Obstetrics & Gynaecological Services
Assessments, treatments and care
Preconceptual counselling can not only improve your chances of conceiving but of having a healthy pregnancy and a healthy baby. If you are planning a pregnancy, we will cover the ffg.
- Stopping your current birth control method – what you can expect and if there may be a waiting period till conception.
- Taking folic acid (at least 400mcg daily for 2months prior).
- Vaccines (eg. Rubella) and screening you may need (eg. cervical & breast cancer screening, STIs including HIV)
- Optimising chronic medical conditions eg. diabetes, high blood pressure, thyroid disease, obesity, depression, eating disorders, and asthma. Find out how pregnancy can influence or be influenced by health problems you may have.
- Medicines that you may use and what you must avoid (over-the-counter/herbal,/prescription drugs and supplements)
- Improving your overall health eg. reaching a healthy weight, making healthy food choices, being physically active, caring for your teeth and gums, reducing stress, quitting smoking, and avoiding alcohol.
- Health problems that run in your or your partner’s family.
- Problems you have had with prior pregnancies, including preterm birth.
- Family concerns that could affect your health, such as domestic violence or lack of support.
The genes your baby is born with can affect your baby’s health in these ways:
- Single gene disorders are caused by a problem in a single gene. Genes contain the information your body’s cells need to function. Single gene disorders run in families. Examples of single gene disorders are cystic fibrosis and sickle cell anaemia.
- Chromosome disorders occur when all or part of a chromosome is missing or extra, or if the structure of one or more chromosomes is not normal. Chromosomes are structures where genes are located. Most chromosome disorders that involve whole chromosomes do not run in families.
Depending on your genetic risk factors, we may suggest you meet with a genetic counsellor.
- A family history of a genetic condition, birth defect, chromosomal disorder, or cancer
- Two or more pregnancy losses, a stillbirth, or a baby who died
- A child with a known inherited disorder, birth defect, or intellectual disability
- A woman who is pregnant or plans to become pregnant at 35 years or older
- Test results that suggest a genetic condition is present
- Increased risk of getting or passing on a genetic disorder because of one’s ethnic background
- People related by blood who want to have children together
During a consultation, the genetics professional meets with the couple to discuss genetic risks or to diagnose, confirm, or rule out a genetic condition.
Most women will do a home pregnancy test after missing their first period – it is often too early to see a fetus on an ultrasound at this stage, and it creates undue anxiety when the doctor cannot show you what you are expecting to see. Therefore, we recommend that your first appointment (also known as the booking visit) be made between 8–10 weeks of pregnancy provided that you are well till then. If you are struggling with any minor ailments of pregnancy or chronic illnesses that may be exacerbated in the first trimester, feel free to make an appointment sooner.
At the first visit, we will take a detailed history from you and your partner (if accompanying you), perform a full physical examination (if you are unknown to the practice) and most importantly do a dating scan to accurately determine:
- The correct location of the pregnancy (inside/outside of the uterine cavity)
- The number of foetuses
- The gestational age of the pregnancy and your estimated date of delivery.
A discussion regarding first trimester screening tests (and what is available for you to choose from), will then ensue, depending on your risk factors eg. age, previous genetic/chromosomal abnormalities etc.
Should you choose to proceed with first trimester screening, you will be referred to a fetomaternal specialist or a fetal assessment clinic for an NT (nuchal translucency) scan between 11-14wks gestation. You will also need to have some special blood tests done at a laboratory which will include your iron levels, harmful infections that may be transmitted to the baby as well as your blood group etc.
11-14 Week Scan
Most fetal assessment centres or feto-maternal specialists use a combination of the blood results from the laboratory (PAPP-A & BHCG) and the NT measurement to help calculate the risk of your fetus having an abnormality. If the risk is calculated as high risk, you will be offered further diagnostic tests (risks and benefits will be discussed with you at the time of the scan). If the risk is calculated as low, we often treat the pregnancy as “normal” and do a detailed fetal anomaly scan at 18-22wks gestation.
The importance of the 11-14week scan extends far beyond screening for chromosomal (eg. Down’s syndrome) and structural abnormalities (eg. cardiac defects) or to determine the gender of the baby which is not always guaranteed at this stage of the pregnancy. A comprehensive risk assessment for hypertensive conditions or growth restriction, is also done adding the blood flow to the uterus (uterine artery dopplers) and lastly the cervical length is measured to screen for risk of preterm labour.
