Učinak lateralne epiziotomije na funkciju zdjeličnoga dna i seksualnu funkciju poslije vaginalnoga porođaja u prvorodilja [Effect of lateral episiotomy on the function of pelvic floor and sexual function after vaginal delivery in primiparas]

Episiotomy is an obstetrical procedure which extends the vaginal vestibule during fetal expulsion. Lateral episiotomy is widely used, but is rarely mentioned in the literature and its effect on the pelvic floor is unexplored. The available data largely support the theory of the negative or neutral effect of median and mediolateral episiotomy on the pelvic floor. The hypothesis of this study was that lateral episiotomy in primiparas has a protective effect on the emergence of urinary and anal incontinence, as well as sexual dysfunction during the first year postpartum. The aim of this study was to investigate the effect of lateral episiotomy on the pelvic floor in the primiparas in comparison to the group without episiotomy. Prospective study was conducted and consisted of 2 groups, with 100 examinees in each group. The first group consisted of women who had a delivery with lateral episiotomy and another group of women who had a delivery with perineal tears of I. and II. degree and intact perineum. The study included primiparas with singleton pregnancies and spontaneous onset of labor with fetuses in cephalic presentation. Examinations of pelvic floor were conducted at 5 and 8 months after delivery accompanied by specific questionnaires. International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form was used to assess urinary incontinence, while Wexner Scale was used to assess anal incontinence. Female Sexual Function Index was used to assess sexual function. The clinical examinations were consisted of: Pelvic Organ Prolapse Quantification system, cough stress test, transperineal sonography of anal sphincter and pelvic floor muscles and vaginal manometry. There were no significant differences in emergence of stress urinary incontinence between groups in two-time points (episiotomy: 16% and 13.5%; ruptures: 20% and 14.9%). There were also no differences in the occurrence of prolapse. Pelvic floor muscle strength was almost equal by groups as well as the occurrence of symptoms of anal incontinence and sexual dysfunction. There were certain relations between the ages of the examinees, oxytocin and weight of the newborn to poorer results of the questionnaires in episiotomy group. Obstetric and anthropometric variables were not associated with emergence of urinary and anal incontinence in episiotomy group. Our results indicate that the effect of lateral episiotomy on the pelvic floor is comparable to delivery with minimal perineal injuries. Rates of pelvic floor disorders as well as sexual dysfunction were similar by groups. No substantial associations between episiotomy and pelvic floor disorders have been found which is in accordance with majority of studies on other types of episiotomy. To conclude, lateral episiotomy has neither protective, nor negative effect on the onset of pelvic floor disorders and sexual dysfunction in the primiparas

HEMORAGIČNI ŠOK ZBOG RAZDORA RODNICE U BOLESNICE S GONADALNOM DISGENEZOM (46 XX)

We report on hemorrhagic shock due to intracoital vaginal rupture in a sporadic case of gonadal dysgenesis with uterine and bilateral oviduct aplasia (46 XX) verifi ed during laparoscopy. Resuscitation with primary wound sutures was performed with full recovery.Prikazana je bolesnica s hemoragičnim šokom zbog intrakoitalnog razdora rodnice u rijetkom slučaju gonadalne disgeneze i maternične i obostrane aplazije jajovoda (46 XX), što je pronađeno tijekom laparoskopije. Učinjena je reanimacija i primarne šavi ozljede s potpunim oporavkom

Učinak porođaja i epiziotomije na nastanak inkontinencije mokraće u žena: pregled literature

