Pelvic floor muscle training for female urinary incontinence: Does it work?

PURPOSE: Supervised pelvic floor muscle training in patients of stress and mixed urinary incontinence has been recommended. Our aim was to assess the utilisation and effectiveness of our supervised pelvic floor muscle training service and assess the impact of incontinence scores before physiotherapy on the subsequent results of physiotherapy. METHODS: All 271 patients referred to physiotherapy for symptoms of incontinence filled out the International Consultation on Incontinence Modular Questionnaire-Female Lower Urinary Tract Symptoms before starting treatment. Depending on pelvic floor muscle assessment, plans for exercises and follow up were made. If the strength of pelvic floor muscles was poor, electrical stimulation was offered. If awareness of the pelvic floor muscle contraction was poor, bio feedback was offered. Group sessions and vaginal cones were also used. Depending on the response to the treatment; patients were either discharged, referred to Urogynaecology clinic or continued physiotherapy. All patients who were discharged or referred for surgery were given a post treatment questionnaire to fill out. RESULTS: 79 (56 %) of 132 women with stress, 49 (51 %) of 98 with mixed and 27 (66 %) of 41 with urge incontinence reported successful control of symptoms (overall success 54 %). However, 65 % of women with incontinence scores of 0-5 before physiotherapy, 64 % with 6-10, 42 % with 11-15 and mere 28 % with 16-20 achieved success with physiotherapy. 27 (10 %) were lost to follow up. CONCLUSION: 1 in 2 women referred to physiotherapy for incontinence, achieved successful control of symptoms without the need for invasive investigations or surgery. However, poor incontinence scores before the start of physiotherapy is a poor prognostic indicator for success. 90 % women utilised the service.

Accidental delivery of a baby during a caesarean section through a vaginal incision (a laparoelytrotomy).

A 27-year-old woman was admitted at 39 weeks' gestation for induction of labour for gestational diabetes. During artificial rupture of her membranes, cord prolapse occurred necessitating an emergency caesarean section. At closure, the incision, instead of being in the lower uterine segment, was found to be in the vagina about 1.5 cm below the anterior lip of the cervix. This was closed routinely, both mother and the baby made an uneventful recovery and at a 6 week postnatal check-up the vaginal wall was completely healed and normal.

Ruptured intracranial aneurysm in pregnancy: a case report.

Rupture of intracranial aneurysm in pregnancy is rare and the presentation is easily confused with eclampsia. A high index of suspicion could lead to early diagnosis and prompt management. A multidisciplinary team approach is essential for best outcome.

Obstetric management of thyroid disease.

UNLABELLED: Timely treatment of thyroid disease during pregnancy is important in preventing adverse maternal and fetal outcome. At present, thyroid testing is performed on symptomatic pregnant women or those with a history of the disease. Hypothyroidism is very often subclinical in nature and not easily recognized without specific screening programs. Even mild maternal thyroid hormone deficiency may lead to neurodevelopment complications in the fetus. Early maternal thyroxine therapy might be beneficial in these women. The main diagnostic indicator of thyroid disease is the measurement of serum thyroid stimulating hormone and free thyroxine. Availability of gestation-age-specific thyroid stimulating hormone (TSH) thresholds is an important aid in the accurate diagnosis and treatment of thyroid dysfunction. Pregnancy-specific free thyroxine thresholds not presently available are also required. Gestational iodine deficiency is still prevalent in some areas of the United Kingdom. Thyroid peroxidase antibody (TPO Ab) in combination with thyroglobulin autoantibody (TgAb) is an accurate predictor of postpartum thyroiditis (PPT). Early screening and treatment of PPT may be justified on the grounds that it is relatively common and causes considerable postpartum morbidity. Large-scale intervention trials are urgently needed to assess the efficacy of preconception or early pregnancy screening for thyroid disorders. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that thyroid gland physiology changes with pregnancy, recall that levels of thyroid hormones are gestational-age related, and explain that accurate interpretation of both antepartum and postpartum levels of thyroid hormones are important in preventing pregnancy-related complication secondary to thyroid dysfunction and in the diagnosis and management of postpartum thyroiditis.

