The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals.

BACKGROUND: In 2007-2008, two UK-based organisations, the National Institute for Health and Clinical Excellence and the Royal College of Obstetricians and Gynaecologists, published guidelines for the management of care and organisation of outpatient services for women with heavy menstrual bleeding (HMB). In 2010, this study was conducted to provide an update on guideline-related services provided in England and Wales, and whether they are consistent with national clinical guidelines two to three years after publication. METHODS: An organisational survey of outpatient gynaecology clinics was conducted of 221 hospitals in 154 acute National Health Service (NHS) trusts in England and Wales. A questionnaire was distributed to all hospitals to examine provision of diagnostic and therapeutic services in outpatient settings. Descriptive statistics were used to summarize results. RESULTS: The response rate was 100%. For diagnosis, 80% of hospitals had ultrasound, 87% had hysteroscopy, and 98% had endometrial biopsy available. Overall, 76% of hospitals provided an information leaflet, 8% referred patients to a website for information, and 20% did not provide any written information. A dedicated menstrual bleeding clinic was present in 38% of hospitals. Only 30% of hospitals reported that they have a local written protocol regarding the care and management of women with HMB. CONCLUSION: The majority of hospitals offer appropriate diagnostic and surgical services for women with HMB. However, local protocol development may not reflect the local services. It may be that hospitals are finding it difficult to summon resources to provide clinics for women with menstrual disorders.

Evaluating maternity care using national administrative health datasets: how are statistics affected by the quality of data on method of delivery?

BACKGROUND: Information on maternity services is increasingly derived from national administrative health data. We evaluated how statistics on maternity care in England were affected by the completeness and consistency of data on "method of delivery" in a national dataset. METHODS: Singleton deliveries occurring between April 2009 and March 2010 in English NHS trusts were extracted from the Hospital Episode Statistics (HES) database. In HES, method of delivery can be entered twice: 1) as a procedure code in core fields, and 2) in supplementary maternity fields. We examined overall consistency of these data sources at a national level and among individual trusts. The impact of different analysis rules for handling inconsistent data was then examined using three maternity statistics: emergency caesarean section (CS) rate; third/fourth degree tear rate amongst instrumental deliveries, and elective CS rate for breech presentation. RESULTS: We identified 629,049 singleton deliveries. Method of delivery was not entered as a procedure or in the supplementary fields in 0.8% and 12.5% of records, respectively. In 545,594 records containing both data items, method of delivery was coded consistently in 96.3% (kappa = 0.93; p < 0.001). Eleven of 136 NHS trusts had comparatively poor consistency (<92%) suggesting systematic data entry errors. The different analysis rules had a small effect on the statistics at a national level but the effect could be substantial for individual NHS trusts. The elective CS rate for breech was most sensitive to the chosen analysis rule. CONCLUSIONS: Organisational maternity statistics are sensitive to inconsistencies in data on method of delivery, and publications of quality indicators should describe how such data were handled. Overall, method of delivery is coded consistently in English administrative health data.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis.

OBJECTIVE: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally. METHODS: Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980. RESULTS: The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65). CONCLUSIONS: There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.

Number of embryos for transfer following in-vitro fertilisation or intra-cytoplasmic sperm injection.

BACKGROUND: Multiple embryo transfer during IVF has increased multiple pregnancy rates (MPR) causing maternal and perinatal morbidity. Elective single embryo transfer (SET) is now being considered as an effective means of reducing this iatrogenic complication. OBJECTIVES: To determine in couples undergoing IVF/ICSI (intra-cytoplasmic sperm injection) whether:(1) elective transfer of two embryos improves the probability of livebirth compared with:(a) elective single embryo transfer,(b) three embryo transfer (TET) or(c) four embryo transfer (FET).(2) elective transfer of three embryos improves the probability of livebirth compared with:(a) elective single embryo transfer, or(b) elective four embryo transfer. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register (searched March 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1, 2008), MEDLINE (1970 to 2008), EMBASE (1985 to 2008) and reference lists of articles. Relevant conference proceedings were hand-searched and researchers in the field contacted. SELECTION CRITERIA: Randomised controlled trials were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and quality of trials. MAIN RESULTS: For the update in 2008 five trials compared DET with SET. DET versus TET and DET versus FET were evaluated in a single small trial each. The difference in cumulative livebirth rates (CLBR) after DET and those after SET followed by transfer of a single frozen thawed embryo (1FZET) was not statistically significant (OR 0.81, 95% CI 0.59 to 1.11; p=0.18). There was no statistically significant difference in CLBR after a single fresh cycle of DET versus two fresh cycles of SET (OR 1.23, 95% CI 0.56 to 2.69, p= 0.60 ). The live birth rate (LBR) per woman in a single fresh treatment was higher following DET than SET (OR 2.10, 95% CI 1.65 to 2.66, p<0.00001). The MPR was lower following SET (OR 0.04, 95% CI 0.01 to 0.11; p< 0.00001). The CLBR following two fresh cycles of DET versus two fresh cycles of TET (OR 0.77, 95%CI 0.22 to 2.65, p=0.67) and CLBR after three fresh cycles of DET versus three fresh cycles of TET showed no statistically significant differences (OR 0.77, 95% CI 0.24 to 2.52; p=0.67). There were no statistically significant differences between DET and TET in terms of LBR (OR 0.40, 95%CI 0.09 to 1.85; p=0.24) and MPR (OR 0.17, 95%CI 0.01 to 3.85; p= 0.27). DET led to lower LBR than FET but the difference was not statistically significant (OR 0.35, 95% CI 0.11 to 1.05; p = 0.06). AUTHORS' CONCLUSIONS: In a single fresh IVF cycle, SET is associated with a lower LBR than DET. However there is no significant difference in CLBR following SET+ 1FZET and the LBR following a single cycle of DET. MPR are lowered following SET compared with other transfer policies. There are insufficient data on the outcome of two versus three and four embryo transfer policies.

