Women's experiences of birth and birth options counselling after laparoscopic or open myomectomy.

There is emerging evidence that vaginal birth after open and laparoscopic myomectomy may be safe in many pregnancies, however, there are no studies examining the perspectives of women who have given birth post myomectomy and their preferences regarding mode of birth. We performed a retrospective questionnaire survey of women who had an open or laparoscopic myomectomy followed by a pregnancy within 3 maternity units in a single NHS trust in the UK over a 5-year period. Our results revealed only 53% felt actively involved in the decision making for their birth plan and 90% had not been offered a specific birth options counselling clinic. Of those who had either a successful trial of labour after myomectomy (TOLAM) or elective caesarean section (ELCS) in the index pregnancy, 95% indicated satisfaction with their mode of birth however, 80% would prefer vaginal birth in a future pregnancy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this study is the first to explore the subjective experiences of women who had given birth post laparoscopic or open myomectomy and has highlighted the inadequate involvement of these women in the decision-making process.IMPACT STATEMENTWhat is already known on this subject? Fibroids are the commonest female solid tumours in women of childbearing age with surgical management including open and laparoscopic excision techniques. However, the management of a subsequent pregnancy and birth remains controversial with no robust guidance on which women may be suitable for vaginal birth.What do the results of this study add? We present the first study to our knowledge which explores women's experiences of birth and birth options counselling after open and laparoscopic myomectomy.What are the implications of these findings for clinical practice and/or further research? We provide a rationale for using birth options clinics to facilitate an informed decision-making process and highlight the current inadequate guidance for clinicians on how to advise women having a pregnancy following a myomectomy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this needs to be carried out in a way which promotes the preferences of the women affected by this research.

COVID-19 vaccine hesitancy: a midwifery survey into attitudes towards the COVID-19 vaccine.

BACKGROUND: Ethnically minoritised people have been disproportionately affected by the COVID-19 pandemic. Emerging evidence suggests a lower uptake of the vaccine in ethnically minoritised people, particularly Black females of reproductive age. Unvaccinated pregnant women are high risk for morbidity and mortality from COVID-19. Midwives are the principal healthcare professionals responsible for counselling the pregnant population on decisions relating to vaccine uptake. The aim of this study was to explore midwifery uptake of and attitudes towards the COVID-19 vaccine in two ethnically diverse areas. METHODS: A 45-point questionnaire was circulated over a six-week period to midwives employed in two teaching hospitals in England; London (Barts Health NHS Trust) and Sussex (Brighton and Sussex University Hospitals NHS Trust (BSUH)). A total of 378 out of 868 midwives responded. Results were analysed to determine vaccine uptake as well as factors influencing vaccine hesitancy and decision-making between the two trusts and ethnic groups. Thematic analysis was also undertaken. RESULTS: Midwives of Black ethnicities were over 4-times less likely to have received a COVID-19 vaccine compared to midwives of White ethnicities (52% vs 85%, adjusted OR = 0.22, p = < 0.001). Overall, there were no significant differences between trusts in receipt of the COVID-19 vaccine (p = 0.13). Midwives at Barts Health were significantly more likely to have tested positive for COVID-19 compared to midwives at BSUH (adjusted OR = 2.55, p = 0.007). There was no statistical difference between ethnicities in testing positive for COVID-19 (p = 0.86). The most common concerns amongst all participants were regarding the long-term effect of the vaccine (35%), that it was developed too fast (24%), having an allergic reaction (22%) and concerns about fertility (15%). Amongst unvaccinated midwives, those of Black ethnicity had a higher occurrence of concern that the vaccine contained meat / porcine products (adjusted OR = 5.93, p = 0.04) and that the vaccine would have an adverse effect on ethnic minorities (adjusted OR = 4.42, p = 0.03). CONCLUSION: This study highlights the significantly higher level of vaccine hesitancy amongst Black midwives and offer insights into midwives' concerns. This can facilitate future targeted public health interventions. It is essential that vaccine hesitancy amongst midwifery staff is addressed to improve vaccine uptake in the pregnant population.

Perspectives on modes of labour and delivery after different modalities of surgery for bowel endometriosis.

