Postcoital bleeding: A study of the current practice amongst consultants in the United Kingdom

Objectives

To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

Study design

A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

Results

Six hundred and fourteen (60%) replies were received. Three hundred and thirty-seven (59.8%) of the respondents agree that PCB is a significant clinical issue that requires developing national guidelines for management, 452 (80.1%) do not have local guidelines in their departments, 336 (59.6%) agree with The Department of Health guidelines for referral. Two hundred and eighty-one (49.8%) respondents see women in gynaecology clinic, 94 (16.7%) in colposcopy clinic, while 163 (28.9%) see them in either clinics depending on the workload. Only 275 (48.8%) respondents repeat the cervical smear for those with negative smear history who are still within the national screening interval. Chlamydia testing is performed by 450 (79.8%) respondents, whereas 68 (12.1%) consider investigating the endometrium in selected cases.

Conclusion

The results highlight the wide variations in managing women with PCB. Given the well-reported association with serious pathology, it may be prudent to standardise the management in the UK based on the best available evidence.     

Cesarean delivery in the United Kingdom: time trends in the general practice research database

OBJECTIVE: To estimate recent temporal trends in delivery by cesarean during the past decade and the proportion of vaginal deliveries after prior caesarean in the United Kingdom. METHODS: We conducted a cohort study using information from the General Practice Research Database. We identified all women with 1 or more deliveries between January 1990 and December 1999 and determined the method(s) of delivery. We estimated the proportion of women with vaginal delivery after cesarean in a subcohort who had at least 3 years of follow-up. RESULTS: We identified 39,938 cesareans among 271,663 deliveries (14.7%), with an increase from 12.5% in 1990 to 18.3% in 1999. The proportion of cesarean deliveries increased with age and increased over time in all age groups except women aged younger than 20 years. Among 26,480 women with a caesarean delivery between 1990 and 1996, 7,649 (28.9%) had a subsequent delivery. The proportion of vaginal delivery after prior cesarean decreased from 45% in 1991 to 37% in 1999. CONCLUSION: Cesarean deliveries increased as a proportion of all deliveries in the United Kingdom during the past decade, and the proportion of vaginal delivery after prior cesarean decreased. Still, the proportion of cesarean deliveries is lower and the proportion of vaginal deliveries after prior cesarean is higher in the United Kingdom than in the United States. LEVEL OF EVIDENCE: II-2.     

A prospective study of the correlation between genital pathogens and morbidity following diathermy loop excision of the transformation zone.

A prospective study of 48 women was carried out to estimate the incidence of common genital pathogens in women referred to colposcopy clinic requiring diathermy loop excision and to compare patient morbidity in the subgroups with and without genital pathogens. Of the 43 women included in the analysis, genital pathogens were present in 24 cases (56%) and absent in 19 (44%) of the 24 positive cases, 19 (79%) women had pathogen(s) on the cervical swab, 24 (100%) had pathogen(s) on the high vaginal swab and 15 (63%) had both a positive cervical and high vaginal swab (HVS). The most frequently isolated groups of organisms were mixed anaerobes, alone (four HVS and four cervical) or in combination with Gardnerella vaginalis (four HVS and three cervical) or coliforms (two HVS and two cervical). The mean duration of bleeding and vaginal discharge in the two study groups was not statistically significant (t value 1.97, P 0.05; and t value 0.48, P 0.5, respectively). However, the mean duration of bleeding graded by the patient as being moderate to severe was significantly different in the two groups (t value 3.18 P 0.01). Fifty-six per cent of the women in the study had confirmed genital pathogens, predominantly anaerobes, and the prolonged moderate-to-severe bleeding in this group suggests a potential role for prophylactic bacteriocides, although the study size was unable to implicate a single pathogen.     

