Royal College Of Obstetricians And Gynaecologists Guidelines Research Articles

Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy.

To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India.

Background & objectives:The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for thromboprophylaxis among post-partum women are recommended across Asia. This study was aimed to find the proportion of post-partum women eligible for thromboprophylaxis based on the RCOG guidelines and how many actually received it in a tertiary care health facility in south India.Methods:This cross-sectional study was carried out on 1652 consecutive women who delivered in the setup of tertiary care. Risk stratification for venous thrombosis was done as per the RCOG guidelines. The number of women who received thromboprophylaxis was also noted.Results:Among the 1652 women studied, three [0.18%; 95% confidence interval (CI): 0.06-0.53] were in the high-risk, 598 (36.2%; 95% CI: 33.9-38.6) in the intermediate and 254 (15.4%; 95% CI: 13.7-17.2) in the low-risk category for thrombosis. All the three women in the high-risk and only two women in the intermediate-risk category actually received thromboprophylaxis with heparin.Interpretation & conclusions:It was seen that the number of women needing prophylaxis in our setup, as per the RCOG guidelines, was as high as 601 (36.4%), but only five (0.8%) received it.

Appropriate Documentation of the Timing of Events in the Management of Women with Postpartum Hemorrhage in Aminu Kano Teaching Hospital: A 2-Year Audit.

Background:Appropriate documentation of the timing of events in the management of women with postpartum hemorrhage (PPH) is associated with better outcome.Objective:To find out how best the Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, fares when compared with the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines about appropriate documentation of the timing of events in the management of PPH.Methodology:It was a retrospective study based on findings obtained from the case folders of women who had PPH between January 2016 and December 2017. A structured pro forma was used to extract information such as personal data, type of PPH, vital signs of patients, sequence of events, administration of pharmacological agents, and timing of interventions.Results:There were 5202 patients who presented to the labor ward, and 129 of them were cases of PPH giving an incidence of 2.48%. The mean age of the patients was 20.38 ± 1.13 years, and about half of them (47.6%) were multiparas. There was appropriate documentation in terms of initial assessment, resuscitation, and investigations as the percentages of standards achieved are 85%, 78.6%, and 85.7%, respectively. Sixty-one percent of the patients had treatment within the time recommended and 56% had treatment with appropriate uterotonics. Appropriate documentation of major surgeries according to the guidelines was achieved in 12% of cases.Conclusion:There was good performance in documentation of initial management of patients with PPH when compared with the RCOG guidelines but suboptimal performance in timing of major surgical interventions.

A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines

Guidelines for pharmacologic obstetric venous thromboembolism (VTE) prophylaxis from the American Congress of Obstetricians (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), and the American College of Chest Physicians (Chest) vary significantly. The objective of this study was to determine the practical implications of these recommendations in terms of prophylaxis rates for a tertiary obstetric population. Cross-sectional. Tertiary referral hospital. Patients post-operative day 1 after caesarean delivery. This cross-sectional study evaluated rates of pharmacologic prophylaxis for women based on RCOG, ACOG, and Chest recommendations. Medical, obstetric, and demographic risk factors for thromboembolism were reviewed for individual patients. Rates of prophylaxis based on each of the guidelines with 95% confidence intervals were calculated. Recommended pharmacologic prophylaxis. About 293 patients were included in the analysis. Under RCOG guidelines, 85.0% of patients would receive post-caesarean pharmacologic prophylaxis [95% confidence interval (CI) 80.5-88.6%] compared with 1.0% of patients under ACOG guidelines (95% CI 0.3-3.0%) and 34.8% of patients under Chest guidelines (95% CI 29.6-40.4%). Caesarean during labour, obesity, advanced maternal age, pre-eclampsia, and multiple gestation were among the most commonrisk factors. Recommended prophylaxis differed significantly. Under ACOG recommendations a small minority of patients would receive prophylaxis, whereas under RCOG recommendations a large majority of patients would receive low-molecular-weight heparin. Given the large differences in prophylaxis rates for post-caesarean thromboprophylaxis based on different guidelines, further research is urgently needed to compare the risks and benefits of recommendations. Recommendations from major society guidelines for post-caesarean thromboprophylaxis differ greatly.

