Primary Horizontal version
Techniques in the management of
postpartum haemorrhage
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– balloon tamponade and the brace suture
There is no clear evidence how long the balloon tamponade should be left in place. In most cases, 4 – 6 hours of tamponade should be adequate to achieve haemostasis and ideally, it should be removed during day time hours, in the presence of appropriate senior staff, should further intervention be required.
Background
Dr Jason Lim Registrar Dept of Obstetrics & Gynaecology
Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage which remains as one of the major causes of maternal death in both developed and developing countries. In the 2003 – 2005 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the third highest direct cause of maternal death (6.6 deaths/million maternities). These reports review all the maternal deaths in the UK over a three-year period or triennium. They are a useful resource for obstetricians in Singapore as the level of obstetric care in the UK is very similar to that of Singapore. In the 2003-2005 report, the majority of maternal deaths due to haemorrhage were considered preventable, with 10 out of 17 (58%) cases in the 2003 – 2005 triennium judged to have received ‘major substandard care’. Haemorrhage also emerges as the major cause of severe maternal morbidity in almost all ‘near miss’ audits in both developed and developing countries. Because of its importance as a leading cause of maternal mortality and moridity, effective management of obstetric haemorrhage especially postpartum haemorrhage must be considered a priority in the training of all obstetricians.
Management of Postpartum Haemorrhage The caveat to the management of PPH lies in both resuscitation and a well-rehearsed systematic approach. Several initial measures that can be adopted include the use of oxytocics, syntometrine, misoprostol, ergometrine, carboprost and bimanual uterine compression. If pharmacological measures fail to control the haemorrhage, one can initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available: • • • • •
Below-mentioned is a suggested step-wise process of applying the 16 Fr Rusch Balloon catheter (Figure 1):
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Different Variations
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of balloon tamponade as a ‘test’, serves to affirm its place as first-line ‘surgical’ management.
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Over the past decade, various types of haemostatic compression sutures have been featured in different published case series. The best known type, described in 1997, requires hysterotomy for its insertion and is thus suitable when the uterus has already been opened at caesarean section. The procedure is named after Christopher B-Lynch, a UK obstetrician who devised this method. Observational data suggest that haemostatic suture techniques are effective in controlling severe PPH and in reducing the need for hysterectomy. The B-Lynch suture is technically easy to perform. The procedure can be completed in minutes. We often tell trainees that the procedure is akin to “applying a haversack or backpack to the body of the uterus” because this is what the uterus look like at the end of the procedure. It is our practice to iniially compress the uterus between the two hands of the surgeon to see if bleeding from the atonic uterus. This step, if successful, often predicts that the B-Lynch suture will work. The suture can then be applied with a good chance of success. Both the balloon tamponade with the Rusch balloon and B-Lynch suture have been used to good effect at SGH. They are replacing the traditional and more technically challenging procedures for atonic PPH such as internal iliac artery ligation and can be life-saving when faced with a case of massive PPH.
Pantone PMS 355C
The balloon tamponade intervention is sometimes described as the ‘tamponade test’. A ‘positive test’ (control of PPH following inflation of the balloon) indicates that laparotomy is not required, whereas a ‘negative test’ (continued PPH following inflation of the balloon) is an indication to proceed to laparotomy. The concept
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A Quarterly CME Apr - Jun 2011
Figure 2. Illustration of the B-Lynch technique
In recent years, tamponade using various types of hydrostatic balloon catheter has superseded uterine packing for control of atonic PPH. Case series have used a Foley catheter, Bakri balloon, Sengstaken-Blakemore oesophageal catheter and a condom catheter. The urological Rusch balloon has been described as preferable by virtue of larger capacity, ease of use and low costs.
