An analysis of 84244 patients from the British Columbia cytology-colposcopy program

OBJECTIVE: To determine the diagnostic correlation between referral cytology, initial biopsies and colposcopic impression in patients assessed in a provincial cytology screening program. METHODS: A retrospective review of the computerized cytology screening database for British Columbia (BC), to identify all patients having their first colposcopy between 1986 and 2000 in 24 participating clinics constituted the study population. 84244 patient records were identified for analysis. Colposcopies were performed mainly by 37 general gynecologists as part of a province-wide colposcopy program. Correlation of cytology, colposcopic impression and directed biopsies was performed. RESULTS: The colposcopic impression correlated with the referral cytology within one degree in over 90% of cases. Colposcopists felt cytology underestimated disease in 1.5% and overestimated disease in 8.3%. Cytology-histology correlation within one degree occurred in 82%. Cytology underestimated the result of the biopsies in 2.3% and appeared to overestimate disease in 16.1% of patients. Patients with HSIL cytology had corresponding lesions in 77%, with a further 4.9% having LSIL disease. The predictive accuracy of colposcopy increased with advancing severity of disease expected. As the degree of cytological abnormality worsened, the predictive accuracy of colposcopic diagnosis increased. CONCLUSIONS: Both cytology and colposcopy have high sensitivity but low to moderate specificity. Colposcopy is most accurate in identifying high-grade diseases. Colposcopic impression correlates closely with the cytology diagnosis and combining the two produces optimum results.     

An evaluation of process and protocols for planned home birth attended by regulated midwives in British Columbia

Midwifery emerged as a self-regulated profession in British Columbia in the context of a 2-year demonstration project beginning in 1998. The project evaluated accountability among midwives, defined as the provision of safe and appropriate care and maintenance of standards of communication set by the College of Midwives of British Columbia. Adherence to protocols was measured by using documentation designed specifically for the Home Birth Demonstration Project. Hospital and transport records for selected clients were reviewed by an expert committee. Outcomes among Home Birth Demonstration Project clients were compared with outcomes among women eligible for home birth but planning to deliver in hospital. Adherence to clinical and communication protocols was 96% or higher. Planned home birth was not associated with an increase in risk but prevalence of adverse outcomes was too low to be studied with precision. Recommendations of an expert review committee have been implemented or are under review. Midwives have demonstrated a high degree of compliance with reporting requirements and protocols. Comparisons of birth outcomes of planned home versus hospital births, while supporting home birth as a choice for women, were limited in scope and require ongoing study. Integration of home birth has been a dynamic process with guidelines and policy continuing to evolve.     

Pregnancy outcomes among solid organ transplant recipients in British Columbia

ObjectiveSince 1954, over 14 000 women have given birth after having had an organ transplantation. Unfortunately, some women and physicians remain misinformed about the feasibility and outcomes of pregnancy post transplantation. Our primary objective was to assess their perceptions and difficulties with regard to becoming pregnant. Our secondary objectives were to determine the incidence of pregnancies among transplant recipients in British Columbia and any maternal, graft, or fetal complications.MethodsFrom 1997 to 2007 in British Columbia, there were over 500 female recipients of solid organ transplants. We surveyed recipients in this group who were of child-bearing age.ResultsOne hundred forty of 295 (47%) eligible recipients responded: 44 of these women had attempted pregnancy after transplant, and 31 women gave birth to 47 children. One half of the respondents planned to have children post transplant; 108 of 140 (77%) had no children before transplant. One quarter of the respondents were advised against pregnancy by their physician, and 33% of these women found a new physician to support their pregnancy. Rates of miscarriage (27%), rejection (21%), and prematurity (65%) were higher than expected. Infections were rare, and no birth defects or noteworthy health problems in the offspring were reported.ConclusionOverall, pregnancy appears to be safe following solid organ transplantation, but careful monitoring and counselling are recommended.     

