Obstetrics and Gynaecology Forum - latest Issue

The Centre for Research Excellence in Polycystic Ovary Syndrome (CRE-PCOS) was established some years ago in Australia. This was funded initially by the NHMRC within Australia. It subsequently received support from ESHRE and the ASRM and both these organisations have supplied additional funding. In addition numerous national and international societies and bodies involved in Reproductive Medicine have pledged their co-operation with the activities of this centre.

Stress urinary incontinence (SUI) is a condition affecting a large portion of the population, with a reported prevalence as high as 46% in women. It affects women more than men, with the tendency to increase in incidence with increasing age. This condition causes not only physical distress, but affects women psycho-socially, sexually and financially. Bothersome symptoms vary and as such, management plans should be individualised. Options for the treatment of SUI range from conservative measures to surgical interventions. The Tension-free Vaginal Tape (TVT), as a minimally invasive procedure, has evolved into the gold standard of surgical management of SUI, with excellent long-term efficacy. In the last few years, however, considerable controversy has surrounded this mesh-based sling procedure. Although literaturebased complication rates are low, women have recently reported unacceptable chronic pain and dyspareunia related to the sling. This has resulted in greater scrutiny into vaginal mesh procedures, with the FDA and numerous other medical regulatory bodies around the globe publishing warnings related to these procedures. 

It is important to know what alternative management options are available for SUI and their comparative safety and efficacy. This includes newer more conservative interventions like vaginal laser therapy, as well as the resurgence and modification of older procedures such as the laparoscopic approach to the Burch Colposuspension.

Iron deficiency anaemia (IDA) is an important medical problem in pregnancy and the puerperium. The deleterious effects of IDA on maternal and fetal well-being constitute a huge health problem and a burden, not only in countries with low resources, but also in the industrialised world. This review outlines definitions, epidemiology, diagnosis, complications, treatment modalities and the management in labour and delivery in women with IDA.

Neural tube defects (NTDs) such myelomeningocele and anencephaly are the commonest major congenital CNS abnormalities with a live birth incidence of 2.5/1000 estimated in 2006 in South Africa. Remarkably, 50-70% of NTDs can be prevented by ensuring optimal maternal folate levels at the time of closure of the neural tube which occurs between day 21 and day 28 post conception. 

The aetiology of NTD is multifactorial with both genetic and environmental contributions, many of which are directly linked to folate. Women with a family history of NTD, diabetes, obesity and exposure to teratogens, notably sodium valproate are at greater risk. Genetic testing does not currently have a role in the prevention of NTD. 

Food fortification with folic acid remains the most successful preventative strategy for NTD and has markedly reduced NTD incidence but even in countries where this is mandatory, such as in South Africa, this does not guarantee protective folate levels in all women of child bearing capacity. For this reason, well-established guidelines specify supplementary periconceptual folic acid, either 4-5 mg/day for women at high risk or 0.4mg-0.8 mg/day for those at standard risk. In addition, some recommendations also include an intermediate risk category, advocating a dose of 1mg/day.

As folate is an epigenetic modulator, the safety of food fortification and folic acid supplementation has been closely monitored. Initial concerns about increased risk of cancer and autism spectrum disorder have not been realised and folic acid may even be protective of these conditions. Current evidence assessing safety conclusively demonstrates that the benefits of folic acid clearly outweigh any potential risk.

Genetic counsellors give advice to individuals and families to help them make sense of their diagnosis and make decisions about management. In prenatal diagnosis, these decisions are often complex, compounded by uncertainty about prognosis, and emotional and ethical overlays. The gold standard counselling method since the 1960s has been that of non-directive counselling. This conforms to the current bioethical paradigm where respect for autonomy is held in higher regard than the other ethical principles. However, there have been criticisms of this method, including views that non-directive counselling, by definition, is not possible due to power differentials, and latent biases and non-verbal cues. It is also contended that counsellors and physicians are letting their patient down by giving objective information and then standing back and not supporting patients in difficult decision-making. There has thus been an exploration of alternative counselling models which address these concerns, while maintaining patient autonomy and non-coercion. The shared decision making model has been proposed. This allows information sharing between the patient and counsellor as well as sharing of personal and professional values. Decision aids have also been found to be helpful in this model to support active participation by patients in the decision-making process.

“About 25% of all Western European women of reproductive age are defined as obese with a BMI >30”

“kg/m². A further 25% have a BMI of 25-30kg/m². 

Bariatric surgery has become progressively more common and is effective in treating obesity in these women. This review will specifically address bariatric surgery and its effectiveness in reducing obesity” 

“related complications and diseases in pregnancy.”

Abnormal uterine bleeding (AUB) is a common clinical entity among women in the reproductive age group that can significantly impact on their physical, social and emotional quality of life. In 2009, FIGO redefined the AUB nomenclature and definitions and developed a structured approach for establishing the cause of AUB. This facilitates diagnosis, investigation and research. With the rising costs of healthcare and the need to preserve fertility as women increasingly defer pregnancy, medical options for the treatment of AUB are of critical importance. This review aims to provide an evidence-based approach to the medical management of AUB in line with international guidelines.