P–397 Threatened Miscarriage and increase in Perinatal Morbidity

Study question

Are women presenting with bleeding in the first trimester of pregnancy at a higher risk for perinatal complications later in pregnancy?

Summary answer

Women presenting with bleeding in the first trimester of pregnancy are more likely to experience perinatal and neonatal morbidity in pregnancy.

What is known already

Observational studies and a previously reported systematic review showed that women who experienced threatened miscarriage are more likely to have still birth, intra uterine growth restriction (IUGR), low birth weight, pre-eclampsia, placental abruption, placenta previa, preterm labour, preterm prelabour rupture of membrane, neonatal asphyxia and congenital anomalies in pregnancy. However, the evidence has been inconclusive and currently the women who experience threatened miscarriage receive low risk care.

Study design, size, duration

This was a prospective cohort study conducted on 298 women with threatened miscarriage (Cohort A) and 107 asymptomatic women (Cohort B). The women were recruited over a period of 18 months and were followed up for 9 months until delivery.

Participants/materials, setting, methods

Cohort A were women who presented with bleeding in the early pregnancy assessment unit and had a confirmed heartbeat on ultrasound scan between 6 weeks and 11 + 6 weeks of pregnancy and cohort B were women who were asymptomatic and booked with the community midwives as low risk. Both groups of women were followed up prospectively until delivery and data were collected on any perinatal outcomes and complications for both mother and the neonate.

Main results and the role of chance

The analysis showed that women who had bleeding in early pregnancy were more likely to have preterm delivery (RR 95% CI; 2.98 (1.07 – 8.27)); IUGR (unable to calculate the RR, as none of the women who continued their pregnancies beyond 24 weeks of gestation, developed IUGR in the asymptomatic control cohort. Nonetheless, IUGR occurred more frequently in the threatened miscarriage cohort than the asymptomatic cohort (P-value 0.02)); LBW (RR 95% CI; 6.14 (1.49 – 25.19), neonatal asphyxia (unable to calculate the RR, as none of the babies who were born to women in the asymptomatic control cohort develop neonatal asphyxia. Nonetheless, neonatal asphyxia occurred more frequently in the threatened miscarriage cohort than the asymptomatic cohort (P-value 0.02)). Preterm prelabour rupture of membrane was not significant with a P-value of 0.07.

Limitations, reasons for caution

The major limitation of this study was lower sample size and hence due to the rarity of many of the perinatal and neonatal outcomes, we were unable to calculate the relative risk.

Wider implications of the findings: Current study agrees with the existing literature and reaffirms the association of perinatal and neonatal morbidities with threatened miscarriage and this group of women need to be managed as high-risk group antenatally.

Trial registration number

Not applicable

Variation in availability and use of surgical care for female urinary incontinence: a mixed-methods study

Background

Urinary incontinence affects between 25% and 45% of women. The availability and quality of services is variable and inequitable, but our understanding of the drivers is incomplete.

Objectives

The objectives of the study were to model patient, specialist clinician, primary and secondary care, and geographical factors associated with referral and surgery for urinary incontinence, and to explore women’s experiences of urinary incontinence and expectations of treatments.

Design

This was a mixed-methods study.

Setting

The setting was NHS England.

Participants

Data were collected from all women with a urinary incontinence diagnosis in primary care data, and all women undergoing mid-urethral mesh tape surgery for stress urinary incontinence were included. Interviews were also carried out with 28 women from four urogynaecology clinics who were deciding whether or not to have surgery, and surveys were completed by 245 members of the Royal College of Obstetricians and Gynaecologists with a specialist interest in urinary incontinence.

Data sources

The sources were patient-level data from Hospital Episode Statistics, the Clinical Practice Research Datalink and the Office for National Statistics mortality data linked to Hospital Episode Statistics. Interviews were conducted with women. An online vignette survey was conducted with members of the Royal College of Obstetricians and Gynaecologists.

Main outcome measures

The main outcome measures were the rates of referral from primary to secondary care and surgery after referral, the rates of stress urinary incontinence surgery by geographical area, the risk of mid-urethral mesh tape removal and reoperation after mid-urethral mesh tape insertion.