It is highly recommended that even if one does not entertain the idea of terminating an pregnancy (due to personal values/religious beliefs), that one has the 11-14week scan for the above-mentioned benefits.
18-22 Week Anomaly Scan
The second scan that is recommended & outsourced to accredited sonographers or feto-maternal specialists, is your 18-22week anomaly scan. By this stage of the pregnancy, your baby is large enough (and with sufficient amniotic fluid around it) for us to see any structural abnormalities that may have arisen during the development of the various organs. Usually one can be pretty certain of the gender of the baby by now as well (please inform the sonographers or doctors scanning you, if you & your partner prefer not to know). Most times, the placenta would have attained its final position in the uterus except if it was initially implanted too low – one can only determine if its dangerously low-lying placenta by 28weeks of the pregnancy.
With low risk pregnancies you will require 4-6 weekly examinations and growth scans until 34 weeks, followed by 2 weekly visits until 40 weeks gestation. At every visit you are fully assessed for any new complications that may have developed, any questions are answered, and concerns addressed. In the third trimester we will start discussing your birth preferences re. pain relief, preferred route of delivery etc.
A pregnancy should not be allowed to go 10days beyond the estimated date of delivery without risks of potential complications eg. your baby growing too big with possible difficulties with delivery necessitating a Caesarean Section due to disproportion, your baby outgrowing its source of nutrients and then becoming growth restricted and worst possible case scenario being an unexplained intra-uterine fetal demise. Most gynaecologists will offer you an induction of labour at this stage of the pregnancy provided all other parameters are within normal limits (your blood pressure & urine dipsticks, fetal heart rate tracing).
A high-risk pregnancy may possibly involve more frequent visits to the gynaecologist for more frequent monitoring of either the maternal condition (usually due to other co-existing conditions eg. hypertension, diabetes) or the fetal condition (eg. too much amniotic fluid, concerns with fetal growth). Some of the high-risk conditions in pregnancy that may necessitate a multidisciplinary team approach, while others may require that you be referred to a feto-maternal specialist.
- Cardiac disease
- Diabetes (gestational or already pre-existing diabetes)
- Thrombophilias (either with/without a history of thrombosis)
- Asthma (depending on control)
- Multiple pregnancies (depending on chorionicity)
- Rhesus isoimmunisation
- Certain fetal abnormalities (chromosomal/structural)
While the practice favours vaginal delivery with as little intervention as possible, the most important outcome is the safety of the mother and baby (and not whether you have had a normal vaginal birth or a Caesarean Section). I will advise you if I consider a particular route of delivery to be safer, however you and your partner will need to make an informed decision.
The attached document is adapted from the SASOG (South African Society of Obstetricians & Gynaecologists) version, as the informed consent for a vaginal delivery, which you will be required to sign by your 38week visit. Any questions that you may have after reading the form, will be addressed at this stage.
Assisted Vaginal Delivery
A vaginal delivery may need to be assisted (by use of either the obstetric outlet forceps or a ventouse/vacuum) in its final stages due to either maternal or fetal reasons. These can only be assessed during the second stage of labour.
Vaginal Birth After Caesarean Section (VBAC)
Patients who are a suitable candidates for VBAC (depending on the indication for the previous caesarean delivery & the current pregnancy) and would like to attempt this route of delivery, will need to labour in hospital to ensure quick recourse to repeat Caesarean section should the need arise. One cannot guarantee the success of a VBAC which ranges between 50-70%
There are 2 recommended postnatal visits:
7-10 days after delivery to
- assess your physical, emotional and psychological well-being
- to assess whether feeding (breast/formula) is going well
- to ensure the healing of a caesarean section wound or vaginal tear/episiotomy
- to discuss contraceptive needs (if you are not exclusively breastfeeding)
6 weeks after delivery to
- do a cervical smear as a screening test for cancer (if indicated)
- offer an appropriate contraceptive method (if this has not yet been instituted)
It is important to contact your health care provider if you are feeling unwell, not coping or if you are concerned about any aspect of your recovery.
Your first visit to a gynaecologist can be understandably intimidating, therefore it may be helpful to know what to expect. While some women choose to visit a gynaecologist only when they experience women’s health issues, it is always useful to see us before things start going wrong.
