Cytopathological review of cervical pathology: Impact for women and follow-up results.

BACKGROUND: Cervical screening programs have had an important effect on the reduction of cervical cancer rates. Comprehensive programs require access to pathological review to improve the sensitivity of screening cytology and the specificity of diagnostic histology. AIMS: To determine the number of cases where cervical cytology or histology was amended at cytopathological review; whether amendments were 'upgrades' or 'downgrades', and how amendments aligned with follow-up results for these patients. MATERIALS AND METHODS: A retrospective cohort study was performed of all patients reviewed from January 2016 to December 2017 (n = 287 cases, from 254 patients) at colposcopy multidisciplinary meetings at Wellington Hospital, a tertiary referral hospital. Where amendments to cytology or histology were made, follow-up results were retrieved where available (85.7% and 84.2% respectively). RESULTS: Cytology or histology was amended in 24.7% of cases. Smear cytology was amended in 16.7%. Where cytology was upgraded (n = 9), 44% had subsequent results of equal or higher grade including one case of adenocarcinoma. Where cytology was downgraded (n = 19), 93.8% (81.9-100%) had follow-up studies showing equal or lower results. Cervical biopsy histology was amended in 12.2% of cases (upgraded n = 19, downgraded n = 6). Large loop excision of the transformation zone or cone biopsy histology was amended in three cases (7.9%). CONCLUSIONS: Cytopathological review appears to improve the specificity of the comprehensive cervical screening program, leading to a reduction in unnecessary treatment. Additionally, a small number of cases of malignant or premalignant disease were detected.

Caesarean section wound infection surveillance: Information for action.

Surgical site infection (SSI) following caesarean section is common, resulting in significant morbidity. Several factors are known to contribute to wound infection, including maternal, procedural and antibiotic factors. We sought to clarify these issues and sought opportunities to make improvements. A retrospective cohort study was performed assessing all women who underwent caesarean section in 2014 and 2015 at Wellington Hospital. Any women with culture-positive wound samples within 30 days of surgery were identified, and clinical notes reviewed. Odds ratios (OR) were calculated for available maternal, procedural and antibiotic risk factors. Two simplified surveillance techniques were also tested for their abilities to identify significant trends. The study included 2231 women, of whom 116 (5.2%) were identified as having SSI. Maternal obesity (body mass index (BMI) ≥ 30) was associated with significant SSI risk (OR 4.1, P < 0.001). The pathogen distribution was significantly different between women with BMI < 30 and BMI ≥ 30 (P < 0.001). Increased cefazolin dose based on BMI (3 g dose for BMI ≥ 30) was associated with a significant reduction in SSI (OR 0.309, P < 0.001) and was administered in 74.1% of obese women receiving cefazolin. Maori women had an increased SSI risk (OR 2.1, P = 0.019), as did Samoan women (OR 3.0, P = 0.002). The study reinforces other studies showing that raised BMI is the single biggest risk factor for surgical site infection post-caesarean section. Surveillance using simplified techniques appears to be adequate to identify trends. We believe that concentrating on appropriate antibiotic dosing and targeting special wound care measures will be pivotal interventions in improving outcomes in high-risk groups.

Perimortem caesarean section: Two cases performed in New Zealand hospitals.

Perimortem caesarean section is a term many obstetricians are familiar with despite few encountering it first-hand. It is estimated the intervention will be needed every 53 000 maternities. Despite this rarity it is vital clinicians are trained in detecting and intervening where perimortem caesarean is required. In New Zealand eight perimortem caesareans were performed from 2006 to 2013. Here we discuss two perimortem caesarean sections performed in two New Zealand hospitals alongside current guidance and recommendations.

Poor compliance with standard precautions against infections during minor gynaecological procedures.

BACKGROUND: Splash injuries occurring during minor surgical procedures are associated with a significant infective risk to the operator. It is a common misconception that minor operations carry low risks. AIM: To determine the prevalence of the practice of Standard Precautions by medical staff in the obstetric and gynaecology (O & G) units of two hospitals in New Zealand, and to assess self-observed splash injury rates. METHOD: A cross-sectional survey of all doctors working in the O & G units of two public hospitals servicing a population of 435 000. A self-administered questionnaire was provided to 43 doctors with questions related to the use of Standard Precautions, perceived likelihood of infection from a splash and splash injuries sustained during procedures. RESULTS: The response rate was 76.6% (n = 33/43). Of the respondents, only 30.3% (n = 10) used Standard Precautions during minor procedures. Sixty-four per cent (n = 21) routinely used goggles/visor for eye protection. Forty-five per cent (n = 15) thought they were likely to get an infection from a splash, and 55% (n = 18) of clinicians had experienced a splash injury. Of the minor procedures during which splash injuries had occurred, repair of episiotomy 45.8% (n = 11) was the commonest. CONCLUSIONS: This survey shows poor compliance with guidelines for Standard Precautions to protect from infection despite self-reported rates of splash injury being high at 55%. Effective interventions are needed to increase compliance and prevent infection.