Results

Almost half (45.8%) of women with a new urinary incontinence diagnosis in primary care were referred to a urinary incontinence specialist: 59.5% of these referrals were within 30 days of diagnosis. In total, 14.2% of women referred to a specialist underwent a urinary incontinence procedure (94.5% of women underwent a stress urinary incontinence procedure and 5.5% underwent an urgency urinary incontinence procedure) during a follow-up period of up to 10 years. Not all women were equally likely to be referred or receive surgery. Both referral and surgery were less likely for older women, those who were obese and those from minority ethnic backgrounds. The stress urinary incontinence surgery rate was 40 procedures per 100,000 women per year, with substantial geographical variation. Among women undergoing mid-urethral mesh tape insertion for stress urinary incontinence, the 9-year mesh tape removal rate was 3.3%. Women’s decision-making about urinary incontinence surgery centred on perceptions of their urinary incontinence severity and the seriousness/risk of surgery. Women judged urinary incontinence severity in relation to their daily lives and other women’s experiences, rather than frequency or quantity of leakage, as is often recorded and used by clinicians. Five groups of UK gynaecologists could be distinguished who differed mainly in their average inclination to recommend surgery to hypothetical urinary incontinence patients. The gynaecologists’ recommendations were also influenced by urinary incontinence subtype and the patient’s history of previous surgery.

Limitations

The primary and secondary care data lacked information on the severity of urinary incontinence.

Conclusions

There was substantial variation in rates of referrals, surgery, and mesh tape removals, both geographically and between women of different ages and women from different ethnic backgrounds. The variation persisted after adjustment for factors that were likely to affect women’s preferences. Growing safety concerns over mid-urethral mesh tape surgery for stress urinary incontinence during the period from which the data are drawn are likely to have introduced more uncertainty to women’s and clinicians’ treatment decision-making.

Future work

Future work should capture outcomes relevant to women, including ongoing urinary incontinence and pain that is reported by women themselves, both before and after mesh and non-mesh procedures, as well as following conservative treatments. Future research should examine long-term patient-reported outcomes of treatment, including for women who do not seek further health care or surgery, and the extent to which urinary incontinence severity explains observed variation in referrals and surgery.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Uptake and outcomes of robotic gynaecological surgery in England (2006-2018): an account of Hospital Episodes Statistics (HES)

This was a retrospective study to review the uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018, analysing Hospital Episode Statistics form National Health Service hospitals in England. Women aged 18 years and above who had elective gynaecological surgery were included and those who had undergone robotic gynaecology surgery were included. Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS healthcare regions. Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates were calculated by year and procedure type. Overall 527,217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in the uptake of robotic surgery but there was a marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate was 0.3% and 30-day emergency readmission rate was 4.7%. LOS was statistically, but not clinically, different across time. Other outcomes did not differ by year. Robotic gynaecological procedures are increasingly being used in the English NHS, predominantly for hysterectomy, although in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.

Pelvic floor muscle training for women with pelvic organ prolapse: the PROPEL realist evaluation

Background

Pelvic organ prolapse is estimated to affect 41–50% of women aged > 40 years. A multicentre randomised controlled trial of individualised pelvic floor muscle training found that pelvic floor muscle training was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. Provision of pelvic floor muscle training for prolapse has continued to vary across the UK, with limited availability of specialist physiotherapists to deliver it.

Objectives

This project aimed to study the implementation and outcomes of different models of delivery to increase the service provision of pelvic floor muscle training, and to follow up treatment outcomes for the original trial participants.

Design

A realist evaluation of pelvic floor muscle training implementation conducted within three full case study sites and two partial case study sites; an observational prospective cohort study comparing patient-reported outcomes pre and post intervention in all five sites; and a long-term follow-up study linking previous trial participants to routine NHS hospital data.

Setting

The setting for the realist evaluation was pelvic floor muscle training service delivery models in three NHS sites. The setting for the patient-reported outcome measures study was pelvic floor muscle training services in five NHS sites.

Methods

Realist evaluation qualitative data were collected at four time points in three case study sites to understand the implementation models, uptake, adherence and impact. Interviews involved service managers/leads, consultants, staff delivering pelvic floor muscle training and women receiving pelvic floor muscle training.

Main outcomes measures

Patient-reported outcomes were collected at baseline and at 6 and 12 months across five sites, including the Pelvic Organ Prolapse Symptom Score, health-related quality of life (measured using the EuroQol-5 Dimensions, five-level version, questionnaire), prolapse severity (measured using the Pelvic Organ Prolapse Quantification System), urinary incontinence (measured using International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form) and need for further treatment.

