Medical management of small uterocutaneous fistulae with gonadotrophin releasing hormone analogs: Case report and literature review.

Conventional management of uterocutaneous fistula involves open or laparoscopic excision as well as hysterectomy but there is now increasing recognition of successful medical treatment with gonadotrophin releasing hormone agonists. We describe the fourth case in the literature of successful nonsurgical treatment of uterocutaneous fistula and discuss two important factors affect the success of medical management, namely the size of the fistula and the duration of treatment. We would recommend that a trial of gonadotrophin releasing hormone analogues for at least 6 months particularly in cases of uterocutaneous fistula of 5 mm or less in diameter as this conservative treatment is likely to obviate the need for more hazardous surgical intervention.

COVID-19 vaccination: patient uptake and attitudes in a multi-ethnic North London maternity unit.

PURPOSE: COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and ethnic minority mothers. We performed a 'snapshot' survey to explore vaccine uptake and factors which influence this, as well as underlying beliefs regarding COVID-19 vaccination among pregnant women in a North London hospital. STUDY DESIGN: Pregnant women were invited to complete an anonymised survey, where data were collected on demographics, personal and household vaccination status, and beliefs about the vaccine. Free-text comments were analysed thematically. RESULTS: Two hundred and two women completed the survey, of whom 56.9% (n=115) were unvaccinated and 43.1% (n=87) had received at least one dose of COVID-19 vaccine, with 35.6% (n=72) having received two doses. Factors associated with acceptance of vaccination included: (a) age over 25 years (57.6% vaccinated vs 17.2% under 25 years); (b) Asian ethnicity (69.4% vaccinated vs 41.2% white ethnicity, 27.5% black/Caribbean/African/black-British ethnicity and 12.5% mixed ethnicity) and (c) living in a vaccinated household (63.7% vaccinated vs 9.7% living in an unvaccinated household) (all p<0.001). Vaccine uptake was higher in women who had relied on formal medical advice as their main source of information compared with other sources (59.0% vs 37.5% friends and family, 30.4% news and 21.4% social media). Qualitative data revealed concerns about a lack of information regarding the safety of COVID-19 vaccination in pregnancy. CONCLUSION: Age, ethnicity, household vaccination status and information source influenced vaccination status in our pregnant population. These findings highlight the urgent need to tackle vaccine mistrust and disseminate pregnancy-specific vaccine safety data to pregnant women. TRIAL REGISTRATION NUMBER: 5467.

Did the COVID-19 pandemic affect mental health, training progression, and fertility planning of obstetrics and gynecology trainees? A survey of London trainees.

PURPOSE OF STUDY: To assess impact of COVID-19 pandemic on mental wellbeing, workload, training progression, and fertility planning among London Obstetrics and Gynecology trainees. DESIGN: An anonymous survey comprising 41 peer-validated questions was sent to London trainees. Anxiety and depression were screened using Generalized Anxiety Disorder Questionnaire 7 (GAD 7) and Patient Health Questionnaire-9 (PHQ-9). RESULTS: One hundred and seventy-seven trainees completed the questionnaire, of whom 54% were aged 25-34 years, 43% were senior trainees (ST6-7), and 51% classified themselves as Black, Asian, and Minority Asian (BAME). Although the percentage of respondents with "moderate"/"severe" GAD 7 and PHQ-9 scores was two to three times that of UK population estimates, median GAD 7 and PHQ-9 scores were 7 and 6 ("mild"). Sixteen percent deferred their fertility plans and 26% of ST6-7 trainees changed their Advanced Training Skills Modules. Other issues raised ranged from lack of assistance with electronic portfolio, postponement of examinations, poor senior input for mental health, lack of debriefing for redeployed trainees and requests for deferment of annual reviews. CONCLUSIONS: The pandemic has incurred an impact on mental health, training progression, and fertility planning of London trainees. With recommencement of nonemergency consultations and elective gynecology theater, alongside Royal College of Obstetricians and Gynecologists' Recovery Blueprint to optimize learning opportunities, there is optimism that these challenges can be overcome. Trainers and trainees need to safeguard training opportunities and consider innovative forms of future learning, while anticipating potential effects of subsequent waves.

