest
bacterial STI and is estimated to affect up to 7% of women
under the age of 25 years.17 Risk factors for infection include
age under 25 years, a new sexual partner, more than one
sexual partner in the preceding year and inconsistent use of
barrier contraception. Chlamydia can be detected using
NAATs, either from a vulvovaginal swab or urine. First-line
treatment for women with suspected or confirmed
chlamydial infection is azithromycin 1 g orally as a single
dose, followed by 500 mg once daily for 2 days, or
doxycycline 100 mg twice a day for 7 days.18 Single-dose
treatments are associated with better compliance. Women
should be advised to abstain from intercourse until treatment
is complete and should be referred on to a local sexual health
27
 Investigation and management of postcoital bleeding
service for screening for other STIs and partner notification.
Test of cure is not usually required unless there are
compliance issues, or the patient is pregnant. Less
frequently, gonorrhoea may cause postcoital bleeding. Like
chlamydia, it is best detected using NAATs on a vulvovaginal
swab. First-line treatment of uncomplicated gonorrhoea is
ceftriaxone 1 g intramuscularly as a single dose. Test of cure
is advised for all confirmed cases of gonorrhoea because of
the increasing prevalence of antibiotic-resistant strains.18 All
women who test positive for gonorrhoea should also be
referred on to local sexual health services for further testing
and partner notification.
If endometritis or pelvic inflammatory disease (PID) is
suspected, broad-spectrum antibiotic therapy should be
commenced without delay. Microbiology swabs should
ideally be obtained before commencing antibiotic therapy.
Long-term complications of untreated PID include chronic
pelvic pain, adhesions, ectopic pregnancy and subfertility.
Antibiotic regimens recommended by BASHH18 aim to
ensure treatment of all potential causative microbes,
including gonorrhoea, chlamydia and anaerobes. If the
patient is clinically unwell, they will require inpatient
admission and initial treatment with intravenous
antibiotics. The latest recommended inpatient and
outpatient antibiotic regimens are listed in Table 3.18
Cervical cancer
The prevalence of cervical intraepithelial neoplasia (CIN) and
cancer among women with postcoital bleeding is estimated to
be 3–18%.11 A retrospective study of 314 women with
postcoital bleeding identified 12 cases of invasive cancer
(3.8%) and 54 cases of CIN (17.2%). In this cohort, there
were ten cervical or vaginal cancers, of which eight were
clinically apparent on speculum examination and four had
a normal smear before onward referral for further
investigation.19 A further retrospective study of 142 women
with postcoital bleeding reported no cases of invasive cancer,
but 27 cases of CIN (19.6%), of which 15 were high-grade
disease (CIN2/3).20
The incidence of cervical cancer has fallen significantly
since the introduction of the NHS cervical screening
programme in 1988;21 however, approximately 3200 new
cases of cervical cancer are still diagnosed each year in the
UK.22 Currently, all women aged 25–64 years are routinely
invited for cervical screening. Women are recalled every
3 years until the age of 50, when the screening interval
increases to every 5 years. Screening invitations cease after
the age of 65, unless the woman has previously had a cervical
abnormality or positive HPV test. These women should
continue to be recalled until they have completed follow-up.
HIV-positive women are at higher risk of developing cervical
dysplasia or invasive cancer owing to immunosuppression, so
therefore require annual screening.3
28
High-risk subtypes of the human papillomavirus (hrHPV)
account for nearly all cervical cancers. HPV-16 and HPV-18
are the commonest pathogenic subtypes, accounting for over
70% of cervical cancers. It is estimated that 70% of women
will contract HPV in their lifetime. Most will clear the
infection; however, persistence of HPV DNA can lead to the
development of dysplasia and invasive cancer. The causal
association between hrHPV and cervical cancer led to the
introduction of the HPV vaccination programme in 2008,
with the aim to prevent the acquisition of HPV infection. The
current immunisation programme comprises two doses of
Gardasil, the quadrivalent HPV vaccine, which protects
against HPV-6, HPV-11, HPV-16 and HPV-18.23 The
programme initially targeted 12 and 13-year-old girls but
has since been extended to include boys of the same age.
Indications for colposcopy were discussed earlier in this
review. Women with low-grade lesions (CIN1) can be offered
surveillance with further screening in 12 months. On the
other hand, women with lesions consistent with high-grade
disease (CIN2/3) should be offered excisional treatment at
the first visit (‘see and treat’). Excisional treatment is
associated with a two-fold relative increase in the risk of
preterm birth, but the absolute risk remains low.24 Women
with invasive disease should be referred to a tertiary cancer
centre for further assessment and management.
Vulval and vaginal lesions
Urogenital atrophy results from estrogen deficiency and
is commonest in postmenopausal women. It typically
presents with vulvovaginal dryness and irritation, decreased
lubrication, superficial dyspareunia and, occasionally,
postcoital bleeding secondary to trauma during intercourse.
Examination findings consistent with vaginal atrophy include
pale and dry vaginal mucosa with contact bleeding on the
vaginal walls or cervix. Treatment includes the use of vaginal
moisturisers, lubricants, topical estrogens, dehydroepiandrosterone
(DHEA), ospemifene and laser.
Vulval dermatoses such as lichen planus, lichen sclerosus
and contact dermatitis may cause postcoital bleeding
associated with fissuring of the skin. Patients with these
conditions should be advised to avoid soap and potential
irritants. Regular use of emollients and topical steroids
reduces inflammation and improves skin integrity. Vulval
biopsies should be considered if there are pigmented lesions,
ulcerated or eroded areas, or if the patient fails to respond to
treatment following initial diagnosis. Lichen sclerosus is
associated with a 4.0–6.7% risk of developing squamous cell
carcinoma of the vulva and requires annual review.25 Vulval
intraepithelial neoplasia (VIN) and vulval cancer typically
present with vulval irritation or a palpable lesion, but may
also cause unscheduled bleeding. These lesions may present
as thickened white or pigmented mucosal plaques, warty
lesions, or as persistent ulcers, and may be unifocal or diffuse.
ª 2021 Royal College of Obstetricians and Gynaecologists

Table 3. Recommended antibiotic regimens for the treatment of
pelvic inflammatory disease
Setting First-line antibiotic regimens
Outpatient Intramuscular ceftriaxone 1 g as a single dose + oral
doxycycline 100 mg twice daily for 14 days + oral
metronidazole 400 mg twice daily for 14 days
OR
Oral ofloxacin* 400 mg twice daily for 14 days + oral
metronidazole 400 mg twice daily for 14 days
OR
Oral moxifloxacin* 400 mg once daily for 14 days
Inpatient Intravenous ceftriaxone 2 g daily + intravenous or oral
doxycycline 100 mg twice daily until 24 hours after
clinical improvement
Followed by oral doxycycline 100 mg twice daily for
14 days + oral metronidazole 400 mg twice daily for
14 days
OR
Intravenous clindamycin 900 mg three times a day +
intravenous gentamicin 2 mg/kg loading dose followed
by 1.5 mg/kg three times a day until 24 hours after
clinical improvement
Followed by oral clindamycin 450 mg four times a day or
oral doxycycline 100 mg twice daily for 14 days + oral
metronidazole 400 mg twice daily for 14 days
*Ofloxacin and moxifloxacin should be avoided if high risk of
gonococcal pelvic inflammatory disease
Lesions should be biopsied rather than excised and should
include the area of epithelium where there is transition of
normal to abnormal tissue. If vulval cancer is strongly
suspected on examination, urgent referral to a tertiary cancer
centre should not be delayed while awaiting the biopsy result.
Rarely, postcoital bleeding may be the presenting symptom
for other cancers of the female genital tract. Vaginal
intraepithelial neoplasia (VAIN) and vaginal cancer are
usually asymptomatic, but many women report spotting
following intercourse and unusual vaginal discharge. VAIN
appears as white or red mucosal plaques, whereas vaginal
cancer presents as a persistent ulcerated lesion, usually on the
posterior aspect of the upper third of the vagina. Women
with suspected VAIN or vaginal cancer should be urgently
referred to colposcopy for further assessment and biopsies.4
Finally, postcoital bleeding may occur following trauma to
the lower genital tract, such as a vaginal laceration. A study
by Astrup et al.26 reported that 34% of women aged 19–
40 years sustained some kind of vaginal trauma during
consensual intercourse. In cases of traumatic bleeding,
surgical repair is the standard of care.
ª 2021 Royal College of Obstetricians and Gynaecologists
Owens et al.
No underlying cause
Approximately, 50% of women presenting to primary
care with postcoital bleeding will have no obvious
underlying cause.19 These women can be reassured that 60%
of women experience a spontaneous resolution of symptoms
within 6 months.27
Summary
Postcoital bleeding is a common gynaecological symptom
and is rarely associated with malignancy. There is
inconsistency in the management of postcoital bleeding
among gynaecologists.28 Patients presenting with postcoital
bleeding require a thorough history and examination to
formulate a differential diagnosis and guide further
investigations. A cervical screening test should only be
performed if one is due as part of the NHS cervical
screening programme. Women with a previously negative
screening test have a greatly reduced risk of cervical cancer.
However, a previous negative result does not exclude the
possibility of malignancy and should not delay referral to
colposcopy if there is a clinical suspicion of cervical cancer.
Disclosure of interests
PMH is the current President of the British Society for
Colposcopy and Cervical Pathology. NJW is current Secretary
for the British Gynaecological Cancer Society. GLO has no
conflicts of interest.
Contribution to authorship
GLO and PMH made substantial contributions to the
concept and design of the article. All authors drafted and
edited the article and 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
Infographic S1. Postcoital bleeding
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14 Tanos V, Berry KE, Seikkula J, Raad EA, Stavroulis A, Sleiman Z, et al. The
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ª 2021 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12778
The Obstetrician & Gynaecologist
http://onlinetog.org
Female sexual dysfunction
a b
Victoria Kershaw MRCOG, Swati Jha MD FRCOG
a
Subspecialty Trainee in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root Walk, Sheffield S10
2SF, UK
b
Consultant Gynaecologist, Subspecialist in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root
Walk, Sheffield S10 2SF, UK
*Correspondence. Swati Jha. Email: swati.jha1@nhs.net
Accepted on 31 July 2020. Published online 11 November 2021.
Key content
 Female sexual dysfunction (FSD) is defined as any sexual
complaint or problem resulting from disorders of desire, arousal,
orgasm or sexual pain that causes marked distress or
interpersonal difficulty.
 Various gynaecological problems such as pelvic organ prolapse and
endometriosis affect sexual function and this impacts on
their treatment.
 Management often requires the need to address different
components of the sexual dysfunction.
 Women wish to keep their options relating to sexual function open
well past the menopause, and more women are presenting in later
life with FSD.
Learning objectives

To know how to assess FSD in clinical practice.
Please cite this paper as: Kershaw V, Jha S. Female sexual dysfunction. The Obstetrician & Gynaecologist 2022;24:12–23.https://doi.org/10.1111/tog.12778
Introduction
Expressions of sexuality and intimacy are some of the most
complex aspects of human behaviour, and sexual function is
an important component of quality of life.1 Sexual
dysfunction is more common in women than men, yet it is
less frequently investigated.2 Left untreated, sexual problems
are associated with decreased quality of life, depression and
interpersonal conflicts.3
The Diagnostic and Statistical Manual of Mental Disorders
(DSM) defines female sexual dysfunction (FSD) as “any sexual
complaint or problem resulting from disorders of desire,
arousal, orgasm, or sexual pain that causes marked distress or
interpersonal difficulty”.4 To qualify as a dysfunction, the
problem must be present more than 75% of the time, for more
than 6 months, causing significant distress.
In the DSM-5, there were several updates to the
classification described in the previous version (DSM-4).5
Female hypoactive desire and female arousal disorder were
merged and are now called sexual desire/arousal disorder.
Female orgasmic disorder remained unchanged. The
formerly separate dyspareunia and vaginismus are now
12
2022;24:12–23
Review
*
 To appreciate the reasons why all women attending a gynaecology
clinic should have their sexual function assessed to establish
a baseline.
 To establish realistic expectations of outcomes on sexual function
following treatment of gynaecological problems.
Ethical issues
 Failure to inform women of the risk of deterioration in sexual
function following gynaecological surgery can lead to litigation.
 Some essential treatments, such as vulvectomy or prophylactic
oophorectomy, will result in adverse effects on sexual function,
and women should make informed choices regarding
their treatment.
Keywords: dyspareunia / female sexual dysfunction / genitopelvic
pain disorders / hypoactive sexual desire disorders / orgasmic
disorders
called genitopelvic pain/penetration disorder. Changes to
the terminology are shown in Table 1.
Several other organisations, including the World Health
Organization, International Statistical Classification of
Diseases and Related Health Problems (ICD-10), the
International Consultation of Sexual Medicine (ICSM),
the International Urogynecological Association (IUGA) and
the International Continence Society (ICS), have also
attempted to define FSD.6 Although FSD is perhaps best
regarded as a spectrum of disorders with considerable
overlap between them,1 there is consensus that the main
subcategories of FSD are sexual desire/arousal disorders,
orgasmic dysfunction and sexual pain disorder. Sexual
disorders may be lifelong, acquired, generalised
or situational.4
The National Surveys of Sexual Attitudes and Lifestyles
(NATSAL) are among the largest surveys of sexual behaviour
in the world. They have been carried out in the UK every
10 years since 1990. The third survey (2010–2012) showed
continuation of sexual activity into later life, emphasising the
need for attention to sexual health irrespective of age.7 The
fourth survey was commenced in May 2020.
ª 2021 Royal College of Obstetricians and Gynaecologists