Results

A total of 102 women were recruited to the patient-reported outcome measures cohort study (target, n = 120), and 65 women had matched baseline and 6-month Pelvic Organ Prolapse Symptom Scores. The mean Pelvic Organ Prolapse Symptom Score was 10.18 (standard deviation 5.63) at baseline and 6.98 (standard deviation 5.23) at 6 months, representing a statistically significant and clinically meaningful difference. There was no statistically significant difference between the outcomes obtained from delivery by specialist physiotherapists and the outcomes obtained from delivery by other health-care professionals (mean change in Pelvic Organ Prolapse Symptom Score: –3.95 vs. –2.81, respectively). Services delivered using higher-band physiotherapists only were more costly than services delivered using other staff mixes. The effect of the original pelvic floor muscle training intervention, over a post-intervention period of > 10 years, was a reduction in the odds of any treatment during follow-up (odds ratio 0.61, 95% confidence interval 0.37 to 0.99). The realist evaluation revealed stark differences in implementation. The site with a specialist physiotherapy service resisted change because of perceived threats to the specialist role and concerns about care quality. Pelvic floor muscle training delivery by other health-care staff was easier when there was a lack of any existing specialist service; staff had prior training and interest in pelvic health; staff had support, autonomy, time and resources to deliver pelvic floor muscle training as part of their core role; and surrounding services supported a flow of pelvic floor muscle training referrals.

Limitations

The number of available matched pre and post outcomes for women and the lack of Pelvic Organ Prolapse Quantification System examinations were limitations of this study.

Conclusions

It is possible to train different staff to effectively deliver pelvic floor muscle training to women. Women’s self-reported outcomes significantly improved across all service models. Training should be adequately tailored to differential skill mix needs.

Future work

Future work should include further implementation of pelvic floor muscle training and should include pre- and post-outcome data collection using the Pelvic Organ Prolapse Symptom Score.

Study registration

This study is registered as Research Registry 4919.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 47. See the NIHR Journals Library website for further project information.

Determinants of referral of women with urinary incontinence to specialist services: a national cohort study using primary care data from the UK

BACKGROUND

Female urinary incontinence is underdiagnosed and undertreated in primary care. There is little evidence on factors that determine whether women with urinary incontinence are referred to specialist services. This study aimed to investigate characteristics associated with referrals from primary to specialist secondary care for urinary incontinence.

METHODS

We carried out a cohort study, using primary care data from over 600 general practices contributing to the Clinical Practice Research Datalink (CPRD) in the United Kingdom. We used multi-level logistic regression to estimate adjusted odds ratios (aOR) that reflect the impact of patient and GP practice-level characteristics on referrals to specialist services in secondary care within 30 days of a urinary incontinence diagnosis. All women aged ≥18 years newly diagnosed with urinary incontinence between 1 April 2004 and 31 March 2013 were included. One-year referral was estimated with death as competing event.

RESULTS

Of the 104,466 included women (median age: 58 years), 28,476 (27.3%) were referred within 30 days. Referral rates decreased with age (aOR 0.34, 95% CI 0.31-0.37, comparing women aged ≥80 with those aged 40-49 years) and was lower among women who were severely obese (aOR 0.84, 95% CI 0.78-0.90), smokers (aOR 0.94, 95% CI 0.90-0.98), women from a minority-ethnic backgrounds (aOR 0.76, 95% CI 0.65-0.89 comparing Asian with white women), women with pelvic organ prolapse (aOR 0.77, 95% CI 0.68-0.87), and women in Scotland (aOR 0.60, 95% CI 0.46-0.78, comparing women in Scotland and England). One-year referral rate was 34.0% and the pattern of associations with patient characteristics was almost the same as for 30-day referrals.

CONCLUSIONS

About one in four women with urinary incontinence were referred to specialist secondary care services within one month after a UI diagnosis and one in three within one year. Referral rates decreased with age which confirms concerns that older women with UI are less likely to receive care according to existing clinical guidelines. Referral rates were also lower in women from minority-ethnic backgrounds. These finding may reflect clinicians' beliefs about the appropriateness of referral, differences in women's preferences for treatment, or other factors leading to inequities in referral for urinary incontinence.

Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models

BACKGROUND

Pelvic Floor Muscle Training (PFMT) has been shown to be effective for pelvic organ prolapse in women, but its implementation in routine practice is challenging due to lack of adequate specialist staff. It is important to know if PFMT can be delivered by different staff skill mixes, what barriers and facilitators operate in different contexts, what strategies enable successful implementation and what are the underlying mechanisms of their action. PROPEL intervention was designed to maximise the delivery of effective PFMT in the UK NHS using different staff skill mixes. We conducted a realist evaluation (RE) of this implementation to understand what works, for whom, in what circumstances and why.