The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix

ObjectiveTo evaluate the role of genital pathogens in postoperative morbidity following diathermy loop excision of the transformation zone (LETZ) of the uterine cervix.MethodsPatients with cervical intraepithelial neoplasia (CIN) who underwent diathermy LETZ were included in a prospective study. Cervical swabs for genital pathogens were collected before the diathermy procedure. After surgery, women were followed-up regarding the occurrence and severity of postoperative pain, bleeding, and discharge.ResultsGenital pathogens were present in 463 of 788 (58.8%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms. In patients with genital pathogens, postoperative pain was present in 298 (37.8%), discharge in 262 (33.2%), and bleeding in 236 (29.9%) cases. In patients without genital pathogens, 199 (25.3%) experienced pain, 181 (23.0%) discharge, and 143 (18.1%) bleeding. The differences between the 2 groups were not statistically significant (χ² for pain = 0.675; χ² for discharge = 0.031; χ² for bleeding = 3.444; P > 0.05).ConclusionGenital pathogens are very common among patients with CIN and do not affect the occurrence or severity of pain, discharge, or postoperative bleeding after diathermy LETZ.     

Use of oxytocin to prevent haemorrhage at caesarean section--a survey of practice in the United Kingdom

Objective

Preterm birth remains one of the most challenging areas in obstetrics. The pathogenesis of preterm labor is multifactorial and research on preterm birth has focused principally on infection and inflammatory markers. Recently the focus has turned to potential genetic factors influencing preterm birth. Uteroplacental insufficiency and thrombotic vasculopathy are considered part of the pathogenesis of preterm labor. Investigating the gene expression in the maternal/fetal interface seems of importance to expand our knowledge of the pathophysiology of preterm birth. The renin–angiotensin system (RAS) appears to play an important role in fetal/placental development and uteroplacental circulation. Hence, the aim of this study was to investigate angiotensin converting enzyme (ACE) activity and I/D polymorphisms in the ACE gene in mothers and infants with appropriately grown infants in relation to preterm birth and infant birth weight.

Study design

We conducted a cross-sectional study of 113 term pregnancies (≥37 weeks) and 18 preterm pregnancies (<37 weeks). Umbilical cord bloods (venous and arterial) were obtained from the placenta immediately after delivery for serum ACE activity, ACE genotype analysis of the I/D polymorphism and the acid-base status. Maternal venous samples were obtained just after delivery for analysis of ACE activity and ACE genotype.

Results

The distribution of the maternal ACE genotypes was similar for preterm and term births as was maternal ACE activity. Preterm infants were more likely to be of the DD genotype than term infants (7/18 (39%) vs. 11/83 (13%), p = 0.02) (adjusted p = 0.04). There was no correlation between ACE activity and birth weight (r² 0.00, p = 0.82).

Conclusions

These findings suggest that the ACE genotype of the infant may influence the risk of preterm birth among appropriately grown fetuses.     

Needle versus loop diathermy excision of the transformation zone for the treatment of cervical intraepithelial neoplasia: a randomised controlled trial

OBJECTIVE: To determine whether lower rates or incomplete resection of cervical intraepithelial neoplasia (CIN) may be achieved by needle excision of the transformation zone (NETZ) than with loop excision (LLETZ). DESIGN: A prospective randomised controlled trial. SETTING: A gynaecological oncology centre and a teaching hospital in West London. POPULATION: Four hundred and four women due to receive treatment for suspected CIN. METHODS: Women were randomised to receive either LLETZ or NETZ. MAIN OUTCOME MEASURES: The study was designed to demostrate a difference in the proportion of women with clear histological margins of 82% for LLETZ compared to 94% for NETZ with 90% power at a 5% significance level, allowing for absence of CIN in the treatment specimen in 15%. RESULTS: Four randomised women were excluded from the analysis, as they were ineligible for the study. Three hundred and forty-seven (87%) had CIN in the treatment specimen and could be included in the analysis of excision margins. More women in the NETZ arm had clear histological margins (84.8%vs 75%, (P= 0.03). The median volume of specimens in the NETZ arm was 739 mm(3) larger (P= 0.33) and they were less likely to be removed in multiple pieces (2.5%vs 29.5%, RR 0.09, 95% CI 0.04 to 0.20). Needle excision took longer to perform (median treatment time 210 vs 90 seconds, P<0.0001) and surgeons more often reported the procedure as 'difficult' (9.5%vs 3.0%, RR = 3.17%, 95% CI 1.33 to 7.58). No difference in peri-operative or post-operative complication rates could be demonstrated between the two groups. CONCLUSION: NETZ is more likely to produce a specimen in one piece and with clear margins compared to LLETZ.     

