Background Excessive blood loss is a significant risk of myomectomy with the potential need for hysterectomy.Objective To study the effectiveness of preoperative misoprostol compared with placebo at open myomectomy on intra-and postoperative outcomes.Search strategy PubMed, Cochrane, Scopus, MEDLINE and EMBASE.Selection criteria Randomised control studies of women undergoing open myomectomy for symptomatic fibroids who were given either misoprostol or placebo preoperatively. Data collection and analysisThe revised Cochrane risk-of-bias tool for randomised trials was used to assess the risk of bias. Primary outcomes were blood loss, drop in haemoglobin and need for blood transfusion. Secondary outcomes were operative time, postoperative pyrexia and length of postoperative stay. Pooled effect sizes with corresponding 95% CI were calculated using random effects models. Data were analysed using two statistical models for statistical reliability.Results Eight studies were included with a total of 385 patients, of which 192 received misoprostol. Preoperative misoprostol was significantly associated with lower blood loss by À170.32 ml (95% CI À201.53 to À139.10), lower drop in haemoglobin by À0.48 g/ dl (95% CI À0.65 to À0.31), reduced need for blood transfusion (odds ratio [OR] À0.48, 95% CI À0.65 to À0.31), and a reduction in operative time by À11.64 minutes (95% CI À15.73 to À7.54). There was no difference in postoperative pyrexia or length of postoperative stay.Conclusion Moderate-to high-quality studies have established that misoprostol minimises blood loss and need for blood transfusion at open myomectomy. This low-cost and readily available drug should be routinely administered prior to open myomectomy to improve clinical outcomes.
The latest Confidential Enquiry into Maternal Deaths (2006-2008) shows that venous thromboembolism (VTE) is now the third leading cause of direct maternal mortality, behind sepsis and hypertension. This is likely to be because of improved risk assessment of patients and adequate thromboprophylaxis both antenatally and postnatally. Given the importance of this area, compliance with the departmental VTE guidelines (which were based on previous RCOG guidelines) was reviewed prior to transferring to a revised guideline based on the recent RCOG guideline (2010). The results obtained highlighted the difficulties in achieving good VTE risk assessment, with only 60% of patients being adequately assessed and managed antenatally, and 68% postnatally. The findings led to a revised guideline, and it was anticipated that this change would facilitate improved compliance. Other units are likely to be facing similar difficulties, and therefore these results also aim to encourage others to consider review and assessment of their own VTE risk assessment protocols.
Clinical Governance Advice published by the RCOG states that 'before seeking a women's consent ... you should ensure that she understands the nature of the condition for which treatment is being proposed, its prognosis, likely consequences and risks of receiving no treatment at all'. The importance of obtaining informed consent within obstetrics and gynaecology is highlighted by the litigious nature of our specialty, with CNST data, demonstrating that it makes up 21% of all claims and incur highest cost of any other specialty. We present an audit of the quality of operative consenting for 120 procedures over a 3-month period for five procedures (diagnostic hysteroscopy and laparoscopy, total abdominal hysterectomy, vaginal repair/hysterectomy and lower segment caesarean section) for which we have RCOG advice (Numbers 1, 2, 4, 5, 7, respectively). The quality of consent was also assessed by grade of clinicians. The results identify significant deficiencies when various gynaecological and obstetric procedures are being consented for, and we have discussed various options recommended for improvement.
Introduction Episiotomies are the most commonly performed surgical procedure. Approximately 85% of women will sustain a vaginal tear at delivery, with 70% requiring suturing. NICE guidelines advise on care and management of perineal tears. Given the importance of this, we assessed how women were debriefed within our department on the care of their perineal wound. Methods Questionnaires on perineal trauma were distributed to patients on the postnatal ward. Data collected included awareness of their type of tear, who sutured it, advice regarding analgesia, signs of infection, wound hygiene, bladder and bowel care, pelvic floor exercises and resuming sexual intercourse. Results 61 responses were collated. 41% were sutured by a midwife and 59% by an obstetrician. 70% were unaware of their degree of tear. Less than 50% were advised on symptoms of infection or wound breakdown. Discussion on oral analgesia, pad changes and washing were reported as 72%, 74% and 87% respectively. Only 21% were counseled on resumption of sexual intercourse. Debrief on pelvic floor exercises, urinary and bowel functions were reported at 65%, 64% and 52%. Patients reported the postnatal ward midwives as the most informative (57%), with only 44% of advice coming from the person suturing. 93% stated they would benefit from written advice. Conclusions Women with perineal trauma are not fully informed. It is the duty of the person suturing to debrief women on perineal tears. In addition to highlighting the importance of this to staff during suturing, information leaflets have been devised for patients to take home.
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