Outpatient Procedures

Amniocentesis

Prenatal diagnosis of chromosomal disease involves screening after which an invasive test may be offered.
Amniocentesis involves passing a fine needle through your abdominal wall into the amniotic fluid around the baby and drawing out a small quantity for testing.

Why perform an amniocentesis?

Usually, a non-invasive screening test will have been performed which suggests that you are at greater risk than the general population of having a baby with a chromosomal abnormality. Occasionally, there will be another test that is suggested such as a chemical test.
The screening test may be no more than an assessment of your age or your past history. Commonly it will be a blood test often called the "Double test", "Triple test" or even "Quadruple test", or an ultrasound measurement of the "nuchal fold" of the fetus (a fold of skin behind the head).
The purpose of amniocentesis is to identify affected babies so that a termination of the pregnancy can be offered.

Do I need any preparation?

Your midwife or ante-natal counsellor will have discussed the reasons behind the recommendation. The doctor who is going to perform the operation will discuss it too. It is a very tiny procedure and no special preparation is required other than attending with a full bladder for the ultrasound. If you are very anxious, please talk to your midwife who can reassure you or, perhaps, get a doctor to prescribe something to calm you.

How is it performed?

An ultrasound scan is performed to see where the baby is lying and where there is a suitable pool of liquor (fluid around the baby). This may be performed by an ultrasonographer or the doctor. A very fine needle is inserted so that the tip is in the pool of liquor and the scanner is usually used to confirm the position. The needle is so fine that you will hardly feel it. Local anaesthetic can be used to numb the skin but I believe that inserting it hurts more than the procedure. A small volume of fluid is drawn out and sent away for testing.
Afterwards, you are asked to rest for a short while before you go home.

Are there any serious risks?

It is very rare for the mother to suffer more than a little discomfort at the time of the procedure. This may last a day or two but should not need more than paracetamol to relieve it.
Occasionally she might notice a little bruising at the puncture site.
However, for every 100 women who have an amniocentesis, one will miscarry. (A 1% risk). Some of these would have happened anyway as the fetus was abnormal. Some may be caused by the procedure in some way. In our unit at QEII Hospital, our last audit showed that all the miscarriages in the year were, in fact, abnormal.
If you are Rhesus Negative, there is a risk of being immunised against Rhesus positive blood and so you are given an injection of anti-D immunoglobulin following the procedure. This risk was discovered before the days of ultrasound for all. It was common, then, to pierce the placenta (afterbirth). Now that we can see where it is, this risk is probably extremely low.
There is about a 1% risk that fetal cells will fail to grow and no result is possible. A repeat test would normally be offered.

When will I know the result?

If the amniocentesis was done to check the baby's chromosomes, we offer a rapid test (FISH or PCR) which can give a result for Down's, Edward's and Patau's syndromes in about three working days. This type of testing has a small failure rate.
The full Culture result is available in approximately two weeks. This is reliable, but there is a remote possibility (less than 1 in 2000) that it could fail to detect a small chromosomal abnormality.
The length of time needed for certain special tests (e.g. DNA or genetic testing is variable and will be discussed with those individuals who need the tests.
We appreciate that waiting for the result can be an anxious and distressing time. We will not intrude, but please contact your midwife or one of the support organisations if you need a talk.
Ante-Natal Results and Choices: Website: www.arc-uk.org Helpline: 0207 631 0285
Down's Syndrome Association: Website: www.dsa-uk.com/frameset.htmHelpline: 0208 682 4001

Circumcision

There is no medical reason to circumcise the Newborn. However there are many religious and social indications.
Probably the only indication for circumcision is infection under the prepuce (foreskin) leading to swelling and pain, closure over the end of the glans penis (phimosis) or behind the glans (paraphimosis). However, many societies have adopted the practice, ostensibly for reasons of hygiene.
I will generally perform circumcision at about 7 or 8 weeks after birth using the Hollister "Plastibell" circumcision device. This gives time for the Paediatrician to check the boy and confirm that all is progressing normally. One would not wish to proceed with circumcision if there were a developmental abnormality or if the child were jaundiced or otherwise unwell.

How is the operation done?

A small cut is made inupper surface ofthe foreskin and the device inserted under the skin. A ligature is then tied tightly around the foreskin in a groove in the device. This causes the skin to shrivel and fall off releasing the device in seven or eight days.
At this age, no anaesthetic is required. I find that if the child is fed just after the procedure, any sign of distress disappears.

Are there any risks or complications?

Bleeding is very rare (other than a tiny amount from the foreskin itself) as the blood supply to the foreskin is on the underside of the penis and is not cut.
Infection is rare with normal ablutions.
Scarring is usually minimal though there may be scarring of the shaft in some cases.
It is very important to notify the surgeon if

- There is unusual swelling
- The plastic ring has not fallen off within eight days
- The ring has slipped onto the shaft of the penis
- Healing does not proceed as described.

Urodynamic Assessment


Investigation
We will normally ask you to keep an “input/output chart”, recording each drink that you take and the volume and nature of that drink and also each time that you empty your bladder and the quantity of urine passed. This, in conjunction with a careful history can point toward an over-active bladder or a defective continence mechanism. An Ultrasound scan of the pelvis may be used to exclude the presence of ovarian cysts or other masses. If there is a suggestion of cystitis, we will usually ask for a “mid stream sample” of urine (MSU) for the laboratory to culture any germs.
We will also ask you to complete a questionnaire about how your problem affects your life.
A Urodynamic Assessment will be arranged and an appointment for you to return to the Urogynaecology Clinic when the result will be available.