Higher order repeat caesarean sections: how safe are five or more?

OBJECTIVE: To determine the maternal morbidity and mortality associated with multiple repeat caesarean sections. DESIGN: Retrospective study. SETTING: Security Forces Hospital serving Ministry of Interior and Security Forces personnel in Riyadh, Kingdom of Saudi Arabia. POPULATION: Three hundred and eight case records undergoing between fifth and ninth caesarean section (mean 7) were studied and compared with a control group of 306 patients undergoing third or fourth caesarean section during the period January 1994-December 2002. MAIN OUTCOME MEASURE: Operative and post-operative complications and difficulties. RESULTS: Five or more caesarean sections were associated with a longer operating time as well as an increased rate of severe adhesions. Blood transfusion rate was similar in the two groups but a drop of pre-operative to post-operative haemoglobin was significantly higher in the study group compared with the controls. There was no significant difference in the Apgar score of the baby, neonatal admission rate, incidence of caesarean hysterectomy, uterine scar rupture, placenta praevia, placenta accreta, bladder injury, incidence of postpartum pyrexia, wound infection and urinary tract infection between the two groups. There was no maternal death in the study group but one mother died in the control group. CONCLUSION: The higher order (5-9) repeat caesarean sections carry no specific additional risk for the mother or the baby when compared with the lower order (3 or 4) repeat caesarean sections.

Chronic renal insufficiency in pregnancy.

This article attempts to assess the nature, severity and management of the risks associated with pregnancy in chronic renal insufficiency and end-stage renal disease, including dialysis and transplant recipients. Women with serum creatinine levels of >125 mmol/l are at an increased risk for deterioration in renal function, hypertension with superimposed pre-eclampsia and obstetric complications. Rigid control of hypertension is crucial for a successful pregnancy outcome. A range of antihypertensive drugs are available with angiotensin converting enzyme inhibitors being contraindicated. Women on dialysis have low fertility rates that return to normal following renal transplantation. Immunosuppresive drugs are not associated with increased congenital anomalies. Transplant recipients are at an increased risk for infections that may have implications for the fetus. All groups have an increased risk for prematurity and intrauterine growth restriction. The percentage of pregnancies resulting in surviving infants in women with renal insufficiency and transplant recipients ranges from 80-100%. For women who conceive after dialysis, the likelihood of a surviving infant is approximately 50%.

Passive maternal smoking and pregnancy outcome in a Saudi population.

OBJECTIVE: A prospective study to investigate the effect of passive smoking on birth weight of infants born to women at the Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. METHODS: The study group comprised of 868 singleton live births occurring during January to December 2001 at Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Following delivery, mothers were asked for details of whether they smoked or used tobacco in any other form and if they had exposure to passive smoke at home or in the workplace. The daily exposure time to tobacco smoke was divided into 2 groups; up to 4 hours and 5-8 hours. Obstetric and medical details of the mothers were recorded from case notes, as were the details of the baby. Data was analyzed using Stat Pack Gold Statistical Analysis Package using Student t-test to compare discrete and continuous variables. Stepwise multiple regression analysis was performed to adjust the odds ratio from the influence of confounding factors. RESULTS: Of the 868 women, 440 were passive smokers and 428 not exposed to tobacco smoke constituted the control group. Passive smokers were relatively younger with low parity and income. Passive smoking was significantly associated with a decrease in birth weight after adjusting for other factors (P=0.015) and an increase in the incidence of small for gestation age infants (P=0.0391). There was also no statistically significant difference in the birth weight between women exposed up to 4 hours of smoke and those exposed for 5-8 hours. CONCLUSION: Passive maternal smoking was associated with a decrease in birth weight and an increase in small for gestation age infants. A dose-response relationship between passive maternal smoking and birth weight was not seen.