METHODS

Informed by the Realist and RE-AIM frameworks, the study used a longitudinal, qualitative, multiple case study design. The study took place in five, purposively selected, diverse NHS sites across the UK and proceeded in three phases to identify, test and refine a theory of change. Data collection took place at 4 time points over an 18 month implementation period using focus groups and semi-structured interviews with a range of stakeholders including service leads/managers, senior practitioners, newly trained staff and women receiving care in the new service models. Data were analysed using thematic framework approach adapted to identify Context, Mechanism and Outcome (CMO) configurations of the RE.

RESULTS

A heightened awareness of the service need among staff and management was a mechanism for change, particularly in areas where there was a shortage of skilled staff. In contrast, the most established specialist physiotherapist-delivered PFMT service activated feelings of role protection and compromised quality, which restricted the reach of PFMT through alternative models. Staff with some level of prior knowledge in women's health and adequate organisational support were more comfortable and confident in new role. Implementation was seamless when PFMT delivery was incorporated in newly trained staff's role and core work.

CONCLUSION

Roll-out of PFMT delivery through different staff skill mixes is possible when it is undertaken by clinicians with an interest in women's health, and carefully implemented ensuring adequate levels of training and ongoing support from specialists, multi-disciplinary teams and management.

Making a decision about surgery for female urinary incontinence: a qualitative study of women's views

Introduction and hypothesis

This qualitative interview study explores aspects women with urinary incontinence(UI) reflect upon when considering whether or not to have surgery. Conducted prior to the recent mesh pause in the UK, the article provides insights for current and future approaches to shared decision-making.

Methods

Qualitative in-depth interviews of 28 patients referred to secondary care for stress and mixed UI who were considering UI surgery. Participants were recruited from four urogynaecology clinics in the Midlands and South England, UK. Interviews were conducted in clinics, in patient homes, and by telephone. Data analysis was based on the constant comparative method.

Results

Participants’ accounts comprised three key concerns: their experience of symptoms, the extent to which these impacted a variety of social roles and demands, and overcoming embarrassment. Accounts drew on individual circumstances, values, and concerns rather than objective or measurable criteria. In combination, these dimensions constituted a personal assessment of the severity of their UI and hence framed the extent to which women prioritized addressing their condition.

Conclusions

Acknowledging women’s personal accounts of UI shifts the concept of ‘severity’ beyond a medical definition to include what is important to patients themselves. Decision-making around elective surgery must endeavour to link medical information with women’s own experiences and personal criteria, which often change in priority over time. We propose that this research provides insight into how the controversy around the use of mesh in the UK emerged. This study also suggests ways in which facilitating shared decision-making should be conducted in future.

Awareness of and attitudes towards cervical cancer prevention among migrant Eastern European women in England

Objectives

It has been hypothesized that, in England, the rise in incidence of cervical cancer and the fall in screening coverage might be attributable in part to the effect of migration of Eastern European born women. We explored the attitudes and behaviours of these women towards cervical cancer prevention strategies.

Methods

A mixed methods study using quantitative surveys and in-depth semi-structured qualitative interviews was conducted between April 2015 and December 2016.

Results

In total, 331 surveys and 46 interviews were completed. Native English women had greater knowledge that a smear test is a screening test for pre-cancerous cervical cells (90% vs. 71% p≤0.01), whereas migrant Eastern European women believed that it was conducted as part of a full gynaecological examination (46% vs. 21% p≤0.01) and that the screen interval was annual (18% vs. 4% p≤0.01). Distrust of the English healthcare system resulted in some Eastern European women returning to their country of birth for screening. Poor awareness of cervical cancer prior to migration and lack of information at registration with a general practitioner in England were associated with failure to participate in screening.

Conclusions

The views and attitudes expressed by the migrant Eastern European women in this study suggest that they are not fully participating in cervical screening in England. Targeted education at the point of contact with healthcare services in England is needed to increase cervical screening participation among these women.

Women's experiences of receiving care for pelvic organ prolapse: a qualitative study

BACKGROUND

Pelvic organ prolapse is a common urogenital condition affecting 41-50% of women over the age of 40. To achieve early diagnosis and appropriate treatment, it is important that care is sensitive to and meets women's needs, throughout their patient journey. This study explored women's experiences of seeking diagnosis and treatment for prolapse and their needs and priorities for improving person-centred care.

METHODS

Twenty-two women receiving prolapse care through urogynaecology services across three purposefully selected NHS UK sites took part in three focus groups and four telephone interviews. A topic guide facilitated discussions about women's experiences of prolapse, diagnosis, treatment, follow-up, interactions with healthcare professionals, overall service delivery, and ideals for future services to meet their needs. Data were analysed thematically.