A significant part of the visit is spent in getting to know you, by taking a detailed social, medical, surgical and gynaecological history with a special focus on your menstrual history and any significant family history that may impact your future health. If you are sexually active, some questions may be asked in order to identify risk factors for sexually transmitted infections as well as your need for contraception. The physical examination includes a full general examination, assessment of your breasts and thyroid gland and concludes with special focus on the abdominal and pelvic exam (depending on your symptoms). Not every patient requires an internal pelvic examination or a Pap smear – we will discuss the need for this at the time of your consultation. Most patients will receive an ultrasound of their pelvic organs (which may be done via the transvaginal route or using a transabdominal probe).
We will discuss any abnormal findings with you (and your partner/parent/companion), go through various treatment options and assist you to choose an appropriate therapy (if required). You will also have the opportunity to ask any questions.
A woman’s menstrual cycle usually commences around the age of puberty (12-14yrs of age, although it may be earlier or later). The first few cycles may be irregular (amount, duration and length) although once a regular cyclical pattern of bleeding has been established, any changes may indicate an underlying cause which will need to be investigated.
You may have abnormal uterine bleeding if you have one or more of the following symptoms:
- You get your period more often than every 21 days or further apart than 35 days
- Your period lasts longer than 7 days
- Your bleeding is heavier than normal or associated with clots.
- If there is significant associated pelvic/lower abdominal pain
- If you are developing symptoms or signs of anaemia (tiredness, syncope, palpitations)
Chronic pelvic pain means that you have experienced pain symptoms for more than 6months which may not be confined to the time of your period and is often associated with a chronic disorder or underlying condition eg. endometriosis, infection, prolapse, fibroids, tumours, cysts on ovaries, irritable bowel syndrome, other problems with bowel, bladder or nerves. Sometimes, despite all kinds of investigation we may not find the cause of pelvic pain.
The most common cause of pelvic pain is endometriosis, in which pieces of the lining of the uterus (endometrium) is found outside of the uterus and may attach to other organs or structures within the pelvis and abdomen. Most patients will eventually require a small “keyhole” surgical procedure (laparoscopy and biopsy) to confirm the diagnosis of endometriosis. There are various modalities of treatment for this condition which need to be tailored to your specific needs.
Fibroids are non-cancerous tumours/growths that arise from the muscle layer of the uterus and typically develop during one’s reproductive years under the stimulation of oestrogen. They may vary in size, number and location (in relation to the uterus) and most often are asymptomatic. When they do cause symptoms, these may include menstrual abnormalities (usually heavy cyclical bleeding), infertility or recurrent miscarriages, pressure symptoms on the surrounding structures eg. the bladder/bowel causing frequent urination or constipation respectively or the presence of a mass in the lower abdomen/pelvic area. Fibroids are usually diagnosed on examination & by ultrasound.
If fibroids cause symptoms, they should to be treated – various modalities exist, some which treat the symptoms but do not remove/shrink the fibroids (some birth control methods), while other modalities (surgical/non-surgical) address the fibroids themselves.
Depending on their size, location and number, surgical removal of fibroids can be performed hysteroscopically (via the uterine cavity & vagina with no need for surgical scars on the abdomen), laparascopically (key-hole surgery) or via a laparotomy (larger incision on the abdomen).
Endometriosis is a condition found in women during their reproductive years and is characterised by the presence of endometrial tissue (the lining of the uterus which sheds during a menstrual cycle) in places outside of the uterus. The most common sites that this endometrial tissue can be found are on your ovaries, fallopian tubes and the tissue lining your pelvis (peritoneum) with pain being the predominant symptom. This includes pain, which is worse during the menstrual cycle, pain wih intercourse and sometimes pain with passage of urine/stool. Other symptoms include abnormal bleeding and infertility.
While the cause of endometriosis is multifactorial, there may be a strong genetic link. While the history may be very suggestive and one must always maintain a high index of suspicion of endometriosis, it is often not picked up by our conventional pelvic ultrasound (unless it causes an ovarian cyst also called a “chocolate cyst”). Endometriosis is most reliably diagnosed by diagnostic laparascopy (keyhole surgery where a camera is inserted through the belly-button) and one may treat the condition surgically at the same time.
Treatment depends on the woman’s age, her symptoms and her fertility requirements (immediate & long term). Treatment modalities include hormonal treatment to suppress the growth of endometrial tissue or surgery especially when fertility is desired or if medical management has failed.
