Effects of lateral episiotomy on the emergence of urinary incontinence during the first postpartum year in primiparas: prospective cohort study.

AIM OF THE STUDY: Lateral episiotomy is a widely used procedure, although it is rarely mentioned in the literature and its effects on the pelvic floor are largely unexplored. The purpose of this study is to evaluate the impact of lateral episiotomy on the incidence of urinary incontinence (UI) after vaginal delivery in primiparas. MATERIAL AND METHODS: The study design is a prospective cohort study. The primiparas were divided into two groups. The first group consisted of women who gave birth with lateral episiotomy, while the second group included women who gave birth with an intact perineum or with perineal tears of first and second degree. Assessments of UI were performed at 5 and 8 months after childbirth using the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) questionnaire followed by the stress test. RESULTS: The results revealed no significant differences (p > 0.05) in emergence of stress urinary incontinence (SUI) between the groups at the two time points. There were no statistically significant differences in overall rate of UI, urge urinary incontinence (UUI), or mixed urinary incontinence according to the ICIQ-SF questionnaire. The overall incontinence rate on the first examination was 24% in the episiotomy group and 36% in the perineal laceration group, although the difference was not statistically significant (p = 0.064). On the second examination, rates were similar and without a statistically significant difference. CONCLUSIONS: Lateral episiotomy has a neutral effect on the onset of UI in primiparous women in the first year after delivery.

Effect of Delivery and Episiotomy on the Emergence of Urinary Incontinence in Women: Review of 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 medio-laterally 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 medio-lateral 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.

A study on utilization of oral contraceptives in the City of Zagreb (2008-2010).

Main aim of this study is to quantify and analyze the utilization and utilization trends of oral hormonal contraceptives in the City of Zagreb, 2008-2010, and to propose potential interventions, if necessary. Data gathered from Zagreb pharmacies were assessed by Anatomical Therapeutic Chemical Classification of drugs and Daily Defined Dose methodology. An alarming decrease in total utilization of hormonal contraceptives by 76% from 2008-2009 was found as the main result of this study. A major decrease by 95.5% in utilization of G03AB04 subgroup, sequential combined oral contraceptives, was noted in the year 2009. The subgroup G03AC0, progesterone-only pill group, showed a stable trend, and it became the most utilized subgroup in 2010, due to the decrease in utilization of both fixed and sequential combined oral contraceptives. Utilization of oral contraceptives in Croatia is not regulated adequately, since such dynamics in utilization can occur unnoticed. Measures need to take place in order to improve this situation. Proposed measures include organized farmacovigilance, prescription based on guidelines, and strict screening for risk factors in women seeking oral contraception. More research is required in Croatia to understand the pattern of utilization of hormonal contraceptives and to find the true cause of decrease in utilization of oral contraceptives.

A study on the quality of outpatient prescription of psychopharmaceuticals in the City of Zagreb 2006-2009.

The lack of Croatian studies which could determine the justifiability of excessive psychopharmaceutical utilization was an encouragement to conduct this research. Furthermore, regarding the conduction of this study, it would be possible to determine whether the trend of drug utilization has increased, decreased or perhaps stabilized. The data on the outpatient utilization of psycholeptics and psychoanaleptics were collected from all Zagreb pharmacies, 2006-2009. Based on the collected data for all N05 and N06 groups of drugs, the defined daily doses (DDD) and DDD per thousand inhabitants per day (DDD/TID) have been calculated using the Anatomical-Therapeutic-Chemical classification (ATC) for 2006, 2007, 2008 and 2009. To indicate the quality of drug prescription the Drug Utilization 90% (DU 90%) method was used. Moreover, in order to determine a more precise quality of individual drug group prescriptions, the indicators have been calculated by determining the proportion of the total utilization of individual therapeutic and pharmacological therapeutic subgroups in DDD/TID a day. The utilization of anxiolytics (N05B) accounts for most of the psycholeptic utilization in the City of Zagreb throughout the entire study period. In the study period, the utilization of antidepressants has slightly increased, by 10.5%, taking the first and the last years of the period into account. In 2006, 5 benzodiazepines and the hypnotic zolpidem, as well as 5 selective serotonin reuptake inhibitors (SSRIs) and 1 third generation antipsychotic (olanzapin) were found in the DU 90% segment. In 2009, the DU 90% segment also comprised 5 benzodiazepines and the hypnotic zolpidem, as well as 6 SSRIs and 1 third generation antipsychotic (olanzapin). In the City of Zagreb, a general insight into the quality of psychopharmaceutical prescriptions indicates stability in comparison to earlier studies. The ratio index of the first generation antipsychotic utilization, compared to the third generation antipsychotics, shows an increase in the quality of prescription. Also, the ratio index of total tricyclic antidepressants (TCA) and SSRI utilization indicates improvement in quality of prescription. The ratio index of the entire outpatient utilization of anxiolytics and antidepressants expressed in DDD/TID unfortunately shows a very mild increase of prescription quality. Benzodiazepines accounted for more than 50% of the outpatient utilization of psychopharmaceuticals throughout the study period, which proves the need for precise guidelines as the most significant means of drug rationalization and utilization. It is necessary to identify priorities and problems in order to solve them successfully, by monitoring drug utilization and prescription on a national level. Results demonstrate that within the primary health care system, there is a need for constant education on rational prescription of this drug group.

Unusual case of OHVIRA syndrome with a single uterus, unrecognized before labor and followed by an intrapartal rupture of obstructed hemivagina.

PURPOSE: The acronym for obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) was created to describe patients with an obstructed hemivagina and ipsilateral renal anomaly and enables inclusion of other uterine anomalies except uterus didelphys. The main goal of this article is to present a rare case of OHVIRA syndrome with intrapartal rupture of obstructed hemivagina. METHODS: We present an unusual case of OHVIRA syndrome with single uterus, uterine septum (previously resected by hysteroscopy) and renal agenesis, unrecognized before labor and followed by an intrapartal rupture of obstructed hemivagina. RESULTS AND CONCLUSION: Various symptoms, included in OHVIRA acronym, are a result of different morphologic variants included in this syndrome. Most likely, in our case, the absence of communication between the cervical canal/patent vagina and the obstructed hemivagina prevented formation of mucocolpos or hematocolpos. This rare clinical variant made our MRI diagnosis of obstructed hemivagina, as well of the entire OHVIRA syndrome, ineffective. We did not find OHVIRA cases in the literature with a single septate uterus and single cervix, associated with obstructed hemivagina diagnosed during and after labor and presented with intrapartal rupture of hemivagina. Because of lack of guidelines, the final decision about management of the labor in such rare cases of OHVIRA syndrome is difficult.

Vaginal delivery through annular placenta -- case report.

Annular placenta is an extremely rare morphological type of human placenta. It is commonly related to placental vessel abnormalities frequently causing antenatal and postnatal hemorrhage and operative delivery. Gravida 4 para 1 had an uneventful course of pregnancy and normal vaginal delivery followed by moderate postpartum hemorrhage. Hemorrhage was found to be local in origin but the placenta was annular in shape and the newborn was delivered through one of the openings. Annular placenta was not recognized before delivery. Its implantation site was in the lower uterine segment but high enough to allow the passage of the fetus through its annular defect and vaginal birth. To our knowledge, this is a first report of annular placenta ending in normal vaginal delivery.

Measuring the volume of uterine fibroids using 2- and 3-dimensional ultrasound and comparison with histopathology.

The aim of this study was clinical testing of the reliability and usability of three-dimensional (3D) and two-dimensional (2D) ultrasound (US) technology. The ultimate aim and purpose of this study was to establish ultrasound methods, standards and protocols for determining the volume of any gynecologic organ or tumor. The study included 31 women in reproductive age and postmenopause. All patients were examined with a RIC 5-9 3D-endovaginal probe (4.3-7.5 MHz) on a Voluson 730 Pro ultrasound device. The volume of myomas was measured by using the existing 2D and 3D ultrasound methods on the above mentioned device. All patients underwent myomectomy or hysterectomy due to clinically and ultrasonographically diagnosed uterine myomas indicating operative intervention. After the operation, the pathologist determined the volume of removed myomas by measuring them in a gauge bowl containing water, i.e. using Archimedes' principle (lift), serving as the control group with histopathologic diagnosis. A total of 155 myoma volumes were processed on 2D display, 31 myoma volumes were preoperatively measured on 3D display and 31 myoma volumes were measured by the pathologist. The values of US measurements for each US method were expressed as mean value of all measurements of myoma volumes. Statistical processing of the results and Student's t-test for independent samples revealed that the 2nd examined US method (measuring of myoma by using an ellipse and the longer tumor diameter) and 4th examined US method (measuring of myoma by using the longer and shorter tumor diameters together with establishing their mean values) in 2D US technique, as well as the 6th examined US method in 3D US technique showed no significant measurement differences in comparison with control measurement in a gauge bowl containing water (p < 0.05), indicating acceptability of the US methods for verifying tumor volumes. The standard error in determining the volume of myomas by the above US methods varied between 15% and 25%, so it is concluded that these three methods can be used in clinical practice to determine tumor volumes, in this case uterine myomas. The 3D MultiPlane method proved to be the most reliable method of determining the volume of uterine myomas.