Early pregnancy assessment; a role for the gynaecology nurse-practitioner

Recent improvements in the investigation of bleeding and pain in early pregnancy has led to simplified clinical guidelines. These in turn have created the opportunity for nurse-led early pregnancy assessment. We arranged for a gynaecology nurse-practitioner with experience to undergo additional training in early pregnancy care. She then took over the daily running of the Early pregnancy assessment centre (EPAC). A review of 200 consecutive cases showed that the nurse followed the guidelines extremely closely in terms of categorisation of patients, referral to the medical team for further investigation and selection of women who required anti-Rh(D) immunoglobulin. In addition, in the first 6 months of the clinic no cases of ectopic pregnancy were overlooked by the nurse-practitioner. Sixty-one per cent of the women attending the clinic did not need to see a doctor.

Probability of early pregnancy loss in women with vaginal bleeding and a singleton live fetus at ultrasound scan

Bleeding is a common feature of early pregnancy affecting about one-fifth of pregnant women in the first trimester. The chance of miscarriage after bleeding and a live fetus at scan has not previously been defined precisely. The purpose of this study was to evaluate the outcome of early pregnancies with a viable singleton fetus that had been complicated by bleeding. A prospective study was performed on 370 women with a singleton live fetus who had presented to the early pregnancy assessment clinic (EPAC) with vaginal bleeding. Women were grouped into light, moderate and heavy loss according to the self-assessed degree of vaginal bleeding. The women were also categorised according to the presence or absence of an intrauterine haematoma. The overall spontaneous miscarriage rate in the study was 11.1%; almost 90% of pregnancies continued to viability. Women with moderate or heavy bleeding had more than twice the rate of miscarriage compared with those with light bleeding. A total of 14% of the women had an intrauterine haematoma and those women were 2.6 times more likely to miscarry than those without (23% vs 9%). This relationship appeared to hold true even after controlling for blood loss. The data presented can be used to guide women with a live fetus about the chance of miscarriage after an episode of vaginal bleeding. We propose that a large multi-centre study should be undertaken to define precisely the risk miscarriage for each gestational week according to a range of clinical and ultrasound characteristics.

Sterilisation counselling: A role for the gynaecology nurse-practitioner

A recent publication of an evidence-based clinical guideline for male and female sterilisation by the Royal College of Obstetrics and Gynaecology (RCOG) created a stimulus for a review of our female sterilisation service. We arranged for a gynaecology nurse-practitioner (A.O.) with extensive experience in general gynaecology and contraception to undergo additional training in counselling female sterilisation. She then took over the daily running of the sterilisation clinic using a care pathway and pre-printed letters. She had open access to a consultant (R.F.) for advice. A review of 100 consecutive referrals showed that the nurse followed the guidelines extremely closely both in terms of referral to the medical team for advice and/or further counselling and quality of documentation. A total of 59% of the women attending the clinic were cared for by the nurse-practitioner alone. Only four had to see a consultant. All women questioned expressed very positive comments about the style and content of counselling and just one stated she preferred to see a doctor.

Maternal serum screening for trisomy 21 in women with a false positive result in last pregnancy

Maternal serum screening for Down syndrome is a common practice in the United Kingdom. A number of factors have been shown to influence the chance of a false positive test result. Analysis of routinely collated information stored on an electronic database in a district general hospital has shown that women with a previous false positive maternal screen are at much greater chance of having a false positive result in their next pregnancy. Overall, there was a fivefold increased risk attributed to biological variation in their serum concentrations of alpha-feto protein (AFP) and human chorionic gonadotrophin (hCG). The potential effect of this was to increase the chance of such women having an unnecessary amniocentesis. Women should be advised of this effect in subsequent pregnancies. Ideally a correction factor should be applied which would reduce the false positive rate without affecting adversely the sensitivity of the test.

Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training

OBJECTIVE

To determine whether the introduction of multi-professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis-delivery interval (DDI).

DESIGN

Retrospective cohort study.

SETTING

Large tertiary maternity unit within a University Hospital in the United Kingdom.

SAMPLE

All cases of cord prolapse with informative case record: 34 pre-training, 28 post-training.

METHODS

Review of hospital notes and software system entries; comparison of quality of management for umbilical cord prolapse pre-training (1993-99) and post-training (2001-07).

MAIN OUTCOME MEASURES

Diagnosis-delivery interval; proportion of caesarean section (CS) in whom actions were taken to reduce cord compression; type of anaesthesia for CS births; rate of low (<7) 5-minute Apgar scores; rate of admission to neonatal intensive care unit (NICU) (if birthweight >2500 g).

RESULTS

After training, there was a statistically significant reduction in median DDI from 25 to 14.5 minutes (P < 0.001). Post-training, there was also a statistically significant increase in the proportion of CS where recommended actions had been performed (from 34.78 to 82.35%, P = 0.003). There was a nonsignificant increase in the use of spinal anaesthesia for CS, from 8.70 to 17.65%, and a nonsignificant reduction in the rate of low Apgar scores from 6.45 to 0% and in the rate of admission to NICU from 38.46 to 22.22%.

