Consent Advice: Risk Figures Compilation

This post is the collection of all RCOG Consent Advice Papers. These papers are very important from an exam point of view and these numbers are to be memorized by heart. As these questions are very straightforward forward and it is easy to score. The only way to memorize these is to revise as much as possible.

• To date, RCOG has published 14 consent advice papers. To download papers: Click Here 
• All RCOG consent advice papers follow a standard for presenting information on risk, which is given below
• For most of the procedures, Consent Form 1 is used except for Amniocentesis for which Consent Form 3 is used
• Before taking consent, it is a good idea to be familiar with the basics of Consent. This blog post Medical Law & Ethics might be helpful in this regard.
• I have compiled this information in the form of tables and tried to give risks in different forms (percentages/fractions) as the same fact can be tested in different ways
• I hope you find this post helpful. Suggestions to improve future posts are welcome

Thanks

Presenting Information on risk

Term	Equivalent numerical ratio	Colloquial equivalent
Very common	1/1 to 1/10	A person in family
Common	1/10 to 1/100	A person in street
Uncommon	1/100 to 1/1000	A person in village
Rare	1/1000 to 1/10 000	A person in small town
Very rare	Less than 1/10 000	A person in large town

Consent Advice #1 Diagnostic Hysteroscopy Under GA 

Serious Risks
Overall	2:1000 or 1:500 or 0.2% (uncommon)
Damage to uterus	Uncommon
Damage to bowel, bladder or major blood vessels	Rare
Failure to gain entry	Uncommon
Infertility	Rare
Death	3-8/100 000 Very rare
Frequent Risks	Infection Bleeding

Consent Advice #2 Diagnostic Laparoscopy

Serious Risks
Overall	2:1000 or 1:500 or 0.2% (uncommon)
Damage to bowel, bladder or major blood vessels	Uncommon 15% bowel injuries → might not diagnosed at time of laparoscopy
Failure to gain entry
Death	3-8/100 000 Very rare
Frequent Risks	Wound Bruising Shoulder-tip Pain Wound Gaping Wound Infection

Consent Advice # 3 Female Sterilisation

Significant Risks
Failure resulting in pregnancy After Laparoscopy	2-5:1000 procedures at 10 yrs (uncommon)
After hysteroscopic sterilisation	2:1000 or 1:500 or 0.2%
Greater risk of ectopic pregnancy
Visceral or blood vessel injury	2:1000 or 1:500 or 0.2%(uncommon)
Death	1:12 000 (very rare)
Regret	More common if done under 30 yrs
Failure to complete the procedure
Frequent Risks	Changes in menstruation→ b/c of stopping hormonal contraception  No direct effect

Consent Advice #4 Abdominal Hysterectomy for Benign Conditions

Serious Risks
Overall risk	4:100 or 4% (common)
Damage to  bladder and/or ureter	7:1000 or 0.7% (uncommon)
Damage to bowel	4:10 000 or 0.04% (rare)
Haemorrhage (needing BT)	23:1000 or 2.3% (common)
Return to theatre	7:1000 or 0.7% (uncommon)
Pelvic abscess/infection	2:1000 or 1:500 or 0.2%
VTE/PE	4:1000 or 0.4% (uncommon)
Death within 6 wks	32:100 000 (rare)
Main causes of death	Pulmonary Embolism Cardiac Disease
Frequent Risks	Wound infection, pain, bruising, delayed wound healing or keloid Numbness, tingling or burning sensation around scar Urine frequency & UTI Ovarian Failure

Consent Advice #5 Vaginal Surgery for Prolapse

Serious Risks
Damage to bladder/urinary tract	2:1000 or 1:500 or 0.2% (uncommon)
Damage to bowel	5:1000 or 1:200 or 0.5%
Excessive bleeding (needing BT) or return to theatre	2:100 or 1:50 or 2%
New or continuing bladder dysfunction	Variable
Pelvic abscess	3:1000 or 0.3% (uncommon)
Failure to achieve desired results/ recurrence	Common
Overall risk of death within 6 wks	37:100 000 (rare)
Frequent Risks	Urinary infection, retention and /or frequency Vaginal bleeding Post-op pain & difficulty/pain with intercourse Wound infection

Consent Advice # 6 Amniocentesis (Consent Form 3)

Serious Risks
Failure to obtain a sample of amniotic fluid	Unable to get sample in first tap 7/100 or 7%
Experienced operator	94% success at 1st attempt 0.8% blood stained sample
Miscarriage	1:100 or 1%
Fetal injury	Rare
Maternal bowel injury	Rare
Amniotic fluid leakage	temporary/prolonged plus risk of preterm delivery
Chorioamniotis	<1:1000 or <0.1%
Failure of cell culture in lab
Frequent Risks	Mild discomfort at needle insertion site

Consent Advice # 7 Caesarean Section

• Overall complications→ increased with C/S during labour
• C/S during Labour → 24%
• C/S Planned →16%
• C/S at 9-10cm dilatation → 33%
• C/S at 0-1 cm dilatation →17%

