[Show abstract][Hide abstract] ABSTRACT: Overactive bladder (OAB) is a symptom syndrome including urgency, frequency, and nocturia - with or without incontinence. It is a common manifestation of detrusor overactivity (DO). DO is a urodynamic observation of spontaneous or provoked contractions of the detrusor muscle is seen during the filling phase of the micturition cycle. OAB is, therefore, both a motor and sensory disorder. Botulinum toxin is a purified form of the neurotoxin from Clostridium botulinum and has been used in medicine for many years. Over the last 10 years, it has been used for the treatment of DO and OAB when standard treatments, such as bladder training and oral anticholinergic medication, have failed to provide symptom relief. Botulinum toxin acts by irreversibly preventing neurotransmitter release from the neurons in the motor end plate and also at sensory synapses, although the clinical effect is not permanent due to the growth of new connections within treated tissues. It is known that botulinum toxin modulates vanillioid, purinergic, capsaicin, and muscarinic receptor expression within the lamina propria, returning them to levels seen in normal bladders. Clinically, the effect of botulinum toxin on symptoms of OAB and DO is profound, with large effects upon the symptom of urgency, and also large effects on frequency, nocturia, leakage episodes, and continence rates. These effects have been seen consistently within eight randomized trials and numerous case series. Botulinum toxin appears safe, with the only common side effect being that of voiding difficulty, occurring in up to 10% of treated patients. Dosing regimens are variable, depending on which preparation is used, but it is clear that dose recommendations have fallen over the last 5 years. There is limited evidence about the efficacy of repeat treatments. Botulinum toxin is an effective and safe second-line treatment for patients with OAB and DO.
[Show abstract][Hide abstract] ABSTRACT: Urinary incontinence (UI) is highly prevalent and common complaint. A large proportion of women with UI can be correctly diagnosed by their symptoms alone. First line of treatment should follow conservative route in a form of pelvic floor muscle training for stress UI and bladder training for the urgency UI. If conservative management is ineffective, medical and surgical treatment is the next considered. For the treatment of over-active bladder and urgency UI, intra-vesical injections of botulinum toxin A, utilising a flexible or rigid cystoscope has become an established treatment. An alternative to the use of onaBoNTA is sacral nerve stimulation (SNS). Vaginal tapes/slings procedures have become treatment of choice for stress UI. Different approaches of introduction of vaginal tape can be used, including retropubic 'bottom-up' (TVT), and transobturator 'inside-out' (TVT-O), or 'outside-in' (TOT). TVT and TVT-O/TOT seem comparable although there are differences in complications (bladder injury with TVT vs. leg pain with TVT-O/TOT). Recently single incision approaches have been introduced whereby the vaginal tape is inserted via a single vaginal incision. Based on current evidence, single incision slings are not recommended. Individual clinicians should decide which to use based on expertise and experience, nevertheless, bladder injuries are probably less of an issue than leg pain.
[Show abstract][Hide abstract] ABSTRACT: Objective
In this article, we try to discuss risk factors and diagnostic difficulties for uterine rupture.
Case series of 12 cases of uterine rupture observed in the Norfolk and Norwich University Hospital in the UK, with an average yearly birth rate of 6,000 deliveries, over a 6-year period.
In the present case series, there was no maternal mortality, and uterine rupture was a rare occurrence (12 in 36,000 births). Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity, and the need for prompt cesarean delivery and uterine repair or hysterectomy. The risk factors for rupture include previous cesarean sections, multiparity, malpresentation and obstructed labor, uterine anomalies, and use of prostaglandins for induction of labor. Previous cesarean section is, however, the most commonly associated risk factor. The most consistent early indicator of uterine rupture is the onset of a prolonged, persistent, and profound fetal bradycardia.
In this case series, we suggest that the signs and symptoms of uterine rupture are typically nonspecific, which makes diagnosis difficult. Delay in definitive therapy causes significant fetal morbidity. The inconsistent signs and the short time in prompting definitive treatment of uterine rupture make it a challenging event. For the best outcome, vaginal birth after previous cesarean section needs to be looked after in an appropriately staffed and equipped unit for an immediate cesarean delivery and advanced neonatal support.