An ovarian cyst is fluid-filled growth that forms on the ovary usually during the reproductive years. While they are quite common, they generally cause no symptoms and are mostly detected as an incidental finding while having a pelvic ultrasound. Majority of ovarian cysts are what we call “functional” cysts which means that they develop at different parts of a woman’s cycle depending on the function of the ovary (most commonly before/during/after ovulation. These cysts usually resolve without treatment although if causing pain, your gynaecologist may recommend hormonal suppression using a birth control pill. Ovarian cysts that may require surgical intervention are those that have grown and are now causing pain, bloating, nausea or pressure on the bladder or bowel. Although most are non-cancerous, they can complicate eg. rupture or undergo torsion, which may warrant emergency surgery.
There are many other types of ovarian cysts and these may only be differentiated by how they look on ultrasound (eg. endometriomas/chocolate cysts, dermoid cysts which can contain hair & teeth) or finally once your doctor has removed them and sent them for microscopic examination.
Ovarian cancer is rare and is a more common in ladies over the age of 50 years (unless one has a strong family history of breast/ovarian/uterine/colon cancer). Any ovarian cysts in a postmenopausal patient requires further investigation and often surgical removal.
PCOS is a metabolic and hormonal condition that affects approximately 10% of females. While the cause is considered multifactorial, we know that there is a strong genetic predisposition for one to develop this condition. It usually presents with irregular menstruation (due to irregular egg production from the polycystic ovaries) and subsequently infertility. Some patients present with symptoms & signs of “hyperandrogenism” which is basically elevated circulating levels of testosterone which can cause increased hair growth (hirsuitism), male pattern hair loss, acne or oily skin. The metabolic features of PCOS include central obesity, insulin resistance and the propensity for hypertension, diabetes and hypercholestrolaemia later in life.
Your gynaecologist will definitely need to scan your ovaries for the typical ultrasound appearance as well as order certain biochemical blood tests to confirm the diagnosis.
While the mainstay of treatment is lifestyle modification (weight loss through diet and exercise), there is a category of PCOS patients who are lean (20%) and do not have insulin resistance and won’t benefit from these lifestyle changes. Treatment of PCOS depends on your symptoms and desire for fertility. Most commonly a birth control pill may be prescribed to regulate one’s cycles or even to tackle the acne and hyperandrogenism. Fertility may be a challenge with PCOS patients often requiring ovulation induction or other assisted reproductive techniques. Potential long term consequences of PCOS besides the metabolic conditions include endometrial thickening and cancer.
Infertility is defined as failing to conceive after 12 months of unprotected intercourse, at least 2-3 times/week. If you are ≥35yrs old however, your gynaecologist may recommend investigations after just 6months of attempts at spontaneous conception. In women, there is a decline in fertility rates with age and our concern is not only regarding quantity but also quality of eggs/oocytes.
It is important that the couple are both present for the consultation so that a detailed history can be obtained from both of you and the relevant investigations be carried out without wasting too much time (it is essential that both partners agree on their desire for a child and the relevant timelines). In one third of cases of infertility, a male factor is found (ie. something wrong with the sperm), while in women the 2 main reasons are 1. lack of regular egg production (oligo-/anovulation which most commonly is due to PCOS) and 2. Abnormalities of the female genital tract eg. blocked tubes, fibroids.
After initial investigations, depending on the cause for failure to conceive spontaneously, you may require referral to a fertility specialist for assisted reproductive techniques eg. intrauterine insemination, ovulation induction or in vitro fertilisation.
Most women will be treated for a urinary tract infection at least once in their lifetimes – they are more common in females due to the proximity of the urethra to the vagina & anus as well as the length of the urethra (shorter in women). Symptoms of a UTI include frequent urination, suprapubic discomfort or a burning sensation when passing urine. If left untreated, a lower urinary tract infection can spread up to the kidneys causing fever, chills, loin/flank pain – this can be serious and may warrant hospital admission.
There are certain risk factors that may predispose some women to recurrent UTIs eg. diabetes, obesity, menopause (due to decreased levels of oestrogen in the vagina). If no response to conservative measures of increasing fluid intake, using a urinary alkalise reg. Citro Soda ®, you may require a broad-spectrum antibiotic. If there is no response to the latter, it is advisable that a specimen of urine gets analysed by the laboratory.
The commonest vaginal infections that women will require treatment for are Candidiasis (commonly called thrush) or Bacterial Vaginosis (which is simply an overgrowth of normal vaginal bacterial flora). Neither of these are STIs and are often follow a course of broad-spectrum antibiotics that you may need for an infection elsewhere in your body. You will need to consult a healthcare worker to differentiate between these types of vaginal discharges so the appropriate medication can be prescribed.