RESULTS

Three themes emerged relating to women's experiences of a) Evaluating what is normal b) Hobson's choice of treatment decisions, and c) The trial and error of treatment and technique. Women often delayed seeking help for their symptoms due to lack of awareness, embarrassment and stigma. When presented to GPs, their symptoms were often dismissed and unaddressed until they became more severe. Women reported receiving little or no choice in treatment decisions. Choices were often influenced by health professionals' preferences which were subtly reflected through the framing of the offer. Women's embodied knowledge of their condition and treatment was largely unheeded, resulting in decisions that were inconsistent with women's preferences and needs. Physiotherapy based interventions were reported as helping women regain control over their symptoms and life. A need for greater awareness of prolapse and physiotherapy interventions among women, GPs and consultants was identified alongside greater focus on prevention, early diagnosis and regular follow-up. Greater choice and involvement in treatment decision making was desired.

CONCLUSIONS

As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure, alongside a multi-professional team approach to treatment decision making. Women presenting with prolapse symptoms need to be listened to by the health care team, offered better information about treatment choices, and supported to make a decision that is right for them.

Knowledge, attitudes and awareness of the human papillomavirus amongst primary care practice nurses: an evaluation of current training in England

Background

The incorporation of Human papillomavirus (HPV) testing into the English cervical screening programme has been met with fear and anxiety. Healthcare professionals need to be adequately informed about HPV to help alleviate patient concerns. The aim of this study was to evaluate the HPV training provided to practice nurses (PNs) and determine their level of HPV knowledge.

Method

A web-based survey was distributed to 147 General Practice surgeries in the Leicester, Leicestershire and Rutland regions, between May and July 2015. The survey explored four broad areas; demographics/level of experience, HPV knowledge, attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.

Results

A total of 128 surveys were completed, with 94 complete responses. Overall awareness of basic HPV facts was adequate; however, detailed, and in some cases basic, knowledge was lacking. 9.6% failed to identify that HPV can cause cervical cancer and 62.8% believed that HPV requires treatment. Not all PNs felt adequately informed about HPV and a need to improve the provision of training was identified.

Conclusion

PNs play a key role in increasing public awareness of HPV and implementing cervical cancer screening. The provision of education to PNs needs to be a priority and current methods of training need to be re-evaluated.

Knowledge of the risk factors and symptoms associated with endometrial cancer in British South Asian and British White women

OBJECTIVE

To explore differences in the background knowledge of Endometrial Cancer (EC), its risk factors, symptoms and prognosis of Endometrial Cancer (EC) between British White (BW) and British South Asian (BSA) women who had undergone treatment for stage I endometrial cancer within the past 3-years.

STUDY DESIGN

Face-to-face, semi-structured interviews exploring knowledge; diagnosis; treatment; follow-up; and survivorship were undertaken and analysed using Thematic Analysis.

RESULTS

Twenty-one women were interviewed (13 BW and 8 BSA). BW and BSA women reported similar views, experiences and concerns with regards to EC. Knowledge appeared to differ amongst the two groups with BSA women reporting being more aware that unscheduled vaginal bleeding could be associated with a malignancy but having lower levels of knowledge of the risk factors that can lead to EC, compared to BW women. There was a lack of understanding of the difference between cervical cancer and EC and as a result, many women reported taking reassurance from negative cervical cytology as excluding EC. There was also the misconception amongst some of the women that there was a link between sexual behaviour and EC. Women from both groups used the lay healthcare system to discuss their situation/symptoms, however BSA women reported to have specifically sought out women within their social network who had previously undergone treatment for EC.

CONCLUSIONS

Greater effort is needed to raise awareness in both the BW/BSA communities of the symptoms associated with EC that should prompt medical review. Educational efforts are required to overcome the reported perception that EC is synonymous with cervical cancer and cannot be detected by cervical screening.

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol

Background

Pelvic Organ Prolapse (POP) is estimated to affect 41%–50% of women aged over 40. Findings from the multi-centre randomised controlled “Pelvic Organ Prolapse PhysiotherapY” (POPPY) trial showed that individualised pelvic floor muscle training (PFMT) was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. However, provision of PFMT for prolapse continues to vary across the UK, with limited numbers of women’s health physiotherapists specialising in its delivery. Implementation of this robust evidence from the POPPY trial will require attention to different models of delivery (e.g. staff skill mix) to fit with differing care environments.

