Green-top Guideline Research Articles

Hospital admission for hyperemesis gravidarum: a nationwide study of occurrence, reoccurrence and risk factors among 8.2 million pregnancies.

What are the maternal risk factors for hyperemesis gravidarum (HG) hospital admission, readmission and reoccurrence in a following pregnancy? Young age, less socioeconomic deprivation, nulliparity, Asian or Black ethnicity, female fetus, multiple pregnancy, history of HG in a previous pregnancy, thyroid and parathyroid dysfunction, hypercholesterolemia and Type 1 diabetes are all risk factors for HG. Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with a history of HG were previously reported to be at higher risk of developing HG; however, most evidence is from small studies. Little is known about associations with other comorbidities and there is controversy over other risk factors such as parity. Estimates of HG prevalence vary and there is a little understanding of the risks of HG readmission in a current pregnancy and reoccurrence rates in subsequent pregnancies, all of which are needed for planning measures to reduce onset or worsening of the condition. We performed a population-based cohort study of pregnancies ending in live births and stillbirths using prospectively recorded secondary care records (Hospital Episode Statistics) from England. We analysed those computerized and anonymized clinical records from over 5.3 million women who had one or more pregnancies between 1997 and 2012. We obtained 8 215 538 pregnancies from 5 329 101 women of reproductive age, with a total of 186 800 HG admissions occurring during 121 885 pregnancies. Multivariate logistic regression with generalized estimating equations was employed to estimate odds ratios (aOR) to assess sociodemographic, pregnancy and comorbidity risk factors for HG onset, HG readmission within a pregnancy and reoccurrence in a subsequent pregnancy. Being younger, from a less socioeconomically deprived status, of Asian or Black ethnicity, carrying a female fetus or having a multiple pregnancy all significantly increased HG and readmission risk but only ethnicity increased reoccurrence. Comorbidities most strongly associated with HG were parathyroid dysfunction (aOR = 3.83, 95% confidence interval 2.28-6.44), hypercholesterolemia (aOR = 2.54, 1.88-3.44), Type 1 diabetes (aOR = 1.95, 1.82-2.09), and thyroid dysfunction (aOR = 1.85, 1.74-1.96). History of HG was the strongest independent risk factor (aOR = 4.74, 4.46-5.05). Women with higher parity had a lower risk of HG compared with nulliparous women (aOR = 0.90, 0.89-0.91), which was not explained by women with HG curtailing further pregnancies. Although this represents the largest population-based study worldwide on the topic, the results could have been biased by residual and unmeasured confounding considering that some potential important risk factors such as smoking, BMI or prenatal care could not be measured with these data. Underestimation of non-routinely screened comorbidities such as hypercholesterolemia or thyroid dysfunction could also be a cause of selection bias. The estimated prevalence of 1.5% from our study was similar to the average prevalence reported in the literature and the representativeness of our data has been validated by comparison to national statistics. Also the prevalence of comorbidities was mostly similar to other studies estimating these in the UK and other developed countries. Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with history of HG were confirmed to be at higher risk of HG with an unprecedented higher statistical power. We showed for the first time that socioeconomic status interacts with maternal age, that hypercholesterolemia is a potential risk factor for HG and that carrying multiple females increases risk of hyperemesis compared with multiple males. We also provided robust evidence for the association of parity with HG. Earlier recognition and management of symptoms via gynaecology day-case units or general practitioner services can inform prevention and control of consequent hospital admissions. The work was founded by The Rosetrees Trust and the Stoneygate Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. C.N.-P. reports personal fees from Sanofi Aventis, Warner Chilcott, Leo Pharma, UCB and Falk, outside the submitted work and she is one of the co-developers of the RCOG Green Top Guideline on HG; all other authors did not report any potential conflicts of interest. Not applicable.

Audit Report on the Clinical Knowledge and Awareness of Molar Pregnancy amongst a Single O&G Cluster in Singapore

This audit was set up to evaluate the current knowledge and awareness of the doctors at medical officer level and above in the obstetric and gynaecological (O&G) cluster with regards to gestational trophoblastic disease, a rare but treatable disease. A questionnaire based on royal college of obstetrician and gynaecologists (RCOG) green-top guideline 38 was created and distributed to the cohort and results were subsequently tabulated and analyzed categorically. Results have shown that all categories of doctors have managed to score above 50% on the questionnaire with the Associate Consultants and Senior Staff Registrars having the highest scores probably because this group of doctors has the most exposure to dealing with patients with the disease as well as them being closest to having just finished their specialist examinations. This audit not only helped to create awareness amongst our clinicians regarding the disease but also confirms good clinical practice amongst them.

