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VOL. 44 NO. 1

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Portal Hypertension
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of the Preterm Neonate
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 MIMS JPOG 2018 VOL. 44 NO. 1 i

2018 VOL. 44 NO. 1

Editorial Board
JOURNAL WATCH
Board Director, Paediatrics
Professor Pik-To Cheung
Associate Professor, Department of Paediatrics and Adolescent Medicine
The University of Hong Kong, Hong Kong 1
• New blood test may predict
Board Director, Obstetrics and Gynaecology
Professor Pak-Chung Ho
autism in children with accuracy
Director, Centre of Reproductive Medicine • Maternal influenza, tetanus
The University of Hong Kong - Shenzhen Hospital, China
toxoid vax not tied to infant
hospitalizations, deaths

Professor Biran Affandi Professor Seng-Hock Quak

University of Indonesia, Indonesia National University of Singapore,
Professor Hextan
Singapore 2
Adjunct Associate Professor
Yuen-Sheung Ngan
Tan Ah Moy
• Iodine deficiency in women may reduce fecundability
The University of Hong Kong, Hong Kong
KK Women’s and Children’s Hospital,
Professor Kenneth Kwek Singapore
KK Women’s and Children’s Hospital,
Dr. Catherine Lynn Silao
Singapore
University of the Philippines Manila, 3
Professor Kok Hian Tan Philippines
KK Women’s and Children’s Hospital, • Antenatal chemo not linked
Dwiana Ocviyanti, MD, PhD
Singapore
University of Indonesia, Indonesia to poor maternal, neonatal
Professor Dato’
Dr. Karen Kar-Loen Chan outcomes
Dr. Ravindran Jegasothy The University of Hong Kong,
Dean Faculty of Medicine, Hong Kong
• Maternal exposure to chemo
MAHSA University, Malaysia
Dr. Kwok-Yin Leung does not negatively impact
Associate Professor Daisy Chan The University of Hong Kong, babies’ cognition
Singapore General Hospital, Singapore Hong Kong
Associate Professor Raymond Dr. Mary Anne Chiong
Hang Wun Li University of the Philippines Manila,
The University of Hong Kong, Hong Kong Philippines
4
Adjunct Associate Professor Dr. Wing-Cheong Leung
Kwong Wah Hospital, Hong Kong, • Gestational weight gain reduced with lifestyle
Ng Kee Chong Hong Kong
Division of Medicine & Academic Clinical intervention
Program (Paediatrics), c/o KK Women’s and
Children’s Hospital, Singapore
 MIMS JPOG 2018 VOL. 44 NO. 1 iii

2018 VOL. 44 NO. 1

REVIEW ARTICLE
OBSTETRICS
CEO Yasunobu Sakai
Managing Editor Elvira Manzano
Medical Editor Elaine Soliven
Designer Sam Shum
5
Production Tetsuya Hamaki, Agnes Chieng, Raymond Choo
Circulation Christine Chok Social Issues of Teenage Pregnancy
Accounting Manager Minty Kwan
Advertising Coordinator Pannica Goh
The UK has the highest rate of teenage
pregnancies in Western Europe, and
Published by: higher rates are found amongst women
MIMS (Hong Kong) Limited
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as those who live in areas of higher
deprivation. Teenage pregnancy can be
a positive event for some young women.
However, there are several adverse social outcomes associated with
Enquiries and Correspondence teenage motherhood in the UK, including being more likely to live in
China Philippines
poverty, being unemployed or having lower salaries, and educational
Yang Xuan Rowena Belgica achievements than their peers.
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Email: enquiry.cn@mims.com Email: enquiry.ph@mims.com Sinead M C Cook, Sharon T Cameron
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Choe Eun Young Vietnam Portal Hypertension in Children
Tel: (82 2) 3019 9350 Nguyen Thi Lan Huong,
Email: inquiry@kimsonline.co.kr Nguyen Thi My Dung Portal hypertension (PH) is an important
Tel: (84 8) 3829 7923 complication of chronic liver disease. It
Indonesia Email: enquiry.vn@mims.com
Fatmawati, Fransiska Simamora, can also be caused by a wide range of
Ruth Theresia, Sari Wiyanti
Tel: (62 21) 729 2662 extrahepatic pathologies in children, and
Email: enquiry.id@mims.com is often clinically silent. Acute variceal
Malaysia haemorrhage (VH) is the most serious
Tiffany Collar, Sumitra Pakry,
Sharon Ong, Wong Wen Dee consequence of PH associated with
Tel: (60 3) 7623 8000 significant morbidity and mortality. Management of PH in children
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consists of medical, endoscopic, and surgical approaches which
are mainly focused on acute treatment as well as reducing the risk
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iv MIMS JPOG 2018 VOL. 44 NO. 1

2018 VOL. 44 NO. 1

REVIEW ARTICLE MIMS JPOG welcomes papers in the

following categories:
GYNAECOLOGY
Review Articles
Comprehensive reviews providing the latest clinical information
26 on all aspects of the management of medical conditions affecting
children and women.
Intermenstrual and Post-Coital Bleeding
Intermenstrual bleeding (IMB) and post- Case Studies
coital bleeding (PCB) are very common Interesting cases seen in general practice and their management.
presenting complaints among women of
reproductive age. The majority of cases of Pictorial Medicine
Vignettes of illustrated cases with clinical photographs.
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CONTINUING
MEDICAL EDUCATION
37
Developmental Care of the Preterm 2 SKP

Neonate
Advances in antenatal, perinatal, and neonatal care lead to increased
survival of preterm infants. As survival rates continued to increase,
so did the angst of “intact survival,” or survival without disabilities.
A recent meta-analysis revealed that at school-age, cognitive scores
of former very low birth weight (VLBW) infants are approximately
10 points lower than those of matched control children1 due to
difficulties with attention, behaviour, visual-motor integration, and
language performance.2-3
Imelda L. Ereno

The Cover:
Social Issues of Teenage Pregnancy
©2018 MIMS Pte Ltd

Peggy Tio, Designer

JOURNAL WATCH PEER REVIEWED
P free adduct in their plasma ultrafiltrate
Paediatrics
New blood test may predict
autism in children with accuracy
Researchers in the UK have developed a
diagnosis test that may make it easier for
clinician to predict autism in young chil-
dren with great accuracy.
Early diagnosis is not usually possi-
ble for autism spectrum disorder as it typi-
cally takes a while for the first symptoms to
manifest. In a recent study, the researchers
found those suffering from the develop-
mental disorder were more likely to have
damaged blood proteins. Children with au-
tism had an increased advanced glycation
endproducts (AGEs), Nε-carboxymethyl-
lysine (CML), and Nω-carboxymethylargi-
nine (CMA), and increased dityrosine (DT),
an oxidation damage marker, in plasma
protein vs healthy controls.
MIMS JPOG 2018 VOL. 44 NO. 1 1
There were also increased CMA- Maternal influenza, tetanus
toxoid vax not tied to infant
and increased urinary excretion of oxi-
hospitalizations, deaths
dation free adducts, alpha-aminoadipic
semialdehyde, and glutamic semialde- Maternal influenza and Tdap (tetanus tox-
hyde in children with autism. Renal clear- oid, reduced diphtheria toxoid, acellular
ance of arginine and CMA was however pertussis) vaccinations during pregnancy
decreased in these children. do not increase the risk for hospitalization
The researchers said the changes in or death in infants, a study has shown.
plasma AGEs were indicative of dysfunc- “We found no increased risk of infant
tional metabolism of dicarbonyl metabo- all-cause hospitalizations, hospitaliza-
lite precursors of AGEs, glyoxal and 3-de- tions from respiratory causes, or all-cause
oxyglucosone. Selective increase of DT mortality in the first 6 months of life,” said
as an oxidative damage marker implicates the researchers led by Dr Lakshmi Suku-
increased dual oxidase activity in children maran from the Centers for Disease Con-
with autism possibly linked to impaired trol and Prevention in Atlanta, Georgia,
gut mucosal immunity. Decreased renal US. Vaccination during pregnancy was
clearance of arginine and CMA in autism defined in the study as a jab given from 7
is indicative of increased arginine trans- days after the start of pregnancy to 7 days
porter activity which may be a surrogate before the end of pregnancy.
marker of disturbance of neuronal availa-
bility of amino acids.
The combination of these biomark-
ers perturbed by proteotoxic stress,
plasma protein AGEs, and DT, yielded
diagnostic algorithms for autism, with 92
percent sensitivity and 84 percent speci-
ficity. The receiver operating characteristic
area-under-the-curve was 0.94.
The study involved 38 children be-
tween ages 5 and 12 who had been diag-
nosed with autism and 38 children with-
out autism. Blood and urine samples were
taken from the children for analysis.
The discovery could lead to earli-
er diagnosis and intervention for autism,
said the researchers led by Dr Attia Anwar
from the Warwick Medical School, Uni-
versity of Warwick, Clinical Sciences Re-
search Laboratories, University Hospital,
Coventry, UK. “We hope the tests will also
reveal new causative factors.”
Anwar A, et al. Advanced glycation endproducts, dityrosine
and arginine transporter dysfunction in autism – a source of
biomarkers for clinical diagnosis. Molecular Autism 2018;9:3.
2 MIMS JPOG 2018 VOL. 44 NO. 1
Long-term data on infants born to
mothers administered influenza and Tdap
vaccines have been lacking. The current
study was the first to look at infant hos-
pitalizations and mortality in the first 6
months of life after influenza and Tdap
vaccines administration in mothers.
Of 413,034 infants involved in the
study, 25,222 were hospitalized (4,644
were due to respiratory cause, 105 from
influenza, 137 because of pertussis) dur-
ing the first 6 months of life; 157 died from
unknown causes, sudden infant death
syndrome, or certain conditions originat-
ing in the perinatal period.
However, there was no association
between infant hospitalization and mater-
nal influenza vaccination (adjusted odds
ratio [adjOR], 1.00, 95 percent confidence
interval [CI], 0.96–1.04) or Tdap vaccina-
tion (adjOR, 0.94, 95 percent CI, 0.88–
1.01). There was also no link between
infant mortality and maternal influenza
(adjOR, 0.96, 95 percent CI, 0.54–1.69) or
Tdap (adjOR, 0.44, 95 percent CI, 0.17–
1.13) vaccinations.
The researchers said the current
study supports the safety of influenza and
pertussis vaccinations during pregnancy
for both the mothers and their babies.
Sukumaran L, et al. Infant Hospitalizations and Mortality
After Maternal Vaccination. Pediatrics 2018;doi:10.1542/
peds.2017.3310.
G are required to determine whether iodine
Gynaecology
Iodine deficiency in women
may reduce fecundability
Moderate-to-severe iodine deficiency
in women of child-bearing age is asso-
ciated with a reduction in fecundability,
according to a new study.
Researchers followed 501 women
(aged 18–40 years) who discontinued
contraception and were trying to con-
ceive for about 5 years. Spot urine sam-
ples were taken for iodine and creatinine
analysis. Fertility monitors were used to
time sexual intercourse and ovulation,
as well as digital pregnancy tests to
detect pregnancies. Factors potentially
affecting fecundity were documented.
At 12 months, 332 women had become
pregnant, 42 did not, and 88 withdrew or
were lost to follow-up.
Women whose iodine–creatinine
ratios were below 50 μg/g (moder-
ate-to-severe deficiency) had a 46 per-
cent reduction in fecundity (p=0.028)
JOURNAL WATCH PEER REVIEWED
vs those whose iodine–creatinine ratios
were adequate (adjusted fecundability
odds ratio of becoming pregnant per
cycle, 0.54, 95 percent confidence inter-
val [CI], 0.31–0.94). Moderate-to-severe
iron deficiency were more common in
women who did not become pregnant
compared with those who did become
pregnant (29.8 percent vs 21.4 percent;
p=0.23). Iodine concentrations in the
mild deficiency range were similar be-
tween women who did and did not be-
come pregnant (22.3 percent and 21.3
percent, respectively; p= 0.88).
“That moderate deficiency is asso-
ciated with difficulty conceiving has im-
portant public health implications,” said
lead author Dr James Mills from the Eu-
nice Kennedy Shriver National Institute of
Child Health and Human Development in
Bethesda, Maryland, US. Almost half the
women in the study had iodine samples in
the deficient range suggesting that many
women trying to become pregnant could
be at risk for fecundity problems. One
of the caveats was that the population
included in the study was largely white,
hence the results may not apply to other
racial/ethnic groups.
Choosing a diet with an adequate
amount of iodine may help, said Mills.
Good sources of iodine are fish, seafood,
milk, and dairy products. Taking prenatal
vitamins that contain iodine may also help
improve iodine levels.
More studies, the researchers said,
deficiency might be added to the list of
considerations when evaluating women
with fecundity problems and whether im-
proving a woman’s iodine status could
also improve her ability to conceive.
Mills J L, et al. Delayed conception in women with low-urinary
iodine concentrations: a population-based prospective cohort
study. Human Reproduction 2018;33:426–433.
JOURNAL WATCH PEER REVIEWED
O Belgium.
Obstetrics
Antenatal chemo not linked
to poor maternal,
neonatal outcomes
Antenatal chemotherapy may not neces-
sarily result in poor neonatal outcomes
in women diagnosed with cancer during
pregnancy, according to a study present-
ed at ESMO Asia 2017.
“Results are mainly reassuring, the
effect of pregnancy on the maternal out-
come does not seem to be negative and
[antenatal chemotherapy] is not an inde-
pendent risk factor for a worse maternal
outcome. We also found reassuring re-
sults on the effects of antenatal therapy on
foetal safety,” said lead author Dr Jorine
de Haan from the Department of Obstet-
MIMS JPOG 2018 VOL. 44 NO. 1 3
rics & Gynaecology at KU Leuven, Leuven, Maternal exposure to
chemo does not negatively
Using data from the INCIP* data- impact babies’ cognition
base, researchers conducted an inter-
national cohort study involving 1,170 Maternal exposure to chemotherapy
patients diagnosed with a primary can- during the second or third trimesters of
cer during pregnancy between 1996 and pregnancy appears to have no impact
2016. on cognitive development in the children,
Breast cancer was the most com- according to a study presented at ESMO
mon cancer diagnosed during pregnan- Asia 2017.
cy, followed by cervical cancer, lymphoma, “[A]ll children [in the studies present-
ovarian cancer, and leukaemia. ed] who have been exposed to chemo-
Researchers evaluated the partic- therapy … looked very healthy and have
ipants every 5 years for over 20 years. good cognitive abilities and normal be-
Over time, changes in oncological man- haviour,” said Tineke Vandenbroucke, a
agement and obstetrical outcome were researcher and clinical psychologist from
observed, where more pregnant women the Department of Gynecological Oncolo-
with cancer were treated with chemother- gy at KU Leuven, Leuven, Belgium.
apy (risk ratio [RR], 1.31) and there were
more live births (RR, 1.04).
Eighty-three percent of patients un-
derwent antenatal chemotherapy only
with ≥1 chemotherapeutic agents.
There was a lower incidence of pre-
term births (RR, 0.93), iatrogenic preterm
births (RR, 0.91), and NICU admission
(RR, 0.91) among infants of patients treat-
ed with antenatal chemotherapy.
However, there was a higher likeli-
hood of infants being small-for-gestation-
al-age (SGA; RR, 1.16), though SGA was
also associated with higher maternal age
(odds ratio [OR], 1.36), systemic disease
in patients diagnosed with cancer during
pregnancy (OR, 1.86), and the use of plat-
inum-based chemotherapy (OR, 3.12).
Further studies are warranted to elu-
cidate the association between SGA and
chemotherapy, said the researchers, who
called for a long-term follow-up of chil-
dren exposed to chemotherapy.
*INCIP: International Network on Cancer Infertility and In the INCIP* follow-up study, chil-
Pregnancy dren whose mothers have been exposed
Dr Jorine de Haan, et al, European Society for Medical Oncolo- to chemotherapy during pregnancy
gy (ESMO) Asia 2017 Congress, November 17-19, Singapore.
were initially evaluated at 18 months
and then followed up at 3, 6, 9, 12, 15,
4 MIMS JPOG 2018 VOL. 44 NO. 1
and 18 years. Evaluation was carried out
through a clinical neurological examina-
tion by a paediatrician.
Results of the cognitive tests were
within normal range in young children
(aged 18 months) who underwent a Bay-
ley test and older children (aged 5–18
years) who had an intelligence test. [Lan-
cet 2012;13:256-264]
However, looking into cognitive
outcomes in relation to pregnancy du-
ration, full-term born children had better
cognitive outcomes than preterm born
children whose mothers underwent
chemotherapy treatment during preg-
nancy, Vandenbroucke highlighted.
“This suggests that gestational age
could influence cognitive development
in children with prenatal exposure to
chemotherapy,” she added. “[P]rema-
turity has an impact on the cognitive
outcome independent of the cancer and
cancer treatment during pregnancy …
[and] may have adverse effects that are
even bigger than those of chemother-
apy and pregnancy. [Therefore], pre-
maturity should be avoided if possible.”
Although prenatal exposure to
chemotherapy does not seem to adverse-
ly affect cognitive abilities of the children
based on tests used in the study, Vanden-
broucke pointed out that “we have infor-
mation from child and adult survivors who
have been treated with chemotherapy
[who] complained of cognitive deficits
like attention and memory problems or
[slower] information processing speeds.”
Longer term follow-up is warranted,
as cognitive problems may be more ap-
parent at school age, she added.
*INCIP: International Network on Cancer Infertility and
Pregnancy
Tineke Vandenbroucke, et al, European Society for Medical
Oncology (ESMO) Asia 2017 Congress, November 17-19,
Singapore.
Gestational weight gain reduced
with lifestyle intervention
Lifestyle intervention may help reduce
the risk of gestational weight gain in ex-
pectant mothers and result in babies with
greater fat-free mass, a study has shown.
The lifestyle programme, compris-
ing healthy diet and physical activity in-
tervention, reduced gestational weight
gain compared with usual obstetrical
care (-3.95 lbs between-group differ-
ence; p=0.003) in women on second
and third trimesters of pregnancy. Their
babies also weighed more and had
greater fat-free mass.
“The intervention impacted foetal
development,” said the researchers.
“The exact mechanisms or mediators
leading to the observed effects on infant
body composition are unknown.”
The study included 210 healthy
women who were either overweight (BMI
>25 but <30) or obese (BMI ≥30), ran-
JOURNAL WATCH PEER REVIEWED
domized to the lifestyle intervention pro-
gramme. Infant fat and fat-free mass at
birth were measured using air displace-
ment plethysmography and quantitative
magnetic resonance, respectively.
There were no between-group dif-
ferences in maternal age, weight, BMI,
and gestational age at baseline. At study
end, gestational weight gain was less in
the lifestyle intervention group by 1.79 kg
(p=0.003). Babies born to mothers ex-
posed to lifestyle intervention had great-
er weight (131 g; p=0.03), fat-free mass
(98 g; p=0.03), and lean mass (105 g;
p=0.006). Fat mass and percent fat were
not significantly different.
The trial was part of the Lifestyle In-
terventions for Expectant Moms (LIFEM-
oms) consortium trials. The researchers
said follow-up data on the babies born
to these mothers may shed light on the
causal role of gestational weight gain
and future overweight or obesity risk in
these babies.
Weight management interventions
for overweight or obese pregnant wom-
en can achieve modest positive impacts
on some measures of weight gain dur-
ing pregnancy, said Christine Olson of
Cornell University in Ithaca, New York,
and Rüdiger von Kries of Ludwig-Maxi-
milians-Universität München in Munich,
Germany, in an accompanying com-
mentary. “Excess gestational weight
gain is a strong predictor of postpartum
weight retention and the risk of devel-
oping obesity as a result of pregnancy
… these results should be an eye open-
er for weight management in these
women.”
Gallager D, et al. Greater Neonatal Fat-Free Mass and Similar
Fat Mass Following a Randomized Trial to Control Excess Ges-
tational Weight Gain; Obesity 2018; 26:578–587;doi:10.1002/
oby.22079; Olson, C. M. and von Kries, R., Interventions Dur-
ing Pregnancy Reduce Excessive Gestational Weight Gain
but Yield Unexpected Effects on Neonatal Body Composition.
Obesity 2018;26:459–460;doi:10.1002/oby.22122.
OBSTETRICS PEER REVIEWED MIMS JPOG 2018 VOL. 44 NO. 1 5