Developing the 'checking' discipline.

We explore how engagement with checklists and adoption of a strict 'checking' discipline help avoid unintentional individual, team and systemic errors. Paradoxically, this is equally important when performing repetitive mundane tasks as well as during times of high-stress workload. In this article, we aim to discuss the different types of checklists and explain how deviations from a 'checking' discipline can lead to never events such as wrong side or site surgery. Well-designed checklists function as mental notes and prompts in clinical situations where the combination of fatigue and stress can contribute to a decline in cognitive performance. Furthermore, the need for proactive discussion by all members of the team during the implementation of the surgical checklist also reinforces the concept of teamwork and contributes towards effective communication. Patient safety is often a product of good communication, teamwork and anticipation: a 'checking' mentality remains the lynchpin which links these factors.

Does temperature of distending medium matter in outpatient hysteroscopy? A double-blinded cohort control observational study of room temperature versus warmed saline.

AIM: There is little data assessing outcomes of outpatient hysteroscopy using warmed versus room temperature saline. The aim of this study was to determine if the temperature of the distending medium during outpatient hysteroscopy affect ease of procedure, clarity of view, procedural discomfort/pain and patient satisfaction. METHODS: This was a double-blinded cohort control quasi-randomized prospective study involving 100 women undergoing outpatient diagnostic and operative hysteroscopy for abnormal uterine bleeding, intrauterine contraceptive devices retrieval and removal of endometrial polyps. Outpatient hysteroscopy was performed either with normal saline either at room temperature (control at 25°C) or warmed to body temperature (37°C). RESULTS: Confounding variables such as age, parity, previous cervical surgery, previous vaginal births, menopausal status and indications for hysteroscopy were similar in the room temperature (n = 48) and warmed saline (n = 52) groups. Mean procedure duration (256 vs 233 s), ease of entry (Visual Analogue Scale [VAS] 9.55 vs 9.4) and the clarity of view (VAS 9.02 vs 9.3) were statistically similar in both groups (all P > 0.05) as was discomfort experienced during hysteroscopy (VAS 6.6/10 vs 6.8/10) and at 5 min post-procedure (VAS 4.2/10 vs 3.2/10) (both P > 0.05). The likelihood of recommending the procedure to a friend was similar in both groups (mean VAS 6.9/10 vs 7.2/10; P = 0.1). CONCLUSION: The temperature of the distension medium did not influence ease of procedure, clarity of hysteroscopy view, procedural discomfort/pain and patient satisfaction. Patients were not any more likely to recommend the procedure to a friend in the warmed saline compared to the room temperature group.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases.

BACKGROUND: The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills. AIM: To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy. MATERIALS AND METHODS: Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hßCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay. RESULTS: Median age and gestation at surgery were 31 years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300 mL (range 100-3500), and five women had blood loss >500 mL. The median serum hßCG level was 6429 IU/L (range: 1800-58690), and the median ectopic size was 4 cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40 h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population. CONCLUSION: We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.

Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population.

PURPOSE: Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety-related behaviours as well as factors that influence this, such as gender, education, age and language. DESIGN: A 20-point questionnaire was employed in a London teaching hospital to explore safety-related behaviours, particularly assessing patient's willingness to challenge healthcare professionals and engagement in taking an active role in their own care while in hospital. Data was also collected on participant demographic details including gender, age, ethnicity, English language proficiency and education status. RESULTS: 85% of the 175 patients surveyed would consider bringing a list of their medications to hospital, but only 60% would bring a list of previous surgeries. Only 45% would actively engage in the WHO Safer Surgery Checklist and over three quarters (80%) would not challenge doctors and nurses regarding hand hygiene, believing that they would cause offence. Female patients who had tertiary education, were fluent in English and less than 60 years of age were statistically more likely to feel responsible for their own safety and take an active role in safety-related behaviour while in hospital (p<0.05). CONCLUSIONS: Many patients are not engaged in safety-related behaviour and do not challenge healthcare professionals on safety issues. Older male patients who were not tertiary educated or fluent in English need to be empowered to take an active role in such behaviour. Further research is required to investigate how to achieve this.