Editorial

Editorial

An audit on the outcome of vaginal Birth after Caesarean Section (VBAC) in a Sri Lankan tertiary care setting and factors associated with failure

Introduction: Caesarean section is a major surgical operation and its rate is on the rise in Sri Lanka as well as in the world. It is recommended to lower the Caesarean section rate due to the risk of potential complications and burden on the health care system. Previous Caesarean is a common indication for planned Caesarean section and vaginal birth after Caesarean section (VBAC) is considered a safe alternative for many women. This audit study was aimed at determining the success rate of VBAC in a local setting and to identify the factors that are associated with failure in this study population. Method: An audit study was carried out in two obstetric units if South Colombo Teaching hospital, Kalubowila and De Soysa hospital for women, Colombo 8 to assess the success rate among women who underwent VBAC. The unit policies included patient choice for decision to undergo VBAC and non-usage of medication either for induction or augmentation of labour. The audit standards were set as a VBAC success rate of 72% (RCOG Green-top guidelines) and a low APGAR (<7) in less than 2% of neonates (set by clinical experience). The demographic and past obstetric factors were compared between groups to determine significant associations. Results: A total of 161 women (37.8% of those with a previous one Caesarean) had opted to undergo VBAC during the study period. It was successful in 69.6% of the total study sample and 84.6% who has had a previous vaginal delivery. Low APGAR scores at 5 minutes was observed in two neonates (1.2%) and both these were in the group with a successful VBAC. The factors associated with failed VBAC in this study population included not having had a previous vaginal delivery (Odds ratio 2.99), poor progress of labour being the indication for previous section (OR 2.32), a cervical dilatation of <2cm at onset of labour (OR 4.43), malpositions in early labour (OR 12.24), and a birth weight of more than 3000g (OR 2.11). Other preciously described factors such as a high BMI and inter-delivery interval failed to show a significant association in this study group. Discussion and recommendations: The take up rate of VBAC in our study population seems to be low. However, the study did not study the reasons contributing to this low rate hence no recommendations can be made. The success rate of VBAC on our group (69%) was very close to the set standards (72%) and the rate of low APGAR at 5 minutes was 1.2% and was achieving the set standard. These figures along with the factors identified to be associated with the failure at VBAC should be used for patient counseling in our local setting. Other units also should carry out such audit projects to find out the success rate of VBAC in their respective units. More in-depth studies should be carried out to find causes for low rate of undergoing VBAC and to determine effective ways to improve it.

Use of hormonal contraception after hydatidiform mole.

Effective contraception is important during monitoring of human chorionic gonadotrophin (hCG) levels after uterine evacuation for hydatidiform mole (HM), to avoid confusion between a rising hCG associated with ongoing gestational trophoblastic disease (GTD) and that resulting from a new pregnancy. Contraception should be started as soon as possible: conception can occur before menses are re-established. But how do women achieve effective contraception in the immediate aftermath of molar pregnancy? Typically, condom use is associated with an 18% contraceptive failure rate over a year of use. Intrauterine contraception has been avoided in GTD because of concerns about possible increased risk of bleeding and uterine perforation. Hormonal contraception (HC) is effective: the progestogen-only implant has a typical use failure rate of only 0.05% over a year, oral contraception 9% and injectables 6%. On discontinuation of HC (except injectables), there is a rapid return to fertility – important to many women after an episode of GTD. However, guidelines regarding use of HC during follow up of HM have been inconsistent. Royal College of Obstericians and Gynaecologists guidance (Green Top Guideline 38, London: RCOG; March 2010) recommended that HC be avoided until hCG levels normalised because of concern that use of combined HC after molar pregnancy might increase the risk of gestational trophoblastic neoplasia. However, a systematic review by Gaffield et al. (Contraception 2009;80:363–71) found no evidence of an effect of combined HC on the course of GTD after HM. On this basis, the 2009 World Health Organization Medical Eligibility Criteria for Contraceptive Use recommended that there should be no restriction on use of HC while hCG levels are elevated in GTD. In line with this, the Faculty of Sexual and Reproductive Healthcare (UK Medical Eligibility Criteria for Contraceptive Use, London: FSRH; 2009) and Centers for Disease Control (US Medical Eligibility Criteria for Contraceptive Use, Atlanta: CDC; 2010) advise that HC can safely be used while hCG remains elevated. In the current retrospective database study, Braga et al. find no association between use of HC started while hCG levels are still raised after uterine evacuation for complete HM and time to hCG regression, development of gestational trophoblastic neoplasia or FIGO risk score. The study includes 2423 women with complete HM. However, only 154 used HC (100 combined oral contraception, 43 progestogen-only pill, 11 progestogen-only injectable). Because numbers of women using each contraceptive were small, methods are considered together as ‘hormonal contraception’. The study is not powered to detect different effects of individual HC methods on GTD outcomes. Progestogen-only implants and non-oral combined contraceptives are not considered. Contraceptive method was not randomised. Prescribing might have been influenced by plateaued or rising hCG levels or by bleeding problems in the weeks following uterine evacuation so there is a potential prescribing bias. Despite its limitations, this study adds to the weight of evidence that suggests HC can safely be used after molar pregnancy before hCG levels normalise. Clinicians caring for women with a diagnosis of molar pregnancy should not forget about contraception and can advise women that the limited evidence is that HC is safe to start. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Spotlight on… maternal medicine