Social Issues of Teenage

Pregnancy
Sinead M C Cook, MFSRH MSc (distinction) BSc (hons) MBChB (hons) PGA Med Ed (SRH) DTMH; Sharon T Cameron, MD MFSRH FRCOG

The UK has the highest rate of teenage pregnancies in Western Europe, and higher
rates are found amongst women with certain social risk factors, such as those who
live in areas of higher deprivation. Teenage pregnancy can be a positive event for
some young women. However, there are several adverse social outcomes associated
with teenage motherhood in the UK, including being more likely to live in poverty,
being unemployed or having lower salaries, and educational achievements than
their peers. Furthermore, children of teenage mothers are more likely to become
teenage parents themselves. Strategies to tackle social issues associated with
teenage pregnancy need to involve concurrent interventions, including education,
skill building, clinical and social support for teenage mothers, and contraception
services for young people and pregnant teenagers.

INTRODUCTION language, the term teenage pregnancy

The United Nations Children’s Fund is often used to describe young women
(UNICEF) defines teenage pregnancy who become pregnant when they have
as conceiving between the ages of 13 not yet reached legal adulthood, the
and 19 years old. However, in common age of which varies across the world.
6 MIMS JPOG 2018 VOL. 44 NO. 1 OBSTETRICS PEER REVIEWED

the 1970s. In the UK, teenage pregnancy and

Bulgaria birth rates were high compared with the rest
Romania of Europe and remained relatively static until
Hungary the late 1990s. However, since then, the rate
has been steadily declining (see Figure 2). In
Latvia
England and Wales, the under 18 conception
United Kingdom
rate reached an all-time low level at 21.0 con-
Estonia
ceptions per 1000 women aged 15–17 years
Greece in 2015. Approximately, 50% of these concep-
Poland tions continue to term and half result in induced

Portugal
abortion. The teenage pregnancy rate in Scot-
land has shown a similar trend and the under
Czech Republic
18 conception rate was 20.1 per 1000 women
Spain
in 2015. In Scotland, England, and Wales, the
France teenage abortion rate has been steadily declin-
Croatia ing since 2008. It is important to note that teen-
Germany age pregnancy rates only include live births,
stillbirths, and abortions. Miscarriages, which
Ireland
may account for up to 25% of all pregnancies,
Italy
are not included. In Northern Ireland, where ter-
Slovenia mination of pregnancy is illegal except to save
Sweden the woman’s life or prevent long-term or per-
Netherlands manent physical or mental harm to the woman,

Denmark
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
Live births per 1,000 women aged 15–17
Figure 1. Teenage birth rates in selected European countries in 2014.
Furthermore, the terms adolescent, young per-
son, and child are often used interchangeably
with teenager, despite having different defini-
tions. The UNICEF definition of teenage preg-
nancy will be used for this article. Globally,
around 16 million teenage women give birth
each year, accounting for around 11% of all
births, and 95% of these occur in low- and mid-
dle-income countries.
The UK has the highest teenage preg-
nancy and birth rates in Western Europe (see
Figure 1). Throughout most countries in West-
ern Europe, the total fertility rate and number
of teenage births has been decreasing and
the age at first birth has been increasing since
statistics are presented in terms of birth rates as
opposed to conception rates. The teenage birth
rate in 2014 was 10.3 per 1000 women under
20 years, which was the lowest rate on record.
In the UK, teenage pregnancy is often as-
sociated with poor social and health outcomes
for mother and child. Globally, complications of
pregnancy and childbirth are the second high-
est cause of death amongst teenagers. Further-
more, whilst teenage deliveries account for 11%
of all births worldwide, they account for 23% of
the overall burden of disease in disability ad-
justed life years (DALYs) attributed to pregnan-
cy and childbirth. Maternal mortality is higher
amongst teenagers than women aged 20–24
years worldwide. However, this varies between
countries, and globally the risk of teenage ma-
ternal mortality is less than for women aged
over 30 years. Box 1 outlines adverse health
outcomes associated with teenage pregnancy
in the UK. This paper will now focus on the so-
cial issues associated with teenage pregnancy.
OBSTETRICS PEER REVIEWED MIMS JPOG 2018 VOL. 44 NO. 1 7

60
Conceptions per 1,000 women

50

40

30

20

10

0
69 71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09 11 13 15
19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20

Figure 2. Under 18 conception rate in England and Wales from 1969–2015.

SOCIAL ISSUES INCREASING THE

Box 1. Adverse Health Outcomes Associated with Teenage Pregnancy
RISKS OF TEENAGE PREGNANCY
A number of social factors have been associ-
• Young mothers are 3 times more likely to suffer from post-partum
ated with an increased risk of teenage preg-
depression
nancy and teenage pregnancy itself has also
• Infant mortality is 60% higher
been linked to an increased risk of a number of
adverse social outcomes. Teenage pregnancy • Infants are more likely to be premature and of lower birth weight
in the UK is therefore often both a marker of • Infants are more likely to have congenital anomalies in central nervous,
social and economic disadvantage at a young gastrointestinal, and musculoskeletal/integumental systems
age and a cause of further disadvantage, and
emotional and physical health problems. How-
ever, teenage pregnancy rates vary significantly occur amongst unmarried teenagers. Fur-
between different countries, and similarly the thermore, most teenage pregnancies are un-
social factors associated with teenage preg- planned and are often associated with binge
nancies also vary. In many countries with the drinking of alcohol. As can be seen in Figure 1,
highest rates of teenage pregnancies, it is as- some European countries have particularly low
sociated with child and adolescent marriage. In teenage birth rates compared with others. In
these contexts, teenage childbearing is often the Netherlands and Scandinavian countries,
an accepted social norm. For example, in Niger, the comparatively lower rates of teenage births
which has the world’s highest teenage preg- have been attributed to high levels of contra-
nancy rate (201/1000 women under 20 years) ception use, comprehensive sex education,
and the highest rate of child marriage, 87% of and a culture of openness regarding a discus-
women are married before they reach 18 years sion on sexual matters. In other countries such
old and 50% will have had a child by this age. as Spain and Italy, it has been attributed to so-
Most high-income countries have low cially conservative traditional values that stig-
teenage pregnancy rates and the majority of matize unmarried teenage mothers. However,
pregnancies are amongst unmarried teenag- this can be seen as a rather simplified view of
ers. In the UK, 96% of teenage conceptions why rates of teenage pregnancies are low in
8 MIMS JPOG 2018 VOL. 44 NO. 1 OBSTETRICS PEER REVIEWED

arguments as to which factors have been most

Poverty and social deprivation are highly associated with teenage pregnancy rates.
Box 2. Factors Associated with Higher Rates of Teenage Pregnancy
Within the UK
• Lower socioeconomic status
instrumental in the decrease of teenage preg-
nancies. Early coitarche has been shown to be
associated with an increased risk of teenage
pregnancy in the UK. When compared to the
Netherlands, however, despite approximately
the same numbers of under 16s admitting to
being sexually active (around one third), Dutch
teenagers are much more likely to use reliable
contraception from the beginning of their sexu-
al lives. Between 8% and 22% of teenagers in
the UK use no contraception at their first inter-
course, and this is higher for those under 16
years old. Moreover, of those who do use con-
traception, many use less reliable methods.
Within the UK, some groups of teenagers
have higher rates of teenage pregnancy than
others. Social factors that appear to be asso-
ciated with increased rates of teenage preg-
nancy within the UK are summarized in Box 2.
Poverty and social deprivation are highly asso-
ciated with teenage pregnancy rates and the
outcomes from teenage pregnancies. Social
deprivation is a composite measure that can

• Living in or leaving a care home include a variety of indicators, including the