Table 1. Categories of female sexual dysfunction
DSM-4 DSM-5
Desire disorders Desire/arousal disorders
Hypoactive sexual desire disorder Merged desire and arousal
Sexual aversion disorder into single category
Deleted sexual aversion
disorder
Arousal disorders
Orgasm disorder Female orgasm disorder
Sexual pain disorders Genito-pelvic pain/
Dyspareunia: pelvic pain with intercourse penetration disorder
Vaginismus: pelvic floor muscle spasm Merged dyspareunia and
leading to pain and obstruction with vaginismus
penetration
Abbreviation: DSM = Diagnostic and Statistical Manual of Mental
Disorders
This article provide an update on FSD terminology, an
understanding of the various gynaecological problems and
their effects on sexual function, as well as the impact of
gynaecological treatments. We also assess the effectiveness of
various therapeutic modalities for this condition.
Psychosexual counselling is outwith the remit of
this article.
Epidemiology
Epidemiological studies have indicated a prevalence of sexual
problems in women of between 30% and 60%. The
commonest sexual problem is lack of interest in sex,
followed by inability to experience orgasm and painful
intercourse.1,8 Studies use different criteria for defining FSD,
hence it is difficult to know the true prevalence. However,
only 21% of women with sexual problems sought help.1
Every general practitioner (GP) will see several women or
couples per year presenting with sexual problems.9 In women
attending a gynaecology clinic, the prevalence of sexual
concerns has reportedly been as high as 98%.10 Despite this,
FSD can be overlooked. It is often disguised as unresolved
complaints and requests for repeated investigations.11
Furthermore, clinicians often avoid discussing sexual
problems, citing reasons such as limited time and training,
embarrassment and absence of effective treatment options.12,13
Normal sexual response cycle
The female sexual response cycle is poorly understood and
challenging to define owing to multiple overlapping
ª 2021 Royal College of Obstetricians and Gynaecologists
Kershaw and Jha
dimensions and complex biopsychosocial influences. It is
now recognised not to be a simple linear progression of
processes, beginning with desire and ending in resolution – a
concept first introduced by Masters and Johnson in
the 1960s.2
The circular model described by Basson14 (Figure 1)
acknowledges the interplay of the sexual responses of both
the mind and the body. Approximately 30% and 50% of
women may reach orgasm during vaginal penetration and
direct clitoral stimulation, respectively.15 However, in
Basson’s model, orgasm is not essential for sexual fulfilment.
In partnered sexual relationships, feelings of love and
emotional intimacy are important to initiate and maintain
sexual satisfaction.16 Mental wellbeing is a robust predictor of
sexual desire and responsiveness; women who defined
themselves as being in good mental health were less likely
to report distress about their sexual relationship than women
who reported lower mental wellbeing scores.17 Studies have
shown a high correlation between low desire and measures of
low self-image, mood instability and tendency towards
anxiety.18 In addition, several factors are commonly cited
as distractions from sexual activity, including concerns
regarding one’s own/partner’s arousal, fear of pregnancy,
fear of sexually transmitted disease and lack of privacy.8
Conservative societal stereotypes with traditional gender-
based expectations exert a profound effect on women’s
sexuality. In some cultures, women may be expected to be
submissive recipients of sex, leading to negative consequences
regarding arousal and orgasm. Although these views are
generally fading, they remain prevalent in some societies.19
Causes of female sexual dysfunction
Healthy sexual function involves a complex interplay between
anatomical, vascular, neurological, hormonal and
psychological factors. Thus, aetiology of FSD is broad and
often multifactorial. Table 2 categorises medical,
gynaecological and psychosocial disorders that may affect
sexual function; however, several other medical illnesses can
also affect sexual function in some way. Various medications
have also been implicated in FSD (Box 1).
Clinical assessment
Patients presenting with gynaecological problems commonly
have underlying sexual dysfunction. This can be caused by
physical problems, psychological factors or a combination of
both. However, patients are often reluctant to volunteer this
information. There is frequently an aspiration that treatment
of gynaecological issues will alleviate sexual problems, but it
is important for patients to have realistic expectations of
what can be achieved prior to undergoing any form of
treatment. This is only possible if a baseline assessment of
13
 Female sexual dysfunction

Willingness to
become receptive

Motivation
Sexual stimuli with
appropriate context
Multple reasons and
Spontaneous ‘innate’
incentives for
desire
insitigation of or
agreeing to sex
Psychological and
biological processing

Nonsexual rewards: Sexual satisfaction

emotional intimacy, with/without orgasm
well-being,
Subjective
from sexual avoidance arousal

Arousal and responsive

sexual desire

Figure 1. Sex reponse cycle14

sexual function is conducted, which should form part of any

routine gynaecological consultation.
Taking a brief sexual history during a new patient visit can
help to identify issues and indicate to the patients that
discussion of sexual concerns is welcome. In a busy
gynaecology clinic, where the presenting complaint is not
FSD, a few quick screening questions such as, ‘Do you have
any concerns about your sex life?’ will help identify any
underlying problem and can be used to begin the
conversation (Table 3).20 The LOFTI acronym (listening,
observing, feelings, thinking and interpreting)21 has been
proposed when assessing sexual problems in women
attending with underlying psychosexual problems.
Clinicians must not make any assumptions about the
patient’s sexual behaviour. It is best to mirror the patient’s
sexual vocabulary so she can relate and understand the
discussion. Some women may respond best to open
questions, while others may feel more comfortable giving
more precise answers to specific questions.19 Others may find
it easier to complete a written sexual function questionnaire,
such as the Female Sexual Function Index.22 There are also
condition-specific questionnaires to assess sexual function.
For example, the Prolapse and Incontinence Sexual Function
Questionnaire (PISQ-31)23 and the IUGA Revised version
(PISQ-IR)24 are routinely used in many urogynaecology
clinics. Quality of life questionnaires also provide a useful
quantitative measure of baseline sexual function and can be
repeated following interventions to assess response.
Aspects to consider when a more detailed history,
examination and investigation is required are shown
in Box 2.
Impact of obstetric conditions/
gynaecological problems
Pregnancy and childbirth
Sexual desire can often decrease during pregnancy.1 This
commonly persists into the postnatal period, with factors such
as the demands of caring for a new baby, fatigue, hormonal
changes, perineal wound healing, breastfeeding, postnatal
depression and change in body image all being implicated.
Indeed,sexual problemsappear to bepermanentlyincreasedafter
childbirth, with 83% experiencing problems in the first
3 months, declining to 64% at 6 months, but never reaching
levels comparable to nulliparous women (38%). It is widely
reportedthatmodeofdeliveryis relatedto postnataldyspareunia,
with operative vaginal delivery being particularly implicated,
carrying at least a two-fold increased risk compared with
spontaneous vaginal delivery.25 Furthermore, operative vaginal
delivery is associated with a persistent rate of dyspareunia of
14% at 12 months. The protective effect of caesarean section on
sexual function appears to be limited to the first 6 months of
the postnatal period compared with spontaneous vaginal
delivery with an intact perineum (3.4% dyspareunia).26
Menopause
The prevalence of FSD in postmenopausal women varies
from 68–86%. In a study of women aged 40–69 years, 71%
reported they were sexually active.27 In this age group,
common sexual complaints include loss of desire, decreased
frequency of sex, dyspareunia, vaginal dryness and
dysfunction of the male partner. In a study of women aged
40–62 years, age was found to negatively influence all

14 ª 2021 Royal College of Obstetricians and Gynaecologists

 Kershaw and Jha

Table 2. Causes of female sexual dysfunction Table 2. (Continued)

Group Subgroup Examples Group Subgroup Examples

Medical Cardiovascular Atherosclerosis Menopause

Hypertension
Ischaemic heart disease Psychosocial Age
Peripheral vascular disease Obesity
Diabetes Smoking, alcohol, drug misuse
Heart failure Socioeconomic class
Relationship difficulties
Neurological Spinal cord injury Life stressors
Stroke Mental health disorders, e.g.
Parkinsonism depression, anxiety, obsessive
Multiple sclerosis compulsive disorder
Diabetic neuropathy Sexual abuse
Traumatic memories
Endocrine Thyroid disease Negative body image
Hyperprolactinaemia Suppressive societal stereotypes
Adrenal insufficiency
Hypopituitarism

Gastrointestinal Inflammatory bowel disease

Faecal incontinence
Irritable bowel syndrome
Liver failure

Rheumatological Inflammatory arthritis Box 1. Medications implicated in female sexual dysfunction

Systemic lupus erythematosus
 Anti-androgens, e.g. cimetidine, spironolactone
Miscellaneous Breast cancer  Anticonvulsants
Chronic kidney disease  Anticholinergics
 Antidepressants, e.g. selective serotonin reuptake inhibitors (SSRIs)
Pelvic Gynaecological Prolapse  Anti-estrogens, e.g. tamoxifen, gonadotrophin-releasing hormone
disorders Fibroids (GnRH) analogues
Endometriosis  Antihistamines
Sexually transmitted infections  Antihypertensives
Gynaecological cancer/precancer  Aromatase inhibitors, e.g. letrozole
Infertility  Sedatives and hypnotics
Childbirth  Hormonal contraception
Congenital mullerian anomalies  Sympathomimetic amines
Previous gynaecological surgery  Metoclopramide
 Metronidazole
Urological Overactive bladder  Cyclophosphamide
Stress urinary incontinence
Urological cancer

Functional Vaginismus domains of sexual function, while menopause only affected

Chronic pelvic pain
Painful bladder syndrome
Vulval Vulvovaginal atrophy
disorders Lichen sclerosus/planus
Systemic dermatoses affecting the
vulva
Sexually transmitted infections
Female genital mutilation
Previous vulval surgery
Hormonal Premenstrual syndrome
Pregnancy
Breastfeeding
Premature ovarian failure
pain and lubrication.1 It seems that ageing itself, and the
associated effects on physical and psychological health status,
can have a more significant impact on sexual function than
the menopause itself.
Subfertility
In couples who are trying to conceive, the goal-orientated
approach to sex can result in the measurement of success or
failure of sexuality in terms of the ability to produce a child,
rather than the pleasure derived from it. When struggling to
conceive, the woman may harbour feelings of being defective,
or experience loss of self-worth and body image, leading to a
decreased sexual desire, sexual arousal disorders and

ª 2021 Royal College of Obstetricians and Gynaecologists 15

 Female sexual dysfunction

Table 3. Screening questions for assessment of female sexual
dysfunction
Screening question
Do you have anyconcerns
regarding your sex life?
Are you currently sexually active?
Box 2. Clinical assessment of female sexual dysfunction
History
Further assessment
 Medical history
 Current medication
If answer no, no further questions  Obstetric history
 Systems review
 Psychiatric history
If answer no, ask  Social circumstances
“Is that related to your current  Current life stressors
health problems?"  History of sexual abuse and female genital mutilation

Are the problems with:
 Sexual desire/libido
 Sexual arousal (including
vaginal lubrication problems)
 Orgasm
Are you experiencing any pain
related to intercourse
(penetration or deep pelvic)?
If anything changes, feel free to
ask in future
anorgasmia. Scheduling sexual activity when trying to
conceive can also be a problem.1
Assess for desire/arousal disorder
Assess for female orgasm disorder
Assess for genitourinary syndrome
of menopause (GSM), vulval
dermatoses pelvic floor muscle
dysfunction, pelvic pathology
Gives permission to patient to
broach the subject in future
consultations.
Examination
 General examination with particular attention to vascular and
neurological systems
 Inspection for vulvar pathology
 Speculum examination to inspect condition of vagina and cervix and
assess for prolapse
 Gentle bimanual examination to elicit tender points and scarring,
assess for pelvic mass
 Assess pelvic floor tone
 Cotton bud evaluation od vestibule for localised tenderness if
indicated by history
Investigations
 Follicle-stimulating hormone or estradiol if symptoms of deficiency
and not known to be menopausal
 Free androgen index and sex hormone binding globulin
 Thyroid function tests if features of thyroid disease
 Prolactin if amenorrhoea/galactorrhoea
 Ferritin if features of iron deficiency
 Test for hyperlipidaemia and diabetes if indicated by clinical
assessment
 Sexual health screen if indicated

Pelvic floor dysfunction Patients should be informed of this as part of the

Up to 50% of women presenting with urogynaecological
problems report FSD.1 Stress urinary incontinence (SUI),
overactive bladder and other lower urinary tract symptoms
can have a negative effect on all domains of sexual function.
Fear of odour, embarrassment, loss of self-esteem and coital
incontinence can all have a considerable impact. Up to one-
third of women with pelvic organ prolapse (POP) also report
FSD. Women with POP are more likely to report
embarrassment and avoidance of sex, dyspareunia, dryness
(53%), lack of sensation (60%), vaginal obstruction (59%),
orgasmic disorders and coital urinary/faecal incontinence.28
Suffering with both prolapse and incontinence has a
cumulative negative effect on sexual function in all
domains. FSD does not appear to correlate with a
particular compartment of prolapse.
Kuhn et al.29 showed that desire, lubrication and sexual
satisfaction improved significantly, and orgasm remained
unchanged, in women who used a pessary for POP and were
sexually active.
In the surgical treatment of POP and SUI,
reconstructing local anatomy and alleviating symptoms
does not necessarily ensure optimal sexual function.
consent process, so they understand that sexual function
could worsen as a result of surgery. Altered perception of
genital health after surgery, with associated fear of
damaging themselves, can also have a negative impact on
FSD. However, despite the theoretical risks, on the whole
sexual dysfunction improves following both prolapse
repair and stress incontinence surgery.
A recent systematic review examining the effect of native
tissue prolapse repair on sexual function showed that 47%
improved, 39% remained unchanged, 18% deteriorated and
4% reported de novo dyspareunia – although this review was
unable to separate results by compartment.30 Increased
postoperative dyspareunia was found consistently when
anterior and posterior repairs were combined in the same
procedure; many gynaecologists may consider a two-stage
procedure for sexually active women requiring repair to both
compartments. When performing pelvic floor repair, ensure
that vaginal length is maintained, excessive vaginal excision
is avoided and introital calibre is preserved.31 Regarding
vaginal vault prolapse, sacrospinous fixation was asso-
ciated with higher rates of dyspareunia than abdominal
mesh sacrocolpopexy.32

