Uterul Se Sectioneaza Cu Bisturiul Rece

- Uterul se sectioneaza cu bisturiul rece, nu cu electrocauterul; pot fi punctul de plecare pt necroza aseptica
- Sutura peretelui uterin (miometru) se face in paralel cu ”extractia” fibromului

- Proba permeabilitatii tubare- ofera informatii despre stricturi/perforatii ale trompei, coloreaza endometrul, asa ca e mai usor de reperat
intraoperator
A 23-year-old woman attends her antenatal booking appointment. She thinks that she is 10 weeks pregnant. This is her first pregnancy. Which one of
the following is not routinely performed?
Assess body mass index2%Pelvic examination46%Urine culture if dipstick urine normal30%Check for red cell alloantibodies13%Hepatitis B
testing9%
NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
 10 antenatal visits in the first pregnancy if uncomplicated

 7 antenatal visits in subsequent pregnancies if uncomplicated
 women do not need to be seen by a consultant if the pregnancy is uncomplicated
Gestation Purpose of visit

8 - 12 weeks (ideally < 10 Booking visit
weeks)
 general information e.g. diet, alcohol, smoking, folic acid, vitamin D,

antenatal classes
 BP, urine dipstick, check BMI
Booking bloods/urine
Gestation Purpose of visit
 FBC, blood group, rhesus status, red cell alloantibodies,

haemoglobinopathies
 hepatitis B, syphilis
 HIV test is offered to all women
 urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy

11 - 13+6 weeks Down's syndrome screening including nuchal scan
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
16 weeks
Routine care: BP and urine dipstick
18 - 20+6 weeks Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl
28 weeks
consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) Routine care as above
Routine care as above
34 weeks Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, 'baby-blues'
38 weeks Routine care as above
40 weeks (only if primip)
Discussion about options for prolonged pregnancy
41 weeks
Discuss labour plans and possibility of induction
*the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For
this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors'
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors
 advancing age
 previous pregnancy and childbirth
 high body mass index
 hysterectomy
 family history
Classification
 overactive bladder (OAB)/urge incontinence

o due to detrusor overactivity
o the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
 stress incontinence: leaking small amounts when coughing or laughing
 mixed incontinence: both urge and stress
 overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
 functional incontinence
o comorbid physical conditions impair the patient’s ability to get to a bathroom in time
o causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
Initial investigation
 bladder diaries should be completed for a minimum of 3 days

 vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
 urine dipstick and culture
 urodynamic studies
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
 bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
 bladder stabilising drugs: antimuscarinics are first-line
o NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
o Immediate release oxybutynin should, however, be avoided in 'frail older women'
 mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
 pelvic floor muscle training

o NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
 surgical procedures: e.g. retropubic mid-urethral tape procedures
 duloxetine may be offered to women if they decline surgical procedures
o a combined noradrenaline and serotonin reuptake inhibitor
o mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased
stimulation of urethral striated muscles within the sphincter → enhanced
contraction

Uterul Se Sectioneaza Cu Bisturiul Rece

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- Uterul se sectioneaza cu bisturiul rece, nu cu electrocauterul; pot fi punctul de plecare pt necroza aseptica

- Sutura peretelui uterin (miometru) se face in paralel cu ”extractia” fibromului

 10 antenatal visits in the first pregnancy if uncomplicated

Gestation Purpose of visit

 general information e.g. diet, alcohol, smoking, folic acid, vitamin D,

 FBC, blood group, rhesus status, red cell alloantibodies,

10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy

 overactive bladder (OAB)/urge incontinence

 bladder diaries should be completed for a minimum of 3 days

If stress incontinence is predominant:

 pelvic floor muscle training

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