• Being involved in crime
• Some ethnic minority groups: Caribbean, Pakistani, and Bangladeshi
• Homelessness
• School excludes, truants, and young people underperforming at
school
• Children of teenage mothers
• Depression
• Having been sexually abused in childhood
these countries, and there are likely a number
of social factors at play. The different impor-
tance of these factors has been the subject of
much debate.
There has correspondingly been much
debate as to why the teenage pregnancy rate
and particularly the number of unplanned preg-
nancies in the UK are so high and numerous
teenage woman’s educational level, health and
employment status, and their parents’ income
and occupation. Women from areas of higher
deprivation have the highest rates of teenage
pregnancies, with 50% of all teenage pregnan-
cies occurring in the 20% most deprived are-
as, despite the most substantial reductions in
teenage pregnancies in recent years having
been in deprived areas. Women who had be-
low average educational achievement at ages
7 and 16 years old also have a significantly
higher chance of becoming a teenage moth-
er. Young fathers are also more likely to come
from lower socioeconomic groups and have
lower educational achievement. The relation-
ship of low educational achievement to high-
er rates of teenage pregnancy remains even
when adjusted for socioeconomic status.
Teenagers from areas of higher depriva-
tion who become pregnant are also more likely
OBSTETRICS PEER REVIEWED
to continue with the pregnancy than undergo
termination of pregnancy. However, over recent
years, there has been a trend of more pregnant
teenage women from deprived areas opting for
abortion.
A review of qualitative studies examining
teenagers’ opinions found three major themes
relating to increased risk of teenage mother-
hood such as dislike of school, poor material
circumstances and unhappy childhood, and
low expectations and aspirations for the future.
These themes are further expanded in Box 3.
While some of these factors overlap with the
factors discussed above, they provide more
personal insights into broad groups such as
low educational attainment and socioeconomic
group and how these factors may be associat-
ed with increased rates of teenage births. For
example, some teenage women see having a
baby as a way to change their circumstances
and ameliorate the effects of adversity.
SOCIAL CONSEQUENCES OF
TEENAGE PREGNANCY
Whilst becoming a parent can be a positive and
life-enhancing experience for some teenagers,
teenage pregnancy, and particularly teenage
childbearing, is associated with a number of
negative social outcomes in the UK. However,
it is important to recognize that some of these
risks are likely associated with the previously
stated underlying associations with teenage
pregnancy, such as social deprivation. Also,
teenage parents tend to access less antenatal
and maternity services which may negatively
impact on social and health outcomes. How-
ever, studies that have attempted to adjust for
pre-existing social disadvantage have found
that teenage childbearing still carries an excess
increased risk of negative outcomes. Teenage
mothers have higher risks of living on lower in-
comes, lower educational achievements, and
difficulties with housing and family conflicts
when compared to their peers. Teenage moth-
ers are also more likely to be socially isolated.
MIMS JPOG 2018 VOL. 44 NO. 1 9
Box 3. Themes from Qualitative Literature Associated with Higher
Likelihood of Becoming a Teenage Parent Within the UK
š Dislike of school
• Lack of support if experiences difficulties at home or school
• Difficulties making friends
• Bullying
• Boredom
• Frustration with rules and regulations
• Lack of relevance
š Poor material circumstances and unhappy childhood
• Have to grow up faster
• Violence
• Poor housing
• Frequent moves
• Family conflict and breakdown
• Lack of good role models
š Low expectations and aspirations for the future
• Bad work experiences
• Lack of local opportunities
• Low or no expectations from others
• Need to escape from or change difficult circumstances
• Desire to leave school as soon as possible and get a job
• Having a baby as most attractive option
Young fathers also appear to have similar edu-
cational, economic, and employment outcomes
to teenage mothers, but there is much less
data on this group. Children born to teenage
mothers are more likely to be born into poverty
and become teenage parents themselves (see
Box 4).
Teenage pregnancy strategies in the UK of-
ten attempt to break the cycle of teenage moth-
ers coming from worse social situations, which
can continue and worsen following becoming a
teenage parent, resulting in their children being
brought up in poor social circumstances and
10 MIMS JPOG 2018 VOL. 44 NO. 1
Box 4. Negative Social Outcomes for Teenage Mothers
• Employment/economic: 22% more likely to be living in poverty by age
30 than mothers aged over 23 years, less likely to be employed, and
if employed, more likely to be on lower incomes than their peers
• Education: 20% more likely to have no qualification by age 30
• Housing: More likely to be living in rented, poor quality housing, and
the need to move during pregnancy
• 
Family: More likely to be lone parents and find themselves in a family
conflict
• 
Children: Children of teenage mothers are more likely to become
teenage parents themselves
having a higher chance of becoming a teenage
parent themselves. Furthermore, reducing rates
of teenage pregnancy is thought to have the po-
tential to reduce other social problems, such as
increasing female education and reducing child
poverty.
Child and youth development programmes that
target academic and social skills can reduce teenage
pregnancy rates
TEENAGE PREGNANCY: A SOCIAL
PROBLEM?
Teenage pregnancy and parenthood in the UK
are associated with certain social risks fac-
tors and outcomes. In terms of negative social
outcomes, teenage pregnancy has become a
social problem and strategies to try to reduce
teenage pregnancy rates in the UK are being
developed. However, some people have crit-
icised framing teenage pregnancy as a social
problem for a number of reasons. Firstly, as-
sociations between negative social outcomes
and teenage pregnancy are likely not directly
causal, but rather a complex chain of circum-
stances. Focusing prevention efforts on at-risk
groups and teenage mothers can risk blaming
individuals and focusing on behaviour change,
OBSTETRICS PEER REVIEWED
while ignoring the wider social situation. Also,
focusing on at-risk groups does not appear to
reduce teenage pregnancies; one programme
actually appeared to increase rates of teenage
pregnancy.
Furthermore, considering pregnant teen-
agers as problem or risk groups can increase
stereotyping and the stigma felt by teenagers
who are pregnant or parents. A widespread UK
stereotype of a teenage mother is someone re-
ceiving state benefits, who is a burden on socie-
ty, with poor educational attainment and whose
children have suboptimal life chances. Stigma
and stereotyping can increase the risk of teen-
age mothers not accessing services and be-
coming more socially isolated. In contexts and
areas where teenage childbearing is socially
accepted, there is often more familial and social
support for the mother. Moreover, viewing all
teenage pregnancies as undesirable disregards
that some teenagers want to become parents
and find parenthood happy and rewarding.
HOW TO REDUCE TEENAGE
PREGNANCIES AND MITIGATE
THE NEGATIVE SOCIAL OUTCOMES
ASSOCIATED WITH TEENAGE
PREGNANCY?
There are strategies aiming to reduce teenage
pregnancies and negative social outcomes as-
sociated with teenage pregnancy both across
the world and in the UK. In 1999, the UK govern-
ment introduced a Teenage Pregnancy Strategy,
which set itself a high target to reduce the rate
of teenage pregnancies in England and Wales
by 50% in 2010; this was not met, the actual de-
crease was 13.3%. The strategy also aimed to in-
OBSTETRICS PEER REVIEWED
Teenage parents tend to access less antenatal and maternity services which may negatively impact on social and health outcomes.
crease the proportion of teenage parents in edu-
cation, employment, and training to reduce their
risk of long-term social exclusion. The number
of teenage mothers engaged in employment,
education, or training doubled during the peri-
od of the strategy. The strategy involved health
promotion campaigns, improving health servic-
es, and school sex education. Despite being dis-
continued in 2010, the teenage pregnancy rate
has continued to fall, reaching the target reduc-
tion rate of 50%, and 55% in 2015. It is argued
that it was the strategy’s multi-faceted approach
that was key to its success since teenage preg-
nancies are influenced by various interconnect-
ed factors. However, some people contend that
wider societal changes not influenced by the
strategy have contributed to declining teenage
pregnancies. These include less alcohol con-
sumption amongst teenagers and changes in
the way teenagers interact, such as increasing
use of social media and the internet.
MIMS JPOG 2018 VOL. 44 NO. 1 11
Although there is no longer a specific teen-
age pregnancy strategy in the UK, reducing
teenage pregnancy rates is still on the policy
agenda as a devolved issue in all four nations
in the UK. For example, in March 2017, sex and
relationships education was made compulso-
ry in secondary schools in England, this was
deemed to be of great importance in continuing
to reduce teenage pregnancies.
Primary prevention of teenage
pregnancy and supporting teenagers
who become pregnant
Reducing rates of teenage pregnancy and im-
proving outcomes for teenage parents and
their children requires a comprehensive strat-
egy with multiple elements. A Cochrane review
found that a combination of health education
and contraceptive promotion is effective at re-
ducing teenage pregnancy rates. However,
interventions that target wider social determi-
12 MIMS JPOG 2018 VOL. 44 NO. 1
When consulting with teenagers, it is important to consider risk assessment, potential abuse, and child protection issues.
nants, such as addressing economic inequali-
ties and improving education and employment
opportunities in areas of high deprivation are
also important. Child and youth development
programmes that target academic and social
skills can reduce teenage pregnancy rates. Pro-
grammes that seem to be particularly success-
ful combine the following elements:
• 
Learning support for those who are strug-
gling academically
• Relationship skills development
• Parental involvement
• Work experience opportunities, volunteering,
and out of school activities
• Support for those experiencing family break-
down and conflict
As well as focusing on primary prevention
of teenage pregnancy, it is important to provide
support for teenage mothers and to reduce rap-
id repeat pregnancies (pregnancies occurring
soon after childbirth, miscarriage, or abortion).
One fifth of pregnancies amongst under 18 year
olds in the UK are repeat pregnancies and near-
OBSTETRICS PEER REVIEWED
ly 1 in 4 teenagers presenting for an abortion
have had a previous pregnancy. Two or more
pregnancies before age 20 is a risk factor for
both adverse obstetric outcomes such as pre-
term birth and low birthweight, and negative
social outcomes. Programmes that appear to
be most successful at reducing rapid repeat
pregnancies integrate clinical and social servic-
es and include home visits and easily accessi-
ble and youth-friendly contraceptive, antenatal,
and postnatal services. These services should
also provide easy access to the most effective
long-acting reversible contraceptives (LARCs),
such as subdermal implants and intrauterine
methods. Provision of these methods reduces
the likelihood of rapid repeat pregnancies by 35
times.
It is particularly important to address social
exclusion associated with teenage motherhood,
through improving access to health services,
providing educational support, further edu-
cation and training, employment support and
childcare, and income support and housing as-
OBSTETRICS PEER REVIEWED
sistance. There are a number of programmes
in the UK, including the CAN (Classes & Advice
Network) parenting scheme that is a network of
parenting classes focused in areas of high dep-
rivation and the Care to Learn programme that
provides support for teenage mothers who want
to continue or further their education.
How can the obstetrician &
gynaecologist contribute?
Whilst many of the interventions required are
broad and outside the immediate clinical set-
ting, there are many ways in which the individ-
ual clinician can contribute to reducing nega-
tive social outcomes associated with teenage
pregnancy. Firstly, it is important to remember
to discuss contraception and sexual health
opportunistically when consulting with young
people. LARCs should be promoted to all
women who are keen to prevent pregnancy
and particularly to teenagers, and they should
be made aware of how to access emergency
contraception if required. The UK Medical El-
igibility Criteria (UKMEC) advises that teenag-
ers and nulliparous women can safely use all
LARCs, including intrauterine contraceptives.
It is important to build appropriate consultation
skills and allow extra time for consultations
with teenagers. Improving access and availa-
bility of youth-oriented contraception servic-
es may help to reduce teenage pregnancies.
During any contraceptive consultation, it is
UKMEC advises that teenagers and nulliparous
women can safely use all LARCs,
including intrauterine contraceptives
also important to offer sexually transmitted in-
fection (STI) screening, and advise using dou-
ble protection ie, contraception and condoms,
due to the high prevalence of STIs in under 20
year olds in the UK. Opportunities should be
MIMS JPOG 2018 VOL. 44 NO. 1 13
Box 5. Guidelines for Provision of Contraception to Under-16s
Department of health guidance: “a doctor or health profession is able
to provide contraception, sexual, or reproductive health advice and
treatment, without parental knowledge or consent, to a young person
aged under 16, provided that:
• She/he understands the advice provided and its implications
• Her/his physical or mental health would otherwise be likely to suffer
and so provision of advice or treatment is in their best interest.”
In addition, it is a good practice to follow the criteria set out by Lord
Fraser in 1985, commonly known as Fraser guidelines:
• “The young person understands the health professional’s advice
• The health professional cannot persuade the young person to inform
his or her parents or allow the doctor to inform the parents that he or
she is seeking contraceptive advice
• 
The young person is very likely to begin or continue having
intercourse with or without contraceptive treatment
• Unless he or she receives contraceptive advice or treatment, the
young person’s physical or mental health or both are likely to suffer
• The young person’s best interests require the health professional
to give contraceptive advice, treatment, or both without parental
consent.”
sought to discuss these topics without a par-
ent present whenever possible. Provision of
clear, nonjudgemental information about abor-
tion, and how to access abortion services may
also avoid late presentation for termination of
pregnancy.
When consulting with teenagers, it is im-
portant to consider risk assessment, potential
abuse, and child protection issues. It is impor-
tant to have a good understanding of child sex-
ual exploitation and safeguarding, which can be
14 MIMS JPOG 2018 VOL. 44 NO. 1
Studies have shown that when provided with optimal antenatal care, outcomes for teenage mothers improve.
achieved through attending regular safeguard-
ing training. Competence to make independent
decisions for contraceptive use (Fraser compe-
tence) should be assessed and documented for
young people under the age of 16 years old (or
under 18 years old in state care) (see Box 5).
All services need to ensure that they are
friendly and accessible to young people. Health
workers should try to make teenagers feel com-
fortable and welcome to relieve embarrass-
ment or feeling of stigmatization. Accessibility
includes physical location and timings. The
ability to have out-of-hours appointments dur-
ing evenings and weekends and to be able to
either drop-in or make fixed appointments is
very important for teenagers. Some hospitals
have dedicated young people’s sexual and
reproductive health and/or maternity services.
Services need to be universal and inclusive, but
there are some particularly socially disadvan-
taged groups and groups that have difficultly
OBSTETRICS PEER REVIEWED
accessing services that may need additional
tailored support. These groups include teenage
mothers and other young people who are:
• Living in deprived areas
• From a minority ethnic group, refugees, asy-
lum seekers, and people who recently arrived
in the UK
• Looked after or leaving care
• Excluded from school or do not attend regu-
larly or have poor educational attainment
• Unemployed or not in education or training
• Homeless
• Living with mental health problems
• Living with physical or learning disabilities
• Living with HIV/AIDS
• Substance misusers (including alcohol mis-
users)
• Criminal offenders
Contraception discussions and plans for
future contraception should occur with all preg-
nant young women, whether they opt to con-
OBSTETRICS PEER REVIEWED
tinue with the pregnancy or for termination. In
general, if possible, young women should leave
the hospital following delivery or termination
with their chosen contraceptive or, if not, with a
clear plan for accessing their chosen method of
contraception.
The National Institute for Health and Care
Excellence recommend that all teenage moth-
ers should be offered a midwife and should also
involve the multidisciplinary team, including an
obstetrician with an interest in teenage pregnan-
cy and the woman’s general practitioner. Stud-
ies have shown that when provided with optimal
antenatal care, outcomes for teenage mothers
improve. When consulting with teenage moth-
ers, there needs to be strong links with relevant
external agencies, as many of the social issues
discussed above cannot be dealt with by the
healthcare sector alone. In many areas of the
UK, there is the opportunity to refer pregnant
teenagers to the Family Nurse Partnership
(FNP). This is a preventative programme that
supports teenage mothers from pregnancy until
their children are 2 years old. It aims to improve
social outcomes for teenage mothers and their
children. Studies in both the UK and US have
shown that the programme improved rates of
smoking cessation, breastfeeding, antenatal
appointment attendance, self-esteem, and re-
turn to education or employment.
CONCLUSION
Within the UK, higher rates of teenage pregnan-
cies are found in women from areas of higher
deprivation and some other groups such as
those with lower educational achievements or
living in care homes. Teenage pregnancy can
be a positive event for some young women.
However, there are a number of adverse social
outcomes associated with teenage motherhood
in the UK. Strategies need to attempt to break a
cycle of those with worse social circumstances
having a higher risk of becoming a teenage par-
ent, which then leads to worse social outcomes
for them and their children, and their children
MIMS JPOG 2018 VOL. 44 NO. 1 15
Practice Points
• Despite declining over recent years, teenage pregnancy rates in
the UK are still the highest in Western Europe.
• 
Social deprivation is associated with higher rates of teenage
pregnancy in the UK, therefore it is important to be aware of an
increased likelihood of social issues when interacting with pregnant
teenagers.
• Teenage pregnancy is associated with negative stereotypes and
stigma which can impact on young pregnant women’s use of
services and increase social isolation.
• A multidisciplinary approach is essential when providing clinical
and social support for teenage mothers.
• Contraception, antenatal, and postnatal services must be young
person friendly.
• Contraception should be discussed with all pregnant teenagers
and a contraceptive plan made to reduce the risk of rapid repeat
pregnancies.
having a higher chance of becoming a teenage
parent themselves. Strategies need to involve
concurrent interventions, including education,
skill building, support for teenage mothers, and
contraception services for young people and
pregnant teenagers.
FURTHER READING
1. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness
Unit. Contraceptive choices for young people. 2010, http://www. fsrh.org/
standards-and-guidance/documents/cec-ceu-guidance-young-people-
mar-2010/ (last accessed 23 June 2017).
2. Faculty of Sexual and Reproductive Healthcare Clinical Effective-
ness Unit. Contraception after pregnancy. 2017, https://www.fsrh.
org/documents/contraception-after-pregnancy-guideline-january-
2017/contraception-after-pregnancy-guideline-final27feb.pdf (last
accessed 23 June 2017).
3. NICE Guidelines. PH51 Contraceptive services with a focus on young
people up to the age of 25. 2014. National Institute for Health and Care
Excellence, http://www.nice.org.uk/guidance/ph51/chapter/about-this-
guidance (last accessed 23 June 2017).
4. Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. In-
terventions for preventing unintended pregnancies among adolescents.
Cochrane Database Syst Rev 2009; 7.
5. Wellings K, Jones KG, Mercer CH, et al. The prevalence of unplanned
pregnancy and associated factors in Britain: findings from the third Na-
tional Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet 2013;
382: 1807–16.
© 2017 Elsevier Ltd. All rights reserved. Initially published in Obstetrics,
Gynaecology and Reproductive Medicine 2017;27(11):327-332.
About the authors
Sinead M C Cook is a Specialist Trainee 4 in Community Sexual and Re-
productive Health, Cardiff and Vale UHB, UK. Conflicts of interest: none
declared.
Sharon T Cameron is a Consultant in Sexual and Reproductive Health at
Chalmers Sexual Health Centre, NHS Lothian, and Honorary Professor at
the University of Edinburgh, UK. Conflicts of interest: none declared.
16 MIMS JPOG 2018 VOL. 44 NO. 1 PAEDIATRICS PEER REVIEWED

Portal Hypertension
in Children
Fang Kuan Chiou, MBBS MRCPCH; Mona Abdel-Hady, MBBch MD MRCPCH

Portal hypertension (PH) is an important complication of chronic liver disease. It can

also be caused by a wide range of extrahepatic pathologies in children, and is often
clinically silent. Acute variceal haemorrhage (VH) is the most serious consequence
of PH associated with significant morbidity and mortality. Management of PH in chil-
dren consists of medical, endoscopic, and surgical approaches which are mainly
focused on acute treatment as well as reducing the risk of variceal haemorrhage.
Current treatment strategies for children with PH are mostly based on extrapolation
of data from adult studies and expert opinion and consensus. A structured protocol,
consisting of surveillance endoscopy with primary and secondary prophylactic ther-
apy by endoscopic variceal ligation or sclerotherapy, is increasingly becoming the
standard of care. This article discusses the causes and current treatment options for
PH in childhood.

