Caesarean section wound infection surveillance: Information for action.

Surgical site infection (SSI) following caesarean section is common, resulting in significant morbidity. Several factors are known to contribute to wound infection, including maternal, procedural and antibiotic factors. We sought to clarify these issues and sought opportunities to make improvements. A retrospective cohort study was performed assessing all women who underwent caesarean section in 2014 and 2015 at Wellington Hospital. Any women with culture-positive wound samples within 30 days of surgery were identified, and clinical notes reviewed. Odds ratios (OR) were calculated for available maternal, procedural and antibiotic risk factors. Two simplified surveillance techniques were also tested for their abilities to identify significant trends. The study included 2231 women, of whom 116 (5.2%) were identified as having SSI. Maternal obesity (body mass index (BMI) ≥ 30) was associated with significant SSI risk (OR 4.1, P < 0.001). The pathogen distribution was significantly different between women with BMI < 30 and BMI ≥ 30 (P < 0.001). Increased cefazolin dose based on BMI (3 g dose for BMI ≥ 30) was associated with a significant reduction in SSI (OR 0.309, P < 0.001) and was administered in 74.1% of obese women receiving cefazolin. Maori women had an increased SSI risk (OR 2.1, P = 0.019), as did Samoan women (OR 3.0, P = 0.002). The study reinforces other studies showing that raised BMI is the single biggest risk factor for surgical site infection post-caesarean section. Surveillance using simplified techniques appears to be adequate to identify trends. We believe that concentrating on appropriate antibiotic dosing and targeting special wound care measures will be pivotal interventions in improving outcomes in high-risk groups.

Over-the-scope-clip system secured nasojejunal tube feeding in refractory hyperemesis gravidarum.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It complicates up to 2% of all pregnancies and can be associated with adverse outcomes. Its management commonly involves a combination pharmacotherapy, however, the efficacy of such treatment is limited. Supplemental nutrition is often required in refractory cases. Enteral route is preferred over parenteral, given the high rate of intravenous catheter-related complications. Enteral feeding tube placement can be challenging and is commonly thwarted by dislodgement. We present a pharmacotherapy refractory HG case where the over-the-scope-clip (OTSC) system was successfully used for durable mucosal fixation of the nasojejunal feeding tube.

Perimortem caesarean section: Two cases performed in New Zealand hospitals.

Perimortem caesarean section is a term many obstetricians are familiar with despite few encountering it first-hand. It is estimated the intervention will be needed every 53 000 maternities. Despite this rarity it is vital clinicians are trained in detecting and intervening where perimortem caesarean is required. In New Zealand eight perimortem caesareans were performed from 2006 to 2013. Here we discuss two perimortem caesarean sections performed in two New Zealand hospitals alongside current guidance and recommendations.

Amniotic fluid embolism after intrauterine fetal demise.

We present a case of the successful treatment of severe amniotic fluid embolism in a 41-year-old woman undergoing emergency caesarean section at 36 weeks of gestation for placental abruption and intrauterine fetal demise. The treatment included prolonged cardiopulmonary resuscitation, emergency hysterectomy, re-operation with intra-abdominal packing and intra-aortic balloon pump insertion. The patient made a remarkable recovery and to date has minimal residual morbidity. Amniotic fluid embolism syndrome (AFES) is a rare and often fatal obstetric condition that remains one of the main causes of maternal mortality in developed countries. The incidence varies from 2 to 6 per 100,000 and suggested mortality rates exceed 60%.1-2 The classic triad of sudden hypoxia, hypotension and coagulopathy with acute onset during labour or immediately after delivery forms the hallmark of the AFES diagnosis, however AFES is primarily a clinical diagnosis of exclusion. We present a case of successful maternal outcome following severe amniotic fluid embolism after placental abruption and intrauterine fetal demise.

Cardiac rehabilitation in New Zealand-moving forward.

Modern guideline-based cardiac rehabilitation provides an evidence-based, cost effective and comprehensive approach to reduce re-infarction and mortality. It offers a multidisciplinary approach to support self-management, improves psychological and social functioning and adherence to recommended life-style changes and medications. The challenge is to broaden uptake of cardiac rehabilitation, increase participation in supervised exercise programs and ensure that healthy behaviours are maintained in the long term. Shared care planning between cardiac rehabilitation specialists and primary health providers could improve long-term adherence by ensuring continuity of care of patients who have completed a Phase 2 cardiac rehabilitation program, either facility or home based.

Sublingual vitamin B12 compared to intramuscular injection in patients with type 2 diabetes treated with metformin: a randomised trial.

