Some important questions in obstetrics and gynecology
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Transcript of Some important questions in obstetrics and gynecology
Some important
questions in obstetrics
and gynecology
Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR
1. A retrospective case-control study including
1,242 pregnant women with fibromyomas who
underwent myomectomy during caesarean
section (CS) and three control groups of 200
matched pregnant women without fibromyomas
who underwent CS deliveries (Group A), 145
patients with fibromyomas who underwent CS
deliveries without removal of fibromyomas
(Group B) and 51 patients with fibromyomas
who had a hysterectomy during CS (1) found
no differences in the mean hemoglobin change,
the incidence of postoperative fever and the
length of hospital stay among groups.
ABOUBAKR ELNASHAR
2. Other smaller case-control studies have also
reported caesarean myomectomy to be safe
and effective. (Evidence level IIa)
3. A prospective non-randomised study
including 29 women found that future fertility
and or subsequent pregnancy outcome was
unaffected by caesarean myomectomy
(Evidence level III)
ABOUBAKR ELNASHAR
RCT: beneficial blastocyst transfer, assisted hatching, salpingectomy for tubal disease, hysteroscopy procedures Endometrial injury IU administration of autologous PBMC
ABOUBAKR ELNASHAR
1- Standardize indications for CS& inductions
Many indications for CS, especially prior to
labour, should be questioned:
Macrosomia
maternal age& parity
CPD
breech .
Shoe size, maternal height& estimations of fetal
size
(US or clinical examination) do not accurately
predict CPD: should not be used to predict
"failure to progress" during labour. (Grade B)
ABOUBAKR ELNASHAR
2- Women with an uncomplicated pregnancy
should be offered induction of labour beyond
41w because this reduces the risk of perinatal
mortality and the likelihood of CS (NICE Clinical
Guideline April 2004) (grade A )
3- The routine use of early US to calculate
gestational age significantly reduces the
incidence of post-term pregnancy (grade A)
Cochrane Review
4- Appropriate use of cervical ripening agents
prior to induction of labor.
5- Correct diagnosis of labour
6- Routine amniotomy should be discouraged
ABOUBAKR ELNASHAR
7-A partogram with a 4-hour action line should
be used to monitor progress of labour of women
in spontaneous labour with an uncomplicated
singleton pregnancy at term.
(grade A).
8-Consultant obstetricians should be involved in
the decision making for CS (Grade C)
9-Use of electronic fetal monitoring should be
restricted to high risk pregnancy and better
understanding of the fetal monitor & what
actually constitutes fetal distress (grade B )
National Guideline Clearinghouse April 2005
10-Continuous support during labour from
women with or without prior training
(Grade A) ABOUBAKR ELNASHAR
11-External cephalic version:
uncomplicated singleton breech pregnancy at
36w should be offered external cephalic version.
Exceptions include women in labour and women
with a uterine scar or abnormality, fetal
compromise, ruptured membranes, vaginal
bleeding, or medical conditions. Grade A
12- When a woman requests a CS because she
has a fear of childbirth, she should be offered
unbiased, individualized information concerning
their birth options. Counselling (such as
cognitive behavioural therapy) to help her to
address her fears in a supportive manner, results
in reduced fear of pain in labour and shorter
labour. (Grade A) ABOUBAKR ELNASHAR
13- VBAC
should be offered and encouraged for all
patients unless there is a separate complicating
risk factor that justifies CS.
VBAC is safer for both mother and infant, in most
cases, than is routine elective CS, which is major
surgery.
Selection criteria :
One low-transverse CS
Clinically adequate pelvis
No other uterine scars or previous rupture
Continuous electronic fetal monitoring.
Availability of anesthesia and personnel for
emergency CS ABOUBAKR ELNASHAR
Contraindications
Patients at high risk for uterine rupture.
Prior classical or T-shaped incision or other transfundal
uterine surgery
Contracted pelvis
Medical or obstetric complication that precludes vaginal
delivery
Inability to perform emergency CS because of
unavailable surgeon, anesthesia, sufficient staff, or
facility
Patient attitude and desire
Patients have much to say about what is done to them.
Patient acceptance of VBAC is important {it would be
unethical to insist on a VBAC trial in a patient adamantly
opposed to such a trial}.