INTRODUCTION with significant morbidity and mortality.

PH in children is a major complication It commonly presents catastrophically
arising from liver cirrhosis and extrahe- with VH, which may occur for the first
patic vascular disorders. It is associated time in a child with no apparent medi-
PAEDIATRICS PEER REVIEWED
cal history, particularly if PH is due to a nonhe-
patic cause. Other common clinical features of
PH include splenomegaly, hypersplenism, and
ascites. Encephalopathy and pulmonary mani-
festations such as hepatopulmonary syndrome
(HPS) and portopulmonary hypertension (PPH)
are important complications but less commonly
encountered in children.
The goals of management of PH are direct-
ed at treating its complications. Controversies
still surround treatment strategies for preven-
tion or reducing the risk of variceal bleeding
and evidence-based recommendations remain
scarce.
PORTAL VENOUS SYSTEM
The liver receives its blood supply from the he-
patic artery and the portal vein (PV). The PV ac-
counts for 75% of the blood supply to the liver
and is formed by the union of the splenic vein
(SV) and the superior mesenteric vein (SMV).
The SMV drains mainly the small intestine, prox-
imal colon, and head of the pancreas. The SV
drains blood from the spleen and the inferior
mesenteric vein (IMV), which receives blood
from the distal large bowel. Before reaching the
liver, the main PV divides into the left and right
portal veins, which in turn divides sequential-
ly into smaller venules. The portal venules and
hepatic arterioles ultimately merge into hepatic
sinusoids that drain into hepatic veins. Three he-
patic veins eventually drain blood from the liver
into the inferior vena cava (IVC). A schematic
representation of the portal venous system is
shown in Figure 1.
PATHOPHYSIOLOGY
PH occurs as a result of increased vascular re-
sistance and/or blood volume through the portal
venous system. The hyperdynamic circulato-
ry state results from a series of physiologic re-
sponses which include splanchnic vasodilata-
tion and activation of the sympathetic nervous
system and renin-angiotensin-aldosterone axis,
which in turn lead to sodium and water retention,
MIMS JPOG 2018 VOL. 44 NO. 1 17
HV to IVC
Liver
Spleen
PV SV
SMV IMV
Abbreviations: SMV = superior mesenteric vein; IMV = inferior mesenteric vein; PV = portal vein;
SV = splenic vein; HV = hepatic veins; IVC= inferior vena cava
Figure 1. Schematic representation of the portal venous system.
hypervolaemia, increased cardiac output, and
splanchnic blood inflow.
Normal portal venous pressure is 7–10
mm Hg, and hepatic venous pressure gradi-
ent (HVPG) ranges from 1–4 mm Hg. HVPG is
the difference between the free hepatic venous
pressure (FHVP) and wedged hepatic venous
pressure (WHVP) which reflects hepatic sinusoi-
dal pressure. PH is defined as portal pressure
greater than 10 mm Hg or HVPG greater than 4
mm Hg.
The most significant pathological conse-
quence of PH is the formation of collateral ves-
sels between the portal venous system and sys-
temic circulation, leading to the development of
varices in the oesophagus, stomach, and rectum.
In adults, HVPG above 10 mm Hg is associated
with oesophageal variceal formation and a pres-
sure gradient above 12 mm Hg is associated with
ascites and variceal bleeding.
CAUSES
The causes of PH are classified into three catego-
ries: Prehepatic, post-hepatic, and intrahepatic,
which can be further subdivided into presinusoi-
dal, sinusoidal, and post-sinusoidal. These are
summarized in Table 1.
18 MIMS JPOG 2018 VOL. 44 NO. 1
Table 1. Classification and Causes of PH in Children
Classification Causes
Prehepatic Portal vein thrombosis
Congenital or acquired stenosis of portal vein
Splenic vein thrombosis
Intrahepatic
Presinusoidal Congenital hepatic fibrosis
Polycystic liver disease
Nodular regenerative hyperplasia
Myeloproliferative diseases (lymphoma,
leukaemia)
Granulomatous diseases (schistosomiasis,
sarcoidosis, tuberculosis)
Noncirrhotic portal fibrosis/Idiopathic PH
Sinusoidal Liver cirrhosis (independent of cause)
Post-sinusoidal Veno-occlusive disease
Post-hepatic Budd-Chiari syndrome
IVC obstruction
Constrictive pericarditis
Right heart failure
Prehepatic causes
Portal vein thrombosis (PVT) is the most common
cause of extrahepatic portal vein obstruction (EH-
PVO) in children. Neonatal events such as umbili-
cal vein catheterization, omphalitis, and sepsis are
common attributable factors, while prothrombotic
disorders such as protein C, protein S, and an-
tithrombin III deficiencies and factor V Leiden mu-
tations have been found to account for up to 35%
of children with PVT. Interestingly, the cause of
PVT remains unidentified in about 50% of cases.
Intrahepatic causes
Various intrahepatic presinusoidal, sinusoi-
dal, and post-sinusoidal causes give rise to in-
creased portal bed resistance within the liver
and PH. Presinusoidal causes include congen-
ital hepatic fibrosis and nodular regenerative hy-
perplasia, which often do not result in impaired
liver function. Sinusoidal obstruction is mainly
due to liver cirrhosis, independent of the under-
lying primary liver disease. The increase in in-
trahepatic vascular resistance in cirrhosis is due
to two factors: the ‘mechanical factor’ is related
PAEDIATRICS PEER REVIEWED
to hepatic architectural derangement caused by
fibrosis and nodule formation, while the ‘dynam-
ic factor’ is related to vasoconstrictive effect from
vasoactive endogenous factors. Post-sinusoidal
obstruction is best represented by veno-occlu-
sive disease (VOD), or sinusoidal obstruction
syndrome, which occurs as a result of condi-
tioning treatment administered prior to haemato-
poietic stem cell transplantation (HSCT). VOD is
characterised by microthrombosis and sclerosis
of hepatic venules, and presents with hyperbili-
rubinaemia, hepatomegaly, and ascites typically
within 3 weeks from HSCT.
Post-hepatic PH
Post-hepatic PH can be due to a hepatic venous
outflow obstruction (Budd-Chiari syndrome),
which is uncommon in children, or cardiac dis-
orders with increased right atrial pressure. In
post-hepatic PH, chronic venous congestion re-
sults in hepatomegaly and can eventually lead to
liver dysfunction and cirrhosis.
CLINICAL PRESENTATION
The main clinical manifestations of PH in chil-
dren are gastrointestinal haemorrhage, sple-
nomegaly, and ascites. Abnormal abdominal
venous patterning (caput medusae) may also
provide an important clue to underlying PH. Oth-
er complications that are less common include
hepatorenal syndrome, pulmonary vascular dis-
ease, growth failure, and encephalopathy. In pa-
tients with extrahepatic PH or compensated liver
disease, there may be no prior symptom and
the first indication of PH may be gastrointestinal
bleed or an incidental finding of splenomegaly.
Gastrointestinal bleeding: Gastrointestinal
haemorrhage is usually from ruptured oesopha-
geal varices, but may also be secondary to portal
hypertensive gastropathy, gastric antral vascular
ectasia, or gastric, duodenal, and peristomal or
rectal varices. VH has been reported to occur
in 17–29% of children with biliary atresia in ret-
rospective cohorts, and nearly half to two-thirds
PAEDIATRICS PEER REVIEWED MIMS JPOG 2018 VOL. 44 NO. 1 19

of children with EHPVO by 16–18 years of age. Table 2. Diagnostic Evaluation of a Child with Suspected PH
The age of the first bleeding episode is related to
the underlying aetiology of PH. Reported medi-
Diagnostic approach Salient features to assess
an ages at presentation of first VH was 3.8 years
History Neonatal history (umbilical catheterisation)
in patients with EHPVO, 17 months to 3 years in
History of liver disease, jaundice
patients with biliary atresia, and 11.5 years in pa- Haematemesis/melaena
tients with cystic fibrosis-related liver cirrhosis.
Physical examination Splenomegaly
VH has been observed to occur more often
Liver size/consistency
in children with intercurrent upper respiratory Abnormal venous patterning
infection and febrile illnesses. The factors pos- Ascites
tulated to contribute to rupture of varices include Mental status (Encephalopathy)
increased abdominal pressure from coughing and Stigmata of chronic liver disease
sneezing, increased cardiac output during febrile Laboratory tests Liver function test
Full blood count to check for anaemia (blood
episode, and use of nonsteroidal anti-inflammatory
loss) or thrombocytopenia (hypersplenism)
medication.
Clotting function
Liver ultrasonography Portal vein: patency, direction of flow,
Splenomegaly: Splenomegaly is a common and Doppler cavernomatous transformation
clinical finding in children with PH and can be Liver parenchyma
an incidental discovery on routine physical ex- Patency/flow in hepatic veins and artery
amination. The haematological consequence Splenomegaly
of hypersplenism, including thrombocytopenia Ascites
Portosystemic shunts
and leucopenia, often misleads clinicians into
Renal abnormalities
performing a work-up for haematological caus-
Upper gastrointestinal Oesophageal, gastric varices
es, resulting in delayed diagnosis of PH. Liver endoscopy Portal gastropathy
function test (LFT) and Doppler ultrasonogra- Other causes of bleeding: gastritis, peptic ulcer
phy are therefore advisable in the evaluation of Liver biopsy Assess degree of liver fibrosis/cirrhosis
children with splenomegaly and hypersplenism. Histological diagnosis of underlying liver
When portal pressure is relieved either with liver disorder
transplantation or portosystemic shunt surgery, WHVP, FHVP, and Evaluate degree of PH
splenomegaly, and hypersplenism are expected HVPG measurement Determination of prehepatic, intrahepatic, or
to improve over time. post-hepatic cause
Abdominal CT scan Assess vascular anatomy for the planning of
shunt surgery
Ascites: Ascites develops when hydrostatic
pressure exceeds oncotic pressure within the
hepatic and mesenteric capillaries, and the fluid
shift overcomes the drainage capacity of the circulation associated with PH. A loop diuretic
lymphatic system. Ascites is usually seen in pa- such as frusemide may be added to enhance
tients with PH due to cirrhosis. Increased sodi- diuresis. Albumin infusions in tandem with diu-
um and fluid retention contributes to further fluid retics can be used to increase intravascular on-
accumulation in the peritoneal space. Treatment cotic pressure and facilitate diuresis, particularly
of ascites includes salt and fluid restriction, and in patients with hypoalbuminaemia from chronic
diuretic therapy. Spironolactone is the first-line liver disease. Paracentesis is reserved for signifi-
diuretic as its property as an aldosterone antag- cant ascites that is refractory to pharmacologic
onist counteracts the renin-angiotensin-aldoster- treatment, causing respiratory compromise, or
one axis that contributes to the hyperdynamic for diagnostic evaluation.
20 MIMS JPOG 2018 VOL. 44 NO. 1 PAEDIATRICS PEER REVIEWED

Figure 2. Endoscopic appearance of oesophageal varices and portal gastropathy. (a) Large, tortuous oesophageal varix (Grade 3) at 5 o'clock
position. (b) Extension and prolapse of varices at gastro-oesophageal junction visualised on retroflexion of endoscope in the stomach. (c) Band
applied on an oesophageal varix. (d) Patchy erythema and “snake-skin” mucosal appearance indicative of portal gastropathy.

Abnormal venous patterning: Prominent ab- HPS is characterised by arterial oxygen-