Episiotomy is obstetric procedure during which the incision extends the vestibule of the vagina during the second stage of labor. Episiotomy was extensively spread with gradual increase of rates in the first half of the 20th century and was performed mediolaterally in all nulliparous women with the idea to protect fetal head from trauma and pelvic floor from injuries. However, reports claiming that episiotomy had no such benefits were published. It was shown that routine mediolateral episiotomy did not protect against the appearance of urinary incontinence after vaginal delivery, while the risk of anal incontinence could be increased. The role of episiotomy in development of pelvic floor dysfunction remains quite unclear. Due to the mentioned reason, restricted episiotomy approach should be accepted. The origin of stress incontinence during pregnancy is controversial and not definitely scientifically proven. Pregnancy per se and older age at first delivery may have impact on the onset of pelvic floor dysfunction. Urinary incontinence in pregnancy increases the risk of later urinary incontinence, both postpartum and later in life. Vaginal delivery is just one of the potential risk factors for development of urinary incontinence. Mechanical pressure by fetus on the pelvic floor structures, limited denervation of the pelvic floor and soft tissue damage during delivery are some of explanations for the onset of stress urinary incontinence. On the other hand, cesarean delivery might not be protective against emergence of urinary incontinence. Further research in this field is needed.Epiziotomija je porodnička operacija u kojoj se incizijom širi predvorje vagine tijekom drugog porođajnog doba. Epiziotomija se intenzivno koristila uz postupno povećanje stope u prvoj polovici 20. stoljeća kao mediolateralni urez međice na svim prvorodiljama s idejom zaštite glave fetusa od traume i zdjeličnog dna od ozljeda. U posljednje vrijeme objavljeni su radovi koji tvrde da epiziotomija nema prije navedene koristi, odnosno da rutinska mediolateralna epiziotomija ne štiti od pojave stresne inkontinencije mokraće nakon vaginalnog porođaja, dok je rizik od pojave analne inkontinencije povećan. Uloga epiziotomije u razvoju disfunkcije zdjeličnog dna ostaje prilično nejasna. Zbog navedenih razloga restriktivni pristup uporabi epiziotomije bi trebao biti prihvaćen. Uzrok stresne inkontinencije tijekom trudnoće je proturječan i nije definitivno znanstveno dokazan. Trudnoća sama po sebi i starija dob pri prvom porođaju mogu imati utjecaj na nastanak disfunkcije zdjeličnog dna. Također pojava inkontinencije mokraće u trudnoći povećava rizik za nastanak inkontinencije mokraće poslije porođaja i u ostatku života. Vaginalni porođaj je samo jedan od potencijalnih čimbenika rizika za razvoj inkontinencije mokraće. Mehanički pritisak fetusa na zdjelično dno, ograničena denervacija zdjeličnih struktura i oštećenja mekih tkiva tijekom porođaja su neka od objašnjenja za pojavu stresne inkontinencije mokraće. Porođaj carskim rezom vjerojatno ne štiti od pojave inkontinencije mokraće. Sve upućuje na to da su daljnja istraživanja u ovom području neophodna

Pregnancy after bilateral fimbrioplasty: classic corrective operation on fallopian tubes in the era of laparoscopy progress and assisted reproductive techniques - case report