UNLABELLED: MAIM: To compare a single 1mg intramuscular hydroxocobalamin injection with a 3-month course of 1mg/day sublingual methylcobalamin supplements on serum vitamin B12 concentrations in participants withtype 2 diabetes treated with metformin. METHOD: Participants on metformin treatment with vitamin B12 concentrations below 220pmol/L were recruited through hospital diabetes clinics and primary care practices. They were randomised to receive either the injection or sublingual treatment. The primary outcome was serum vitamin B12 level after 3 months adjusted for baseline assessed by analysis of covariance (ANCOVA). The trial was registered on the Australia New Zealand Clinical Trial registry (ACTRN12612001108808). RESULTS: A total of 34 participants were randomised; 19 to the tablet, and 15 to the injection. The mean (SD) age, duration of diabetes, and duration of metformin use were, 64.2 (7.3) years, 13.7 (6.4) years, and 11.6 (5.0) years, respectively. After 3 months, the mean (SD) vitamin B12 was 372.1 (103.3) pmol/L in the tablet group (n=19) compared to 251.7 (106.8) pmol/L in the injection group (n=15), ANCOVA estimated difference -119.4 (95% CI -191.2 to -47.6), p=0.002. After 6 months, the mean (SD) serum B12 was 258.8 (58.7) pmol/L in the tablet group (n=17) and 241.9 (40.1) pmol/L in the injection group (n=15); ANCOVA estimated difference -15.2 (95% CI -50.3 to 19.8), p=0.38. Higher metformin dose was associated with lower serum B12 at 3 months, but not at baseline or 6 months. CONCLUSION: Decreased serum vitamin B12 level in patients with type 2 diabetes who are treated with metformin can be corrected through treatment with either hydroxocobalamin injections or methylcobalamin sublingual supplements.

The diagnostic role of ventilation/perfusion scans versus computed tomography pulmonary angiography in obstetric patients investigated for pulmonary embolism at Wellington Hospital from 2010 to 2012.

AIM: To develop best practice clinical guidelines for the use of ventilation/perfusion (V/Q) scanning and computed tomography perfusion angiography (CTPA) in pregnancy and the postpartum period. METHOD: Retrospective analysis of the clinical findings and radiologic investigation for pulmonary embolism (PE) in obstetric women at Wellington Hospital from 2010 to 2012. RESULTS: Fifty-four women were investigated for PE with a V/Q scan or CTPA, including 29 antenatal women and 25 postnatal women. Eleven (37.9%) antenatal women had V/Q scans and 18 (62%) had CTPAs. Five (20%) postnatal women had V/Q scans, 19 (76%) had CTPAs and one (4%) had a V/Q scan followed by a CTPA. Three of the 54 women (5.6%) had a positive radiologic finding of PE (two by V/Q scan and one by CTPA). Four (22.2%) antenatal women and 5 (25%) postnatal women had a diagnosis made on CTPA, which was not seen on chest x-ray. CONCLUSION: This audit found that clinicians varied in their investigation of cases suspected of PE. We have proposed a clinical pathway for the investigation of PE in pregnancy and the postpartum period.

Management of postmenopausal bleeding by general practitioners in a community setting: an observational study.

AIM: To evaluate the safety and effectiveness of a clinical pathway for investigation of postmenopausal bleeding (PMB), managed primarily by general practitioners. Women with an endometrial thickness (ET) ≥5mm on transvaginal ultrasound (TVUS) require either a pipelle biopsy in primary care or referral for specialist care. METHOD: Data on 241 women with PMB were reviewed retrospectively over a 5-year follow-up period. Twenty-five women were excluded as they did not satisfy PMB clinical pathway criteria. RESULTS: TVUS showed 121 women had an ET <5mm, 83 an ET ≥5mm, and 12 an endometrial polyp. In the women with ET ≥5mm, 38 had a pipelle biopsy performed in primary care, 36 were referred directly to secondary care, and 9 declined further investigations. Only 17 pipelle biopsies provided sufficient tissue, with the remaining 21 women referred to secondary care. Seven cases of endometrial cancer were identified, 4 by pipelle biopsy and 3 by hysteroscopy. Of the study cohort, 68% were managed solely by their general practitioner to the point of diagnosis, while 81% with an ET ≥5mm required management in secondary care at some stage. No further cases of endometrial cancer were identified in reviews of patient medical records and cancer registries. CONCLUSION: Community-based investigation of PMB is an alternative model of care with no evidence of additional risks to the patient. Targeted education of general practitioners on pipelle biopsies is essential to maximise the effectiveness of the pathway.

Outcomes in HrHPV-positive women with low grade cervical smears and normal or low grade initial colposcopy results.