dominal venous patterning develops in PH due
to spontaneous portocollateral shunting through
subcutaneous veins. Prominent periumbilical veins
(caput medusae) are a result of decompression
of portal pressure through umbilical vein recan-
alisation that leads to periumbilical collaterals. In
children with short bowel syndrome and intestinal
failure-associated liver disease, stomal varices are
often present and are common sites for bleeding.
Pulmonary complications: HPS and PPH are
rare complications in children with PH, and their
pathogenesis remain unclear.
ation defect in the setting of liver disease and
is thought to occur as a result of excessive
vasoactive mediators which lead to abnormal
vasodilatation of pulmonary arterioles and cap-
illaries causing arteriovenous shunting and ven-
tilation-perfusion mismatch. Patients with HPS
present with dyspnoea, cyanosis, and digital
clubbing. Liver transplantation is the only ef-
fective treatment for children with HPS but out-
come is poor if HPS is at an advanced stage with
significant hypoxaemia.
PPH is defined as an elevation of the mean
pulmonary arterial pressure and increased vas-
PAEDIATRICS PEER REVIEWED
cular resistance in the setting of PH and in the
absence of cardiopulmonary disease. Symp-
toms of PPH include exertional dyspnoea, fa-
tigue, palpitations, syncope, and chest pains.
Liver transplantation is feasible only in the ear-
ly stages prior to the onset of frank right-sided
heart failure.
Other complications: Hepatic encephalopathy
occurs in the context of decompensated liver
disease and PH with anatomical and functional
portosystemic shunting, and signs may be sub-
tle particularly in young children. Growth retar-
dation is also a recognised complication of PH in
children and may be related to portal hyperten-
sive enteropathy, underlying liver dysfunction,
and growth hormone resistance.
DIAGNOSIS OF PH
The aims in the clinical evaluation of a child with
PH are to evaluate for the underlying cause, and
assess for complications of PH (Table 2). Labo-
ratory tests should include LFT and clotting func-
tion to assess for liver disease, and full blood
count (FBC) for evaluation of hypersplenism.
Doppler ultrasonography allows visualisation of
the size, patency and flow of the portal vein, and
detection of cavernomatous transformation, por-
tosystemic shunts, splenomegaly, and ascites. It
is also a useful tool for evaluation of liver disease
and patency of hepatic veins. Upper gastrointes-
tinal endoscopy is performed for diagnosis and
treatment of varices (Figure 2). Endoscopy may
also detect portal gastropathy, characterised by
erythema and oedema of the gastric mucosa
with ‘snake-skin’ or mosaic pattern, cherry-red
spots, and mucosal friability. Catheter meas-
urement of HVPG, which is considered the gold
standard technique to measure portal venous
pressure in adults, is also feasible in children
but data in paediatrics are limited. Angiography
by computer tomography (CT) or magnetic res-
onance (MR) provides detailed imaging of both
intrahepatic and extrahepatic vasculature which
is essential for planning shunt surgery.
MIMS JPOG 2018 VOL. 44 NO. 1 21
Table 3. Initial Management Steps in Acute VH
Resuscitation and general management
• Intravenous (IV) fluid resuscitation
š IV crystalloid fluids
š Red blood cell transfusion: target haemoglobin of 70–80 g/L
• Nil by mouth, nasogastric tube on free drainage
• Correct coagulopathy (Vitamin K, fresh frozen plasma) and
thrombocytopenia (if less than 20 x 109/L)
• Empiric broad-spectrum antibiotics
• Monitor vital signs, urine output, conscious level, blood sugar
and haemoglobin
Pharmacotherapy
• Octreotide (IV): 1–5 mcg/kg/hour continuous infusion
• Omeprazole (IV): 1 mg/kg/dose od or ranitidine (IV) 1–3 mg/kg/
dose tds
• Sucralfate (NG/PO): 250–1000 mg qds
• Lactulose (PO) start with 0.5 mL/kg/dose tds and titrate to
achieve 2–4 soft stools
Endoscopy
• Endoscopic variceal ligation
• Endoscopic sclerotherapy
Early referral to/discussion with paediatric hepatologist/
gastroenterologist
MANAGEMENT
Therapy of PH is mainly directed at prevention
and treatment of VH. The management can
be divided into primary prophylaxis of the first
episode of bleeding, management of acute
VH (see Table 3), and secondary prophylaxis
of subsequent bleeding episodes. Most treat-
ment strategies are derived and extrapolated
from adult studies, and paediatric data remain
lacking at present. A recent publication sum-
marises expert opinion on paediatric PH, by
reviewing and adapting the recommendations
from the Baveno V Consensus Workshop on
methodology of diagnosis and therapy in portal
hypertension.
Primary prophylaxis
Avoiding the morbidity and mortality associat-
ed with the first VH is the rationale behind pri-
22 MIMS JPOG 2018 VOL. 44 NO. 1
TIPS may be used in children with end-stage liver disease with refractory VH as an effective bridge to liver transplantation.
mary prophylaxis. Practice among paediatric
hepatologists varies and decisions on primary
prophylaxis may be influenced by individual pa-
tient factors. For instance, primary prophylaxis
may be valuable in patients who live in remote
areas far from emergency medical care. In pae-
diatrics, nonspecific beta-blockers (NSBB) and
endoscopic variceal ligation (EVL) are options
considered for primary prophylaxis.
NSBB reduce portal pressure by decreas-
ing cardiac output and inducing splanchnic
vasoconstriction via β1 and β2-receptor block-
ade. Studies in adults have shown that reduc-
ing resting heart rate by 25% or HVPG by 20%
decreases bleeding rate in cirrhosis. There are
no randomized trials assessing the efficacy of
propranolol as prophylaxis of VH in children,
and data from cohort studies did not include
effect of treatment on HVPG. There are also
concerns that young children receiving NSBB
may experience worse outcomes as a result of
hypovolaemic shock because of their physio-
logic reliance on their tachycardic response to
PAEDIATRICS PEER REVIEWED
shock and poor ability to increase stroke vol-
ume. In general, NSBB should be avoided as
first-line primary prophylactic therapy in chil-
dren till further evidence on appropriate dos-
ing, efficacy, and safety is established.
Prophylactic EVL is performed on high-risk
varices seen during surveillance endoscopy in
children with liver disease and PH. EVL as pri-
mary prophylaxis in children is well-tolerated,
with low subsequent bleeding rate and no re-
ports of major complication. It has been shown
to be superior to sclerotherapy in terms of effi-
cacy and safety in both adults and children. In
small children in whom banding devices cannot
be used in small paediatric endoscopes, scle-
rotherapy may be the only practical option for
management of large varices, but further safety
data are required before routine use can be rec-
ommended.
Management of acute VH
Acute VH is the most severe complication of
PH, with an associated mortality of up to 20% in
PAEDIATRICS PEER REVIEWED
Surveillance endoscopy and prophylactic EVL are increasingly adopted as standard of care in paediatric patients with PH.
patients with chronic liver disease. Initial man-
agement of variceal bleeding is aimed at stabi-
lizing the patient. Vital signs must be monitored
and intravenous access should be established
promptly. Tachycardia and hypotension are signs
of significant blood loss, however patients on be-
ta-blocker therapy may not manifest the expect-
ed compensatory tachycardia and are at higher
risk of haemorrhagic shock. Volume restoration
with crystalloids and red blood cell transfusion is
usually required, but caution must be exercised
to avoid overfilling the intravascular space and
increasing portal pressure. Red blood cell trans-
fusion should be administered conservatively
to achieve a general target haemoglobin level
between 70 and 80 g/L. Nasogastric (NG) tube
placement is safe and is useful in detecting ongo-
ing bleeding and removing blood from the stom-
ach, which can precipitate encephalopathy and
aggravate further bleeding. Vitamin K deficiency,
particularly in cholestatic liver disease, should
be corrected. Transfusion of clotting factors and
platelets are reserved for cases of profound co-
MIMS JPOG 2018 VOL. 44 NO. 1 23
agulopathy or thrombocytopenia (less than 20 x
109/L), and must be balanced against the risk of
fluid overload, especially in liver disease with its
associated complications of cerebral oedema and
recurrent variceal bleeding. Antibiotic prophylaxis
has been shown to decrease mortality in adults. A
high index of suspicion for bacterial infection is vi-
tal in acute VH and intravenous antibiotics should
be started promptly if sepsis is suspected.
Pharmacotherapy: In suspected VH, vasoactive
drugs should be started early before endoscopy
is performed, and continued for 2–5 days. These
vasoactive drugs include vasopressin, somato-
statin, or their analogues. Two drugs, octreotide
and terlipressin, are suitable for paediatric use.
Octreotide is a synthetic analogue of so-
matostatin that has been shown to decrease
splanchnic blood flow and its efficacy in manag-
ing variceal bleed in children has been report-
ed in observational studies. An initial bolus of
1 g/kg and continuous infusion of 1–3 mcg/kg
per hour appear to be safe and effective in con-
24 MIMS JPOG 2018 VOL. 44 NO. 1
trolling active VH in children. Newer longer-act-
ing somatostatin analogues are currently under
investigation.
Terlipressin is a long-acting synthetic ana-
logue of vasopressin which also has a vasocon-
strictive effect on the splanchnic system leading
to reduced portal blood flow. It does not require
continuous infusion. However, there are no pro-
spective data in children and no specific dose
recommendations in paediatrics at present.
Endoscopy: Endoscopic therapy is recom-
mended in any patient who presents with upper
gastrointestinal bleeding and in whom varices
are known or suspected cause of bleeding.
Ideally, patients should undergo endoscopy
as soon as possible within 24 hours after ad-
equate resuscitation. EVL is the recommended
modality of endoscopic therapy for acute oe-
sophageal VH, with lower rates of complica-
tions compared with endoscopic sclerotherapy
(EST). Nevertheless, EST remains an option in
small infants and young children, in whom EVL
is technically challenging as passing the band-
ing apparatus may not be possible due to its
size.
After endoscopic therapy, patients should
continue to fast for at least 2 hours before liquid
and soft solid feeding is introduced gradually as
tolerated. Treatment with sucralfate is also rec-
ommended as it appears to decrease the risk of
early rebleeding.
Balloon tamponade: The Sengstaken-Blakemore
tube is designed to stop VH by physical compres-
sion on oesophageal and gastric varices with bal-
loon tamponade. It is reserved for rare cases of
severe, refractory VH, and should only be used in
an intensive care facility by trained medical staff
and for a maximum of 24 hours until definitive
treatment can be instituted.
Transjugular intrahepatic portosystemic
shunt (TIPS): Rebleeding may be managed with
repeat endoscopy. However, persistent bleeding
PAEDIATRICS PEER REVIEWED
refractory to pharmacotherapy and endoscopic
treatment is an indication for TIPS. A catheter is
introduced into the hepatic vein (HV) via the jug-
ular vein, a tract is created between the PV and
HV, and a stent is placed to form a permanent
portosystemic shunt. Main complications are
shunt thrombosis leading to rebleeding, and en-
cephalopathy as with any portosystemic shunt-
ing. The experience in paediatrics is limited but
TIPS may serve as an important rescue therapy
in refractory bleeding.
Emergency surgery: Emergency surgical shunt
procedures, or oesophageal transection and/or
devascularisation in the setting of acute VH are
rarely performed because of associated high
mortality and morbidity. Emergency liver trans-
plantation performed for acute VH is rarely neces-
sary and is also associated with poor outcomes.
Secondary prophylaxis: Children who have
experienced VH should be offered secondary
prophylaxis to reduce the risk of recurrent bleed-
ing. EVL is the preferred modality for secondary
prevention because of its better safety profile
and less number of sessions required compared
with sclerotherapy. Based on expert consensus,
EVL should be performed every 2–4 weeks after
the first VH, followed by 6–12 monthly. In infants
and young children where EVL is technically not
feasible, EST is the recommended alternative
therapy.
There is currently insufficient evidence to
recommend the routine use of NSBB in sec-
ondary prophylaxis for VH in children. In pa-
tients who fail endoscopic treatment for the
prevention of rebleeding, the options are sur-
gical portosystemic shunting, TIPS, and liver
transplantation.
Portosystemic shunting – the goal of
shunt procedures is to divert portal blood flow
and decrease portal venous pressure. These
techniques include mesocaval shunt in which
the shunt is formed between the SMV and IVC,
PAEDIATRICS PEER REVIEWED
portacaval shunt in which the shunt is formed
between PV and IVC, and distal splenorenal
shunt in which the shunt is formed between
SV and left renal vein. These procedures divert
blood from normal hepatic metabolism and are
therefore associated with increased risk of he-
patic encephalopathy especially in patients with
intrahepatic disease. Hence, surgical portosys-
temic shunting in children with decompensated
liver disease is associated with poor outcomes,
with reported complications of recurrent bleed-
ing, encephalopathy, and death. Instead, chil-
dren with decompensated liver disease should
be assessed and considered for liver transplan-
tation. In contrast, portosystemic shunting is a
feasible option in patients with presinusoidal
PH, such as in congenital hepatic fibrosis, and
EHPVO.
If technical expertise is available, TIPS may
be an alternative mode of therapy in children in
whom surgical shunting is not feasible. TIPS may
be used in children with end-stage liver disease
with refractory VH as an effective bridge to liver
transplantation.
Mesoportal bypass – the meso-Rex bypass
procedure is considered for children specifically
with extrahepatic PVT. In this procedure, a graft
is placed between the SMV and the left portal ve-
nous system, thereby bypassing the EHPVO and
restoring physiological portal blood flow. The ad-
vantage of this approach is that it minimises the
risk of hepatic encephalopathy encountered in
portosystemic shunting. With any shunt surgery,
the complication of shunt thrombosis must be
considered, particularly in patients with underly-
ing prothrombotic disorders.
SUMMARY
There is a wide range of causes that lead to PH
in children, management is focused mainly on
prevention and acute treatment of VH which is its
most severe and frequent complication. Current
recommendations in children are based on ex-
trapolation of data from adult studies and expert
MIMS JPOG 2018 VOL. 44 NO. 1 25
Practice Points
• VH is the most serious complication of PH in children, timely
resuscitation and endoscopic therapy are vital.
• PH is often asymptomatic and may present with life-threatening
bleeding.
• Splenomegaly and hypersplenism in a child should prompt the
clinician to suspect PH.
• Surveillance endoscopy and prophylactic EVL are increasingly
adopted as standard of care in paediatric patients with PH.
paediatric opinion. A structured protocol with
surveillance endoscopy and primary and sec-
ondary prophylactic treatment to prevent VH is
gaining acceptance as standard of care for pae-
diatric patients with PH.
SUGGESTED READING
1. Shepherd RW. Chronic liver disease, cirrhosis, and complications: Part
1 (portal hypertension, ascites, spontaneous bacterial peritonitis (SBP),
and hepatorenal syndrome (HRS)). In: Murray KF, Horslen S, eds. Dis-
eases of the liver in children: evaluation and management. Springer,
2014; 483–95.
2. Di Giorgio A, D’Antiga L. Portal hypertension in children. In: Guandalini S,
Dhawan A, Branski D, eds. Textbook of pediatric gastroenterology, hepa-
tology and nutrition: a comprehensive guide to practice. Springer, 2016;
791–817.
3. Gugig R, Rosenthal P. Management of portal hypertension in children.
World J Gastroenterol 2012; 18: 1176–84.
4. Giouleme O, Theocharidou E. Management of portal hypertension in chil-
dren with portal vein thrombosis. J Pediatr Gastroenterol Nutr 2013; 57:
419–25.
5. Van Heurn LW, Saing H, Tam PK. Portoenterostomy for biliary atresia:
long-term survival and prognosis after esophageal variceal bleeding. J
Pediatr Surg 2004; 39: 6–9.
6. Miga D, Sokol RJ, MacKenzie T, Narkewicz MR, Smith D, Karrer FM. Sur-
vival after first esophageal variceal hemorrhage in patients with biliary
atresia. J Pediatr 2001; 139: 291–6.
7. Lykavieris P, Gauthier F, Hadchouel P, Duche M, Benard O. Risk of gas-
trointestinal bleeding during adolescence and early adulthood in children
with portal vein obstruction. J Pediatr 2000; 136: 805–8.
8. Alberti D, Colusso M, Cheli M, et al. Results of a stepwise approach to
extra-hepatic portal vein obstruction in children. J Pediatr Gastroenterol
Nutr 2013; 57: 619–26.
9. Duche M, Ducot B, Tournay E, et al. Prognostic value of endoscopy in
children with biliary atresia at risk for development of varices and bleed-
ing. Gastroenterology 2010; 139: 1952–60.
10. Hoeper MM, Krowka MJ, Strassburg CP. Portopulmonary hypertension
and hepatopulmonary syndrome. Lancet 2004; 363: 1461–8.
11. Schneider BL, Bosch J, de Franchis R, et al. Portal hypertension in chil-
dren: expert pediatric opinion on the report of the Baveno V Consensus
Workshop on methodology of diagnosis and therapy in portal hyperten-
sion. Pediatr Transpl 2012; 16: 426–37.
12. McKiernan P, Abdel-Hady M. Advances in the management of childhood
portal hypertension. Expert Rev Gastroenterol Hepatol 2015; 9: 575–83.
© 2017 Elsevier Ltd. All rights reserved. Initially published in Paediatrics and
Child Health 2017;27(12):540–545.
About the authors
Fang Kuan Chiou is a Clinical Fellow in Paediatric Hepatology, Liver Unit,
Birmingham Children’s Hospital, Birmingham, UK. Conflict of interest: none
declared.
Mona Abdel-Hady is a Consultant Paediatric Hepatologist, Liver Unit, Bir-
mingham Children’s Hospital, Birmingham, UK. Conflict of interest: none
declared.
26 MIMS JPOG 2018 VOL. 44 NO. 1 GYNAECOLOGY PEER REVIEWED

Intermenstrual
and Post-Coital Bleeding
Sinead Morgan, MBBS BSc (Hons) MRCOG; Shreelata Datta, MBBS BSc (Hons) LLM MRCOG MD

Intermenstrual bleeding (IMB) and post-coital bleeding (PCB) are very common
presenting complaints among women of reproductive age. The majority of cases
of unscheduled bleeding in premenopausal women result from benign conditions
such as endometrial polyps, infection, or oral contraceptive use. Cervical and
endometrial cancers, however, are associated with abnormal bleeding and therefore
it is essential that women with these symptoms are evaluated carefully. The single
most important stage in the assessment of women with unscheduled bleeding is
a vaginal speculum examination, and the presence of bleeding should not delay
this essential investigation. Women with risk factors for endometrial malignancy
or symptoms suggestive of gynaecological pathology may warrant ultrasound
examination and/or endometrial biopsy. This review discusses three common
causes of IMB and PCB, and outlines some of the important considerations in the
assessment and management of these patients.

INTRODUCTION ical advice in their reproductive years.