Tubarni čimbenik kao uzrok bračnog steriliteta u praksi susreće se u oko 30 do 40% slučajeva. Zbog sve boljih rezultata metoda asistirane reprodukcije, mikrokiruški zahvati na jajovodima moraju biti jasno indicirani, bez obzira na to rade li se takvi zahvati laparotomijskim ili laparoskopskim pristupom. Prikazali smo slučaj fimbrioplastike u 35-godišnje žene liječene zbog sekundarnog bračnog steriliteta prije 12 godina. Također smo opisali trudnoću i porod ove žene. Uzrok steriliteta je bila obostrana terminalna okluzija jajovoda, dokazana rendgenskom histerosalpingografijom. Obrada pacijentice započeta je nakon tri godine sekundarnog steriliteta. Uredna intrauterina trudnoća ostvarena je u prvom pokušaju, dva mjeseca nakon obostrane fimbrioplastike. Trudnoća i porod navedene pacijentice protekli su uredno. Cilj ovoga rada je da se s vremenskim odmakom od 12 godina prikažu prijašnji tehnički operativni dosezi u ovom području ginekološke kirurgije, te da se iz današnje perspektive analiziraju rezultati klasičnih korektivnih operacijskih zahvata u području jajovoda s onima koji se danas izvode laparoskopskom operativnom tehnikom.Tubal infertility factor as a cause of matrimonial sterility is encountered in practice in about 30 to 40% of cases. Since the results of assisted reproduction techniques are improving every day, microsurgical procedures on Fallopian tubes must be strictly indicated, even if such procedure is done by laparotomic surgery or laparoscopic approach. In this article, we present a case of fimbrioplasty in a 35-year-old woman, who was treated for secondary infertility 12 years ago. Also, we describe the pregnancy and delivery of this woman. The cause of infertility was bilateral distal tubal occlusion, confirmed by x-ray hysterosalpingography. This patient started treatment within three years of secondary infertility diagnosis. Regular intrauterine pregnancy was achieved by first attempt, two months after bilateral fimbrioplasty. The course of pregnancy and delivery were normal. The aim of this article is to assess technical achievements of gynecological surgery, during a 12-year time span, and also to analyze the results from today\u27s perspective of classical corrective surgical procedures on the Fallopian tubes, compared to those that are now performed by laparoscopic operative techniques

Periurethral bulking agents in the treatment of female stress urinary incontinence

Stress urinary incontinence (SUI) is a common type of urinary incontinence in women, affecting large proportion of women. Surgical methods, especially suburethral sling operations are the most important modes of the treatment of SUI. Bulking agents were created as an alternative to conventional surgical methods and may be the first line of therapy in certain patients. Periurethral bulking implies implantation of various biocompatible agents around the urethra in order to improve coaptation of the urethral walls during intra-abdominal pressure elevation. The rates of cure are lower with bulking methods as compared with surgical techniques but are associated with a lower prevalence of postoperative complications. Bovine collagen remains the most frequently injected agent worldwide, with cure rates of 53% at 12 months after procedure. Polyacrylamide hydrogel and silicone micro implants have showed promising results, with about 64% improvement rate at 18 to 24 months after procedure. Application of urethral bulking agents is minimally invasive procedure and is mostly applied outpatiently in local anesthesia. Urethral bulking agents are safe for clinical usage. Bulking agents should not be recommended as a method of final cure because they only lead to short-term improvement

Compendium of sling operative techniques in the treatment of stress urinary incontinence in women

