Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study.

BACKGROUND: Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. METHODS: Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. RESULTS: Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40-0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. CONCLUSION: The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.

Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period.

INTRODUCTION: Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS: A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS: During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS: The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.

Tapentadol versus oxycodone analgesia and side effects after laparoscopic hysterectomy: A randomised controlled trial.

BACKGROUND: Tapentadol is an opioid, which acts as a µ-opioid receptor agonist and inhibits noradrenaline reuptake in the central nervous system. This dual mechanism of action results in synergistic analgesic effects and potentially less side effects. This has been shown in treatment of chronic pain but postoperative studies are sparse. OBJECTIVES: The main aim was to compare the analgesic effect of tapentadol with oxycodone after laparoscopic hysterectomy. Opioid side effects were recorded as secondary outcomes. DESIGN: Randomised, blinded trial. SETTING: Single-centre, Oslo University Hospital, Norway, December 2017 to February 2019. PATIENTS: Eighty-six opioid-naïve American Society of Anesthesiologists physical status 1 to 3 women undergoing laparoscopic hysterectomy for nonmalignant conditions. INTERVENTION: The patients received either oral tapentadol (group T) or oxycodone (group O) as part of multimodal pain treatment. Extended-release study medicine was administered 1 h preoperatively and after 12 h. Immediate-release study medicine was used as rescue analgesia. MAIN OUTCOME MEASURES: Pain scores, opioid consumption and opioid-induced side effects were evaluated during the first 24 h after surgery. RESULTS: The groups scored similarly for pain at rest using a numerical rating scale (NRS) 1 h postoperatively (group T 4.4, 95% CI, 3.8 to 5.0, group O 4.6, 95% CI, 3.8 to 5.3). No statistically significant differences were found between the groups for NRS at rest or while coughing during the 24-h follow-up period (P = 0.857 and P = 0.973). Mean dose of oral rescue medicine was similar for the groups (P = 0.914). Group T had significantly lower odds for nausea at 2 and 3 h postoperatively (P = 0.040, P = 0.020) and less need for antiemetics than group O. No differences were found for respiratory depression, vomiting, dizziness, pruritus, headache or sedation. CONCLUSION: We found tapentadol to be similar in analgesic efficacy to oxycodone during the first 24 h after hysterectomy, but with significantly less nausea. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03314792.

Transvaginal Sonographic Imaging and Associated Techniques for Diagnosis of Ovarian, Deep Endometriosis, and Adenomyosis: A Comprehensive Review.

Imaging of endometriosis and in particular deep endometriosis (DE) is crucial in the clinical management of women facing this debilitating condition. Transvaginal sonography (TVS) is the first-line imaging method and magnetic resonance imaging (MRI) may provide supplemental information. However, the delay in diagnosis of up to 10 years and more is of concern. This problem might be overcome by simple steps using imaging with emphasis on TVS and referral to tertiary care. Finally, TVS is crucial in mapping extent and location of disease in planning surgical therapy and counseling women regarding various therapeutic options. This review presents the available data on imaging of endometriosis with a focus on TVS and MRI for DE, adenomyosis, and ovarian endometriomas including endometriomas in pregnancy as well as the use of "soft markers." The review presents an approach that is in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement.

Hysterectomy in Norway 2008-18. / Hysterektomi i Norge 2008­18.

BACKGROUND: Hysterectomy is a common gynaecological procedure. No Norwegian guidelines for the choice of hysterectomy surgical method exist, but international guidelines recommend minimally invasive surgery. The objective of this study was to investigate the kinds of surgical methods that were used for hysterectomies in the period 2008-18. Furthermore, we wished to identify the scope of robot-assisted hysterectomies and to find out whether salpingectomies are undertaken on a benign indication in Norway. MATERIAL AND METHOD: The study is based on data from the Norwegian Patient Registry. Relevant variables for all gynaecological hysterectomies in Norway in the period 2008-18 were collected at the individual level. RESULTS: During the study period, 53 178 hysterectomies were registered in the Norwegian Patient Registry. The proportion of hysterectomies that were performed with minimally invasive techniques increased from 41 % to 73 % during the study period. Robot-assisted hysterectomies accounted for 15 % of the total in 2018. The number of concomitant salpingectomies also increased during the period, and were performed in more than half of all hysterectomies undertaken on a benign indication. INTERPRETATION: Norwegian gynaecologists largely follow international guidelines and recommendations regarding minimally invasive hysterectomy and salpingectomy. Although the total proportion of minimally invasive hysterectomies is now relatively high, there are considerable variations between the different health trusts.

