Improvement in Outcomes of Major Obstetric Hemorrhage Through Systematic Change.

OBJECTIVE: To report the outcomes over 14 years of sustained systematic institutional focus on the care of women with major obstetric hemorrhage, defined as estimated blood loss greater than 1,500 mL. METHODS: A retrospective cohort study of women with major obstetric hemorrhage at our hospital from 2000 to 2014 compares baseline conditions (age, multiparity, prior cesarean delivery, morbidly adherent placenta), morbidity (lowest mean temperature, lowest mean pH, coagulopathy, hysterectomy), and mortality among three time periods (period 1=January 2000 to December 2001, period 2=January 2002 to August 2005, period 3=September 2005 to December 2014). We also describe the systematic changes that helped to sustain our improved outcomes. RESULTS: During the three time periods, there were 5,811, 12,912, and 38,971 births; the rate of major obstetric hemorrhage increased over these periods: 2.1, 3.8 and 5.3 cases per 1,000 births, respectively. Two deaths from hemorrhage occurred in period 1 and none thereafter. Among women who experienced massive hemorrhage, morbidity significantly improved in each successive period: median lowest pH increased from 7.23 to 7.34 to 7.35 (periods 2 and 3 significantly higher than period 1), median lowest maternal temperature (°C) improved, 35.2 to 36.1 to 36.4 (all difference significant), and the rate of coagulopathy decreased, 58.3% to 28.6% to 13.2% (period 3 significantly lower than periods 1 and 2) (all P values <.001). Peripartum hysterectomies were more frequent and more frequently planned over time rather than urgent in each successive period: 0 of 6 to 6 of 18 (33%) to 31 of 64 (48.4%) (P=.044). During period 3, we reorganized the obstetric rapid response team, instituted a massive transfusion protocol and use of uterine balloon tamponade, and promoted a culture of safety in two ways-through more intensive education regarding hemorrhage and escalation (encouraging all staff to contact senior leaders). CONCLUSION: A sustained level of patient safety is achievable when treating major obstetric hemorrhage, as shown by a progressive decrease in morbidity despite increasing rates of hemorrhage.

Does speculum lubricant affect liquid-based Papanicolaou test adequacy?

BACKGROUND: There is a paucity of data on the effect of vaginal lubricants on specimen adequacy in the era of liquid-based Papanicolaou (Pap) tests. Current manufacturer recommendations advise against the use of lubricants, especially those that contain carbomers or carbopol polymers. There is, however, no conclusive evidence to support this recommendation. Moreover, the data that does exist is conflicting. METHODS: Retrospective review was performed of all liquid-based Pap tests collected between January 2010 and March 2012 by the Gynecologic Oncology division at a single hospital. Specimen adequacy was compared for vaginal and cervical specimens that were collected with and without a lubricant. Results were also compared for specimens collected with lubricants that did or did not contain carbomers. RESULTS: There was no significant difference in specimen adequacy for cervical or vaginal Pap test specimens collected with a water-soluble lubricant not containing carbomers, compared to those collected without a lubricant. There was, however, a significantly higher rate of insufficient specimens when a water-soluble lubricant containing carbomers was used. This difference was most pronounced for vaginal Pap tests (26.9% versus 1.2%, OR = 30.3, 95% CI = 16.6-55.1, P < .0001). CONCLUSIONS: Lubricants containing carbomers should be avoided when collecting liquid-based Pap tests because they can significantly decrease specimen adequacy. Lubricants that do not contain these substances do not significantly affect specimen adequacy. If there is an unusual increase in unsatisfactory Pap tests, the cytology laboratory should notify clinicians and work with them to determine the cause.

Peripartum thromboprophylaxis before and after implementation of a uniform heparin protocol.

