Obstetrics and Gynaecology

Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study (2018)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios; *Underwood, Martyn ; *Parry-Smith, William; *Panikkar, Jane

Citation:
Archives of Gynecology and Obstetrics; Apr 2018; Vol.297(4):1015-1025

Abstract:
PURPOSE To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTSWe identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

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The role of the myosure hysteroscopic tissue removal system in the office setting at detecting abnormal pathology in women with post-menopausal bleeding, who have had blind endometrial sampling reported as inadequate, inactive or benign endometrium (2017)

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Type of publication:
Conference abstract

Author(s):
*Underwood M. ; *Chadha R.; *Hudda A.; *Green J.; *Fry M.; *Barker V.

Citation:
Journal of Minimally Invasive Gynecology; 2017; vol. 24 (no. 7)

Abstract:
Study Objective: Identify any histological discrepancy between blind endometrial sampling (ES) reported as inadequate, inactive or benign endometrium and office based hysteroscopy with the MyoSure tissue removal system in women with post-menopausal bleeding (PMB). Design: retrospective review of cases from our PMB clinic. Setting:Women attending the PMB clinic who's ES is reported as benign, inactive or inadequate. MyoSure Lite or Classic devices were used for the removal of these lesions. Patients:Women with PMB having an endometrial polypectomy using the MyoSure tissue removal system. Intervention: The MyoSure Lite & Classic tissue removal systems were used to remove endometrial polyps in women with PMB who's ES was inactive, inadequate or benign. Histological comparison between the ES and MyoSure histology was made. Measurements and Main Results: 616 women underwent hysteroscopic evaluation for abnormal uterine 2017; 399 were post-menopausal of which 186 women (46.6%) had inactive endometrium, 82 women (20.6%) had inadequate, 109 (27.3%) had benign/polyp and 22 (5.5%) had simple hyperplasia or higher grade disease detected on the blind endometrial sampling prior to polypectomy. The MyoSure polypectomy of those women with "Proliferative/benign endometrium" demonstrated that 19.3% had higher grade disease (Simple, complex, complex with atypia or cancer) than the ES, for the "inactive group 10.8% had high grade disease and those with an inadequate ES 13.4% had higher grade disease. (Table presented) Endometrial thickness in the PMB group ranged from 1.5-45 mm with a mean of 10.6 mm. There were no reported complications in all 616 cases. Conclusion: This retrospective review of patients with inadequate, inactive or benign ES has demonstrated the significant benefit to patient of having the polyp removed simply without complication in the office setting using the MyoSure tissue removal system. Between 10.8-19.3% will have higher grade disease detected using the MyoSure device, which would have an impact on their medical management.

Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D.; *Underwood M .; *Parry-Smith W.; *Panikkar J.

Citation:
Geburtshilfe und Frauenheilkunde; Mar 2017; vol. 77 (no. 3); p. 284-289

Abstract:
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7?%) cases of CIN2 and 142 (35.3?%) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1?% were nulliparous and 36.6?% were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7?% and 57.1?%. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6?%, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95?% CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.

Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D, *Underwood M , *Parry-Smith W, *Panikkar J.

Citation:
Archives of Gynecology and Obstetrics. 2017 Apr;295(4):979-986

Abstract:
PURPOSE:
To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies.
METHODS:
This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment.
RESULTS:
We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months.
CONCLUSION:
We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.

A national colposcopy survey comparing destructive versus excisional treatment for CIN (2016)

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Type of publication:
Conference abstract

Author(s):
Parry-Smith W., *Papoutsis D., Parris D., *Panikkar J., Redman C., *Underwood M.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, June 2016, vol./is. 123/(99)

Abstract:
Introduction Women found to have high grade CIN should be offered either ablative treatment or large loop excision of the transformation zone with appropriate biopsy. Objective 1) To learn if a trial of ablative versus excisional treatment would be supported by fellow colposcopists in the UK 2) To investigate the current practice amongst colposcopists with regards to ablative treatment for high grade CIN 3) To gain an understanding of aspects of practice such as use of local anaesthetic during punch biopsies Methods An electronic questionnaire was sent to all registered colposcopists in the United Kingdom (total = 1677). Of these, 325 responded (19%). The study was granted ethical approval by the council of the British Society for Colposcopy and Cervical Pathology (BSCCP). Results The majority of colposcopists n = 248 (76%) felt that a study investigating the morbidity and Test of Cure outcomes comparing excisional and destructive treatments was needed. A reduced complication and morbidity rate would be the greatest factor to encourage colposcopists to use destructive treatments more often n = 250 (76.92%). If a destructive treatment were found to have a significantly reduced complication, morbidity, and equal or higher patient satisfaction rate during the procedure, but resulted in a slightly higher need for further treatment 5%, this was acceptable to n = 140 (43.1%) of those surveyed. However, a further treatment rate of 2.5% was acceptable to n = 196 (60.1%). The majority n = 182 (56%) of colposcopists did not perform destructive treatments for high grade disease; For those who did not perform destructive treatments the main reason was that they were not aware of sufficient evidence for its use n = 98 (30.2%) and had no experience nor training n = 33 (10.25%). Cold coagulation was the most common destructive treatment n = 100 (31%) that colposcopists could perform, with diathermy n = 70 (22%), laser n = 11 (3.4%) and cryotherapy n = 10 (3.1%) being less prevalent. The majority of colposcopists took two punch biopsies per patient n = 190 (58.5%), with only n = 45 (13.8%) taking three or more biopsies. Silver nitrate was the most favoured haemostatic technique following punch biopsy n = 217 (66.7%), with n = 269 (87.1%) using no local analgesia. Conclusion A study investigating morbidity and Test of Cure of excisional compared with destructive treatments for high grade CIN would be supported by most participating colposcopists. Variation in practice regarding both treatment and diagnosis exists. This has quality assurance implications for a standardised national screening programme.

