Sambit Mukhopadhyay

Could a mediolateral episiotomy prevent obstetric anal sphincter injury

OBJECTIVEnTo analyse the significance of risk factors and the role of episiotomy in preventing obstetric anal sphincter injury at vaginal delivery.nnnSTUDY DESIGNnThis 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.nnnRESULTSnThe 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.nnnCONCLUSIONnParity, 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.

Pelvic organ prolapse: review of the aetiology, presentation, diagnosis and management.

Pelvic organ prolapse is a common condition affecting a large number of women. Incidence increases after the menopause. Age, parity and obesity are the most consistently reported risk factors. Many women can be asymptomatic of prolapse but common symptoms include a sensation of a bulge or fullness in the vagina or urinary, bowel or sexual dysfunction. Management depends upon symptoms and the type and grade of the prolapse as well as any associated medical co-morbidities. Management options include expectant, conservative or surgical approaches. Up to 10% of women having a surgical procedure for prolapse will require a second procedure. It is, therefore, important to consider lifestyle modifications such as weight loss and conservative measures including pelvic floor muscle training, topical estrogens and pessaries as initial management options.

Can we predict shoulder dystocia

PurposeTo analyse the significance of risk factors and the possibility of prediction of shoulder dystocia.MethodsThis 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.ResultsThe 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 3,000xa0g or less.ConclusionIt 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.

Rupture of rudimentary uterine horn pregnancy at 37 weeks gestation with fetal survival

Pregnancy in rudimentary uterine horn is rare and associated with maternal and fetal mortality and morbidity. This patient presented with unexplained abdominal pain antenataly. Laparotomy for suspected abruption at 37xa0weeks revealed ruptured rudimentary horn with placenta accreta. A subtotal hemihysterectomy was performed. The result was fetal salvage in good condition.

A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice.

ObjectiveIn this article, we try to discuss risk factors and diagnostic difficulties for uterine rupture.MethodsCase 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.ResultsIn 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.ConclusionIn 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.

Obesity and the Incidence of Bladder Injury and Urinary Retention Following Tension-Free Vaginal Tape Procedure: Retrospective Cohort Study

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.

Induction of labour and the mode of delivery at term

Summary 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.

Early safety and efficacy outcomes of a novel technique of sacrocolpopexy for the treatment of apical prolapse

To assess the safety and efficacy of a modified technique of bilateral abdominal sacrocolpopexy in which both uterosacral ligaments are replaced with polyvinylidene fluoride mesh to provide support to the cervix (cervico‐sacropexy [CESA]) or vaginal vault (vagino‐sacropexy [VASA]).

Mesh for prolapse surgery: Why the fuss?

Pelvic organ prolapse is a common gynaecological problem. Surgical techniques to repair prolapse have been constantly evolving to reduce the recurrence of prolapse and need for reoperation. Grafts made of synthetic and biological materials became popular in the last decade as they were intended to provide extra support to native tissue repairs. However, serious complications related to use of synthetic meshes have been reported and there is increasing medico-legal concern about mesh use in prolapse surgery. Some mesh products already have been withdrawn from the market and the FDA has introduced stricter surveillance of new and existing products. Large randomized studies comparing mesh with non-mesh procedures are lacking which creates uncertainty for the surgeon and their patients. The small cohorts of the RCTs available with short follow-up periods just allow the conclusion that the mesh repair can be helpful in the short to medium term but unfortunately are not able to prove safety for all patients. In particular, current clinical reports cannot define for which indication what material may be superior compared to non-mesh repair. Quality control through long-term individual and national mesh registries is needed to keep a record of all surgeons using mesh and all devices being used, monitoring their effectiveness and safety data. Meshes with better biocompatibility designed specifically for use in vaginal surgery may provide superior clinical results, where the reduction of complications may allow a wider range of indications.

Trends in prolapse surgery in England

Introduction and hypothesisWomen have a lifetime risk of undergoing pelvic organ prolapse (POP) surgery of 11–19%. Traditional native tissue repairs are associated with reoperation rates of approximately 11% after 20xa0years. Surgery with mesh augmentation was introduced to improve anatomic outcomes. However, the use of synthetic meshes in urogynaecological procedures has been scrutinised by the US Food and Drug Administration (FDA) and by the European Commission (SCENIHR). We aimed to review trends in pelvic organ prolapse (POP) surgery in England.MethodsData were collected from the national hospital episode statistics database. Procedure and interventions-4 character tables were used to quantify POP operations. Annual reports from 2005 to 2016 were considered.ResultsThe total number of POP procedures increased from 2005, reaching a peak in 2014 (Nu2009=u200929,228). With regard to vaginal prolapse, native tissue repairs represented more than 90% of the procedures, whereas surgical meshes were considered in a few selected cases. The number of sacrospinous ligament fixations (SSLFs) grew more than 3 times over the years, whereas sacrocolpopexy remained stable. To treat vault prolapse, transvaginal surgical meshes have been progressively abandoned. We also noted a steady increase in uterine-sparing, and obliterative procedures.ConclusionsFollowing FDA and SCENIHR warnings, a positive trend for meshes has only been seen in uterine-sparing surgery. Native tissue repairs constitute the vast majority of POP operations. SSLFs have been increasingly performed to achieve apical support. Urogynaecologists’ training should take into account shifts in surgical practice.