When I was asked to do a review of the coverage of maternal medicine in TOG I was unsure what I would find. Have we covered the breadth of the subject? Have we concentrated in the obvious areas? Are the articles all written by leaders in their field or by trainees hoping to get a foothold on their climb towards academic achievement? The first article on maternal medicine appeared in TOG volume 1 1999 (TOG 1999;1:29–32). Written by one of the founders of maternal medicine in the UK, John Davison, it was an educational article on chronic renal disease in pregnancy. Whilst the field has moved on in the last 16 years, this well written article is an excellent introduction to the subject. The first article on hypertension in pregnancy was published in 2003 (TOG's 5th year). Written by Glanville and Walker (TOG 2003;5:149–154) this remains an authoritative description of HELLP, its pathogenesis and management (albeit they did not know about the beneficial affects of magnesium for the premature baby). Over the years there have been another five articles on hypertension and, taken as a whole, these give a comprehensive guide on the pathophysiology and management of hypertension in pregnancy and the puerperium. One of the most recent was a scholarly and comprehensive discussion on the use of aspirin (and calcium) in the prevention of pre-eclampsia (TOG 2014;16:245–250). As we have improved the care of pregnant women, cardiac disease has risen to be the commonest cause of maternal death. The importance of this is reflected in an article by Wuntaakal et al. (TOG 2013;15:247–255) on myocardial infarction in pregnancy and a pair of articles by Gelson et al. (TOG 2007;9:15–20 and TOG 2007;9:83–87) on acquired and congenital heart disease. This pair of articles elegantly describes the complex multidisciplinary care these women require and the excellent results that can be achieved. Sepsis has featured heavily in maternal mortality statistics in recent years with a peak in deaths from Group A Streptococcus in the 2006–8 triennium and sepsis accounting for 1 in 4 of all maternal deaths in the 2009–2012 report (MBBRACE 2014). This area has been covered with articles on appendicitis (TOG 2015;17:105–110), genital tract sepsis (TOG 2012;14:106–114) and Group A Streptococcus (TOG 2012;14:9–16). Through this series of articles, TOG has taken a lead in ensuring that clinicians are informed and may help in the campaign to control sepsis. Of all the UKOSS updates published over the years, the most influential was in 2011 during the H1N1 season. Marian Knight's short article (TOG 2011;13:63) on AH1N1 influenza in pregnancy brought home to many the dangers of influenza in pregnancy, the possible role of timely anti-viral treatment and the importance of the influenza vaccine. Then there are the less serious but common conditions that bother all obstetricians such as headache in pregnancy and asthma in pregnancy. Revell and Morrish (TOG 2014;16:179–184) describe how to differentiate between common and serious causes of headaches in pregnancy with a helpful discussion of ‘red flag’ symptoms. Goldie and Brightling (TOG 2013;15:241–245) bring us up-to-date with treatments of asthma, how to reduce the risk of exacerbation and the role of modern treatments, such as montelukasts. Mental health disorders are not ignored with articles on anorexia nervosa (TOG 2012;14:179–187), postnatal affective disorders (TOG 2008;10:231–235) and maternal depression (TOG 2008;10:151–155). This is just a taste of the over 30 articles on maternal disease in pregnancy that have appeared in TOG in the last 15 years. I recommend them to all obstetricians, GPs with an interest in improving maternal health and our midwifery colleagues. Along with the regular updates from UKOSS, summaries of RCOG Green-top Guidelines, and release of key messages from MBBRACE (released online in TOG on the day of the release of the data in December 2014 [TOG 2015;17: 72–73]), TOG is leading the way in helping obstetricians across the world improve maternal outcomes. A virtual issue of all TOG articles on maternal medicine is available at http://onlinetog.org.