Claims for compensation from women with cervical cancer in Norway-A retrospective, descriptive study of a 12-year period.

INTRODUCTION: In Norway, all patient-reported claims for compensation are evaluated by The Norwegian System of Patient Injury Compensation (NPE). The number of claims from women with cervical cancer is rising, and the approval rate is high. Our aim was to study claims for compensation from women with cervical cancer to identify the type of failures, when, during the time-course of treatment, the medical failures occurred, and the consequences of the failures. MATERIAL AND METHODS: A retrospective, descriptive study of claims for compensation to NPE from cervical cancer patients during a 12-year period, from 2007 through 2018. We used anonymized medical expert statements and summaries of NPE cases. RESULTS: In all, 161 women claimed compensation for alleged medical failure related to cervical cancer. Compensation was approved for 100 (62%) women. Mean age at the time of alleged failure was 37.5 years (SD ±9.9). The main reasons why women sought medical attention were routine cervical screening (56%), or vaginal bleeding or discharge (30%). In approved cases, incorrect evaluation of cytology and histology was the cause of most failures (72%). Mean delay of cervical cancer diagnosis for approved cases was 28 months (SD ±22). Treatment not in accordance with guidelines was the cause of failure in 2% of the cases, and failure during follow up was the cause of failure in 12%. Consequences of the failures were as follows: worsening of cancer prognosis (89%), treatment-induced adverse effects, such as loss of fertility (43%) and/or loss of ovarian function in premenopausal women (50%), and permanent injury after chemo-radiation (27%). Seven women (7%) died, most probably as a consequence of the failure. CONCLUSIONS: The main cause of medical failure in women with cervical cancer was incorrect pathological diagnosis. The main consequences of failures were worsening of cancer prognosis and treatment-induced adverse effects. Increased focus on the quality of pathological examinations, and better routines in all parts of the cervical examinations might improve patient safety for women in risk of cervical cancer.

Noninvasive Diagnosis of Adenomyosis: A Structured Review and Meta-analysis of Diagnostic Accuracy in Imaging.

OBJECTIVE: To conduct a systematic review and meta-analysis to evaluate imaging methods used to diagnose adenomyosis. DATA SOURCES: A thorough search was completed through the Cochrane Central Register of Controlled Trials, EMBASE, and PubMed or MEDLINE databases from January 2000 to June 2019. METHODS OF STUDY SELECTION: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Quality Assessment of Diagnostic Accuracy Studies 2 tool, studies reporting the diagnostic accuracy of an imaging method and histopathology as a reference standard were selected and prospectively registered in the International Prospective Register of Systematic Reviews. Statistical analysis was performed using the R-package Meta-Analysis of Diagnostic Accuracy. TABULATION, INTEGRATION, AND RESULTS: Of the 1168 records identified, 10 studies were included in the meta-analysis, and these included 827 patients undergoing 2- or 3-dimensional transvaginal ultrasound (TVUS) and 317 patients undergoing magnetic resonance imaging (MRI). The risk of bias was low or unclear for all Quality Assessment of Diagnostic Accuracy Studies domains. The overall prevalence of adenomyosis was 40%. Overall MRI, 2-dimensional TVUS, 3-dimensional TVUS, and TVUS had the following aggregated diagnostic qualities (95% confidence interval): sensitivity of 78% (70%-84%), 74% (68%-79%), 84% (77%-89%), 78% (73%-82%); specificity of 88% (83%-92%), 76% (71%-79%), 84% (77%-89%), 78% (74%-81%); positive likelihood ratio of 6.8 (4.5%-10%), 3 (2.5%-3.7%), 5.2 (3.6%-7.4%), 3.5 (3%-4.2%); negative likelihood ratio of 0.25 (0.18%-0.35%), 0.34 (0.27%-0.43%), 0.19 (0.13%-0.28%), 0.28 (0.23%-0.34%); and pooled area under the operator curve of 0.77, 0.7, 0.83, 0.73, respectively. The pooled area under the operator curve for all modalities was not significantly different (all: p ≥.4). CONCLUSION: As a result of the systemic review and meta-analysis, we identified TVUS and MRI as good and comparable noninvasive imaging methods for diagnosing adenomyosis, leading us to recommend TVUS as the first-line diagnostic imaging method and MRI as a second-line method, if TVUS is inconclusive.