16 ª 2021 Royal College of Obstetricians and Gynaecologists


A systematic review noted that following surgery for SUI
(mid-urethral tape/colposuspension/autologous fascial sling),
coital incontinence probably improves.33 Overall sexual
function probably remains unchanged, although there is a
small possibility of improvement or even deterioration
following surgery. The retropubic or obturator approach
does not influence sexual function.33
Some studies show promising results regarding the effect
of sacral nerve stimulation and percutaneous tibial nerve
stimulation on FSD in patients undergoing treatment for
pelvic floor dysfunction.34,35
Dysfunctional uterine bleeding and pelvic pain
Endometriosis, fibroids and adenomyosis may be associated
with dyspareunia. Erratic, heavy or painful menstrual
bleeding can also affect sexual function considerably.
Sexual function after hysterectomy has been studied
extensively. It has been hypothesised that damage to the
autonomic nerve endings of the cervicovaginal area and
vaginal shortening may interfere with lubrication, orgasm
and sexual pleasure.36 In addition, hysterectomy may have
psychological effects, leading to loss of feminine identity and
self-esteem. The largest prospective study to date is the
Maryland Women’s Health Study, which found that, at
24 months post-hysterectomy, there was increased frequency
of sexual activity and improvement in dyspareunia, orgasm,
libido and vaginal dryness.37 The surgical approach
(abdominal, vaginal, laparoscopic) did not affect sexual
outcomes. The method of vaginal cuff closure did not impact
on sexual function.31 Furthermore, a randomised controlled
trial (RCT) comparing total versus subtotal hysterectomy
found no difference in postoperative dyspareunia, quality of
orgasm or sexual satisfaction. Concomitant oophorectomy
can, however, be implicated in FSD, particularly in
premenopausal women, because of the resultant abrupt
reduction in estrogen and testosterone production. Hormone
replacement therapy (HRT) is usually recommended for
patients under the age of 50 years undergoing bilateral
oophorectomy. Replacement testosterone can also be offered
if necessary.
Gynaecological precancer/cancer
Patients with an abnormal cervical smear result were
found to have a negatively affected sexual function in all
domains and more negative feelings towards
their partners.38
There is a high prevalence of FSD amongst gynaecological
cancer patients, with 74% reporting low sexual desire and
40% suffering from dyspareunia. There are direct effects of
disease and treatment, as well as psychological and
behavioural changes that disrupt sexual function.
Complaints in this patient group include vaginal dryness,
short vagina, inelastic vagina and dyspareunia. Radiotherapy
ª 2021 Royal College of Obstetricians and Gynaecologists
Kershaw and Jha
is more debilitating to sexual function than radical
hysterectomy. The growing interest in FSD after pelvic
surgery has led to the development of nerve-sparing
surgical techniques.
Female genital mutilation
Female genital mutilation (FGM) types 2 and 3 can affect all
aspects of sexual function and are associated with post
traumatic stress disorder (PTSD), low self-esteem, disturbed
self-identity, desire/arousal disorders and orgasmic disorders,
as well as pain and obstruction during intercourse.39
Management should be multifaceted, with a combination
of approaches including psychotherapy. However, despite
best efforts, some women will have permanent dysfunction.
Psychosexual counselling may be required to address
their problems.
Many of the surgical treatments described for the
treatment of underlying gynaecological problems can
induce psychosexual problems postoperatively because of
factors such as loss of fertility, disfigurement, depression and
anxiety about one’s desirability as a sexual partner.40 Anxiety
regarding a return of normal sexual function heightens these
problems. A period of psychosexual adaptation is often
required before sexual function returns to normal. Partners
may also be affected psychologically owing to concerns about
causing harm following surgery.41
Management
A multidisciplinary approach is often required when
managing FSD.19 For example, a patient suffering from
genitopelvic pain disorder (vaginismus) may benefit from
cognitive behavioural therapy (CBT), vaginal dilator use,
lubricants, pelvic floor physiotherapy and relaxation
techniques. Even after treatment of an underlying
medical/gynaecological cause, the history of FSD may
have longer lasting psychological effects and the patient
may still benefit from psychosexual counselling/
psychological interventions.
General principles
 Educating the patient (and partner, where relevant) about
normal physiological response and anatomy may be
necessary. Physiological changes related to ageing and
implicated medical conditions should be explained.
 Lifestyle modifications, nonpharmacological therapies and
psychosexual counselling may be considered first-line
intervention in cases where aetiology is not physical.
 Review medications and, in conjunction with the GP/
prescriber, consider alternatives or reduced doses of
medications implicated in FSD.
 Treatment of underlying gynaecological/medical condition.
17
 Female sexual dysfunction
Lifestyle modifications
Weight loss, smoking cessation, reduction in alcohol
consumption, establishing a healthy diet and a regular
exercise regime are all valuable interventions for improving
FSD and health.42
Dedicating specific time to spend with their partner can
also help to improve women’s quality of sexual life.43
Nonpharmacological therapies
Physiotherapy
Pelvic floor exercises that focus on the functional control of
each muscle in the pelvis can be helpful for women suffering
from genitopelvic pain disorder.44 Practising contracting and
relaxing the pelvic floor can help bring this under voluntary
control. Deep pelvic relaxation is important to practice when
also using vaginal dilator therapy.
Pelvic floor physiotherapy is also part of the first-line
management of SUI and first-stage POP.45 Following a 6-
month course of pelvic floor physiotherapy, 39% of women
reported an improvement in sexual function. Pelvic floor
exercises were associated with increased control, strength and
awareness of the pelvic floor, improved self-confidence,
sensation of a ‘tighter’ vagina, improved libido and orgasms,
resolution of pain with intercourse and heightened sexual
gratification for partners.46 No difference was found between
standard physiotherapy and electrical stimulation.47
Zahariou48 evaluated the effect of pelvic floor muscle
training on sexual function in a group of women with SUI.
All domains of the FSFI were significantly improved
12 months after treatment.
In a study of healthy women, strong or moderate pelvic
floor muscle contractions were associated with significantly
higher scores on both orgasm and arousal domains of the
FSFI compared with women with weak contractions.49
Vaginal dilators
Dilators can be useful for women who experience involuntary
pelvic muscle contraction (vaginismus) or vaginal stenosis.
Beginning with a small device, the dilators gradually increase
in size until, ultimately, intercourse is introduced.50 Results
are better when this is supervised, either by a specialist nurse
or women’s health physiotherapist, to provide the support
these patients require. Better outcomes have been reported
when used in conjunction with topical estrogen cream for
menopausal women.51
Self-stimulation and devices
The benefits of self-stimulation have been reported in
literature, as women learn more about their sexual response
cycle and become more familiar with their body.
Masturbation is an effective way for women who have
18
never achieved orgasm to learn how to do so without the
pressure of interacting with their partner.
Frequent masturbation in couples was associated with
relationship dissatisfaction, suggesting that it may not be
healthy for a couple to replace partnered sexual activity with
individual sexual activity. Indeed, there is evidence to suggest
that partnered sexual activity may create a higher level of
emotional wellbeing.19
Clitoral vacuum/therapy devices are handheld, battery-
operated devices with a small, soft plastic cup that applies a
gentle vacuum over the clitoris and a low-level vibratory
sensation to cause increased blood flow.52 They are designed
to be used three or more times a week for approximately
5 minutes at a time. Small studies have shown that use of this
device may improve arousal and orgasm;53 however, these
have not been tested in well-conducted trials.
Vibration devices are designed for both clitoral and vaginal
stimulation. A relationship between vibrator use and positive
sexual functioning has been reported.19
Psychotherapies
Cognitive behavioural therapy/sex therapy
Cognitive behavioural therapy (CBT)/sex therapy focuses on
identifying and modifying maladaptive thoughts,
expectations and behaviours that negatively affect sexual
functioning. Strategies are suggested to improve the couple’s
emotional connection and communication, but the evidence
is controversial.54 When couples are being consulted, they are
encouraged to focus on the strengths as well as weaknesses in
their relationship. Homework assignments are given for the
couple to practice skills, such as turning the idea of sexual
obligation into pleasure, learning to focus on sensations
rather than anxieties and communicating openly with their
partner. One approach is the use of sensate focus techniques,
consisting initially of nonsexual physical touch with gradual
progression toward sexual touch. Partners are encouraged to
provide feedback about what touches are pleasurable to help
reduce performance-related anxiety.55
Psychosexual counselling
The aim of psychosexual counselling is to understand and
manage emotional factors, which are not always experienced
at a conscious level, but interfere with sexual performance
and enjoyment. Counselling sessions are aimed at assessing
the attitudes, anxieties and fantasies relevant to
understanding the sexual problem in conjunction with a
detailed physical examination. This may take place over
several consultations. During the consultation, issues relating
to the impact of upbringing and memories of family, social
life and religious beliefs56 on sexual function may be
uncovered. Past relationships, self-esteem, previous sexual
abuse and trauma are also explored. Details of psychosexual
ª 2021 Royal College of Obstetricians and Gynaecologists

counselling are out with the remit of this article, but have
been previously discussed in The Obstetrician &
Gynaecologist.21 However, all gynaecologists should have
basic training in providing psychodynamic therapy and
identifying patients who require formal input from a
psychosexual counsellor.
Psychosexual counselling is practised by clinicians,
including gynaecologists with adequate training (for
example, from the Institute of Psychosexual Medicine,
IPM). It is available in many, but not all, areas on the
NHS. It adopts a psychodynamic approach, which attempts
to connect the mind to the body.21 For gynaecologists who
lack training, it remains essential to recognise which women
require input from a trained psychosexual counsellor.
Yoga, relaxation techniques, hypnotherapy
Since stress and fatigue contribute to FSD, stress
management activities such as yoga or meditation may be
beneficial. Furthermore, hypnosis and relaxation therapies
have been cited as promising interventions for vaginismus,
but there is no conclusive evidence to support their use
at present.57
Medical therapies
Lubricants and vaginal moisturisers
Women who are menopausal, breastfeeding and/or suffering
with a genital arousal disorder may lack vaginal lubrication
and experience dyspareunia.58 Topical lubricants and vaginal
moisturisers can be used to relieve these symptoms. These
treatments can be used as required at the time of intercourse,
in addition to regular treatment with topical estrogen if
appropriate. Women should be advised to use a lubricant
that is physiologically similar to natural vaginal secretions.59
Hormones
Estrogen
A fall in estradiol levels can result in vaginal smooth muscle
atrophy and increased vaginal acidity, leading to
discomfort.60 Systemic HRT in isolation may not always
address these problems and vaginal estrogen may still be
required to treat FSD related to vulvovaginal atrophy.
Topical estrogen is currently available in the form of a
vaginal ring, vaginal creams and vaginal pessaries.
Breastfeeding women experiencing hormonal imbalance
caused by estrogen deficiency can also benefit from topical
estrogen as a treatment for dyspareunia and vaginal
dryness.61 Reassurance may be given that symptoms will
improve following cessation of breastfeeding.
The use of systemic estrogen in the form of HRT must be
considered carefully for the treatment of FSD alone.
However, for women suffering from a combination of
ª 2021 Royal College of Obstetricians and Gynaecologists
Kershaw and Jha
vasomotor symptoms and vulvovaginal atrophy, systemic
HRT would be appropriate62 following adequate discussion
with the patient.
Following breast cancer treatment, women who are on
aromatase inhibitors for adjuvant therapy (as opposed to
tamoxifen) are more likely to suffer with sexual dysfunction.
This can affect compliance and there may be a place for the
use of local estrogens in this cohort following adequate
discussion with the patient and her oncologist.63
Intravaginal prasterone
Prasterone is a steroid precursor, which is converted to
estrogen and androgens. Several studies have shown a
moderate benefit for vulvovaginal atrophy, although
prasterone has not been compared directly with other
treatments such as topical estrogen.
Ospemifene
Ospemifene is a selective estrogen receptor modulator, which
is licensed for the treatment of vulvovaginal atrophy in
women for whom topical estrogen is not suitable. This is
supported by a systematic review and meta-analysis, which
found that ospemifene is an effective treatment for
dyspareunia secondary to vulvovaginal atrophy.64 However,
the contraindications for ospemifene are similar to those for
estrogen, including breast cancer, endometrial hyperplasia
and history of venous thromboembolism, thereby limiting
its use.
Tibolone
Tibolone is a synthetic steroid with estrogenic, progestogenic
and androgenic properties, commonly used for the treatment
of menopausal symptoms. A study by Nijland et al.65
demonstrated that tibolone improved overall sexual
function, increased frequency of sex and reduced sexually
related personal distress in postmenopausal women with
FSD.45 However, tibolone is associated with a higher
increased risk of stroke than other HRT options.66
Testosterone
Testosterone production naturally declines after the
menopause. Low levels of testosterone are associated with
decreased libido, arousal and orgasm. Testosterone therapy in
the form of a transdermal patch or gel has resulted in
significant improvement in various domains of sexual
function in postmenopausal women,67 although there is a
lack of long-term safety data and several undesirable side
effects, including alopecia, hirsutism, acne, breast pain,
headache, adverse liver function, lipid profile change,
increased risk of cardiovascular disease, insulin resistance
and metabolic syndrome. It is perhaps best suited to patients
suffering from surgical menopause or a medical condition
resulting in androgen deficiency. In surgical menopause there
19
 Female sexual dysfunction

is an abrupt 50% reduction in production of testosterone in
contrast to the gradual decline in ovarian and adrenal
androgen production that ordinarily occurs naturally
with age.
Guidelines published by the National Institute for Health
and Care Excellence (NICE)62 and Cochrane reviews68 on
menopause now recommend considering testosterone
supplementation as HRT for women with low sexual desire
if estrogen replacement alone is not effective. The American
College of Obstetrics and Gynecology42 suggests that, if
prescribed, a 3–6-month trial is recommended, with
assessment of testosterone levels at baseline and after 3–6
weeks of initial use to ensure levels remain within the normal
range. It also suggests that if continuing therapy is used,
follow-up clinical evaluation and testosterone measurement
should take place every 6 months to assess for
androgen excess.
Oxytocin and progesterone have no role in the treatment
of FSD.
Drug therapy
Several drugs have been used for the management of FSD,
with variable results. These are discussed in Table 4.
Surgical
No operation is designed to improve sexual dysfunction and
evidence for a positive effect is lacking.
Lasers
Women suffering from breast cancer are a particularly
vulnerable group, with a high prevalence of lubrication
difficulties, dyspareunia and a low level of sexual desire.69
Topical estrogen is sometimes used off licence in this group
of women, but there is unwillingness to prescribe this long