Screening for Group B streptococcus should be routine in pregnancy: FOR: The case for screening

In the 1970s, early-onset group B streptococcus disease (EOGBSD) was identified as the major infectious cause of first-week neonatal morbidity and mortality in the USA. From the 1980s, clinical trials showed that administering intravenous penicillin prevented up to 90% of such cases. The American Congress of Obstetricians and Gynecologists (ACOG) issued recommendations for intrapartum antibiotic prophylaxis (IAP) in 1996, and in 2002 they recommended universal culture-based screening of all pregnant women at 35–37 weeks of gestation. During this time, the incidence of EOGBSD fell from >1.5 cases/1000 live births to <0.4 cases/1000 live births, as explained in the 2010 guidelines from the US Centers for Disease Control and Prevention report (www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm). Similar falls have been seen in other countries/regions that have introduced routine screening and IAP, such as Canada, Australia and New Zealand, France, Germany, Spain, Belgium, Italy, Poland, Argentina, Chile, Kenya, Hong Kong, Oman and Japan (there are more). In contrast, since 2003 the Royal College of Obstetricians and Gynaecologists (RCOG) has continued to recommend a risk-based approach in the UK, even though this has not been associated with a fall in the incidence of EOGBSD in England (it remains at about 0.36 cases/1000 live births, which equates to about 400 cases per year). The average incidence per thousand in Northern Ireland is about 0.51, in Scotland is 0.36 and in Wales is 0.32, highlighting local variations in incidence (the incidence can be as high as 0.88–1.15/1000; G. Rao, Northwick Park and Luton Hospitals, pers. comm.). If the incidence fell by 75%, as expected from the experience of other countries, this would save 300 families per year in the UK the trauma of dealing with EOGBSD. But would screening in the UK be cost effective? Colbourn et al. (BMJ 2007;335:655) concluded that ‘culture testing for low risk term women, while treating all preterm and high risk term women, would be the most cost effective option’, while Kaambwa et al. (BJOG 2010;117:1616–27) wrote that, ‘The current strategy of risk-factor-based screening is not cost-effective compared with screening based on culture’. The cost of the enhanced culture medium (ECM) testing of low vaginal and rectal swabs is estimated at £11, and the swabs can be performed by the women themselves if they choose screening. Concerns have been expressed about penicillin allergy, but true anaphylaxis is rare. Law et al. (J Med Screen 2005;12:60–68) reported that there were no recorded deaths in the first 1.8 million women given IAP in the USA, and other reports have stressed that giving IAP under direct supervision is very safe. Concern has been expressed about the practice of giving women (and therefore their fetuses) large doses of broad-spectrum antibiotic before skin incision for caesarean section, as currently recommended by the RCOG, in terms of the effect it might have on the development of the newborn's immune system. In contrast, penicillin is narrow spectrum, GBS has never developed resistance to it and there is no evidence that preventing EOGBSD encourages other organisms to invade. The widespread use of penicillin for over 60 years means that any organisms able to become resistant to it are likely to have already done so. Current RCOG guidelines recommend giving IAP if a woman is found serendipitously (on a swab for vaginal irritation, for example) to be a GBS carrier. On grounds of equity and choice, pregnant women at 35–37 weeks of gestation should be offered an equal opportunity to determine their GBS status and protect their babies, which can only be achieved by screening. Philip Steer chairs the medical advisory committee of Group B Strep Support, which campaigns for GBS screening to be universally available. ■

A survey on knowledge of female genital mutilation guidelines

The increase in immigration from countries with a high prevalence of female genital mutilation (FGM) has highlighted the need for knowledge and sensitivity in this area of healthcare in high-resource countries. We have surveyed with an online questionnaire 607 members, fellows and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG) on knowledge about the RCOG guidelines for FGM. Completed training and more practical experience with women affected by FGM significantly increased knowledge. Many respondents were not aware of specialist services locally (22.9%) or how to access them (52.3%). Some areas of insufficient knowledge were identified, in particular in relation to psychiatric morbidity, HIV, hepatitis B and pelvic infection. More specialized training efforts might improve this aspect.