Women's satisfaction with midwife-led continuity of care: an observational study in Palestine.

OBJECTIVES: A midwife-led continuity model of care had been implemented in the Palestinian governmental health system to improve maternal services in several rural areas. This study investigated if the model influenced women's satisfaction with care, during antenatal, intrapartum and postnatal period. DESIGN: An observational case-control design was used to compare the midwife-led continuity model of care with regular maternity care. PARTICIPANTS AND SETTING: Women with singleton pregnancies, who had registered for antenatal care at a rural governmental clinic in the West Bank, were between 1 to 6 months after birth invited to answer a questionnaire rating satisfaction with care in 7-point Likert scales. PRIMARY OUTCOME: The mean sum-score of satisfaction with care through the continuum of antenatal, intrapartum and postnatal period, where mean sum-scores range from 1 (lowest) to 7 (highest). SECONDARY OUTCOME: Exclusive breastfeeding. RESULTS: Two hundred women answered the questionnaire, 100 who received the midwife-led model and 100 who received regular care. The median time point of interview were 16 weeks postpartum in both groups. The midwife-led model was associated with a statistically significant higher satisfaction with care during antenatal, intrapartum and postnatal period, with a mean sum-score of 5.2 versus 4.8 in the group receiving regular care. The adjusted mean difference between the groups' sum-score of satisfaction with care was 0.6 (95% CI 0.35 to 0.85), p<0.0001. A statistically significant higher proportion of women who received the midwife-led continuity model of care were still exclusively breastfeeding at the time point of interview, 67% versus 46% in the group receiving regular care, an adjusted OR of 2.56 (1.35 to 4.88) p=0.004. CONCLUSIONS: There is an association between receiving midwife-led continuity of care and increased satisfaction with care through the continuum of pregnancy, intrapartum and postpartum period, and an increased duration of exclusive breastfeeding. TRIAL REGISTRATION NUMBER: NCT03863600.

Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker.

OBJECTIVES: To assess the diagnostic accuracy of a junctional zone (JZ) thickness of ≥ 12 mm and morphological features of the JZ in MRI in diagnosing adenomyosis in a premenopausal study population. METHODS: This single-center, prospective observational study consecutively enrolled 93 premenopausal women suffering from a benign gynecological condition, from September 2014 to August 2016. Institutional review board approval and written consent were obtained. All participants underwent MRI and hysterectomy with a histopathological examination. MR images were evaluated in a blinded fashion by two independent readers. The maximum junctional zone thickness (JZmax), presence of JZmax ≥ 12 mm, and any irregular appearance of the JZ (defined as irregular outer or inner borders, focal thickening, presence of high-intensity signal foci, or fingerlike indentations at the inner border) were documented, and the diagnostic performance was evaluated with the AUC, chi-square test, and multiple regression. RESULTS: Adenomyosis was histopathologically confirmed in 57 (61%) of the women. JZmax was not positively correlated with adenomyosis diagnosis (AUC = 0.57, p = 0.26) and did not differ significantly between those with and without adenomyosis (10.3 vs 10.1 mm, p = 0.88), nor was a cutoff of JZmax ≥ 12 mm (n = 30/57 (53%) vs n = 16/36 (44%), p = 0.29). The presence of an irregular JZ showed the best association with adenomyosis among the evaluated signs (sensitivity 74% (95% CI, 60, 85); specificity 83% (95% CI, 67, 94) (p < 0.001)). CONCLUSIONS: JZmax was not correlated with adenomyosis in the present premenopausal study population, but direct signs of adenomyosis such as irregularities of the JZ provided a good diagnostic accuracy. KEY POINTS: • Measuring the junctional zone thickness is of limited value for diagnosing adenomyosis with MRI and should not be used for diagnosing adenomyosis in premenopausal women with moderate disease severity. • An irregular appearance of the junctional zone, the presence of myometrial cysts, and adenomyoma appear to provide the highest specificity for diagnosing adenomyosis. • A consensus for the definition and reading of the junctional zone is needed.

