Some important questions in obstetrics and gynecology

Some important questions in obstetrics and gynecology

1. Some important
questions in obstetrics
and gynecology
Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR

2. 1. Is myomectomy during
cesarean section
recommended?
ABOUBAKR ELNASHAR

3. 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.

ABOUBAKR ELNASHAR

4. 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)

ABOUBAKR ELNASHAR

5. 2. How to manage an
infertile women >35 yrs?
ABOUBAKR ELNASHAR

6. Allow 6 m
Investigations
ORT
TSH
letrozole


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7. 3. How to manage infertile
female her husband staying
2to 3 m every year?
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8. Timing cycle
Stimulate ovulation
IUI
Keep Semen and IUI

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9. 4. How to manage infertile
woman with failed 2 or
more IVF?

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


ABOUBAKR ELNASHAR

11. 5. How to decrease the
horrible increasing rate
in C.S?

ABOUBAKR ELNASHAR

12. 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)
ABOUBAKR ELNASHAR

13. 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
ABOUBAKR ELNASHAR

14. 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

15. 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

16. 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

17. 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}.

ABOUBAKR ELNASHAR

18. 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


ABOUBAKR ELNASHAR

19. 6. How to manage
PROM at 20-26 w?

ABOUBAKR ELNASHAR

20. 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
ABOUBAKR ELNASHAR

21. 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
ABOUBAKR ELNASHAR

22. 7. How to
management IUFD at
2 or 3
rd
T with
previous 2 CS



ABOUBAKR ELNASHAR

23. ABOUBAKR ELNASHAR

24. 8. What are indications of
Circulage in normal cervix
after repeated abortion in
1
st
and 2
nd
trimester?


ABOUBAKR ELNASHAR

25. 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


ABOUBAKR ELNASHAR

26. 9. What is evidence
based ligation of
varicocele in male
infertility
ABOUBAKR ELNASHAR

27. Varicoceles
No varicocelectomy.
{does not improve pregnancy rates}
NICE2013

ABOUBAKR ELNASHAR

28. 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

29. 10. How to closure C.S
one or 2 layers?
pretioneal closure or not?


ABOUBAKR ELNASHAR

30. 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
(unless2 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
ABOUBAKR ELNASHAR

31. 11. Place of internal
int.iliac ligation in
pp.hge?

ABOUBAKR ELNASHAR

32. 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


ABOUBAKR ELNASHAR

33. 12. How to mange a pregnant
patient exposed to Rubella
virus?
ABOUBAKR ELNASHAR

34. ACOG Education and Technical Bulletins 2002 SOGC 2008
Management of exposed pregnant women
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35. ACOG Education and Technical Bulletins 2002 SOGC 2008
Management of exposed pregnant women
ABOUBAKR ELNASHAR

36. 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

37. 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.
ABOUBAKR ELNASHAR

38. ABOUBAKR ELNASHAR