Puerperal pyrexia: a review. Part I.

UNLABELLED: Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part I of this review provides background information and definitions, discusses the incidence and risk factors, explains the microbiology and pathophysiology of various infections, and delineates the signs and symptoms of major puerperal infection. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

Puerperal Pyrexia: a review. Part II.

UNLABELLED: Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part II of this review describes the best management of wound infection, pelvic abscess, episiotomy infection, thrombophlebitis, mastitis, urinary tract infection, and miscellaneous infections. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

The diagnostic role of ventilation/perfusion scans versus computed tomography pulmonary angiography in obstetric patients investigated for pulmonary embolism at Wellington Hospital from 2010 to 2012.

AIM: To develop best practice clinical guidelines for the use of ventilation/perfusion (V/Q) scanning and computed tomography perfusion angiography (CTPA) in pregnancy and the postpartum period. METHOD: Retrospective analysis of the clinical findings and radiologic investigation for pulmonary embolism (PE) in obstetric women at Wellington Hospital from 2010 to 2012. RESULTS: Fifty-four women were investigated for PE with a V/Q scan or CTPA, including 29 antenatal women and 25 postnatal women. Eleven (37.9%) antenatal women had V/Q scans and 18 (62%) had CTPAs. Five (20%) postnatal women had V/Q scans, 19 (76%) had CTPAs and one (4%) had a V/Q scan followed by a CTPA. Three of the 54 women (5.6%) had a positive radiologic finding of PE (two by V/Q scan and one by CTPA). Four (22.2%) antenatal women and 5 (25%) postnatal women had a diagnosis made on CTPA, which was not seen on chest x-ray. CONCLUSION: This audit found that clinicians varied in their investigation of cases suspected of PE. We have proposed a clinical pathway for the investigation of PE in pregnancy and the postpartum period.

Efficacy of mifepristone for cervical priming for second-trimester surgical termination of pregnancy.

OBJECTIVE: To determine whether mifepristone plus misoprostol was as effective as misoprostol with or without laminaria (depending on gestational age) for cervical preparation for second-trimester termination of pregnancy. METHODS: A retrospective cohort study was carried out among women who underwent surgical termination between 14 and 19+6 weeks of pregnancy. Those who received preoperative mifepristone were compared with those who did not. The study group received mifepristone plus misoprostol before dilation and evacuation of the uterus between May 2008 and September 2011. The comparison (non-mifepristone) group received misoprostol with or without laminaria between January 2005 and April 2008. RESULTS: There was no difference between the groups in terms of difficulty of cervical dilation, with an overall relative risk for moderate-difficult dilation in the mifepristone group of 0.91 (95% confidence interval, 0.49-1.68). There was no difference between the groups with regard to complications arising from the procedure. CONCLUSION: Mifepristone is effective for cervical priming prior to second-trimester dilation and evacuation in both multiparous and primiparous women, without an increase in complication rates.

Outcomes in HrHPV-positive women with low grade cervical smears and normal or low grade initial colposcopy results.

AIM: To determine outcomes in HrHPV-positive women with low grade cervical smears and normal or low grade initial colposcopy biopsy results in a cohort of women over a 2-year follow-up period. BACKGROUND: The revised National Cervical Screening (NCS) programme guidelines in New Zealand were implemented in October 2009. The guidelines state that women 30 years and older should undergo reflex HPV testing. If this test confirms the presence of HrHPV, women are to be referred for a colposcopic assessment. The guidelines do not mention what the follow-up period should be of women with HrHPV and normal or low grade abnormalities at colposcopy/biopsy. METHOD: In this study we followed up women 30 years and older referred to Wellington Hospital from 1/10/2009 to 1/10/2011 with a LGSIL or ASC-US smear and positive HrHPV test. Those with a normal or low grade biopsy result were followed over a 2-year period to determine outcomes. RESULTS: Our study found that 4% of women with initial normal biopsy results and 15.2% with initial low grade results had progressed to high grade (CIN 2/3/invasion) over a 2-year follow-up period. During the same time period, 68% of women with an initial normal biopsy and 61% with a low grade biopsy had a normal colposcopy after 2 years. Twenty-eight percent of women with normal and 24% of those with initial with low grade biopsy continued to have LG abnormalities at 2 years of follow-up. CONCLUSION: Women 30 years and older who are HrHPV-positive and have low grade abnormalities at colposcopic biopsy may be followed up with a 12-month cervical smear rather than repeat colposcopy as the risk of progression to a high grade abnormality is low.

Multiple levels on LLETZ biopsies do not contribute to patient management.