CONCLUSIONS

The introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse. Future studies could assess whether this improved management translates into better outcomes for babies and their mothers.

Seroprevalence of schistosomiasis in African patients infected with HIV

BACKGROUND

Schistosomiasis is a highly prevalent parasitic infection causing significant morbidity and mortality in sub-Saharan Africa. Infection is asymptomatic for many years. Long-term complications such as portal hypertension and bladder cancer can be prevented by treatment with praziquantel.

OBJECTIVES

The aim of this study was to determine the prevalence of schistosomiasis in HIV-infected African patients attending our department.

METHODS

From March 2005, all patients of African origin attending our HIV clinics were tested for schistosomal antibodies using a peroxidase enzyme-linked immunosorbent assay (ELISA). Stool and urine specimens from seropositive patients were examined for ova. All seropositive patients were offered treatment with praziquantel.

RESULTS

Of 122 patients tested, 21 (17%) were ELISA positive for schistosomiasis. Ova were found in stools from four patients and on a cervical smear in one patient. There were no significant differences between infected and uninfected patients other than the presence of eosinophilia (48 vs. 6%; P<0.001), and 17 seropositive patients were treated with praziquantel.

CONCLUSIONS

The seroprevalence of schistosomiasis in HIV-infected patients of African origin in the UK is high. We recommend that screening for schistosomiasis should be offered to these patients and those found to be positive treated with praziquantel.

Amniocentesis counselling: a role for the midwife-practitioner

Recent publication of an evidence-based clinical guideline by the Royal College of Obstetricians and Gynaecologists (RCOG 2005) for invasive testing in pregnancy stimulated a review of our prenatal diagnosis counselling service. This coincided with a reduction in the hours worked by obstetric trainees and a need to streamline antenatal care. We arranged for a senior midwife (KE) with extensive experience in general midwifery and fetal medicine to undergo additional training in counselling for amniocentesis. She then took over the running of the counselling service supported by an in-house care pathway. She had open access to a consultant (RF) for advice. A review of the case notes of 60 consecutive women who attended for counselling showed that the midwife followed the guidelines extremely closely both in terms of process and quality of the documentation. A total of 58 of the women were counselled solely by the midwife-practitioner. Only two required additional counselling by the consultant. Of a subset of 27 women surveyed by telephone questionnaire, only two (7.4%) were surprised to have been counselled by a midwife; 25 (93%) said the counselling was excellent or good; 17 (63%) said they would prefer to see a midwife in any future pregnancy and only one woman said she would prefer to see a doctor.

A comparison of variability in Papanicolaou and liquid-based cytology inadequacy rates using Shewhart control charts

OBJECTIVE

To use Shewhart control charts to compare variability in inadequacy rates from Papanicolaou (Pap) and liquid-based cytology (LBC).

DESIGN

Retrospective analysis of quality assurance data.

SETTING

Eleven Welsh cytology laboratories.

METHODS

Shewhart 'p' charts were plotted for proportions of slides reported as inadequate. Charts were compared for statistical control.

MAIN OUTCOME MEASURES

Evidence of statistical control in the processes.

RESULTS

Control charts allowed easy interpretation of patterns in the data. Variability in inadequacy rates was much lower for LBC than for Pap cytology.

CONCLUSION

Monitoring inadequate rates with Shewhart charts provides more information than tabular monitoring reports, assisting in quality improvement. With respect to inadequacy rates, LBC is less variable than Pap cytology.

Lack of isohemagglutinin production following minor ABO incompatible unrelated HLA mismatched umbilical cord blood transplantation

While immune hemolysis due to donor isohemagglutinin (IH) production often complicates minor ABO incompatible peripheral blood hematopoietic stem cell transplantation (PBSCT), it is not known if this occurs with umbilical cord blood transplantation (UCBT). We compared IH production and hemolysis following minor ABO allogeneic PBSCT and UCBT. We reviewed 24 ABO minor incompatible allogeneic PBSCTs and 14 ABO minor incompatible UCBTs. Patients were evaluated for donor-derived IH by reverse ABO grouping. Evaluation of hemolysis was based on clinical and laboratory findings of anemia associated with increased RBC transfusion need, concomitant with the appearance of donor-derived IH. Of the 24 ABO minor incompatible allogeneic PBSCTs, 15 produced donor-derived IH from 6 to 88 days following transplantation, with seven of 15 patients exhibiting clinically evident hemolysis. There was no significant difference in days to leukocyte engraftment or infused CD34 cells in patients with or without donor-derived IH. None of the 14 patients receiving ABO incompatible UCBTs showed evidence of donor-derived IH following transplantation with a median follow-up of 60 days. We conclude that donor IHs are not produced in patients undergoing minor ABO incompatible UCBTs suggesting fundamental immunologic differences between allogeneic PBSCT and UCBT.