Closing the loop on thromboprophylaxis post caesarean section

BackgroundVenous thromboembolism is one of the leading causes of Direct Maternal Death. Caesarean section is a significant risk factor. The Royal College of Obstetricians and Gynaecologists (RCOG) issued guidelines for...

Triaging women with ovarian masses for surgery: observational diagnostic study to compare RCOG guidelines with an International Ovarian Tumour Analysis (IOTA) group protocol

To compare guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) based on the Risk of Malignancy Index (RMI) with a protocol based on logistic regression model LR2 developed by the International Ovarian Tumour Analysis (IOTA) group for triaging women with an ovarian mass as low, moderate, or high risk of malignancy. Observational diagnostic study conducted between 2005 and 2007 at 21 oncology referral centres, referral centres for ultrasonography and general hospitals. In all, 1938 women undergoing surgery for an ovarian mass. RCOG guidelines use the RMI to triage women as low (RMI < 25), moderate (25-250), or high (above >250) risk. The IOTA protocol uses LR2s estimated probability of malignancy (<0.05 indicates low risk, ≥ 0.05 but <0.25 moderate risk, and ≥ 0.25 high risk). Percentages of benign, borderline and invasive tumours classified as low, moderate or high risk. The IOTA and RCOG protocols classified 71.1% and 62.1% of benign tumours as low risk, respectively (difference 9.0; 95% CI 6.2-11.9, P < 0.0001). Of invasive tumours, 88.6% and 73.6% were labelled high risk (difference 15.0; 10.6-19.4, P < 0.0001), and 3.0% and 5.2% were labelled low risk (difference -2.2; -4.6 to 0.2, P = 0.07) respectively by each protocol. Similar results were found after stratification for menopausal status. The IOTA protocol was more accurate for triage than the RCOG protocol. The IOTA protocol would avoid major surgery for more women with benign tumours while still appropriately referring more women with an invasive tumour to a gynaecological oncologist.

Do the CEMACH and RCOG green top recommendations influence the outcome of women with morbidly adherent placenta? A review of 16 antenatally diagnosed cases

Objectiveto assess the effect of CEMACH and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines in the management of women with morbidly adherent placentae (MAP).DesignA prospective observational study of 16...

Are we doing too many instrumental deliveries in theatre?

BackgroundThe Royal College of Obstetricians and Gynaecologists (RCOG) provides guidance on which instrumental deliveries should be performed in theatre: malpositions, baby>4000 g, midcavity and a body mass index>30 kg/m2. The...

A complete audit cycle of management of third/fourth degree perineal tears

SummaryWe present a complete audit cycle of the management of third/fourth degree perineal tears in the three Glasgow maternity hospitals measured against the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Guideline No. 29 (www.rcog.org.uk). Following an initial 6-month data collection period, shortcomings in the practice were identified, circulated and an operative proforma was designed and introduced. A re-audit demonstrated improved compliance with the RCOG guidelines. We recommend the introduction of an operative proforma to aid management and documentation of third/fourth degree tear repairs.

Compliance with the published RCOG guidelines in women undergoing hysterectomy for menorrhagia in a district general hospital

SummaryThe Royal College of Obstetricians and Gynaecologists (RCOG) published guidelines describing the management of menorrhagia in primary and secondary care. In this study, we reviewed retrospectively, the compliance with these guidelines in women who underwent a hysterectomy for menorrhagia over a 3-year period in a District General Hospital. Case notes were reviewed for 22 women in whom the uterus was reported normal on histology. There was a high level of compliance in clinical assessment before hysterectomy. Nearly 70% of women received some form of medical treatment, however only 50% were offered endometrial ablation. Compliance was high in imparting information about the risk factors of hysterectomy and in administering thromboprophylaxis.

