Prevention of surgical site infection and sepsis in pregnant obese women

Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.

Bacterial vaginosis in pregnancy - a storm in the cup of tea

Human vaginal microbiota is dominated by Lactobacillus spp both in the non-pregnant and pregnant state. Bacterial vaginosis (BV) is an imbalance of vaginal microbiota caused by a reduction in the normal lactobacillary bacteria, and a heavy over-growth of mixed anaerobic bacteria. Various clinical (Amsel's Criteria), laboratory (Nugent's score) and molecular diagnostic method (quantitative PCR) are used for diagnosis. BV in pregnancy is associated with increased risk of preterm birth, low birth weight, chorioamnionitis and postpartum endometritis, apart from bothersome vaginal discharge. Antibiotic treatment with metronidazole or clindamycin are effective in eradicating bacterial vaginosis and safe to use in pregnancy. Treatment of bacterial vaginosis has not been shown to improve obstetric outcomes in women at low risk of preterm birth, but may reduce the risk of preterm birth and low birth weight in women at increased risk of preterm birth. Routine screening and treatment is not recommended in low risk women. Test for cure should be performed after treatment. Further research is required on other treatment modalities such as probiotic therapy and microbiota transplantation.

Stillbirth and associated perinatal outcomes in obstetric cholestasis: a systematic review and meta-analysis of observational studies

BACKGROUND

Obstetric cholestasis is a condition occurring in pregnancy with suspected adverse perinatal outcomes. Stillbirth is a significant adverse event associated with obstetric cholestasis and considered for intervention in pregnancy.

OBJECTIVES

There are multiple studies with epidemiological data with regards to the outcomes of obstetric cholestasis. Our hypothesis is to the test the association of stillbirth and related outcomes in obstetric cholestasis.

SEARCH STRATEGY & SELECTION CRITERIA

Two independent reviewers did independent searches and selection with a standardized design as outlined in the PRISMA statement.

ANALYSIS

The retrieved relevant literature was subjected to a rigorous quality assessment and followed by standardized interpretable results.

RESULTS

The pooled estimate in this study showed that there was no significant difference in the stillbirth rates in the obstetric (OC) population when compared to the non-obstetric cholestasis (reference) population. However, there was an increased risk of preterm birth in the OC population compared to the reference population; however, the cesarean section and induction of labor results were directly related.

DISCUSSION

This study provides an epidemiological data related to the perinatal outcomes associated with obstetric cholestasis, specifically stillbirth. This result is likely to produce a benchmark for current evidence-based practice and to assist future research in understanding the implication of associated stillbirth risk and related outcomes with OC.

Postpartum Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome): A systematic review of case reports and case series

INTRODUCTION

Ogilvie's Syndrome or Acute Colonic Pseudo-Obstruction (ACPO) is a rare condition characterized by massive dilatation of the colon in the absence of mechanical obstruction. About 10% of all reported cases are related to Obstetric and Gynaecological procedures, Caesarean section being the commonest associated factor. Acute intestinal dilatation, if not treated, may lead to perforation and faecal peritonitis with consequent high morbidity and mortality.

MATERIALS AND METHODS

An electronic literature searches were performed in PubMed, EMBASE, Google scholar and hand searches for relevant references were included without any language restriction. All the records reported after year 2002 were included for the full review. We analyzed the quality of the reports and the data was further analyzed for their respective risk factors, clinical features, management methods, morbidity and mortality.

RESULTS

The results from our searches included a total of 125 cases of postpartum ACPO. A total of 66 cases were reported in 37 publications after year 2002. Details of delivery were recorded in 13(19%), clinical manifestations in 49(69%), imaging results in 43(65%) and management described in 100% of the cases. Although 62(92%) cases were following caesarean section, no specific antepartum or intrapartum factors were associated with ACPO. The caesarean sections performed for indications of preeclampsia, multiple pregnancy, antepartum haemorrhage/placenta previa were more in this group of patients who developed ACPO compared to caesarean sections performed for same indication in general population of England and Wales. Abdominal distension and pain were the commonest symptoms, followed by vomiting. Fever was common in patients with perforation. Twenty eight (43%) patients had intestinal perforation or impending perforation, and 31(47%) patients required laparotomy. Conservative management was successful in 33(50%) patients. All patients with a caecal diameter of more than 12cm perforated compared to 3/17 with a diameter of less than 9cm. Most perforations were diagnosed between postoperative day 3 and day 5. Only one case of mortality has been recorded (1.5%).