Ovarian cancer death reduction for women at high risk: workload implications for gynaecology services

Ovarian cancer spreads early, presents late and is difficult to cure. Reducing death rates from ovarian malignancy has focussed on the unaffected females of families with a high chance of a mutant gene such as BRCA1 and BRCA2. We set up a familial ovarian cancer service in a district general hospital in the UK, serving a population of 330,000. The clinical genetics team acted as gatekeepers to the service. Risk assessment, ultrasound and biochemical screening and prophylactic oophorectomy were discussed. Gene testing was offered when appropriate. This study reviews the levels of activity for the first 8 years of the service. In all, 153 women were referred, of whom 34 (16%) did not have significant clinical histories. Of the 114 who fulfilled the UKFOCSS criteria for family history and age, four were quickly found to be gene mutation negative and 20 (17%) declined intervention. A total of 29 (25%) chose prophylactic oophorectomy and 61 (54%) chose ultrasound screening.

Morbidity in patients waiting for tonsillectomy in Cardiff: a cross-sectional study

Objective: Our aim was to determine the morbidity of patients awaiting tonsillectomy.

Design: The study comprised a questionnaire survey of 379 children and 278 adults waiting over 12 months for tonsillectomy.

Outcome measures: These comprised frequency of infection, sickness absence and continuing desire for surgery.

Results: Response rates were 70 per cent (children) and 60 per cent (adults). Morbidity was similar in adults and children, and in those waiting more or less than two years. In the six months prior to the study, 86 per cent of children and 83 per cent of adults had had tonsillitis. Sixty per cent of children and 50 per cent of adults had had three or more episodes. Sixty-two per cent of children and 59 per cent of adults had had at least one long episode of tonsillitis, and 29 per cent of children and 24 per cent of adults had had more than three long episodes. Eighty-nine per cent of children had missed school at least once, compared with 71 per cent of adults missing work at least once (p = 0.01). The frequency of infection was significantly associated with patients' desire for surgery (p < 0.001).

Conclusions: Patients awaiting tonsillectomy experience considerable morbidity. This study does not support the hypothesis that untreated patients will ‘outgrow’ their condition.

Prevalence of, and risk factors for, hepatitis C virus infection among recent initiates to injecting in London and Glasgow: cross sectional analysis

Our aim was to compare the prevalence of antibody to hepatitis C virus (anti-HCV) among recently initiated injecting drug users (IDUs) in London and Glasgow, and to identify risk factors which could explain differences in prevalence between the cities. Complementary studies of community recruited IDUs who had initiated injection drug use since 1996 were conducted during 2001-2002. Data on HCV risk behaviours were gathered using structured questionnaires with identical core questions and respondents were asked to provide an oral fluid specimen which was tested anonymously for anti-HCV but was linked to the questionnaire. Sensitivities of the anti-HCV assays for oral fluid were 92-96%. Prevalence of anti-HCV was 35% (122/354) in London and 57% (207/366) in Glasgow (P < 0.001). Multifactorially, factors significantly associated with raised odds of anti-HCV positivity were increasing length of injecting career, daily injection, polydrug use, having had a needlestick injury, and having served a prison sentence. In addition lower odds of anti-HCV positivity were associated with non-injection use of crack cocaine and recruitment from drug agencies. After adjustment for these factors, the increased odds of anti-HCV associated with being a Glasgow IDU were diminished but remained significant. HCV continues to be transmitted among the IDU population of both cities at high rates despite the availability of syringe exchange and methadone maintenance. Effectiveness of harm reduction interventions may be compromised by inadequate coverage and failure to reduce sufficiently the frequency of sharing different types of injecting equipment, as well as the high background prevalence of HCV, and its high infectivity. Comprehensive action is urgently required to reduce the incidence of HCV among injectors.

Polymorphisms of the renin-angiotensin system and the severity of fibrosis in chronic hepatitis C virus infection

Patients with chronic hepatitis C virus (HCV) infection vary in their rates of fibrosis progression. The renin-angiotensin system (RAS) regulates fibrosis. Polymorphisms in the genes of the RAS may contribute to the outcome of renal and cardiovascular disease. We studied four RAS gene polymorphisms in 195 patients with chronic HCV infection. Patients were grouped by Ishak stage of fibrosis on liver biopsy: group 1 (fibrosis score 0 or 1; n = 97), group 2 (fibrosis score 2 or 3; n = 73) and group 3 (fibrosis score 4-6; n = 25). Polymorphisms of the angiotensinogen (AGT) gene (M235T and AT-6), the angiotensin I converting enzyme gene and the type 1 angiotensin II receptor gene were assayed. There was no difference in the distribution of these polymorphisms of the RAS between the fibrosis groups. There did not appear to be any increased prevalence of fibrosis if two or even three of the polymorphisms associated with increased RAS effect were present. On multivariate analysis factors significantly associated with fibrosis were necroinflammatory activity (P < 0.001) and age (P < 0.001). No association was identified between these four RAS polymorphisms and fibrosis in chronic HCV infection.