We don’t usually take smears in pregnancy but sometimes a smear is taken before you realise you are pregnant. At other times you may have had an abnormal smear before the pregnancy and your doctors may want to keep a check on things whilst you are pregnant. An abnormal smear in pregnancy can be easily managed without causing any harm to the pregnancy.
If the smear shows a very low grade abnormality, technically called “borderline nuclear atypia,” we would usually recommend repeating the smear in 6 months time. In pregnancy this can be left safely until 3 months after delivery, if this is your first abnormal smear and you have had regular smears up until then.
If the smear shows any other abnormality we recommend colposcopy. This just means having a careful look at the cervix with magnification and will not harm the pregnancy. A biopsy is not usually necessary during pregnancy. Depending upon the abnormality your doctor may suggest you have further colposcopies during pregnancy but usually we leave treatment until about three months after delivery.
The most important thing is not to get too worried by the smear result but just to follow the advice you are given and get it checked out.
HPV vaccination is working very well and is extremely safe and the WHO, as well as a number of governments, has recommended that it is given to all girls and young women. Since its introduction in 2007, it has been taken up by many countries who have introduced national programs for vaccination, usually through schools.
The vaccine has a very good safety record and has been given to millions of people already. It is made up of just one of the proteins from the outer coat of each of the virus types included. The protein is produced artificially so the vaccine contains pure protein rather than other parts of the virus making it very safe.
The vaccine is very effective at preventing infection but it is not effective for women who already have infection. Since the vaccine gives better levels of protecting antibodies than a natural infection with the virus, it helps to prevent a second infection with the same virus. Studies so far suggest that protection will last for at least 10 years and possibly longer.
The vaccine is usually given to young girls but older women can benefit from vaccination and the vaccines have approval for use in women beyond teenage years.
Although the vaccine protects against the two most common cancer causing virus types, studies suggest that a degree of cross protection occurs against other virus types.
The vaccination involves three injections spaced out over 6 months. No adverse effects have been linked with the vaccine apart from discomfort at the injection site and mild flu like symptoms.
St Paul’s is the fifth cathedral to have stood on the site since 604, and was designed by Sir Christopher Wren and built between 1675 and 1710, after its predecessor was destroyed in the Great Fire of London. This was the first cathedral to be built after the English Reformation in the sixteenth century, when Henry VIII removed the Church of England from the jurisdiction of the Pope and the Crown took control of the Church.
Among the events marked at St Paul’s are royal occasions. In 1897 Queen Victoria chose to commemorate her diamond jubilee here. More recently Queen Elizabeth II has celebrated her jubilees at St Paul’s , and also her 80th birthday in 2006. Royal weddings have been held here as well: the marriage of Catherine of Aragon to Prince Arthur in 1501 and famously the wedding of HRH the Prince of Wales to Lady Diana Spencer in 1981. St Paul’s has also been the site of state funerals of British military leaders, including Admiral Lord Nelson, the Duke of Wellington and of the wartime Prime Minister, Sir Winston Churchill.
A hand held ultrasound machine
Doctors love fancy bits of kit, and there is no better example of this than when it comes to ultrasound imaging. There are fabulous machines around that give spectacular images – but how good does an image have to be to get the diagnosis right? -
My colleague Ahmad Sayasneh published a paper yesterday in the journal Ultrasound in Obstetrics and Gynecology – in which he showed that small hand-held ultrasound machines of the type pictures on the left can give very useful information in a variety of clinical situations. In his study of 204 patients he looked at whether management based on the hand held machine was any different to when a large very expensive department machine was used. Surprisingly in only 2 cases would immediate management have been different. The images obtained were not as good – but the point is that the images were good enough to make a sensible clinical decision.
This is particularly important in early pregnancy care. A women with bleeding and pain in early pregnancy needs to know if the pregnancy is in the right place (i.e. not an ectopic pregnancy) and if there is a heartbeat in order to be reassured about viability. It seems small inexpensive hand held machines can do this satisfactorily in most cases. These machines are light and truly pocket sized – and one imagines it should be possible to “toughen” them and enable them to be recharged using solar power or a car battery – and so make them useful in many environments where ultrasound may not be available. I need to declare my bias – as I work with Ahmad – but I think this is an important paper that may lead to much better accessibility to ultrasound.
I think everyone knows the old adage that pregnant women are “eating for two” is not only wrong but positively unhealthy. Yesterday in the British Medical Journal, Shakila Thangaratinam and colleagues published an analysis of papers designed to see if interventions to control maternal weight in pregnancy improved the outcome both for the mother and her baby. This paper reviewed 44 randomised trials involving 7278 women.
The interventions in the studies typically involved introducing a balanced diet and/or introducing walking for 30 minutes or light intensity resistance training. Some studies also introduced behavioural modification for women with problems of binge eating.
