Some important

questions in obstetrics

and gynecology

Aboubakr Elnashar

Benha University Hospital, Egypt

ABOUBAKR ELNASHAR

1. Is myomectomy during

cesarean section

recommended?

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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.

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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)

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2. How to manage an

infertile women >35 yrs?

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Allow 6 m

Investigations

ORT

TSH

letrozole

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3. How to manage infertile

female her husband staying

2to 3 m every year?

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Timing cycle

Stimulate ovulation

IUI

Keep Semen and IUI

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4. How to manage infertile

woman with failed 2 or

more IVF?

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RCT: beneficial blastocyst transfer, assisted hatching, salpingectomy for tubal disease, hysteroscopy procedures Endometrial injury IU administration of autologous PBMC

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5. How to decrease the

horrible increasing rate

in C.S?

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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)

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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

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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}.

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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

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6. How to manage

PROM at 20-26 w?

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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

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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

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7. How to

management IUFD at

2 or 3rd T with

previous 2 CS

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8. What are indications of

Circulage in normal cervix

after repeated abortion in

1st and 2nd trimester?

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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

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9. What is evidence

based ligation of

varicocele in male

infertility

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Varicoceles No varicocelectomy. {does not improve pregnancy rates}

NICE2013

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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

10. How to closure C.S

one or 2 layers?

pretioneal closure or not?

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

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11. Place of internal

int.iliac ligation in

pp.hge?

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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

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12. How to mange a pregnant

patient exposed to Rubella

virus?

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ACOG Education and Technical Bulletins 2002 SOGC 2008

Management of exposed pregnant women

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ACOG Education and Technical Bulletins 2002 SOGC 2008

Management of exposed pregnant women

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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.

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