Journal of Obstetrics and Gynecology of India 12/2013; 62(6). DOI:10.1007/s13224-012-0328-4
[Show abstract][Hide abstract] ABSTRACT: Background/Aims. Aim of the study was to establish an effect of obesity on the incidence of bladder injury or urinary retention following tension-free vaginal tape (TVT) procedure. Methods. This was a retrospective cohort study based at the Norfolk and Norwich University Hospital in the UK. Study population included 342 cases of TVT procedures. Incidence of bladder injury was 4.7% (16/342). Rate of urinary retention was 9% (31/342). Body mass index (BMI), age, type of analgesia, concomitant prolapse repair, and previous surgery were factors studied. Univariate analysis was performed to establish a relationship between BMI and complications, followed by a multivariable regression analysis to adjust for age, concomitant surgery, type of analgesia, and previous surgery. Results. Neither univariate analysis nor multivariate regression analysis revealed any statistically significant influence of obesity on the incidence of bladder injury or urinary retention. Unadjusted odds ratios and adjusted odds ratios for bladder injury and urinary retention by BMI groups were OR 1.7296 CI 0.4818-6.2097; OR 1.3745 CI 0.5718-3.3043 and adj. OR 2.885 CI 0.603-13.8; adj. OR 1.299 CI 0.502-3.365. Conclusion. Obesity does not appear to influence the rate of bladder injury or urinary retention following TVT procedure.
Obstetrics and Gynecology International 06/2011; 2011:746393. DOI:10.1155/2011/746393
[Show abstract][Hide abstract] ABSTRACT: To analyse the significance of risk factors and the possibility of prediction of shoulder dystocia.
This was a retrospective cohort study. There were 9,767 vaginal deliveries at 37 and more weeks of gestation analysed during 2005-2007. Studied population included 234 deliveries complicated by shoulder dystocia. Shoulder dystocia was defined as a delivery that required additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. First, a univariate analysis was done to identify the factors that had a significant association with shoulder dystocia. Parity, age, gestation, induction of labour, epidural analgesia, birth weight, duration of second stage of labour and mode of delivery were studied factors. All factors were then combined in a multivariate logistic regression analysis. Adjusted odds ratios (Adj. OR) with 95% confidence intervals (CI) were calculated.
The incidence of shoulder dystocia was 2.4% (234/9,767). Only mode of delivery and birth weight were independent risk factors for shoulder dystocia. Parity, age, gestation, induction of labour, epidural analgesia and duration of second stage of labour were not independent risk factors. Ventouse delivery increases the risk of shoulder dystocia almost 3 times, forceps delivery comparing to the ventouse delivery increases risk almost 3.4 times. Risk of shoulder dystocia is minimal with the birth weight of 3,000 g or less.
It is difficult to foretell the exact birth weight and the mode of delivery, therefore occurrence of shoulder dystocia is highly unpredictable. Regular drills for shoulder dystocia and awareness of increased incidence with instrumental deliveries are important to reduce fetal and maternal morbidity and mortality.
Archives of Gynecology 06/2011; 285(2):291-5. DOI:10.1007/s00404-011-1953-3 · 1.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This is a retrospective cohort study to establish the effect of induction of labour (IOL) on the mode of delivery for term pregnancy. Studied population included 11,660 deliveries and out of these, 8,314 were normal vaginal deliveries; 1,775 instrumental deliveries and 1,571 emergency caesarean sections. The frequency of IOL was 23.6%. A univariate analysis was carried out to establish a relationship between IOL and mode of delivery. The multivariable regression analysis was carried out to adjust this relationship for parity, age, gestational age, epidural analgesia and birth weight. IOL at term lowered the risk of instrumental delivery (p=0.009) and had no influence on the rate of caesarean section (p=0.861). Hence, the study demonstrates that women in whom induction is decided upon, the instrumental delivery and caesarean section rate is not any higher than in the group where a spontaneous labour is awaited.
Journal of Obstetrics and Gynaecology 05/2011; 31(4):304-6. DOI:10.3109/01443615.2011.561890 · 0.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This case report refers to a 17-year-old woman who was admitted to a gynaecological ward with severe lower abdominal pain.