ABOUBAKR ELNASHAR
Interventions have no Influence on
Likelihood of CS
(Grade A) National Guideline Clearinghouse
April 2005
Walking in labour
Non-supine position during the second stage of
labour
Immersion in water during labour
Epidural analgesia during labour
ABOUBAKR ELNASHAR
Expectant management
Single-course corticosteroid
Prophylactic antibiotics
Group B streptococcal prophylaxis
Tocolytics for 48 h —no consensus
PPROM at 24-34 Weeks
Luseley &Baker Ob& Gyn,An evidence based text for RCOG 2010 : G :B
ACOG Practice Bulletin No. 80 ,2007
ABOUBAKR ELNASHAR
Patient counseling
Expectant management or induction of labor
Group B streptococcal prophylaxis is not
recommended
Corticosteroids are not recommended
Antibiotics—there are incomplete data on use
PPROM at 18-23 Weeks
Luseley &Baker Ob& Gyn,An evidence based text for RCOG 2010 : G :B
ACOG Practice Bulletin No. 80 ,2007
ABOUBAKR ELNASHAR
8. What are indications of
Circulage in normal cervix
after repeated abortion in
1st and 2nd trimester?
ABOUBAKR ELNASHAR
Indications
1. Three or more previous preterm births and/or
second-trimester losses.
2. History of one or more spontaneous mid-
trimester losses or preterm births
before 24 w. TVS: cervix is 25 mm or less
ABOUBAKR ELNASHAR
Treatment of varicoceles became the most common treatment for male infertility merely on an empirical basis. However, in the age of evidence-based medicine it is surprising that only a few, and mainly recent, randomized controlled clinical trials with relevant outcome parameters have been published to allow adequate judgement of treatment effectiveness. Moreover, difficulties in study design could also be detected in most of these high-quality studies. Despite these difficulties and in contrast to the majority of uncontrolled studies on varicocelectomy, meta-analysis of these randomized controlled clinical studies involving 385 patients showed no significant treatment benefit and questions the common practice of varicocelectomy. Even the high-quality studies show conflicting results and therefore the topic of varicocele treatment will remain controversial and further randomized clinical trials should readdress this issue. For the time being, intervention by surgical or angiographic occlusion of the spermatic vein cannot be recommended. ABOUBAKR ELNASHAR
Do Don’t
1. Double gloves for women who
are HIV-positive
2. Transverse lower abdominal
incision (Joel Cohen)
3. Blunt extension of the uterine
incision
4. Oxytocin (5 IU) by slow IV
injection
5. Controlled cord traction for
removal of the placenta
6. Close the uterine incision with
two suture layers
7. Check umbilical artery pH if CS
performed for fetal compromise
8. Facilitate early skin-to-skin
contact for mother and baby
Close subcuta space
(unless2 cm fat)
Use superficial wound
drains
Use separate surgical
knives for skin and
deeper tissues
Use forceps routinely to
deliver baby’s head
Suture either the visceral
or the parietal
peritoneum
Exteriorise the uterus
Manually remove the
placenta
ABOUBAKR ELNASHAR
ligation of the internal iliac arteries
a high level of surgical skill
Avoiding hysterectomy in only 50 per cent of
cases.
The surgical time and complication rate in
were also higher than when a hysterectomy
was performed.
Effectiveness is not yet proven.
Deteriorate if the iliac veins are injured.
Balloon tamponade and haemostatic suturing
may be more effective than internal iliac artery
ligation and they are unquestionably easier to
perform
ABOUBAKR ELNASHAR
ACOG Education and Technical Bulletins 2002 SOGC 2008
Management of exposed pregnant women
ABOUBAKR ELNASHAR
ACOG Education and Technical Bulletins 2002 SOGC 2008
Management of exposed pregnant women
ABOUBAKR ELNASHAR
13. Male patients is receiving ribavirin and
interferon alpha 2B (Pegetron) combination
therapy for chronic hepatitis C.
His wife recently found out she is 6 w pregnant.
They are concerned that the medications might
have affected his sperm. How should I advise
them?
ABOUBAKR ELNASHAR
Paternal exposure to ribavirin–interferon alpha
2B has no adverse effects on reproduction.
Although we do not have sufficient information
to confirm this, several pregnancies where the
father had been exposed to these medications
turned out fine.
If an unexpected pregnancy occurs while the
father is receiving this therapy, there is no
medical indication for terminating pregnancy.
Although ribavirin is a potential teratogen,
there seems to be no immediate reason for
terminating pregnancy when a father has been
exposed to it.
ABOUBAKR ELNASHAR