Methods

A Realist Evaluation (RE) of implementation and outcomes of PFMT delivery in contrasting NHS settings will be conducted using multiple case study sites. Involving substantial local stakeholder engagement will permit a detailed exploration of how local sites make decisions on how to deliver PFMT and how these lead to service change. The RE will track how implementation is working; identify what influences outcomes; and, guided by the RE-AIM framework, will collect robust outcomes data. This will require mixed methods data collection and analysis.

Qualitative data will be collected at four time-points across each site to understand local contexts and decisions regarding options for intervention delivery and to monitor implementation, uptake, adherence and outcomes. Patient outcome data will be collected at baseline, six months and one year follow-up for 120 women. Primary outcome will be the Pelvic Organ Prolapse Symptom Score (POP-SS). An economic evaluation will assess the costs and benefits associated with different delivery models taking account of further health care resource use by the women. Cost data will be combined with the primary outcome in a cost effectiveness analysis, and the EQ-5D-5L data in a cost utility analysis for each of the different models of delivery.

Discussion

Study of the implementation of varying models of service delivery of PFMT across contrasting sites combined with outcomes data and a cost effectiveness analysis will provide insight into the implementation and value of different models of PFMT service delivery and the cost benefits to the NHS in the longer term.

The effect of vaginal closure technique on early post-operative pain following vaginal prolapse surgery: a feasibility pilot study and qualitative assessment

BACKGROUND

Surgery for pelvic organ prolapse is a common surgical procedure. There is little research studying post-operative pain, contrasting with extensive literature on pain after childbirth trauma which shows that suture method has a significant effect on pain. We designed a protocol for a trial comparing suture techniques and post-operative pain, and conducted a pre-protocol pilot to inform our trial design.

METHODS

Routine surgical data, post-operative pain scores (from 10 cm Visual Analogue Scales, VAS) and analgesic requirements were obtained from the notes of a cohort of women undergoing vaginal prolapse surgery. Median VAS scores at 4, 12 and 24 hours were compared by suture material used and method of closure (single continuous suture or interrupted sutures). The women whose data were obtained were invited to attend focus groups of up to six people in the twelve weeks following surgery. A semi structured question guide was used, and interviews were recorded, transcribed anonymously and analysed using the constant comparative method of grounded theory. Ethical approval was not sought because formal pre-protocol work is exempt for UK ethical requirements, but formal written consent on standard forms was obtained for publishing outcomes and anonymised comments from participants.

RESULTS

Complete VAS data and operative details were available from 41 women. Surgery was completed using absorbable polyglactin sutures with continuous suturing (17 women) or interrupted sutures (24 women). Pain scores at 4 and 12 hours were similar; pain at 24 hours was greater in the women with interrupted sutures (median VAS 3 (range 0-8) versus 1.5 (0-8) (p = 0.0513). Analgesic needs were similar. Two focus groups (nine participants) revealed that women regarded post-operative pain as insignificant and not a topic worthy of formal research. It was apparent that the use, and especially removal of, vaginal packs was a practice associated with pain which women remembered as a significant part of their post-operative experience.

CONCLUSIONS

Formal pre-protocol work is informative; we found a moderate difference in our proposed outcomes, suggesting a trial was feasible but women themselves were unconvinced of the need for formal research into pain following vaginal surgery.

Cost-effectiveness of duloxetine: the Stress Urinary Incontinence Treatment (SUIT) study

OBJECTIVE

To assess the cost-effectiveness of duloxetine compared with conservative therapy in women with stress urinary incontinence (SUI).

METHODS

Cost and outcome data were taken from the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month, prospective, observational, naturalistic, multicenter, multicountry study. Costs were assessed in UK pound and outcomes in quality adjusted life years using responses to the EuroQol (EQ-5D); numbers of urine leaks were also estimated. Potential selection bias was countered using multivariate regression and propensity score analysis.

RESULTS

Duloxetine alone, duloxetine in combination with conservative treatment, and conservative treatment alone were associated with roughly two fewer leaks per week compared with no treatment. Duloxetine alone and with conservative treatment for SUI were associated with incremental quality-adjusted life-years (QALYs) of about 0.03 over a year compared with no treatment or with conservative treatment alone. Conservative treatment alone did not show an effect on QALYs. None of the interventions appeared to have marked impacts on costs over a year. Depending on the form of matching, duloxetine either dominated or had an incremental cost-effectiveness ratio (ICER) below pound900 per QALY gained compared with no treatment and with conservative treatment alone. Duloxetine plus conservative therapy had an ICER below pound5500 compared with no treatment or conservative treatment alone. Duloxetine compared with duloxetine plus conservative therapy showed similar outcomes but an additional cost for the combined intervention.