She underwent an explorative laparotomy, which revealed a large mass arising from the appendix. Her uterus, ovaries and tubes
were found to be normal. Appendicectomy and omental biopsy was performed. Histology revealed a mesenteric fibromatosis–desmoid
Gynecological Surgery 01/2011; 8(2):235-238. DOI:10.1007/s10397-009-0467-5
[Show abstract][Hide abstract] ABSTRACT: This case report refers to a 32-year-old primiparous woman with a mild asthma, who had a normal vaginal delivery in a birthing pool and developed an acute postpartum chest pain due to pneumomediastinum and subcutaneous chest emphysema. After 72 hours of observation, she was discharged home without any residual symptoms.
Obstetrics and Gynecology International 12/2010; 2010:956142. DOI:10.1155/2010/956142
[Show abstract][Hide abstract] ABSTRACT: To analyse the significance of risk factors and the role of episiotomy in preventing obstetric anal sphincter injury at vaginal delivery.
This is a retrospective cross-sectional study in the Norfolk and Norwich University Hospital in the UK. All caesarean sections and non-vertex presentations were excluded, which resulted in a study population of 10,314 deliveries. Obstetric anal sphincter injury (OASI) was defined as third or fourth degree tears to the anal sphincter muscles, with or without a tear involving the anal mucosa. First a univariate analysis was done to identify factors that had a significant association with OASI. Factors included parity, age, gestation, labour induction method, duration of second stage, use of epidural analgesia, episiotomy, method of delivery, time and month of delivery, and birth weight. All factors were then combined in a multivariate logistic regression analysis. The multivariate analysis was then repeated including only factors that had a significant association with OASI in the univariate analysis. Adjusted odds ratios with 95% confidence intervals (CI) were calculated.
The frequency of anal sphincter lacerations was 3.2%. There were statistically significant associations between an increased incidence of OASI and parity, birth weight, method of delivery and shoulder dystocia. Women giving birth without a mediolateral episiotomy were 1.4 times more likely to experience OASI (95% CI 1.021-1.983). Interestingly, the incidence of OASI has risen between 2005 and 2007.
Parity, age, birth weight, method of delivery and shoulder dystocia are strongly associated with obstetric anal sphincter injury. Mediolateral episiotomy appears to be protective against OASI but a randomised controlled trial would be needed to confirm this. The rising incidence of OASI after normal vaginal deliveries may be related to adoption of the hands off technique or increased identification of tears.
European journal of obstetrics, gynecology, and reproductive biology 03/2010; 150(2):142-6. DOI:10.1016/j.ejogrb.2010.03.002 · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare the failure rate (pregnancies) of a Pomeroy procedure and Filshie clips tubal occlusion at the time of Caesarean section.
This is a retrospective observational study done in a district general hospital in the UK. There were 290 sterilisations performed at the time of Caesarean section over the period of 1994-2007. Studied population included 203 Pomeroy procedures and 87 Filshie clips applications. Follow-up period ranged from 2 to 15 years. A birth register and an operating theatre database were used to identify patients who underwent Caesarean section with a tubal occlusion. These patients' names were checked against the antenatal booking database, the early pregnancy assessment unit database, the operating theatre database in case of ectopic pregnancies, and a termination of pregnancy database to recognise failed sterilisation.
There was no failure of tubal occlusion with a Pomeroy procedure (0/203). The failure rate of Filshie clips tubal occlusion was 1.15% (1/87) (p = 0.3). The length of the follow-up period ranged from 2 to 15 years (for Pomeroy procedure, median was 9 years and inter-quartile range (IQR) was 7; for Filshie clip, median was 8 years and IQR was 7).
Pomeroy technique appears to carry a lower risk of a failed sterilisation than Filshie clips tubal occlusion at the time of Caesarean section. However, Pomeroy procedure needs to be balanced against the speed and simplicity of Filshie clips tubal occlusion.
Archives of Gynecology 12/2009; 281(6):1073-5. DOI:10.1007/s00404-009-1314-7 · 1.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This case report refers to a 26-year-old woman who attended a gynaecological clinic with a painful vulval swelling. She underwent surgical excision, was found to have a rare vulval low-flow arteriovenous malformation and was treated with embolisation therapy.
Archives of Gynecology 01/2009; 280(2):271-3. DOI:10.1007/s00404-008-0875-1 · 1.28 Impact Factor