The findings suggest that “dietary intervention” reduced maternal weight gain by the order of about 4 kg. This in turn reduced complications in pregnancy such as high blood pressure, diabetes and preterm delivery. Perhaps not surprisingly these interventions helped overweight women most.
The diets usually comprised of 30% fat, 15-20% protein and 50-55% carbohydrate.
There are problems with this study. It pools lots of studies into one pot – and so it is open to bias. A bigger issue is that it is not possible to know whether it is the actual weight loss or the nature of the intervention that improves outcome. In other words it might be the introduction of different food in itself rather than the weight loss caused but the change in diet that improves outcomes. This is important if we are to understand how to best manage patients.
Irrespective of these limitations these data confirm the view that pregnant women – especially if they are overweight – should be encouraged to follow a careful diet in pregnancy from early on and to avoid gaining too much weight. It is also important for pregnant women to understand that exercise in pregnancy is a good thing as long as it is not taken to extremes.
A tubal ectopic pregnancy with a visible yolk sac
As trainee gynaecologists one of the first things we learnt is the idea that a women with pain/bleeding/almost any symptoms has an ectopic pregnancy until proved otherwise. Over time maybe this teaching has slipped. In a recent study from Nora van Mello and colleagues in Amsterdam (published in Fertility and Sterility) the conclusion was that relatively poor outcomes were usually due to substandard care rather than something intrinsic about the ectopic pregnancies themselves.
In this study poor outcome was defined as severe intra-abdominal bleeding needing a blood transfusion of more than four units of blood. In these cases substandard care was reported in 43% compared to 14% of stable ectopic pregnancies. The poor care was most often misdiagnosis.
This study was on relatively small numbers – just 128 cases. Furthermore socio-economic data were not available in all women from the study – which may be a very significant factor. However this study certainly suggests that there is no room for complacency with ectopic pregnancy. In “developed” countries this is possible as trainee doctors see fewer women who have collapsed secondary to blood loss from an ectopic. Although at risk of sounding like Methuselah – this was not so uncommon when I was training. The result is that clinicians and even patients do not give ectopic pregnancy the respect it deserves. Medicine has a habit of biting you just when you think things are OK, and ectopic pregnancy falls into this category. Most ectopic pregnancies are found early and treatment is straightforward – even though the impact on an individual couple may be huge. However a lack of awareness, failing to carry out a urinary pregnancy in all women of fertile age with pain, not recognising that gastro-intestinal symptoms such as diarrhoea are sometimes a feature – all these things can lead to a disaster. There is also a need for education amongst women. Any women should be educated to be aware of the risk factors and to carry out a home pregnancy test in the event that they have suggestive symptoms. If everyone is aware of the possible risk then severe morbidity should be avoided in most cases.
Recurrent miscarriage is a blight on a couple. There is only so many times a person can cope with being told it is “bad luck” or “the odds are really in your favour next time”. Undoubtedly this may be true for many couples, and a number of women are labelled as suffering from recurrent pregnancy loss or miscarriage when in fact the lottery which is early pregnancy has not been in their favour. However there certainly does seem to be a group where there is a real problem. Looking at their reproductive history is often illuminating. Getting pregnant is easy – in fact if anything they are super fertile with conception times of one to two months. The result is pregnancy after pregnancy in quick succession – but all ending in miscarriage. This appears to be a high risk group where something different is going on.
There have been many hypotheses to explain apparent recurrent miscarriage from disorders of blood clotting to thyroid disease and NK cells.
Professor Jan Brosens of Warwick University has a different hypothesis. He believes the problem relates to defective decidualisation. This is the process whereby the cells in the endometrium change (differentiate) from ones that are called stromal into “decidual” cells. If decidualisation takes place properly Brosens believes the endometrium has the ability to recognise defective embryos and in effect reject them. In a sense the normally decimalised endometrium acts as a natural quality control measure. Conversely a failure of the process of decidualisation means quality control is impaired and is associated with early placental failure. This also means the implantation window will be longer which might explain the super fertility seen in women with recurrent miscarriage.
The idea of miscarriage being associated with a prolonged implantation window is not new. In 1999 Wilcox published a seminal paper in the New England Journal of Medicine on the same subject – where he looked at the implantation window by examining the LH surge in relation to the first appearance of hCG in serum.
The decidualisation hypothesis is attractive as is pulls together a number of strands. It is unifying in that it explains increased miscarriage, super fertility, sub fertility and the possible development of late obstetric complications due to impaired placentation. It also means that a tendency to miscarry may be transient and the implantation window may correct itself – or indeed be amenable to intervention to treat the disorder. Professor Brosens (pictured left) work is innovative and it will be fascinating to see how this area of research develops.
Women who have had a miscarriage often read widely on the internet to try to understand what may have been the reason it happened. It is highly likely that they will find something about the possible role of NK cells and various articles about how treatment may improve their chances in a future pregnancy. So what is the real story here?
