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.

Screening for gestational diabetes mellitus: a Caribbean perspective.

Gestational diabetes mellitus (GDM) is defined as a glucose intolerance first recognised in pregnancy. The World Health Organization (WHO) in 2015 revised the definition into either diabetes in pregnancy (DIP) which includes pre-existing diabetes (type 1 or type 2) that antedates pregnancy or diabetes diagnosed during pregnancy with the WHO diagnostic criteria for diabetes mellitus (DM) in the non-pregnant state, and GDM for milder forms of hyperglycaemia in pregnancy. The main purpose of the screening and diagnosis of GDM is to identify pregnancies in which the foetus is at a high risk of an adverse perinatal outcome, and the mother and the offspring are of serious long-term sequelae. This review of the literature provides an overview of associated prevalence, risk factors and diagnosis of GDM. It also addresses the benefits of screening with supportive evidence. Based on this review, we recommend especially in low-resourced countries such as the Caribbean, adoption of a universal screening with the two-step method.

Sister Society Meeting on Global Education Development and Collaboration: Meeting Report.

OBJECTIVES: To identify common barriers to teaching and training and to identify strategies that would be useful in developing future training programs in gynecologic oncology in low- and middle- income countries. METHODS: There is a lack of overall strategy to meet the needs of education and training in gynecologic oncology in low- and middle- income countries, the leaderships of sister societies and global health volunteers met at the European Society of Gynecologic Oncology in October 23, 2015. The challenges of the training programs supported by gynecologic oncology societies, major universities and individual efforts were presented and discussed. Strategies to improve education and training were identified. RESULTS: Major challenges include language barriers, limited surgical equipment, inadequate internet access, lack of local support for sustainability in training programs, inadequate pathology and radiation oncology, finance and a global deficiency in identifying sites and personnel in partnering or developing training programs. The leaderships identified various key components including consultation with the local Ministry of Health, local educational institutions; inclusion of the program into existing local programs, a needs assessment, and the development of curriculum and regional centers of excellence. CONCLUSIONS: Proper preparation of training sites and trainers, the development of global curriculum, the establishment of centers of excellence, and the ability to measure outcomes are important to improve education and training in gynecologic oncology in low- and middle- income countries.

Pregnancy outcomes of women with cardiac disease.

OBJECTIVE: To determine and predict the maternal and neonatal outcomes of pregnancies occurring in patients with cardiac disease. METHOD: This retrospective review included 147 pregnancies identified from antenatal, delivery, and nursery records. Information concerning the nature and severity of the pre-existing cardiac disease, comorbidities, risk scores, obstetric or cardiac complications, and pregnancy outcomes were collected. The data were analyzed using SPSS Windows version 22. RESULTS: In all, 111 (73.5%) of the cohort had acquired heart disease and 4 (2.7%) of patients belonged to WHO class IV, in which pregnancy is not recommended. Additionally, 12 (8.1%) were categorized as being at significant risk of having a cardiac complication. The proportion of patients that had maternal and perinatal mortality was 6 (4.0%) and 7 (4.8%), respectively. The WHO and CARPREG scoring systems were reliably able to predict cardiac events (P < 0.01). Mothers who received preconception counseling had significantly fewer occurrences of cardiac and obstetric events than those who did not. CONCLUSION: Cardiac disease in pregnancy in women managed at our center was most often an acquired disease. The baseline risk assessment scores accurately predicted the likelihood of adverse cardiac outcomes.

The Effect of Obstetric Drills Training - Jamaica Core Obstetric Teaching and Training in Emergencies (JOTTIE) on Postpartum Haemorrhage at a Jamaican Teaching Hospital.

OBJECTIVE: To evaluate whether the initiation of JOTTIE, a one day simulation training course focussed on the management of common obstetric emergencies, was associated with a reduction in the morbidity and mortality associated with postpartum haemorrhage (PPH) at the University Hospital of the West Indies (UHWI). STUDY DESIGN: We conducted a retrospective comparative study that evaluated the incidence of multiple outcomes related to maternal morbidity secondary to PPH, during the two year period immediately prior to the introduction of JOTTIE (pre course arm, N = 88) or the two year period, one year post introduction (post course arm, N = 103) for all women who had vaginal deliveries complicated by PPH at UHWI. A relationship was said to be statistically significant if p < 0.05. Additionally, the study examined risk factors in relation to severity of haemorrhage. RESULTS: Genital tract trauma represented the highest recorded cause of PPH (approximately 71%). The data revealed that patients in the pre training arm were similarly likely to have no adverse outcome in comparison to patients in the post training arm (p = 0.962). There was also no statistically significant relationship between the time period of patient exposure in relation to the JOTTIE course and severity of PPH (p > 0.05). Uterine fibroids and Crohn's disease were the only co-morbidities found to increase the likelihood of severe PPH, at 5.154 times (p = 0.019,OR = 5.154, CI = 1.314-20.212) and 17.848 times (p = 0.085,OR = 17.848,CI = 0.672-474.365), respectively. CONCLUSIONS: This study suggests that prior to the introduction of the JOTTIE the rate of maternal morbidity associated with PPH was relatively low at UHWI and there was no significant effect on its management or a significant reduction in maternal morbidity since introduction of the course. Future research on the morbidity related to the other obstetric emergencies addressed at JOTTIE is needed in order to assess the effect of the course as a whole.