External cephalic version at term: a survey of consultant obstetric practice in the United Kingdom and Republic of Ireland

Objective To undertake a survey of external cephalic version (ECV) in the United Kingdom and Republic of Ireland.
Design In June 1995 every consultant obstetrician and gynaecologist in the United Kingdom and Republic of Ireland was sent a postal questionnaire which asked whether ECV was routinely performed for breech presentation after 37 weeks of gestation, assuming no contraindications. If consultants did not perform ECV, a supplementary question enquired whether they referred patients to a colleague who would perform ECV. The questionnaires were colour coded for country and dispatched from the Postgraduate Education Department of the Royal College of Obstetricians and Gynaecologists (RCOG).
Results Overall, 78% of questionnaires were returned. The percentage of consultants routinely practising ECV in each country was as follows: Northern Ireland 82%; Scotland 64%; Republic of Ireland 64%; England 43%; and Wales 41%. When these figures were compared with the latest RCOG Annual Statistical Returns for breech delivery and caesarean section for breech delivery, there was an inverse correlation between the percentage of obstetricians performing ECV in any one country and the incidence of breech delivery ( P < 0.001). There was a similar inverse correlation for the percentage of obstetricians performing ECV and the caesarean section rate for breech delivery ( P < 0.001).
Conclusion Although postal survey results are not necessarily an accurate reflection of what happens in clinical practice, these data are supported by evidence from the Cochrane Database of Systematic Reviews indicating that ECV after 37 weeks reduces the incidence of both breech delivery and caesarean section for breech delivery.     

Loop diathermy excision of the abnormal cervical transformation zone

Abstract. Six-hundred patients with abnormal cervical transformation zones were treated by loop diathermy excision. The patients were referred to the colposcopy clinic in the Regional Department of Gynaecological Oncology, Gateshead with abnormal cervical cytology. The indications for treatment, management and follow-up are presented. All patients were managed as out-patients under local anesthesia (71%) or as half-day inpatients under short general anesthesia (29%). Patients were treated with loop diathermy excision of visible lesions or with loop diathermy conization as required. Eradication of cervical intra-epithelial neoplasia (CIN) was achieved with one treatment in 95.5% of cases of CIN. The procedure is rapidly and easily performed. Major morbidity is rare. Only two patients required blood transfusion following treatment. Loop diathermy excision is ideally suited to a policy of combined diagnosis and treatment for these patients allowing efficient use of clinic time. The danger of inadvertant local destruction of early invasive disease is minimized. When preliminary colposcopically directed punch-biopsy histology was compared to definitive loop histology, CIN3 was detected in 27.4% of loops where the punch biopsies failed to show CIN and one case of CIN3 on punch biopsy was upgraded to invasive squamous carcinoma on loop biopsy. Loop excision biopsy therefore gives more complete histologic information than traditional punch biopsy. This technique is effective, efficient, economical and highly acceptable to both patient and practitioner. It is now the treatment of choice for management of the abnormal transformation zone in our practice.     

Use of oxytocin to prevent haemorrhage at caesarean section—A survey of practice in the United Kingdom

Objective

To establish the views and current practice of obstetricians and anaesthetists with regard to the use of oxytocin to prevent haemorrhage at caesarean section.

Study design

A national survey of all lead consultant obstetricians and anaesthetists for the labour ward in the United Kingdom. A postal questionnaire was sent to all clinicians with one subsequent reminder to non-responders. The use of oxytocin bolus and infusion, perceived side effects of intravenous oxytocin, estimated blood loss at caesarean section, and willingness to participate in a future clinical trial were explored.

Results

The response rate was 84% (365 respondents). A slow bolus of 5 IU oxytocin was the preferred approach of obstetricians and anaesthetists (153, 86% and 171, 92%, respectively). Oxytocin infusions were used routinely by 72 clinicians (20%) with selective use for particular clinical circumstances by 289 (80%). Most clinicians used either 30 IU (158, 43%) or 40 IU (192, 53%) infusions over 4 h, with a total of 38 different regimens. The perceived risk of side effects with an oxytocin infusion was low. Estimated “average” blood loss varied (150–1500 ml) with 56 clinicians (17%) and 93 (28%) reporting a >20% risk of postpartum haemorrhage for elective and emergency caesarean sections, respectively.

