Why is ethnicity a risk factor for postpartum haemorrhage?

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity on a global scale. Ethnic background is known to be a determinant of variation in the outcomes of women receiving maternity care across the world. Despite free maternity healthcare in the UK National Health Service, women with an ethnic minority background giving birth have an increased risk of PPH, even when other characteristics of the mother, the baby and the care received are considered. Improving PPH care has significant implications for improving health equity. The underlying causes of ethnic disparities are complex and multifaceted. It requires a deep dive into analysing the unique patient factors that make these women more likely to suffer from a PPH as well as reflecting on the efficacy of intra and postpartum care and prophylactic treatment these women receive.

Cell salvage techniques and obstetric haemorrhage.

Over the last decade, the incidence of postpartum haemorrhage has risen because of increasing maternal age at time of delivery, multiple births, obesity and increased obstetric interventions, resulting in most of these women requiring blood transfusions. While lifesaving, blood transfusion is not without risk. Recipients may rarely develop transfusion-transmitted infections or suffer immunological sequelae. Intraoperative cell salvage is recommended by several national policy making organisations as a safe cost-effective alternative to autologous blood transfusion in both emergency and elective settings. Moreover, emerging data has also revealed that autotransfusion of vaginally shed blood is both feasible and safe. These techniques are useful in patients who decline blood transfusions for both personal and religious reasons and should therefore be taken into consideration when planning place of birth.

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.

Case of a chronic ectopic pregnancy misdiagnosed as pelvic inflammatory disease.

The definition of a chronic ectopic pregnancy (CEP) is poorly defined in the literature and making a timely diagnosis can be incredibly challenging. This is primarily due to its broad range of clinical presentations and conflicting biochemical and sonographic results. Often, CEPs are mistaken for ovarian malignancies, pelvic inflammatory disease (PID), uterine fibroids or endometriosis, therefore, leading to a delayed diagnosis. We present a case report of a woman who was initially misdiagnosed with PID and then later preoperatively diagnosed with a CEP. This case particularly highlights the diagnostic dilemma posed by CEPs and raises awareness of the key clinical symptoms, biochemical and sonographic investigations which in combination can contribute towards making a timely preoperative diagnosis.

Should the laparoscopic approach be the norm for appendicectomy in the third trimester of pregnancy?

Our case describes a pregnant woman with acute appendicitis who presented in the third trimester and underwent a laparoscopic appendicectomy. She made a rapid postoperative recovery and the pregnancy was otherwise uncomplicated, ending with a spontaneous vaginal birth at 41 weeks. The diagnosis of acute appendicitis can be unclear in pregnancy. Difficulty in establishing diagnosis due to atypical presentation often leads to delay in surgery, resulting in significant maternal and fetal morbidity and mortality. Surgical intervention should be prompt in cases of suspected appendicitis and the laparoscopic approach is advocated in the first two trimesters. In the third trimester (after 28 weeks), laparotomy is often performed due to the size of the uterus and the theoretical risk of inadvertent perforation with trocar placement. More recently, several authors have described successful outcomes following laparoscopic appendicectomy after 28 weeks and with increasing reassuring data, we suggest that this minimally invasive approach should be considered in managing appendicitis in the third trimester.

The use of hormone therapy and its alternatives in women with a history of hormone dependent cancer.

OBJECTIVE: Treating the effects of menopause in women with history of oestrogen-dependent cancers presents a clinical dilemma. Endocrine adjuvant agents like tamoxifen and other cancer treatments, often induce premature menopause. Vasomotor, psychological and somatic symptoms may be more severe in these women. The risk of hormone therapy (HT) and its efficacy must be balanced. Currently, there are no consensus guidelines for the management of these patients. STUDY DESIGN: This is a retrospective study carried out between 10/01/2011 and 27/01/2012 in a tertiary referral menopausal clinic. MAIN OUTCOME MEASURES: Data was collected about cancer type and treatment, symptoms, prior use of T, bone density analyses and menopause treatments. RESULTS: 590 patient records were scanned and 146 patients (24.7%) had a history of cancer. Of these, 45.9% were younger than 50 years old. 67.1% comprised breast cancer patients, of which 69.4% were on adjuvant endocrine agents. 24.7% consisted of gynaecological cancer patients who were predominantly treated with surgery in conjunction with adjuvant therapies. 90.4% of the women had at least one menopause-related symptom, vasomotor symptoms being most prevalent, followed by psychological and vaginal symptoms. Women used a variety of HT and non-HRT therapies for their symptoms. Of the 77 women who had a personal history of oestrogen receptor positive cancers, 19.5% chose to take HT in spite of it being contraindicated. CONCLUSIONS: Prescribing HT to women with a history of hormone dependent cancer remains controversial. Patient 'Quality of Life' must be considered. More research is required in this area.