AIM: Cervical large loop excision of the transformation zone (LLETZ) specimens are performed both to treat and to diagnose or exclude cervical pre-neoplasia. Examination of these specimens forms a significant part of the routine histological work load of the pathologist, yet histological confirmation of squamous intraepithelial lesion (SIL) or completeness of excision, does not alter the treatment of SIL. When the LLETZ procedure is done, the treatment is complete, the dysplasia having been subject to excision as well as diathermy during the procedure. METHOD: In this study, records of 1139 women who underwent LLETZ treatment for SIL were examined. The grade of SIL present and the margin status were extracted from histology reports and linked to post-LLETZ follow-up cytology and histology, for a period of 2 years. RESULTS: SIL recurrence in women with high grade (HG-SIL), low grade SIL (LG-SIL) and normal LLETZ biopsy results was not significantly different. There was no significant difference between the recurrence rates of HG-SIL and LG-SIL with SIL at margins compared to SIL clear of margins. DISCUSSION: Pathologists spend significant time examining multiple levels of LLETZ biopsies, grading SIL, determining margins and trying to find SIL in 'normal' LLETZ biopsies. None of this affects the subsequent follow-up. The most useful data the pathologist can provide is whether invasion is present or not. Pathological effort should be directed to examining multiple levels of those with HG-SIL to find invasion, rather than spending time looking at multiple levels of normal or LG-SIL LLETZ biopsies.

Assessing cephalopelvic disproportion: back to the basics.

Dystocia, or abnormally slow progress in labor, can result from cephalopelvic disproportion (CPD), malposition of the fetal head as it enters the birth canal, or ineffective uterine propulsive forces. Cephalopelvic disproportion occurs when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in "failure to progress" in labor for mechanical reasons. Untreated, the consequence is obstructed labor that can endanger the lives of both mother and fetus. Despite the use of imaging technology in an attempt to predict CPD, there is poor correlation between radiologic pelvimetry and the clinical outcome of labor. Clinical pelvimetry still has a place in obstetrics for predicting or confirming CPD, but without appropriate training and repeated practice of this clinical skill, it is in danger of becoming a lost art. For this review, a computerized search of the terms cephalopelvic disproportion, dystocia, pelvimetry, obstructed labor, and malposition was done using MEDLINE, PUBMED, SCOPUS, and CINAHL, and historical articles, texts, articles from indexed journals, and references cited in published works were also reviewed.

Eating and drinking in labor: should it be allowed?

Eating and drinking in labor is a controversial subject with practice varying widely by practitioners, within facilities, and around the world. The risk of aspiration pneumonitis and anesthesia-related deaths at cesarean section has resulted in adherence to historical practices of starving women in labor. Studies have shown that the risk of this anesthetic-related complication is low. It is the fear of the birth-attendant to bear full responsibility if a patient inhales gastric contents when giving in to demands for liberal fluid and food regimes during labor that governs practice. While the bulk of evidence supports fluid intake in labor, there are insufficient published studies to draw conclusions about the relationship between fasting times and the risk of pulmonary aspiration during labor. Whether or not allowing food and fluid throughout labor is beneficial or harmful can only be determined by further research. A computerized search was done of MEDLINE, PUBMED, SCOPUS and CINAHL, as well of historical articles, texts, articles from indexed journals, and references cited in published works.

Reliability of ultrasound estimation of fetal weight in term singleton pregnancies.

AIM: To assess the reliability of ultrasound estimation of fetal weight undertaken antenatally at Wellington Hospital (Wellington City, New Zealand) in women with a singleton pregnancy = or >37 weeks gestation. METHOD: Data were collected retrospectively for pregnant women who had undergone ultrasound estimation of fetal weight <7 days prior to a term delivery (= or >37 weeks gestation) over the period of July 1998-June 2005. Stillbirths and multiple pregnancies were excluded. Ultrasound fetal weight estimations, calculated using a locally modified Woo formula, were compared with the infant's actual birth weight. RESULTS: A total of 1177 infants were studied. The mean absolute error and mean signed error (+/-SD) of ultrasound fetal weight estimations were 7.0+/-5.7% and -0.2+/-9.0%, respectively (n=1177). Three-quarters of estimations were within 10% of birth weight. Ultrasonic estimation of fetal weight tended to overestimate the weight of small infants (<2500 g; mean signed error = +3.5%+/-9.1%, n=98) and underestimate the weight of large infants (= or >4000 g; mean signed error = -3.3+/-8.7%, n=170). Both large and normal weight infants of women with diabetes tended to have their weight underestimated (mean signed error = -5.1+/-9.2%, n=48). Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonic detection of fetal weight = or >4000 g in non-diabetic women were 61%, 96%, 69%, and 94%, respectively. For detection of fetal weight = or >4500, the figures were 50%, 98%, 47%, and 98%, respectively. CONCLUSION: The accuracy of ultrasound estimations of fetal weight performed at Wellington Hospital within 7 days of delivery in term singleton pregnancies was at least similar and sometimes better than that reported in other studies. For one in four women, however, the fetal weight estimation was more than 10% different from the actual birth weight of their infant. Ultrasound measurements had a tendency to overestimate the weight of small infants while underestimating the weight of both large infants and the infants of diabetic mothers. As the reliability of ultrasound estimation of fetal weight to detect larger babies was poor, the use of such an objective measurement in the management of suspected macrosomia in term singleton pregnancies should be avoided.