Serious Risks
Maternal
Emergency Hysterectomy	7-8:1000 or 0.7-0.8% uncommon
Need for further surgery at later date	5:1000 or 0.5% uncommon
Admission to ICU	9:1000 or 0.9% uncommon
Thromboembolic disease	4-16:10 000 rare
Bladder injury	1:1000 or 0.1% rare
Ureteric injury	3:10 000 or 0.03% rare
Death	1:12 000 very rare
Future pregnancies
Increased risk of uterine rupture in subsequent pregnancy/delivery	2-7:1000 or 0.2-0.7% uncommon
Increased risk of antepartum stillbirth	1-4:1000 or 0.1-0.4% uncommon
Increased risk of placenta previa/accreta in subsequent pregnancy	4-8:1000 or 0.4-0.8% uncommon
Frequent Risks
Maternal
Persistent wound/abdominal discomfort in first few months	9:100 or 9% common
Increased risk of repeat C/S	1:4 or 25% very common
Readmission to hospital	5:100 or 5% common
Haemorrhage	5:1000 or 0.5% uncommon
Infection	6:100 or 6% common
Fetal
Lacerations	1-2:100 or 1-2% common

Consent Advice #8 Laparoscopic Management of Tubal Ectopic Pregnancy

Serious Risks
Damage to bowel, bladder, uterus or major blood vessels	Up to 15% bowel injuries might not be diagnosed at time of laparoscopy
Failure to gain entry
Overall risk	2:1000 or 1:500 or 0.2%
Death	3-8:100 000
Frequent Risks	Inability to identify an obvious cause Bruising Shoulder-tip pain Wound gaping Wound infection Hernia at site of entry
Persistent trophoblastic tissue (if done salpingotomy)	4-8:100 or 4-8%

Consent Advice # 9 Repair of 3rd/4th Degree Perineal Tears Following Childbirth

Serious Risks
Common	Incontinence of stool and/or flatus
Uncommon	Delivery by C/S in future
Rare	Haematoma Consequences of failure of repair
Very rare	Rectovaginal fistula
Frequent Risks
Fear, difficulty & discomfort in passing stool (immediate postpartum)
Suture migration
Granulation tissue
Fecal urgency	26:100 or 26% very common
Perineal pain & dysparunia	9:100 or 9%
Wound Infection	8:100 or 8%
Urinary Infection

Consent Advice #10 Surgical Management of Miscarriage & Removal of Persistent Placental or Fetal Remains

Serious Risks
Uterine Perforation	1:1000 or 0.1% uncommon May not be diagnosed & may be up to 15:1000 or 0.15% uncommon Use of cervical primer→ associated with increased abdominal pain
Significant trauma to cervix	<1:1000 uncommon
Increased risk of preterm birth in next pregnancy	OR 1.29 PTL <37wks
Frequent Risks
Bleeding lasting up to 2 wks	Very common
Needing Blood transfusion	0-3:1000 or 0-0.3% uncommon
Persistent bleeding >14 days or very heavy bleeding	Investigate for possible incomplete procedure or retained placental and/or fetal tissue
Localise pelvic infection	40:1000 or 4/100 or 4% common
Repeat surgery	3:1000 or 0.3% (uncommon) to 18:1000 or 1.8%(common)
Intrauterine adhesions	3-38:100 or 3-38%
Overall pooled incidence	Any type of management of miscarriage→ 19% or 19:100 Surgical evacuation→16.3-18.5% or 16-18:100
Severity of adhesions Proportional to number of evacuation procedures performed	Mild → 58% Moderate→ 28% Severe →14%
Alternative treatment options	Duration/severity of pain; pelvic infection; anxiety→ same with all methods of miscarriage
Overall success rate (misoprotol+surgery)	80-99%
Effect on fertility	None with any method
Pelvic infection	Expectant→ 2.5% Medical/surgical→ 2.9%
Expectant management vs active/surgical	No different in pain duration Fewer GI effects 14% vs 28% Longer bleeding 4-17 days vs 2-15 days Significantly Greater chance of: BT 1.6% vs 0.4%  Unplanned intervention 35% vs 18%
Overall satisfaction with all methods	Same

Consent Advice #11 Operative Vaginal Delivery

Serious Risks
Maternal
3rd/4th degree tear	1-4:100 or 1-4% in vacuum (common) 8-12:100 or 8-12% with forceps (very common)
Extensive Vaginal/vulval tears	1:10 or 10% in vacuum 1:5 or 20% with forceps
Fetal
Subgaleal Haematoma	3-6 :1000 or 0.3-0.6% uncommon
Intracranial Haemorrhage	5-15 :10 000 uncommon
Facial Nerve Palsy	Rare
Frequent Risks
Maternal
PPH	1-4:10 or 10-40% very common
Vaginal tear/abrasion	Very common
Anal sphincter /voiding dysfunction
Fetal
Forceps marks in face	Very common
chignon/cup marking on scalp (esp in vacuum)	Very common
Cephalhaematoma	1-12:100 or 1-12% common
Facial or scalp lacerations	1:10 or 10% common
Neonatal jaundice/hyperbilirubinaemia	5-15:100 or 5-15% common
Retinal haemorrhage	17-38:100 or 17-38% very common
Extra procedure: episiotomy	5-6:10 or 50-60% in vacuum 9:10 or 90% with forceps