CONCLUSIONS

Although the limitations of the use of SUIT's observational data for this purpose need to be acknowledged, the study suggests that initiating duloxetine therapy in SUI is a cost-effective treatment alternative.

Patient reported outcomes tools in an observational study of female stress urinary incontinence

AIMS

To determine which patient characteristics, incontinence and non-incontinence related, are associated with the symptom severity scores of the Urogenital Distress Inventory (UDI) and the International Consultation on Incontinence Questionnaire Urinary Incontinence (ICIQ-UI); and to determine the association of both patient characteristics and symptom severity scores with quality-of-life scores of the Incontinence Impact Questionnaire (IIQ) and the Incontinence-Quality of Life (I-QOL) questionnaire.

METHODS

Women presenting with stress urinary incontinence (SUI) symptoms in primary and secondary care entered the Stress Urinary Incontinence Treatment Study (SUIT), an observational study evaluating the cost-effectiveness of duloxetine compared to other non-surgical treatments for SUI. At enrollment patients completed the UDI-6, the short form ICIQ-UI, the IIQ-7 and the I-QOL. Multivariate linear regressions were performed with the UDI-6, ICIQ-UI SF, IIQ-7, and I-QOL as outcomes.

RESULTS

The total number of incontinence episodes is the most significant explanatory variable of the two symptom questionnaire scores, but the UDI-6 score also reflects the type of incontinence. The variability of the condition-specific quality-of-life questionnaires is primarily explained by the symptom severity questionnaire scores. Although there is a high intercorrelation, both these symptom questionnaires independently contributed significantly to the IIQ-7 and I-QOL total scores.

CONCLUSIONS

The UDI-6 and ICIQ-UI SF can be regarded as scientifically sound symptom questionnaires in UI evaluation; but they have differences. Since the UDI-6 and ICIQ-UI SF independently contribute to the quality-of-life scores, this suggests that in incontinence research symptom questionnaires should not focus only on incontinence, but on a broader range of urogenital symptoms.

Patient characteristics impacting health state index scores, measured by the EQ-5D of females with stress urinary incontinence symptoms

OBJECTIVE

To describe the characteristics of women seeking treatment for symptoms of stress urinary incontinence (SUI) and to investigate the association of SUI symptoms with generic health-related quality of life (HRQoL) as measured by the EuroQol (EQ-5D) instrument.

METHODS

The Stress Urinary Incontinence Treatment (SUIT) study was a 12-month observational study in four European countries that evaluated the cost-effectiveness of duloxetine compared with other forms of nonsurgical intervention in the treatment of the symptoms of SUI. Four hundred thirty-one physicians observed women seeking treatment for their SUI, and recorded the care provided and the outcomes of that care at enrollment and at 3, 6 and 12 months afterward The impact of SUI on baseline HRQoL as expressed by the EQ-5D index score was assessed by linear and logistic regression.

RESULTS

Three thousand seven hundred sixty-two women were enrolled into SUIT, with the largest patient group from Germany. Overall, the majority of women were postmenopausal, had a mean age of 58.0 years, were not current smokers, and tended to be overweight (mean body mass index [BMI]=27.7 kg/m2), with at least one comorbidity. The health state index scores were significantly and independently influenced by the presence of comorbidity(ies) affecting quality of life, total number of stress and urge incontinence episodes, urinary incontinence subtype, comorbidity(ies) affecting incontinence, BMI, socioeconomic status, educational status, age, and country.

CONCLUSION

This article describes the characteristics of patients at the SUIT enrollment visit, and demonstrates that the number of incontinence episodes has a significant impact on the EQ-5D index score.

Clinically overt postpartum urinary retention after vaginal delivery: a retrospective case-control study

We set out to determine the incidence of symptomatic postpartum urinary retention (PUR) after vaginal delivery and to establish any associated risk factors. We carried out a retrospective case-control study of women having PUR after vaginal delivery from 2001 to 2005. Four controls, matched for date of delivery, were selected for each case in univariate and multivariate conditional logistic regression analyses. There were 15,757 deliveries and 30 cases of PUR (incidence 0.2%). Median duration of PUR was 19 days (range 3-85). Eighty percent were managed with intermittent self-catheterization. The use of regional analgesia increased the risk of PUR [odds ratio (OR) 6.33, 95% confidence interval (CI) 2.01-19.96], while ethnicity (Caucasian vs Asian) reduced the risk (OR 0.27, CI 0.08-0.85) (p<0.05). PUR is uncommon but carries significant morbidity. Epidural analgesia and Asian ethnic origin increase the risk. We recommend routine catheterization for up to 24 h after delivery after epidural analgesia.

A comparison of urodynamic diagnoses and detrusor muscle function in white and South Indian Asian women

PURPOSE

We compared urodynamic data and the final diagnosis after testing between white and Asian women investigated for urinary incontinence.

MATERIALS AND METHODS

Urodynamic traces of consecutive women investigated between January 2002 and December 2003 were reviewed. Urodynamic diagnoses were classified as normal, urodynamic stress incontinence, detrusor overactivity (DOA) or mixed incontinence. In DOA cases the amplitude and number of detrusor contractions, and the volume at which the first involuntary contraction occurred were recorded. Data were compared by ethnic group.

RESULTS

The distribution of diagnoses was significantly different between Asian and white women (p <0.0001). In Asian and white women we noted urodynamic stress incontinence in 22% and 53% (OR 0.24, 95% CI 0.13 to 0.48), DOA in 28% and 17% (OR 1.88, 95% CI 0.98 to 3.60) and mixed incontinence in 22% and 7% (OR 3.74, 95% CI 1.70 to 8.22), respectively. Post-void residual volume (p = 0.02), volume at strong desire to void (p = 0.03) and cystometric capacity (p = 0.0002) were lower in Asian women. In those with DOA the first contraction occurred at a lower volume in Asian woman (57 vs 179 ml, p = 0.002). Asian women had more contractions (5 vs 3, p = 0.009) with higher maximum (50 vs 32 cm H2O, p = 0.004) and average (34.4 vs 25.3 cm H2O, p = 0.03) detrusor pressure.

CONCLUSIONS

In women who undergo urodynamics a greater proportion of Asian women have DOA and mixed incontinence compared with white women. Functional differences in detrusor contraction pressures exist, which may suggest a fundamental difference in bladder function or disease etiology. Exploration of this theory requires further study.

Factors that influence women's decisions about whether to participate in research: an exploratory study

BACKGROUND

Women are increasingly being asked to consider participating in medical research. We sought to investigate views of women who participated in and declined to participate in a study that was part of a program of maternity care research.

METHODS

An exploratory study using focus group interviews and semistructured interviews was conducted. A purposive sample of 17 postnatal women who had participated in research, from a hospital in the North West of England, were interviewed. An open coding mechanism to identify emergent themes was used for the analysis of data.

RESULTS

Of women who had not declined to participate in any research, the following themes were identified: altruism versus self-protection, enhanced versus inferior care, professional guidance versus self-direction, and welcome versus unacceptable methodology. Of women who had participated in some research but declined to participate in other research, the following themes were identified: feeling disempowered by the process, inability to believe equipoise existed, and practical inconvenience.

CONCLUSIONS

These findings suggest that although health care researchers adopt an individualistic approach to care, they may fail to adopt a similar approach within research. What is important and acceptable to women needs to be ascertained to develop appropriate research strategies. This plan will ensure that research is carried out to the highest ethical standard, which may increase recruitment rates.

Computerised analysis of fetal heart rate recordings in maternal type I diabetes mellitus

OBJECTIVE

1. To study computerised cardiotocograph parameters from women with type I diabetes; 2. to examine the significance of observed differences from the expected normal values.

DESIGN

Prospective observational study in the third trimester of pregnancy.

SETTING

The medical antenatal clinic of a tertiary referral centre.

POPULATION

Twenty-six women with type I diabetes mellitus with a singleton pregnancy.

METHODS

Computerised cardiotocograph recordings were made weekly from 28 to 39 weeks. Derived parameters were compared with the published figures for uncomplicated singleton pregnancies. Details of maternal blood sugar, labour and delivery and neonatal outcome were recorded. Data were compared between groups according to the computerised analysis of the antenatal CTGs.

RESULTS

One-hundred and thirty-one recordings were made with a median of five per patient (range 1-12). 1 1.3% showed absent episodes of high variation compared with the expected value of 0.8%, a difference of 9.5% (95% CI 4.5-15.3). Differences in short term variation, basal heart rate, frequency of fetal movements and heart rate accelerations were also found which changed with gestation. Overall these changes represented a more immature form of fetal heart rate than that which would be expected. No relationship between the changes and adverse fetal outcome could be identified.

CONCLUSIONS

Significant differences exist in cardiotocographs in maternal type I diabetes compared with normal fetuses. The changes may represent a delay in fetal maturation. The analysis mode of the computer will register these as abnormal features, but there is no evidence that they are pathological. We would recommend that computerised analysis is not used to assess pregnancies complicated by maternal type I diabetes mellitus.