Improving Maternal and Neonatal Health by a Midwife-led Continuity Model of Care - An Observational Study in One Governmental Hospital in Palestine.

BACKGROUND: From 2013 a midwife-led continuity model of care was implemented in the Nablus region in occupied Palestine, involving a governmental hospital and ten rural villages. This study analysed the relation between the midwife-led model and maternal and neonatal health outcomes. METHOD: A register-based, retrospective cohort design was used, involving 2201 singleton births between January 2016 and June 2017 at Nablus governmental hospital. Data from rural women, with singleton pregnancies and mixed risk status, who either lived in villages that offered the midwife-led continuity model and had registered at the governmental clinic, or who lived in villages without the midwife-led model and received regular care, were compared. Primary outcome was unplanned caesarean section. Secondary outcomes were other modes of birth, postpartum anaemia, preterm birth, birth weight, and admission to neonatal intensive care unit. FINDINGS: Statistically significant less women receiving the midwife-led model had unplanned caesarean sections, 12·8% vs 15·9%, adjusted risk ratio (aRR) 0·80 (95% CI 0·64-0·99) and postpartum anaemia,19·8% vs 28·6%, aRR 0·72 (0·60-0·85). There was also a statistically significant lower rate of preterm births within the exposed group, 13·1% vs 16·8, aRR 0·79 (0·63-0·98), admission to neonatal intensive care unit, 7·0% vs 9·9%, aRR 0·71 (0·52-0·98) and newborn with birth weight 1500 g and less, 0·1% vs 1·1%, aRR 0·13 (0·02-0·97). INTERPRETATION: Receiving the midwife-led continuity model of care in Palestine was associated with several improved maternal and neonatal health outcomes. The findings support further implementation of the model. Implementation research, including randomised studies, would be useful to further investigate the effect and feasibility of the model in a low resource setting. FUNDING: This study was partly funded by the Research Council of Norway through the Global Health and Vaccination Program (GLOBVAC), project number 243706. The implementation received public funding through Norwegian Aid Committee (NORWAC).

Approved claims for compensation from gynecological patients in Norway-What characterizes the cases? A 14-year nationwide study.

INTRODUCTION: The Norwegian System of Patient Injury Compensation (NPE) evaluates all patient-reported claims in Norway. Our aim was to study the cases from gynecological patients approved by NPE in order to identify the main reasons for the injuries, the consequences of the treatment failure for the women, and the time course when the treatment failure occurred. MATERIAL AND METHODS: A retrospective, descriptive study of approved gynecological compensation claims during a 14-year period, based on patient files from NPE. RESULTS: In all, 1454 women claimed compensation for injury related to gynecological treatment in Norway from 2000 to 2013. Compensation was approved for 438 (30.1%) women. Eleven women declined participation in the study and 16 cases were excluded, leaving 411 cases for further analyses. Consent to participate was given by 211 (51.3%) women, who gave full access to all their NPE files. Anonymized resumes and expert statements were used for the 138 (33.6%) women who did not respond and the 62 (15.1%) women who were deceased. Guidelines or good clinical practice were not followed in 40.5% of the cases. The most common reasons for injury were surgical complications (67.6%), delayed (22.4%) and incorrect (17.0%) diagnoses, and failure of communication (11.7%). The main consequences of injuries were need for extensive treatment (64.2%), permanent injury (55.2%) and impaired physical ability (41.9%). Worsening of cancer prognosis occurred in 58 women (14.1%) and death due to treatment failure in 29 (7.1%) women. Most failures occurred during the treatment period (75.2%). CONCLUSIONS: We found that the main reason for injuries in gynecological patients was non-adherence to guidelines or good clinical practice. Surgery-related injuries were most common. Increased focus on adherence to guidelines and surgical skills might improve patient safety for gynecological patients in Norway.

In Vivo Adenomyosis Tissue Sampling Using a Transvaginal Ultrasound-guided Core Biopsy Technique for Research Purposes: Safety, Feasibility, and Effectiveness.

