Abstracts
DOI: 10.1111/1471-0528.12495 www.bjog.org
Oral presentations
FC.1 Changing the provision of ERPCs: a service improvement project
Sirha, R; Alkufaishi, A; Alzoubei, A West Middlesex University Hospital, London, United Kingdom Objective: To assess the local and regional provision of ERPCs including waiting times and patient satisfaction at our unit. To implement strategies for service improvement. Background: Approximately 20% of pregnancies will miscarry and the associated trauma is underestimated. Up to 50% will suffer some form of psychiatric morbidity. Management choice and its provision heavily influence both the recovery and the economic burden on the NHS. A large proportion of women prefer a surgical evacuation of retained products of conception (ERPC). At West Middlesex Hospital, the original care pathway for elective ERPCs was highly dependent on bed managers and gave the patient responsibility for booking their procedure. Prolonged waiting times and patient complaints highlighted deficiencies and room for improvement. Methods: Audit, trainee and patient satisfaction survey. The results obtained were used for a trust funded management and service improvement project. Results and conclusions: Patients initially waited an average of 2.5 days for an ERPC, (range: 0–6 days). Over half (53%) of patients were ‘dissatisfied’ with waiting times and women found the process ‘emotionally exhausting and stressful’. A new care pathway was designed and implemented, involving a multi disciplinary approach to generating an efficient and patient centred process. It created dedicated theatre sessions and patients were given a specific date within 24 hours of review, eliminating unpredictability. A re-audit showed waiting times fall to an average of 1.6 days, with patients significantly less distressed by their experience. In addition to these changes a proposal to create a manual vacuum aspiration service in our unit was put forward. We anticipate that this will reduce waiting times further and potentially the associated anaesthetic and operative complications and costs.
FC.2 Do we practice what we preach? A survey of UK O&G trainees’ attitudes to caesarean delivery for maternal request
Aref-Adib, M1; Khasriya, R2; Lamb, BW3; Selo-Ojeme, D4 1
Department of Obstetrics and Gynaecology, Queen’s Hospital, Romford, United Kingdom; 2 Department of Obstetrics and Gynaecology, Barnet Hospital, London, United Kingdom; 3 Department of Surgery and Cancer, Centre for Patient Safety and Service Quality, St. Mary’s Hospital, Imperial College London, London, United Kingdom; 4 Department of Obstetrics and Gynaecology, Chase Farm Hospital, Enfield, United Kingdom Objective: To assess the attitudes of UK Obstetrics and Gynaecology (O&G) trainees towards caesarean delivery for maternal request (CDMR); and to identify differences in attitude towards patients and preferences for their own mode of delivery. Background: In the last 30 years UK caesarean rates have trebled, with 7% performed for maternal request. NICE states that maternal choice is a valid indication for caesarean delivery for maternal request (CDMR). However, there are concerns about the increasing caesarean rate given its associated morbidity, as well as increased financial cost. It is important to understand the attitudes of O&G trainees towards CDMR, as well as their own attitudes and behaviour in order to understand future trends in clinical practice. Methods: From February 2013–June 2013 an internet survey was sent to trainees via UK Deaneries. Questions were multiple choice covering trainees’ personal preferences towards and experience of CDMR; attitudes to CDMR without medical indication; and how they might treat a patient making such a request. Trainees’ demographic data were also collected. Results: In total 240 O&G trainees from seven Deaneries participated. 78% of respondents were female. 6/101 (6%) respondents who had their own children had opted for CDMR in their first pregnancy. 28/132 (22%) would choose CDMR in their first pregnancy. Reasons for CDMR included concerns about pelvic floor and perineum, safety of the baby and convenience. Asked about CDMR, 47% disagreed, 24% neither agreed nor disagreed, and 29% agreed. Asked whether they would grant a patient CDMR 60% responded yes; citing maternal choice, psychological concerns, perineal/pelvic floor injury, and safety of the baby in descending popularity. 40% responded no; citing risk to future pregnancy, bladder/bowel injury, bleeding, infection, DVT/PE, hysterectomy and cost in descending popularity. Conclusion: In practice, a large majority of O&G trainees would choose vaginal delivery for themselves or their partners. Our results are encouraging for the future: as the next generation of
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
1
Oral presentations
consultants, trainees’ positive attitudes towards vaginal delivery may help to reduce the rising caesarean rate.
FC.4 The effect of maternal heart disease on fetal growth
Gelson, E; Johnson, M FC.3 Is HPV 51 a candidate for type-replacement following vaccination?