Medical abortion at 9-13 weeks' gestation: a review of 1076 consecutive cases.

OBJECTIVE: The aim of the study was to assess the use, efficacy and factors influencing the outcome of medical abortion at 9-13 weeks' gestation. METHODS: Retrospective chart review of consecutive women undergoing medical abortion at 9-13 weeks' gestation was done. RESULTS: A total of 1927 abortions were carried out at 9-13 weeks' gestation, of which 1076 (55.8%) were undertaken medically. Efficacy decreased with increasing gestation (p=.02). Surgical evacuation was carried out in 45 (4.2%) women including 10 (2.7%) at 64-70 days, 11 (3.3%) at 71-77 days, 10 (5.1%) at 78-84 days and 14 (8.0%) at 85-91 days of gestation (p=.02). Indications for surgery included continuing pregnancy [16 (1.5%) women], retained sac [5 (0.5%)], incomplete abortion [20 (1.9%)] and emergency curettage for bleeding [4 (0.4%)]. The number of misoprostol doses used and the induction-to-abortion interval both significantly increased with gestation (p<.001), while analgesia requirements did not vary with increasing gestation (p=.18). CONCLUSIONS: Medical abortion at 9-13 weeks' gestation is an effective alternative to surgery. Medical methods should be offered routinely at these gestations, thus increasing women's choice.

Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation.

The aim of this study was to assess women's preferences and acceptability of medical (MA) and surgical abortion (SA) at 10-13 weeks gestation. This was a partially randomized patient preference trial. Women were offered to enter the randomized arm of the trial. Those who expressed a strong preference for a method were entered into the preference arm. A total of 368 women were randomized (188 medical and 180 surgical) while 77 entered the preference arm (15 medical and 62 surgical). Prior to abortion, 253 women (72%) indicated a preference for MA while 98 (28%) showed a preference for surgery (p < .0001). Despite having a preference for a particular method, women were content with alternatives. Women were more likely to choose the same abortion method again if they had shown a preference for that method prior to abortion (p = .002 and .01 for MA and SA, respectively). The availability of MA is an important option for many women who wish to avoid surgery or anesthesia and should now be offered routinely in the late first trimester.

Women's perceptions, expectations and satisfaction with induced labour--a questionnaire-based study.

OBJECTIVES: To evaluate the understanding and expectations of women undergoing labour induction, to assess their actual experience of the process and to compare their satisfaction with labour to those labouring spontaneously. STUDY DESIGN: Four hundred and fifty women at term undergoing induction of labour and cervical ripening with prostaglandinE2 vaginal tablets and 450 women labouring spontaneously were recruited into the study. The induction group were requested to complete a questionnaire prior to the start of their induction process and another questionnaire post-delivery. The post-delivery questionnaire contained two sections, one pertaining to issues to do with the induction and the second with the actual labour process. The spontaneously labouring group was requested to complete a questionnaire post-delivery, which only contained the section pertaining to the actual labour process. The main outcome measures were satisfaction with labour, perception of pain and length of labour between the induced and spontaneous labour groups, and issues that the women might wish changed about their induction. RESULTS: In the induction group, 34.7% were not satisfied with the information they received about the induction prior to the procedure and 27.2% expected to deliver within 12h of the administration of the inducing agent. Post-induction, 40% of the women felt the most important aspect they would like to change about their induction were they to have another one, would be the speed of the induction, 13.6% felt they might wish to take the inducing agent orally, 7% to have fewer vaginal examinations and 9% to have fewer complications. Among the women who returned questionnaires, 26.3% had a caesarean delivery in the induction group and 21.4% in the spontaneous labour group. Significantly more women were satisfied with their labour in the spontaneous labour group 79.5% versus 70.4%, RR 0.89, 95% CI 0.8-0.96, P=0.006). CONCLUSIONS: Labour that is artificially induced does result in lower satisfaction rates as compared to that following spontaneous onset. The longer time delay between the start of the induction and the delivery plays a significant part in this, with the mode of administration of the inducing agent, more vaginal examinations and the increase in caesarean deliveries being perceived as secondary issues. There is a need to improve the information provided to women undergoing labour induction, to counter unrealistic expectations and thereby improve satisfaction.

