Is gynaecological surgical training a cause for concern?: a questionnaire survey of trainees and trainers.

BACKGROUND: Concerns have been raised as to whether the current postgraduate training programme for gynaecological surgery is being detrimentally affected by changes in working practices, in particular the European Working Time Directive (EWTD). The purpose of this study was to investigate the surgical activity of obstetrics and gynaecology trainees and to explore trainees' and trainers' opinions on the current barriers and potential solutions to surgical training. METHODS: Two questionnaire surveys were conducted, one to obstetrics and gynaecology trainees working within the West Midlands Deanery and a second to consultant gynaecologists in the West Midlands region. RESULTS: One hundred and four trainees (64.3%) and 66 consultant gynaecologists (55.0%) responded. Sixty-six trainees (66.7%) reported attending up to one operating list per week. However, 28.1% reported attending up to one list every two weeks or less and 5 trainees stated that they had not attended a list at all over the preceding 8 weeks. Trainees working in a unit with less than 3999 deliveries attended significantly more theatre sessions compared to trainees in units with over 4000 deliveries (p = 0.007), as did senior trainees (p = 0.032) and trainees attached to consultants performing major gynaecological surgery (p = 0.022). In the previous 8 weeks, only 6 trainees reported performing a total abdominal hysterectomy independently, all were senior trainees (ST6 and above). In the trainers' survey, only two respondents (3.0%) agreed that the current program produces doctors competent in general gynaecological surgery by the end of training, compared to 48 (73.8%) respondents who disagreed. CONCLUSIONS: Trainees' concerns over a lack of surgical training appear to be justified. The main barriers to training are perceived to be a lack of team structure and a lack of theatre time.

Maternal serum α-fetoprotein at 11-13 weeks' gestation in spontaneous early preterm delivery.

OBJECTIVE: To examine the potential value of maternal serum level of α-fetoprotein (AFP) in the first trimester of pregnancy in the prediction of spontaneous early preterm delivery. METHODS: Maternal serum concentration of AFP at 11-13 weeks' gestation was measured in a case-control study of singleton pregnancies delivering phenotypically normal neonates, including 33 cases with spontaneous delivery before 34 weeks and 99 matched controls delivering after 37 weeks. The median multiple of the median (MoM) serum AFP in the two outcome groups was compared and the bivariate gaussian distributions were simulated in a previously described screened population of 33,370 pregnancies to estimate the performance of screening for early delivery by a combination of maternal characteristics and obstetric history with serum AFP. RESULTS: In the preterm delivery group compared to the term delivery group, the median serum AFP MoM was higher (1.33 vs. 0.97, p = 0.006). The estimated detection rate of preterm delivery, at a false-positive rate of 10%, from maternal characteristics and obstetric history was 27.5% and this increased to 36.0% with the addition of serum AFP. CONCLUSIONS: Measurement of serum AFP at 11-13 weeks improves the prediction of early preterm delivery provided by maternal characteristics and obstetric history.

First-trimester screening for trisomy 21 using alpha-fetoprotein.

OBJECTIVE: To investigate the potential value of adding maternal serum alpha-fetoprotein (AFP) to free ß-human chorionic gonadotropin (ß-hCG) and PAPP-A and fetal nuchal translucency (NT) thickness in first-trimester screening for trisomy 21. METHODS: In this case control study, serum AFP was measured in 100 trisomy 21 and 1,500 euploid pregnancies in which screening for trisomy 21 had been performed by a combination of serum free ß-hCG and PAPP-A and fetal NT at 11-13 weeks' gestation. We examined the effect of adding AFP on the performance of screening by the combined test. RESULTS: In the trisomy 21 pregnancies, the median multiple of the normal median AFP, adjusted for gestational age, maternal weight, racial origin, smoking status and method of conception, was significantly reduced (0.7037, 95% CI: 0.6398-0.7739). Adding AFP to the combined test improved the performance of screening and for a risk cut-off of 1 in 100, the false-positive rate was reduced from 2.8 by 0.4% (95% CI: 0.13-0.77%) without a significant change in detection rate. CONCLUSIONS: Inclusion of serum AFP improves the performance of the first-trimester combined test in screening for trisomy 21.

Body mass index at 11-13 weeks' gestation and pregnancy complications.

OBJECTIVE: To examine the association between body mass index (BMI) at 11-13 weeks' gestation and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics. METHODS: This was a prospective screening study for adverse obstetric outcomes in women with singleton pregnancies attending for their first routine hospital visit at 11(+0)-13(+6) weeks of gestation. The maternal weight and height were measured and the BMI was calculated. Regression analysis was performed to examine the association between BMI and each of the adverse pregnancy outcomes. RESULTS: We examined 41,577 pregnancies with a live fetus at 11-13 weeks. There was a significant contribution from maternal BMI, in addition to maternal characteristics and obstetric history, in the prediction of subsequent miscarriage, stillbirth, preeclampsia, gestational hypertension, gestational diabetes mellitus, delivery of small and large for gestational age neonates, and both elective and emergency cesarean section, but not spontaneous preterm delivery. The risk for each pregnancy complication increased exponentially with BMI, except for delivery of small for gestational age neonates which decreased with BMI. CONCLUSIONS: Maternal BMI at 11-13 weeks can be combined with other maternal characteristics and obstetric history to estimate patient-specific risks for many pregnancy complications.

Maternal serum alpha-fetoprotein in normal pregnancy at 11-13 weeks' gestation.

OBJECTIVE: To establish a reference distribution of maternal serum alpha-fetoprotein (AFP) at 11-13 weeks' gestation and define the contribution of maternal variables that influence the measured concentration of AFP. METHODS: Serum concentration of AFP at 11-13 weeks was measured in 1,500 singleton pregnancies which were not complicated by hypertensive disorders or diabetes mellitus and resulted in the live birth at or after 37 weeks of phenotypically normal neonates with birth weights above the 5th and below the 95th percentile. Multiple regression analysis was used to account for maternal characteristics that influence the measured concentration of AFP and a distribution of log multiples of the median (MoM) values was fitted. RESULTS: Log(10) AFP increased with gestational age, decreased with maternal weight and was significantly affected by maternal racial origin, smoking status and method of conception. Compared with values in Caucasian women who were non-smokers and conceived spontaneously, AFP MoM was on average 23% higher in Afro-Caribbeans and 8% lower in East Asians, 11% higher in smokers and 10% higher in those conceiving by in vitro fertilization. CONCLUSION: In normal pregnancies at 11-13 weeks, serum AFP increases with gestational age and is affected by maternal race, weight, smoking status and method of conception.