Conclusion

There is wide variation in the use of oxytocin at caesarean section reflecting limited research in this area. Excess haemorrhage is considered to occur frequently and the perceived risk of oxytocin bolus and infusion is low. Further research is required addressing the optimal use of oxytocic agents at caesarean section.     

The role of frozen sections in gynaecological oncology: survey of practice in the United Kingdom

Objective

To assess the use of frozen section diagnosis in gynaecological oncology in the United Kingdom.

Study design

A questionnaire was circulated electronically to gynaecological pathologists and surgeons. The results were collated and compared with the available literature on this subject.

Results

Our survey showed that the use of frozen sections varies with the resource setting and the preferences and practices of the practitioners. Frozen sections are most often used in diagnosis of ovarian/pelvic masses and assessment of lymph nodes in cervical carcinoma.

Conclusion

Frozen section diagnosis is of value in certain areas of gynaecological oncology, while it is of limited or no value in others. Each multidisciplinary team should develop their own local protocols for intraoperative frozen section examination and support developing expertise in frozen section diagnosis in the adopted areas of the practice.     

Electroconization with loop diathermy. A retrospective series of 307 cases

The electroconization with diathermic loop is a good procedure in the cervical dysplasia because there is a respect of the cervical tissue with a low cost, low complications, easy and quickly technic and a precise histological analysis of the histologic specimen. The indications are represented by high grade lesions, cyto-histologic discordance and endocervical squamo-columnar junction with a low grade lesion. The authors proposed a retrospective study about 307 cases of the electroconization with diathermic loop realised between January 1993 and June 1998.     

Treatment of cervical intraepithelial neoplasia: experience with the low-voltage diathermy loop

Eighty patients with cervical abnormalities that were proved by colposcopy were treated with the low-voltage diathermy loop by excision biopsy of isolated lesions (n = 14), excision of the transformation zone (n = 52), or by cone biopsy (n = 14). Treatment was performed at the time of initial assessment with the patient under a local anesthetic. Treatment proved acceptable to patients and minimal discomfort was reported. Primary hemorrhage was not a problem, although secondary hemorrhage occurred in 3.7% of patients. Excision was histologically complete in 85% of cases, and excision was clinically complete in the remaining cases. Diathermy coagulation to the base of the lesion ensured hemostasis and destroyed any residual cervical intraepithelial neoplasia. Follow-up cytologic findings were normal in 91% of patients at 3 months, and colposcopy showed no abnormality in 95% of patients at 6 months. The squamocolumnar junction was fully visible in 91% of patients. Thus excisional techniques with the low-voltage diathermy loop appear to be a viable treatment option for cervical intraepithelial neoplasia.     

Management of diabetic pregnancies in the United Kingdom.

The aim of this postal questionnaire survey was to identify facilities currently available for the care of pregnant diabetic women in the United Kingdom and determine how closely these reflect the standards recommended by The St Vincent Declaration Action Programme. A questionnaire was sent to a physician and an obstetrician in each of the 255 obstetric hospitals in the UK. Two hundred and forty-five (96.1%) hospitals replied, with most of these managing 20 or less insulin dependent diabetics per year. Of the hospitals, 58.4%, had a special combined diabetic antenatal clinic; 86.6% of the units had a single physician responsible for diabetic care, whilst more than one obstetrician was involved in 50.6% of the units. Prepregnancy counselling was provided in 87.4% of the hospitals. Home blood glucose monitoring was used in 97.9% of the units. Ideal mean pre- and postprandial blood glucose concentrations were 6.0 mmol/1 (SD 0.82) and 7.9 mmol/l (SD 0.91), respectively. Ultrasound was routinely used to assess fetal growth in 98.7% of the units. The mean gestational age for elective caesarean section was 38.2 weeks (SD 0.55), compared with 39.0 weeks (SD 0.35) for planned vaginal delivery. During labour, 98% of the units used a dextrose and insulin infusion, but only 53.7% of the units maintained an intrapartum maternal blood glucose of between 4 and 6 mmol/l. We conclude that there is widespread variation in the management of the pregnant diabetic patient, and much practice is suboptimal. Many of the recommendations of the St Vincent Declaration are not being met by current UK practice.