Profile of women with pelvic organ prolapse at the University Hospital of the West Indies risk factors and presentation.

POP affected 40% of participants in the WHI trial. Risk factors include parity, vaginal delivery, large babies, advancing age, obesity, hysterectomy and lifting. Data suggest African-American women have a lower prevalence of symptomatic POP than other racial groups. Literature review did not show a study of risk factors and symptoms in a black population. Cross-sectional study of women with POP attending urogynaecology clinic at the UHWI from May to October 2013, using an interviewer administered questionnaire was performed and analysed using SPSS version 19 program (SPSS Inc., Chicago, IL). One hundred and eight participants were included: 94.7% postmenopausal (mean 65.08 years) and 94.5% parous (mean 4). Risk factors included obesity (mean BMI 28.82 kg/m2), hysterectomy (28.7%), heavy lifting (51.9%) and chronic cough (13.9%). Symptoms included stress incontinence (40.7%), stranguria (16.7%), faecal incontinence (13.9%), constipation (31.5%), coital urinary and faecal incontinence (6.3%, 12.6%). We concluded risk factors for POP in this population correlates with other studies. Stress urinary incontinence and constipation most frequently reported symptoms in this population.Impact StatementWhat is already known on this subject? Pelvic organ prolapse (POP) is a common condition with multifactorial aetiology. As seen in systematic reviews (Vergeldt TFM, Weemhoff M, IntHout J, Kluivers KB. 2015. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. International Urogynecology Journal 26(11):1559-1573). Study shows white women appeared to have more overall symptoms both from prolapse, as well as urinary symptoms, as compared with black women (Ford AT, Eto CU, Smith M, Northington GM. 2019. Racial differences in pelvic organ prolapse symptoms among women undergoing pelvic reconstructive surgery for prolapse. Female Pelvic Medicine & Reconstructive Surgery 25:130-133).What do the results of this study add? The result highlights the fact that Black women are exposed to similar risk factors and have similar symptoms to other racial groups for POP.What are the implications of these findings for clinical practice and/or further research? These findings can be used to educate women with risk factors about the possibility of developing symptomatic POP. Further research is needed to ascertain the prevalence of POP and to assess knowledge and attitude in this population as we hypothesise that there is generalised assumption in that being black is protective from POP.

Maternal morbidity and mortality associated with mode of delivery in sickle cell disease.

This retrospective observational study compared pregnancy outcomes based on mode of delivery in women with homozygous sickle cell disease (HbSS) to women without (HbAA) using delivery records of 48,600 parturients between January 1992 and January 2020. Fisher's exact tests and Mann-Whitney's test were used to analyse variables based on sickle cell status. Vaginal delivery and HbSS were more associated with labour induction/augmentation (AOR = 2.4, (0.7-7.8)), intrapartum complications (AOR = 2.6, (0.5-14)), postpartum haemorrhage (AOR = 2.8 (0.5-15.2)) and postpartum infections (AOR = 9.6 (1.7-54.4)). Caesarean delivery resulted in more postpartum infections in the HbSS group (AOR = 23.6 (0.9-638.4)). Vaginal delivery in HbSS resulted in more intrapartum complications and postpartum haemorrhage but caesarean delivery greatly increased the risk of postpartum infections and hypertensive disorders. Sickle cell disease (SCD) did not confer increased risk of adverse perinatal outcomes regardless of mode of delivery.Impact StatementWhat is already known on this subject? Women with homozygous sickle cell disease (SCD) are at an increased risk of postpartum infections, undergoing caesarean delivery, admission to the neonatal intensive care unit and overall perinatal mortality when compared to women with normal haemoglobin genotype. Comparisons have been made between homozygous SS disease and haemoglobin SC disease revealing higher rates of maternal and foetal morbidity in both groups.What do the results of this study add? Studies comparing maternal and foetal morbidity based on mode of delivery are lacking. To our knowledge, this study is the first examine maternal and perinatal outcomes in women with SCD undergoing vaginal and abdominal delivery compared to women with normal haemoglobin. We found that vaginal delivery in SCD is associated with more postpartum haemorrhage and caesarean delivery was linked to more hypertensive disorders and postpartum infections then compared to women with normal haemoglobin. Converse to other reports, there was no difference in perinatal outcomes based on mode of delivery.What are the implications of these findings for clinical practice and/or further research? Caesarean delivery and SCD greatly increased the risk of postpartum infections and hypertensive disorders but did not confer a higher risk of postpartum haemorrhage. There were more maternal deaths in SCD women who underwent caesarean vs. vaginal delivery and this requires further study to determine the pregestational predictors of adverse outcomes. Women with SCD who achieve a successful primary vaginal delivery may have reduced risk of complications in subsequent pregnancies, possibly comparable to women without the disease.

