Rapid identification of group B streptococcus carriage by PCR to assist in the management of women with prelabour rupture of membranes in term pregnancy.

BACKGROUND: Management of prelabour rupture of membranes at term (37 weeks gestation or later) (TPROM) remains complicated in the absence of a rapid assay for group B streptococcus (GBS) colonisation. AIMS: To evaluate the accuracy and clinical utility of a commercial PCR assay, compared with culture, for detection of GBS colonisation in pregnant women presenting with TPROM. METHODS: A prospective study of women presenting with TPROM conducted in a large tertiary hospital (Westmead Hospital, Australia). Five hundred and seventy-four consecutive women with TPROM were enrolled between July 2006 and November 2007. Paired low vaginal and anal swabs were collected from women presenting with TPROM for PCR and culture on GBS selective agar following broth enrichment. Primary outcomes were sensitivity and specificity of PCR compared with GBS selective enrichment culture. Secondary analyses included comparison with a historical but otherwise similar cohort regarding clinical utility, maternal and neonatal outcomes. RESULTS: PCR sensitivity and specificity were 89.0% (95% CI - 82.8-93.6%) and 97.9% (95% CI - 96.0-99.0%), respectively, compared with culture. 72.3% of women were aware of their GBS PCR status within 3 h of presentation. Compared with the historical cohort, PCR reduced the requirement for intrapartum antibiotics by 25.6% (P < 0.001). There were no significant differences in maternal outcomes or combined rates of admissions to neonatal intensive care or special care nursery. CONCLUSIONS: Group B streptococcus PCR is an accurate, rapid, safe and practical alternative to culture for detection of GBS colonisation in pregnant women at the time of TPROM. This method has the potential advantage to reduce costs associated with length of hospital stay.

Vaginal vault dehiscence after laparoscopic hysterectomy over a nine-year period at Sydney West Advanced Pelvic Surgery Unit - our experiences and current understanding of vaginal vault dehiscence.

BACKGROUND: A retrospective analysis of all women undergoing hysterectomy at Sydney West Advanced Pelvic Surgery Unit (SWAPS) was performed in the nine-year period from 2001 to 2009. AIMS: To evaluate the incidence, timing and presenting symptoms of vaginal vault dehiscence after hysterectomy, especially via the laparoscopic approach to gain further understanding of patient risk factors and surgical factors that may predispose to this complication. METHODS: Women who presented with vaginal vault dehiscence were identified and possible pre-operative, intra-operative and post-operative risk factors were assessed. A comprehensive literature search was performed to assess the current understanding and incidence of vault dehiscence after laparoscopic hysterectomy. RESULTS: A total of 1224 hysterectomies were performed between 2001 and 2009. 989 (80.80%) were performed laparoscopically of which five women (0.42%) presented with vault dehiscence post-operatively. All had undergone total laparoscopic hysterectomy resulting in a vault dehiscence rate of 1.59% after total laparoscopic hysterectomy specifically. Baseline characteristics included a mean age of 42.8 years (37-51 years), mean BMI of 26.8 kg/m(2) (23.8-32.3 kg/m(2)) and a mean parity of two deliveries (1-3 deliveries). The main presenting symptom of vaginal vault dehiscence was vaginal bleeding. Women with confirmed vaginal vault dehiscence readmitted to hospital at a mean of 18 days (11-28 days) post-operatively. CONCLUSION: Vaginal vault dehiscence is a rare complication after hysterectomy, but more common after a laparoscopic approach. A delayed presentation with vaginal bleeding was the main presenting symptom in this study - a literature review has shown common presenting symptoms to include abdominal pain, vaginal evisceration and vaginal bleeding. Techniques specific to total laparoscopic hysterectomy seem especially important in the increased risk of vaginal vault dehiscence seen after laparoscopic hysterectomy.