Bowel or intestinal endometriosis is estimated to affect 5-37% of women with deep infiltrative endometriosis (DIE), especially in the rectum and recto-sigmoid junction. However, there are no current guidelines or consensus regarding safest mode of delivery in pregnant women after different surgical interventions for bowel/intestinal endometriosis. From October 2019 to February 2020, we conducted an online survey of members of the British Society for Gynaecological Endoscopy (BSGE). These included questions on what gynaecologist members would recommend as modes of delivery in women who had different surgical modalities for bowel endometriosis, and the particular factors that influence such recommendations. Analysis of data was performed using SPSS for Windows (V9) software package. One hundred and two members of BSGE completed the survey (61.76% of BSGE gynaecologist members). Only 30.39% of respondents counsel women, pre-operatively, about possible effects of surgical treatment of bowel endometriosis on their subsequent mode of delivery. Our survey highlights wide variation in practice that currently exists. Around 70% of clinicians are not counselling patients regarding delivery options pre-surgery despite almost one-third recommending planned caesarean section if the vagina is opened. Further studies are required to stratify the risk factors for such patients when attempting vaginal delivery or caesarean section.IMPACT STATEMENTWhat is already known on this subject? Treatment of colorectal endometriosis consists of rectal shaving, discoid resection or segmental colorectal resection. However, the relationship between different surgical modalities for bowel endometriosis and the subsequent safe mode of labour and delivery remains unclear.What do the results of this study add? No study has been published that specifically looked at the particular course and outcome of labour and delivery after each of these bowel surgeries; rectal shaving, disc excision, or segmental colorectal resection. Our study highlights the wide variations in practice that currently exists. Despite around 70% of clinicians not counselling women regarding delivery options pre-surgery, almost one-third would recommend a planned caesarean section if the vagina is opened.What are the implications of these findings for clinical practice and/or further research? This study suggests that risk factors should be stratified for such patients when attempting a vaginal delivery or undergoing a caesarean section. Guidance from the ESGE and/or BSGE would be useful to aid in the counselling and informed consent of such patients.

Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery.

INTRODUCTION: Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery. METHODS: A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded. RESULTS: Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management. CONCLUSION: Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.

In vivo Simulation-Based Learning for Undergraduate Medical Students: Teaching and Assessment.

An increasing emphasis on simulation has become evident in the last three decades following fundamental shifts in the medical profession. Simulation-based learning (SBL) is a wide term that encompasses several means for imitating a skill, attitude, or procedure to train personnel in a safe and adaptive environment. A classic example has been the use of live animal tissue, named in vivo SBL. We aimed to review all published evidence on in vivo SBL for undergraduate medical students; this includes both teaching concepts as well as focused assessment of students on those concepts. We performed a systematic review of published evidence on MEDLINE. We also incorporated evidence from a series of systematic reviews (eviCORE) focused on undergraduate education which have been outputs from our dedicated research network (eMERG). In vivo SBL has been shown to be valuable at undergraduate level and should be considered as a potential educational tool. Strict adherence to 3R (Reduce, Refine, Replace) principles in order to reduce animal tissue usage, should always be the basis of any curriculum. In vivo SBL could potentially grant an extra mile towards medical students' inspiration and aspiration to become safe surgeons; however, it should be optimised and supported by a well-designed curriculum which enhances learning via multi-level fidelity SBL.

COVID-19 in Women's health reducing the risk of infection to patients and staff during acute and elective hospital admission for gynaecological surgery.

The novel coronavirus SARS-Cov-2 has changed healthcare on a worldwide scale. This highly contagious respiratory virus has overwhelmed healthcare systems. Many staff were redeployed, and there was widespread cessation of non-urgent outpatient clinics and surgery. Outpatient clinics and theatre areas were converted to COVID-19 wards and intensive care units. Following the first peak, services began to recommence with new triaging and prioritisation guidance to safeguard patients and staff. Different countries and healthcare systems produced differing guidance and, in particular, variation in the best approach to continuing acute and elective surgical procedures. This chapter collates and evaluates the increasing international literature concerning the surgical management of gynaecological conditions during the pandemic, such that clear inferences, recommendations and guidance can be generated to aid clinical practice and safeguard against further major disruption arising from further COVID-19 peaks. The available data are assessed within the context of the current phase of the COVID-19 pandemic.

ABC of Surgical Teaching: Time to Consider a Global Blueprint for Holistic Education.