Abdomino-pelvic packing revisited: An often forgotten technique for managing intractable venous obstetric haemorrhage.

BACKGROUND: Surgical packing should not be seen as a 'bail out' for the less skilled obstetrician who is unable to control obstetric haemorrhage using conventional techniques. Rather, this should be considered in cases of coagulopathy or where haemorrhage persists from raw surfaces, venous plexuses and inaccessible areas. MATERIALS AND METHODS: Data from seven women who underwent abdomino-pelvic packing for intractable postpartum bleeding were collected. The primary outcome was success of intra-abdominal packing and secondary outcomes included estimated blood loss, units transfused, length of stay and postoperative complications. RESULTS: All seven women (median age 39 years, interquartile range (IQR) 3.25) had caesarean section deliveries with median estimated blood loss of 5521.4 mL (IQR 4475) and median of 6.9 (IQR 4.75) units transfused. Abdomino-pelvic packing was successful in all cases including in three women who had continued bleeding after peripartum hysterectomy. In the remaining four, bleeding stopped with packing, enabling the uterus to be conserved. The median number of packs inserted was 6.1 (IQR 4.2) and median shock index at time of decision to pack was 0.98 (IQR 0.13). The median pack dwell time was 30.8 h (IQR 24), while median length of stay following removal was 48 h (IQR 2.14). CONCLUSION: Intractable bleeding in these seven cases was successfully controlled by abdomino-pelvic packing, allowing supportive correction of hypothermia, tissue acidosis, coagulopathy and hypovolemia. The technique of packing is an essential skill in managing massive obstetric haemorrhage, in addition to uterine balloon tamponade, compression sutures and peripartum hysterectomy.

Maternal outcomes following massive obstetric haemorrhage in an inner-city maternity unit.

This retrospective study evaluates the effects of a massive postpartum haemorrhage (PPH) on maternal outcomes in an inner-city London hospital. One hundred and eighty-four cases of a massive primary PPH (>2000 mL) were identified over a seven-year period. A sub-group analysis was performed to assess whether 2000-3000 mL blood loss (134 cases) was associated with specific maternal characteristics or reduced adverse outcomes compared with >3000 mL blood loss (50 cases). Bakri balloon tamponade (BBT) was the most frequent form of surgical management in both groups (21 vs. 46%), followed by compression sutures (16.4 vs. 24%), the 'uterine sandwich' technique (6.7 vs. 14%) and the hysterectomy (0 vs. 4%). There were significant differences between these groups in placenta praevia as the cause of blood loss (8 vs. 22%, p = .01), length of stay (4.6 vs. 5.9 d, p = .02), use of BBT (p = <.01) and hysterectomy (p = .03). PPH is associated with premature maternal morbidity and mortality. The incidence is increasing in high income countries despite various guidelines, skills training and identification of risk factors. A prediction and assessment of blood loss remain the very cornerstone for a prompt, effective management. Our study shows that the morbidity is clearly related to the amount of blood loss and highlights the existing variable practices for the management of PPH. Impact statement What is already known on this subject? A postpartum haemorrhage (PPH) remains a common cause of maternal morbidity and mortality. Massive PPH (>2000 mL) rates continue to rise in developed countries. The management of PPH includes the medical treatment followed by surgical methods including the Bakri balloon tamponade (BBT), compression sutures or a hysterectomy. What do the results of this study add? This retrospective study evaluates the effects of a massive PPH (blood loss >2000 mL) on maternal outcomes. One hundred and eighty-four cases of a massive PPH were identified over a seven-year period. Sub-group analysis was performed to assess whether a 2000-3000 mL blood loss was associated with specific maternal characteristics and differences in obstetric practice compared with a >3000 mL blood loss. There were significant differences between these groups in placenta praevia, as the cause of blood loss, the length of stay, the use of BBT and the hysterectomy rates. What are the implications of these findings for clinical practice and/or further research? An early identification of the risk factors of a massive PPH is essential to improve maternal outcomes and is an important part of the antenatal, intrapartum and postpartum period. The prediction and assessment of blood loss remain key for a prompt, effective management. The amount of blood loss is related to adverse maternal outcomes and the management techniques applied. BBT has an essential role to play and should be included as part of the core training in the management of a PPH.