Cannabis Use in Pregnancy in British Columbia and Selected Birth Outcomes

ObjectiveThis study sought to determine the association between cannabis use in pregnancy and stillbirth, small for gestational age (SGA) (<10th percentile), and spontaneous preterm birth (<37 weeks).MethodsThe study used abstracted obstetrical and neonatal medical records for deliveries in British Columbia from April 1, 2008 to March 31, 2016 that were contained in the Perinatal Data Registry of Perinatal Services British Columbia. Chi-square tests were conducted to compare maternal sociodemographic characteristics by cannabis use. Logistic regression was conducted to determine the association between cannabis use and SGA and spontaneous preterm births. Cox proportional hazards regression modelling was used to identify the association between cannabis use and stillbirth. Secondary analyses were conducted to ascertain differences by timing of stillbirth (Canadian Task Force Classification II-2).ResultsMaternal cannabis use has increased in British Columbia over the past decade. Pregnant women who use cannabis are younger and more likely to use alcohol, tobacco, and illicit substances and to have a history of mental illness. Using cannabis in pregnancy was associated with a 47% increased risk of SGA (adjusted OR 1.47; 95% CI 1.33–1.61), a 27% increased risk of spontaneous preterm birth (adjusted OR 1.27; 95% CI 1.14–1.42), and a 184% increased risk of intrapartum stillbirth (adjusted HR [aHR] 2.84; 95% CI 1.18–6.82). The association between cannabis use in pregnancy and overall stillbirth and antepartum stillbirth did not reach statistical significance, but it had comparable point estimates to other outcomes (aHR 1.38; 95% CI 0.95–1.99 and aHR 1.34; 95% CI 0.88–2.06, respectively).ConclusionCannabis use in pregnancy is associated with SGA, spontaneous preterm birth, and intrapartum stillbirth.     

Knowledge on periconceptional use of folic acid in women of British Columbia

OBJECTIVE: Our purpose was to evaluate the knowledge of folic acid and its use preconceptionally in women of British Columbia. METHODS: The study was conducted at British Columbia Women's Hospital in Vancouver, Canada, between April 15 and June 15, 1999. Pregnant women and women in the postpartum period were asked to complete a survey on folic acid. RESULTS: In total, 1,004 women completed the questionnaire during the study period. Seventy-one percent of the women knew that vitamins could help prevent birth defects. Of those, 76.3% identified folic acid as the one vitamin specifically associated with reduction of birth defects. It was identified that 49.4% of all women took vitamins prior to pregnancy. CONCLUSIONS: Women in the population studied were relatively well informed about the benefits of folic acid, but less than 50% of them took vitamins prior to conception.     

Satisfaction with planned place of birth among midwifery clients in British Columbia

The purpose of this study was to compare satisfaction with the birth experience among a population of women planning birth at home versus in hospital. In British Columbia, Canada, all midwives offer women meeting eligibility requirements for homebirth the choice to give birth in hospital or at home. Therefore, satisfaction can be attributed to planned place of birth, as the caregivers were the same in both settings. The mean overall score on the Labour Agentry Scale among women who had planned a homebirth (n = 550), 188.49 +/- 16.85, was significantly higher than those who planned birth in hospital (n = 108), 176.60 +/- 23.79; P < .001. Overall satisfaction with the birth experience was higher among women planning birth at home, 4.87 +/- 0.42 versus 4.80 +/- 0.49 on a scale of 1 to 5, although this difference was not statistically significant; P = .06. Among women whose actual place of birth was congruent with where they had planned, overall satisfaction was higher in the homebirth group, 4.95 +/- 0.20 versus 4.75 +/- 0.53; P < .001. Although satisfaction with the birth experience was high in both the home and hospital settings, women planning birth at home were somewhat more satisfied with their experience, particularly if they were able to complete the birth at home.     

Test Uptake and Case Detection of Syphilis,HIV, and Hepatitis C Among Women Undergoing Prenatal Screening in British Columbia, 2007 to 2011

ObjectiveTest uptake and case detection trends for rubella, syphilis, HIV, and hepatitis C (HCV) were compared among the 2007 to 2011 cohort of women undergoing prenatal testing in British Columbia. Analysis involved linkage of provincially centralized laboratory and surveillance data to assess prenatal test uptake and rates of newly diagnosed versus prevalent infections.MethodsWe included prenatal specimens submitted from BC women aged 16 to 45 years in 2007 to 2011. Laboratory records were linked to provincial surveillance systems to identify confirmed maternal syphilis and HIV cases. Previous positive status was determined for HIV and HCV if a prior confirmed case was identified from laboratory records. We determined rates of HIV and HCV newly identified at prenatal screening (new diagnoses per 100 000 per year). Prevalence for HIV and HCV was the sum of all new and prior diagnoses (prevalence per 100 000 per year).ResultsOf 233 203 women, 96.9% were screened for rubella, 93.3% for syphilis, 93.8% for HIV, and 21.5% for HCV. From 2007 to 2011, the overall rates of new diagnoses were 15.4, 5.1, and 82.8 cases per 100 000 per year for syphilis, HIV, and HCV, respectively. The overall prevalence was 45.9 and 551.5 cases per 100 000 per year for HIV and HCV, respectively (0.05% and 0.6%). From 2007 to 2011, new diagnoses of HCV decreased 40% from 106.0 to 62.1 cases per 100 000 per year. HCV prevalence did not change and increased with maternal age.ConclusionThis study links surveillance and laboratory data to provide a provincial picture of prenatal screening test uptake and case detection, with the advantage of distinguishing new from prior diagnoses. This information can help guide prenatal communicable disease screening policy.     