Contraceptive practices in women with chronic medical conditions.

Contraception in women with severe medical conditions is a potential measure to reduce maternal mortality. We sought to determine the contraceptive use in women with medical conditions at the University Hospital of the West Indies (UHWI) in Jamaica to determine if there is room for improvement in contraceptive use. Participants were identified from the medical out-patient departments and questionnaires administered. Two hundred and sixty females between 18 and 44 years with varied chronic medical conditions were included. Those included were systemic lupus erythematosus (SLE), diabetes, hypertension (HTN), thyroid disease, cardiac and renal disease. The total current use of contraception was 58.4%, while 41.6% were not on contraceptives. The use of barrier methods and long-acting reversible contraceptives (LARCs) was 71% and 10%, respectively. The current use of contraception in patients with sickle cell disease (SCD) was 84% (p=.004) and in rheumatoid arthritis (RA), 14% (p=.028). Fifty-eight (58, 24.2%) of the women were using two or more methods of contraception. There is a role for improving contraceptive use among women with medical conditions as they are at increased risk of pregnancy complications.IMPACT STATEMENTWhat is already known on this subject? Women with medical comorbidities significantly contribute to both direct and indirect causes of maternal mortality. Contraception may play an integral role in reducing the risk of dying in chronically ill women; however, the use of contraception in this group is often suboptimal.What the results of this study add? This study adds to the literature that in this high-risk group, there is an underuse of long-acting reversible contraceptives, which is ideal for this population.What the implications are of these findings for clinical practice or further research? The results will provide evidence that this high-risk group of women should be targeted and counselled regarding their risk of morbidity and mortality in pregnancy as well as contraception use while their condition is optimised. From this evidence, services may be put in place in institutions, especially in low-resource settings.

Mind the gap: primary care physicians and gynecologists' knowledge about menopause and their attitudes to hormone therapy use in Jamaica.

OBJECTIVES: The study objective was to evaluate physicians' knowledge, attitude, and practices toward menopause and hormone therapy. METHODS: This study was a cross-sectional study using a stratified sample of physicians across the four health regions in Jamaica, between September and October 2017. A total of 145 physicians (75% response rate) completed a questionnaire to assess knowledge and attitudes toward menopause and prescribing hormonal therapy. Univariate and bivariate analyses were used to describe and compare the knowledge, attitudes, and practices in participants. RESULTS: The majority of physicians (66%) self-reported a moderate level of knowledge of menopausal treatment options. Self-reported knowledge was associated with years in practice (P < 0.0001) and level of experience (P < 0.0001). Those who identified as having good and moderate knowledge were likely to discuss treatment options with patients (P < 0.005), while physicians with good knowledge were more likely to prescribe hormone therapy (P < 0.05). Correct responses regarding common menopause symptoms were noted in >60% physicians; however, there was a precipitous fall in correct responses regarding findings related to the Women's Health Initiative (<45%). More consultant grade physicians were confident and less confused about prescribing hormone therapy (P < 0.05) compared to junior grade physicians. When stratified by level of experience, knowledge level was the factor that discouraged physicians from seeing symptomatic menopausal patients (P < 0.05). CONCLUSIONS: This study highlights the gaps in knowledge and practices and a need for carefully designed curricula to provide individualized, risk-mitigated training in menopause healthcare.