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 .

Association of Progestin Contraceptive Implant and Weight Gain.

OBJECTIVE: To evaluate initiation of a two-rod, 150-mg levonorgestrel contraceptive implant on women's perceived and observed body weight. METHODS: We conducted a secondary analysis of data from an open, randomized controlled trial of adult, nonpregnant, human immunodeficiency virus-negative women attending a public clinic in Kingston, Jamaica, who were assigned to initiate implant use either immediately or after a 3-month delay. The primary objective of the parent study was to assess the effect of initiation of the implant on the frequency of condom use. We compared study arms during follow-up using one-sided χ tests for differences in perceived weight gain and loss, one-sided Wilcoxon-Mann-Whitney tests for median gain in measured weight, and logistic regression with generalized estimating equations for risk of gaining greater than 2 kg. RESULTS: From 2012 to 2014, women were assigned to the implant (n=208) or delay arm (n=206). At 3 months, more women in the implant arm (15.3%) reported perceived weight gain than in the control arm (4.3%) (P=.01). Despite differences in perception, the implant and control arms did not differ significantly in median weight gain at 1-month (0.0 kg and 0.0 kg, respectively; P=.44) and 3-month visits (0.5 kg and 0.0 kg, respectively; P=.27). Study arms did not differ in risk of gaining greater than 2 kg (odds ratio 0.9, 95% confidence interval 0.6-1.3). CONCLUSION: We found no evidence of weight gain from short-term implant use. Through the power of the nocebo effect, the practice of counseling women to expect possible weight gain from initiating implant use could lead them to perceive weight gain even in its absence and contribute to the early discontinuation of this highly effective contraceptive method.

Effects of initiating a contraceptive implant on subsequent condom use: A randomized controlled trial.

OBJECTIVE: To evaluate whether initiation of a contraceptive implant, a method of long-acting reversible contraception, reduces condom use, as measured by a biomarker of recent semen exposure [prostate-specific antigen (PSA)]. STUDY DESIGN: We conducted a randomized controlled clinical trial in which 414 Jamaican women at high risk for sexually transmitted infections (STIs) attending family planning clinics received the contraceptive implant at baseline ("immediate" insertion arm, N=208) or at the end ("delayed" insertion arm, N=206) of a 3-month study period. Participants were tested for PSA at baseline and two follow-up study visits and were asked about their sexual activity and condom use. RESULTS: At baseline, 24.9% of women tested positive for PSA. At both follow-up visits, the prevalence of PSA detection did not significantly differ between the immediate versus delayed insertion arm [1-month: 26.1% vs. 20.2%, prevalence ratio (PR)=1.3, 95% confidence interval (CI)=0.9-1.9; 3-month: 25.6% vs. 23.1%, PR= 1.1, 95% CI=0.8-1.6]. The change in PSA positivity over the three study visits was not significantly larger in the immediate arm compared to the delayed arm (1-sided p-value of .15). CONCLUSIONS: Contraceptive implants can be successfully introduced into a population at high risk of unintended pregnancy and STIs without a biologically detectable difference in unprotected sex in the short term. This information strengthens the evidence to support promotion of implants in such populations and can help refine counseling for promoting and maintaining use of condoms among women who choose to use implants. IMPLICATIONS: Sex unprotected by a condom was not higher over 3 months in women receiving a contraceptive implant, compared with those not receiving the implant.

Outcome of radical hysterectomies performed by general gynecologists in Jamaica.