Table 4. Drug therapy for female sexual dysfunction

Drug
group Examples Mechanism Evidence

Vasodilators Sildenafil (Viagra) Increases availability of cyclic guanosine
monophosphate (cGMP), which mediates vascular
smooth muscle relaxation via nitric oxide signalling
resulting in genital engorgement
Evidence for sildenafil is mixed
Has been shown to be beneficial in FSD secondary to
spinal cord injury and SSRI use
Large RCT of women with sexual arousal disorder
reported no benefit
Not licensed for FSD79

L-arginine, prostaglandin, All currently under investigation, no definitive

phentolamine, evidence to support use at present
vasoactive intestinal
peptide (VIP)

Dopamine Bupropion, Act centrally to influence behavioural states Dopamine agonists are effective in improving desire
agonists apomorphine, Given the central action of these drugs there is a in women with hypoactive desire disorder
cabergoline high occurrence of side effects, such as nausea, Cabergoline can improve FSD secondary to
vomiting and headaches antipsychotic-induced hyperprolactinaemia
Bupropion can help FSD related to SSRI use
Sublingual/intranasal apomorphine is currently
under investigation in the hope with will be quicker
acting and associated with few side effects

Serotonin Flibanserin Acts central to influence mood and behavioural FDA-approved from 2015 for treatment of
1a agonist/ states hypoactive desire disorder, although a systematic
2a review showed minimal or no improvement in
antagonist symptoms and a high rate of adverse effects
including dizziness, fatigue and nausea
Must abstain from alcohol to avoid hypotension/
syncope
Not licensed in UK

Muscle Tizanidine Centrally active alpha-2 agonist used as a muscle Superior to placebo in treating high-tone pelvic floor
relaxant relaxant dysfunction

Abbreviations: FDA = US Food and Drug Administration; FSD = female sexual dysfunction; RCT = randomised controlled trial; SSRI = selective
serotonin reuptake inhibitor

20 ª 2021 Royal College of Obstetricians and Gynaecologists


term. Lubricants and vaginal moisturisers have limited
efficacy when used alone in women for the treatment of
severe vulvovaginal atrophy.
Preliminary data for both erbium and carbon dioxide
vaginal lasers in the treatment of vulvovaginal atrophy are
promising. These may be an alternative for breast cancer
patients, but should not be introduced into clinical practice
without more robust evidence. In a recent systematic review,
vaginal laser therapy was effective in treating vulvovaginal
atrophy in breast cancer survivors, with improvement in
dyspareunia, vaginal dryness and sexual function.70 There is
therefore an urgent need for RCTs to assess the long-term
safety and efficacy of lasers.
Genital cosmetic surgery
Several surgical procedures have been developed that are
advertised as improving sexual function by altering the
appearance and/or the function of the female genital tract.
Such procedures include labioplasty, vaginoplasty, perineoplasty
and laser rejuvenation. They probably have an effect on body
image, rather than a clinical effect. Evidence supporting the
efficacy and safety of these procedures on sexual function
is lacking.6
Vestibulectomy
In vestibulectomy, the painful tissues of the vestibule are
identified and removed. An RCT by Bergeron et al.71 reported
significantly less dyspareunia in patients with localised
vulvodynia who underwent vestibulectomy than those treated
with CBT and electromyographic biofeedback. However, in a
study by Das et al.,72 outcomes on long-term sexual function
were more variable, with only 57% patients being satisfied
postoperatively. It is now rarely performed in the UK.
Fenton’s procedure
Fenton’s procedure can be offered when a patient experiences
dyspareunia secondary to narrowing, or skin-splitting at the
posterior fourchette, usually secondary to obstetric scarring.
It is used rarely for vulval dermatoses, such as lichen
sclerosus. However, benefit from this procedure is probably
modest and there is a paucity of evidence. Worsening of
dyspareunia is a potential risk. A small study of 24 women by
Chandru73 showed that at 12 months postoperatively, 14
women (60.8%) reported complete relief and moderate relief
was reported in nine (39%). Frappell et al.74 describe an
alternative to the Fenton’s procedure, in the form of an
opposing Z-plasty with V-Y advancement of perineum (the
‘Plymouth procedure’). Functional outcome assessed by
enjoyment of sexual intercourse improved in 78% of women.
Trigger point injections
A prospective study investigated the role of trigger point
injections in women with levator ani muscle spasm. The
ª 2021 Royal College of Obstetricians and Gynaecologists
Kershaw and Jha
injection given was a 5-ml mixture of 0.25% bupivacaine, 2%
lidocaine, and 40 mg of triamcinolone per trigger point.
Three months after injections, 72% of women reported
improvement.75 Other combinations of medications have
also been used. The authors’ own preference is to use
bupivacaine, hyaluronidase and depot-medrone.
Botox injections to the pelvic floor muscles
Refractory vaginismus may respond to Botox injections
into the puborectalis and pubococcygeus.76,77 This should be
used in adequately selected cases with appropriate patient
counselling because the evidence for its use is limited to very
specific conditions.
Genital reconstructive surgery
In women undergoing distorting genital surgery, various
surgical techniques are employed to preserve/give provision
for sexual function in these patients. These may include local
and regional flaps and grafts, although further description of
surgical reconstructive options is beyond the remit of
this article.
Conclusion
FSD is a common condition with considerable detrimental
effects on quality of life, but is unfortunately often
overlooked by clinicians. As gynaecologists we must strive
to identify and explore sexual problems with our patients as
we are uniquely placed to do so. This also allows for
evidence-based counselling regarding any future
gynaecological treatment, including likely outcomes the
patient can expect for their sexual function.
Disclosure of interests
SJ is an Associate Editor for The Obstetrician & Gynaecologist;
she was excluded from editorial discussions and had no
involvement in the decision to publish.
Contribution to authorship
VK researched, wrote and edited the manuscript. SJ
instigated, researched, wrote and edited the manuscript.
Both authors approved the final version.
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23
 DOI: 10.1111/tog.12789 2022;24:7–11
The Obstetrician & Gynaecologist
Commentary
http://onlinetog.org

TOGadvisor: the role of online feedback in obstetrics and

gynaecology
Lorraine S Kasaven BSc (Hons) MRCOG PGCert,a* Srdjan Saso PhD MRCOG,b Jara Ben Nagi MRCOG MD,c,d
Karen Joash BSc (Hons) MRCOG MSc PGCert, Joseph Yazbek MD MRCOG,f J Richard Smith MD FRCOG,g
e

Tom Bourne PhD FRCOG FAIUM,h Benjamin P Jones BSc (Hons) MRCOG PhDi
a
Clinical Research Fellow, Department of Cancer and Surgery, Imperial College London, UK and Department of Cutrale Perioperative and Ageing
Group, Imperial College London, UK
b
Honorary Clinical Lecturer, Department of Surgery and Cancer, Imperial College London, UK and Gynaecological Oncology Consultant, Queen
Charlotte’s and Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
c
Honorary Clinical Senior Lecturer, Department of Cancer and Surgery, Imperial College London, UK
d
Consultant Gynaecologist and Reproductive Medicine and Surgery Specialist, Centre for Reproductive and Genetic Health, London W1W 5QS, UK
e
Consultant Obstetrician and Gynaecologist, Queen Charlotte’s and Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
f
Honorary Clinical Senior Lecturer, Department of Cancer and Surgery, Imperial College London, UK and Consultant Gynaecological Oncology
Surgeon, Queen Charlotte’s and Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
g
Honorary Senior Lecturer, Imperial College London, UK and Consultant Gynaecological Oncology Surgeon, Queen Charlotte’s and Chelsea
Hospital, Imperial College NHS Trust, London W12 OHS, UK
h
Professor of Gynaecology, Imperial College London, UK and Consultant Gynaecologist at Queen Charlottes and Chelsea Hospital, Imperial College
NHS Trust, London W12 OHS, UK
i
Obstetrics and Gynaecology Trainee Registrar, Queen Charlotte’s and Chelsea Hospital, Imperial College NHS Trust, London W12 OHS, UK
*Correspondence: Lorraine S Kasaven. Email: lk226@doctors.org.uk

Accepted on 23 February 2021.

Please cite this paper as: Kasaven LS, Saso S, Ben Nagi J, Joash K, Yazbek J, Richard Smith J et al. TOGadvisor: the role of online feedback in obstetrics and
gynaecology. The Obstetrician & Gynaecologist 2022;24:7–11. https://doi.org/10.1111/tog.12789

at least £23 billion of consumer spending per year.2 In

Introduction
In recent years there has been an exponential rise in online
feedback from patients reporting health experiences.1 While
undoubtedly facilitated by increased availability of and access
to the internet, a series of institutional changes within the
UK’s National Health Service (NHS) has compounded the
uptake. In 2004, NHS trusts were obliged to report service
outcomes to the Healthcare Commission to be published
online, allowing public access to information. In 2007, the
launch of the NHS website provided a platform for patients
to evaluate clinicians and hospitals online. Consequently, in
2016, NHS England implemented a strategy to incorporate
technology into the future of the NHS, supporting digital
transformation to revolutionise the way health care is
provided. The emphasis on a patient-centred approach has
facilitated the development of numerous physician feedback
websites, including iWantGreatCare, Care Opinion
and Doctoralia.
Feedback is integral to improving standards across
disciplines. In the travel and hospitality industries, online
feedback is fundamental and has been estimated to influence
medicine, systematic patient feedback has been shown to help
trainees identify areas of improvement, resulting in enhanced
interpersonal skills.3 Institutionally, feedback can improve
healthcare provision and quality of services. This is
epitomised by the fact that clinical outcomes are associated
with patient satisfaction,4 to an extent whereby hospitals
rated poorly have higher mortality rates.5 However, evidence
remains inconsistent regarding the association between
online ratings and quality of care,6 and there are various
ethical arguments that require consideration prior to
increased implementation. The aim of this commentary is
to discuss and summarise these considerations.
Perceptions of online feedback
The successful implementation of new healthcare initiatives
depends on the attitudes of the stakeholders involved.7 It is
therefore essential to consider healthcare professionals’
perceptions of online feedback. Despite the intention to
improve health care, many healthcare professionals remain
sceptical, with reluctance to embrace feedback websites.8 In a

ª 2022 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. 7
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.
 TOGadvisor: the role of online feedback in obstetrics and gynaecology
survey of 1000 doctors, 57% perceived that online feedback is
generally negative.9 However, analysis of 228 113 online
comments revealed a markedly higher frequency of positive
evaluative words compared with negative (75% versus
25%),10 suggesting attitudes may be influenced by
unrealistically negative misconceptions.1 Moreover, a
number of studies have demonstrated the motivations for
providing online feedback are often to praise a service, rather
than to complain.11
The core drivers of online feedback are undoubtedly the
doctor and patient, with a shared goal to assess healthcare
standards and improve quality of care. Figure 1 illustrates a
model of online feedback encompassing these drivers, in
addition to a number of factors required by healthcare
providers deemed integral to improving patient experience,
as described by the NHS Trust Development Authority
framework for enhancing patient experience.12
Patients who give online feedback usually retain
anonymity, which facilitates the expression of honest
opinions,13 thereby enhancing autonomy and empowering
them to leave negative or critical comments.1 Furthermore,
social media platforms such as Facebook, Instagram and
Twitter are bound by statutory rights including the freedom
of speech.14 Therefore, members of the public are within
their rights to post uncensored content in the absence of peer
review. Many doctors perceive the ability to write
unregulated comments as dangerous, exposing them to
professional vulnerability and risk of online bullying or
defamation.1 Although NHS Choices report regulations are
in place to protect clinicians by removing inflammatory
remarks, concerns remain regarding implementation in
practice and the inability to respond prior to publication,6
resulting in many doctors demanding more formal
Capacity and
capability to
Leadership
effectively collect
feedback
Patient Doctor
Reporting and Service Healthcare Analysis and
publication outcomes standards triangulation
Driving quality
improvement and
learning
Figure 1. Model of online feedback
8 ª 2022 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
regulation.1 Such professional vulnerability is compounded
further by doctors’ duty of candour to maintain
confidentiality, thus restricting their ability to contextualise
comments or defend themselves.
Professional bodies, including the Medical Defence
Union, provide guidance for doctors receiving negative
online feedback. This includes responding to feedback
positively, addressing policies of the service provider
publishing the comments, or requesting the right to be
forgotten online – acknowledged by the Court of Justice of
the European Union – through subtraction of search results
from search engines including Google, Bing and Yahoo.15
Currently, there are a lack of distinctive considerations of
law specific to medical professionals seeking action against
defamation.16 However, doctors can take legal action if
online comments are perceived to injure the reputation or
discredit the individual in the estimation of peers within
their society.16 Legal action does not guarantee a successful
outcome and may take a number of months to resolve,
associated with expensive costs. Publicity from pursuing
legal action against libel may also draw further attention to
the defamatory comment. Therefore, a number of doctors
may be discouraged from pursuing legal action. The
Defamation Act 2013 provides a number of defences that
may also be difficult to challenge. Evidence from consumer
markets demonstrates that online responses to negative
feedback improve satisfaction among those complaining17
and improve perceptions of trustworthiness.18 This further
highlights the disadvantages doctors face. As such, the
initiative to respond to online feedback in a regulated and
confidential manner may improve patient satisfaction and
rebuild patient–doctor trust.
Impact on doctors
While positive feedback can enhance reputation and
potentiate career prospects, negative or malicious feedback
in the public domain can conversely have a lasting negative
impact on a clinician’s career. Significant psychological
burden such as reduced confidence and self-esteem may
arise, which in turn could impact clinical practice. Doctors
who receive complaints are twice as likely to report suicidal
thoughts, 77% more likely to suffer moderate to severe
depression and have twice the risk of moderate to severe
anxiety.19 Moreover, data from more than 10 000 doctors
reported 45% of doctors felt powerless, 42% emotionally
distressed and 21% unsupported when dealing with patient
complaints.20 Reports of clinicians personally acquiring court
orders to remove online reviews21 highlight similar issues
that may arise as a consequence of negative online feedback.
Obstetrics and gynaecology has one of the highest attrition
rates of all specialties (30%).22 A study of more than 3000
obstetrics and gynaecology doctors in the UK identified that

