Jeffrey Wilkinson

Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel

Acute menorrhagia is a common gynecological disorder. Prevalence is high among women with inherited bleeding disorders and recent guidance for optimal management is lacking. Following a comprehensive review of the literature, an international expert panel in obstetrics, gynecology and hematology reached consensus on recommendations regarding the management of acute menorrhagia in women without a diagnosed bleeding disorder, as well as in patients with von Willebrand disease, platelet function disorders and other rare hemostatic disorders. The causes and predictors of acute menorrhagia are discussed and special consideration is given for the treatment of women on anticoagulation therapy. This review and accompanying recommendations will provide guidance for healthcare practitioners in the emergency management of acute menorrhagia.

Management of abnormal uterine bleeding in adolescents.

Adolescence in girls is marked by a host of physical and psychological changes, including those associated with menstruation. Abnormal uterine bleeding (AUB) is one of the most commonly encountered medical problems in this transition from childhood to maturity. Although common, this problem is likely underreported and population-derived prevalence rates are not well described for adolescents. Small studies, however, suggest that the problem transcends ethnic and geographic boundaries. In Nigeria, 12.1% of adolescents experienced heavy menstrual bleeding which affected their work or school performance. In Hong Kong, 17.9% of girls at a mean age of 15 reported heavy menstrual bleeding. In Sweden, 37% of girls with an average age of 16.7 reported heavy menstruations. Similar rates have been reported in Malaysia and Turkey. Abnormal uterine bleeding includes a number of different types of bleeding patterns. In the medical literature, different terminologies have been used to describe the symptoms of AUB and the underlying disorders including dysfunctional uterine bleeding, menorrhagia, metrorrhagia, menometrorrhagia, etc. However, confusion and lack of agreement over the use of these terminologies have been demonstrated. Therefore, a study group established by the International Federation of Gynecology and Obstetrics recommended that these terminologies should be replaced by simple descriptive terms which specify

Prevalence and predictors of giving birth in health facilities in Bugesera District Rwanda.

BackgroundThe proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda.MethodsUsing census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18–50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities.ResultsAnalysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery.ConclusionsThe strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

A Code of Ethics for the fistula surgeon

Vesicovaginal fistulas from obstructed labor no longer exist in wealthy industrialized countries. In the impoverished countries of sub‐Saharan Africa and south Asia obstetric fistulas continue to be a prevalent clinical problem. As many as 3.5 million women may suffer from this condition and few centers exist that can provide them with competent and compassionate surgical repair of their injuries. As this situation has become more widely known in the industrialized world, increasing numbers of surgeons have begun traveling to poor countries to perform fistula operations. To date, these efforts have been carried out largely by well‐intentioned individuals, acting alone. An international community of fistula surgeons who share common goals and values is still in the process of being created. To help facilitate the development of a common ethos and to improve the quality of care afforded to women suffering from obstetric fistulas, we propose a Code of Ethics for fistula surgeons that embraces the fundamental principles of beneficence, non‐maleficence, respect for personal autonomy, and a dedication to the pursuit of justice.

Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: A qualitative study

BackgroundObstetric fistula affects a woman’s life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman’s quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula.MethodsIn-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2xa0years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis.ResultsAbout half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women’s concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities.ConclusionsNearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

Knowledge, attitudes, and practices in safe motherhood care among obstetric providers in Bugesera, Rwanda

To determine the knowledge, attitudes, and practices of obstetric care providers (OCPs) in Bugesera District, Rwanda, crucial to the delivery of safe motherhood services.

Comparison of obstetrical risk in adolescent primiparas at tertiary referral centres in Tanzania and Austria

Purpose.u2003Adolescent childbearing is most prevalent in Sub-Saharan Africa. Deliveries in adolescent primiparas at an Austrian and an East African tertiary referral centre were compared to reveal differences in obstetric outcome. Methods.u2003A total of 186 primiparas delivering at an age of 17 or less between 1999 and 2005 at the Austrian centre were compared with 209 adolescent primiparas who delivered between 2005 and 2007 at the African centre. The type of delivery and complications were studied. Results.u2003Adolescent primiparas accounted for 1.2% of the overall obstetric population at the Austrian centre, as compared with 2.3% at the East African centre (pu200a<u200a0.01). When comparing the adolescents outcome at the Austrian centre with the outcome of 22–27 years old primiparas at the same institution, we noted that the rates of adverse obstetric outcomes were higher among the adult group. However, at the East African centre the opposite was observed. Conclusions.u2003In contrast to the results of Africa, data from Austria show that the obstetric outcome in adolescent pregnancies can be favourable. However, socioeconomic considerations have to be taken into account. Education and health knowledge seem critical for young females particularly in low-resource settings like East Africa.

Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

Determine whether a 1‐hour pad test at discharge can identify continence status within 120 days of obstetric vesicovaginal fistula (VVF) repair.

Identifying Patients With Vesicovaginal Fistula at High Risk of Urinary Incontinence After Surgery.

OBJECTIVE: To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair. METHODS: We conducted a prospective cohort study among 401 women undergoing their first vesicovaginal fistula repair at a referral fistula repair center in Lilongwe, Malawi, between September 2011 and December 2014, who returned for follow-up within 120 days of surgery. We used logistic regression to develop a risk score to identify women with a high likelihood of residual urinary incontinence, defined as incontinence grade 2–5 within 120 days of vesicovaginal fistula repair, based on preoperative clinical and demographic characteristics (age, number of years with fistula, human immunodeficiency virus status, body mass index, previous repair surgery at an outside facility, revised Goh classification, Goh vesicovaginal fistula size, circumferential fistula, vaginal scaring, bladder size, and urethral length). The sensitivity, specificity, and positive and negative predictive values of the risk score at each cut point were assessed. RESULTS: Overall, 11 (3%) women had unsuccessful fistula closure. Of those with successful fistula closure (n=372), 85 (23%) experienced residual incontinence. A risk score cut point of 20 had sensitivity of 82% (95% confidence interval [CI] 72–89%) and specificity 63% (95% CI 57–69%) to potentially identify women with residual incontinence. In our population, the positive predictive value for a risk score cut point of 20 or higher was 43% (95% CI 36–51%) and the negative predictive value was 91% (95% CI 86–94%). Forty-eight percent of our study population had a risk score 20 or greater and, therefore, would have been identified for further intervention. CONCLUSION: A risk score of 20 or higher was associated with an increased likelihood of residual incontinence with satisfactory sensitivity and specificity. If validated in alternative settings, the risk score could be used to refer women with a high likelihood of postoperative incontinence to more experienced surgeons.

The Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage

To evaluate the Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage (PPH).