Consent Advice #12 C/S for Placenta Praevia

Serious Risks
Maternal
In all women with placenta praaevia
Emergency Hysterectomy	11:100 or 11% very common
Need for further laparotomy during recovery	75:1000 or 7.5% common
Thromboembolic disease	3:100 or 3% common
Bladder or ureteric injury	6:100 or 6% common
Future placenta praevia	23:1000 or 2.3% common
Massive obstetrical haemorrhage	21:100 or 21% very common
Placenta praaevia & previous C/S Emergency hysterectomy	27:100 or 27% very common
Abnormally adherent placenta (e.g placenta accrete)	Advice that hysterectomy is highly likely
Frequent Risks
Maternal Admission to ICU Infections Blood Transfusion	Fetal Admission to NICU

Consent Advice #13 Morcellation for Myomectomy or Hysterectomy

This is the latest consent advice released in October 2019. It has some important facts in addition to risks associated with the procedure. I have extracted a few of those facts

Morcellation → process of cutting tissues into smaller pieces to facilitate its removal from body

Sarcoma

• Even if surgery is done for a benign condition, exact nature cannot be confirmed until histopathological examination
• No specific bio markers for uterine sarcoma
• UK→ over 400 cases of gynaecological sarcomas diagnosed each year
• Most common sub site → UTERUS
• Most common histological subtype → Leiomyosarcoma
• Age & menopause→ v important factors
• Risk figure for Perimenopausal <50 yrs → 1:1250 to 1:769
• Under 50 yrs → unsuspected sarcoma in presumed benign fibroid → 2.5 per 1000
• Presumed Fibroids → more likely to be sarcomas in peri/post-menopausal, if rapidly growing & solitary 
• Risk rises sharply → around menopause 6 cases per 1000 procedures (1:166)
• Peak age of uterine sarcoma → b/w 50 -55 yrs
• Above 60 yrs → 7.5 to 15.3 per 1000 cases (1:133 to 1:65)
• Before morcellation, → USG or MRI should be performed
• Guiding principle → if sarcoma suspected→ DO NOT do morcellation
• If sarcoma suspected → Perform en bloc resection with total hysterectomy

Serious & frequently occurring risks
Unintended morcellation of uterine sarcoma
Worsening the prognosis of an existing sarcoma	Diagnosis of metastatic sarcoma→ median survival 18 months  Sarcoma mortality higher in morcellated group than in non morcellated Age adjusted 10-yr uterine sarcoma survival → 32% in morcellation treated vs 57% in non-morcellated group
Disseminate fibroids	1:120 (uncommon) to 1:1200 (rare)
Damage to bowel, bladder, ureters & blood vessels	Risk is with laparoscopic hysterectomy/myomectomy

Consent Advice #14 Planned Caesarean Birth

	Planned Caesarean Birth	Planned Vaginal Birth
Risks for the woman
Perineal Tears (3rd/4th degree)	0 / 100 000	560 / 100 000 vaginal births ~1 in 179
Urinary incontinence occuring >1 yr after birth	27 520 / 100 000 ~1 in 4	48 700 / 100 000 ~1 in 2
Fecal incontinence occurring >1 yr after birth	7410 / 100 000  ~1 in 13	No difference for unassisted vaginal birth 15 000 / 100 000 for AVB  ~1 in 7
Urinary tract injury	About 1 / 1000	0 / 1000
Wound infection (may require admission)	2-7 / 100 ~1 In 14-15	Variable infection rates of perineal tear or episiotomy <1 / 100 to 13 / 100 Less likelihood of readmission
Hospital stay	~4 days	~ 2 and a half days
Uterine rupture in future pregnancy or birth	1020 / 100 000 ~1 in 98	40 / 100 000 ~1 in 2500
Emergency Hysterectomy	150 / 100 000 ~1 in 670	80 / 100 000 ~1 in 1250
Placenta Accreta Spectrum in future pregnancy	100 / 100 000  ~1 in 1000	40 / 100 000 ~1 in 2500
Maternal death	24 / 100 000  ~1 in 4200	4 / 100 000  ~1 in 25 000
Anesthesia Risks	As discussed with Anaesthetist	As discussed with Anaesthetist
Risks for the baby
Skin lacerations / cuts	1-2 / 100	Unlikely with unassisted vaginal birth Up to 10 / 100 with AVB
Childhood obesity	4560 / 100 000  ~1 in 22	4050 / 100 000 ~1 in 25
Asthma	1810 / 100 000 ~1 in 55	1500 / 100 000  ~1 in 67
Higher neonatal mortality	50 / 100 000  ~1 in 2000	30 / 100 000 ~1 in 3300

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