36% fulfilled the criteria for burnout.23 The widespread
implementation of online feedback may encourage
comparison between peers, promoting competitive – rather
than collaborative – working relationships, which may
potentiate further the challenges of working in the
specialty. It is therefore unsurprising that the British
Medical Association (BMA) have raised concerns regarding
slander and opposed clinician rating sites.24
For those working in private practice, there may also be
significant financial implications for doctors exposed to poor
reviews or suboptimal ratings. This is exemplified by data
highlighting that patients who were exposed to a neighbour’s
negative physician review were significantly less likely to
choose the physician than those exposed to a positive
recommendation only.25
Limitations
Online feedback refers predominantly to interpersonal
skills, rather than clinical care received.10 It could be
argued that ratings focusing primarily on interpersonal
skills do not correlate with professional competency,
thereby bringing into question the validity of patient
feedback.6 This is reaffirmed by the fact online ratings of
doctors do not predict quality of care or peer assessment of
clinical performance.26 Questions have been raised
regarding how representative online feedback is of the
entire population,27 as those who post online comments
are predominantly younger in age.28 Furthermore, the use
of clinician rating websites is reliant upon the cognitive
capability of the user and as such may exacerbate
inequality between educated and less educated patients,
or indeed lower socioeconomic groups who do not have
access to the internet.
Following a complaint, clinical practice has been shown to
be more defensive,23 including healthcare professionals
performing more investigations, over referring or
prescribing, avoiding performing procedures or not
accepting high-risk patients.19 Doctors may make the
correct clinical decision in the best interests of the patient,
but if the patient does not agree, an inappropriately negative
review may be left. For example, a woman with chronic pelvic
pain expecting further investigation such as a diagnostic
laparoscopy in the first instance, may not agree with the
suggestion of a therapeutic trial of hormonal medication as
first-line treatment. Following such scenarios, doctors may
change their perfectly appropriate clinical practice to avoid
future negative or malicious reviews.
Role in professional development
Obstetrics and gynaecology trainees are required to complete
work-based assessments, including team observation forms
ª 2022 The Authors. The Obstetrician & Gynaecologist published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
Kasaven et al.
from work colleagues, which anonymously assess clinical
performance and nontechnical competencies such as
professionalism and communication. As evidence suggests
colleagues’ perceptions of a physician’s workplace behaviour
correlate significantly with clinical performance,29 it could be
argued that such assessments, which are completed by
healthcare professionals governed by good clinical practice
and regulated by educational supervisors, would be more
appropriate in the public domain. Such a system would
negate many of the limitations associated with patient
feedback and may provide a more robust online presence for
doctors. Alternatively, self-reported patient questionnaires
can be considered a feasible feedback tool, although their
usage is limited by a lack of validity and reliability.30
However, doctors interpersonal skills questionnaires (DISQs)
are associated with high internal consistency that fulfils the
criteria for various types of validity, and as such they can be
considered as a feedback tool.31,32 The efficacy of self-
reported patient questionnaires is likely to be improved
further, by collecting feedback immediately following the
doctor encounter and including regular reassessment by
new patients.30
Conclusion
There are multifactorial, varying and contrasting advantages
and disadvantages of online feedback in obstetrics and
gynaecology, as summarised in Box 1. Many doctors
remain sceptical about its implementation, owing to fears
of negative, unregulated comments. Moreover, as positive
feedback does not necessarily constitute excellent clinical
care, its role in the healthcare profession remains uncertain.
However, feedback, whether positive or negative, remains
essential for continued personal, professional and
institutional improvement. With the continued uptake in
online platforms and the ongoing plans to transform the
NHS into a digitalised healthcare system, it may be an
inevitable part of the future of being a doctor in obstetrics
and gynaecology. An example of this is the COVID-19
pandemic, which has demanded widespread restructuring of
NHS services and adaptation to the clinical care delivered
within the specialty. Patients are increasingly encouraged to
engage with technology and the internet, permitting a
number of elective services to continue. We may therefore
anticipate an escalation in the application and relevance of
social media and online feedback during this pandemic,
which may continue for the foreseeable future. In a
specialty where less face-to-face interaction is expected
from elective clinical work, online feedback will be
paramount in aiding professional development. As such,
continued debate and ethical reflection is vital, with a view
to increasing regulation and enhancing protection for
healthcare professionals.
9
 TOGadvisor: the role of online feedback in obstetrics and gynaecology
Box 1. Advantages and disadvantages of online feedback.
Advantages
 The majority of online feedback has proven to be positive and in
praise of the NHS
 Evidence suggests that patient feedback can be used more
effectively as an assessment tool of professionalism and
communication, rather than the team observation forms
completed by colleagues
 Patient ratings can be used to measure healthcare standards and
improve quality of care
 Online access to reviews of hospitals and clinicians provide patients
with the autonomy to make informed decisions regarding their
health care
 Feedback encourages emphasis on the patient-centred approach
 Online feedback assists the incorporation of technology into the
future of the NHS, supporting digital transformation of how health
care is provided
 Positive feedback can improve clinicians’ self-esteem and job
satisfaction
 Positive feedback can enhance reputation and potentiate career
aspects
Disadvantages
 The majority of doctors feel feedback is unrepresentative of the
patient population, as mainly younger people have access to
technology
 Patient anonymity can provoke the invitation for negative comments
 Not all feedback is strictly regulated by governing bodies, exposing
doctors to professional vulnerability
 Patient confidentiality restricts the ability for doctors to respond to
comments online
 Negative comments can cause reputational damage, resulting in
significant psychological burden for the clinician. E.g., increased
rates of depression, suicidal thoughts, anxiety or loss of income
 Negative feedback can potentially increase the risk of litigation and
encourages defensive practice
 Online feedback encourages competition between peers, promoting
performance anxiety
 Feedback has been criticised for focusing on interpersonal skills,
rather than an assessment of professional competency
Contribution to authorship
LSK wrote the article. SS, JBN, KJ, JY, RS and TB provided
expertise and revised the final draft. BPJ conceived the
manuscript, helped write the article and reviewed the
final draft.
Disclosure of interests
There are no conflicts of interest.
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The_commercial_use_of_consumer_data.pdf 2015].
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3 Greco M, Brownlea A, McGovern J. Impact of patient feedback on the
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4 Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in
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sectional survey of the attitudes and experiences of United Kingdom health
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10 Brookes G, Baker P. What does patient feedback reveal about the NHS? A
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13 Lu R, Bol L. A comparison of anonymous versus identifiable e-peer review on
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14 Peck JL. Social media in nursing education: responsible integration for
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16 Freckelton IR. Internet disruptions in the doctor–patient relationship. Med
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17 Gu B, Ye Q. First step in social media: Measuring the influence of online
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Challenges to the credibility of patient feedback in primary healthcare
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28 Terlutter R, Bidmon S, Ro €ttl J. Who uses physician-rating websites?
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11
 DOI: 10.1111/tog.12781 2022;24:67–72
The Obstetrician & Gynaecologist
Education
http://onlinetog.org

The blind spot: value-based health care in obstetrics and

gynaecology
Osama Naji MD MRCOG,a* Vivienne Souter MD FRCOG,b Edward Mullins PhD MRCOG,c
Jonathan Gaughran MRCS MRCOG,d Yasser Diab MSc MRCOG,e J Edward Fitzgerald BA MSc MRCS FRSPH,f
Tom Bourne PhD FRCOG FAIUM,g Edward Morris MD PRCOGh
a
Consultant Gynaecologist, Guy’s and St Thomas’ Hospital, London, UK
b
Medical Director, Obstetrical Care Outcomes Assessment Programme (OBCOAP), Foundation for Health Care Quality, Seattle, Washington, USA
c
NIHR Academic Clinical Lecturer in O&G, Imperial College London, UK
d
Doctorate Research Fellow in Gynaecology, Guy’s and St Thomas’ Hospital, London, UK
e
Lead of Service, Gynaecology Department, Guy’s and St Thomas’ Hospital, London, UK
f
Head of Healthcare, KPMG Islands Group, London, UK
g
Professor of Practice, Women’s Health, Imperial College London, UK
h
Consultant Gynaecologist, Norwich, UK and President, Royal College of Obstetricians and Gynaecologists, London, UK
*Correspondence: Osama Naji. Email: o.naji@alumni.imperial.ac.uk

Accepted on 14 February 2021. Published online 7 January 2022.

Key content Learning Objectives

 Continuing financial constraints on the UK’s National Health
Service means the need for clinicians to provide high-quality care
in a cost-effective way has never been greater.
 While the medical education system equips doctors with skills to
provide safe clinical care, it should also provide an understanding
of healthcare costs and cost-effectiveness analysis.
 Value-based care is becoming a key paradigm in women’s health
services, where clinicians must employ strategies for delivering
value, rationalising costs and capitalising on the use of
emerging technologies.
 The calculation of value of an intervention for providers and
service users may differ; care must be taken to ensure this concept
is adapted for, and not imposed on healthcare systems.
 Engaging trainees in systems transformation and embedding the
concepts of ‘do no financial harm’ are essential to ensure
sustainable healthcare services.
 To understand the principles of value-based health care.
 To highlight the importance of adopting ‘cost-conscious’ care
within daily clinical practice.
 To learn the differences between ‘cost’, ‘charge’, ‘price’
and ‘reimbursement.
 To encourage developing value-based competencies for future
medical workforce through utilising out of programme placements
and digital resources.
Ethical Issues

The ethical obligation of clinicians to consider cost may encompass
justice and equity. However, the impact of practicing value-based
health care is yet to be evaluated.
Keywords: cost effectiveness / health care costs / health economics /
value based health care

Please cite this paper as: Naji O, Souter V, Mullins E, Gaughran J, Diab Y, Fitzgerald JE, Bourne T, Morris E. The blind spot: value-based health care in obstetrics
and gynaecology. The Obstetrician & Gynaecologist 2022;24:67–72. https://doi.org/10.1111/tog.12781

A key barrier to determining the value of health care is the

Introduction
Healthcare spending is currently the single greatest outlay for
the UK Government. It has increased dramatically in the past
65 years from 7.7% of total public expenditure in 1955/56 to
17.9% in 2018/19 (Figure 1).1 This upward trend in healthcare
costs is likely to continue given the ageing population and
increasing service costs. The Office for Budget Responsibility
(OBR) predicts health expenditure will rise further from 7.2%
of the national income today to 10.2% in the next 20 years.
This equates to an excess of £66 billion. Therefore, developing
strategies for sustainable healthcare funding is critical for the
National Health Service (NHS).1
lack of metrics at a national level, which could provide
feedback on the investment made in health care. A composite
health index, comprising health outcome measures,
modifiable risk factors and the social determinants of
health is under consideration by the Office for National
Statistics.2 Potential shortcomings of this measure include the
selection and availability of indices and the use to which
policymakers may put them; however, it would be a step
towards valuing health as an asset at a national level.3
The high proportion of the UK budgetary spend on health
care could drive a shift to value-based care and the search for
more effective and affordable solutions. New artificial

ª 2021 Royal College of Obstetricians and Gynaecologists 67

 Value-based health care in obstetrics and gynaecology

Figure 1. Annual UK public spending on health in real terms (2019–2020 prices) and as a percentage of national income. Reproduced with
permission from the Institute of Fiscal Studies.1

intelligence (AI) technologies, for example, are growing more
advanced paradigms to empower patients; healthcare
professionals need to adopt AI as a way to quickly analyse
large amounts of patient data to gain insights about patient
populations. To utilise those insights, interaction is needed
between data, technology and healthcare experts. Indeed,
models have been proposed in which computer-generated
analytics are augmented by human decision-making and
algorithms are informed by medical experts.3
The General Medical Council (GMC) states that one of a
doctor’s duties in the workplace is to “use resources
efficiently for the benefit of patients and the public”.
However, the role of clinicians, both in training and at
consultant level, in determining national healthcare
expenditure has been largely absent over the past 20 years.
Unfortunately, there is little provision in the medical
education system to help address this challenge; healthcare
professionals must be familiar with basic statistics without
formal training in interpreting cost-effectiveness records.
This is not because of their lack of interest in healthcare costs,
since nearly 80% of physicians believe that controlling these
costs is a part of their responsibilities, but rather to
historically regarding administrative and cost-controlling
proposals as restrictive to the scope of their daily
clinical practice.4
Today women represent 51% of the UK population and
47% of the workforce.2 Therefore, it is important that future
obstetricians and gynaecologists are equipped to understand
cost information just as they must understand complex
maternal medicine and other genomic treatments. This will
not be achieved by merely providing them with cost data, but
rather the skill set to interpret these data to facilitate optimal
decision-making. With the current competing healthcare
needs and limited resources facing the NHS, the time has
come to restart the conversation about the role of doctors in
healthcare spending. In this article we shed light on the basic
principles of value-based care. We explain the importance of
acquiring a good level of healthcare financial literacy to
deliver not only safe and effective women’s clinical care, but
also value for those who deliver, receive and pay for that care.
Definition and perspectives
In 2006, Michael Porter, Professor of Health Economics at
Harvard Business School, published the book Redefining
Health Care: Creating Value-Based Competition on Results.
This book invites transition to a system of value-based health
care (VBHC). This has become a controversial issue in the
healthcare sector, with many organisations struggling with
the questions of where to start, how to define value and how
to make the value of health care more transparent.5 VBHC is
fundamentally focused on what constitutes ‘value’ for
patients and it is defined as, “Patient-relevant outcomes,
divided by the costs per patient across the full cycle of care to
achieve these outcomes”. It seeks to maximise the value of
care for patients, while at the same time reducing the cost of
this care (Figure 2).
Figure 2. Calculation of patient values.