CONCLUSIONS

No specific risk factors could be identified for postpartum ACPO. A postpartum patient with abdominal distension and pain should have appropriate imaging to rule out colonic dilatation and/or perforation. Perforation may occur with a caecal diameter of less than 9cm but it is more likely if the diameter exceeded 12cm. The mortality risk appears to be low in the postpartum group compared to other patients with ACPO. There is a need for establishing national level databases to capture all the relevant data in a consistent manner, to understand this rare disease process.

Effect of anandamide on endometrial adenocarcinoma (Ishikawa) cell numbers: implications for endometrial cancer therapy

BACKGROUND

We have previously shown that patients with endometrial carcinoma express elevated concentrations of the endocannabinoid, anandamide (AEA), in both their plasma and their endometrial tissue and that the endometrial carcinoma cell line, Ishikawa, contains the receptors to which AEA binds. Several studies have reported that human and rodent cancer cell lines die in response to high AEA concentrations. The incidence of endometrial carcinoma continues to escalate and, although surgical treatment has improved, morbidity and mortality rates have not. A move towards a novel non-surgical therapeutic option is thus required, and the endocannabinoid system provides a good candidate target. We aimed to investigate the effects of AEA on the survival and proliferation of an endometrial carcinoma cell model.

METHODS

This prospective basic research study was conducted at a UK teaching hospital. Ishikawa cells were cultured in vitro, and a range of AEA concentrations (0-10 000 nM) were added to the cells. The effect of AEA was measured at different timepoints (4, 18, 24, 48, and 72 h). Primary outcome was cell proliferation and cell viability as measured with a commercial proliferation-apoptosis assay in which assay colour at 420 nm is directly proportional to cell density. One-way ANOVA was performed with Prism (version 7).

FINDINGS

Ishikawa cells were sensitive to AEA-mediated cytotoxicity in a pseudo dose-dependent manner. AEA caused a significant decrease in cell number only at concentrations above 1000 nM (mean 28·1% [SE 7·8], n=12; p<0·0001). The decrease in cell viability that occurred at 4, 18, and 24 h was partly restored at 48 and 72 h suggesting that the AEA growth inhibitory effect is time limiting.

INTERPRETATION

Our results show that AEA induces a decrease in Ishikawa cell number probably through inhibition of cell proliferation rather than cell death. These data suggest that the increased plasma and tissue AEA concentrations observed in patients with endometrial cancer is a counter mechanism against further cancer growth and points to the endocannabinoid system as a potentially new therapeutic target.

FUNDING

University Hospitals of Leicester NHS Trust.

Employee engagement within the NHS: a cross-sectional study

BACKGROUND

Employee engagement is the emotional commitment of the employee towards the organisation. We aimed to analyse baseline work engagement using Utrecht Work Engagement Scale (UWES) at a teaching hospital.

METHODS

We have conducted a cross-sectional study within the National Health Service (NHS) Teaching Hospital in the UK. All participants were working age population from both genders directly employed by the hospital. UWES has three constituting dimensions of work engagement as vigor, dedication, and absorption. We conducted the study using UWES-9 tool. Outcome measures were mean score for each dimension of work engagement (vigor, dedication, absorption) and total score compared with control score from test manual.

RESULTS

We found that the score for vigor and dedication is significantly lower than comparison group (P< 0.0001 for both). The score for absorption was significantly higher than comparison group (P< 0.0001). However, total score is not significantly different.

CONCLUSION

The study shows that work engagement level is below average within the NHS employees. Vigor and dedication are significantly lower, these are characterised by energy, mental resilience, the willingness to invest one's effort, and persistence as well as a sense of significance, enthusiasm, inspiration, pride, and challenge. The NHS employees are immersed in work. Urgent need to explore strategies to improve work engagement as it is vital for improving productivity, safety and patient experience.

Knowledge, skills and attitude of evidence-based medicine among obstetrics and gynaecology trainees: a questionnaire survey

Objectives

To determine current evidence-based medicine skills and practice among trainees.

Design

Questionnaire study.