Minimally invasive management of 14–16-week abdominal ectopic with hemoperitoneum: an emergency laparoscopic procedure

Since the first laparoscopic cholecystectomy on a pregnant lady in 1991, a plethora of articles and case studies have been published addressing laparoscopy and their role in pregnancy. The Royal College of Obstetricians and Gynecologists Green-top Guidelines recommends laparoscopic surgery as the preferred approach in early ectopic tubal pregnancies. Laparoscopic versus laparotomy management of abdominal ectopic is a traumatic experience both on physical and emotional levels. The case study was a 36-year-old gravida 2 para 0 patient, previously normal pregnant lady, in which the follow-up ultrasound revealed moderate hemoperitoneum at 14–16 weeks of gestation. Upon urgent diagnostic laparoscopy, massive hemoperitoneum was detected despite no clinical signs of hemodynamic instability. Uterus was found to be within the normal measurements consistent with the nonpregnant state. Multiple myomas were clearly seen in the uterine wall. A fetus of 14–16 weeks was detected attached to the colon during formal laparoscopic pelvic and abdominal exploration for ectopic pregnancy. Operative laparoscopy for abdominal ectopic in skillful hands can be considered a feasible management technique carrying all the advantages of a minimally invasive procedure.

Screening for Group B streptococcus should be routine in pregnancy: AGAINST: Current evidence does not support the introduction of microbiological screening for identifying carriers of Group B streptococcus

For this argument, I am referring to microbiological screening, with swabs taken from the vagina and/or rectum in late pregnancy, with the intention of identifying carriers of Group B streptococcus (GBS), so that intrapartum antibiotic prophylaxis (IAP) can be offered, with the aim of preventing early-onset GBS sepsis in newborns in the UK. Given this, the question of whether screening should be routine has already been answered. The evidence has been reviewed by the National Institute for Health and Care Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG), and most comprehensively by the National Screening Committee (NSC; www.screening.nhs.uk/groupbstreptococcus), and there is agreement that the current evidence does not support the introduction of microbiological screening. These bodies have acknowledged that not all countries, when reviewing this evidence, have reached the same conclusion (Verani et al. Revised guidelines from CDC MMWR 2010;59(RR10);1–36); however, given the situation in the UK, a clear policy decision has been reached. So what do we do with this policy? Well, the first question to ask is ‘how do we enact and monitor a policy of NOT initiating a screening programme?’ Most of our efforts are directed at auditing and monitoring the offer and uptake of programmes, using clinical governance processes to ensure adherence to the programme, with rigorous quality control. Should we not do the same when we have a policy of not offering screening? Should trusts audit their own practice to ensure adherence to national policy? And what role does the Care Quality Commission have in ensuring that trusts do this? Adherence to national policy, whether that is to screen or not to screen, is important when making sure that scarce resources are used most effectively. What new evidence could change this policy? Before initiating a new programme, the NSC want to see a randomised controlled trial comparing the new programme with existing care. This has infrequently happened with many existing screening programmes (e.g. cervical cancer) and, with the promise of a GBS vaccine constantly ‘round the corner’, the time and expense of running a trial of antenatal GBS screening seems unlikely to happen. In my view there are two main issues that hamper the assessment of harms and benefits of antenatal GBS screening. The first is the artefact introduced by using GBS culture-positivity when assessing the outcome of the use of IAP. The presence of antibiotic in the baby's circulation will inhibit the growth of the organism, despite the clinical picture of sepsis. This artefact means we remain uncertain how effective IAP really is. The second is the huge number of women who require IAP for the small number of symptomatic neonatal infections that are likely to be prevented, with the resulting concerns about the impact that antibiotics given at the time of labour may have on the longer-term outcomes for a large number of babies. This uncertainly about impact was highlighted by the follow-up of the ORACLE trial (Kenyon et al. Lancet 2008;376:1319–27), but extends well beyond that, with concerns that selection pressure applied to the developing microbiota may have profound long-term health consequences (Bedford Russell & Murch BJOG 2006;113:758–65; Quigley Gastroenterol Hepatol 2013;9:560–69). Added to which, there is growing international pressure to limit the use of antibiotics in the face of increasing resistance and a lack of new antibiotic development (www.gov.uk/government/uploads/system/uploads/attachment_data/file/138331/CMO_Annual_Report_Volume_2_2011.pdf). Being able to identify women and babies who would most benefit from antibiotics would be an important step in balancing the benefits versus harms of such a programme. Member of RCOG Greentop Guideline development group and advisor to the National Screening Committees review of Screening for Group B streptococcal infection in pregnancy 2012. ■

Green‐top Guideline No. 65: The Management of Women with Red Cell Antibodies during Pregnancy

The Obstetrician & GynaecologistVolume 16, Issue 3 p. 224-224 Guideline Summary Green-top Guideline No. 65: The Management of Women with Red Cell Antibodies during Pregnancy First published: 16 July 2014 https://doi.org/10.1111/tog.12125Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume16, Issue3July 2014Pages 224-224 RelatedInformation

Royal College of Obstetricians and Gynaecologists guidelines: How evidence-based are they?