The impact of distractions and interruptions during Cesarean Sections: a prospective study in a London teaching hospital.

PURPOSE: During Cesarean Sections, distractions which interrupt task specific activities include auditory, equipment, theatre traffic, and irrelevant communication. Aims of this study were to investigate frequency and types of distractions and to assess impact on patient safety and theatre efficiency. METHODS: Prospective observational study in a London hospital in women undergoing elective and emergency Cesarean Sections. Distractions were recorded prospectively in primiparous women having uncomplicated elective and emergency Cesarean Sections over a 4 week period. Level of distraction is categorized as I: no noticeable impact on surgical team; II: ≥ 1 team member affected; and III: all members affected. Safety outcomes assessed included perioperative complications such as postpartum hemorrhage, organ injury, postsurgical pyrexia (first 48 h), return to theatre, readmissions, and postdelivery anemia < 7 g/dl. RESULTS: Data from 33 elective and 23 emergency cases were collected. Mean number of level II/III distractions/case was 13.20 (± 6.93) and number of level II/III distracting events was greater during elective compared to emergency cases (mean 14.91 vs 12.00, p = 0.04). In total, 17.89% of distractions occurred during crucial part of surgery between skin incision and delivery of baby, while delays resulting from level II/III distractions accounted for 11.25% of total operating time. There were no intra- or postoperative complications observed in the cohort of cases. CONCLUSIONS: Distractions did not culminate in perioperative complications, but disrupted surgeons' task activity, prolonging mean procedure duration by 26.8%. Recognising sources and effects of distractions will enable measures to be taken to improve theatre productivity and patient safety.

Knowledge of pelvic floor problems: a study of third trimester, primiparous women.

INTRODUCTION AND HYPOTHESIS: Pelvic floor problems in women (urinary incontinence, faecal incontinence, uterovaginal prolapse) are common, and have an adverse effect on quality of life. We hypothesized that there is low knowledge of these problems amongst primiparous women in their third trimester of pregnancy. METHODS: We conducted a cross-sectional study in antenatal clinics of three hospitals in London, UK, from 2011 to 2013. Primiparous women aged ≥18 years and in the third trimester of pregnancy answered questions on pelvic floor problems. Knowledge scores were calculated based on the proportion of questions answered correctly. RESULTS: A total of 249 women completed the question set. The average knowledge score across all domains was low at 45 %. Scores were lowest for the less common problems of faecal incontinence (35 %) and prolapse (36 %). The score for urinary incontinence was higher at 63 %, but low when questions explored more detailed levels of knowledge (41 %). Knowledge scores were positively associated with both education to tertiary level and the use of books as the information source on pregnancy and delivery. Only 35 % of women cited antenatal classes as a source. CONCLUSIONS: Knowledge of pelvic floor problems is low amongst third-trimester, primiparous women in this London-based population. Adequate knowledge of these problems is important for women to be able to make informed choices about their antenatal care and to seek help if problems arise. The data suggest scope for health-care professionals to raise these issues early during pregnancy, and to help women access accurate sources of information.

Vaginal Myomectomy Using the Dührssen (Longitudinal Median Cervical) Incision: A Case Series of 19 Patients.