Surgical abortion using manual vacuum aspiration under local anaesthesia: a pilot study of feasibility and women's acceptability.

OBJECTIVE: Studies from the USA have reported the efficacy and high acceptability of surgical abortion using manual vacuum aspiration (MVA) under local anaesthesia. The aim of this study was to assess the feasibility, acceptability and efficacy of surgical abortion using MVA under local anaesthesia for termination of pregnancy up to 63 days' gestation, within a UK National Health Service setting. METHODS: Surgical abortion was carried out using MVA under local anaesthesia. Women's satisfaction with the procedure, and pain and anxiety levels, were assessed. The main outcome measures were: (1) feasibility assessed through successful completion of the procedure without the need for general anaesthetic or conversion to suction vacuum aspiration, (2) efficacy assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure. RESULTS: The mean (SD) gestation was 50 (9.4) days. A total of 55/56 (98%) women had a successful procedure and did not require any further surgical or medical treatment. Fifty-five (98%) women were satisfied with the procedure, 48 (86%) said they would recommend it to a friend and 45 (80%) said they would have the same method again in the future. Anxiety levels, as reflected by the visual analogue scales, showed a significant fall in anxiety scores following the procedure (p<0.01). CONCLUSIONS: Surgical abortion using MVA under local anaesthesia is effective and acceptable to women. These findings now need to be assessed in the context of a randomised trial.

Home self-administration of misoprostol for medical abortion up to 56 days' gestation.

OBJECTIVE: Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. METHODS: Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire. RESULTS: A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)]. CONCLUSIONS: This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.

The accuracy and efficacy of screening tests for Chlamydia trachomatis: a systematic review.

Screening women for lower genital tract infection with Chlamydia trachomatis is important in the prevention of pelvic inflammatory disease, ectopic pregnancy and infertility. This systematic review aims to state clearly which of the available diagnostic tests for the detection of C. trachomatis would be most effective in terms of clinical effectiveness. The review included all studies published from 1990 onward that evaluated diagnostic tests in asymptomatic, young, sexually active populations. Medline and Embase were searched electronically and key journals were hand-searched. Further studies were identified through the Internet and contact with experts in the field. All studies were reviewed by two reviewers and were scored by Irwig's assessment criteria. Additional quality assessment criteria included a documented sexual history and recording of previous chlamydial infection. The reviews were subjected to meta-analysis and meta-regression. The 30 studies that were included examined three types of DNA-based test--ligase chain reaction (LCR), PCR and gene probe--as well as enzyme immuno-assay (EIA). The results showed that while specificities were high, sensitivities varied widely across the tests and were also dependent on the specimen tested. Pooled sensitivities for LCR, PCR, gene probe and EIA on urine were 96.5%, 85.6%, 92% and 38%, respectively, while on cervical swabs the corresponding sensitivities of PCR, gene probe and EIA were 88.6%, 84% and 65%. Meta-analysis demonstrated that DNA amplification techniques performed best for both urine and swabs in low prevalence populations. We conclude that nucleic acid amplification tests used on non-invasive samples such as urine are more effective at detecting asymptomatic chlamydial infection than conventional tests, but there are few data to relate a positive result with clinical outcome.

Surgical abortion.

This review of surgically-induced abortion focuses on conventional first trimester suction evacuation. Manual vacuum aspiration at early gestations and dilatation and evacuation at more advanced gestation are also considered. The place of surgical abortion in contemporary abortion practice is reviewed alongside developments in medical abortion. There is still debate about the best method for later abortions. Patient choice and pre-procedure assessment are considered fundamental to practice. The importance of antibiotic prophylaxis or infection screening is highlighted. The value of ultrasound emerges. The need for cervical priming is considered along with choice of suitable pharmacological agents. Current practice and the procedure of surgical abortion is outlined. Complications and strategies to minimize risk are detailed. The overview concludes with consideration of the impact on future reproductive health.

Parallel observation of four methods for screening women under 25 years of age for genital infection with Chlamydia trachomatis.

