Perineal injuries during vaginal birth in low-resource countries.

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.

Laparoscopic approach to vesicovaginal fistulae.

The surgical repair of vesicovaginal fistula (VVF) over the last two decades has evolved from the transabdominal/transvaginal route to minimally invasive techniques of laparoscopy and robotic surgery. The indications for laparoscopic repair include supratrigonal fistulae, and stenotic/narrow vaginas that make vaginal access to the fistula site difficult. In the current published literature, comparable results have been reported with open surgery. The initial techniques were performed to simulate the open classic technique described by O'Conor, but with better imaging, exposure and magnification, the modified O'Conor (smaller cystotomy) and the extravesical approaches (no cystotomy) are being performed with comparable results. Difficulties such as depth perception, suturing and ergonomics together with the steep learning curve associated with laparoscopy have been overcome with the introduction of robotics. Reports on laparoendoscopic single site surgery (LESS) and transvesicoscopic VVF repairs with successful outcomes have been published, but studies on a large number of patients are needed to establish their effectiveness. Difficulties of managing suturing have been circumvented with the usage of the barbed suture; however, more data are required to establish its efficacy. Although the laparoscopic/robotic approach of a VVF repair offers numerous advantages, the best chance of success is achieved with the first surgical attempt using an approach that the surgeon is familiiar in performing.

Hepatic pregnancy managed conservatively.

We present a case of hepatic pregnancy and discuss expectant management, use of newer imaging techniques and approaches to management, such as leaving the placenta in situ, the use of magnetic resonance imaging and sonography in the follow-up of placental involution. This case report illustrates that conservative management is feasible.

An audit of obstetric fistulae in a teaching hospital in South Africa.

Obstetric fistulae are still common in the rural areas of South Africa. This study describes the demographic and clinical characteristics of 41 women with obstetric urinary fistulae. All were from poor socioeconomic backgrounds and had limited or no access to antenatal care.

Emergency gynaecology.

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.