STUDY OBJECTIVE: To determine if it is possible and safe to obtain adenomyosis tissue in vivo without removing the uterus in order to use it for further molecular investigations of adenomyosis, which would allow investigating the pathogenesis of the disease. DESIGN: A prospective cohort study. SETTING: A university hospital. PATIENTS: Eighty-one premenopausal women scheduled for a hysterectomy because of various benign indications were included. INTERVENTIONS: Ultrasound-guided, transvaginal uterine core biopsy samples were obtained, and the required time was registered. Any trauma to the pelvic organs, blood loss, and other complications were documented during the subsequent hysterectomy. Two biopsy samples were analyzed histopathologically to confirm the presence of adenomyosis, and another 2 were snap frozen using liquid nitrogen for use in further research. Laser microscopic dissection and RNA extraction were performed on the collected samples. MEASUREMENTS AND MAIN RESULTS: Biopsy specimens could be obtained in 80 (99%) of the 81 cases. There was no visible trace of the biopsy retrieval in 20 women (25%), perforation of uterine serosa or peritoneum was present in 56 (70%), and ongoing minor bleeding occurred in 4 (5%). The median amount of bleeding was 2 mL (range, 0-200 mL). No serious complications were observed. The procedure took 6.1 ± 1.9 minutes (mean ± standard deviation). Adenomyosis tissue was obtained in 10 (22%) of the 45 cases with adenomyosis. The inner myometrium with the junctional zone was accessible in all cases. It was possible to produce frozen sections, extract RNA, and dissect single adenomyosis glands with laser microscopic dissection. CONCLUSIONS: No serious complications caused by the uterine biopsies were observed. This technique opens up the possibility of investigating early stages of adenomyosis and the inner myometrium containing the junctional zone independent of hysterectomy specimens.

Development of a clinical prediction model for diagnosing adenomyosis.

OBJECTIVE: To develop a multivariate prediction model for diagnosing adenomyosis using predictors available through transvaginal ultrasonography and clinical examinations. DESIGN: Prospective observational single-center study. SETTING: Teaching university hospital. PATIENT(S): One hundred consecutively enrolled premenopausal women aged 30-50 years, undergoing hysterectomy due to a benign condition and not using hormonal treatment. INTERVENTION(S): Preoperative 2-D and 3-D transvaginal ultrasonography investigations were performed, and the results were documented in a standardized form. Clinical information was collected using a questionnaire. Histopathology confirmed the outcome. MAIN OUTCOME MEASURE(S): Diagnostic performance (sensitivity, specificity, area under the curve (AUC)) of a multivariate prediction model for adenomyosis. Independent diagnostic performance of single predictors and their quantitative effect (ß) in the final model. RESULT(S): The final model showed a good test quality (area under the curve [AUC] = 0.86, [95% confidence interval = 0.79-0.94], optimal cutoff 0.56, sensitivity of 85%, specificity 78%). The following nine predictors were included ([sensitivity, specificity, ß] or [AUC, ß]): presence of myometrial cysts (51%, 86%, ß = 0.86), fan-shaped echo (36%, 92%, ß = 0.54), hyperechoic islets (51%, 78%, ß = 0.62), globular uterus (61%, 83%, ß = 0.2), normal uterine shape (83%, 61%, ß = -0.75), thickest/thinnest ratio for uterine wall (0.61, ß = 0.26), maximum width of the junctional zone in sagittal plane (0.71, ß = 0.1), regular appearance of junctional zone (31%, 92%, ß = -1.0), and grade of dysmenorrhea measured on a verbal numerical rating scale (0.61, ß = 0.08). CONCLUSION(S): We have presented a multivariate model for diagnosing adenomyosis that weights predictors based on their diagnostic significance. The reported findings could aid clinicians who are interpreting the heterogeneous appearance of adenomyosis in ultrasonography. CLINICAL TRIAL REGISTRATION NUMBER: NCT02201719.

Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study.