68 ª 2021 Royal College of Obstetricians and Gynaecologists


Although the concept of VBHC emanated from the US
healthcare system, the principles are universal. The UK, like
many other countries with a state-dominated healthcare
structure, had historically lower costs and favourable
mortality statistics. However, the NHS is now facing an
accelerated rate of cost increases like those in the United
States, with new evidence suggesting alarming quality
problems that are comparable to the US model. It is
therefore important to stress that lower quality does not
save money; conversely, it often leads to complications
necessitating additional care and ultimately substantially
raising healthcare and indirect costs.5
Is VBHC achievable in the NHS?
The UK has long been on the front line among European
countries looking to expand their use of VBHC. A key to
shifting the focus to ‘value’ is reducing variation in the
care pathway. In the wake of devolution of health care in
1999, the NHS has experimented with pay-for-performance
models to identify and eliminate localised variation in
treatment pathways. This seemed to be ineffective and,
since then, the NHS continued to be the subject of
periodic structural reforms.6 An important step towards
standardising care within the NHS was establishment of
the influential National Institute for Health and Care
Excellence (NICE) in 1999. NICE had two specific roles:
approval of prescription medicines through technology
appraisal and provision of evidence-based guidelines on
various topics. A relevant example is the NICE
recommendation for the wider use of long-acting
reversible contraception (LARC) after commissioning a
cost-effectiveness analysis based on a decision analytic
model.7 The NHS, by law, must fund medicines that NICE
approves within 90 days of its published decision. On the
other hand, the Health and Social Care Act (2012) was
designed to put clinicians in charge of commissioning
healthcare services, replacing 152 primary care trusts with
211 specialised Clinical Commissioning Groups (CCGs).
These reforms are widely credited with increasing, rather
than decreasing healthcare costs.8
In 2011 the Royal College of Obstetricians and
Gynaecologists (RCOG) published its Expert Advisory
Group Report High Quality Women’s Healthcare. This was
in response to the NHS reforms, and workforce and financial
pressures, acknowledging that delivery of women’s health
services in the current configurations is unsustainable.8 The
key recommendations were:
 Commissioning women’s health care through a managed
women’s health network to facilitate better coordination of
services, standardisation of delivery and improved
clinical outcomes.
ª 2021 Royal College of Obstetricians and Gynaecologists
Naji et al.
 Information and communications technology solutions
are urgently required to ensure efficiency savings without
compromising quality.
 To invest in future training programmes that match future
service needs in a value-based, cost-saving environment.
Value-based maternity care: health
outcome measures
Confirming value requires measuring outcomes and costs.
When evaluating clinical outcome measures, maternity care
is exceptional in that it involves two patients: the pregnant
person and their baby. Patient input is also a key component
to evaluating quality in pregnancy care. Although periodic
patient surveys evaluating maternity care are undertaken in
the UK, there is no standardised method on how to best
measure patient-reported outcome measures (PROMs) and
patient-reported experience measures (PREMs).9 The US
childbirth experience survey published by Gregory et al.10
found that patient characteristics (parity, demographics and
pregnancy complications) were – perhaps surprisingly – not
closely correlated with patient satisfaction with childbirth
care in hospital. However, patients who felt they received
understandable explanations from their doctor said that staff
members were compassionate, that they knew how to care for
themselves and their baby on discharge and were overall
more satisfied with their care.
Recognising a lack of standardised outcome measures as a
barrier to applying VBHC in maternity care, the International
Consortium for Health Outcomes Measurement (ICHOM)
proposed a standardised set of perinatal outcome measures
that includes both maternal and newborn clinical outcomes
and PROMs.11 The clinical measures focus on adverse
outcomes such as maternal death, intensive care unit
admission, blood transfusion and neonatal injury and death.
Positive clinical outcomes, such as undisturbed birth, which
has also been identified by providers and consumers as an
important perinatal quality indicator, are not included. The
patient reported measures include five patient surveys across
the antepartum period and up to 6 months postpartum.
ICHOM also identified 13 ‘case-mix’ factors that are patient
characteristics or risk factors (for example, maternal age,
parity, body mass index, pre-existing medical conditions),
which may influence the rate of ICHOM outcome measures.
It is important to account for case-mix factors to allow fair
comparison of quality measures among different healthcare
systems. The ICHOM measure set currently lacks
implementation and validation studies, but is a positive
move towards developing a comprehensive perinatal
quality standard.
VBHC requires consideration of the cost in addition to
quality. Currently, several innovative models of care have
69
 Value-based health care in obstetrics and gynaecology
been proposed to improve quality, decrease costs and
promote PROMs/PREMs. These are delivered through
incorporation of mid-level clinicians, community midwives
and, additionally, holistic patient-centred care, group
prenatal visits, patient engagement in self-monitoring
and telemedicine.12
Costs of care
In 2012/13, maternity care alone was responsible for
approximately £2.6 billion of NHS spending, corresponding
to approximately £3,700 per birth and representing 2.8% of all
healthcare expenses.13 Most women receiving maternity care
in the NHS have favourable outcomes and positive
experiences of care. However, the Government has pledged
to make further improvements in women’s health care. For
example, since 2007 there has been an increase in midwifery-
led units, more consultant involvement in care, and progress
has been made in line with the Government’s commitment to
improve outcomes. The Department of Health has set a
‘Maternity Safety Ambition’ to halve the rate of stillbirth,
neonatal death, maternal deaths and brain injuries by 2025
and to reduce the preterm birth rate to 6% in the same time
span.14 Investments made in the Maternity Transformation
Programme, hopefully balanced by a decrease in medicolegal
costs, could potentially improve quality of care and reduce
adverse outcomes.15 However, reforming the payment system
for maternity care remains key and value-based interventions
in maternity care services have received relatively
little attention.
Gynaecology services: right person, right
place, first time
In 2017/18, there were 3 690 908 attendances to outpatient
gynaecology services, with a 78% attendance rate, which
decreased from 82% in 2007/08.16 This trend may indicate a
rise in hospital or patient cancellation rates, or a pure
reduction in the need for outpatient services. Therefore, the
entire ranges of elective care services needs urgent redesign at
the system level to achieve better demand management that
could improve patient care, both from the value of patient
perspectives and from the efficiency standpoint. The NHS
Long Term Plan sets out ambitions to alternative models of
care to avoid up to 30% of face-to-face appointments17.
These include addressing the needs of local populations and
targeting interventions for those people most at risk.
Technology offers promising possibilities to support this
transformation. Below are some of the challenges and
opportunities in gynaecology care.
There is geographical and socioeconomic variation in both
access and service provision to several gynaecology services,
and this leads to variation in hospital stay between different
70
Table 1. Summary of differences between various financial
transactions. Reproduced with permission from the AMA Journal of
Ethics.16
Term Definition
Cost The expense incurred to providers to deliver
healthcare services to patients
Charge or Price The amount asked by a provider for a healthcare
service
Reimbursement A payment made by a third party to a provider, this
may be for every service delivered, every hospital
stay, or each episode of hospital admission
units for procedures often considered to be day cases.16 This
represents a huge challenge to provide standardised, efficient
and quality care. However, with challenges often come
opportunities. NHS RightCare is an initiative to decrease
unnecessary variation in care, improve population health and
promote fairer health care in terms of access, patient
experience and outcomes. Its goal is for everyone to have
appropriate, timely care in the optimal healthcare settings
and to utilise resources as effectively and efficiently as
possible.18 There are several quality metrics for this
programme, but for the scope of this article we focus on
three important points from obstetrics and gynaecology
training and education perspectives:
 Engaging more trainees with support from executive-level
leaders in projects related to both PROMs and PREMs.
This will give them permission to innovate, help unlock
problems and feed learning and insights back into
the system.
 Helping trainees through integrated educational
programmes to better understand healthcare cost terms
to differentiate between value measures and quality
measures. We summarise some of the common terms
in Table 1.19
 Assisting newly appointed consultants through fast-track
health management courses to equip them with the skill
sets required to lead with sufficient financial acumen.
VBHC competency
Traditionally, it has been routine practice for UK trainees in
obstetrics and gynaecology to learn to provide the best
possible care for women and expectant mothers, leaving the
cost considerations aside. The time to revisit this concept is
due. The ‘best possible’ needs to be taken in the full meaning:
it must be safe, effective and also valuable – in other words,
‘worth it’ for the woman and her baby.20
ª 2021 Royal College of Obstetricians and Gynaecologists