AIM: The objective of this study was to assess the utilization of postpartum thromboprophylaxis with heparin in patients according to the Royal College of Obstetrics and Gynaecology Green-Top guidelines after change from an opt-in to an opt-out policy for health care providers ordering heparin thromboprophylaxis after cesarean delivery. STUDY DESIGN: The present study is a retrospective review of 500 consecutive births at one academic institution before and after implementation of a uniform thromboprophylaxis policy with heparin for all cesarean deliveries. An "opt-out" policy for ordering physicians was implemented by automatically defaulting to order heparin in the electronic order set used after cesarean delivery. RESULTS: Cesarean delivery rates were similar during both time periods. Heparin thromboprophylaxis was indicated in 99.6% of the cesarean delivery population before implementation and 94.5% after implementation. Prior to implementation only 5.7% received thromboprophylaxis compared to 96.1% after implementation, P<0.0001. CONCLUSION: An opt-out heparin thromboprophylaxis policy improves compliance with thromboprophylaxis guidelines compared to an opt-in policy. Institutions should consider opt-out heparin thromboprophylaxis policies after cesarean deliveries to improve compliance with recommendations.

Extremely short cervix in the second trimester: bed rest or modified Shirodkar cerclage?

OBJECTIVE: The objective of this study was to compare modified Shirodkar cerclage to bed rest for treatment of the midtrimester extremely short cervix. METHODS: This study used a concurrent retrospective cohort design at two institutions over the same period, 2000-2010. Patients were included at both institutions when midtrimester endovaginal ultrasound cervical length was ≤ 15 mm and had modified Shirodkar cerclage (cerclage group) at New York Hospital Queens and bed rest (control group) at Weill Cornell Medical Center. Cerclage was placed as high on the cervix as possible. Indomethacin and antibiotics were used perioperatively. RESULTS: The cerclage group included 112 patients and the control group included 55 patients. Median postoperative cervical length in the cerclage group was 3.3 cm (interquartile range 3.0-3.6). Cerclage patients were less likely to deliver preterm at 37, 35, 32, and 28 weeks (P=0.0066, 0.0004, 0.0023, and 0.03 respectively) and had longer latency (median 120 vs. 94 days P<0.0001). Kaplan-Meier survival curve showed a significant benefit in favor of cerclage (P=0.0043). CONCLUSIONS: Our data suggest that modified Shirodkar cerclage as high as possible on the cervix with perioperative indomethacin and antibiotics is superior to bed rest for treatment of the midtrimester extremely short cervix (≤15 mm). We propose a randomized trial of this specific technique.

Effect of prior hysterectomy on the anterior and posterior vaginal compartments of women presenting with pelvic organ prolapse.

OBJECTIVE: To describe the effects of hysterectomy on the anterior and posterior vaginal compartments and specific pelvic organ prolapsed quantification (POP-Q) data points. METHODS: In a retrospective case-control study, data were analyzed from patients presenting at a urogynecologic center in Manhasset, USA, with urogenital prolapse between January 1, 2008, and December 31, 2010. Patients who underwent hysterectomy for indications not including prolapse were compared with age- and parity-matched women without prior hysterectomy. POP-Q points were measured and converted to stages for each vaginal compartment. The t test, Wilcoxon rank sum, and Fisher exact tests were used to compare normally distributed variables, nonparametric data, and categoric variables, respectively. RESULTS: Seventy-one patients who underwent prior hysterectomy were matched to 71 patients with intact uteri. Women with prior hysterectomy had significantly greater prolapse at POP-Q point Bp and worse overall posterior compartment prolapse compared with those without prior hysterectomy. Women who underwent hysterectomy were more likely to have stage 2 or greater prolapse (OR 2.6, 95% CI, 1.3-5.2; P=0.01). CONCLUSION: When matched for age and parity, women with prior hysterectomy had significantly greater posterior compartment prolapse compared with those without. Prior hysterectomy had no significant effect on the anterior vaginal compartment.

One port laparoscopic technique for interval placement of intraperitoneal chemotherapy port under direct visualization.

PURPOSE: In an effort to minimize catheter-related complications we present a 1-port laparoscopic procedure for interval placement of an intraperitoneal chemotherapy catheter under direct visualization. METHODS: A single 5-mm laparoscopic port is placed in the umbilicus. A 5-cm incision is made in the midaxillary line and a pocket is created to hold the intraperitoneal chemotherapy port. The introducer is then tunneled from the pocket towards the umbilicus and is used to pierce the fascia under direct visualization. It is then tunneled towards the camera and removed through the umbilical port. The catheter is cut and allowed to fall back into the abdomen under direct visualization. RESULTS: No patient had their chemotherapy regimen altered because of catheter-related complications. Specifically, there were no other infections, leakage, blockage, or access problems. CONCLUSIONS: In selected patients, this may be considered as a new minimally invasive option.