Inkontinencija mokraće često je stanje, posebno u žena i bitno utječe na kvalitetu svakodnevnog života. Pogođeno je čak do 50% žena starije životne dobi. Etiologija inkontinencije mokraće i prolapsa zdjeličnih organa nije u cijelosti poznata, ali dovodi se u vezu s vaginalnim porodom. Pri vaginalnom porodu dolazi do poremećaja statike organa male zdjelice uslijed prevelikog rastezanja i oštećenja mišića i fascija. Žene pikničke konstitucije, žene u perimenopauzi, a pogotovo žene u postmenopauzi, zbog pada razine estrogena znatno češće bivaju pogođene. Početkom 90-ih godina 20. stoljeća Integralna teorija Petrosa i Ulmstena označila je prekretnicu u razvoju novih minimalno invazivnih sling metoda. Sve stresne inkontinencije urina (SIU) mogu se liječiti sling metodama koje su danas zlatni standard u liječenju SIU. Nove, minimalno invazivne sling metode većinom su zamijenile klasične operacije za liječenje SIU, bez bojazni od slabije učinkovitosti. Ovim pregledom minimalno invazivnih sling metoda za liječenje SIU želi se usporediti učinkovitost i komplikacije pojedinih inačica navedenih metoda. Obrađene metode uključuju TVT (Tension free Vaginal Tape) metodu, TOT (Transobturator Tape) metodu, TVT-O (Tension free Vaginal Tape- Obturator), te najnoviju tehniku MiniArc®. TVT metoda podrazumijeva postavljanje mrežaste trake retropubično pod srednju trećinu uretre. Učinkovitost TVT metode kreće se od 86 do 99%. TOT je transopturatorna metoda, razvijena s ciljem smanjenja intraoperativnih komplikacija povezanih s prodorom kroz retropubični prostor, koje su moguće kod TVT metode. Nadalje, novija sling tehnika TVT-O u kojoj traka prolazi kroz opturatorni otvor u smjeru od iznutra prema van, svojevrsna je alternativa TOT metodi, jer smanjuje mogućnost komplikacija povezanih s TOT metodom. Najnovija tehnika, MiniArc®, nastavak je razvoja minimalno invazivnih metoda liječenja SIU, ali za jednoznačan zaključak o učinkovitosti i sigurnosti potrebno je više podataka o ovoj metodi. Sve metode podjednako su učinkovite, te bolesnice imaju značajno poboljšanu kvalitetu života nakon zahvata. Sumarno, može se reći da transopturatorni pristup ima manje težih komplikacija nego retropubični.Incontinence of urine is a common condition, especially in women, affecting the quality of everyday life. Up to 50% of elderly women are affected. The etiology of this condition is not known entirely, although it is often linked to vaginal delivery. During vaginal delivery, the pelvic organs lose their original position, due to overstretching or damage of muscles and fasciae. Overweight women, as well as those in peri- and postmenopause, due to low estrogen levels, suffer more frequently of this condition. In the early 1990s the Integral theory by Petros and Ulmsten demarked a turning point in the development of new minimally invasive sling methods. All types of stress urinary incontinence (SUI) can be treated by sling methods, which, in turn, are a golden standard for the treatment of this condition. These new, minimally invasive methods, can fully replace older, classic operations for treatment of SUI, without any concern of deficient results. This review intended to put emphasis on the comparison of these sling methods, in order to see if they are equally successful, and if there is a difference in the risk of complications. Sling methods taken into account are TVT (Tension free Vaginal Tape), TOT (Transobturator Tape) method, and TVT-O (Tensionfree Vaginal Tape-Obturator), as well as the newest method MiniArc®. The TVT method includes placing a mesh tape, retropubic, under the middle third of the urethra. This method is from 86% to 99% effective. The TOT method was developed in order to decrease complications associated to penetrating through the retropubic space, which are more common when using TVT. Further on, a newer technique, in which the sling passes from “inside-out” the TVT-O, is an alternative to the TOT method, since it minimizes the possibility of complications associated to the TOT. The latest technique, MiniArc®, is an extension of the endeavor to create the least invasive method for SUI treatment, but more extensive data about this method is required. All sling methods are equally effective and women report a higher quality of life after undergoing a sling procedure. To conclude, it can be said that the transobturator approach is less likely to develop severe complications than the retropubic approach

Umbilical cord wrapping and enlargement in monochorionic monoamniotic twins with letal outcome

We present the case of tapered umbilical cords in monoamniotic monocorial twins with late abortion as an outcome. A pregnant woman at the age of 38 had healthy course of her second pregnancy. In the 9th week of gestation, an monoamniotic monocorionic pregnancy was diagnosed by ultrasound. Early amniocentesis was done due to the older age of a mother. During the procedure an enlargement of the umbilical cord was discovered, and the wrapping of the two umbilical cords. Mosaic trisomy of the 21st chromosome was proved. In the 19 w + 3 d gest., negative heart beats were detected for both of fetuses. The induction of abortion was initiated by prostaglandin vaginal gel (dinoprost). There were no signs of maceration, the weights were 230 and 190 grams, with increased and wrapped umbilical cords. The pathohistological fi nding confi rmed monochorionic-monoamniotic twin pregnancy with a long and tightly knit umbilical cord with complete blood fl ow obstruction and no signs of fetal malformalities. Also, there were no clinical signs of fetal transfusion syndrome. It is probably that the umbilical cord of the second twin was hypoplastic and with more complications