Link to more details or full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201606002-00174&LSLINK=80&D=ovft

Consultants as victims of bullying and undermining: A survey of Royal College of Obstetricians and Gynaecologists consultant experiences (2016)

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Type of publication:
Journal article

Author(s):
Shabazz T., Parry-Smith W., *Oates S., Henderson S., Mountfield J.

Citation:
BMJ Open, June 2016, vol./is. 6/6(no pagination)

Abstract:
Objective: To explore incidents of bullying and undermining among obstetrics and gynaecology (O&G) consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine. Design: Questionnaire survey. Setting: Royal College of Obstetricians and Gynaecologists (RCOG). Participants: O&G consultant members/fellows of the RCOG working in the UK. Main outcome measures: Measures included a typology of 4 bullying and undermining consequences from major to coping. Results: There was a 28% (664) response rate of whom 44% (229) responded that they had been persistently bullied or undermined. Victims responded that bullying and undermining is carried out by those senior or at least close in the hierarchy. Of the 278 consultants who answered the question on 'frequency of occurrence', 50% stated that bullying and undermining occurs on half, or more, of all encounters with perpetrators and two-thirds reported that it had lasted more than 3 years. The reported impact on professional and personal life spans a wide spectrum from suicidal ideation, depression and sleep disturbance, and a loss of confidence. Over half reported problems that could compromise patient care. When victims were asked if the problem was being addressed, 73% of those that responded stated that it was not. Conclusions: Significant numbers of consultants in O&G in the UK are victims of bullying and undermining behaviour that puts their own health and patient care at risk. New interventions to tackle the problem, rather than its consequences, are required urgently, together with greater commitment to supporting such interventions.

Suicidal ideation during pregnancy in British Pakistani women (2016)

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Type of publication:
Conference abstract

Author(s):
*Sharif A., Gire N., Tomenson B., Chaudhry N., Husain M.

Citation:
European Psychiatry, March 2016, vol./is. 33/(S272-S273)

Abstract:
Introduction Suicide is a major public health problem and one of the common causes of maternal mortality. Rates of suicide and self-harm are higher in British South Asian women compared to the majority white population. Suicidal Ideation (SI) is a significant risk factor associated with self-harm and suicide. Objective To explore the prevalence and risk factors of SI in British Pakistani women. Aim To identify risk factors associated with SI, in order to inform future preventive strategies. Method This is a secondary analysis of a larger study which looked at depression during pregnancy and infant outcomes. Par ticipants who consented (women aged 18 or over, in their third pregnancy trimester) were initially assessed for maternal depression using the Edinburgh Post-Natal Depression Scale (EPDS), with one of the questions on the EPDS being on SI. Participants who met the study criteria, were further assessed regarding sociodemographic factors, perceived social support, social adversity and isolation. Results The rate of SI in this group of women was 8.1%, with baseline interview results suggesting that women with SI being significantly more likely to be aged 20 or less, have experience of severe life events and being less likely to have social support. Conclusion This area of research is key to understanding SI in British Pakistani women, to better develop culturally sensitive interventions for use within this group.

A dedicated undergraduate gynaecology teaching clinic: The Keele experience (2016)

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Type of publication:
Journal article

Author(s):
Katali H.M., *Parry-Smith W.R., Eliot R.L., Omahony F.

Citation:
Journal of Obstetrics and Gynaecology, February 2016, vol./is. 36/2(227-229)

Abstract:
Much discussion in the literature centres on how best to teach medical students the intricacies of gynaecological assessment and the subsequent formulation of a management plan. At Keele University skills are initially developed in a simulated setting and then transferred to the workplace where students continue to develop their skills. A dedicated undergraduate gynaecology teaching clinic has been developed and comprises of 2-3 students and a tutor. All 38 students rotating through the department between January and June 2013 were invited to complete an anonymous questionnaire to evaluate this clinic and 36 (95%) of them responded. Respondents felt significantly more comfortable taking a gynaecology history, ensuring privacy during examination and formulating a management plan post-clinic (all p < 0.001), with female students feeling significantly more comfortable than their male counterparts (p = 0.04). The use of this clinic shows great promise to help students learn an unfamiliar and challenging skill.