STUDY OBJECTIVE: To examine demographics and outcome measures of women having undergone vaginal excision of myomas through the Dührssen (longitudinal median cervical) incision. DESIGN: Prospective case series (Canadian Task Force classification II-3). SETTING: A London teaching hospital. PATIENTS: Nineteen patients with either a submucous myoma (type 1) located near the cervix or a pedunculated intracavity myoma (type 0), excised via the Dührssen incision. INTERVENTIONS: Dührssen (median longitudinal) incision on the anterior or posterior cervical lip. MEASUREMENTS AND MAIN RESULTS: Duration of procedures, intraoperative complications, estimated blood loss, length of stay, percent of patients discharged in 24 hours, and readmission rates were studied. Between 2009 and 2016, 19 women had their myomas (submucous type 1, n = 17; pedunculated intracavity type 0, n = 2) removed vaginally with the Dührssen incision. The median age at time of procedure was 46 years (range, 43-55), and the most common indication was menorrhagia, which occurred in 90% of cases. The median myoma size was 7 cm (range, 6-9), whereas the median duration of surgery was 60 minutes (range, 40-120). Anterior cervical incisions were performed in 60% of cases, and 20% of the patients received gonadotropins for medical debulking of the myomas before surgery. One patient sustained a bladder injury that occurred when making the anterior cervical incision. The median length of stay was 8 hours (range, 6-36) and the median estimated blood loss was 90 mL (range, 50-150). The median duration of follow-up was 4 years (range, .5-6), and no patients had symptoms that were attributable to the procedure. CONCLUSION: This is a useful technique that complements a minimally invasive surgeon's repertoire and is a viable alternative when hysteroscopic myomectomy is deemed unsuitable because of location and size of the myomas.

Retrospective Cohort Study to Assess Outcomes, Cost-Effectiveness, and Patient Satisfaction in Primary Vaginal Ovarian Cystectomy versus the Laparoscopic Approach.

STUDY OBJECTIVE: To compare surgical outcomes, cost-effectiveness, and patient satisfaction in women undergoing primary vaginal or laparoscopic ovarian cystectomy for benign ovarian cysts. DESIGN: Retrospective cohort control study (Canadian Task Force classification II-3). SETTING: Gynecologic unit at a university-affiliated hospital. PATIENTS: Fifty patients who underwent primary ovarian cystectomy either through the vaginal route via posterior colpotomy (n = 29) or laparoscopic route (n = 21). INTERVENTIONS: Nonmalignant ovarian cysts were initially determined by transvaginal ultrasonography and serum tumor markers. The index group of women (n = 29) underwent vaginal ovarian cystectomy via a posterior colpotomy incision, whereas the control group (n = 21) comprised women who had laparoscopic ovarian cystectomy using the traditional "grasp and peel" technique. The following outcomes were evaluated: duration of surgery, intraoperative complications, estimated blood loss, length of inpatient stay, and postoperative pain (visual analogue scale). The average cost of both surgical methods was calculated by factoring in theater time, equipment required, and the length of hospital stay. Patients were then surveyed to compare postoperative pain and satisfaction scores as well as the time taken to return to work (in days). MEASUREMENTS AND MAIN RESULTS: The 2 groups had similar mean ages (35.79 vs 36.72 years) and cyst diameter (6.8 vs 6.6 cm) (p > .05 in both cases). Vaginal ovarian cystectomy took a mean of 13.7 minutes longer (91.7 vs 78.0 minutes, p < .001) to perform and resulted in a greater mean estimated blood loss (116.1 vs 95 mL, p < .001). The spillage rate in the index group was 6-fold less compared with control cases (6% ± 2.4% vs 35% ± 4.6, p < .01). Although patients from the index group spent a mean of 2 hours longer as inpatients (10.9 vs 8.9 hours, p < .001), they reported a lower mean visual analogue pain score (2.01/10 vs 3.95/10, p < .05) and higher patient satisfaction scores (8.2/10 vs 6.5/10, p < .001). Mean perioperative cost of women who underwent vaginal ovarian cystectomy was lower (£1690.13 vs 1761.67) and they returned to work quicker compared with the laparoscopic group (13.6 vs 39.2 days, p < .001). CONCLUSION: Vaginal ovarian cystectomies took longer to perform and led to longer inpatient stay. However, these women had less postoperative pain and reported higher satisfaction scores compared with laparoscopic ovarian cystectomy, with a quicker return to work. The vaginal approach is a viable and cost-effective alternative to the laparoscopic approach in carefully selected patients.