A Review of Physician Anaesthesia Prescribing Practices in an Abortion Clinic in British Columbia

ObjectiveThe primary purpose of this study was to review the standard prescribing practices of physicians providing local anaesthesia in a major abortion clinic in British Columbia.MethodsWe conducted a retrospective review of patients who underwent a first trimester surgical abortion at the Comprehensive Abortion and Reproductive Education (CARE) Program at BC Women’s Hospital and Health Centre during 2004 (n = 1546). Patients’ demographics and reproductive history including age, weight, gestational age, and gravidity were recorded. Main outcomes recorded were dosage of lidocaine administered and amount of conscious sedation (midazolam and fentanyl) administered for pain management. Incidence of toxicity was also recorded.ResultsAlmost one half (49.9%) of the patients received 20 mL of 0.5% lidocaine, and the remainder received 20 mL of 1.0% lidocaine. The volume of conscious sedation did not differ between groups. There was a positive correlation computed between midazolam and fentanyl dosages (r = 0.583, P < 0.01). Neither was significantly associated with gravidity. Gestational age was associated with both midazolam and fentanyl dose (r = 0.05, P = 0.047; r = 0.06, P = 0.024). There was no reported incidence of toxicity.ConclusionSimilar doses of midazolam and fentanyl were administered to patients regardless of the amount of lidocaine given (20 mL of either 0.5% or 1.0%). Further investigation is required to assess whether fentanyl and midazolam doses used during procedures can be used as surrogate measurements of pain. Our findings suggest it would be reasonable to consider using a lower dose of local anaesthetic for first trimester abortions to further reduce the risk of toxicity.     

Experience with dysgerminomas at the Cancer Control Agency of British Columbia.

Twenty-five cases of ovarian dysgerminoma are reviewed. Most commonly the tumor occurred in the younger age group. Four tumors were found during pregnancy. In seven patients metastases occurred; only two of these have died of dysgerminoma. Corrected 5-year survival is 91%. Treatment consisting of surgery and radiation appears to give best results. Chemotherapy is of benefit in some cases.Results are discussed and current treatment policy at CCABC is presented.     

Unknown Antenatal HIV-Infection Status Has Declined Over Time in British Columbia,Canada

Objectives

The objective was to determine whether the proportion of pregnant women with unknown antenatal HIV-infection status is declining over time in British Columbia (BC) and whether associated factors are amenable to intervention.

Neonatal Mortality Risk Related to Birth Weight and Gestational Age in British Columbia

ObjectivesTo provide gender-specific neonatal mortality grids depicting relative risk in narrow birth weight ranges at each week of gestation. The grids will provide practitioners with clinically relevant information pertinent to pregnancy, delivery, and postnatal care in Canada.MethodsRecords from the British Columbia Vital Statistics Agency birth and death registries from 1981 to 2000 were deterministically linked and resulted in a 99.86% linkage rate. Risk ratios were computed by dividing percent neonatal mortality in 250 g birth weight categories at each week of gestation by the overall gender-specific mortality rates for the full period. We adjusted random rate fluctuations that were due to low frequencies in the narrow birth weight and gestational age strata.ResultsFemales exhibited greater survival across the full spectrum of birth weight by gestational age strata, but their mortality configurations were noticeably different from those of males. In addition, there were demarcations in both grids that depicted relatively abrupt changes in risk ratios. Although the crude mortality rates in BC decreased during the study period, the use of risk ratios reduced the disparity in crude rates over time.ConclusionThese gender-specific mortality grids refine and enhance previously available comparisons by portraying neonatal mortality risks in narrow birth weight ranges at each week of gestation.     

Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia

ABSTRACT: Background: The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. Methods: All women planning a hospital birth attended by a midwife during the 2‐year study period who were of sufficiently low‐risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group (n =488). The comparison group included women meeting the same eligibility requirements but planning a physician‐attended birth in hospitals where midwives also practiced (n =572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Results: Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39–0.86), narcotic analgesia (OR 0.26, 95% CI 0.18–0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16–0.30), amniotomy (OR 0.74, 95% CI 0.56–0.98), and episiotomy (OR 0.62, 95% CI 0.42–0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04–0.83) in the midwifery group. Conclusions: A shift toward greater proportions of midwife‐attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity. (BIRTH 34:2 June 2007)     

Thresholds for Small for Gestational Age Among Newborns of East Asian and South Asian Ancestry

ObjectiveTo determine the risk that newborn infants of East Asian and South Asian ancestry may be misclassified as small for gestational age (SGA).MethodsWe performed a single-centre, cross-sectional study of a cohort of liveborn infants born to women who had been born in Canada (n = 2362), East Asia (n = 1565) and South Asia (n = 753) and generated smoothed birth weight curves for males and females. We determined the rate of misclassification of infants of East Asian and South Asian maternal origin as SGA, using conventional weight centile cut-offs, rather than those specific to each ethnic group.ResultsInfants of Canadian-born mothers had a mean birth weight that was 144 g and 218 g greater than newborns of mothers of East Asian and South Asian origin, respectively. Using the 3rd centile cut-off for infants of Canadian-born mothers, 7 per 1000 female and 14 per 1000 male infants of East Asian maternal origin were potentially miscategorized as SGA at birth. Among female and male infants of mothers of South Asian origin, the corresponding rates were 29 and 46 per 1000.ConclusionBirth weight curves may need to be modified for newborns of East Asian and South Asian parentage to make a more accurate diagnosis of SGA.     

Identifying Barriers to Treatment for Women With Cervical Dysplasia in Rural Northern British Columbia

Objective

This study seeks to identify barriers to colposcopy examination faced by patients living in Northern BC to improve outcomes for women at risk of developing cervical cancer.

Laparoscopic Versus Abdominal Myomectomy: Practice Patterns and Health Care Use in British Columbia

ObjectiveTo examine the relative frequency and surgical outcomes of laparoscopic myomectomy compared with abdominal myomectomy in British Columbia.MethodsA linked database containing hospital admission, operating room, and emergency room data from 2007 to 2011 from eight Vancouver Coastal Health and Providence Health Region hospitals in British Columbia was used to conduct a retrospective cohort study of women who had myomectomy for uterine fibroids. All consecutive women who had abdominal or laparoscopic myomectomy at five hospitals were included in the study. Patients who had submucosal fibroids or hysteroscopic procedures were excluded. Abdominal and laparoscopic myomectomies were contrasted in terms of patient characteristics and surgical outcomes. Statistical significance was assessed using t tests, Wilcoxon, chi-square, and Fisher exact test; a two-sided P value < 0.05 was considered significant.ResultsOf eight hospitals offering gynaecologic surgery, myomectomies were performed at five hospitals located in metropolitan areas. Of 436 women undergoing myomectomy, 88 cases (20.2%) were laparoscopic, 342 (78.4%) were abdominal, and 6 (1.38%) were laparoscopic with conversion to laparotomy. Women who had laparoscopic rather than abdominal myomectomies were slightly older (mean 38.7 vs. 37.4 years, respectively, P < 0.05). No significant difference was observed in median operative time (106 vs. 95 min), but length of stay was decreased for laparoscopic myomectomies (median 1 vs. 2 days, P < 0.01). No significant differences were observed between laparoscopic and abdominal routes in the rates of admission to intensive care, prolonged hospitalization (> 3 days), or rehospitalization.ConclusionMyomectomies are performed in urban, metropolitan areas in British Columbia, and a significant fraction of myomectomies are performed by laparoscopy. Compared with abdominal myomectomies, laparoscopic myomectomies in pre-selected patients are associated with decreased length of stay and comparable perioperative surgical outcomes.     