Urodynamic Assessment - this is a simple test in which we measure the pressure exerted by the muscle coating of the bladder. In our clinic one of our experienced Sisters performs the test as we can appreciate that some women find it extremely embarrassing. There is no cutting or pain involved. Fine plastic tubes are inserted through the natural passages into the bladder and into the back passage. The pressures are measured by electronic transducers and the patterns of pressure recorded on a computer enabling the doctors to come and assess the bladder function later.

Normal Chart .


Detrosur Instability Chart.


How is this test performed? - When you arrive, you will be asked to empty your bladder on a special commode. We appreciate that in this unusual situation, you may find it difficult and a little delay is to be expected. Just relax and let the natural process occur. After that, you are asked to lie down and the tubes are gently inserted. We then measure the pressure along the length of the urethra (the tube from the bladder to the outside) by gently withdrawing the tube at a steady rate. The catheter is then reinserted and your bladder slowly filled with water from a bag, measuring the pressure exerted by the bladder muscle. You will be asked to tell Sister when you first feel your bladder is full enough to go to the toilet. At this point she will probably ask you to cough and measure the pressure that that produces. She will then fill the bladder a bit more until you have a strong desire to void. Lastly, you will again be asked to empty your bladder, this time with tubes in place to measure pressures. An appointment will be made to return to the Urogynaecology Clinic for one of the doctors to discuss these test findings and arrange any appropriate treatment.

About Your Hysteroscopy

Why would a Hysteroscopy be recommended?
In the past we used to do a D & C (dilatation and curettage), but nowadays we can see inside the womb and therefore be much more accurate in diagnosis. A thin telescope called a hysteroscope is passed very gently through the cervix (the neck of the womb) into the womb itself. By attaching the hysteroscope to a TV camera and either looking at the screen or looking down the telescope, a full clear view of the inside of the womb is seen. At this stage, any disease can be seen and a biopsy (a sample of tissue) taken if necessary.
Hysteroscopy might be suggested to you to find out causes of heavy periods or any other unexplained bleeding, causes of miscarriage or several other less common problems. Using special instruments many operations may be performed inside the womb by hysteroscopy.


What Should I Expect?

When you come into hospital, the doctor will explain the procedure to you and ask you to sign a consent form. At that stage, if there are any questions that you would like to ask about the procedure, please do so. You need to inform either the doctor or the nurse present if you have any allergies or have had bad reactions to drugs or other tests in the past. They would also like to know about any previous surgery or operations you have had performed. You will be asked to take off all your clothes below the waist and wear a hospital gown. During the procedure you will be made to feel as comfortable as possible on an examination couch.
If you are having a general anaesthetic, the anaesthetist will see you and send you off to sleep.
If you are having a local anaesthetic, a nurse will be at your side throughout. She will ask you to rest your legs on two knee supports which are placed on either side near the end of the couch. Very gently, an instrument called a speculum, used when taking a cervical smear, is placed within the vagina to enable the doctor to see the neck of the womb. A warm antiseptic solution is used to clean the surface of the cervix. The hysteroscope is gently placed close to the outer opening of the cervix and at this stage a slight cramping feeling may be felt within the lower part of the tummy, not unlike period pain. The hysteroscope is passed through the cervix into the womb and if you wish you can often watch the progress on a nearby television screen. Any findings seen can be explained at this time. The whole procedure is likely to take about 15-20 minutes. After the examination you will be allowed to rest in a nearby waiting area.

What Complications of Surgery might there be?

These are, in general, very rare for this minor surgery.
Complications of Anaesthesia: The anaesthetist will be able to discuss this with you. Alternatively, look at the Association of anaesthetists web site (see weblinks)
Pain:  This is usually mild and similar to period pain.  It usually needs no more than simple painkillers.
Bleeding: Scraping the lining of the womb will usually cause light bleeding. It is not more than a period in most cases.  Coming into hospital may affect the timing or nature of your next period (if you are still having them)
Infection:  Probably the most common type of infection is a "water infection", though even this is rare.  Occasionally there may be an unpleasant, smelly discharge from the womb suggesting infection there.  It is easily treated with antibiotics.
Blood clots (DVT):  These are extremely rare for such brief and minor surgery.  Unless you have specific risk factors, no prevention is necessary other than getting up and about quickly after the operation.

Complications of this operation in particular

Perforation of the uterus:  Sometimes an instrument makes a small hole in the womb.  This happens about 6 times per 1,000 operations.  It will only very rarely cause further complications unless you are pregnant when the womb is more likely to bleed.  You may have to be observed overnight to be on the safe side.  Occasionally another operation is needed (risk less that 1 per 1,000).
Failed procedure:  This is rare and simply means that it was not possible to see inside the womb.

Going Home

If you are going home after the procedure, it would be advisable that somebody comes to pick you up. It is important to rest quietly at home for the remainder of the day.

When Do I Know The Result?

Immediately after the examination the doctor will usually explain his findings in full. If you have had a general anaesthetic, you will probably find it better to discuss the findings fully at your follow-up consultation when you are fully recovered from the anaesthetic. If a biopsy or polyps have been removed at the time of the procedure, it will be a couple of weeks before the results are available for discussion at your follow-up consultation.

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