NK cells are part of the immune system and are found both in the blood (pNK) and in the lining of the uterus (womb) – so called uNK. It seems these two types of NK cells are rather different. NK cells in the blood have a toxic action on foreign insults such as virus’s and tumour cells. In contrast uNK cells do not seem to have these actions – although they do have the ability to stimulate new blood vessel growth (angiogenesis), and it is thought that they are able to impact on how the cells in the developing placenta (the trophoblast) invade and implant in the uterus in the very early stages of a pregnancy.
The interest in NK cells has been boosted by studies that compared women with a history of recurrent miscarriage (RM) and control groups where there was no such history. The studies have suggested that there are increases in both pNK and uNK cells in women who have recurrent miscarriage. The problem with all studies on recurrent miscarriage is how to define it. Unfortunately however many miscarriages are used as the definition, some of the women will have been incredibly unlucky,rather than there being some kind of fundamental problem. So there is a heterogenous population in some of these studies – which can make it difficult to interpret them and as the population is mixed – if there is a real finding to be made it might be diluted.
So what are we to make of the NK story? In August 2011 Tang and colleagues published a systematic review in the international journal Human Reproduction on this subject. This means they looked at all the relevant publications on NK cells – chose the ones they thought were the best according to some predetermined criteria – and pooled the results. Their conclusion was that there was insufficient evidence in the literature to know if there is any value in measuring either pNK or uNK. Furthermore they stated that more studies were needed before measurements of NK cells can be considered as a useful test to determine whether a pregnant women may benefit from immunotherapy. Contrary to what is often thought such systematic reviews are open to bias, but even so the data suggests that in clinical practice there is no justification in measuring NK cells. The logical consequence of this is that using immunotherapy outside the context of a clinical trial is not appropriate.
This does not mean that NK cells are not important. What is clear from the systematic review is that there are insufficient good quality studies from which to form a view. At the moment the data are simply not there. Until we get more information women who make a decision to undergo immunotherapy should be told very clearly that there is no evidence to support its use. Unfortunately for a couple who have been through the experience of several miscarriages, almost any treatment may seem “worth trying” as the alternative of doing nothing is just too difficult to live with. It is essential that clinicians do not exploit such a vulnerable group by offering expensive treatment with little or no prospect of it working. If a couple wants to explore the possibility of immunotherapy it would seem more appropriate to put them in touch with one of the academic centres where NK studies are taking place (for example Professor Siobhan Quenby in Warwick see lecturing in the picture to the left).
The systematic review from Tang and colleagues can be found at this address: http://www.ncbi.nlm.nih.gov/pubmed/21613313
Pink flamingoes photographed at Slimbridge Wildfowl and Wetlands trust in Gloucestershire
Incomplete healing of Caesarean section (CS) scars is a recognised sequelae to this operation, and may be associated with complications in later pregnancies. These can include scar pregnancy, a morbidly adherent placenta, scar dehiscence or rupture. To date there is uncertainty relating to the factors that lead to poor scar healing and how to recognize it. In recent years, there has been an increase in studies using ultrasound that describe scars as deficient, poorly, incompletely or inadequately healed with few data to associate the morphology of the scar with the functional integrity of the lower segment of the uterus.
There is a need to accurately characterize scars and to explore their clinical relevance in subsequent pregnancy and future conception. Furthermore the tendency to describe the ultrasound features of scars as “deficient” inevitably leads the reader to conclude that “deficient” relates to function and not just appearance. Our view is that an alternative terminology should be developed, and that the morphology of a Caesarean scar should be described on the basis of objective measurements and in descriptive ultrasound terms only. We have published a general consensus article in agreement with other research groups and established standarised methods of assessment of Caesarean scars in pregnant women.
Improvements in imaging have facilitated the evaluation of Caesarean scars both before and during pregnancy. CS scars remain visible in the majority of women throughout pregnancy. CS scars can be reproducibly measured in three dimensions when assessed by transvaginal scans in all phases of pregnancy. Our research group has also established that The presence of a CS scar in the uterus is associated with an increase in the number of posterior placentas and a reduced number that implant in the fundus of the cavity. There is also an increase in the number of low-lying anterior placentas in the CS group. Migration of a low-lying placenta is independent of the presence of a Caesarean scar in the uterus, and that larger scars show a greater decrease in size during pregnancy. Maternal age as well as a previous history of vaginal birth after Caesarean section (VBAC) is strongly associated with scar size in subsequent pregnancies. Both the absolute value and changes seen in CS scars during pregnancy have the potential to be tested as predictors of performance in trials of VBAC.
Until we know more about how the ultrasound appearances of a scar relate to function we must be very cautious about how we interpret scan findings. Already being requested to examine a CS scar is not a rare event in an ultrasound department. Telling a women that her scar Looks “deficient” is unlikely to give her confidence when embarking on a trial of labour. It is very important that we carry out the necessary studies to be clear what scar appearance on ultrasound means before we create a serious iatrogenic problem.