Effect of age, body mass index, and parity on Pelvic Organ Prolapse Quantification system measurements in women with symptomatic pelvic organ prolapse.

AIM: To evaluate the effect of age, body mass index (BMI), and parity on Pelvic Organ Prolapse Quantification (POP-Q) system measurements in women with symptomatic prolapse. MATERIAL AND METHODS: The charts of 603 women with symptomatic prolapse were reviewed. Patients with prior prolapse surgery or hysterectomy were excluded. POP-Q measurements were recorded by a single examiner. Data were analyzed using descriptive statistics, the Pearson's product-moment correlation, and Wilcoxon signed rank test. RESULTS: Three hundred and eleven patients met inclusion criteria. Mean age was 63.4 years, mean parity was 2.6, and mean body mass index (BMI) was 26.6 kg/m(2) . Increasing age was correlated with worsening scores on Ba (r = 0.33, P < 0.0001), C (r = 0.14, P < 0.02), D (r = 0.14, P = 0.02) and Bp (r = 0.13, P = 0.02), while parity was only correlated with worsening scores on Aa (r = 0.12, P = 0.04). There was no correlation between BMI and any POP-Q data point. CONCLUSION: The effect of increasing parity was seen solely on point Aa in women with symptomatic prolapse. Age affected all vaginal compartments, while BMI had no impact on POP-Q data points.

Lynch Syndrome: Awareness among Medical Students at a United States Medical School.

INTRODUCTION: Lynch syndrome was first described in the 1950s however until recently it was rarely included in medical school curricula. As a result, many practicing physicians have limited exposure, potentially contributing to significant under diagnosis. As identification of Lynch syndrome prior to malignancy allows for intensified screening, prophylactic surgery and improved patient outcomes, all physicians should be aware of the characteristics of affected families. We aim to determine the overall level of awareness of Lynch syndrome among medical students at an American medical school. METHODS: A voluntary and anonymous questionnaire was delivered to students at an American medical school. The survey instrument assessed the respondent's perceived knowledge regarding the genetics and recommended screening for carriers of Lynch syndrome mutations. RESULTS: The questionnaire was distributed to the entire student body (405 students) with a response rate of 50%. Fifty-nine percent of students reported that they had learned about Lynch syndrome; 27% of first year students, 44% of second year students; 90% of third year students and 100% of fourth year students. Of the students familiar with Lynch syndrome, the reported knowledge of the underlying genetics was 46%, available genetic screening, 18%, criteria used to screen for the syndrome, 24%, recommendations for colon screening, 31% and recommendations for endometrial cancer screening, 17%. CONCLUSION: The majority of medical students surveyed had been exposed to Lynch syndrome and awareness increased over each year of education. Significantly more students were aware of recommendations for colon cancer screening than endometrial cancer screening (32% versus 17%, p = 0.01). Studies of the natural history of Lynch syndrome indicate that affected women are more likely to present with endometrial cancer than colon cancer and while there are no prospective data proving the efficacy of endometrial cancer screening in this high-risk population, the endometrium is easily accessible and can be sampled using simple office techniques. In addition, prophylactic hysterectomy and bilateral salpingo-oophorectomy are reasonable risk reducing interventions for the prevention of both uterine and ovarian cancer. Our findings suggest that increased emphasis must be placed on teaching the gynecologic manifestations of Lynch Syndrome in order to avoid the misconception that it is simply a colon cancer syndrome.

Comparison of quality-of-life changes in patients with stress urinary incontinence after midurethral sling placement.