Surgical management of ectopic pregnancy in a district general hospital

SummaryThe mainstay of management of ectopic pregnancies is laparoscopic surgery. Other treatment options include open laparotomy, methotrexate or expectant approach. Recently the Royal College of Obstetricians and Gynaecologists (RCOG) revised its guidelines regarding management of suspected ectopic pregnancies. We undertook a retrospective study looking at management of ectopic pregnancies over a defined 12-month period (1 October 2003 – 30 September 2004) in a district general hospital to the north of London and compared this with the recommended RCOG guidelines . Cases of ectopic pregnancy were identified from the theatre, ward log, and cross-referenced with histopathological reports. The case notes of these women were reviewed and data extracted according to a drawn-up questionnaire. A total of 64 cases met the diagnostic criteria and were included in the study. Nine of the 64 cases were haemodynamically unstable and seven underwent rapid laparotomy. All of the stable 55 cases underwent laparoscopy, which was converted to open laparotomy in 13 cases (23.6%). Three patients were treated with methotrexate all of whom had been previously managed surgically. The majority of cases of ectopic pregnancy were managed according to the RCOG recommendations. Further changes in practice will be required to incorporate expectant and primary medical management as proposed by the recent guidelines (RCOG ). This study reveals progress achieved in management of ectopic pregnancies in UK with the introduction of RCOG guidelines .

Management of genital chlamydial infections at termination of pregnancy services in England and Wales: where are we now?

To determine the range of policies and practices related to the management of genital chlamydial infection employed at termination of pregnancy services in England and Wales. Cross-sectional descriptive study. England and Wales. Termination of pregnancy providers. Survey questionnaire administered to termination of pregnancy providers. Policies and practices for the management of genital chlamydial infection in women seeking termination of pregnancy with comparison to the national guidelines of the chief medical officer (CMO) and the Royal College of Obstetricians and Gynaecologists (RCOG). One hundred and thirty-eight (48%) practices responded to the survey, with representation across England and Wales. Policies for screening and/or treatment of chlamydial infection existed for 70% of providers. We found three practice patterns for the management of genital chlamydial infection among termination of pregnancy attenders: 70% of providers tested their own attenders prior to termination and treated if necessary; about 25% of providers administered prophylaxis without testing; and a small number of providers (< 5%) neither tested nor treated attenders. These patterns may be the result of differences in the CMO and RCOG guidelines. Given the impact of untreated genital chlamydial infection in women attending for termination, consistent recommendations from the CMO and RCOG may encourage uniform practice for the management of chlamydial infection in this vulnerable population.

Information contained in miscarriage-related websites and the predictive value of website scoring systems

Objectives: To identify websites providing information about early pregnancy loss and compare this information with published guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG). The value of ‘Silberg’ and ‘Health on the net (HON)’ website scoring systems in predicting the information provided via websites identified was assessed. Study design: A cross-sectional survey. Sample: Nineteen websites identified via two search engines (http://www.lycos.co.uk and http://www.msn.co.uk). Methods: Websites were searched for specific information in a structured manner and then scored by two independent observers against the website scoring systems and against a scoring system derived from guidelines published by the RCOG. Main outcome measures: Website scores against the scoring systems and against RCOG guidelines. Results: Information concerning miscarriage contained within these websites was poor and scored accordingly against the RCOG guidelines (median score, 4.5/8). The website scoring systems did not predict the RCOG scores for a website (HON score RS=0.193 (95% confidence interval from −0.286 to 0.595), Silberg score, RS=0.035 (95% confidence interval from −0.426 to 0.482)). Conclusions: Few relevant websites were identified despite searching a large number via two search engines. The websites found did not answer our specific questions and consequently scored poorly against the RCOG guidelines. RCOG scores did not correlate with either scoring system. Web-based information for women attending with early pregnancy complications needs to be easily accessed and comprehensive. Written information given to women when seen with early pregnancy complications should include details of available comprehensive websites. Professional organisations, colleges or Government agencies should provide this type of information.