Setting

Electronic survey was sent to all obstetrics and gynaecology trainees in East Midlands South Deanery, and responses collected were anonymous.

Participants

All obstetrics and gynaecology trainees in East Midland South Deanery.

Main outcome measures

Self-reported attitude, skills and knowledge in various components of evidence-based medicine.

Results

69 trainees were included in the study of which 35 responded. Among all respondents, almost 72% of trainees use non-evidence-based methods to find answers for their clinical questions, whereas only 18% use appropriate evidence-based medicine practice for such queries. Just 35% of trainees have minimum skills of literature searching. Most of the trainees struggle to understand various components of evidence-based medicine. Nearly 80% of trainees do not have formal education or training with regard to evidence-based medicine.

Conclusions

This study highlights the inadequacy of evidence-based medicine skills among trainees and urges that evidence-based medicine be incorporated in formal training along with specialty study modules.

Plasma MIC-1 and PAPP-a levels are decreased among women presenting to an early pregnancy assessment unit, have fetal viability confirmed but later miscarry

Background

We have recently shown first trimester Macrophage inhibitory cytokine-1 (MIC-1) and Pregnancy Associated Plasma Protein-A (PAPP-A) serum concentrations are depressed among asymptomatic women destined to miscarry. Here we examined whether plasma levels of MIC-1 and PAPP-A are depressed among women presenting to an Early Pregnancy Assessment Unit (EPAU), noted to have a confirmed viable fetus, but subsequently miscarry.

Methods

We performed a prospective cohort study, recruiting 462 women in the first trimester presenting to EPAU and had fetal viability confirmed by ultrasound. We obtained plasma samples on the same day and measured MIC-1, PAPP-A and human chorionic gonadotrophin (hCG), grouping the cohort according to whether they later miscarried or not. To correct for changes in analyte levels across gestation, we expressed the data as Multiples of the normal Median (MoMs).

Results

We recruited 462 participants presenting to EPAU at 5-12 weeks gestation. Most (80%) presented with symptoms of threatened miscarriage (e.g. abdominal pain, vaginal bleeding). 34 (7.4%) subsequently miscarried. Median plasma MIC-1 levels among those who miscarried were 50% of those with ongoing pregnancies (Miscarriage cohort MoM 0.50 (25^th-75^th centiles: 0.29-1.33) vs ongoing pregnancies MoM 1.00 (0.65-1.38); p=0.0025). Median plasma PAPP-A MoMs among those who miscarried was 0.57 (0.00-1.12), significantly lower than those with ongoing pregnancies (MoMs 1.00 (0.59-1.59); p=0.036). Plasma hCG levels were also significantly depressed among those who miscarried compared to those with ongoing pregnancies. However, the performance of MIC-1 as a diagnostic marker to predict miscarriage in this cohort was modest, and not improved with the addition of hCG.

Conclusion

MIC-1 and PAPP-A levels are significantly depressed in women presenting to EPAU with ultrasound evidence of fetal viability, but later miscarry. While they are unlikely to be useful as predictive biomarkers in this clinical setting, they probably play important roles in the maintenance of early pregnancy.

Pixelwise quantification of placental perfusion visualized by 3D power Doppler sonography

PURPOSE

We present a new method for noninvasive automatic measurement of perfusion intensity (PixelFlux method) in standardized 3 D power Doppler sonography to quantify differences of perfusion intensities among different placental layers.

MATERIALS AND METHODS

Power Doppler sonographic videos of anterior and central placentas were recorded at various gestational ages (13 to 38 weeks) under defined conditions in 22 women with uncomplicated pregnancies which ended in the delivery of an appropriately grown fetus. Tissue perfusion intensity in four placental layers was calculated as the product of the Doppler amplitude and the perfused area encoded by power Doppler signals related to the area of the respective layer. Measurements are given as the percentage of maximal possible perfusion.

RESULTS

Significant differences in placental perfusion intensities in the uterine wall (6.6 %), the maternal flow within the intervillous space (2.4 %), the fetal flow within placental villi (1.6 %) and the chorionic plate (9.3 %) were demonstrated with a continuous increase in the uterine wall and the placental villi.

CONCLUSION

Placental perfusion intensity was quantified noninvasively from 3 D power Doppler signal data in an easily accomplishable manner with a new software-based measurement procedure. There are significant differences in perfusion intensities among placental layers. Placenta perfusion measurement with the PixelFlux method is feasible and can discern significant perfusion differences among different placenta layers.