Evidence-based medicine aims to translate scientific research into good medical practice. The Royal College of Obstetricians and Gynaecologists publishes recommendations and guidelines to guide clinicians in decision-making. In this study, the evidence base underlying the ‘Green-top Guidelines’ has been analysed in order to establish the quality of research underlying recommendations. During this descriptive study of 1,682 individual recommendations, the authors found that only 9–12% of the guidelines were based on the best quality (Grade A) evidence. The authors believe that this type of analysis serves to provide greater clarity for clinicians and patients using guidelines and recommendations in the field of obstetrics and gynaecology to make collaborative clinical decisions.

Survey of external cephalic version services in the East of England region: Comparison of services in 2007 and 2012

External cephalic version (ECV) has been recognised by the Royal college of Obstetricians and Gynaecologists (RCOG) as a safe procedure for the conversion of breech presentations to cephalic presentation. The need to reduce the incidence of breech presentations is due to the associated increase in complications for both mother and baby in a breech delivery. The RCOG published the Green-top Guideline No. 20a in December 2006 and revised it in December 2010. In our study, we conducted a survey across all hospitals in the East of England (EoE) region in 2007 and 2012 to assess the ECV service and to determine if this fulfils the RCOG recommendations.

PA.21 Does all placenta praevia need hospital admission?

IntroductionThere are controversies regarding inpatient vs outpatient management of placenta praevia. RCOG1 recommends that the care should be tailored according to the need of individual. This retrospective study aimed to...

PPO.37 Snapshot of Post-Mortem Examinations following Stillbirths at a University Hospital

IntroductionStillbirth incidence is 1 in 200 births. 2.6 million 3rd trimester stillbirths occur worldwide every year. Parents should be offered full post-mortem (PM) examination to elicit the cause of the...

PPO.68 Fetal Movements and Stillbirth – Are We Educating Women Sufficiently?

BackgroundPerinatal mortality rate in Scotland is approximately 6.9/1000 births, with a stillbirth rate of 5.1/1000 births.1 Although the mortality rate has been declining,2 this remains a significant problem due to...

PLD.42 ‘Sepsis Six’ – Adaptation of a trust innovation in Maternity

IntroductionSepsis was the leading cause of maternal death in the 2006–2008 Confidential Enquiry, 1 which led the development of the RCOG Guideline recommending early treatment to reduce morbidity and mortality.2...

PLD.33 Intrapartum antibiotic prophylaxis against early onset Neonatal Group B Streptococcal (GBS) sepsis in women known to be colonised; how good are we?

ObjectivesEvaluate practice in tertiary care obstetric unit on the prevention of early-onset neonatal GBS disease.BackgroundThe single most important risk factor for early-onset GBS infection is maternal colonisation leading to fetal...

PLD.55 Introduction of Breech Clinic in a tertiary care setting to aid informed decision-making in mothers with breech presentation at term

BackgroundThe incidence of breech presentation is 3–4% at tem. Since the publication of Term Breech Trial, elective Caesarian section (ELCS) has been the default mode of delivery with little or...

PFM.50 Does the RCOG Small for Gestational Age (SGA) guideline recommendation on risk stratification for serial scans improve our detection of Fetal Growth Restriction (FGR) at Term?

The RCOG have recently published guidance on referral for serial growth scans based on risk stratification at booking.1 The aim is to improve the surveillance of the SGA fetus and...

PFM.72 A retrospective descriptive analysis of anaesthesia for transvaginal cervical cerclage

IntroductionTransvaginal cervical cerclage (TVCC) is a common operation in pregnancy requiring an anaesthetic. Regional anaesthesia (RA) aims for T10 sensory blockade.1 No data exists to guide the type of anaesthesia...

PA.44 How will the updated March 2013 RCOG Green-top Guideline ‘The Investigation and Management of the Small-for-Gestational-Age Fetus’ impact our antenatal maternity services? Will there be a service provision gap impacting our ability to adhere to the recommended guidance?

IntroductionSmall for gestational age (SGA) fetuses are at increased risk of perinatal morbidity and mortality. The new RCOG SGA Guideline recommends screening for minor and major risk factors at booking...