Table 2. Innovative approaches to promote VBHC approach among
frontline clinicians. Reproduced with permission from the Journal of
Graduate Medical Education.23
Approach Description
I-CARE Traditional, morning report-style teaching
Interactive Cost- run by senior clinicians to conduct a safe
Awareness Resident diagnostic evaluation at a low expense
Exercise
SOAP-V Included V for value
Modified Subjective- The model prompts trainees to consider if
Objective-Assessment- ordering a test would change
Plan management of the patient and if the
patient’s values were incorporated into
the care plan
OR-SCORE Providing surgeons with feedback on the
Operating Room costs of their surgical cases to reduce
Surgical Cost Reduction unnecessary waste
It provides price transparency of surgical
preparation time, surgical time and
supply costs in a snapshot, followed by
discussions to coach surgeons practising
at higher costs
With the current upsurges in digital health, an integration
of VBHC into undergraduate medical curriculums is needed.
Albeit in a different healthcare system, most US medical
schools now integrate discussions of cost, value and
effectiveness into their curricula. A recent survey by the
Association of American Medical Colleges (AAMC)21 found
that 129 of 140 responding medical schools had offered a
course on the cost of health care during the 2013/14 academic
year. In 2015, Gupta and colleagues from the USA 22
developed the ‘Teaching Value in Healthcare Learning
Network’; an online Google+ community. Its aim was to
create a short-term platform to disseminate innovation to
provide high-value care to educators and system leaders. The
network had three components:
 Thirty-minute webinar discussions with national leaders
in healthcare
 Online discussion forum to facilitate sharing slides
 Online storehouse for disseminating materials related to
value innovations
Both speakers and members of the network reported great
satisfaction with the format and usefulness of the innovations
shared. We summarise some of the topics discussed
in Table 2.22
In UK postgraduate obstetrics and gynaecology training, a
welcome step forward over the past 10 years was ‘simulation-
based education’ (SBE), which has proved to be a well-
ª 2021 Royal College of Obstetricians and Gynaecologists
Naji et al.
defined method for providing both value for money and
quality assurance.23 In 2016, as part of the NHS Mandate,
NHS England developed the Clinical Entrepreneur Training
Programme. This is another promising step designed to offer
opportunities for junior doctors from various specialties to
nurture their entrepreneurial interests during clinical
training. The programme provides entrepreneurial support,
including access to mentors and coaches, internships and
introductions to commercial organisations.
Reflecting the GMC guidelines promoting excellence in
medical education and training, the Royal College of
Surgeons of England (RCS) has stated that suitable
surgeons can acquire healthcare management experience in
many different settings, including the private sector.24 An
example is the joint partnership between RCS and McKinsey
& Company for a 1-year fellowship in healthcare
management. In this programme, trainees receive
structured training and practical experience through
working on client-facing projects in healthcare
improvement and reforms in the NHS.25 Trainees in
obstetrics and gynaecology could be supported to follow
suit by facilitating out-of-programme placements and
training partnerships with other stakeholders in both
government and the private sectors.
The future
It has been estimated that up to 30% of total healthcare
spending is wasted.26 In the UK, perhaps one development to
capture in the post-COVID era is utilisation of the virtual
world and digital technology. The implementation of
telephone clinics in several NHS hospitals is an important
step, provided appropriate patient selection; it can certainly
provide high-value care, good patient satisfaction and
acceptable costs to both the environment and the
healthcare system. Healthcare professionals in obstetrics
and gynaecology must be equipped to influence and drive
health policy for the benefit of the women they care for.
Furthermore, future trainees will have a responsibility to
ensure women’s healthcare is cost-effective and sustainable –
particularly considering that obstetrics and gynaecology
occupied almost 50% of the total value spent by the NHS
on overall clinical negligence claims in the 2019/20 financial
year accounts.27 If universal coverage provided by the NHS
for women’s health services is to continue, training in value-
based health care delivery is needed. Therefore, dedicating
the early years of the training curriculum to build
foundations of health care financial literacy, basic
management and simulation training can set up a suitable
platform to build on, and will ensure that UK obstetrics and
gynaecology training remains an attractive and forward-
thinking specialty for both domestic and
international graduates.
71
 Value-based health care in obstetrics and gynaecology
Disclosure of interests
TB is supported by the National Institute for Health Research
(NIHR), Biomedical Research Centre based at Imperial
College Healthcare NHS Trust and Imperial College
London. The views expressed are those of the author(s)
and not necessarily those of the NHS, the NIHR or the
Department of Health.
Contribution to authorship
ON drafted the manuscript. All authors participated in
concept discussions, revised and amended/revised
subsequent versions and approved the final version
for submission.
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1 Stoye G, Zaranko B. UK health spending. London: Institute for Fiscal
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2 Pearson-Stuttard J, Murphy O, editors. Chief Medical Officer annual report
2018. Health 2040 – better health within reach. London: Department of
Health and Social Care; 2018 [https://assets.publishing.service.gov.uk/
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health_within_reach.pdf].
3 Elwell-Sutton T, Finch D, Alderwick H. A health index for England:
opportunities and challenges. London: The Health Foundation; 2019.
[https://www.health.org.uk/publications/long-reads/a-health-index-for-
england-opportunities-and-challenges].
4 Farkas C, van Biesen T. The new cost-conscious doctor: changing America’s
healthcare landscape. Boston, MA: Bain & Company; 2011 [https://www.
bain.com/insights/the-new-cost-conscious-doctor].
5 Porter M, Tesiberg E. Redefining health care. Creating positive-sum
competition to deliver value. Harvard Business Review Press; 2006.
6 Timmins N. Never again? The story of the Health and Social Care Act 2012.
A study in coalition government and policy making. The Kings Fund;
Institute for Government; 2012 [https://www.instituteforgovernment.org.
uk/sites/default/files/publications/Never%20again_0.pdf].
7 Mavranezouli I; LARC Guideline Development Group. The cost-effectiveness
of long-acting reversible contraceptive methods in the UK: analysis based on
a decision-analytic model developed for a National Institute for Health and
Clinical Excellence (NICE) clinical practice guideline. Hum Reprod
2008;23:1338–45.
8 Royal College of Obstetricians and Gynaecologists (RCOG). High quality
women’s health care: a proposal for change. Expert Advisory Group Report.
London: RCOG; 2011 [https://www.rcog.org.uk/globalassets/documents/
guidelines/highqualitywomenshealthcareproposalforchange.pdf].
9 Harrison S, Alderdice F, Henderson J, Quigley MA. You and Your Baby: a
national survey of health and care. Oxford: National Perinatal Epidemiology
Unit, University of Oxford; 2018 [https://www.npeu.ox.ac.uk/assets/
downloads/maternity-surveys/reports/You%20and%20Your%20Baby%
202018%20Survey%20Report.pdf].
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10 Gregory KD, Korst LM, Saeb S, Greene N, Fink A, Fridman M, et al.
Childbirth-specific patient-reported outcomes as predictors of hospital
satisfaction. Am J Obstet Gynecol 2019;220:201.e1–19.
11 Nijagal MA, Wissig S, Stowell C, Olson E, Amer-Wahlin I, Bonsel G, et al.
Standardized outcome measures for pregnancy and childbirth, an ICHOM
proposal. BMC Health Serv Res 2018;18:953.
12 Gareau S, L opez-De Fede A, Loudermilk BL, Cummings TH, Hardin, JW,
Picklesimer AH, et al. Group prenatal care results in Medicaid savings with
better outcomes: a propensity score analysis of centering pregnancy
participation in South Carolina. Matern Child Health J 2016;20:1384–93.
13 Department of Health. Maternity Services in England Report. London:
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2013/11/10259-001-Maternity-Services-Book-1.pdf].
14 Department of Health. Safer maternity care: the national maternity safety
strategy – progress and next steps. London: Department of Health; 2017
[https://assets.publishing.service.gov.uk/government/uploads/system/
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and_next_steps.pdf].
15 NHS England. Maternity Transformation Programme update. London: NHS
England; 2018 [https://www.england.nhs.uk/wp-content/uploads/2018/05/
04-pb-24-05-2018-maternity-transformation-programme.pdf].
16 NHS England and NHS Improvement. Transforming elective care services:
gynaecology. London: NHS England; 2019 [https://www.england.nhs.uk/
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17 NHS England. The NHS Long Term Plan. London: NHS England; 2019
[https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-
term-plan-version-1.2.pdf].
18 NHS England. NHS Right Care Pathways. London: NHS England [https://
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20RightCare%20is%20a%20programme,best%20use%20of%20available%
20resources,best%20use%20of%20available%20resources].
19 Arora V, Moriates C, Shah N. The challenge of understanding health care
costs and charges. AMA J Ethics 2015;17:1046–52.
20 Sudhof L, Shah NT. In pursuit of value-based maternity care. Obstet Gynecol
2019;133:541–51.
21 Healthcare Finance News. Medical Schools now teaching how to have
conversations about healthcare costs [https://www.healthcarefinancenews.
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care-costs].
22 Gupta R, Shah NT, Moriates C, Wallingford S, Arora VM. Disseminating
innovations in teaching value-based care through an online learning
network. J Grad Med Educ 2017;9:509–13.
23 NHS Health Education England. National framework for simulations-based
education. London: NHS England; 2019 [https://www.hee.nhs.uk/sites/
default/files/documents/National%20framework%20for%20simulation%
20based%20education.pdf].
24 General Medical Council (GMC). Promoting excellence. London: GMC
[https://www.gmc-uk.org/education/standards-guidance-and-curricula/
standards-and-outcomes/promoting-excellence].
25 The Economist. Value-based health care in the UK: A system of trial and
error [https://www.slideshare.net/economistintelligenceunit/valuebased-
healthcare-in-the-uk-a-system-of-trial-and-error].
26 Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA
2013;310:577–8.
27 NHS Resolution. Clinical negligence numbers steady, but rising costs remain
a concern. London: NHS Resolution; 2019 [https://resolution.nhs.uk/2019/
07/11/clinical-negligence-numbers-steady-but-rising-costs-remain-a-
concern/].
ª 2021 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12786 2022;24:79–81
The Obstetrician & Gynaecologist
http://onlinetog.org
MBRRACE-UK update: Key messages from the UK and
Ireland Confidential Enquiries into Maternal Death and
Morbidity 2021
The latest report from the UK and Ireland Confidential
Enquiries into Maternal Deaths and morbidity, the eighth in
the now annual report format, includes surveillance and
Confidential Enquiries covering the period 2017–19.1 The
report also includes reviews into the care of women who died
during or after pregnancy in the Republic of Ireland as well as
the UK. Following the annual topic-specific format, this
report includes topic-specific reviews into the care of women
who died from mental health-related causes, venous
thromboembolism, homicide and malignancy. The report
also includes a Morbidity Confidential Enquiry into the care
of women who gave birth aged over 45 years.
Key facts and figures
 There was a statistically nonsignificant decrease in the
overall maternal death rate in the UK between 2014–16
and 2017–19, which is now 8.79 per 100 000 maternities
(95% confidence interval [CI] 7.58–10.12). There remains
a greater than four-fold difference in maternal mortality
rates among women from Black ethnic backgrounds and
an almost two-fold difference among women from Asian
ethnic backgrounds compared with white women. Women
who live in the 20% most deprived areas have double the
maternal mortality rate of women who live in the 20%
most affluent areas.
 The majority of women who died had multiple co-
morbidities. Eight percent of the women who died during
or up to a year after pregnancy in the UK in 2017–19 were
at severe and multiple disadvantages. The main elements
of multiple disadvantage were a mental health diagnosis,
substance use and domestic abuse.
 Cardiac disease remains the largest single cause of maternal
deaths. Neurological causes (epilepsy and stroke) are the
second most common cause of maternal death. There
remains a concerning number of deaths due to Sudden
Unexpected Death in Epilepsy (SUDEP).
 There was a statistically nonsignificant decrease in
maternal death rates from direct causes between 2014–16
and 2017–19. Thrombosis and thromboembolism remain
ª 2021 Royal College of Obstetricians and Gynaecologists
MBRRACE-UK update
the leading cause of direct maternal death during or up to
6 weeks after the end of pregnancy. Maternal suicide
remains the leading cause of direct deaths occurring within
a year after the end of pregnancy.
Key messages for care
Care of older mothers
 The older women whose care was examined fell broadly
into two groups. Some were women who had several
previous children; their pregnancy was often unplanned,
many were late to engage with maternity services and often
they chose to make decisions against the advice of those
caring for them. Half were women who had conceived
through assisted reproduction techniques, frequently with
donated embryos and often had multiple pregnancies.
Many of these women had not undergone a pre-pregnancy
assessment and embarked on pregnancy with pre-existing
medical conditions such as hypertension and other cardiac
risk factors. For women who choose to embark on assisted
reproduction treatment, there is always an opportunity for
pre-pregnancy assessment and optimisation of a woman’s
health. This may include weight reduction, smoking
cessation and changes to medication. The risks of
pregnancy should be clearly described including the
chance of needing iatrogenic preterm delivery with its
associated neonatal complications.
 The majority of older pregnant women whose care was
reviewed for the purposes of this report had pre-existing
co-morbidities, assisted reproduction, obesity, or all three.
Several had pregnancies additionally complicated by
multiple pregnancy. On the basis of this multitude of
risk factors in addition to older maternal age, the majority
should be offered aspirin to prevent pre-eclampsia,
screening for gestational diabetes, serial growth scans and
thromboprophylaxis antenatally and/or postnatally.
Guidance relevant to the care of older pregnant women,
due to their multiple risks, is contained within multiple
guidelines, and fewer than a third of women received care
in line with every relevant guideline. In view of the
79
 MBRRACE-UK update
increasing numbers of women giving birth at older ages, it
would be helpful to have a single collated source of
recommendations for the care specifically of older women.
Until such a collated source exists, it is important to be
aware of all relevant preventive interventions
and investigations.
 Older women, particularly those who conceive
spontaneously (rather than with donor eggs), are more
likely to have a fetus with trisomy 21 or other
chromosomal abnormality. It is important that other
aspects of their care are not delayed while investigations
are performed. Consultant appointments and evidence-
based effective preventive interventions such as aspirin
should not await the results of prenatal diagnosis.
 Although older women becoming pregnant spontaneously
may be less likely to receive pre-pregnancy counselling, the
opportunity to provide post-pregnancy counselling is
equally important for future pregnancies and for joining
up obstetric and medical care to optimise a woman’s long-
term health.
Care of women with mental health problems and
multiple adversity
 There were many examples where women should have
been referred to specialist services and were not. It was
striking how few women were engaged with specialist
community services. Where pathways into care were not
clear, there was, at times, confusion over which service had
been engaged and delays in referral to the specialist mental
health team. As services expand further, including the
development of maternity psychological therapies teams, it
will be important to ensure new services are fully
embedded within clear care pathways. These pathways
should take into account all other aspects of perinatal
mental health provision, including specialist roles within
midwifery and obstetric services, in order to avoid any
confusion over roles and responsibilities.
 Over one-third of women who died by suicide had
experienced a pregnancy or postnatal loss event and more
than half of women who died from substance misuse had a
similar loss event. Women are even more at risk after a
perinatal loss event, including child removal, and good
communication and care coordination are
therefore essential.
 There were a number of examples of failure to prescribe or
deprescribing because the woman was pregnant. There
were also women who were on prescribed medication on
discovering the pregnancy and who made the decision to
discontinue. For several, there was no re-evaluation in the
postnatal period, when they were more likely to be
vulnerable to relapse, of whether they would benefit
from recommencing medication, either prophylactically or
to manage emergent symptoms. If psychotropic
80
medication has been discontinued in advance of, or
during, pregnancy, it is important to ensure women have
an early postnatal review to determine whether they should
recommence medication.
 Women with substance misuse are often more vulnerable
and at greater risk of relapse in the postnatal period, even
if they have shown improvement in pregnancy. They
should be reviewed for re-engagement in the early
postpartum period where they have been involved with
addictions services in the immediate preconception period
or during pregnancy.
Care of women with cancer
 Several women became pregnant during or shortly after
completing cancer treatment and no one had discussed
contraception. All medical staff, of whatever specialty,
should be aware that women of reproductive age may
become pregnant during treatment for mental and
physical health conditions and therefore need
contraceptive advice. All staff should be able to provide
that advice.
 Several women died from metastatic melanoma diagnosed
during pregnancy. Most of the women who died had a
relatively short gap between completion of their cancer
treatment and their pregnancy. When the pregnancy was
planned, it was unclear whether women had received any
pre-pregnancy advice. Women should receive specialist
advice regarding the gap after treatment before becoming
pregnant – a space of 2 years is recommended for most
cancers where guidance exists. It is important to recognise
that the gap is not because pregnancy is thought to impact
on the course of the disease but because recurrence risks
are greatest in the 2 years after initial diagnosis and
pregnancy may impact on the treatment options the
women can receive.
 Guidance is needed on how quickly women should be seen
in an obstetric consultant clinic after pregnancy is
diagnosed following a previous cancer diagnosis. Several
women were not seen until mid-late second trimester by
which time discussions about continuing the pregnancy
could not be undertaken. Women with active or very
recent cancer treatment should be seen by an obstetric
consultant in the first trimester to allow discussion of
individual risks and choices.
 There were several examples where imaging was not done,
both for diagnosis and staging. The reluctance to use
appropriate imaging led to a delay making diagnoses and
resulted in some women presenting on multiple occasions
with worsening symptoms, some of which, such as
vomiting and fatigue, were attributed to pregnancy.
Additionally, where symptoms had been attributed to
pregnancy, they were not followed up postnatally. It is
essential to ensure symptoms of possible cancer are
ª 2021 Royal College of Obstetricians and Gynaecologists

followed up postnatally. If they do not resolve, they are
unlikely to be due to pregnancy.
Prevention and management of thromboembolism
 Women’s risks, before, during and after pregnancy, are not
static. Periods of increased risk of venous
thromboembolism (VTE) occur during and after
pregnancy, which underpins recommendations to
reassess VTE risk at every opportunity. Several women
had episodes of hospital admission, concurrent
gastrointestinal infections when they became dehydrated
or periods of immobility, when their risk of VTE was
raised. This risk was either not recognised, because
reassessment was not carried out, or not acted on.
Assessment of VTE risk is an expected standard for any
hospital admission. This applies to all healthcare settings in
secondary care (maternity, surgical, medical) and mental
health hospitals.
 Assessors observed wide variation in the tools used to
document VTE risk, some of which did not reflect national
guidance and therefore risk was assessed incorrectly. A
recommendation made previously in these reports was the
need for a tool to make risk scoring consistent. This review
again emphasises that not only is a tool required, but that
there is a need to ensure the tool is consistent across all
systems and routes of use (paper or electronic).
 Assessors noted that several women who died were likely
to have been omitting their low molecular weight heparin
prophylaxis partially or completely, and it is important
that women’s adherence with administration is taken into
account in any antenatal or postnatal assessment.
Conclusions
The recurring theme identified in this report revolves around
risk and the fact that risk is not static, but dynamic. There is a
need for recognition of the role that pre- and post-pregnancy
actions can have in significantly decreasing risk, and,
ª 2021 Royal College of Obstetricians and Gynaecologists
MBRRACE-UK update
conversely, the additional risk women are placed under
during pregnancy by clinician behaviours which focus on
concerns over a woman’s pregnancy rather than concerns
over a woman herself. This emphasises again the need for
care pre-pregnancy, during pregnancy and after pregnancy by
the multidisciplinary team skilled in pregnancy medicine.
The morbidity enquiry into the care of women giving birth at
aged 45 or over illustrated many of the complexities of
intersecting risk and risk perception. Pregnancy at advanced
maternal age is known to be associated with higher rates of
maternal mortality, higher rates of pregnancy loss and other
pregnancy complications, and yet the average age at first
childbirth continues to increase. Very few women planning
pregnancy at an advanced maternal age had a clearly
documented discussion over the potential health impacts to
them or their unborn child.
Beginning to address these wider cultural and structural
biases affecting women’s care on the basis of their pregnancy
or the potential to become pregnant is fundamental to the
prevention of maternal mortality. These issues intersect with
other biases women experience due to their ethnicity,
socioeconomic status, co-morbidities, language, disability
or social complexity. Addressing these structural biases must
start with early medical, midwifery and nursing education.
Marian Knight MA DPhil FFPH FRCP Edin FRCOG
MBRRACE-UK Maternal Programme Lead, NIHR Professor of Maternal
and Child Population Health, National Perinatal Epidemiology Unit,
Nuffield Department of Population Health, University of Oxford, Old Rd
Campus, Oxford, OX3 7LF, UK
Email: marian.knight@npeu.ox.ac.uk
Reference
1 Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R, Kenyon S,
Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving
Mothers’ Care - Lessons learned to inform maternity care from the UK and
Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017–19.
Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021.
Available at: www.npeu.ox.ac.uk/mbrrace-uk
81
 DOI: 10.1111/tog.12794 2022;24:73–6
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 24 issue 1