Unscheduled vaginal bleeding is a com- It has been estimated that almost one
mon indication for women to seek med- quarter of premenopausal women ex-
GYNAECOLOGY PEER REVIEWED MIMS JPOG 2018 VOL. 44 NO. 1 27

perience intermenstrual bleeding with almost 8% Table 1. Causes of IMB

experiencing PCB at some time. In women un-
der the age of 35, unscheduled bleeding is more
Physiological Ovulation
commonly associated with contraceptive use,
Vaginal Adenosis
and in older women, benign gynaecological con-
Vaginal cancer
ditions such as polyps and fibroids are more com-
Cervical Cervical polyp
monly seen and malignancy is more prevalent.
Cervical cancer
Although malignancy is rare in premenopausal Infection (chlamydia, gonorrhoea)
women, menstrual irregularities can be one of the Condylomata
first symptoms of gynaecological cancer. The as- Uterine Endometrial polyp
sociation between abnormal bleeding and cancer Fibroids
can be a source of significant anxiety for patients. Endometritis
IMB is defined as bleeding at any time dur- Adenomyosis
Endometrial cancer
ing a woman’s cycle other than during menstru-
Caesarean scar defect
ation. PCB is nonmenstrual bleeding occurring
Malpositioned IUCD
immediately or shortly after intercourse. IMB and
Ovarian Hormone secreting tumours
PCB often coexist and therefore the causes of
Hormonal Hormonal contraceptive use
both must be considered in women attending
Poor compliance with hormonal contraceptive
with unscheduled vaginal bleeding. In many Perimenopausal hormonal changes
women, no cause for bleeding is identified and
Other Drug use (tamoxifen, anticoagulants)
it may resolve without intervention. Unscheduled Drug interaction with hormonal contraceptives
bleeding is often accompanied by other men-
strual disorders including menorrhagia, dysmen-
orrhoea, or dyspareunia (Tables 1 and 2).
• Women over the age of 35 with PCB for over
ASSESSMENT OF WOMEN WITH 4 weeks
INTERMENSTRUAL OR POST-COITAL • 
Persistent IMB and negative examination
BLEEDING findings
Unscheduled vaginal bleeding has a myriad of • Persistent PCB or IMB bleeding at any age
causes and the different pathologies can coexist. • Failure of previous treatment
A thorough gynaecological history and careful • Abnormal appearance to cervix or vagina on
examination is an essential aid to diagnosis and speculum examination
will guide the need for further investigation. In • Cervical pathology not suspicious of cancer
younger women, malignancy is uncommon and that may require treatment (polyp/ectropion)
unscheduled bleeding is more commonly asso- • Pelvic mass
ciated with hormonal contraceptive use and is
generally termed “breakthrough bleeding”. With History taking
increasing age, fibroids and polyps are more In the first instance, pregnancy must be exclud-
commonly seen and abnormal bleeding in these ed in any patient presenting with unscheduled
women should arouse suspicion of malignancy. bleeding. A comprehensive menstrual histo-
Women with unscheduled bleeding who ry should be taken and details of cycle length
warrant referral to secondary care include: and regularity should be elicited. The pattern of
• Women over the age of 45 with IMB abnormal bleeding in relation to the menstrual
• Women under the age of 45 with IMB and risk cycle should be outlined, for example, regular
factors for endometrial cancer mid-cycle bleeding may suggest bleeding in
28 MIMS JPOG 2018 VOL. 44 NO. 1
Table 2. Causes of PCB
Vaginal Vaginal cancer
Vaginitis
Cervical ectropion
Cervical
Cervical polyp
Cervical cancer
Infection
Uterine Endometrial polyp
Other Trauma
association with ovulation which is experienced
by 1–2% of women.
The presence of other gynaecological
symptoms such as menorrhagia, dyspareu-
nia, dysmenorrhoea, vaginal discharge and
temperature should be sought, and details
of past deliveries and pregnancies should be
obtained.
A contraceptive history should be taken
including current and past contraceptive use,
compliance with contraception and the concur-
rent use of medication that may have resulted
in a drug interaction. A detailed sexual history is
particularly important in women under the age
of 25 or those who have a new sexual partner as
these women are at higher risk of sexually trans-
mitted infections (STIs).
A past smear history is essential and should
include information regarding the most re-
cent smear test result as well as details of past
smear abnormalities, previous colposcopy, and
treatments.
A family or personal history of gynaeco-
logical, breast, or gastrointestinal malignancy
should be elicited and smoking status should be
ascertained.
Examination
Assessment of body mass index (BMI) is impor-
tant due to the association between endometrial
cancer and elevated BMI. Abdominal examina-
tion may reveal a pelvic mass in patients with
large fibroids.
GYNAECOLOGY PEER REVIEWED
Bimanual and speculum examination are
mandatory in women with unscheduled bleeding.
Findings suggestive of cervical malignancy are
contact bleeding, ulceration, friable tissue, or a
craggy irregular cervix. The presence of vaginal
discharge and cervical excitation is suggestive of
infection and the cervix may appear red, congest-
ed, or oedematous on speculum examination. A
cervical ectropion or endocervical polyp may be
seen. The vulva and vaginal walls should be care-
fully examined. Consideration should be given to
extragenital areas as unscheduled bleeding can
arise from the bladder or rectum.
Investigations
A cervical smear test should be performed if not
up to date. If the cervix appears abnormal referral
to colposcopy should not be delayed while wait-
ing for a smear test result. Vaginal swabs should
be taken in those at risk of infection. In patients
with concurrent menorrhagia, a full blood count
should be performed to assess for anaemia.
Transvaginal ultrasound is useful to assess
fibroids and endometrial abnormalities. Endome-
trial cavity abnormalities are best assessed on
a post-menstrual ultrasound and saline sonog-
raphy may aid diagnosis of endometrial polyps
where there is uncertainty.
Endometrial cancer is rare in young wom-
en, particularly when there are no additional risk
factors, however the incidence rises sharply after
the age of 40 and therefore endometrial biopsy
should be considered in these women. Endome-
trial biopsy is indicated in women over 45 with
IMB, women with persistent IMB, and in cases
where treatment has failed to improve symptoms.
Endometrial sampling can be performed as a
blind procedure or under hysteroscopic guid-
ance. Hysteroscopy is particularly useful when
a focal endometrial lesion is suspected on ultra-
sound and directed biopsy is needed or to allow
the removal of polyps or submucous fibroids.
Risk factors for endometrial cancer include:
• Elevated BMI
• Age over 45
GYNAECOLOGY PEER REVIEWED
Menstrual irregularities can be one of the first symptoms of gynaecological cancer.
• Polycystic ovarian syndrome
• Perimenopausal women with anovulatory cycles
• Oestrogen secreting ovarian tumours
• Tamoxifen use
• Systemic oestrogen use
• Diabetes
• Personal or family history of breast, endome-
trial, or colorectal cancer (Lynch syndrome)
• Previous endometrial hyperplasia
ENDOMETRIAL POLYP
Case 1
A 38-year-old nulliparous woman is referred to
the gynaecology clinic with a 12-month history
of IMB. Her last smear test was 6 months ago
and it was normal. She has a regular sexual
partner and uses condoms for contraception.
An infection screen arranged by her GP was
normal. She has no significant past medical
MIMS JPOG 2018 VOL. 44 NO. 1 29
or surgical history and does not take regular
medication.
How would you assess this patient?
A full gynaecological history should be taken.
In this case, there was no relationship between
her IMB and the stage of her menstrual cycle.
Her periods were regular but heavy and painful.
Abdominal examination did not identify a pelvic
mass. Bimanual and speculum examination did
not reveal any abnormality.
In this case, further investigation with ultra-
sound is indicated due to her persistent symp-
toms and absence of other identifiable cause.
See Table 1 for differential diagnoses.
Ultrasound findings
An ultrasound scan was performed on day 3 of
her menstrual cycle. The report describes the
uterus as retroverted with an endometrial thick-
30 MIMS JPOG 2018 VOL. 44 NO. 1
Transvaginal ultrasound is useful to assess fibroids and endometrial abnormalities.
ness of 9.7 mm. The midline endometrial echo
was disrupted by an 8 x 6 x 6 mm homogenous
structure consistent with an endometrial polyp.
There was a single feeding vessel on colour Dop-
pler examination. Both ovaries appeared normal.
Transvaginal ultrasound is the first line
imaging modality for endometrial assessment.
Endometrial polyps appear as hyperechoic ar-
eas within the endometrial cavity and are best
visualised in the early follicular phase of the cy-
cle when the endometrium is thin. Saline can
be instilled into the endometrial cavity to aid
visualization.
Pathophysiology of endometrial polyps
Endometrial polyps are focal overgrowths of en-
dometrial glands and stroma covered by surface
epithelium and can vary in size from a few millime-
tres up to several centimetres, they can be single
or multiple. They are common in both pre- and
GYNAECOLOGY PEER REVIEWED
post-menopausal women and many are asymp-
tomatic. They are usually benign but hyperplastic
or malignant change can be seen within polyps.
The prevalence of endometrial polyps in the gen-
eral population has been reported at 7.8%. The
incidence of polyps increases with age and malig-
nancy is more likely in older women and in wom-
en with symptomatic polyps. The prevalence of
malignant polyps has been reported at 1.7% in
women of reproductive age compared with 5.4%
in post-menopausal women.
Polyps are associated with a number of
symptoms including IMB, PCB, post-menopau-
sal bleeding, vaginal discharge, menorrhagia,
and infertility.
What are the management options for
this patient?
The high prevalence of asymptomatic endome-
trial polyps has called into question the causal
GYNAECOLOGY PEER REVIEWED
Small polyps (<1 cm) may regress spontaneously particularly in premenopausal women, while large polyps are more likely to be symptomatic.
relationship between endometrial polyps and
unscheduled bleeding, and this must be borne
in mind when counselling patients. Management
depends on symptoms, age, fertility wishes, and
risk of malignancy. Small polyps (<1 cm) may
regress spontaneously particularly in premeno-
pausal women, while large polyps are more like-
ly to be symptomatic.
Conservative management may be con-
sidered in premenopausal women with asymp-
tomatic small polyps as the risk of malignan-
cy in these cases is low. This group of women
should, however, be encouraged to report any
abnormal bleeding as this may warrant surgical
treatment.
The presence of an endometrial polyp and
abnormal bleeding increases the risk of ma-
lignancy from 2.16% to 4.15% and therefore,
polypectomy is usually recommended, both to
detect endometrial malignancy and to improve
MIMS JPOG 2018 VOL. 44 NO. 1 31
abnormal bleeding. This is best done via oper-
ative hysteroscopy to allow complete resection
of the polyp, and this can be achieved under
local or general anaesthesia depending on the
clinical circumstances. Patients should be coun-
selled regarding the surgical risks of operative
hysteroscopy in addition to the recurrence risk
of endometrial polyps which has been reported
to be as high as 15%. Polyp resection may also
be appropriate in subfertile patients as increased
pregnancy rates have been reported after pol-
ypectomy, although further research is needed
to see if this improves live birth rates.
CERVICAL ECTROPION
Case 2
A 22-year-old woman attended with PCB for 4
months. She has an otherwise regular menstru-
al cycle and her periods are not heavy or pain-
32 MIMS JPOG 2018 VOL. 44 NO. 1
A speculum examination should be performed in any woman presenting with PCB or persistent IMB.
ful. She has had a recent negative sexual health
screen and uses condoms for contraception.
She has no significant past medical or surgical
history. She is anxious regarding the possibility
of cervical cancer as she has been told that she
is too young for cervical screening.
How would you assess this patient?
After taking a detailed gynaecological and
sexual history, pregnancy must be exclud-
ed. The presence of PCB warrants speculum
and bimanual examination to assess a local
cause of bleeding. See Table 2 for differential
diagnoses.
The pertinent point in this case is that this
patient is not yet part of the National Health Ser-
vice Cervical Screening Programme, and the
concern is that of missing a diagnosis of cervical
cancer.
GYNAECOLOGY PEER REVIEWED
The current age range for cervical screen-
ing in the UK is 25–64 with 3 yearly screening
until aged 49 and 5 yearly thereafter. A review by
the Advisory Committee on Cervical Screening
found that the number of cervical cancer cases
diagnosed in 20–24 years of age does not ap-
pear to be increasing and may be expected to
fall with the advent of the national human papillo-
mavirus (HPV) vaccination programme. Screen-
ing is not recommended in this age group as it
does not reduce the incidence of mortality from
cervical cancer.
Screening in younger women is also
thought to have the potential to cause more
harm than good. HPV infection is common in
women under 25 and there is good evidence that
minor cellular changes occur frequently in these
women but appear to regress spontaneously.
Screening these women would result in a high
GYNAECOLOGY PEER REVIEWED MIMS JPOG 2018 VOL. 44 NO. 1 33

number of colposcopy referrals and subsequent

treatments which in addition to causing undue
anxiety could increase the risk of preterm labour
in future pregnancies.
There are approximately 50 cases per year
of cervical cancer in women aged 20–24 result-
ing in 0–5 deaths. A significant contributing fac-
tor in these deaths was a delay in diagnosis due
to a delay in gynaecological examination as ab-
normal bleeding was ascribed to dysfunctional
uterine bleeding or contraceptive use.
Abnormal vaginal bleeding is very common
in women aged 20–24 with 1 in 600 describing
PCB and up to 1% describing IMB. Both of these
symptoms could arise as a result of cervical
cancer and therefore young women with these
symptoms require thorough assessment.
A speculum examination should be per-
formed in any woman presenting with PCB or
persistent IMB and where appropriate, a cervi-
cal smear should be taken. If the cervix appears
abnormal, a 2-week wait referral to colposcopy
should be arranged without awaiting the result
of cervical cytology. If the cervix appears nor- E ndometrial biopsy is indicated in women over 45 with persistent IMB and in
mal, screening should be arranged for STIs younger women with risk factors.
and appropriate treatment and full sexual health
screening offered if necessary. If symptoms per- What are the management options?
sist despite appropriate treatment, gynaecologi- Cervical ectropion is a benign condition where
cal referral is indicated. cervical eversion results in the columnar epi-
Most invasive cervical cancers that cause thelium of the endocervix. It characteristically
PCB will be visible on speculum examination. appears as a red ring around the cervical os. It
The incidence of cervical cancer is low in the is considered a normal physiological process as
UK due to the presence of a national screening a result of exposure to oestrogens. It is there-
programme. The risk of cancer is particularly low fore seen in young women, during pregnancy
in women who have had a recent normal smear and in combined oral contraceptive users. It is
test (0.6%). The incidence of invasive cancer in usually asymptomatic but can result in vaginal
women with PCB is higher than that of asymp- discharge or PCB.
tomatic women, and therefore colposcopic as- Exposure of the columnar epithelium to
sessment should be arranged without delay if vaginal secretions results in squamous meta-
there are concerns regarding the appearance of plasia and this often produces a resolution of
the cervix. symptoms, therefore conservative manage-
Other more common causes of PCB may ment may be appropriate in some cases. In
be identified on speculum examination (Table 2). patients on the combined oral contraceptive
In this case, this patient was found to have a cer- pill (COCP) changing to a non-oestrogen con-
vical ectropion. taining contraceptive may be beneficial. In
34 MIMS JPOG 2018 VOL. 44 NO. 1 GYNAECOLOGY PEER REVIEWED

• Assess compliance with contraception

• Consider STI screening
• Review smear history and screen if due
• Assess for other gynaecological symptoms
• Consider speculum and bimanual examination
• Endometrial assessment for high-risk groups
• Smoking cessation advice

Progesterone implant,
COCP POP IUS, or DMPA

• Allow a 3-month trial of pill before
changing
• Advise against cycling packets
• Increase dose of ethinylestradiol up to
35 micrograms
• Try alternative COCP
• Combined vaginal ring may improve
cycle control
• Consider switching desogestrel users
to a traditional POP
• 
Mefenamic or tranexamic acid may
shorten duration of a bleeding episode
• 3-month trial of first-line COCP used
either continuously or cyclically
• 
No evidence to support reducing
injection interval in DMPA users
• Mefenamic or tranexamic acid may
shorten duration of bleeding episode
in DMPA users

Abbreviations: STI = sexually transmitted infection; COCP = combined oral contraceptive pill; POP = progesterone only pill; IVS = intrauterine system;
DMPA = depot medroxyprogesterone acetate

Figure 1. Summary of management of unscheduled bleeding in hormonal contraceptive users.