Ensure all equipment ready. Ensure good adequate lighting available. Position patient in lithotomy. Prepare approximately 1 L of warmed saline or water. An assistant uses lateral retractors to expose and identify cervical os. Apply sponge artery forceps to anterior lip of cervix. Use a pair of forceps to guide the 16 Fr Rusch Balloon catheter into the uterine cavity almost reaching the uterine fundus. Insufflate approximately 500mls to 750mls of warmed saline or water into the Rusch Balloon catheter to inflate the balloon within the uterine cavity. Do NOT pump any water into the catheter’s inner small balloon. Upon inflating the balloon with approximately 500mls to 750mls water, apply 2 cord clamps at the distal end of the Rusch Balloon catheter away from the introitus to secure the water within the balloon.
MICA (P) 116/05/2011
Haemostatic Compression Sutures (B-Lynch Sutures)
Haemostatic brace suturing (such as B-Lynch compression sutures) Bilateral ligation of uterine arteries Bilateral ligation of internal iliac arteries Selective arterial embolisation by an interventional radiologist Early recourse to hysterectomy
Balloon Tamponade
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Observe for any further PPH. Insert an indwelling urinary catheter and vaginal pack to retain the Rusch balloon within the uterine cavity.
Head A/Prof Tan Hak Koon Senior Consultant Prof Charles Ng Prof Ho Tew Hong Dr Yu Su Ling A/Prof Tay Sun Kuie Dr Yong Tze Tein Dr Chua Hong Liang Dr Tan Lay Kok Dr Devendra K (Chief Editor, OGN) Dr Tan Poh Kok Consultant Dr Tan Wei Ching Dr Fong Kah Leng Dr Hemashree Rajesh Associate Consultant Dr Tan Eng Loy Dr Cindy Pang Dr Elisa Koh Registrar Dr Jason Lim Dr Renuka Devi Dr Ravichandran N
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Figure 1. Illustration of a Rusch Balloon Catheter
Senior Consultant Prof Ho Lai Yun A/Prof Daisy Chan (Advisor, OGN) Dr Lian Wee Bin Dr Selina Ho
Consultant Dr Varsha Atul Shah Dr Poon Woei Bing Registrar Dr Masitah Binte Ibrahim Dr Sridhar Arunachalam Staff Registrar Dr Imelda L. Ereno
Enuresis in children
CME Activities
Ovarian stimulation in ART Techniques in the management of
postpartum haemorrhage
• 4th Gynaecological & Early Pregnancy Ultrasound Workshop 24 Sept 2011 SGH PGMI.
– balloon tamponade and the brace suture
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Enuresis
in children
Enuresis is derived from the Greek word ‘to make water’, also known as “bedwetting”. Enuresis may be defined as involuntary wetting of the bed whilst asleep beyond an age when dryness is achieved in the vast majority. Wetting in the daytime is known as incontinence. Enuresis can be classified as primary or secondary enuresis. Primary enuresis is the commoner form (80%) where the child never achieved dryness, whereas secondary enuresis implies that the wetting occurred after the child had achieved continence for 6 months prior to the onset of symptoms. It is important to search for a pathological cause when a child presents with secondary enuresis. Children generally attain bladder control in the daytime first and later on during the night. About 85% and 98% of children attain daytime urinary control by 2.5 and 3 years respectively, whereas 48% and 78% attain similar control in the night hours. The prevalence of bedwetting is 15% at 5 years old, 10% at 7 years old and 5% by 10 years old. Up to 1% of adults are still bed-wetters! There is no racial preponderance. Enuresis is 2 – 3 times more common among males than females. Enuresis has strong familial tendency. If one parent (usually the father) is affected, there is a 40% risk of his child having enuresis. If both parents are affected, then the risk to the child increases to 77%. An autosomal dominant pattern of inheritance had been reported, with chromosomes 8, 12, 16 and 22 being implicated. The presence of positive family history can be used to advantage when counselling families, because the affected child can be reassured that there is hope of outgrowing the problem in a similar fashion as the parent. It is a commonly held belief that nocturnal enuresis represents a maturational or developmental delay in achieving bladder control. Children diagnosed with enuresis are believed to have, not only delayed maturation of bladder control, but also small functional bladder capacity. Studies showed that some bed-wetters could not reduce night-time urine production, due to relative lack of secretion of anti-diuretic hormone (ADH), also known as vasopressin.