BACKGROUND: Educating and equipping students and trainees into clinicians capable of meeting healthcare demands and service provision needs is essential. Unprecedented events like COVID-19 pandemic, highlight urgent need for reformation of training to ensure high quality education is maintained. To this end, we describe an innovative and globally adaptable blueprint for establishing a surgical curriculum, aiming to optimize preparation of future surgeons. METHODS: We used a structured protocol to synthesize evidence from previous systematic reviews focused on surgical education alongside a series of focused original educational studies. This approach allowed incorporation of prospectively applied novel ideas into the existing landscape of published evidence. All material used for this proof of concept derives from the outputs of a dedicated research network for surgical education (eMERG). RESULTS: We propose the foundation blueprint framework called "Omnigon iG4" as a globally applicable model. It allows adaptation to individual local educational environments for designing, appraising and/or refining surgical curricula. We also describe the "Omnigon iG4 Hexagon Pragmatic Model," a novel perspective model which assesses the performance of our blueprint in a multi-layer fashion. This "Hexagon" model is the first to introduce pragmatic outcomes in curricula performance assessment. CONCLUSIONS: This proof of concept, "Omnigon iG4," proposes an adaptable version of a curriculum blueprint. The framework allows educators to establish a surgical curriculum with the ability to map out competencies, permitting full control over their intended learning outcomes. This can form the basis for developing globally adaptable multifaceted Simulation-Based learning (SBL) courses or even surgical curricula for undergraduates.

Laparoscopic Myomectomy: An Alternative Approach to Tackling Submucous Myomas?

STUDY OBJECTIVE: To evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations. DESIGN: Retrospective cohort study. SETTING: University-affiliated hospital in London. PATIENTS: A total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2). INTERVENTIONS: Analysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications. MEASUREMENTS AND MAIN RESULTS: Patient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas. CONCLUSION: Laparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.

The Use of Ulipristal Acetate (Esmya) Prior to Laparoscopic Myomectomy: Help or Hindrance?

INTRODUCTION: The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy. MATERIALS AND METHODS: We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period. RESULTS: A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence. CONCLUSION: We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.

Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre.

BACKGROUND: The aim of this study was to analyse the demographic data and peri-operative outcomes of women undergoing a laparoscopic myomectomy and assess what factors, if any, precluded using the laparoscopic approach. METHODS: A single surgeon observational study of 323 patients undergoing a laparoscopic myomectomy was undertaken. Data was collected prospectively over a 12-year period and analysed using SPSS. Surgical outcomes included operating time, estimated blood loss, conversion to laparotomy, intraoperative and postoperative complications and duration of inpatient stay. RESULTS: A total of 323 patients underwent a laparoscopic myomectomy over the 12-year period. The majority of fibroids removed were intramural (49%) and subserosal (33%). The mean size of fibroids removed was 7.66 ± 2.83 (7.34-7.99) cm, and the mean number was 4 ± 3.62 (3.6-4.39), with the greatest being 22 removed from a single patient. Average blood loss was 279.14 ± 221.10 (254.59-303.69) ml with mean duration of surgery and inpatient stay recorded as 112.92 ± 43.21 (107.94-117.91) min and 1.88 ± 0.95 (1.77-1.99) days, respectively. No major intraoperative complications were noted, and the conversion to laparotomy rate was 0.62%. All histology following morcellation was benign. Over the 12-year period despite increasingly large and more numerous fibroids being tackled, increasing experience resulted in a simultaneous reduction in overall blood loss, operating time and duration of inpatient stay. CONCLUSIONS: Laparoscopic myomectomy is a safe and efficacious procedure that should be considered the gold standard surgical treatment option for fibroids. With experience, the procedure can be undertaken with minimal complications, a low risk of conversion to laparotomy and early discharge from hospital, even in cases of large and multiple fibroids that historically would have required the open approach. This allows even the most complex of cases to now benefit for the advantages of the minimal access approach.

Is ulipristal acetate the new drug of choice for the medical management of uterine fibroids? Res ipsa loquitur?

Ulipristal acetate (Esmya©) has been hailed the new wonder drug with regard to the medical management of uterine fibroids, and many postulate that it will remove the need for surgical treatment in the future. While the results from the PEARL studies are certainly promising and its amenorrhoeic rates and reduction in fibroid size are unquestionable, there is still a paucity of data with regard to its long-term effects, the effects on its usage prior to surgery and its variable efficacy in different ethnic populations. To facilitate our knowledge further, independent studies with clear outcome measures evaluating the long-term effects of the drug in a wider, more representative, ethnic minority population as well as assessing its true cost-effectiveness compared to surgery are needed. The aim of this article is to review the historical aspects with regard to the management of uterine fibroids to gain an understanding of where we are now and to evaluate the wider use of ulipristal acetate, both its benefits and limitations and postulate where to go in the future in order to allow our women to make safe and informed choices regarding their treatment options.