Use of Continuous Electronic Fetal Monitoring in a Preterm Fetus: Clinical Dilemmas and Recommendations for Practice

The aim of intrapartum continuous electronic fetal monitoring using a cardiotocograph (CTG) is to identify a fetus exposed to intrapartum hypoxic insults so that timely and appropriate action could be instituted to improve perinatal outcome. Features observed on a CTG trace reflect the functioning of somatic and autonomic nervous systems and the fetal response to hypoxic or mechanical insults during labour. Although, National Guidelines on electronic fetal monitoring exist for term fetuses, there is paucity of recommendations based on scientific evidence for monitoring preterm fetuses during labour. Lack of evidence-based recommendations may pose a clinical dilemma as preterm births account for nearly 8% (1 in 13) live births in England and Wales. 93% of these preterm births occur after 28 weeks, 6% between 22–27 weeks, and 1% before 22 weeks. Physiological control of fetal heart rate and the resultant features observed on the CTG trace differs in the preterm fetus as compared to a fetus at term making interpretation difficult. This review describes the features of normal fetal heart rate patterns at different gestations and the physiological responses of a preterm fetus compared to a fetus at term. We have proposed an algorithm “ACUTE” to aid management

Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate

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Effect of Anterior Compartment Endometriosis Excision on Infertility

Background and Objectives: Laparoscopic surgical excision of bladder nodules has been demonstrated to be effective in relieving associated painful symptoms; the data are lacking concerning the impact of anterior compartment endometriosis on infertility. We conducted this study to evaluate whether or not the surgical excision of deep endometriosis affecting the anterior compartment plays a role in restoring fertility. Methods: This multicentre, retrospective study included a group of 55 patients presenting with otherwise-unexplained infertility who had undergone laparoscopic excision of anterior compartment endometriosis with histological confirmation. Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term followup of fertility outcomes. Results: The pregnancy rate following surgical excision of endometriotic lesions was 44% (n = 11) among those with anterior compartment involvement alone and 50% (n = 15) in case of posterior lesions association without any significant difference. The symptoms related to bladder endometriosis resolved in the 84.2% of the cases with a recurrence rate of 1.8% at the 2-year followup not requiring further surgery. Conclusion: Laparoscopic excision of anterior compartment endometriosis is effective in restoring fertility in patients with otherwise-unexplained infertility and in treating endometriosis-related symptoms

Standard Approach to Urinary Bladder Endometriosis

Study Objective: Urinary endometriosis accounts for 1% of all endometriosis where the bladder is the most affected organ. Although the laparoscopic removal of bladder endometriosis has been demonstrated to be effective in terms of symptom relief with a low recurrence rate, there is no standardized technique. Partial cystectomy allows the complete removal of the disease and is associated with low intra- and postoperative complications. Here we describe a stepwise approach to a rare case of a large endometriosis nodule affecting the trigone of the urinary bladder. Design: Step-by-step video explanation of a large endometriotic nodule excision (Canadian Task Force classification III). Setting: IRCAD AMITS – Barretos | Hospital Pio XVI. The video was approved by the local institutional review board. Patient: A 31-year-old woman. Intervention: Laparoscopic approach for bladder endometriosis. Measurements and Main Results: We present a case of a 31-year-old woman who complained of dysuria and hematuria with a bladder nodule of 3 cm affecting the bladder trigone. Laparoscopic complete excision of the nodule was performed. Laparoscopy began with full inspection of the pelvic and abdominal cavity. Vaginal examination under laparoscopic view helped to determinate the dimensions of the bladder nodule. Strategy consisted of bilateral dissection of the paravesical fossae and the identification of both uterine arteries and ureters. The bladder was slowly dissected from the uterine isthmus and was intentionally opened, thus helping the surgeons to identify the lateral and lower limits of the nodule and its proximity to both ureters. Bilateral double J stents were previously placed to guide the excision and further suture. Once the nodule was removed, the remaining wall consisted of the lower aspect of the trigone, both medial lower parts of the ureter, and the apex of the bladder. Suturing was performed in 2 steps. A simple monofilament interrupted suture was applied vertically at the lower wall between both ureters. The same technique was applied horizontally on the bladder dome. Pressure test demonstrated adequate correction. The patient was discharged 2 days later with a bladder catheter and double J stent. After 15 days, both indwelling catheter and ureteric stent were removed, and patient was submitted to a cystogram where no leakage was found. If a leakage had been found on the cystogram, the bladder should be allowed an additional week of continuous drainage. Early follow-up demonstrated a lower bladder capacity that was resolved within 6 months. After a 1-year follow-up the patient had no symptoms and demonstrated no recurrence. She is now 20 weeks pregnant with no need of assisted reproductive methods. Conclusion: The technique showed in the video demonstrates the feasibility of a laparoscopic approach for bladder endometriosis. Furthermore, the laparoscopic approach allowed the removal of the large nodule, reducing the risk of small bladder symptoms

Step-by-step type C laparoscopic radical hysterectomy with nerve-sparing approach

Study Objective: To show the laparoscopic technique to perform type C radical hysterectomy with a nerve-sparing approach and pelvic lymphadenectomy. Design: Educational video with step-by-step explanation of the technique using videos and pictures to highlight the anatomic landmark that guides the procedure. Setting: The goal of this procedure is to enlarge the resection of the paracervix at the junction with internal iliac vascular system, leaving the neural part of the structure under the deep uterine vein untouched. Type C consists in the resection of the uterosacral ligament at the rectum level and the vesicouterine ligament at the bladder level. The ureter is mobilized completely, and 15 to 20mm of the vagina from the tumor or cervix is resected. Performing such an enlarged hysterectomy, the preservation of the nerve supply to the bladder is crucial, leading to the creation of the subclasses. Type C1 conserves a nerve-sparing approach remaining above the deep uterine vein, whereas in type C2 a resection beyond this landmark including the neural part of the paracervix is performed. Interventions: Total laparoscopic type C1 radical hysterectomy with pelvic lymphadenectomy. Conclusion: This video shows the feasibility of type C radical hysterectomy through a minimally invasive approach. The possibility to perform this type of procedure laparoscopically matches with the more conservative approach to cervical cancer, bringing all the advantages of this technique into this field of gynecologic surgery

Employing laparoscopic surgery for endometriosis

Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis