Cystorrhaphy 595y

Cystorrhaphy, suture of bladder wound, injury or rupture; complicated Synonyms Suture of bladder rupture complicated by previous surgery Suture of wound, injury, or rupture of bladder Suture of bladder injury complicated by congenital defect CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED Suture of bladder injury Suture of bladder rupture complicated by congenital defect Suture of bladder rupture Suture of bladder injury complicated by previous surgery ID

http://purl.bioontology.org/ontology/T/51865

altLabel

Suture of bladder rupture complicated by previous surgery Suture of wound, injury, or rupture of bladder Suture of bladder injury complicated by congenital defect CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED Suture of bladder injury Suture of bladder rupture complicated by congenital defect Suture of bladder rupture Suture of bladder injury complicated by previous surgery

T LEVEL

CC

TDTK CONCEPT ID

1008302

cui

C0372384 C3867815 C3522855 C3867816 C3514622 C3522854 C3867817 C3867818

Date created

Pre-1990

Inverse of SIB notation

Cystorrhaphy, suture of bladder wound, injury or rupture; simple 51865

prefLabel

Cystorrhaphy, suture of bladder wound, injury or rupture; complicated

REPORTABLE

T

tui

T061

subClassOf

Cystorrhaphy, suture of bladder wound, injury or rupture

Postpartum Hemorrhage in Emergency Medicine 

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Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, E, RDMS, FACEP, FAAEM, FACHE more...

Overview

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Presentation DDx Workup Treatment Medication Updated: Nov 07, 2015

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Practice Essentials

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Background Pathophysiology Frequency Prognosis Patient Education Show All References

Practice Essentials Defining postpartum hemorrhage (PPH) has historically been difficult. Waiting for a patient to meet PPH criteria, particularly in resource-poor settings or in cases of sudden hemorrhage, may delay appropriate intervention. Any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered PPH and managed accordingly. PPH can be divided into 2 types: early (< 24 hours after delivery) and late (24 hours to 6 weeks after delivery). Most cases of PPH (>99%) are early.

Signs and symptoms The clinical history should begin with consideration of signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of PPH, and selecting therapies, as follows. Severity of bleeding:      

Is the placenta delivered? What has been the duration of the third stage of labor? How long has the bleeding been heavy? Was initial postdelivery bleeding light, medium, or heavy? Are symptoms of hypovolemia present? In delayed PPH, what is the bleeding pattern since delivery? Intervention guides:

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Is there a history of transfusion or transfusion reaction? What was the reason for transfusion? Past medical history Allergies Predisposing factors and potential etiology:

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History of PPH Gravity, parity, length of most recent pregnancy, history of multiple gestations Number of fetuses for the most recent pregnancy Pregnancy complications Spontaneous versus manual delivery of the placenta Vaginal delivery versus cesarean delivery, current and past Cesarean delivery – Planned in advance, decided on after a failed vaginal delivery attempt, or performed on an emergency basis Other uterine surgeries Personal or family history of bleeding disorder

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Medications Vaginal penetration since delivery Signs or symptoms of infection Other information helpful for continued management Time and location of delivery, and any assistant(s) involved Location and provider of prenatal care Health of infant at delivery and any complications or concerns before, during, or after delivery Past surgical history The physical examination should focus on determining the cause of the bleeding. Important organ systems to assess include the following:

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Pulmonary (pulmonary edema) Cardiovascular (heart murmur, tachycardia, strength of peripheral pulses) Neurologic (mental status changes from hypovolemia) Specifically, examination should include the following:

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Abdominal examination Perineal examination Speculum examination of the cervix and vagina Bimanual examination Placental examination See Presentation for more detail.

Diagnosis Laboratory studies that may be helpful include the following:       

Complete blood count (CBC) with hemoglobin and hematocrit Coagulation studies Electrolytes Blood urea nitrogen (BUN) and creatinine Type and crossmatch Liver function tests (LFTs), amylase, lipase Lactate Imaging studies to be considered include the following:

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Ultrasonography – This is a fast and helpful modality for imaging pelvic structures and should be the first-line study for pelvic pathology  Computed tomography (CT) – This may be a helpful follow-up study when ultrasonography is not diagnostic and may also be the first-line study when a pelvic hematoma or abscess is suspected  Magnetic resonance imaging (MRI) – This study can help determine whether a fluid collection (hematoma or abscess) is intrauterine or extrauterine when ultrasonography or CT does not; it can also help to distinguish a placenta accreta from simple retained products of conception See Workup for more detail.

Management Prehospital care includes the following:  

Primary survey of the mother (vital signs, ABCs) Immediate interventions as appropriate – Gentle massage of the uterine fundus; fluid resuscitation with crystalloids; packing of any visible perineal lacerations; oxytocin  Minimal measure necessary on scene to stabilize the mother and baby for transport and further care Emergency department care includes the following: 

History and physical examination according to acute life algorithms

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Immediate OB/GYN consultation Primary survey (ABCs) Laboratory studies (including blood cultures if the patient is febrile or the vaginal blood/discharge is malodorous)  Secondary survey – Focused physical examination; bedside ultrasonography (FAST)  Interventions to address specific presentations as appropriate – Uterine atony; uterine rupture; trauma; retained placental tissue; uterine inversion; thrombosis Immediate consultation with an OB/GYN is vital. If no OB/GYN is available, a general surgeon should be consulted. Direct with the blood bank is essential for assuring timely arrival of any blood products ordered.

Hysteroscopy 

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Author: John C Petrozza, MD; Chief Editor: Michel E Rivlin, MD more...

Overview Workup Treatment Updated: Dec 30, 2015

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Background

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History of the Procedure Indications Relevant Anatomy Contraindications Show All Tables References

Background Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. The basic hysteroscope is a long, narrow telescope connected to a light source to illuminate the area to be visualized. With a patient in the lithotomy position, the cervix is visualized by placing a speculum in the vagina. The distal end of the telescope is ed into a dilated cervical canal, and, under direct visualization, the instrument is advanced into the uterine cavity. A camera is commonly attached to the proximal end of the hysteroscope to broadcast the image onto a large video screen. Other common modifications are inflow and outflow tracts included in the shaft of the telescope for fluids. Media, such as sodium chloride solution, can be pumped through a hysteroscope to distend the endometrial cavity, enabling visualization and operation in an enlarged area. Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical problems. Hysteroscopic polypectomy, myomectomy, and endometrial ablation are just a few of the commonly performed procedures. Given their safety and efficacy, diagnostic and operative hysteroscopy have become standards in gynecologic practice.

Equipment Hysteroscopes The telescope consists of 3 parts: the eyepiece, the barrel, and the objective lens. The focal length and angle of the distal tip of the instrument are important for visualization (as are the fiberoptics of the light source).

Angle options include 0°, 12°, 15°, 25°, 30°, and 70°. A 0° hysteroscope provides a panoramic view, whereas an angled one might improve the view of the ostia in an abnormally shaped cavity. Hysteroscopes are available in different styles, including rigid and flexible (used most commonly in clinical settings) hysteroscopes, hysteroscopes, and microcolpohysteroscopes. The diameter of each instrument varies and is an important consideration. The requirement of a sheath for input-outflow of distention media increases the size of the hysteroscope. Rigid hysteroscopes Rigid hysteroscopes are the most commonly used instruments. Their wide range of diameters allows for inoffice and complex operating-room procedures. Of the narrow options (3-5 mm in diameter), the 4-mm scope offers the sharpest and clearest view. It accommodates surgical instruments but is small enough to require minimal cervical dilation. In addition, patients tolerate this instrument well with only paracervical block anesthesia. Rigid scopes larger than 5 mm in diameter (commonly 8-10 mm) require increased cervical dilation for insertion. Therefore, they are most frequently used in the operating room with intravenous (IV) sedation or general anesthesia. Large instruments include an outer sheath to introduce and remove media and to provide ports to accommodate large and varied surgical instruments. Flexible hysteroscopes The flexible hysteroscope is most commonly used for office hysteroscopy. It is notable for its flexibility, with a tip that deflects over a range of 120-160°. Its most appropriate use is to accommodate the irregularly shaped uterus and to navigate around intrauterine lesions. It is also used for diagnostic and operative procedures. During insertion, the flexible contour accommodates to the cervix more easily than does a rigid scope of a similarly small diameter. The view was initially described as having a ground-glass quality, which was markedly less desirable than the view obtained with rigid scopes.[1] New, digitally enhanced scopes now offer similar image quality to a rigid hysteroscope lens. Light source Each hysteroscope is attached to an internal or external light source for illumination at the distal tip. Energy sources include tungsten, metal halide, and xenon. A xenon light source with a liquid cable is considered the superior option.[2, 3] Surgical instruments Surgical instruments are available in both rigid and flexible forms to be inserted through the operating channels of the scopes. Examples of surgical instruments and their uses are listed below:        

Scissors - To incise a septum, excise a polyp, or lyse synechiae Biopsy forceps - To perform directed biopsy for pathologic review Grasping instruments - To remove foreign bodies Roller ball, barrel, or ellipsoid - To perform endometrial ablation and/or desiccation (This instrument is used with a resectoscope.) Loop electrode - To resect a fibroid or polyp or endometrium (This instrument is used with a resectoscope.) Scalpel - To cut or coagulate tissue, with high power density at its tip (This instrument is used with a resectoscope.) Vaporizing electrodes – To destroy endometrial polyps, fibroids, intrauterine adhesions, and septa; also used for endometrial ablation (This instrument is used with a resectoscope.) Morcellator – To cut and remove endometrial polyps or fibroids Improvements in hysteroscope design have improved the effectiveness of the inflow-outflow channels and of specific operating instruments. For example, the Chip E-Vac System (Richard Wolf Medical Instruments Corporation, Vernon Hill, Ill) incorporates a suction channel and a pump to aid in removing chips of tissue during resection. This feature improves visibility and may decrease time otherwise spent emptying the pieces from the endometrial cavity.

Another instrument in the forefront is a hysteroscopic morcellator (Smith & Nephew, Inc, Andover, Mass), which may reduce myomectomy and polypectomy time by morcellating and removing tissue in 1 movement under direct visualization. It requires cervical dilation to 9 mm. A new hysteroscopic morcellating system called MyoSure (Interlace Medical, Inc, Framingham, Mass) is reported to work just as well, removing submucosal fibroids up to 3 cm in diameter, with a unit that only requires cervical dilation to 6 mm. This smaller diameter suggests it may be used in an office setting.

Energy sources and uses Monopolar and bipolar electricity, as well as laser energy, all have uses in hysteroscopy. Monopolar cautery The resectoscope is a specialized instrument often used with a monopolar, double-armed electrode and a trigger device for use in hypotonic, nonconductive media, such as glycine. It cuts and coagulates tissue by means of desiccation with resistive heating.[4] The depth of thermal damage is based on several factors: endometrial thickness; speed, pressure, and duration of during motion; and power setting. [5, 4] A thin electrode can cut tissue, whereas one with a large surface area, such as a ball or barrel, is best suited for coagulation.[6] Bipolar cautery The VersaPoint system (Gynecare, Inc, Somerville, NJ), uses bipolar circuitry for electrosurgery, which can be performed in isotonic conductive media. This system includes a spring tip for hemostatic vaporization of large areas, a ball tip for precise vaporization, and a twizzle tip for hemostatic resection and morcellation of tissue. There is also a cutting loop similar to traditional resectoscopy.[4] Bipolar resectoscopes have been designed by both Karl Storz (Tuttlingen, ) and Richard Wolf Medical Instruments Corporation (Vernon Hill, Ill). The latter has developed the Princess (Petite Resectoscope Including E-Line and S-Line Systems), a 7 mm resectoscope — the smallest bipolar resectoscope available. In addition, the Chip E-Vac System (Richard Wolf Medical Instruments Corporation, Vernon Hill, Ill) can be used with bipolar and monopolar energy. Laser techniques Several fiberoptic lasers are available for gynecologic use, including potassium-titanyl-phosphate (KTP), argon, and Nd:YAG lasers. They all have different wavelengths, though the KTP and argon lasers have similar properties.

Media The use of media is critical for panoramic inspection of the uterine cavity. The medium opens the potential space of the otherwise narrow uterine cavity. Intrauterine pressures needed to adequately view the endometrium are proportional to the muscle tone and thickness of the uterus. The refractive index of each medium affects magnification and visualization of the endometrium. Gases Carbon dioxide (CO2) is rapidly absorbed and easily cleared from the body by respiration. The refractory index of CO2 is 1.0, which allows for excellent clarity and widens the field of view at low magnification. The gas easily flows through narrow channels in small-diameter scopes, making it useful for office-based diagnostic hysteroscopy. However, this method offers no way to clear blood from the scope. With CO2, a hysteroscopic insufflator is required to regulate flow and limit maximal intrauterine pressure. (Note that laparoscopic insufflators are not safe.) A flow rate to 40-60 mL/min at a maximum pressure of 100 mm Hg is generally accepted as safe. Pressures and rates higher than this can result in cardiac arrhythmias, embolism, and arrest.[2] Fluids

The advantage of fluid over gas is the symmetric distention of the uterus with fluid and its effective ability to flush blood, mucus, bubbles, and small tissue fragments out of the visual field. Both low-viscosity and highviscosity fluid media can be used for distention. A pressure of 75 mm Hg is usually adequate for uterine distention; rarely is more than 100 mm Hg required, and pressures higher than this can increase the risk of intravasation of medium.[7] Various delivery systems are designed to suit the many media used for uterine distention and to accurately record volumes of inflow and outflow. This recording is important because fluid can leave the uterus by means of intended efflux systems, cervical or tubal leakage, or intravasation. Preventing excess absorption of hypotonic fluids is essential for patient safety. The simplest delivery system is a syringe that most often is used with high-viscosity Dextran 70. Hanging, gravity-fed containers to deliver low-viscosity fluids can be raised or compressed with a cuff; however, these can be unreliable in estimating intrauterine pressures. Pumps are available to monitor pressure and volume for low-viscosity media. Media then usually flows into the uterine cavity through an inner sheath around the hysteroscope. A perforated outer sheath is used for collection or efflux of media. This design creates laminar flow, which keeps the visual field clear.[1] As noted above, new, sophisticated efflux mechanisms have been designed to improve the clearance of both blood and particulate matter from the operating space. Closed systems actively return fluid to a pump reservoir, whereas open systems allow free flow of the medium out the cervix into a collection bag for volume monitoring. 0.9% sodium chloride solution and lactated Ringer solution Normal sodium chloride solution and lactated ringer solution are isotonic, conductive, low-viscosity fluids that can be used for diagnostic hysteroscopy and for limited operative procedures. Surgical procedures using mechanical, laser, monopolar (only with the ERA sleeve or Opera Star systems), and bipolar energy (VersaPoint system) are safe (see Surgical instruments and Energy sources and uses above). Two major disadvantages associated with these solutions include (1) their miscibility with blood, which obscures visibility with bleeding, leading to the need for increased volumes to clear the operative field, and (2) their excellent conductivity, which precludes procedures that use standard monopolar electrosurgery. 5% Mannitol, 3% sorbitol, and 1.5% glycine The hypotonic, nonconductive, low-viscosity fluids 5% mannitol, 3% sorbitol, and 1.5% glycine improve visualization when bleeding occurs. They can be used in diagnostic as well as operative hysteroscopy. (Note that 5% mannitol can be used only with monopolar operative procedures.) All impose a risk of volume overload and hyponatremia from intravascular absorption (particularly > 2 L). Therefore, careful fluid monitoring is required during their use. When intravasation of 5% mannitol occurs, it stays in the extracellular compartment; treatment of this condition is discontinuing the procedure and istering diuretics.[7] 3% sorbitol is broken down into fructose and glucose and therefore has an added risk of hyperglycemia when absorbed in excess. Use 1.5% glycine with caution in patients with impaired hepatic function because glycine is metabolized to ammonia. Dextran 70 The only high-viscosity medium available, Dextran 70 (Hyskon; Pharmacia Laboratories, Piscataway, NJ) is a nonelectrolytic, nonconductive fluid that can be used in all types of procedures. It is immiscible with blood and minimally leaks through the cervix and tubes, allowing for excellent visibility during surgical procedures. Like the other nonelectrolytic fluids, however, prevent absorption of more than 500 mL to avoid fluid overload. With each 100 mL of Dextran 70 absorbed, the intravascular volume increases by 800 mL. [7, 8] Allergic reactions and anaphylaxis, fluid overload, disseminated intravascular coagulopathy, and destruction of instruments are adverse effects of this medium.