Wai Yoong

Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage

Objectives  To identify women undergoing peripartum hysterectomy in the UK and to describe the causes, management and outcome of the associated haemorrhage.

Application of uterine compression suture in association with intrauterine balloon tamponade ('uterine sandwich') for postpartum hemorrhage.

We evaluated in a prospective observational study the use of a ‘uterine sandwich’ technique (uterine compression sutures in association with intrauterine tamponade) in women who had had unsuccessful medical treatment for postpartum hemorrhage. Ten of the 11 patients had cesarean sections (complicated by placenta previa and uterine atony) and one had a normal delivery. The median estimated blood loss and units of blood transfused were 1500ml (range 750–4000ml) and two units (range 0–9), respectively. B‐Lynch sutures were placed in two patients and Haymans modification was used in nine. Bakri balloon tamponade was in place for a median of 22hours (range 17–27hours), while the median volume infused in the balloon was 300ml (range 150–350ml). The combined technique was successful in avoiding hysterectomy in all cases, and there was no documented postpartum morbidity. This is a simple and quick surgical technique that can be used to treat atonic postpartum hemorrhage, particularly in conjunction with placenta previa.

Clitoral inclusion cyst: a complication of type I female genital mutilation

Magati F. and Spreafico L. (2001) Tension free vaginal tape: analysis of outcomes and complications in 404 stress incontinent women. International Urogynaecology Journal of Pelvic Floor Dysfunction, 12, S24. Olsson I. and Droon U.B. (1999) A three year postoperative evaluation of the tension-free vaginal tape. Gynecologic and Obstetric Investigation, 48, 267 – 269. Peschers U.M., Tunn R., Buczkowski M. and Perucchin D. (2000) Tension free vaginal tape for the treatment of stress urinary incontinence. Clinical Obstetrics and Gynaecology, 43, 670 – 675. Volkmer B.G., Nesslauer T., Rinnab L., Schradin T., Hautmann R.E. and Gottfried H.W. (2003) Surgical interventions for complications of the tension free vaginal tape procedure. Journal of Urology, 169, 570 – 574.

Tibial nerve stimulation for overactive bladder syndrome unresponsive to medical therapy

Overactive bladder syndrome is defined as a symptom syndrome which includes urinary urgency, with or without urge incontinence, usually accompanied by frequency (>8 micturations/24 h) and nocturia. Conservative treatment usually comprises behavioural techniques, bladder retraining, pelvic floor re-education and pharmacotherapy but up to 30% of patients will remain refractory to treatment. Although second-line treatment options such as sacral nerve stimulation and intravesical botulinum A injections are valuable additions to the therapeutic arsenal, they are relatively invasive and can have serious side-effects. Inhibition of detrusor activity by peripheral neuromodulation of the posterior tibial nerve was first described in 1983, with recent authors further confirming a 60–80% positive response rate. This review was undertaken to examine published literature on percutaneous tibial nerve stimulation and to discuss outcome measures, maintenance therapy and prognostic factors of this technique.

Female genital mutilation/cutting: knowledge, attitude and training of health professionals in inner city London.

OBJECTIVES To assess the knowledge, attitude and training on female genital mutilation/cutting (FGM/C) amongst medical and midwifery professionals working in an area of high prevalence of the condition. STUDY DESIGN Prospective observational study using a questionnaire designed to assess knowledge, attitude and training received by health care professionals on the practice of FGM/C. Factors which may affect knowledge, attitude and training were compared between groups. RESULTS 92.9% (n=79) questionnaires were returned. All respondents were aware of FGM/C but only 27.8% correctly identified the grade from a simple diagram. Three quarters (72.4% and 77.2% respectively) were aware of the complications of FGM/C and of the legislation in the United Kingdom. Of the respondents, 13.9% agreed that a competent adult should be allowed to consent to FGM/C if requested but only 8.9% agreed that the procedure should be medicalised to reduce the associated morbidity. Less than 25% of respondents had received formal training in recognising or managing this condition. CONCLUSION Although the majority of respondents were aware of FGM/C, their ability to identify the condition and its associated morbidity remain suboptimal; more training is recommended in larger cities with a higher prevalence of this condition.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PurposeTo systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.MethodsSystematic literature search of Medline from years 1946–2012 using terms: “stem”, “cell”, “stress”, “urinary”, and “incontinence”. Included studies presented empirical data on the treatment of SUI using SCT. Outcomes: adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.ResultsEight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2–12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.ConclusionData suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Uterine necrosis following application of combined uterine compression suture with intrauterine balloon tamponade.

Techniques such as uterine compression sutures and intrauterine balloon tamponade have been described individually as uterine preserving treatments for postpartum haemorrhage (PPH), and these two surgical strategies can be further combined to apply tension synergistically to both surfaces of the myometrium when the single technique was not able to control PPH. Th e successful applications of the ‘ uterine sandwich ’ using uterine compression sutures in conjunction with Bakri balloon tamponade have been described in a case series of fi ve women in late pregnancy with persistent uterine atony (Nelson and O ’ Brien 2007) and in two case reports of massive haemorrhage (Danso and Reginald 2002; Price et al. 2006). More recently, Yoong and colleagues (2011) reported a series using Hayman suture combined with Bakri balloon tamponade to control PPH in 11 patients with uterine atony and placenta praevia. Up to now, no complications have been described in the literature following the ‘ uterine sandwich ’ technique. We would like to share a lesson learnt from a case of uterine necrosis, which occurred following the insertion of a B-Lynch compression suture and intrauterine balloon tamponade.

Myasthenia gravis and pregnancy

Summary Myasthenia gravis (MG) is a chronic autoimmune disorder of neuromuscular transmission characterized by varying degrees of weakness and easy fatigability of the skeletal muscles. Precipitants of myasthenic symptoms or crises include physical and emotional stress, systemic illness, infections, hypo or hyperthyroidism, pregnancy, any type of surgery with general anaesthesia as well as corticosteroids. The authors report two cases of MG in pregnancy and discuss briefly the various aspects of the disease course and management in pregnancy. As MG occurs predominantly in women of reproductive years, it is important that obstetricians are aware of this condition and its management in pregnancy.

Posterior colpotomy-a retrieval route for solid ovarian tumours.

Sir, We read with interest the article by Ghezzi et al.1 on the use of the transumbilical port for removal of gynaecological specimens following laparoscopic excision. While this technique may be relatively uncomplicated for simple cystic structures, which can be decompressed, solid ovarian tumours may prove more challenging and certainly, morcellation within the Endo Catch (Tyco Healthcare Group LP, Norwalk, CA,

The relationship of ethnicity, maternal height and shoe size, and method of delivery

In a bid to determine the relationship of ethnicity, maternal height and shoe size as predictors of cephalopelvic disproportion, we conducted a prospective comparative study of primigravidas at term with singleton pregnancies, who had undergone spontaneous labour. A total of 208 primigravidas were studied; 151 (62.9%) achieved vaginal delivery and 57 (37.1%) had emergency caesarean section for failure-to-progress. We found a statistically significant positive correlation between maternal height and vaginal delivery (p = 0.04), but no correlation with maternal shoe size was found (p = 0.24). This study also showed that Caucasian women were significantly more than twice as likely to achieve vaginal delivery compared with Africans (p = 0.02). Maternal height of at least 162.5 cm, has a sensitivity of 74% and a specificity of 43% for predicting vaginal delivery. We concluded that the most predictive anthropometric measurement for vaginal delivery is maternal height.