symptomatic patients in whom conservative
measures have failed, consideration may be
given to local treatment. Once infection and
malignancy have been excluded, cryocauteri-
zation or diathermy may be performed under
colposcopic guidance.
BLEEDING ASSOCIATED WITH
CONTRACEPTIVE USE
Case 3
A 27-year-old nulliparous woman attends gynae-
cology clinic with a 6-month history of IMB. She
has been taking the COCP for 8 months. She has
no significant past medical or surgical history.
Her last cervical smear test was 18 months ago
and it was normal (Figure 1).
How would you assess this patient?
A detailed gynaecological and contraceptive his-
tory is essential in this case to aid diagnosis. The
possibility of pregnancy should be considered
and a pregnancy test should be performed on
sexually active women using hormonal contra-
ception with unscheduled bleeding.
A detailed menstrual history should be
taken with particular attention to her bleeding
pattern prior to starting oral contraception. The
current type of oral contraception and compli-
ance should be ascertained. The use of any
concurrent prescribed, over-the-counter, or
herbal preparations needs to be outlined due
to the possibility of a drug interaction. A histo-
ry of illness that may have interfered with the
absorption of medication should be assessed.
GYNAECOLOGY PEER REVIEWED
A sexual history should be taken and
screening for infections particularly Chlamydia
trachomatis and Neisseria gonorrhoea should
be performed in women under 25, women of
any age with a new partner, and women with
more than one partner in the past year. Single
vaginal swabs are available to screen for both
infections or vaginal self-swabs can be used.
Urinary testing for STIs is no longer recom-
mended. A cervical screening history should
be taken and a smear test performed if it is
due.
Other gynaecological symptoms such
as dyspareunia, vaginal discharge, or PCB
should be elicited to assess whether the cause
for bleeding is related to hormonal contracep-
tive use. A smoking history should be elicited
as breakthrough bleeding is more prevalent
among smokers.
Women should be advised prior to start-
ing hormonal contraceptives that unscheduled
bleeding in the first 3 months is not uncom-
mon and usually settles with continued use.
Unscheduled bleeding for the first 6 months
with the progesterone IUS or implant may be
considered normal. The presence of PCB al-
ways warrants a speculum and bimanual ex-
amination. Where it is IMB only, for less than
3 months, with a normal smear history, no risk
factors for STIs and no symptoms suggestive
of gynaecological pathology. A conservative
approach without examination could be con-
sidered with a follow-up review arranged. If
her bleeding had continued for more than 3
months, she had not had up to date cervical
screening, or if she had any other gynaecolog-
ical symptoms or requested examination then
bimanual and speculum examination should
be performed.
In women over the age of 45 with persistent
unscheduled bleeding or a change in bleeding
pattern and younger women with risk factors
for endometrial cancer, endometrial assess-
ment with ultrasound scan ± endometrial biopsy
should be considered.
MIMS JPOG 2018 VOL. 44 NO. 1 35
What are the management options for
this patient?
After excluding others causes for unscheduled
bleeding, the management depends on the type
of contraception used.
Combined oral contraceptive pill
General principles in the management of irreg-
ular bleeding with oral contraception include
ensuring adherence to pill taking and avoiding
cycling of packets in COCP users as this can
result in breakthrough bleeding. Smoking ces-
sation advice should be offered as smoking is
linked to a higher incidence of breakthrough
bleeding.
Unscheduled bleeding is less common with
the COCP compared with the progesterone only
pill (POP). The COCP with the lowest dose of
ethinylestradiol to achieve cycle control is usu-
ally prescribed for contraceptive purposes. In
cases of unscheduled bleeding, trying an alter-
native COCP with a different oestrogen or pro-
gestogen component may help. Increasing the
dose of ethinylestradiol up to a maximum of 35
µg often improves cycle control. The combined
vaginal ring has also been shown to improve cy-
cle control compared with the COCP and so can
be offered as an alternative.
Progesterone only pill
The progesterone only pill (POP) is a more suit-
able alternative to the COCP in women who are
breastfeeding, women over 35 years of age, in
smokers and in women in whom oestrogens are
contraindicated. The pattern of bleeding can
vary between the different types of POP. Women
taking the desogestrel POP (Cerazette®) can be
advised to try a different POP, but it should be
explained that they may still experience bleed-
ing and the pattern may be different, which may
be more or less acceptable to some women.
About 50% of women taking Cerazette® will be
amenorrhoeic or have infrequent bleeding after
1 year, and the other 50% will have frequent or
prolonged bleeding. Traditional POP prepara-
36 MIMS JPOG 2018 VOL. 44 NO. 1
Practice Points
• Pregnancy must be excluded in any woman of reproductive age
presenting with unscheduled bleeding.
• The first symptom of gynaecological cancer can be a change in
menstrual pattern, including unscheduled vaginal bleeding, and
these symptoms therefore should prompt the need for bimanual and
vaginal speculum examination.
• Women with symptoms suggestive of cervical cancer including
PCB, persistent vaginal discharge, and IMB should undergo
gynaecological examination and be referred for colposcopy if
cancer is suspected.
• Women with unscheduled bleeding and a previous negative smear
result have a greatly reduced risk of cervical cancer. However,
a previous negative smear result should not delay referral to
colposcopy if there is a clinical suspicion of cervical cancer on
examination.
• Women aged under 25 with abnormal vaginal bleeding who are
found to have a normal cervix on examination should be screened
for infection and treated appropriately. Persistent symptoms (6–8
weeks) should prompt gynaecological referral.
• Endometrial biopsy is indicated in women over 45 with persistent
IMB and in younger women with risk factors.
• 
Unscheduled bleeding is common in the first 3 months with
hormonal contraception, but persistent symptoms, the presence of
risk factors, or the other gynaecological symptoms warrants further
investigation.
tions are associated with less amenorrhoea and
less prolonged bleeding, but frequent irregular
bleeding is common. There is no evidence that
taking two POPs a day improves bleeding.
Progesterone only implant, depot
medroxyprogesterone acetate or IUS
The addition of a first-line COCP containing
30–35 µg of ethinylestradiol for 3 months may
help reduce unscheduled bleeding in this group
of women, although it is not licenced for this
indication. Evidence that this is beneficial is
available for users of the progesterone IUS and
implant but evidence of its benefit is lacking for
patients using depot medroxyprogesterone ace-
tate (DMPA), although its use is nevertheless ad-
vised. The COCP can be given cyclically or in a
continuous pattern and can be repeated as often
GYNAECOLOGY PEER REVIEWED
as needed provided there are no contraindica-
tions to oestrogen use.
For women using DMPA, there is no evidence
that reducing the interval between injections im-
proves bleeding. Mefenamic acid or tranexamic
acid may be beneficial in the short-term by reduc-
ing the length of bleeding episodes in women us-
ing DMPA but evidence of similar benefit has not
been found in users of the implant or IUS.
CONCLUSION
Unscheduled bleeding in premenopausal wom-
en is usually a result of benign disease, but
consideration must be given to the possibility
of malignancy in all cases. Further investigation
to exclude malignancy is warranted in women
over the age of 45 years and in younger wom-
en with additional risk factors. Prolonged or
persistent symptoms despite treatment should
prompt the need for further evaluation to ex-
clude malignancy.
There is considerable overlap in symptom-
atology in conditions associated with IMB and
PCB, and history taking is an essential tool in the
diagnosis of these patients. Bimanual and spec-
ulum examination is indicated in almost all cases
of unscheduled vaginal bleeding and a delay in
performing these important tests has been shown
to result in an unacceptable delay in diagnosis,
thereby increasing the morbidity and mortality as-
sociated with gynaecological cancers.
FURTHER READING
1. Department of Health. Clinical practice guidance for the assessment of
young women aged 20–24 with abnormal vaginal bleeding, 2010.
2. NICE Clinical Guideline. Heavy menstrual bleeding, January 2007.
3. Lumsden MA, Gebbie A, Holland C. Managing unscheduled bleeding
in non-pregnant premenopausal women. BMJ 2013 Jun 4; 346: f3251.
https://doi.org/10.1136/bmj.f3251.
4. Management of unscheduled bleeding in women using hormonal contra-
ception. Faculty of Sexual and Reproductive Healthcare, 2009.
5. NHS Cervical Screening Programme. Colposcopy and Programme Man-
agement, NHSCSP Publication number 20, Third edition March 2016.
© 2017 Elsevier Ltd. All rights reserved. Initially published in Obstetrics,
Gynaecology and Reproductive Medicine 2017;27(12):379–384.
About the authors
Sinead Morgan is a Specialist Registrar in Obstetrics and Gynaecology at
Princess Royal University Hospital, King’s College Hospital NHS Foundation
Trust, London, UK. Conflicts of interest: none declared.
Shreelata Datta is a Consultant Obstetrician and Gynaecologist at King’s
College Hospital NHS Foundation Trust, London, UK. Conflicts of interest:
none declared.
CONTINUING MEDICAL EDUCATION
Developmental Care of the
Preterm Neonate
Imelda L. Ereno, MD, DPPS (Philippines), ADPCH (Singapore), FPSMID (Philippines)
INTRODUCTION
Advances in antenatal, perinatal, and neo-
natal care lead to increased survival of pre-
term infants. As survival rates continued to
increase, so did the angst of “intact surviv-
al,” or survival without disabilities. A recent
meta-analysis revealed that at school-age,
cognitive scores of former very low birth
weight (VLBW) infants are approximate-
ly 10 points lower than those of matched
control children1 due to difficulties with
attention, behaviour, visual-motor integra-
tion, and language performance. 2-3
NEURODEVELOPMENTAL CARE
Neurodevelopmental care is a broad term
applied to physician–nursing practices,
physical environmental elements, and
family involvement philosophies that may
favourably impact the neurodevelopment
of the premature newborn.4 The funda-
mental objective of developmental care is
to support the child’s brain development.5
(See Table 1) Sensory input affects the wir-
ing of neuronal networks and their mode of
functioning as well as the behaviour of the
newborn. Infants born very prematurely
may be overstimulated during a critical pe-
riod when their brain is developing rapidly.
Treatment and care procedures received
during hospitalisation may cause discom-
fort and pain in the very preterm infants,
and making it difficult for these infants to
experience undisturbed periods of restful
sleep. In rodents, pain during the neonatal
period has been found to result in long-last-
MIMS JPOG 2018 VOL. 44 NO. 1 37
2 SKP
Table 1. Aims of Neurodevelopmental Care
• Reduction of infant’s stress and agitation
• Energy conservation and enhanced recovery
• Caregiver understanding of infant´s behavioural cues
• Encouragement and support of parents in the primary caregiver role
• Minimisation of potential harm due to the ex utero environment
• Promotion of normal growth and development
• Prevention of abnormal postures
• Stabilisation at each stage of infant´s neurodevelopmental maturation and
support of emerging behaviours and organisation
• Enhanced family emotional and social wellbeing
ing enhancement of stress responses,6 al- incides with typical in utero sensory expo-
tered neuronal circuits, learning deficits,
7
sures, and with the uterine environment
and behavioural changes.8 Similarly, vari- providing a more controlled and filtered
ations in maternal care have been shown exogenous sensory input. This is the ra-
to promote synaptogenesis, learning, and tionale for limiting excessive sensory stim-
memory, as well as influence the expres-
9
ulation during early sensory development.
sion of neuropeptide receptors related to Supported by animal studies, “Sequential
normal gender-specific adult behaviours. 10
Theory of Sensory Development” suggests
that atypical and mistimed sensory stimu-
NEUROSENSORY lation play an influential role in brain devel-
DEVELOPMENT opment.13 Atypical onset and intensity of
Neurosensory development follows a se- developing sensory experience afterwards
quential pattern. Sensory development (eg, early or excessive visual input) may
begins with sensations particularly to the interfere with the development or function
skin, followed by kinaesthetic, chemosen- of an earlier developing system (eg, audi-
sory, auditory and visual development.11-12 tory or chemosensory). Early or enhanced
(See Figures 1 and 2) The timing, inten- visual experiences may lead to accelerat-
sity, and nature of exogenous stimulation ed development of the visual system with
are all important to normal neurosensory an associated decline in auditory or chem-
development. This staged maturation co- osensory responsiveness.14-16
38 MIMS JPOG 2018 VOL. 44 NO. 1 CONTINUING MEDICAL EDUCATION

Skin (T) Endogenous Stimulation/

12-14 weeks Critical Period of Development
%REM Sleep

‡
Synaptogenesis Synaptogenesis

Kinaesthetic/Movement (T)
14-16 weeks

‡ Synaptic Refinement
Synaptic Pruning

Chemosensory (C) Exogenous Stimulation/ NICU Hospitalisation

16-18 weeks %NREM Sleep
‡
28 wks Term 2-3 yo Adult
Auditory (A)
Reprinted by permission from Macmillan Publishers Ltd: Journal of Perinatology 2007;27 Suppl 2:S48–S74, copyright 2007
24-28 weeks
Figure 3. Relationship of endogenous and exogenous stimulation, REM/NREM sleep and
‡ brain plasticity4

Vision (V)
28-34 weeks MODEL OF THE SYNACTIVE
ORGANIZATION OF BEHAVIOURAL DEVELOPMENT
Systems:
T = Tactile; C = Chemosensory; A = Auditory; V = Vision Attentional/Interactive
State
Motor
Figure 1. Neurosensory development Autonomic

ENVIRONMENT ORGANISM
World at Large Week Behaviour
47-52 Object Play
Cochlear function, Parental
42-46 Social Reciprocation
Peripheral sensory organs Extrauterine
37-41 Focused Alertness
Environment
22-24 weeks 32-36 Rapid Eye Movement
Coordinated Resp. Movement

‡ Isolette 28-31 Complex Movements Thumb Sucking

25-27 Foetal Respiratory Movement
21-24 Rapid Eye Movements
Parental
Blink-startle responses to Intrauterine
17-20 Coordinated Hand-to-Face Movements

vibrio-acoustic stimulation Environment 13-16 Eye Opening and Eye Movements

24-25 weeks 9-12 Isolated Head and Limb Movements

2-8 Flexor Posture

‡
Conception
➛ 4 Twitching Movement

Reprinted by permission from John Wiley and Sons: Als, H., Toward a synactive theory of development: Promise for the assessment
and support of infant individuality. Infant Ment. Health J. 1982;3:229–243
40 dB Threshold
27-29 weeks Figure 4. The model of synactive theory of development20

‡ ROLE OF SLEEP IN BRAIN marked decrease in sleep requirements

DEVELOPMENT with relatively less REM sleep with age.17
13.5 dB Adult The “Ontogenic hypothesis” theorizes that This association of extended REM sleep
Threshold level
42 weeks normal sleep cycles, with a predominance during a period of rapid brain maturation,
of rapid eye movement (REM) sleep, are stabilising to adult levels with brain matu-
necessary for early brain development.17-18 rity, is demonstrated in animals as well.19
Figure 2. Auditory system development With maturation, there is a gradual shift This progressive maturation process in the
towards adult sleep–wake cycles, and a prematurely born infant is not equivalent
CONTINUING MEDICAL EDUCATION
Table 2. Neurosensory Development According to Gestational Age
Neurosensory Early preterm
development (≤27 weeks)
Behavioural Poorly differentiated
development
Handling results in physiologic
instability
Physiologic instability ranges
from typical stress signs to
exhausted collapse
Motor Movements are mainly jerks,
development twitches, and startles
Weak muscle tone
Decreased flexion in limbs,
trunk, and pelvis
Unable to control posture,
movement, and tone
Eye development Eyelids may be fused at 23–25
weeks
Cornea hazy until 27 weeks
Pupil reflex is absent
Limited ability to maintain lid
tightening
Eyes may open but do not focus
Responds to light/visual
stimuli with behavioural and
physiological signs of stress
Ear development Inner ear fully functional
Responds to soft voice and
sound. Shows preference for
mother’s voice
Physiological instability
to noise/auditory activity
Gastrointestinal Immature gastrointestinal
development system
Developing preterm
(28–32 weeks)
Gradually become more
distinct by 32 weeks
Quiet/deep sleep increases
around 30 weeks
Handling results in
physiologic instability
More controlled movements
by 32 weeks
Muscle tone develops slowly
Beginning flexion of hips
and legs
Sluggish pupil response to
light
Able to maintain lid
tightening in response to
bright light
Eye opening in dim light
May focus briefly on visual
stimuli
Rapid uncoordinated eye
movements
Complete middle ear and
transmission section of
auditory system
Orientation to soft sound
Quickly fatigues to auditory
stimulation
Sensitive to loud noise
Rooting reflex present
Growing preterm
(33–36 weeks)
More distinct behavioural
states
Smoother transition between
states
May arouse for feeding
Smoother and more
controlled movements
Stronger flexion of knees
and hips during rest and
development of tone in the
lower extremities
Turns head from side to side
Improved capability
to self-regulate
Increased ability to maintain
lid tightening in response to
bright light
Eye opening and alert state
at low lighting
Infant may have difficulty
breaking gaze on a highly
stimulating object
Functional sensory and
transmission portions of the
auditory system
Increased responsiveness to
voice stimuli with a preference sounds
for soft human voice
Responses to noise and
auditory environments begin
to organize
Startle response with loud
noise
Suck, swallow, and breathe
coordination shows some
rhythmicity but coordination
can be inconsistent
MIMS JPOG 2018 VOL. 44 NO. 1 39
Older preterm
(≥37 weeks)
Increased tolerance to handling
and interventions
States well defined with clear
transitions
Periods of alertness for
socialization with longer
attention spans
Wide range of movements
Controlled movements
Trunk and extremities usually
flexed at rest
Self-regulates behaviour with
movement and posture
Preference for human face
Sees best at a distance of
20–25 cm
Immature sight, development at
0–6 months
Consistent and organized
response to noise
Localize and discriminate
Stress behaviours may still
be displayed to certain loud
sounds
Prefers gradual onset of
auditory stimuli
More consistent suck, swallow,
and breathe coordination
40 MIMS JPOG 2018 VOL. 44 NO. 1 CONTINUING MEDICAL EDUCATION

