Due to the associated social stigma, most women experiencing symptoms of anal incontinence (AI) do not seek medical assistance or volunteer their symptoms when consulting a healthcare provider for other conditions. As gynaecologists, we regularly have contact with women who could be experiencing AI, particularly those with urinary incontinence or pelvic organ prolapse, those who have undergone pelvic radiotherapy or women following childbirth. Although most of the investigations and specific management for patients with AI will be performed by other members of the multidisciplinary healthcare team (e.g. colorectal surgeons, dieticians, occupational therapists, physiotherapists) we have an important role to play in identifying these patients and referring them appropriately.Keywords: Anal incontinence; Faecal incontinence; Obstetric anal sphincter injury

A vaginal delivery has a profound impact on the pelvic floor with the potential for significant functional sequelae. There is an increasing trend among obstetricians to perform a caesarean section to preserve pelvic floor function. This in turn has contributed to an increasing caesarean section rate, both in South Africa and internationally. What impact does vaginal delivery have on pelvic floor dysfunction and can we prevent these problems by resorting to an abdominal delivery? When it comes to preventing urinary incontinence, caesarean section has been shown to be protective; reducing the risk by about 50%, but the effect appears to dissipate with time. For faecal incontinence, caesarean delivery has only a marginal impact with one study showing that 167 caesarean sections need to be done to prevent one case of faecal incontinence. Forceps delivery appears to double the risk of faecal and urinary incontinence compared to normal vaginal delivery. In terms of sexual function, caesarean section is associated with a sensation of better vaginal tone for both partners but no difference in any other parameters. Vaginal delivery is significantly associated with pelvic organ prolapse, with the risk rising with increased vaginal parity. caesarean section is strongly protective against the development of prolapse. This should be viewed in the context of an increased mortality rate for elective caesarean section, with one study showing this to be about 3.6 times that of vaginal delivery. Every women embarking on a caesarean delivery to protect her pelvic floor should be counselled by her obstetrician about the limitations and risks of this procedure.Keywords: Caesarean section; Incontinence; Pelvic organ prolapse

Preterm birth continues to be a global public health burden. Most neonatal deaths occur as a result of prematurity, and among those who survive, a substantial proportion develop disability during childhood. Preterm birth usually follows spontaneous preterm labour, preterm prelabour rupture of membranes, or iatrogenic preterm delivery. Short-term tocolysis is generally indicated to arrest labour in order for corticosteroids to be given, or for the woman to be transferred to a higher level of neonatal care. Hexoprenaline was the cornerstone of such therapy in South Africa for many years. A wide variety of tocolytic drugs have been in clinical use around the world, yet the evidence that they confer benefit to the infant remains open to debate. Some tocolytic drugs may possibly be harmful. In this review the evidence for efficacy and safety of the various commonly used tocolytic drugs will be scrutinized, in particular their effect on infant health and maternal safety. Data on newer agents will also be reviewed, and future directions for tocolytic therapy will be explored.Keywords: Hexoprenaline; Pregnancy; Preterm labour; Tocolysis

Death rates from cancer are falling in almost all countries. It is tempting to attribute these encouraging trends equally to, screening, early detection and better treatments. There is a great deal of scientific research being invested in these endeavours and all are rigorously scrutinised. Screening has an intuitive attraction and is often emotionally championed to be “the responsible thing to do”. Recent work has questioned the scope and role of screening in three major fields of Women’s Health namely cervical cytology, mammography and ovarian cancer detection. If gynaecologists are to be advocates for women’s health then they must be sure that correct, evidence-based information is distributed. What was true about screening 7 years ago is not necessarily true today and the present “facts” may not be true in the future. Vested interests in the promotion of screening do exist and the well-woman visit needs to be able to prove that all its steps are in the woman’s interests. This article raises new evidence about screening and argues for the evaluation in all screening on a benefits/harms ratio and then the choice being agreed by the care-giver and patient. As the evidence changes, so do our prejudices come under scrutiny. Are we prepared to objectively review our position in the light of new data?Keywords: Cervical cytology; Mammography; Ovarian cancer screening

Postpartum haemorrhage (PPH) is a major direct cause of maternal mortality worldwide, and primary PPH accounts for most of these deaths. Secondary PPH is not usually as catastrophic and certainly less frequent but may still cause significant morbidity, and if not appropriately managed, can also lead to maternal death. The common causes of secondary PPH include subinvolution of the placental site, retained products of conception and endometritis. Rare causes such as uterine or cervical neoplasms as well as vascular abnormalities including uterine artery pseudoaneurysm, should be excluded, especially in patients not responding to uterotonics and antibiotics. Traditionally the treatment of uterine artery pseudoaneurysms would warrant a surgical approach, but recently selective uterine artery embolization (UAE) has become the treatment of choice. Ultrasound-guided thrombin injection of these vascular anomalies has also been successfully used in appropriate cases. With the availability of these uterine-preserving techniques, clinicians should perhaps consider UAE in the haemodynamically stable patient before resorting to surgery.

Rudimentary horn pregnancy is a rare complication that is thought to occur in 1:76000 pregnancies. Rupture of the horn in pregnancy is considered the most serious and common complication of rudimentary horns. The investigation of choice is considered to be magnetic resonance imaging (MRI). Evaluation of renal tract anomalies is mandatory in all patients withmullerian anomalies. Excision of all rudimentary horns with endometrial cavity is recommended to prevent complications. We present a case of ruptured rudimentary horn of a unicornuate uterus at 18 weeks gestation.

The use of HAART (Highly Active Antiretroviral Therapy) has significantly decreased the morbidity and mortality in individuals infected with HIV. Many couples who are infected with HIV (sero-discordant and sero-concordant) seek assistance with conception. The objective of the paper is to address the options available to these couples using artificial reproductive techniques (ART), in order to decrease the risk of transmission of HIV to the uninfected partner and the unborn fetus.

The human papilloma virus has been shown to play a significant aetiological role in invasive cervical cancer. The changes caused by human papilloma virus can be evaluated using Pap smear. The discovery of Pap smears has led to an unprecedented dramatic decline in the incidence of cervical cancer over the past five decades. This has been the case in high income countries due to effective cervical cancer screening programmes. The effectiveness of this simple cost-effective tool has led to attemptsat improving the quality of the Pap smear sample as well as the processing technique in the laboratory. This has led to the introduction of Liquid based cytology, a technique slowly replacing conventional cytology in the world due to its advantages. Although initially thought to be more sensitive and specific than conventional cytology, recent studies suggest that there are no significant differences in this aspect. The main advantage is that Liquid based cytology is less likely to be unsatisfactory or limited. Liquid based cytology has also reduced the screening time leading to improved turn-around time. The specimen submitted for liquid based cytology can be used to perform further tests such as molecular and microbiological studies. The Pap smear still plays an integral part in cervical cancer screening, despite recent advances in detection of human Papilloma virus using molecular techniques. The implementation of cervical screening programmes in low and middle income countries will assist in reducing the mortality related to invasive cervical cancer.

Mrs K P, a 29 year old P0G1 who presented at 12 weeks gestation for routine antenatal care. Aneuploidy screen revealed that her composite risk for Down's syndrome using a combination of nuchal translucency (measurement was 1.1mm), nasal bone assessment and biochemistry was low. Her blood group was O positive and screening tests for syphilis, rubella and HIV were negative. There was no family history of genetic or congenital anomalies. The rest of the antenatal care until 22 weeks was uneventful.