Bowden, S; Houghton, R; Edwards, A; Fiander, AN; Hibbitts, S HPV Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom Objective: To determine whether HPV 51 should be considered a candidate for type-replacement post-vaccination. Background: Human papillomavirus (HPV) infection is a necessary cause of cervical cancer. Study of HPV type-specific prevalence is important for determining the impact of prophylactic HPV vaccination and monitoring type-replacement. Between 2009 and 2010, Cardiff University HPV Research Group conducted the Base HPV 2009 study to determine HPV prevalence in unvaccinated women aged 20–22 years in Wales. Preliminary analysis found that type 16 was the most prevalent followed by types 18 and 51. The high proportion of HPV 51 infections observed was unexpected and is an uncommon finding of known HPV prevalence studies. Methods: The first 100 single and multiple HPV 51 positive liquid-based cytology samples from Base HPV 2009 were selected for re-analysis. Each sample underwent DNA re-extraction and was retested using GP5+/6+ HPV 51 PCR-ELISA and E7 HPV 51 PCR methods. Data were correlated with age, social deprivation score and cytology. Results and conclusions: Direct repeat of HPV 51 PCR-EIA identified 146/195 (75.0%) samples as HPV 51 positive. E7 PCR identified 166/195 (85.1%) samples as HPV 51 positive. When classified by cytological grade, the prevalence of confirmed HPV 51 increased with grade. This study confirms that the HPV 51 prevalence observed in Base HPV 2009 is truly high and warrants further consideration. There is limited evidence that current vaccines confer cross-protection for HPV 51. HPV 51 therefore represents a potential candidate for type-replacement post-vaccination. This study highlights the need for further longitudinal investigation into HPV 51 prevalence. The data would recommend that HPV 51 be considered for inclusion in any future multivalent vaccine.
Chelsea and Westminster Hospital, London, United Kingdom Objective: To determine the effect of maternal heart disease on fetal growth and neonatal outcomes. Background: Few studies have focussed on the impact on the fetus and neonate in women with heart disease. However, neonatal mortality rates of 4% and fetal growth restriction in up to 8% of pregnancies in women with heart disease have been reported. The risk of fetal and neonatal complications has been associated with poor maternal functional class and left heart obstruction. Methods: A retrospective cohort study of women with heart disease booked between 1996 and 2010 was performed and compared with a control population. The cases population was divided into four groups; those with an acyanotic cardiac lesion associated with a reduced cardiac output, or a normal cardiac output, those with cyanotic heart disease and those taking a beta-blocker. Birthweight centiles were calculated using a computer-generated chart and neonatal complications were noted. Results: A total of 325 pregnancies in 271 women were identified. Neonatal complications occurred in 136 (42%) case pregnancies, significantly higher than in the control population (odds ratio 2.977, 95% confidence interval 2.218–3.995, P < 0.0001). Three stillbirths and four neonatal deaths occurred (perinatal mortality rate 2%) with 43 (13%) preterm births and 94 (29%) newborns born small for gestational.
Conclusions: This cohort study demonstrates a high rate of
neonatal complications in women with heart disease. The presence of maternal cyanosis and a reduced cardiac output appear to be associated with preterm delivery and a reduced birthweight.
2
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
DOI: 10.1111/1471-0528.12495 www.bjog.org
Oral presentations
FC.1 Changing the provision of ERPCs: a service improvement project
Sirha, R; Alkufaishi, A; Alzoubei, A West Middlesex University Hospital, London, United Kingdom Objective: To assess the local and regional provision of ERPCs including waiting times and patient satisfaction at our unit. To implement strategies for service improvement. Background: Approximately 20% of pregnancies will miscarry and the associated trauma is underestimated. Up to 50% will suffer some form of psychiatric morbidity. Management choice and its provision heavily influence both the recovery and the economic burden on the NHS. A large proportion of women prefer a surgical evacuation of retained products of conception (ERPC). At West Middlesex Hospital, the original care pathway for elective ERPCs was highly dependent on bed managers and gave the patient responsibility for booking their procedure. Prolonged waiting times and patient complaints highlighted deficiencies and room for improvement. Methods: Audit, trainee and patient satisfaction survey. The results obtained were used for a trust funded management and service improvement project. Results and conclusions: Patients initially waited an average of 2.5 days for an ERPC, (range: 0–6 days). Over half (53%) of patients were ‘dissatisfied’ with waiting times and women found the process ‘emotionally exhausting and stressful’. A new care pathway was designed and implemented, involving a multi disciplinary approach to generating an efficient and patient centred process. It created dedicated theatre sessions and patients were given a specific date within 24 hours of review, eliminating unpredictability. A re-audit showed waiting times fall to an average of 1.6 days, with patients significantly less distressed by their experience. In addition to these changes a proposal to create a manual vacuum aspiration service in our unit was put forward. We anticipate that this will reduce waiting times further and potentially the associated anaesthetic and operative complications and costs.