OBJECTIVES: To compare four methods of screening women for Chlamydia trachomatis in an obstetrics and gynaecology department. STUDY DESIGN: A total of 303 healthy women under 25 years were recruited from antenatal, induced abortion, and family planning clinics. Each underwent parallel testing of endocervical specimens by enzyme immunoassay (EIA) and ligase chain reaction (LCR), vulval swabs by LCR, and urine by LCR. Outcome measures included sensitivity, specificity, acceptability of each method, and the influence of pregnancy. RESULTS: Overall prevalence (95% CI) was 9.9% (6.8-14%). All methods had a high rate of detection (75-100%), not affected by pregnancy. Urine was most acceptable, followed by vulval swabbing. CONCLUSIONS: Opportunistic screening of women under 25 years attending obstetric and gynaecology affiliated clinics found high rates of C. trachomatis infection. Both urine and vulval swab methods were highly sensitive, acceptable, and not affected by pregnancy status. Due to pragmatic issues surrounding the urine method, screening by vulval swabs deserves wider recognition.

Manual vacuum aspiration (MVA) in the management of first trimester pregnancy loss.

BACKGROUND: Manual vacuum aspiration is not widely used for the evacuation of retained products of conception in western Europe despite its well-proven success and safety record. Nor is there much information about its use under intravenous (systemic) analgesia or patient-controlled anaesthesia in modern settings. AIM: To evaluate the use of manual vacuum aspiration for the evacuation of retained products of conception under systemic analgesia or patient-controlled anaesthesia in the management of first trimester miscarriages. METHODS: Fifty-eight women with a diagnosis of first trimester miscarriage (42 missed and 16 incomplete miscarriages) were treated with manual vacuum aspiration under systemic analgesia or patient-controlled anaesthesia. Success rates and patient satisfaction and acceptability were recorded. RESULTS: Of the 58 women recruited, 42 underwent the procedure under systemic analgesia and 15 under patient-controlled sedation while 1 woman opted for general anaesthesia. Successful evacuation was achieved in all cases. Both analgesic methods were associated with high levels of patient satisfaction and acceptability. CONCLUSIONS: Manual vacuum aspiration is an option in the management of all first trimester pregnancy losses. Comparisons with other treatment options are indicated.

New challenges for gamete donation programmes: changes in guidelines are needed.

In the UK, the Human Fertilisation and Embryology Act 1990 prevents children born as a result of donor-assisted conception from gaining access to identifying information about their genetic origins. There is growing concern that current screening protocols regarding gamete donation are ill-suited, especially in relation to genetic disease. There are no guidelines addressing the issues of confidentiality that might arise if a disease emerges after insemination and establishment of pregnancy. Donors may become aware that they are at risk of a familial condition after they have donated gametes or recipients of donated gametes may become aware of a genetic illness in the resulting child. At present, there is no agreed method for allowing this information to be given to the donor or other recipients of gametes from that person. We suggest that these issues should be raised with donors, and appropriate counselling and predictive tests offered to them. Changes in regulations regarding gamete donation should be considered that accommodate recent and possible future developments in genetics. Furthermore, consideration should be given to the storage of samples of DNA from donors for the future provision of genetic information.

Reproductive outcomes following induced abortion: a national register-based cohort study in Scotland.

OBJECTIVE: To investigate reproductive outcomes in women following induced abortion (IA). DESIGN: Retrospective cohort study. SETTING: Hospital admissions between 1981 and 2007 in Scotland. PARTICIPANTS: Data were extracted on all women who had an IA, a miscarriage or a live birth from the Scottish Morbidity Records. A total of 120 033, 457 477 and 47 355 women with a documented second pregnancy following an IA, live birth and miscarriage, respectively, were identified. OUTCOMES: Obstetric and perinatal outcomes, especially preterm delivery in a second ongoing pregnancy following an IA, were compared with those in primigravidae, as well as those who had a miscarriage or live birth in their first pregnancy. Outcomes after surgical and medical termination as well as after one or more consecutive IAs were compared. RESULTS: IA in a first pregnancy increased the risk of spontaneous preterm birth compared with that in primigravidae (adjusted RR (adj. RR) 1.37, 95% CI 1.32 to 1.42) or women with an initial live birth (adj. RR 1.66, 95% CI 1.58 to 1.74) but not in comparison with women with a previous miscarriage (adj. RR 0.85, 95% CI 0.79 to 0.91). Surgical abortion increased the risk of spontaneous preterm birth compared with medical abortion (adj. RR 1.25, 95% CI 1.07 to 1.45). The adjusted RRs (95% CI) for spontaneous preterm delivery following two, three and four consecutive IAs were 0.94 (0.81 to 1.10), 1.06 (0.76 to 1.47) and 0.92 (0.53 to 1.61), respectively. CONCLUSIONS: The risk of preterm birth after IA is lower than that after miscarriage but higher than that in a first pregnancy or after a previous live birth. This risk is not increased further in women who undergo two or more consecutive IAs. Surgical abortion appears to be associated with an increased risk of spontaneous preterm birth in comparison with medical termination of pregnancy. Medical termination was not associated with an increased risk of preterm delivery compared to primigravidae.