OBJECTIVE: To compare changes in quality of life for women undergoing either suprapubic or transvaginal midurethral sling placement for stress urinary incontinence (SUI). METHODS: A retrospective cohort study was conducted involving 113 patients who underwent transvaginal or suprapubic midurethral sling placement for SUI over 2 years at a US institution. All patients completed a short form of the urogenital distress inventory (UDI-6) questionnaire preoperatively and postoperatively. Preoperative and postoperative UDI-6 scores were compared between the 2 groups. Data were analyzed using the Mann-Whitney U test and the Fisher exact test. RESULTS: A midurethral sling was placed using the suprapubic approach in 70 patients, and 43 patients underwent the procedure using the transvaginal approach. Preoperatively, there was no statistical difference between mean UDI-6 scores for the suprapubic versus the transvaginal group (48.5 versus 51.0 P = 0.9). Postoperatively, patients who underwent a suprapubic procedure had significantly lower mean UDI-6 scores than those who underwent a transvaginal procedure (10.6 versus 17.0; P < 0.005). CONCLUSION: Suprapubic midurethral sling placement was associated with a significantly greater quality of life postoperatively compared with the transvaginal procedure.

Quality of life after treatment with midurethral sling and concomitant prolapse repair in patients with mixed versus stress urinary incontinence.

AIMS: To compare quality of life in patients with mixed urinary incontinence (MUI) to stress urinary incontinence (SUI) after treatment with a retropubic midurethral sling and concomitant prolapse repair. METHODS: Sixty-three patients met inclusion criteria. Patients completed the short form of the urogenital distress inventory (UDI-6) questionnaire pre- and postoperatively. Concomitant procedures included anterior/posterior colporrhaphy, paravaginal repair, LeForte, vaginal hysterectomy, and sacrospinous ligament fixation. RESULTS: Preoperatively, those with MUI had significantly higher UDI-6 scores (59.8 ± 16.6 vs. 42.3 ± 14.5, respectively, P < 0.0001). Postoperatively, there was no difference in UDI-6 scores (P = 0.87). Subjective cure rate for SUI was the same in patients with MUI versus SUI (73%). Patients with MUI demonstrated a significantly greater improvement in UDI-6 scores as compared to patients with SUI. CONCLUSIONS: Patients with MUI compared with SUI demonstrated a greater improvement in quality of life after midurethral sling placement and concomitant pelvic organ prolapse repair as assessed by a disease-specific quality of life questionnaire (UDI-6).

The prevalence of microscopic hematuria in women with pelvic organ prolapse.

OBJECTIVE: : The objective of the study was to determine the prevalence of microscopic hematuria (MH) in women with pelvic organ prolapse. STUDY DESIGN: : Data of all patients presenting to a urogynecologic center with pelvic organ prolapse between 2008 and 2010 were reviewed. Microscopic hematuria was defined as 3 or more red blood cells per high-power field on at least 2 urinalysis specimens with negative cultures. Exclusion criteria included age younger than 40 years, presence of gross hematuria, menses, or urologic disease. Statistical analysis was performed using JMP 4.0.4 (SAS Institute, Cary, NC). RESULTS: : The population consisted of 572 women aged 40 to 96 years. Fifty-five patients (9.6%) met the criteria for MH, and 126 (22%) had 3 or more red blood cells per high-power field on 1 urinalysis. No cases of urologic malignancy were diagnosed on further workup. All patients with microhematuria had cystoceles on examination. CONCLUSIONS: : Our findings suggest that the prevalence of MH is increased in women with pelvic organ prolapse.

The significance of a thickened endometrial echo in asymptomatic postmenopausal patients.

OBJECTIVE: The purpose of this study was to evaluate the significance of a thickened endometrial echo in an asymptomatic, postmenopausal patient. STUDY DESIGN: A retrospective review was conducted of all women who underwent transvaginal ultrasonography between January 2003 and August 2008, were found to have an endometrial thickness of at least 5mm and were subjected to endometrial sampling. RESULTS: Sixty-five postmenopausal women, without vaginal bleeding underwent ultrasonographic evaluation with subsequent endometrial sampling. The mean endometrial stripe thickness was 9.7 mm (range: 5.4-22). Four (6.2%) cases of simple/complex hyperplasia were identified and two (3.1%) cases of atypical hyperplasia were diagnosed. Zero (0%) specimens were identified as adenocarcinoma. Twenty-eight (43.1%) polyps and eleven (16.9%) leiomyomata were identified. CONCLUSION: The use of transvaginal sonography as a screening tool in this population is not validated and need not trigger routine evaluation.