History-taking Careful history –taking is important as part of the diagnostic process. The child’s fluid intake, daytime voiding, number of episodes of bedwetting, sleep pattern (snoring, narcolepsy, night terrors, nightmares etc), any period of dryness and dietary history must be obtained. It is not uncommon to encounter a typical history where the child had little fluid intake at school, but comes back in the evening with increased consumption of food/drink leading to increased urine output. Psycho-social impact can be the cause or more likely the result of enuresis; it is important to establish the psycho-social impact of bedwetting on the child’s self-image, since the more severely affected child will need earlier and more intensive treatment. Pathological conditions need to be kept in mind when eliciting a history, such as overactive bladder, neurogenic bladder, cystitis, constipation, urethral obstruction in a male child, seizures, persistent wetting from an ectopic ureter(s), diabetes mellitus and diabetes insipidus.
Dr Sridhar Arunachalam Registrar Department of Neonatal & Developmental Medicine
Physical Examination The examination of an enuretic child is often unremarkable. Nonetheless, detailed examination is required to exclude organic causes. Generally the examination should include the child’s blood pressure, genital inspection to rule out labial adhesions, palpation of kidneys/ bladder, neurological examination of the lower limbs and spinal examination to rule out spinal dysraphism. The anal wink reflex is elicited to evaluate the spinal arc at S2,3,4.
Investigations Urine analysis and culture may be used to screen for urinary infections. Urine sugar and specific gravity help to screen for diabetes mellitus and diabetes insipidus respectively. Imaging modalities including ultrasound of kidneys/ bladder may be required to assess for residual urine following incomplete voiding (residual urine is regarded as significant if more than 5mls). Trabeculation of the bladder may be seen in obstructed and neurogenic bladders. Micturating cysto-urethrogram may be indicated if there is significant post-voiding residual urine or trabeculation. Urodynamic studies are performed in children with neurogenic bladder. MRI is reserved for children with obvious spine abnormalities, abnormal neurological examination, gait abnormalities and daytime symptoms.
Management Management of the enuretic child must be individualised depending on the child’s age, severity of bedwetting and psycho-social impact. 1) Management consists of positive reinforcement strategies which reinforce desired behaviours (such as encouraging or rewarding the child for ‘dry nights’ while ignoring the wet ones). Fluid intake especially in the evenings needs to be regulated and bladder emptying advised before going to bed. These measures need to be continued for at least 3 months before they are considered ineffective. 2) Alternative modes involve the use of alarms, which has up to 80% success rate. A urine-sensitive detector pad is placed under the child’s bed-sheets, while the alarm is placed on a bedside table. The alarm is triggered whenever urine is in contact with the pad, prompting the child to awaken so that he can cease voiding and get out of bed to complete voiding at the toilet. 3) Medications like desmopressin or imipramine have been proven in randomised control trials to be effective, although relapses were reported when therapy was stopped. In conclusion, enuresis is a very common problem that can affect a child’s psycho-social wellbeing. It is important to understand the maturational process of bladder development, when managing the affected child with enuresis.
Ovarian
Dr Hemashree Rajesh Consultant Dept of Obstetrics & Gynaecology
stimulation in ART
• Ovarian stimulation is one of the most important aspects of Assisted Reproduction. It is directed to ensure that a sufficient number of eggs are retrieved (roughly 10 eggs) to ensure that at least 2 good quality embryos are transferred back to the uterus in that cycle. Too enthusiastic a stimulation may result in ovarian hyperstimulation while too cautious an approach would result in an inadequate ovarian response. This step in IVF is often poorly understood by gynaecologists and doctors who are not directly involved in the treatment of infertile patients. This article will summarise the different ovarian stimulation regimes and the basis for their use.