Interruptions and distractions in the gynaecological operating theatre: irritating or dangerous?

Distractions and interference can include visual (e.g. staff obscuring monitors), audio (e.g. noise, irrelevant communication) and equipment problems. Level of distraction is usually defined as I: relatively inconsequential; II: > one member of the surgical team affected; III: the entire surgical team affected. The aim of this study was to observe the frequency and impact of distracting events and interruptions on elective gynaecology cases. Data from 35 cases were collected from 10 consecutive operating sessions. Mean number of interruptions was 26 episodes/case, while mean number of level II/III distractions was 17 episodes/case. Ninety per cent of interruptions occur in the first 30 minutes of the procedure and 80.9% lead to level II/III distraction. Although no complications were directly attributable to the observed distractions, the mean prolongation of operating time was 18.46 minutes/case. Understanding their effects on theatre environment enables appropriate measures to be taken so that theatre productivity and patient safety are optimised. PRACTITIONER SUMMARY: This observational study of 35 elective cases shows a mean interruption rate of 26 episodes/case with 80.9% affecting > one member of operating team, leading to mean prolongation of 18.46 minutes/case. Theatre staff should be aware of these findings and appropriate measures taken to optimise theatre productivity and patient safety.

Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study.

STUDY OBJECTIVE: To assess the effect of enhanced recovery pathway implementation on patient outcomes after vaginal hysterectomy (VH) performed to treat benign indications. DESIGN: Case-control study examining outcome measures including length of stay, pain scores, postoperative morbidity, and readmission rates after implementation of the Enhanced Recovery after Surgery (ERAS) program for VH (Canadian Task Force classification II). SETTING: Teaching hospital. PATIENTS: Fifty patients who underwent VH after implementation of ERAS were compared with 50 control patients before ERAS. Patients were matched for age, indication for surgery, American Society of Anesthesiologists grade, and surgeon. INTERVENTION: ERAS pathway. MEASUREMENTS AND MAIN RESULTS: Length of stay, percentage of patients discharged within 24 hours, use of urinary catheter and vaginal packing, and readmission rates were determined. Perioperative expenditures were compared, and cost-effectiveness of ERAS was assessed. Median patient vs control age (49.0 vs 51.0 years), parity (2.0 vs 2.0), and body mass index (26.5 vs 28.3) were statistically comparable. After ERAS implementation, the median length of stay was reduced by 51.6% (22.0 vs 45.5 hours; p < .01), and the percentage of patients discharged within 24 hours was increased by 5-fold (78.0 vs 15.6%; p < .05). Frequency of catheter use (82.0% vs 95.6%) and use of vaginal packing (52.0 vs 82.2%) were significantly lower in the post-ERAS group, and these devices were removed earlier (14.5 vs 23.7 hours and 16.0 vs 23.0 hours, respectively; p < .05 in all cases). Attendance in the Accident and Emergency Department (12.0% vs 0%; p > .05) and inpatient readmission rate (4.0% vs 0%; p > .05) were similar in both groups. Despite having to start a "gynecology school" and employ a specialist Enhanced Recovery nurse, a cost savings of 9.25% per patient was demonstrated. CONCLUSION: The ERAS program in benign VH reduces length of stay by 51.6% and enables more women to be discharged within 24 hours, with no increase in patient readmissions rates.