Table 2. Neurosensory Development According to Gestational Age (continued)

Neurosensory Early preterm Developing preterm Growing preterm Older preterm

development (≤27 weeks) (28–32 weeks) (33–36 weeks) (≥37 weeks)
Gag reflex presents at 26 Poor suck, swallow, and Rooting reflex emerges Increased endurance for oral
weeks’ gestation; breathe coordination feeding
Sucking may appear but not
synchronized with swallow
Nipple feeding usually
tolerated
Taste and smell Taste and smell receptors are functional
Physiologic responses to unpleasant olfactory stimuli have been documented by research

to the normal, uninterrupted progression

in term-born infant, and the undefined and
obvious challenges of prematurity may re-
sult in subsequent brain reconfiguration or
brain plasticity.4 (See Figure 3)

BEHAVIOURAL LANGUAGE OF
THE PRETERM NEONATE
“Synactive Theory of Development”20 is
the framework for understanding infant’s
behaviour. The principle of synaction (See
Figure 4) states that development pro-
ceeds through the continuous balancing
of approach and avoidance, continuous
intraorganism subsystem interaction, and
differentiation and organism-environment
interaction to realize a hierarchical spe-
cies’ unique developmental agenda. Ob-
servation of the preterm infant’s behaviour
provides a way to infer the infant’s devel-
opmental goals and assess the infant’s
current functional competence and state
of equilibrium. These behaviours were
noted under the three main systems, (1)
Autonomic system; (2) Motor system;
and (3) State system, with emphasis on
the emerging attention system. The fourth
system, (4) Self-regulation or regulatory
system, reflects the infant’s current suc-
cesses and efforts in returning to sub-
system reintegration and calmness once
the three basic subsystems have been
Figures 5a and 5b. Traditional task and protocol-focused NICU
disrupted and disorganized. All these
reliably observable behavioural commu-
nications provide valuable information for
the clinician and caregiver in how best to
structure and adapt care, and interaction
to enhance the infant’s competencies and
strengths and prevent or diminish signals
of stress, discomfort, and/or pain.
AGE-APPROPRIATE
DEVELOPMENTAL CARE
Ideally, in utero environment is where in-
fants receive positive sensory input, pro-
tection, and a variety of stimuli in an inte-
grated and multimodal fashion. In utero,
the foetus is provided secure boundaries
for generalized flexion and gentle, secure
containment for motor development, au-
ditory input from mother’s voice, bowel
sounds, blood flow from placenta and um-
bilical cord, as well as filtered sounds from
the extrauterine environment. The tradi-
tional task- and protocol-focused NICU en-
vironment presents complete separation
from the parent, sensory overload, and
simultaneously, the frequent experience of
invasive and painful events. (See Figures
5a and 5b) Prolonged diffuse sleep states,
unattended crying, abrupt blood flow
changes due to shifts into supine position,
routine and rapid handling, invasive pro-
cedures such as suctioning, high ambient
sound and light levels, lack of opportunity
for sucking, and often poorly timed social
and caregiving interactions, all exert del-
eterious effects upon the immature brain
and appear to alter its subsequent devel-
opment. The focus is now being placed
on maximizing the quality of care in the
NICU environment. Tables 2 and 3 showed
CONTINUING MEDICAL EDUCATION
Table 3. Summary of Age-Appropriate Developmental Care
Developmental Early preterm
care (≤27 weeks)
Handling and Provide opportunity of
intervention undisturbed rest
Slow, controlled gentle
handling
Containment during
intervention
Vary infant head and body
position
Avoid stroking or patting
Consider day/night patterns
for intervention
Positioning Supportive positioning
Opportunities for movement
Provide boundaries
Light and vision Minimize light exposure
Visual toys and pictures are
not appropriate
Dim lights in room at night
Sound and hearing Minimize environmental noise
Attend to alarms promptly
Close incubator doors quietly
Developing preterm
(28–32 weeks)
Provide opportunity of
undisturbed rest
Slow, controlled gentle
handling
Gently prepare infant for
handling with a soft voice or
gentle touch
Vary infant head and body
position
Containment during
intervention
Cluster care. Provide “time
out” after intervention
Consider infant cues
AVOID stroking or patting
Consider day/night patterns
for intervention
Supportive positioning
Opportunities for movement
Provide boundaries
Minimize light exposure
Visual toys and pictures are
not appropriate
Dim lights in room at night
Shading from light gives
appropriate opportunities for
spontaneous eye opening
Minimize environmental noise
Attend to alarms promptly
Close incubator doors quietly
Growing preterm
(33–36 weeks)
Consider infant cues
Slow, controlled gentle
handling
Patting or stroking may be
tolerated
Hold infant during feeding if
awake
Introduce kangaroo care
Consider day/night patterns
for intervention
Provide boundaries
Swaddle infant for initial
baths
Infants in cot: lie on back,
swaddle below shoulder
level, no nest/blanket around
face, vary infant’s head
position for sleep
Minimize light exposure
Protect infants from bright
light during caregiving
Support emerging need for
eye contact – preference for
human faces
Dim lights at night
Minimize environmental noise
Parents to talk softly to their
baby as cues allow
Audio tapes are NOT
recommended
MIMS JPOG 2018 VOL. 44 NO. 1 41
Older preterm
(≥37 weeks)
Rhythmic care patterns
to enhance sleep–wake
organization
Swaddle or contain during
uncomfortable or noxious
procedures
Patting and stroking may be
tolerated
Hold infant for feeding
Breastfeeding during or after
painful procedures
Kangaroo care opportunities
Infants in cot
Approach from different sides to
avoid R-sided head preference
Supervised “tummy time” and
side-lying position to promote
hands to midline posture
Low lighting, protect from
bright lights
Dim lights at night
Offer opportunities for visual
stimulation if infant displays
longer attention span
Avoid loud noise and multiple
sound sources
Auditory stimulation as per
baby's cues
Music audiotapes if parents
wish – NOT to be set on
continuous play
42 MIMS JPOG 2018 VOL. 44 NO. 1 CONTINUING MEDICAL EDUCATION

Table 3. Summary of Age-Appropriate Developmental Care (continued)

Developmental Early preterm Developing preterm Growing preterm Older preterm

care (≤27 weeks) (28–32 weeks) (33–36 weeks) (≥37 weeks)
Ensure CPAP and ventilator tubing Ensure CPAP and ventilator tubing
is regularly cleared of water is regularly cleared of water
Audio tapes are NOT Encourage parents to talk softly
recommended to their babies as cues allow
Audio tapes are NOT
recommended
Non-nutritive Encourage hand-to-mouth Encourage hand-to-mouth Encourage hand-to-mouth Encourage hand-to-mouth
sucking contact contact contact contact
No pacifier unless sucking Preemie pacifier to support non- Small pacifier to encourage Encourage non-nutritive
cues evident nutritive sucking wider jaw excursion sucking during NG/OG feeds
and for comfort
Suction orally only when Do not offer pacifier prior to Do not offer pacifier prior to Standard small pacifier
necessary painful procedure painful procedure to encourage wider jaw
excursion
Suction orally only when Suction orally only when Do not offer pacifier prior to
necessary necessary painful procedure
Taste and smell Familiarize infant with the smell Familiarize infant with the smell Parents to hold infant during Parents to hold infant during
of breastmilk of breastmilk NG/OG feedings NG/OG feedings
Protect from noxious odour Protect from noxious odour Protect from noxious odour Protect from noxious odour
(alcohol wipes, antiseptics,
perfume)
Dip pacifier or teat in milk Dip pacifier or teat in milk
prior to use prior to use
Parental Promote early and continued Promote early and continued Promote early and continued Promote parental
involvement parental involvement to parental involvement to parental involvement to independence
observe infant’s cues/ observe infant’s cues/ observe infant’s cues/
behaviours behaviours behaviours
Emphasize low tolerance for Teach parents to identify Promote independence by Offer opportunity for
stimulation infant’s readiness for touch and encouraging parents with education on deep-water
handling feeding and care bathing, massage techniques,
and infant development
Assist with care – gentle touch Assist with care – top and tail
and containment wash, kangaroo care

the stages of neurosensory development
and age-appropriate developmental care
based on gestational age group, respec-
tively.
POSITIONING AND
CONTAINMENT
In utero, the infant is flexed, midline position
with head, back, and feet contained by the
uterus. It allows soothing, self-regulation by
touching the face and sucking of fingers.
Muscular development is dependent on
buoyancy and contained uterine space.
When a preterm infant is born, it loses the
containment of the uterus. Without the
surrounding amniotic fluid, the effect of
gravity is felt and this affects muscular de-
velopment. The goal of positioning and
containment is to mimic intrauterine expe-
rience which is to facilitate flexed, midline
positioning of extremities. Swaddling and
containment of the infant with general flex-
ion of the extremities and trunk is a general
approximation of this effect.21 It is a means
to promote sleep with decreased awaken-
ings during quiet sleep (QS) and longer peri-
ods of REM sleep. It also appears to improve
self-regulation, diminished pain, and stress
responses, and decrease arousal level in-
cluding crying, and may promote neuro-
muscular development in the preterm infant.
SENSITIVE HANDLING AND
CUE-BASED CARE
There are various handling techniques to
support the neurodevelopmental needs
CONTINUING MEDICAL EDUCATION
of the preterm infants, and these include
gentle arousal (talking softly and touching
gently before handling), gentle and slow
minimal handling, containment during care
procedures, and swaddling for weighing
and bathing. Avoid sudden position chang-
es and overstimulation. Whenever possible,
try to minimize unnecessary light and noise
during handling. A clutter of toys may be
overwhelming. To facilitate self-consoling/
calming behaviour, provide soothing in-
terventions or comfort measures such as
non-nutritive sucking, containment of in-
fant’s arms and/or legs by gently holding the
infant’s hands together on the chest and/or
hold the legs tucked up, provide grasping
opportunities, and kangaroo care (skin-
to-skin contact). To support the vestibular
system, the infant is gradually turned while
maintaining a flexed and midline position.
Be mindful to stress cues during handling,
and respond by providing containment
holds and time-outs (short breaks) to ena-
ble physiological recovery before resuming
the activity with a much slower pace.
MODULATION OF SOUND
EXPOSURE
Noise is an iatrogenic environmental haz-
ard in the NICU that can have deleterious
effects on preterm and term infants. Exces-
sive noise in the NICU can result in unde-
sirable physiologic responses, disrupt nor-
mal sleep patterns, cause noise-induced
hearing loss, and affect caregivers’ com-
munication and job performance. Safe
sound levels in the NICU are an important
aspect of optimizing care for this vulnerable
group of patients. The American Academy
of Pediatrics and Recommended Stand-
ards for Newborn ICU Design have guide-
lines for acceptable sound levels in the
NICU.22-23 However, observational studies
have shown that sound levels in the NICU
often exceed these recommendations:
• 
American Academy of Pediatrics,
Committee on Environmental Health,
199722
° Sound levels not > 45 dB
• Recommended Standards for New-
born ICU Design. Report of the 8
Consensus Conference on Newborn
ICU Design, January 26, 201223
° Standard 27: Acoustic Environment:
In infant rooms and adult sleep ar-
eas, the combination of continuous
background and operational sound
shall not exceed an hourly Leq of 45
dB and an hourly L10 of 50 dB, both
A-weighted slow response. Tran-
sient sounds or Lmax shall not exceed
65 dB, A-weighted, slow response.
MODULATION OF LIGHT
EXPOSURE
A preterm infant’s ability to protect the eyes
is limited by his physiologic immaturity. The
pupillary light reflex, which controls the
amount of light entering the eye, is highly
correlated with gestational age. Fielder24
found that no infant less than 30 weeks’
gestational age at birth had a pupillary re-
flex. At 34 weeks’ gestation, only 86% have
light reflex and at 35 weeks’ gestation, all
infants had the reflex present. Infants who
had no reflex also had a larger papillary di-
ameter. Therefore, the very immature infant
receives a larger retinal light dose than their
older counterparts. Direct ambient light has
a negative effect on the development of a
preterm infant’s visual neural architecture.
Recommended Standards for Newborn
ICU Design. Report of the 8th Consensus
Conference on Newborn ICU Design,
January 26, 201223
• Standard 22 – Ambient Lighting in In-
fant Care Areas: Ambient lighting lev-
els in infant spaces shall be adjustable
through a range of at least 10 to no
MIMS JPOG 2018 VOL. 44 NO. 1 43
more than 600 lux (approximately 1–60
foot candles), as measured at each
bedside. Both natural and electric light
sources shall have controls that allow
immediate darkening of any bed po-
th
sition sufficient for transillumination
when necessary.
• Electric light sources shall have a colour
rendering index (CRI) of no less than 80,
and a gamut area (GA) of no less than
80 and no greater than 100. The sourc-
es shall avoid unnecessary ultraviolet or
infrared radiation by the use of appropri-
ate lamps, lens, or filters.
• 
No direct view of the electric light
source or sun shall be permitted in
the infant space. Any lighting used
outside the infant care area shall be
located to avoid infant’s direct line of
sight to the fixture.
CONCLUSIONS
Neurodevelopmental outcome is the
benchmark of neonatal care. Even in
medically healthy preterm infants, these
challenges lead to an increase in neu-
rodevelopmental difficulties such as
specific learning disabilities, lower IQ,
executive function and attention deficit
disorders, lower thresholds to fatigue,
more visual-motor impairments, spa-
tial processing disturbances, language
comprehension and speech problems,
emotional vulnerabilities, and difficulties
with self-regulation and self-esteem. De-
velopmental care practices support the
infant’s growth and maturation by reduc-
ing stress, enhancing self-regulatory be-
haviours, and maximizing neurodevelop-
mental outcomes.
About the author
Dr Imelda L. Ereno is a Senior Resident Physician in the
Department of Neonatal and Developmental Medicine,
Singapore General Hospital.
For a complete list of References material, please write
to the editor.
44 MIMS JPOG 2018 VOL. 44 NO. 1 CME QUESTIONS

Program pendidikan kedokteran berkelanjutan ini dipersembahkan oleh

MIMS, bekerjasama dengan Ikatan Dokter Indonesia.
Setelah membaca artikel ‘Developmental Care of the Preterm Neonate’,
jawab pertanyaan berikut kemudian kirimkan dengan menggunakan
formulir jawaban yang sudah disediakan ke CME MIMS Journal of
Paediatrics, Obstetrics & Gynaecology, untuk mendapatkan 2 SKP.

ARTIKEL CME 2 SKP

Developmental Care of the Preterm

Neonate
Jawab pertanyaan di bawah ini dengan Benar atau Salah.

1. Neurodevelopmental outcome of the infant born preterm is the benchmark of neonatal care.
2. Kangaroo care promotes self-regulation and state regulation in preterm infants.
3. Among the neurosensory systems, vision develops last hence modulation of light exposure is
recommended to commence at 28 weeks’ gestation.
4. REM sleep is key to early brain development.
5. Neurodevelopmental care encompasses evidence-based physician–nursing practices, environmental
modifications, and family involvement philosophies that may favourably impact the neurodevelopment of
the premature newborn.
6. Loud noise causes apnoea, bradycardia, and desaturation in preterm infants.
7. A 34 weeks’ gestation infant may tolerate nipple feeding.
8. Developmental care planning is initiated when the infant is medically stable and ready for discharge.
9. Positioning and containment facilitates flexed, midline positioning of extremities which mimics intrauterine
environment.
10. Behaviour is the infant’s way of communicating his developmental needs, functional competence, and
state of equilibrium.