OBJECTIVE: To review the modified (type II) radical hysterectomy procedures performed by 4 general gynecologists at the University Hospital of the West Indies, and to compare the outcomes with those of other published studies. METHODS: The case notes of the 58 women who underwent radical hysterectomies between January 1997 and December 2006 were reviewed. Accuracy of staging, duration of the operation, operative blood loss, types and rates of complications, recurrence rates, and 5-year survival rates were assessed. RESULTS: Accuracy of clinical staging, duration of the procedure, blood loss, and operative and postoperative complications were comparable to previously published data. The 5-year survival rate of 77.6% was also comparable to results seen in some other publications. CONCLUSION: General gynecologists with significant experience in general gynecologic surgery who underwent adequate, but abbreviated, training became competent in performing a radical hysterectomy, with outcomes comparable to those seen in high-resource countries.

Chlamydia trachomatis, herpes simplex virus 2, and human T-cell lymphotrophic virus type 1 are not associated with grade of cervical neoplasia in Jamaican colposcopy patients.

BACKGROUND: A few recent studies have suggested that other sexually transmitted infections may increase the likelihood of a human papillomavirus (HPV) infection progressing to high-grade cervical neoplasia and cancer. GOAL: The goal was to assess whether exposures to Chlamydia trachomatis, human T-cell lymphotrophic virus type 1 (HTLV-I), and/or human simplex virus type 2 (HSV-2) are greater in colposcopy patients with cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) than in patients with low-grade cervical neoplasia (CIN1). STUDY DESIGN: Sequential patients (n=447) attending a colposcopy clinic in Kingston, Jamaica, a country with high cervical cancer rates and high HTLV-I prevalence, were tested for (1) HPV DNA by L1 consensus primer (MY09/11) polymerase chain reaction assays, (2) C trachomatis DNA by ligase chain reaction, (3) C trachomatis antibodies by both microimmunofluorescence and a peptide (VS4) enzyme linked immunosorbent assay (ELISA), (4) HTLV-I antibodies by ELISA confirmed by western blotting, and (5) HSV-2 antibodies by a recombinant HSV-2-specific ELISA. Odds ratios and 95% confidence intervals were estimated with use of multinomial logistic regression models. RESULTS: HPV DNA detection was associated with grade of cervical neoplasia but other evaluated sexually transmitted infections were not. CONCLUSIONS: HTLV-I, C trachomatis, and/or HSV-2 were not associated with severity of cervical neoplasia in Jamaican women.

The epidemiology of cervical cancer: a comparison of early and late disease - abstract

Sixty patients with a diagnosis of cervical cancer were interviewed. 30 patients with early disease were compared with 30 patients with late disease to determine if their epidemiological variables were similar and to determine if access to health care and Pap Smear utilisation were similar. The results showed that while risk factors and access to health care were similar the patients with late disease were older [mean age 55.5 versusn 45 years (p=0.006) of a higher parity [mean parity 5.3 versus 3.3 (p =0.004)], mainly from the lowest social class, or those who had never had a Pap smear (20 percent versus 0 percent) or who had a Pap smear infrequently (15 percent versus 60 percent routine screening) and 1.1 versus 4.9 mean life time number of Pap smears (p =0.006). (AU)

Complete non-puerperial uterine inversion as a result of a uterine sarcoma

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.(Au)

Large loop excision of the transformation zone (LLETZ) an alternative treatment for cervical intraepithelial neoplasia

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative method of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cerix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4 per cent of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4 per cent), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques. (AU)

Knowledge, attitudes and practices of women regarding pap smears - abstract

The aims of the study were to assess women's knowledge, attitudes and practices regarding cervical cancer and screening, to see how knowledge influences attitudes and how both influence practice, and to examine certain social and demographic correlates. Between January 29, 1996 and February 29, 1996, 209 female patients, aged 19 years and over, were interviewed in the Casualty Department of the University Hospital of the West Indies. A questionnaire measuring knowledge, attitudes and practices regarding Pap smears and cervical cancer and selected characteristics of the patients and their partners were administered by a single interviewer. Quota sampling methodology was employed. Most of the respondents (98 percent) had heard about Pap smears, but the majority did not know that its main purpose is to help in the prevention of cervical cancer, as opposed to its detection. Only a majority of patients knew what the cervix is and that it is the part of the body that Pap smears are concerned with. The majority of respondents had positive attitudes with respect to cervical screening. However, having positive attitudes and possessing knowledge about Pap smears did not significantly influence compliance with screening, and apathy accounted for a significant portion of non-compliance. If a nationwide screening programme is to be successful, patient motivation and behaviour modification will need to be addressed. (AU)