Observational study to investigate vertically acquired passive immunity in babies of mothers vaccinated against H1N1v during pregnancy

OBJECTIVE

The primary objective was to determine the proportion of babies who acquired passive immunity to A/H1N1v, born to mothers who accepted vaccination as part of the national vaccination programme while pregnant (during the second and/or third trimesters) against the novel A/H1N1v influenza virus (exposed group) compared with unvaccinated (unexposed) mothers.

DESIGN

An observational study at three sites in the UK. The purpose was to determine if mothers immunised against A/H1N1v during the pandemic vaccination period transferred that immunity to their child in utero.

SETTING

Three sites in the UK [Queen's Medical Centre, Nottingham; City Hospital, Nottingham (both forming University Hospitals Nottingham), and Leicester Royal Infirmary (part of University Hospitals Leicester)].

PARTICIPANTS

All pregnant women in the second and third trimester presenting at the NHS hospitals above to deliver were eligible to participate in the study. Women were included regardless of age, social class, ethnicity, gravida and parity status, past and current medical history (including current medications), ethnicity, mode of delivery and pregnancy outcome (live/stillbirth).

INTERVENTIONS

At enrolment, participants provided written consent and completed a questionnaire. At parturition, venous cord blood was obtained for serological antibody analysis. Serological analysis was undertaken by the Respiratory Virus Unit (RVU), Health Protection Agency (HPA) Centre for Infections, London.

MAIN OUTCOME MEASURES

The primary end point in the study was the serological results of the cord blood samples for immunity to A/H1N1v. Regarding a suitable threshold for the determination of a serological response consistent with clinical protection, this issue is somewhat complex for pandemic influenza. The European Medicines Agency (EMEA) Committee for Human Medicinal Products (CHMP) judges that a haemagglutination inhibition (HI) titre of 1 : 40 is an acceptable threshold. However, this level was set in the context of licensing plain trivalent seasonal vaccine, where a titre of 1 : 40 is but one of several related immunogenicity criteria, and supported by paired sera capable of demonstrating a fourfold rise in antibody titre in response to vaccination. The current study mainly investigated the effects of an AS03-adjuvanted monovalent vaccine, and it was not possible to obtain paired sera where the initial sample was taken before vaccination (in vaccinated subjects). Of possibly greater relevance is the fact that it has been established from the study of early outbreaks of pandemic influenza in secondary schools in the UK (HPA, unpublished observations) that an HI antibody titre of 1 : 32 seems to be the threshold for a humoral response to 'wild-type' A/H1N1v infection. On that basis, a threshold of 1 : 32 is at least as appropriate as one of 1 : 40, especially in unvaccinated individuals. Given the difficulties that would accrue by applying thresholds of 1 : 32 in unvaccinated patients and 1 : 40 in vaccinated patients, we have therefore applied a threshold of 1 : 32 and 1 : 40, to increase the robustness of our findings. Differences arising are described. A microneutralisation (MN) titre of 1 : 40 may be also used, although it is not part of the CHMP criteria for vaccine licensure. Nonetheless, we utilised this analysis as a secondary end point, based on a conservative threshold of 1 : 60.

RESULTS

Reverse cumulative distribution percentage curves for haemagglutinin dilution and MN titres demonstrate background immunity in babies of unvaccinated mothers of 25%-30%. Humoral immunity in babies of vaccinated mothers was present in 80% of the group. The difference in positive immunity between the babies of unvaccinated and vaccinated mothers was statistically significant (chi-squared test, p < 0.001).

CONCLUSIONS

Our findings reveal a highly significant difference in HI titres between babies born to mothers vaccinated with pandemic-specific vaccine against A/H1N1v during the 2009-10 pandemic period. The subjects recruited were comparable from a baseline perspective and thus do not represent different groups that otherwise could have introduced bias into the study. Continued circulation of 2009 A/H1N1-like viruses is uncertain, but is possible as seasonal influenza in years to come. It is possible that future seasonal waves may display increased virulence. Given the adverse outcomes experienced for a small proportion of pregnant women during the influenza pandemic of 2009-10, this study provides useful evidence to support vaccination in pregnancy to protect both the mother and baby.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.