Sexually transmitted infections are often asymptomatic until they affect the upper genital tract (uterus and fallopian tubes) where they may cause serious long-term complications eg. chronic pelvic pain, infertility. If you think you may be at risk of having acquired an STI, a series of tests will be done by your doctor (blood and urine samples) or alternatively one may be prescribed a set of three antibiotics that cover most sexually transmitted organisms.
Prolapse of one or more of a woman’s pelvic organs most commonly occurs in the perimenopause/menopausal years due to declining oestrogen levels from the ovary. Other risk factors that predispose women to POP include prolonged labour, difficult deliveries (especially big babies & those assisted by obstetric forceps). Symptoms include the sensation of something bulging out of the vagina or that of lower abdomino-pelvic discomfort. Occasionally these may be associated with bladder symptoms (either involuntary loss of urine or difficulty in passing urine) or difficulty in passing stool.
Depending on your symptoms, age, level of physical activity, co-exisiting medical conditions, past surgery, and degree of prolapse, your gynaecologist may recommend conservative management or surgery.
Any per vaginal bleeding after the menopause (1year after your last menstrual period) in a patient not on hormone therapy, warrants investigation. While the commonest causes of PMB are benign (atrophy ie. thinning of the lining of the female genital tract due to diminishing oestrogen production by the ovaries or polyps of the lining of the uterus/cervix), it is important to exclude female cancers which occur in the older women.
Even if the bleeding stops spontaneously, please consult your gynaecologist as soon as possible so he/she can do a detailed evaluation. Remember to mention if you are taking any medication including hormonal, over-the-counter or natural medication especially any blood-thinning agents.
SPECIAL GYNAECOLOGY SERVICES
While most general practitioners and clinics provide contraceptive services, choosing the appropriate contraceptive method should entail the taking of a thorough history as well as a detailed physical examination to exclude any risk factors. For every client, there is a safe and effective family planning method that will suit her needs while causing the least side effects. We offer the full range of female family planning methods and those couples seeking a male sterilisation (vasectomy) will be referred to the appropriate specialist.
Once your pap smear shows any abnormal cells or exposure to high risk strains of HPV, your general practitioner or general gynaecologist or women’s health nurse may recommend that you either have a repeat smear in 6-12 months’ time (to give your body a chance to clear these abnormal cells) OR be referred for a colposcopy +/- biopsy.
A colposcopy is a non-painful examination of the cervix with a special microscope that aids the colposcopist (some gynaecologists are trained in colposcopy) to highlight the abnormal cells and exclude cancer. A biopsy (small piece of cervical tissue) may be removed under local anaesthetic and sent to the laboratory for further examination. Depending on the outcome of the biopsy, further treatment may be required. Your colposcopist will have the biopsy results from the laboratory in 2-3 days and will inform you, should treatment (removal of all the affected abnormal cells) be necessary or just regular surveillance.
The transition from the reproductive years to the menopause, can be a difficult time in a woman’s life. While most sail through, without the need for medical intervention, others struggle with a variety of symptoms to varying degrees (these include hot flashes, night sweats, sleep disturbances, mood swings/irritability, vaginal dryness, discomfort with intercourse, frequent UTIs). For those, whose symptoms significantly affect their quality of life, there is hope in the form of hormone therapy. While there are many complimentary and alternate medications on the market, the only effective treatment for vasomotor symptoms related to the menopause (in addition to healthy lifestyle changes), is oestrogen replacement. There is however a timeframe when HT can be instituted safely before the risks outweigh the benefits. There are also various ways in which HT can be administered. This will be discussed at your first consultation with your gynaecologist, as well as initial screening investigations done (mammogram, cervical smear and essential blood tests including hormonal levels).
Osteoporosis is a condition of bone weakening which increases of fractures which in turn can lead to significant disability. Bones that commonly break include vertebrae, bones of the forearm, the hip and femur. The risk factors for developing osteoperotic fractures include being female, having a low body weight, low levels of oestrogen (either associate with premature ovarian failure or menopause), smoking, and some medications. Often weakening of the bones may be completely asymptomatic therefore your gynaecologist may recommend/refer you for a bone mineral density scan which is then used to determine your fracture risk and help plan necessary intervention. Prevention and treatment include calcium, vitamin D, weight-bearing exercise, and osteoporosis medications (which may include oestrogen therapy).
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