The mid-forearm arteriovenous fistula as vascular access for haemodialysis

Successful chronic haemodialysis requires permanent vascular access. The Scribner procedure which utilizes an external arteriovenous shunt, the internal synthetic arteriovenous shunt and the direct arteriovenous fistula as described by Cimino and Brescia have all been used for haemodialysis. Of the three methods, the arteriovenous fistula is the most trouble-free and durable. However, as originally described and constructed in the distal forearm, the morbidity associated with this method is significant. The cubital fossa fistula has even more problems. The mid-forearm fistula was designed by the authors and has been used for chronic haemodialysis over the past eighteen years. This article compares the various methods of access used in the haemodialysis units of the University Hospital of the West Indies and the Kingston Regional Hospital. The mid-forearm fistula was found to have lowest initial failure rate and was associated with fewer complications than any of the other methods used for access. (AU)

Lifestyle factors and cervical dysplasia in Jamaica [abstract]

OBJECTIVE: Investigation of the impact of womens' sexual lifestyles on the development of cervical dysplasia. METHODS: Cases were recruited from women referred to the Colcoscopy Clinic, University Hospital of the West Indies, who had abnormal pap smears. Age-matched controls were recruited from the Gynaecology clinic. Women who consented to particpated were guaranteed anonymity and confidentiality and then interviewed on their sexual lifestyles. RESULTS: To date, 223 participants have been recruited: control (n=57), CIN I (n=69), CIN II (n=44), CIN III (n=32), Carcinoma (Ca) (n=9), and 12 cases whose colposcopy results are not yet available. One hundred and sixty-four of the 166 cases were diagnosed with the human papilloma virus (HPV). Twenty percent of the participants were unemployed, 21 percent were skilled/non-manual workers, while 21 percent were semi-skilled non-manual workers. Seven percent of the women occupied professional/managerial positions. There was no significant difference in age at first intercourse, number of lifetime sexual partners, number of biological fathers of their children, use of barrier contraceptives and pap smear history, between controls (n=57) and cases (n=166). When CIN I was grouped with the controls (n=126), there was a significant difference in the number of these women's lifetime sexual partners (4.1ñ2.4), compared to the women with CIN II-Ca (5.2ñ4.2), p=0.029. There was no significant difference in age between the two groups mean/SD (36.6ñ10.1 vs 36.8ñ10.5 yrs). CONCLUSIONS: The findings indicate that factors other than sexual behaviour play a role in the aetiology of cervical dysplasia in this population. (AU)

Large loop excision of the transformation zone (LLETZ) an alternative treatment for cervical intraepithelial neoplasia

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative method of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cerix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4 per cent of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4 per cent ), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques.

Complete non-puerperial uterine inversion as a result of a uterine sarcoma

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.

Cervical intraepithelial neoplasia is not associated with elevated serum neopterin levels

Neopterin, a marker of cellular immune activation, was elevated in patients who had cervical cancer in previous studies. To examine neopterin in the presence of precursors to cervical cancer (i.e. cervical intraepithelial) we measured serum levels in 185 colposcopy patients in Jamaica, a country with high cervical cancer incidence, and in 72 age-matched Jamaican women selected from a large population-based sample. We also measured serum levels of B-2 microglobulin, another commonly used marker of immune activation. Neopterin and B-2 microglobulin levels were not elevated in colposcopy patients; neither were they rel ted to severity of cervical neoplasia. In multivariable analysis, neither adjustments for detection of cervical human papillomavirus DNA by PCR nor detection of antibodies to human T-cell lymphotropic virus type 1 (a retrovirus endemic to Jamaica) altered our findings. The absence of serologically detectable increase in cellular immune activation linked to cervical intraepithelial neoplasmia does not involve susbtantial systemic immune activation. (AU)

Type-specific prevalence of human papillomavirus DNA among Jamaican colposcopy patients

Human papillomavirus (HPV) types differ in their associations with cervical cancer. Therefore, the types of HPV in precancerous lesions are important. In many regions with high cancer incidence, the HPV types in precancerous lesions have not been well studied. In Jamaica, a country that has high cervical cancer incidence, 174 colposcopy patients were tested for HPV DNA using polymerase chain reaction. HPV DNA detection was strongly related to presence and grade of cervical neoplasia (P<.001). Furthermore, severe neoplastic change was most highly associated with HPV DNA types also considered high-risk for severe neoplassia in other populations. HPV-45 DNA, a high-risk type uncommon in most previously tested countries, was detected in 12 percent of patients who had neoplasia. Thus, cervical neoplasia in Jamaica, as elsewhere, is linked to HPV. The high prevalence of HPV-45 DNA was notable, and its relation to high cervical cancer incidence in Jamaica must be assessed. (AU)