Long Cycle
• It begins with “down regulation” from the 2nd day of a period for 10-14 days using GnRH agonists. The purpose of down regulation is to suppress follicular growth and to ensure follicles mature at an even pace such when subsequent stimulation is performed. This enables the collection of oocytes of similar maturity for use in IVF. Once we confirm pituitary down regulation by estradiol values (< 250pmol/l), we start the patient on gonadotropins to stimulate follicular growth. Every 2-3 days an ultrasound is done to look at the growth velocity of the follicles. When there are more than 3 follicles > 18 mm, we administer a dose of HCG. Thirty six hours after HCG trigger we collect the oocytes, transvaginally under sedation using ultrasound guidance.
The antagonist cycle uses GnRH antagonists to help with pituitary suppression. This is a patient friendly cycle and lasts 2 weeks till egg retrieval. It is also used in patients with a low ovarian reserve.
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On the 2nd or 3rd day of the period, the patient starts to inject gonadotropins for oocyte recruitment. After 5 days of stimulation an ultrasound is done and if a sufficient number of follicles are growing we add a GnRH antagonist to the cycle to suppress the LH surge from the pituitary gland until the follicles are mature. We monitor the patient with ultrasound and blood tests (Keep the progesterone < 5nmol/l and LH < 10 iu/l) until there are at least 3 follicles more than 18 mm when we trigger the patient with a dose of HCG 10000 IU. Oocyte retrieval is scheduled 36 hours after the HCG injection, similar to the long cycle.
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The short agonist cycle is used for patients with a low oocyte reserve. This regime helps retrieve more eggs for these patients than the long cycle. However the cohort may not be homogenous and comprise of mature and immature eggs compared to the long cycle.
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In these patients, Gonadotropins and Gonadotropin agonists are started simultaneously on day 2-3 of menses. The agonists cause a flare of the intrinsic gonadotropins (FSH and LH) for the first few days and maximise follicular recruitment, thereafter they suppress the pituitary for the rest of the cycle. After five days of the combined drugs we monitor the ovary with ultrasound scans to determine follicular growth. If there is inadequate recruitment of follicles, the gonadotropin dose is increased. Once we have 3 follicles more than 18 mm, we trigger ovulation with HCG and schedule oocyte retrieval.
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From the day of oocyte retrieval we initiate luteal support with oral dydrogesterone or crinone (progestogens) for the next 14 days. The husband provides the sperm on the same day as oocyte retrieval and the scientists fertilise the egg. The embryo is transferred into the uterus 2-5days after oocyte retrieval. On the 14th day after embryo transfer (in the case of a day 2 embryo) or 11 days after a blastocyst transfer( D5 embryo) we do a serum HCG to evaluate for pregnancy.
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Occasionally we use clomiphene citrate for a few days in addition to gonadotropins to reduce the cost of the cycle.
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There are risks associated with ovarian stimulation- Hyperstimulation occurs in a minority of the cycles. We treat these patients with cabergoline (a dopamine agonist similar to bromocriptine) and if they are not symptomatic, proceed with embryo transfer. If the hyperstimulation is severe, we retrieve the oocytes, freeze the embryos and transfer them back at a later date (around 3 months). Rarely some patients have no eggs retrieved or very few eggs. If very few eggs are retrieved and the fertilisation is poor, they may have no embryos to be transferred in on Day2. If the stimulation monitoring shows a very poor recruitment of follicles we may abandon the cycle.
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When used appropriately with good patient selection, controlled ovarian stimulation enables sufficient number of oocytes to be collected for IVF without subjecting the patient to unnecessary risk or inconvenience. Individualising the regimens for stimulation is a challenging process and, at SGH, this is achieved by a multi-disciplinary discussion between IVF specialists and embryologists for each patient prior to initiating IVF.
Antagonist Cycle
• Depending on the patient’s age, reason for IVF, history, BMI, FSH levels and Antral follicular count, the IVF team offers different stimulation regimes for the individual. The common stimulation regimes used are the “long cycle”, the “short cycle” and the “antagonist cycle”. • The long cycle is the commonest and most popular stimulation protocol. It has the best overall results, however the stimulation regime is long and the whole process of stimulation to egg retrieval and embryo transfer takes almost 1 month.
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Short Cycle