Video Summary:http://links.lww.com/MENO/A814 .

Retained placenta in homozygous sickle cell disease.

OBJECTIVE: To document an increased prevalence of retained placenta in mothers with homozygous sickle cell disease. METHODS: A retrospective review (January 1, 1992, to December 31, 2005) at the University Hospital of the West Indies revealed 174 singleton deliveries in women with sickle cell disease who were matched by delivery date and age 1:1 with 174 mothers with normal hemoglobin phenotype. Cesarean delivery in 62 mothers (36%) with sickle cell and in 41 women with normal hemoglobin (24%) left 112 sickle cell and 133 normal hemoglobin pregnancies with spontaneous deliveries. Retained placenta was defined by an interval of at least 30 minutes. Duration and details of the third stage of delivery were obtained by review of records. Duration of delivery stages was assessed by Kaplan-Meier survival charts and tested using the log rank test. Known risk factors were sought by logistic regression or exact logistic regression when the number of outcomes was small. RESULTS: First-stage duration was similar in maternal genotypes (sickle cell 470 minutes [median] compared with normal hemoglobin 335 minutes [median]), but in sickle cell disease, the second stage was slightly delayed (sickle cell 16 minutes compared with normal hemoglobin 15 minutes) and the third stage (sickle cell 7 minutes compared with normal hemoglobin 6 minutes). Retained placenta occurred in 20 mothers (17.9%) with sickle cell (interval 30-340 minutes) compared with four among the women in the control group (3.0%, 30-107 minutes). Apart from a weak association with combined oxytocin and misoprostol, there were no significant associations with known risk factors or with hematologic indices within sickle cell disease. CONCLUSION: Retained placenta is common among mothers with sickle cell disease, and the lack of association with known risk factors suggests that maternal sickle cell disease may be a risk factor. LEVEL OF EVIDENCE: II.

Effect of high dose folic acid supplementation in pregnancy on pre-eclampsia (FACT): double blind, phase III, randomised controlled, international, multicentre trial.

OBJECTIVE: To determine the efficacy of high dose folic acid supplementation for prevention of pre-eclampsia in women with at least one risk factor: pre-existing hypertension, prepregnancy diabetes (type 1 or 2), twin pregnancy, pre-eclampsia in a previous pregnancy, or body mass index ≥35. DESIGN: Randomised, phase III, double blinded international, multicentre clinical trial. SETTING: 70 obstetrical centres in five countries (Argentina, Australia, Canada, Jamaica, and UK). PARTICIPANTS: 2464 pregnant women with at least one high risk factor for pre-eclampsia were randomised between 2011 and 2015 (1144 to the folic acid group and 1157 to the placebo group); 2301 were included in the intention to treat analyses. INTERVENTION: Eligible women were randomised to receive either daily high dose folic acid (four 1.0 mg oral tablets) or placebo from eight weeks of gestation to the end of week 16 of gestation until delivery. Clinicians, participants, adjudicators, and study staff were masked to study treatment allocation. MAIN OUTCOME MEASURE: The primary outcome was pre-eclampsia, defined as hypertension presenting after 20 weeks' gestation with major proteinuria or HELLP syndrome (haemolysis, elevated liver enzymes, low platelets). RESULTS: Pre-eclampsia occurred in 169/1144 (14.8%) women in the folic acid group and 156/1157 (13.5%) in the placebo group (relative risk 1.10, 95% confidence interval 0.90 to 1.34; P=0.37). There was no evidence of differences between the groups for any other adverse maternal or neonatal outcomes. CONCLUSION: Supplementation with 4.0 mg/day folic acid beyond the first trimester does not prevent pre-eclampsia in women at high risk for this condition. TRIAL REGISTRATION: Current Controlled Trials ISRCTN23781770 and ClinicalTrials.gov NCT01355159.

Counselling patients with uterine fibroids: a review of the management and complications.

Fibroids are very common in Afro-Caribbean women. They can cause severe complications. The treatment modalities are not without risk and should be weighed against the complications of the fibroids.