CPD credits can be claimed for the following questions With regard to the impact of menopause on
online via the TOG CPD submission system in the RCOG sexual function,
CPD ePortfolio. You must be a registered CPD participant of
7. age negatively influences all domains of
the RCOG CPD programme (available in the UK and
sexual function. ThFh
worldwide) in order to submit your answers.
8. approximately 50% of women aged 40 to
Completion of TOG true/false questions can be claimed as a
69 years are sexually active. ThFh
Specific Learning Event. Participants can claim two credits per
set of questions if at least 70% of questions have been answered With regard to the relationship between pelvic floor
correctly. CPD participants are advised to consider whether the dysfunction and sexual function,
articles are still relevant for their CPD, in particular if there are 9. up to one-third of women with pelvic organ
more recent articles on the same topic available and if clinical prolapse report sexual problems. ThFh
guidelines have been updated since publication. 10. experiencing both prolapse and incontinence
Please direct all questions or problems to the CPD Office. has a cumulative negative effect on
Tel: +44 (0)20 7772 6307 or email: cpd@rcog.org.uk. sexual function. ThFh
The blue symbol denotes which source the questions refer 11. after native tissue prolapse repair, the most
to including the RCOG journals, TOG and BJOG, and RCOG likely outcome is no change in
guidance, such as Green-top Guidelines (GTGs) and sexual function. ThFh
Scientific Impact Papers (SIPs). All of the above sources are 12. sacrospinous fixation is associated with lower
available to RCOG Members and Fellows via the RCOG rates of dyspareunia compared with
website. RCOG Members, Fellows and Associates have full abdominal sacrocolpopexy. ThFh
access to TOG content via the TOG app (available for iOS
and Android). With regard to the impact of hysterectomy on
sexual function,
13. the vaginal route is associated with worsening
TOG Female sexual dysfunction dyspareunia compared with other routes. ThFh
14. subtotal hysterectomy is associated with less
With regard to sexual dysfunction,
dyspareunia than total hysterectomy. ThFh
1. it is more common in men than women. ThFh 15. laparoscopic vaginal cuff closure is associated
2. it is investigated more in men than women. ThFh with lower rates of dyspareunia. ThFh
3. for a diagnosis to be made, symptoms must be
In the treatment of female sexual dysfunction,
present for more than 50% of the time and for
more than 6 months and cause 16. weight loss in obese patients has been shown
significant distress. ThFh to help improve sexual function. ThFh
4. about 10–20% of women are affected. ThFh 17. both systemic and vaginal estrogen have been
used effectively to treat sexual dysfunction
With regard to the impact of pregnancy and childbirth on
related to vulvovaginal atrophy. ThFh
sexual function,
18. systemic progesterone may be offered to
5. sexual desire often increases patients with a history of estrogen-dependent
during pregnancy. ThFh cancer to improve sexual function. ThFh
6. when compared with spontaneous vaginal 19. in surgical menopause, there is an abrupt 50%
delivery with an intact perineum, the reduction is testosterone production. ThFh
protective effect of caesarean section on sexual 20. Botox
injections into the perineum is a
function is limited to the first 6 months of the recognised treatment option for
postnatal period. ThFh refractory vaginismus. ThFh

ª 2022 Royal College of Obstetricians and Gynaecologists 73

 CPD

TOGInvestigation and management of TOG Cervical cancer in pregnancy: diagnosis,

postcoital bleeding staging and management
Recognised causes of postcoital bleeding include, Cervical cancer,
1. cervical ectropion. ThFh 1. is the commonest gynaecological malignancy
2. endometriosis. ThFh diagnosed in pregnancy. ThFh
3. cervical intraepithelial neoplasia. ThFh 2. incidence rates are set to plateau over the
4. submucosal fibroids. ThFh next 10 years. ThFh
5. chlamydial infection. ThFh 3. symptoms differ in pregnancy when compared
with the nonpregnant patient. ThFh
Initial investigations of postcoital bleeding in women in
4. invades locally first (affecting the vagina,
the reproductive age group should include,
parametrium and uterosacral ligaments). ThFh
6. urinary pregnancy test. ThFh 5. has the potential to metastasize to the fetus. ThFh
7. cervical screening test in those under 25 years
During pregnancy,
of age. ThFh
8. swabs to test for sexually 6. routine recall smear tests are best deferred
transmitted infections. ThFh until 3 months postpartum. ThFh
9. colposcopy. ThFh 7. colposcopic assessment of the cervix as part of
10. endometrial pipelle biopsy. ThFh managing positive cervical screening results is
best deferred until postpartum. ThFh
Regarding cervical cancer,
8. an excisional biopsy of the cervix has an
11. it is the leading cause of postcoital bleeding in increased risk of haemorrhage. ThFh
women under age 25. ThFh 9. the use of FIGO staging of cervical cancer is
12. a negative screening test excludes diagnosis. ThFh not recommended. ThFh
13. it is predominantly caused by HPV-6 and 10. magnetic resonance imaging is the first-line
HPV-11. ThFh method for staging of cervical cancer. ThFh
14. HIV-positive women should be 11. sentinel lymph node biopsy is considered an
screened annually. ThFh important step in staging of cervical cancer. ThFh
15. about 1 in 2400 women aged under 25
With regard to the management of patients diagnosed with
presenting to primary care with
cervical cancer in pregnancy,
postcoital bleeding will have this as
the cause. ThFh 12. delivery is best by caesarean section. ThFh
13. termination of pregnancy is recommended
Regarding management of postcoital bleeding,
prior to commencing treatment. ThFh
16. a cervical biopsy is recommended before 14. it is best provided by an experienced
offering cryotherapy for a multidisciplinary team. ThFh
cervical ectropion. ThFh 15. they are at higher risk of postnatal depression. ThFh
17. hysteroscopy and endometrial sampling is 16. it is recommended that the placenta is sent
indicated in peri- and postmenopausal for histology. ThFh
women with a cervical polyp. ThFh 17. the option to undergo ovarian transposition
18. nonpregnant women diagnosed with before treatment should be discussed with the
chlamydia require test of cure following aim of preserving ovarian function. ThFh
completion of treatment. ThFh
Neoadjuvant chemotherapy,
19. if a lower genital tract cancer is suspected,
knowing the biopsy results is 18. is a contraindication to breastfeeding. ThFh
essential before referral to a tertiary 19. is required at a higher dose in pregnancy. ThFh
cancer centre. ThFh 20. is the first-line treatment choice for patients
20. ospemifene is a recognised treatment in cases diagnosed with stage 1A cervical cancer
secondary to atrophic vaginitis. ThFh in pregnancy. ThFh

74 ª 2022 Royal College of Obstetricians and Gynaecologists

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19. a recognised complication of sclerotherapy is

TOGAccessory cavitated uterine peritoneal leakage of the instilled alcohol. ThFh
malformations (ACUMs): an unfamiliar 20. studies have reported intrauterine adhesions
cause of severe dysmenorrhoea following surgical treatment. ThFh
Accessory cavitation uterine malformations (ACUMs),
1. are lesions involving the uterine cavity. ThFh TOGPregnancy in underweight women:
2. contain a central cavity lined with implications, management and outcomes
functional endometrium. ThFh
Conditions associated with a body mass index (BMI)
3. contain clear fluid in the cavity. ThFh
of <19.5 kg/m2 include,
4. are typically found inferior to the attachment
of the round ligament. ThFh 1. hypothyroidism. ThFh
5. are surrounded by a myometrial mantle with a 2. hyperthyroidism. ThFh
concentric arrangement of smooth 3. malnutrition. ThFh
muscle fibres. ThFh 4. anorexia nervosa. ThFh
5. gestational diabetes. ThFh
With regard to the current understanding of the aetiology
and clinical characteristics of ACUMs, BMI below 19.5 kg/m2 is associated with,
6. they are thought to arise from duplication and 6. cardiac anomalies in the fetus. ThFh
persistence of the Wolffian ducts. ThFh 7. preterm delivery. ThFh
7. they are seen to mostly affect 8. fetal growth restriction. ThFh
peri-menopausal women. ThFh 9. pre-eclampsia. ThFh
8. the most common presenting symptom Pregnant women with low BMI,
is dysmenorrhea. ThFh
9. pelvic pain as a symptom is thought to be due 10. are more likely to develop postpartum
to the stretching of the cavity from the cyclical haemorrhage after delivery. ThFh
accumulation of blood. ThFh 11. are more likely to be over the age of 40 years. ThFh
12. are less likely to have
With regard to investigation of patients suspected to intrapartum complications. ThFh
have ACUMs,
Complications associated with hyperthyroidism in
10. transvaginal ultrasound examination of the pregnancy include,
pelvis will show a characteristic fluid content
of the cavity. ThFh 13. preterm labour. ThFh
11. a defining ultrasound characteristic is 14. an increased risk of intrauterine fetal death. ThFh
increased vascularity within the cavity. ThFh 15. early onset pre-eclampsia. ThFh
12. on magnetic resonance imaging, the Women with a known eating disorder in pregnancy,
myometrial mantle appears hypointense on
16. are at risk of relapse during pregnancy. ThFh
T2-weighted images. ThFh
17. should be screened for additional mental
13. histologically, the lining of the cavity contains
health disorders. ThFh
glands and stroma. ThFh
Signs that may suggest an underlying eating
Differential diagnoses of ACUMs include,
disorder include,
14. a unicornuate uterus with a functioning
18. male pattern hair loss. ThFh
rudimentary horn. ThFh
19. parotid enlargement (hamster sign). ThFh
15. a haemorrhagic degenerating fibroid. ThFh
20. fine facial hair. ThFh
With regard to the treatment of ACUMs,
16. hormonal suppression has been shown to Preconception health in the well
TOG
alleviate pain symptoms. ThFh woman
17. the levonorgestrel intrauterine system is the
treatment of choice in young patients. ThFh With regard to preconception care,
18. there is evidence that laparoscopic surgical 1. it improves maternal and neonatal outcomes. ThFh
excision has a better outcome than 2. more than 50% of all pregnancies are
laparotomy excision. ThFh currently unplanned. ThFh

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3. a high socioeconomic status is associated with 12. female undernutrition contributes to 20% of
poorer maternal and neonatal outcomes. ThFh maternal deaths worldwide. ThFh
4. interventions during the maturation phase of 13. zinc deficiency has been linked to
gametes has no impact on preterm births. ThFh
obstetric outcomes. ThFh
Concerning interventions in preconception care,
With regard to maternal behaviour before and
14. the recommended minimum amount of aerobic
during pregnancy,
activity per day is 30 min of intense activity. ThFh
5. smoking in pregnancy has been associated 15. a population increase in maternal
with a 20% increased incidence of haemoglobin of 1 g/dL has been shown to
late stillbirths. ThFh reduce the risk of mortality by
6. ingestion of three standard units of alcohol approximately 35%. ThFh
per week increases the risk of
With regard to infections in pregnancy,
developmental and cognitive disability in
the offspring. ThFh 16. Zika virus has been shown to cause
7. folic acid supplementation has been shown to microcephaly in the fetus. ThFh
prevent the recurrence risk of neural tube 17. genital herpes is a recognised cause of
defects by up to 75%. ThFh encephalitis in the newborn. ThFh
8. fortification of food with iron has been shown 18. the combination of pyrimethamine and
to have a greater impact on pregnancy than sulfonamides is safe to administer in the first
iron supplementation. ThFh trimester for the management of
toxoplasmosis infection. ThFh
With regard to nutritional health,
With regard to exposure to chemicals and their impact
9. the prevalence of obesity in women globally is
on health,
estimated to be more than 20%. ThFh
10. a body mass index of 22 kg/m2 has been 19. high lead levels are associated with
associated with multiple preterm birth. ThFh
obstetric complications. ThFh 20. high mercury levels in the mother are
11. stunted growth is often the result of associated with child deficits in language,
adequate nutrition. ThFh attention and memory. ThFh

76 ª 2022 Royal College of Obstetricians and Gynaecologists