OBJECTIVE: To analyse the current situation of caesarean section in Palestine using the Robson Ten Group Classification System (TGCS). DESIGN: A population-based birth cohort study. SETTING: Obstetrical departments in three governmental hospitals in Gaza. PARTICIPANTS: All women (18 908) who gave birth between 1 January 2016 and 30 April 2017. METHODS: The contributions of each group to the study population and to the overall rate of caesarean section were calculated, as well as the rate of caesarean section in each TGCS group. Differences in proportions between study hospitals were assessed by χ2 test. MAIN OUTCOME MEASURES: The main outcome was the contributions of each group to the overall caesarean section rate. RESULTS: The overall rate of caesarean section was 22.9% (4337 of 18 908), ranging from 20.6% in hospital 1 to 24.6% in hospital 3. The largest contributors to the overall caesarean section rate were multiparous women with single cephalic full-term pregnancy who had undergone at least one caesarean section (group 5, 42.6%), women with multiple pregnancies (group 8, 11.6%) and those with single cephalic preterm labour (group 10, 8.1%). Statistically significant differences in caesarean section rates between the study hospitals were observed in group 1 (nulliparous women with single cephalic full-term pregnancy and spontaneous labour), group 4 (multiparous with single cephalic full-term pregnancy with induced labour or prelabour caesarean section), group 5 (multiparous with single cephalic full-term pregnancy with previous caesarean section) and in group 7 (multiparous with breech presentation). CONCLUSION: Women in groups 5, 8 and 10 were the largest contributors to the overall caesarean section rate in the study hospitals. Efforts to reduce the differences in obstetrical care between hospitals need to be directed towards increasing the proportion of vaginal births after caesarean section and by reducing primary caesarean section in multiple pregnancies and preterm labour.

Differences in rates and odds for emergency caesarean section in six Palestinian hospitals: a population-based birth cohort study.

OBJECTIVE: To assess the differences in rates and odds for emergency caesarean section among singleton pregnancies in six governmental Palestinian hospitals. DESIGN: A prospective population-based birth cohort study. SETTING: Obstetric departments in six governmental Palestinian hospitals. PARTICIPANTS: 32 321 women scheduled to deliver vaginally from 1 March 2015 until 29 February 2016. METHODS: To assess differences in sociodemographic and antenatal obstetric characteristics by hospital, χ2 test, analysis of variance and Kruskal-Wallis test were applied. Logistic regression was used to estimate differences in odds for emergency caesarean section, and ORs with 95% CIs were assessed. MAIN OUTCOME MEASURES: The primary outcome was the adjusted ORs of emergency caesarean section among singleton pregnancies for five Palestinian hospitals as compared with the reference (Hospital 1). RESULTS: The prevalence of emergency caesarean section varied across hospitals, ranging from 5.8% to 22.6% among primiparous women and between 4.8% and 13.1% among parous women. Compared with the reference hospital, the ORs for emergency caesarean section were increased in all other hospitals, crude ORs ranging from 1.95 (95% CI 1.42 to 2.67) to 4.75 (95% CI 3.49 to 6.46) among primiparous women. For parous women, these differences were less pronounced, crude ORs ranging from 1.37 (95% CI 1.13 to 1.67) to 2.99 (95% CI 2.44 to 3.65). After adjustment for potential confounders, the ORs were reduced but still statistically significant, except for one hospital among parous women. CONCLUSION: Substantial differences in odds for emergency caesarean section between the six Palestinian governmental hospitals were observed. These could not be explained by the studied sociodemographic or antenatal obstetric characteristics.

Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine.

OBJECTIVES: To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience. DESIGN: A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention. SETTING: All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion. PRIMARY AND SECONDARY OUTCOMES: Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models. RESULTS: 14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care. TRIAL REGISTRATION NUMBER: NCT03145571; Results.

Preoperative evaluation in women with uterine leiomyosarcoma. A nationwide cohort study.