FC.2 Do we practice what we preach? A survey of UK O&G trainees’ attitudes to caesarean delivery for maternal request
Aref-Adib, M1; Khasriya, R2; Lamb, BW3; Selo-Ojeme, D4 1
Department of Obstetrics and Gynaecology, Queen’s Hospital, Romford, United Kingdom; 2 Department of Obstetrics and Gynaecology, Barnet Hospital, London, United Kingdom; 3 Department of Surgery and Cancer, Centre for Patient Safety and Service Quality, St. Mary’s Hospital, Imperial College London, London, United Kingdom; 4 Department of Obstetrics and Gynaecology, Chase Farm Hospital, Enfield, United Kingdom Objective: To assess the attitudes of UK Obstetrics and Gynaecology (O&G) trainees towards caesarean delivery for maternal request (CDMR); and to identify differences in attitude towards patients and preferences for their own mode of delivery. Background: In the last 30 years UK caesarean rates have trebled, with 7% performed for maternal request. NICE states that maternal choice is a valid indication for caesarean delivery for maternal request (CDMR). However, there are concerns about the increasing caesarean rate given its associated morbidity, as well as increased financial cost. It is important to understand the attitudes of O&G trainees towards CDMR, as well as their own attitudes and behaviour in order to understand future trends in clinical practice. Methods: From February 2013–June 2013 an internet survey was sent to trainees via UK Deaneries. Questions were multiple choice covering trainees’ personal preferences towards and experience of CDMR; attitudes to CDMR without medical indication; and how they might treat a patient making such a request. Trainees’ demographic data were also collected. Results: In total 240 O&G trainees from seven Deaneries participated. 78% of respondents were female. 6/101 (6%) respondents who had their own children had opted for CDMR in their first pregnancy. 28/132 (22%) would choose CDMR in their first pregnancy. Reasons for CDMR included concerns about pelvic floor and perineum, safety of the baby and convenience. Asked about CDMR, 47% disagreed, 24% neither agreed nor disagreed, and 29% agreed. Asked whether they would grant a patient CDMR 60% responded yes; citing maternal choice, psychological concerns, perineal/pelvic floor injury, and safety of the baby in descending popularity. 40% responded no; citing risk to future pregnancy, bladder/bowel injury, bleeding, infection, DVT/PE, hysterectomy and cost in descending popularity. Conclusion: In practice, a large majority of O&G trainees would choose vaginal delivery for themselves or their partners. Our results are encouraging for the future: as the next generation of
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
1
Oral presentations
consultants, trainees’ positive attitudes towards vaginal delivery may help to reduce the rising caesarean rate.
FC.4 The effect of maternal heart disease on fetal growth
Gelson, E; Johnson, M FC.3 Is HPV 51 a candidate for type-replacement following vaccination?
Bowden, S; Houghton, R; Edwards, A; Fiander, AN; Hibbitts, S HPV Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom Objective: To determine whether HPV 51 should be considered a candidate for type-replacement post-vaccination. Background: Human papillomavirus (HPV) infection is a necessary cause of cervical cancer. Study of HPV type-specific prevalence is important for determining the impact of prophylactic HPV vaccination and monitoring type-replacement. Between 2009 and 2010, Cardiff University HPV Research Group conducted the Base HPV 2009 study to determine HPV prevalence in unvaccinated women aged 20–22 years in Wales. Preliminary analysis found that type 16 was the most prevalent followed by types 18 and 51. The high proportion of HPV 51 infections observed was unexpected and is an uncommon finding of known HPV prevalence studies. Methods: The first 100 single and multiple HPV 51 positive liquid-based cytology samples from Base HPV 2009 were selected for re-analysis. Each sample underwent DNA re-extraction and was retested using GP5+/6+ HPV 51 PCR-ELISA and E7 HPV 51 PCR methods. Data were correlated with age, social deprivation score and cytology. Results and conclusions: Direct repeat of HPV 51 PCR-EIA identified 146/195 (75.0%) samples as HPV 51 positive. E7 PCR identified 166/195 (85.1%) samples as HPV 51 positive. When classified by cytological grade, the prevalence of confirmed HPV 51 increased with grade. This study confirms that the HPV 51 prevalence observed in Base HPV 2009 is truly high and warrants further consideration. There is limited evidence that current vaccines confer cross-protection for HPV 51. HPV 51 therefore represents a potential candidate for type-replacement post-vaccination. This study highlights the need for further longitudinal investigation into HPV 51 prevalence. The data would recommend that HPV 51 be considered for inclusion in any future multivalent vaccine.
Chelsea and Westminster Hospital, London, United Kingdom Objective: To determine the effect of maternal heart disease on fetal growth and neonatal outcomes. Background: Few studies have focussed on the impact on the fetus and neonate in women with heart disease. However, neonatal mortality rates of 4% and fetal growth restriction in up to 8% of pregnancies in women with heart disease have been reported. The risk of fetal and neonatal complications has been associated with poor maternal functional class and left heart obstruction. Methods: A retrospective cohort study of women with heart disease booked between 1996 and 2010 was performed and compared with a control population. The cases population was divided into four groups; those with an acyanotic cardiac lesion associated with a reduced cardiac output, or a normal cardiac output, those with cyanotic heart disease and those taking a beta-blocker. Birthweight centiles were calculated using a computer-generated chart and neonatal complications were noted. Results: A total of 325 pregnancies in 271 women were identified. Neonatal complications occurred in 136 (42%) case pregnancies, significantly higher than in the control population (odds ratio 2.977, 95% confidence interval 2.218–3.995, P < 0.0001). Three stillbirths and four neonatal deaths occurred (perinatal mortality rate 2%) with 43 (13%) preterm births and 94 (29%) newborns born small for gestational.
Conclusions: This cohort study demonstrates a high rate of
neonatal complications in women with heart disease. The presence of maternal cyanosis and a reduced cardiac output appear to be associated with preterm delivery and a reduced birthweight.
2
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