AIM: To determine outcomes in HrHPV-positive women with low grade cervical smears and normal or low grade initial colposcopy biopsy results in a cohort of women over a 2-year follow-up period. BACKGROUND: The revised National Cervical Screening (NCS) programme guidelines in New Zealand were implemented in October 2009. The guidelines state that women 30 years and older should undergo reflex HPV testing. If this test confirms the presence of HrHPV, women are to be referred for a colposcopic assessment. The guidelines do not mention what the follow-up period should be of women with HrHPV and normal or low grade abnormalities at colposcopy/biopsy. METHOD: In this study we followed up women 30 years and older referred to Wellington Hospital from 1/10/2009 to 1/10/2011 with a LGSIL or ASC-US smear and positive HrHPV test. Those with a normal or low grade biopsy result were followed over a 2-year period to determine outcomes. RESULTS: Our study found that 4% of women with initial normal biopsy results and 15.2% with initial low grade results had progressed to high grade (CIN 2/3/invasion) over a 2-year follow-up period. During the same time period, 68% of women with an initial normal biopsy and 61% with a low grade biopsy had a normal colposcopy after 2 years. Twenty-eight percent of women with normal and 24% of those with initial with low grade biopsy continued to have LG abnormalities at 2 years of follow-up. CONCLUSION: Women 30 years and older who are HrHPV-positive and have low grade abnormalities at colposcopic biopsy may be followed up with a 12-month cervical smear rather than repeat colposcopy as the risk of progression to a high grade abnormality is low.

Efficacy of mifepristone for cervical priming for second-trimester surgical termination of pregnancy.

OBJECTIVE: To determine whether mifepristone plus misoprostol was as effective as misoprostol with or without laminaria (depending on gestational age) for cervical preparation for second-trimester termination of pregnancy. METHODS: A retrospective cohort study was carried out among women who underwent surgical termination between 14 and 19+6 weeks of pregnancy. Those who received preoperative mifepristone were compared with those who did not. The study group received mifepristone plus misoprostol before dilation and evacuation of the uterus between May 2008 and September 2011. The comparison (non-mifepristone) group received misoprostol with or without laminaria between January 2005 and April 2008. RESULTS: There was no difference between the groups in terms of difficulty of cervical dilation, with an overall relative risk for moderate-difficult dilation in the mifepristone group of 0.91 (95% confidence interval, 0.49-1.68). There was no difference between the groups with regard to complications arising from the procedure. CONCLUSION: Mifepristone is effective for cervical priming prior to second-trimester dilation and evacuation in both multiparous and primiparous women, without an increase in complication rates.

Multiple levels on LLETZ biopsies do not contribute to patient management.

AIM: Cervical large loop excision of the transformation zone (LLETZ) specimens are performed both to treat and to diagnose or exclude cervical pre-neoplasia. Examination of these specimens forms a significant part of the routine histological work load of the pathologist, yet histological confirmation of squamous intraepithelial lesion (SIL) or completeness of excision, does not alter the treatment of SIL. When the LLETZ procedure is done, the treatment is complete, the dysplasia having been subject to excision as well as diathermy during the procedure. METHOD: In this study, records of 1139 women who underwent LLETZ treatment for SIL were examined. The grade of SIL present and the margin status were extracted from histology reports and linked to post-LLETZ follow-up cytology and histology, for a period of 2 years. RESULTS: SIL recurrence in women with high grade (HG-SIL), low grade SIL (LG-SIL) and normal LLETZ biopsy results was not significantly different. There was no significant difference between the recurrence rates of HG-SIL and LG-SIL with SIL at margins compared to SIL clear of margins. DISCUSSION: Pathologists spend significant time examining multiple levels of LLETZ biopsies, grading SIL, determining margins and trying to find SIL in 'normal' LLETZ biopsies. None of this affects the subsequent follow-up. The most useful data the pathologist can provide is whether invasion is present or not. Pathological effort should be directed to examining multiple levels of those with HG-SIL to find invasion, rather than spending time looking at multiple levels of normal or LG-SIL LLETZ biopsies.

Pregnancy loss rate following routine genetic amniocentesis at Wellington Hospital.

AIMS: To determine the institutional pregnancy loss rate following second-trimester genetic amniocentesis. METHODS: Data from 293 consecutive women who had routine genetic amniocentesis at Wellington Hospital from 1 January to 31 December 2001 were collected. The primary outcome measure was pregnancy loss rate up to 6-weeks post-procedure. Secondary outcomes were pregnancy loss after 6 weeks and culture failure. RESULTS: Complete information on the pregnancy outcome was obtained for 269 of 293 pregnancies (92%); corresponding to 275 procedures, including two twin pregnancies and four repeat amniocentesis for culture failure (1.3%). There were two miscarriages within 6 weeks of amniocentesis; giving a pregnancy loss rate of 2/269 pregnancies (0.74 %), or 2/275 amniocentesis procedures (0.73%). Of these pregnancies, one fetus had 'trisomy 21'-giving a corrected pregnancy loss rate within 6 weeks of amniocentesis of 1/269 (0.37%) pregnancies or 1/275 (0.36%) amniocentesis procedures. The pregnancies lost after 6 weeks of amniocentesis was three in 269 pregnancies (1.1%); including one neonatal death at 31 weeks due to a lethal congenital anomaly, and two fetal deaths in utero (one at 23 weeks with a non-lethal congenital anomaly and a normal karyotype, and the other at 27 weeks from toxoplasmosis). CONCLUSIONS: The pregnancy loss rate from amniocentesis and the culture failure rate in Wellington Hospital (using modern techniques) are similar to rates found in recently published studies.