INTRODUCTION: The goal of this study was to assess the sensitivity of different preoperative diagnostic tools used in women with uterine leiomyosarcomas. MATERIAL AND METHODS: Retrospective cohort study of all women with verified uterine leiomyosarcoma in Norway in the period 2000 to 2012. Data were collected from the Cancer Registry of Norway and medical records. RESULTS: There were 212 women diagnosed with uterine leiomyosarcoma in the 13-year period. Histopathological examinations by fractional curettage or endometrial biopsies verified malignancy in 55/142 (38.7%). MRI suggested malignancy in 45/55 (81%) of the examinations. CT evaluations indicated suspected malignancy in 64/107 women (59.8%). Biomarkers had low sensitivity for leiomyosarcoma, but suggested more advanced stage disease when high values were detected. Stage IV disease was present in 53.1% versus 25.5% (p = 0.01) of women with CA 125 values above 35 kU/L, compared with women with normal CA 125 values. In 115/212 (54.2%), leiomyosarcoma was only diagnosed postoperatively by histopathological examination of the removed specimen. CONCLUSIONS: Preoperative diagnostic modalities appear to have low sensitivity for differentiating leiomyosarcoma from fibroids. In Norway, approximately 54% of uterine leiomyosarcoma are unidentified before surgery. MRI evaluation was the imaging modality with the greatest sensitivity in identifying leiomyosarcoma preoperatively.

Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study.

INTRODUCTION: The risk of morcellation of occult uterine leiomyosarcomas (LMS) during laparoscopic procedures has been under scrutiny over recent years. The objective of this study was to assess the operative treatment performed in women with uterine LMS in Norway in 2000-2012, including the number of morcellated LMS. MATERIAL AND METHODS: Retrospective nationwide cohort study. The study participants were all women with histopathologically verified uterine LMS in Norway during 2000-2012. The data were collected from the Cancer Registry of Norway, National Patient Registry and medical records. RESULTS: There were 212 women diagnosed with uterine LMS in Norway in 2000-2012. Mean age at time of diagnosis was 58.1 years (SD ± 12.5). The most frequent symptom in women suffering from LMS was abnormal uterine bleeding [110/212 (51.9%)]. LMS was histopathologically verified in 49/212 (23.1%) preoperatively. In 48/212 (22.6%), a malignant condition was suspected and they were treated accordingly. In 115/212 (54.2%), malignancy was not suspected at time of surgery and the women were treated according to the treatment protocol for fibroids. In only four patients was tissue retrieval by power morcellation conducted, accounting for 1.9% of all LMS cases. CONCLUSIONS: In more than 50% of women suffering from LMS, a malignant diagnosis was not confirmed or suspected prior to surgery. In our material, power morcellation of LMS has not lead to reduced survival. We suggest that power morcellators may be used in surgical treatment of selected cases of premenopausal women with symptomatic, presumed benign uterine leiomyomas.

Assessment of Surgical Competence: Development and Validation of Rating Scales Used for Laparoscopic Supracervical Hysterectomy.

OBJECTIVE: To develop a procedure-specific rating scale for laparoscopic supracervical hysterectomy (LSH), and to compare the construct validity and reliability with a general rating scale in laparoscopic surgery, global operative assessment of laparoscopic skills (GOALS). DESIGN: Prospective interobserver study. In collaboration with an expert group, we developed the procedure-specific rating scale, competence assessment tool for laparoscopic supracervical hysterectomy (CAT-LSH). LSH was performed by gynecologists with different levels of surgical competence levels (13 procedures were performed by inexperienced trainees, 13 by intermediate experienced, and 15 by laparoscopic experts). All procedures were video-recorded. Surgical performance was evaluated in all procedures using both CAT-LSH and GOALS by the surgical assistant, as well as by 2 blinded observers evaluating the video recordings. SETTING: University teaching hospital. PARTICIPANTS: Laparoscopic experts, consultants and gynecological registrars from the Department of Gynecology. RESULTS: There were significant differences between the 3 proficiency groups in both the rating scales. Mean GOALS score evaluated by the operating assistant and the 2 observers were for inexperienced surgeons 16.4 vs. 13.6 (p < 0.01), for surgeons with intermediate experienced 22.6 vs. 19.5 (p < 0.05) and for expert surgeons 26.1 vs. 22.4 (p < 0.01), respectively. Corresponding results for the CAT-LSH scores were 41.0/34.6 (p < 0.01), 49.2/43.1 (p < 0.01), and 58.7/51.1 (p < 0.01), respectively. The interrater reliability measured by the interclass correlation coefficient between the surgical assistant and the 2 blinded observers for GOALS and CAT-LSH were 0.71 and 0.75, respectively. CONCLUSIONS: The GOALS and CAT-LSH appear to have construct validity and high interrater reliability. Assessment of surgical competence during LSH is feasible in daily practice with objective rating scales like CAT-LSH and GOALS.