Reuse of carboplatin and paclitaxel in patients with relapsed endometrial cancer--the British Columbia Cancer Agency experience

ObjectiveTo evaluate the efficacy of reusing carboplatin and taxol in women with relapsed endometrial cancer.MethodsRetrospective analysis of our database of newly diagnosed high-risk patients with endometrial cancer treated with carboplatin–paclitaxel at diagnosis, with subsequent relapse for the period of 1995–2007.Results111 patients of 200 relapsed. They had either endometroid or papillary serous histologies. Strategies utilized upon first relapse were: no treatment (n = 33), surgery (n = 4), hormones (n = 8), irradiation (n = 14) and chemotherapy (n = 52). Carboplatin and paclitaxel was reused in 31 (60% of 52 retreated with chemotherapy or 29% of the total cohort of 111). There was no statistically significant difference in stage at diagnosis or grade at diagnosis between those retreated with chemotherapy or not or with carboplatin–paclitaxel versus another regimen. The patients retreated were a selected subgroup as only those with initial response or treated adjuvantly were offered carboplatin–paclitaxel. CR or PR were achieved in 8 (42%) patients with endometroid type cancer. In the papillary serous group 6 (50%) had CR or PR. Median PFS from first relapse was 8 months for endometroid and 9 months for papillary serous histology. OS was 15 months and 26 months respectively from first relapse.ConclusionCarboplatin–taxol regimen is an efficacious treatment. Due to the patient selection these outcomes reported are likely to be an overstatement of what could be achieved in practice.     

Bedside resuscitation of newborns with an intact umbilical cord: Experiences of midwives from British Columbia

Contextlevel 1 evidence supports the practice of delayed cord clamping, and many doctors and midwives consider it routine care when delivering vigorous, term neonates. However, scarce research exists regarding the risks or benefits of delayed cord clamping for infants needing resuscitation with positive pressure ventilation. Nonetheless, some midwives in British Columbia already practice intact cord resuscitation (ICR) at planned home births and in the hospital in order to facilitate delayed cord clamping for infants who need resuscitation.Methodswe distributed an online survey to all registered midwives in British Columbia through the Midwives Association of BC between October 22nd and November 13th, 2014. This survey examined how midwives balance a commitment to delayed cord clamping with the need for resuscitation in home and hospital settings.Findingsa total of 82 midwives responded to the survey (response rate=35%). Many have practiced ICR (56, 69%). However, the majority (42, 78%) of respondents had only performed this type of resuscitation at planned home births and not in the hospital setting. In both settings, midwives found the ergonomics of resuscitation with an intact cord challenging, but cited a smoother physiologic transition for neonates as their primary reasons for this practice, despite the obstacles. Midwives reported a greater ability to use their delivery equipment to provide stable thermoregulation at the bedside at planned home births during a resuscitation compared with the set up of hospital delivery rooms.Conclusionalthough the majority of participants practice ICR at planned home births, very few use this practice in the hospital setting. In the home, ergonomics is the primary obstacle for easily practicing ICR; hospital culture, protocols and lack of training are additional barriers to this practice in the hospital setting. Ergonomics and lack of appropriate set up in the delivery room were also primary obstacles. Midwives expressed a desire to find ways to incorporate ICR into the hospital setting.     

Women’s Health Themes Across the Undergraduate Medical Curriculum at the University of British Columbia

ObjectiveThe overall objective of the project was to determine whether the current MD undergraduate curriculum at the University of British Columbia (UBC) met the minimum competencies in women’s health according to available guidelines.MethodsOvid and MEDLINE were searched for information on women’s health topics in medical undergraduate curricula. The Association of Professors of Obstetrics and Gynaecology (APOG) and the Association of Professors of Gynecology and Obstetrics (APGO) medical student objectives were used as a framework for evaluation of the UBC curriculum. The APGO women’s health care competencies for medical students were also compared with these objectives. A comprehensive review ouate of the medical curriculum at UBC was then carried out to analyze whether, when, and where the APOG and APGO objectives were met.ResultsOf the 93 women’s health competencies outlined by APGO, only two were not formally addressed in the UBC curriculum. Almost two thirds (60 of the 93) of the competencies are covered in the obstetrics and gynaecology third-year clerkship, which is just one of the 14 teaching settings available for potential coverage of the women’s health care competencies.ConclusionTopics in women’s health appear to be well addressed by the UBC medical undergraduate curriculum, although this review was unable to determine whether and how extensively these topics were actually delivered.