Misoprostol for open myomectomy: a systematic review and meta-analysis of randomised control trials.

BACKGROUND: Excessive blood loss is a significant risk of myomectomy with the potential need for hysterectomy. OBJECTIVE: To study the effectiveness of preoperative misoprostol compared with placebo at open myomectomy on intra- and postoperative outcomes. SEARCH STRATEGY: PubMed, Cochrane, Scopus, MEDLINE and EMBASE. SELECTION CRITERIA: Randomised control studies of women undergoing open myomectomy for symptomatic fibroids who were given either misoprostol or placebo preoperatively. DATA COLLECTION AND ANALYSIS: The revised Cochrane risk-of-bias tool for randomised trials was used to assess the risk of bias. Primary outcomes were blood loss, drop in haemoglobin and need for blood transfusion. Secondary outcomes were operative time, postoperative pyrexia and length of postoperative stay. Pooled effect sizes with corresponding 95% CI were calculated using random effects models. Data were analysed using two statistical models for statistical reliability. RESULTS: Eight studies were included with a total of 385 patients, of which 192 received misoprostol. Preoperative misoprostol was significantly associated with lower blood loss by -170.32 ml (95% CI -201.53 to -139.10), lower drop in haemoglobin by -0.48 g/dl (95% CI -0.65 to -0.31), reduced need for blood transfusion (odds ratio [OR] -0.48, 95% CI -0.65 to -0.31), and a reduction in operative time by -11.64 minutes (95% CI -15.73 to -7.54). There was no difference in postoperative pyrexia or length of postoperative stay. CONCLUSION: Moderate- to high-quality studies have established that misoprostol minimises blood loss and need for blood transfusion at open myomectomy. This low-cost and readily available drug should be routinely administered prior to open myomectomy to improve clinical outcomes. TWEETABLE ABSTRACT: Use of misoprostol at open myomectomy reduces blood loss and need for blood transfusion with no impact on postoperative pyrexia.

Venous thromboprophylaxis in pregnancy: the implications of changing to the 2010 RCOG guidelines.

The latest Confidential Enquiry into Maternal Deaths (2006-2008) shows that venous thromboembolism (VTE) is now the third leading cause of direct maternal mortality, behind sepsis and hypertension. This is likely to be because of improved risk assessment of patients and adequate thromboprophylaxis both antenatally and postnatally. Given the importance of this area, compliance with the departmental VTE guidelines (which were based on previous RCOG guidelines) was reviewed prior to transferring to a revised guideline based on the recent RCOG guideline (2010). The results obtained highlighted the difficulties in achieving good VTE risk assessment, with only 60% of patients being adequately assessed and managed antenatally, and 68% postnatally. The findings led to a revised guideline, and it was anticipated that this change would facilitate improved compliance. Other units are likely to be facing similar difficulties, and therefore these results also aim to encourage others to consider review and assessment of their own VTE risk assessment protocols.

How good are obstetric and gynaecology trainees at reviewing and debriefing their patients following operative deliveries?

High levels of obstetric involvement are associated with psychological morbidity in patients postnatally. Operative deliveries contribute to up to 40% of deliveries. Given this, we decided to assess how well patients were being reviewed and debriefed following operative deliveries within our unit. A total of 53 notes following operative deliveries were analysed. To assess the quality of debriefing, the notes were reviewed for evidence of documentation on discussion for reason, procedure and complications of mode of delivery, advised plan for next delivery and contraception advice. Feedback questionnaires were given to patients on discharge to complete, regarding their understanding on the events surrounding their delivery. To assess how well doctors reviewed their own deliveries, we searched the notes for documented evidence of primary operator review. Our results identify significant deficiencies in doctors reviewing and debriefing patients following operative deliveries.

The quality of operative consenting against RCOG advice as standard.

Clinical Governance Advice published by the RCOG states that 'before seeking a women's consent ... you should ensure that she understands the nature of the condition for which treatment is being proposed, its prognosis, likely consequences and risks of receiving no treatment at all'. The importance of obtaining informed consent within obstetrics and gynaecology is highlighted by the litigious nature of our specialty, with CNST data, demonstrating that it makes up 21% of all claims and incur highest cost of any other specialty. We present an audit of the quality of operative consenting for 120 procedures over a 3-month period for five procedures (diagnostic hysteroscopy and laparoscopy, total abdominal hysterectomy, vaginal repair/hysterectomy and lower segment caesarean section) for which we have RCOG advice (Numbers 1, 2, 4, 5, 7, respectively). The quality of consent was also assessed by grade of clinicians. The results identify significant deficiencies when various gynaecological and obstetric procedures are being consented for, and we have discussed various options recommended for improvement.