Elisabeth J. Adams

Differences in episiotomy technique between midwives and doctors

Objectives To examine the practice of making an episiotomy and to determine any differences in practice between professional groups.

How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial.

Objective  To compare two surgical techniques and two types of suture material for anal sphincter repair after childbirth‐related injury.

Risk scoring system for prediction of obstetric anal sphincter injury

Objective  The objective was to begin the process of developing an antenatal risk scoring system, as a first step towards examining whether elective Caesarean section for women at high risk of injury could be an effective and acceptable intervention.

Factors predictive of post-TVT voiding dysfunction.

In this study we assessed the incidence of voiding dysfunction in women 6 months after undergoing a tension-free vaginal tape (TVT) procedure. Logistic regression was then used to look for significantly associated factors from a range of patient, urodynamic and surgical variables. From a group of 267 women we identified 22 (8%) who needed to perform daily intermittent self-catheterisation (ISC) as a result of the TVT surgery. When potential predictive factors were examined individually there were three that appeared to be associated with the need to use ISC: menopausal status,previous incontinence surgery and the centile score for average voiding flow rate (as derived from a volume--flow rate nomogram). Following multivariate logistic regression this flow rate centile score showed the strongest association with post-TVT voiding dysfunction, the likelihood of needing ISC increasing as the centile score fell. This factor has not previously been described but is readily assessed pre-operatively and may be useful in case selection for TVT.

Antenatal screening for postpartum urinary incontinence in nulliparous women: a pilot study

UNLABELLED Antenatal screening for postpartum urinary incontinence in nulliparous women: a pilot study. OBJECTIVE To examine the utility of joint mobility scoring (JMS) as a screening test for postpartum urinary incontinence. STUDY DESIGN A prospective cohort study in a teaching hospital involving 150 nulliparous women. JMS was calculated. The incidence of incontinence and pad use was recorded. Univariate and multiple logistic regression analyses were used to identify factors independently associated with incontinence. RESULTS Hundred and three women completed the study. 43.7% of subjects were incontinent antenatally and 4.9% remained incontinent at the study end. JMS was normally distributed and similar in continent and incontinent women. Elbow hyperextension (>180 degrees ) was associated with postnatal incontinence (odds ratio 10.6; 95% CI 1.24, 90.8). Elbow hyperextension had a sensitivity of 80%, specificity of 75%, positive predictive value of 14%, and negative predictive value of 99% for postnatal incontinence. CONCLUSION Joint hypermobility score is not a useful screening test. Elbow hyperextension is associated with an increased likelihood of postnatal urinary incontinence. It is unclear whether this test has clinical utility outside a research setting.

A urinary control device for management of female stress incontinence.

Objective To examine the performance of a silicon urinary control device for nonsurgical management of women with genuine stress incontinence. Methods A 3-month prospective study involved 41 women with genuine stress incontinence. They completed urinary diaries of voiding, incontinence, and severity of incontinence on a 4-point scale over a week. Subjects were taught how to apply the device and used it as required from the second week. Visual analogue scales were used to record aspects of use (such as acceptability, comfort, and ease of application), and 2-hour perineal pad tests were completed at recruitment, after 2 weeks, and after 3 months. Data were compared by Mann-Whitney U test, or Wilcoxon test. Results Ten women (24.4%) declined to participate and six (14.6%) withdrew before 2 weeks. Ten (24.4%) failed to attend for 2-week follow-up and 11 (26.8%) did not continue for 3 months. Two (4.9%) did not attend 3-month follow-up. Only two women (4.9%) completed the study. There was no difference in pad test results or in results from voiding diaries. Conclusion The urinary incontinence device had low acceptability and was ineffective, and we cannot recommend it for nonsurgical management of genuine stress incontinence.

Retrievable inferior vena cava filter for thrombolic disease in pregnancy

Sir, We read the case-report of Neill et al. (Vol 104, December 1997)’ with interest, having recently been involved in a similar case, where an inferior vena cava filter was used in a 20 year old woman at 25 weeks gestation in her first pregnancy. Our patient presented with pain and discolouration of her left leg. Doppler ultrasound confirmed a left ilio-femoral thrombosis, with extensive fresh unstable clot in the distal iliac vein, while the inferior vena cava (IVC) was patent. In view of her high risk of pulmonary embolism, a Gunther tulip vena cava filter (William Cook Europe, Bjaeversikov, Denmark) was inserted, using a standard technique via the right internal jugular vein under low-dose pulsed fluoroscopic imaging. The filter was placed with its upper end below the right renal vein, rather than in the suprarenal position recommended by Neill et ul. I because of the potential risk of renal vein thrombosis. The Gunther tulip filter was selected in our patient because of the possibility of retrieval for up to 10 days after insertion. Unfortunately, extensive thrombus was still present in the left ilio-femoral vein after nine days, despite full heparin anticoagulation. In view of this, a decision was taken to leave the filter in situ. The patient continued her pregnancy with heparin anticoagulation until 37 weeks gestation, when labour was induced and she had a normal delivery of a live infant. She was anticoagulated with warfarin for three months after delivery. Subsequent thrombophilia investigations demonstrated the presence of a Leiden V mutation. We are concerned about the likely long term effects of a permanent IVC filter in such a young woman. We carried out a review of the literature, and came across several disturbing reports of complications resulting from migration of all or part of the filter, including intra-cardiac migration2. We feel that the use of the term ‘retrievable’ is somewhat misleading when applied to these devices In pregnancy, unless the thrombo-embolic event occurs in a patient after fetal lung maturity has been achieved, it is likely that the filter will need to remain in situ for longer than 10 days, in order to reduce the risk of embolism in the remainder of the pregnancy and the postnatal period. It is unclear from the literature whether the presence of the filter itself is an indication for long-term anticoagulant treatment, although one report suggested that there was no benefit from anticoagulation after placement of the filtes. We agree with Neill et al. that follow up of young patients with IVC filters is necessary to identify the long-term risks of these devices Inferior vena cava filters will continue to have a role in patients at high risk of pulmonary embolism and those who have heparin hypersensitivity; however, we would caution against their widespread use in young women until more is known about their long term complications.

Oxybutynin for detrusor instability with adjuvant salivary stimulant pastilles to improve compliance: results of a multicentre, randomized controlled trial

Objective To test the hypothesis that compliance with oxybutynin would be improved if the severity of dry mouth could be reduced, thus leading to improved urinary symptom response and improved outcome, in a randomized, controlled trial of oxybutynin with or without salivary stimulant pastilles in patients with detrusor instability.

Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound

Objective  To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter.