Danish Journal of Obstetrics and Gynaecology

Antibiotic prophylaxis practices in cesarean section with focus on timing – a Danish national survey

2022-11-05T08:45:15+00:00

Introduction: The last Danish survey in 1995 on the antibiotic prophylactic practices in cesarean section found that there was no consensus between delivery wards. Since then national guidelines have been established. We therefore wanted to see if clinical practice regarding antibiotic prophylaxis had become more uniform.

Methods: In February of 2019 the delivery wards in Denmark (n=21) were contacted to answer an online questionnaire regarding type and dose of antibiotic prophylaxis used, timing of the administration, and differences between elective and emergency cesarean section.

Results: All twenty-one wards applied a single dose of 1500 mg Cefuroxime, a 3rd generation cephalosporin. Three wards (14%) administered antibiotic prophylaxis after cord clamping and eighteen (86%) prior to clamping, with nine (43%) wards having changed practice during the last 10 years. Three wards recalled the precise year for the change, six wards gave an approximate range of years, and five wards did not remember. The exact timing of the antibiotic varied from 0-60 minutes prior to incision, with sixteen (76%) wards reporting giving antibiotics usually 0-30 minutes prior to and of those, eleven (52%) immediately prior. All wards had the same prophylactic antibiotics principles for emergency and elective cesarean sections.

Conclusion: Most wards adhere to national guideline recommendations, but recollection was imperfect as to when changes in practices were implemented. We suggest that current and previous guidelines from hospitals in Denmark be stored in a national database, or more preferably that a national cesarean birth registry be established, accounting for the frequent local changes and interpersonal differences in clinical practice.

Blood Pressure Measurement in Pregnancy – Interarm Differences and The Necessity of Multiple Consecutive Measurements

2022-01-20T12:00:35+00:00

Objective: To investigate multiple blood pressure measurements and interarm differences in a pregnant population.

Method: Pregnant women attending routine antenatal ultrasound scans in gestational weeks 11-13 or week 20 had three consecutive blood pressure measurements on each arm conducted according to international guidelines. Mean and mean difference between the 1^st measurement (BP-A) and 2^nd+ 3^rd measurements combined (BP-B) as well as between right and left arm, respectively, were calculated and compared by paired t-test. Bland-Altman plots illustrate means and mean-differences of systolic and diastolic pressure between BP-A and BP-B.

Results: One-hundred women were included. Mean systolic, diastolic and arterial blood pressure for BP-A were 112.1 mmHg, 70.6 mmHg and 84.4 mmHg, respectively, while mean BP-B were 109.8 mmHg, 69.2 mmHg and 82.8 mmHg. Mean differences in systolic, diastolic and mean arterial pressure (MAP) between BP-A and BP-B were 2.5 mmHg (P<0.001, 95% Confidence interval (CI) 1.7;3.2), 1.5 mmHg (P<0.001, 95% CI 1.0;2.0) and 1.8 mmHg (P<0.001, 95% CI 1.4;2.2). Mean interarm differences in systolic, diastolic and MAP were 3.1 mmHg (P<0.001, 95% CI 1.9;4.3), 0.75 mmHg (P=0.019, 95%CI 0.1;1.4) and 2.4 mmHg (P=0.01, 95% CI 0.6;4.2).

Conclusion: In pregnancy, the first blood pressure measurement of three consecutive is significantly higher than the following two. Blood pressure on the right arm is significantly higher compared to the left arm. International guidelines on blood pressure measurements should apply to pregnant women.

Tubo-ovarian abscesses and the effect of transvaginal ultrasound guided drainage – a retrospective cohort study

2021-11-18T13:57:42+00:00

Objective:
Tubo-ovarian abscesses (TOA) are a serious complication to pelvic inflammatory disease with long-term complications such as infertility and chronic pain. Treatment consists of intravenous antibiotics combined with laparoscopic or transvaginal ultrasound-guided drainage (TVULD), but the evidence regarding optimal treatment are scarce, and evaluation of short- and long-term effects have yielded inconsistent results. Our aim was to evaluate the effect of transvaginal ultrasound-guided drainage with antibiotic treatment on both short- and long-term outcomes for patients admitted with a tubo-ovarian abscess.

Methods:
All women admitted with a TOA to our department were included from March 2017- May 2020. They were evaluated with a gynecological examination, TVUL, white blood cell count (WBC) and CRP. All received intravenous antibiotics and were evaluated for possible TVULD. All received orally administered antibiotics upon discharge, and follow-up was with a 1-3-month interval until patients were without symptoms or underwent laparoscopic surgery.

Results:
Forty patients were included, 30 (75%) premenopausal. Mean size of TOA were 6.3 cm (SD 2.3), and 35 (87.5%) patients received both antibiotics and drainage. Eighteen (45%) patients underwent secondary surgery following the TOA, and comparing the surgery vs. non-surgery group, we found that at admission temperature, WBC count at admission, aspirated material in ml and need of more than one drainage predicted undergoing laparoscopy following discharge. However, when performing multivariate analysis comparing the two groups regarding the abovementioned factors as well as age, admission time, antibiotic treatment time and follow-up, we did not find any statistically significant difference (p=0.072). Finally, we found that more than one drainage increased the risk of undergoing laparoscopy (OR 8, CI 1.43-44.92).

Conclusion:
TVULD combined with antibiotics are a safe and effective treatment for TOAs. We found a trend supporting that patients needing laparoscopy following initial TVULD present with a more severe clinical picture and that different clinical and paraclinical factors could be used as predictors for undergoing secondary laparoscopy. Finally, we saw that patients with more than one drainage, have an increased risk of requiring secondary laparoscopy. These findings and predictors need to be tested and confirmed in larger prospective studies.

Four-year follow-up on a gynecologic laparoscopic skills curriculum and discussion of its implementation

2022-07-05T08:16:01+00:00

Introduction

Simulation-based training of surgical skills is transferable to the operating room, but implementation of a specific skills curricula is still challenging. Ongoing efforts serve to identify and implement the optimal curriculum for ensuring patient safety. In 2013 the validated ‘basic laparoscopic skills curriculum’ was introduced for first-year residents in obstetrics and gynecology in Eastern Denmark. The aim of this study was to follow-up on implementation of the curriculum through a four-year period and identify facilitators and barriers.

Material and method

The ‘basic laparoscopic skills curriculum’ comprises four steps encompassing theoretical education (step 1 & 2) , proficiency-based technical skills training on virtual reality simulators (step 3), and a one-day surgical course with participants practicing procedures on sedated pigs (step 4) . All participants were first-year residents in obstetrics and gynecology in Eastern Denmark from September 2014 to August 2018. The ‘basic laparoscopic skills curriculum’ was administered by the Copenhagen Academy for Medical Education and Simulation (CAMES). Dropouts were asked to complete an electronic questionnaire on why they did not finish the curriculum.

Results

During the four-year follow-up, 107 first-year residents participated in the curriculum. One-hundred completed step three (93%) and 99 (92.5%) step 4. Participants spent a median of 249, IQR 164 minutes (min. 64, max. 630) on the virtual reality simulator. Median time for completing all four steps of the curriculum was 56 days, IQR 98 (min. 14, max 253).

Conclusions

Completion rates were continuously high over four years in this basic laparoscopic skills curriculum for residents. One likely reason is that the curriculum was partially mandatory, combined with a supportive management that allotted participation time. Self-directed learning, self-study and flexible booking are also considered as playing a crucial role.

Spontaneous expulsion of a large vaginal mass – a case of complete ejection of a detached fibroma in statu nascendi.

2022-06-16T19:26:41+00:00

Objective: Pedunculated fibroids are a subtype of submucousal fibroids, that can prolapse into the cervical canal and vagina while remaining attached to the uterine cavity by a pedicle. This condition is known as fibroma in statu nascendi and its exact prevalence is unknown. As the most frequently presented symptoms are abnormal vaginal bleeding/discharge and lower abdominal pain, a complete release of the pedicle leading to spontaneous expulsion of an isolated fibroid is a rarity.

Methods: A case report describing a complete, spontaneous release of a pedunculated fibroid measuring 8x5 cm.

Results: A 63-year-old woman with no gynecological history was referred by her general practitioner after spontaneous expulsion of a large vaginal mass, which measured 8x5 cm. She had no vaginal bleeding since menopause and she had experienced a few days of whitish discharge and a sensation of something filling the vagina before the mass was expelled. Gynecological examination revealed a normal-appearing vagina and transvaginal ultrasound showed a thin endometrial echo. Histopathological diagnosis confirmed the suspicion of fibroma in statu nascendi.

Conclusion: Prolapsed submucousal fibroids are a well-known condition, that frequently presents as abnormal vaginal bleeding/discharge and lower abdominal pain. Total, spontaneous detachment of the fibroid is rare. The diagnosis is typically evident; however, differential diagnoses, such as endometrial polyps and sarcomas, must be considered and clarified via histopathological evaluation.

Urethral diverticulum and periurethral cyst: symptoms, diagnostics, treatment and outcome.

2022-10-24T16:47:04+00:00

Objectives. In order to contribute to better diagnostic and treatment, we compared the symptomatology, diagnostics, treatment and outcome in women with a urethral diverticulum or a periurethral cyst.

Methods. We performed a retrospective extraction of data from medical records including 70 women with a urethral diverticulum or a periurethral cyst, operated at our department from January 2010 until December 2013. Fischer’s exact test and t-test were used for statistical analyses.

Results. In total, 31 women were diagnosed with a diverticulum and 39 with a periurethral cyst. Women with a diverticulum had significantly more often voiding pain (45 % vs 8 %, p=0.001), urethral/vaginal pain (45% vs 15 %, p=0.01), recurrent urinary tract infection (23 % vs. 5 %, p=0.01), urinary incontinence (45 % vs. 21 %, p=0.04), and urethral discharge (39 % vs. 15 %, p=0.03) compared to women with a periurethral cyst. The only symptom less frequent in the diverticulum group was a bulky feeling (42 % vs. 74 %, p=0.01). In the diverticulum group, 87% had resections and 13% marsupialization, while in the cyst group 59 % had resections and 41 % marsupialization (p=0.02). In the diverticulum group four (13%) experienced recurrence compared to none in the cyst group (p=0.03). Furthermore, one patient referred as a diverticulum had urethral cancer.

Conclusions. Urethral diverticula and periurethral cysts should be considered in women with lower urinary tract symptoms and pain. Urethral diverticula are more complicated to diagnose and to treat.

Tweetable abstract:

Urethral diverticula and periurethral cysts should be considered in women with lower urinary tract symptoms and pain

Comparison of clinical blood pressure measurements to measurements according to guidelines in women admitted to the maternity ward for hypertension.

2022-11-08T19:54:55+00:00

Objective: To assess the adherence to recommended guidelines on measurement of blood pressure in obstetric clinical practice and to determine the difference in blood pressure values between observed clinical measurements and measurements strictly following recommended guidelines.

Methods: We assessed blood pressure of 60 women admitted to the maternity ward for a hypertensive disorder of pregnancy in pregnancy or postpartum. Blood pressure was measured by hospital staff according to usual clinical practice, and study personnel performed the measurement in accordance with international guidelines. Groups were compared using paired sample t-test and the Mantel-Haenszel test.

Results: None of the clinical measurements fulfilled all recommended guidelines. Study systolic and diastolic readings were lower than those obtained in the usual clinical setting (systolic BP -7.0 mmHg (95% confidence interval: -9.2 to -4.8), p<0.001; diastolic BP -2.0 mmHg (95% confidence interval: -3.7 to -0.4), p=0.02). The risk of being categorized as hypertensive (≥140/90mmHg) decreased by 22% (95% confidence interval: 0.05-0.40, p=0.01) and 22/58 (38%) women shifted to a 10 mmHg category lower in systolic blood pressure along with 15/58 (26%) in diastolic blood pressure when measurements were performed by study personnel following recommended guidelines.

Conclusion: Following recommended blood pressure measurement guidelines significantly lowers blood pressure readings and the risk of being categorized as hypertensive.

TWEETABLE ABSTRACT:

Following recommended guidelines significantly decreases blood pressure readings and reduces the risk of being categorized as hypertensive in an obstetrical population.

The Danish Society of Obstetrics and Gynaecology (DSOG) and its history

2023-03-04T20:31:49+00:00

The founding of DSOG

On a dark evening on October 5th, 1898, the ”Forening for Gynækologi og Obstetrik i København, Association for Gynaecology and Obstetrics in Copenhagen”, was founded at a meeting in the Fødselsstiftelsen [Institution for Delivery] in Amaliegade in Copenhagen. The association was the first association for a medical specialty in Denmark, preceding all other medical specialties. Birth assistance has evidently been practiced since the very beginning of mankind, although only much more recently as an obstetric discipline by doctors and midwives. The specialty of gynaecology was in 1898 relatively new, and the boundary between surgery and gynaecology was still being discussed. In 1960 the name of the association was changed to Danish Society of Obstetrics and Gynaecology (DSOG) and for the sake of consistency, this name will mostly be used in this narration. At the founding meeting in 1998 eighteen middle-aged or elderly men attended. New members needed to be invited - one could not just register as you do today. Two founding fathers will be emphasized. [abbreviated]

Editorial - first issue

2023-03-04T22:07:27+00:00

There are more than 160 journals within our specialty indexed in Medline/PubMed. So is there really a need for a new gynecological and obstetrics journal?

We believe so. Several factors may hinder researchers from publishing their studies, especially younger or non-established researchers. To our knowledge, the publishers behind all of the above journals are for-profit and as such, are limited by either not being open access journals or those that are open access, follow the pay-to-publish model. The fees for publishing are often so high that independent researchers cannot pay out of their own pocket and it can be difficult to obtain funding for article processing charges.

Novelty is a criterion most journals ask their peer-reviewers to assess when reviewing submitted manuscripts. This means that reproduction studies and negative findings are more difficult to publish, even though they are the very backbone of the scientific method. Researchers may be hesitant to publish such studies for a hefty fee when they know they are rarely cited, which is why publication bias is a common finding in meta-analyses.

Case reports, protocols, and descriptive studies often have difficulty in finding a suitable journal. Currently, only randomized studies are required to have a protocol registered prior to inclusion of patients. However, it is a good practice for observational studies to do so as well, as there is an inherent penchant for researchers to adjust their aims when they have access to the data. Case reports are often the type of articles less experienced colleagues first try their hands at and can be their stepping-stone into the research world.

Finally, even though the Danish Journal of Obstetrics and Gynaecology is an international journal exclusively publishing articles in English, we believe that having a journal that is mainly read by clinicians from Denmark may help the publishing of Danish guideline résumés and articles specific to a Danish clinical setting. Having such articles regarding changes in clinical practice published for posterity will make it easier for future clinicians to evaluate and account for the effects of such changes. The ability to cite guideline résumés through CrossRef is also encouraging for those participating in producing them and makes it easier to our non-Danish speaking colleagues in the rest of the world to read what the clinical practice is in Denmark. [abbreviated]

Electronic textbook Obstetrics and Gynecology for medical students

2023-03-16T21:47:43+00:00

The purpose of this publication is to describe the success, which you find at Obstetrics and Gynecology - online textbook for medical students - sundhed.dk, an easily accessible, up to date Obstetrics and Gynecology teaching for medical students including international students in the Nordic countries.

In 2018, NFOG (the Nordic Federation of Societies of Obstetrics and Gynecology) decided to finance the production of an electronic textbook for medical students by 1,000,000 Danish kr.:

Text, illustrations, learning principles to be aligned with the curricula for obstetrics and gynecology in Nordic medical schools (and the needs of GPs and junior doctors outside our specialty, but not trainees in obstetrics and gynecology or midwives).
Author fee: none.

Availability

On the internet, for computer, tablet and smartphone. No paper version published.
Based on modern pedagogic principles not addressed in traditional printed books.
Free access to the platform (open source).
Each chapter written by a set of subspecialist authors from three or more Nordic countries.

The editorial committee

Included members from each Nordic country (the authors of this publication).
Distributed relevant topics among 32 obstetrical and 28 gynecological chapters.
Appointed a maximum number of words for each chapter.
Enrolled about 187 authors.

Electronic platform for publication

dk, even though some book companies offer platform with more features. However, sundhed.dk guarantees reliability and offers this service for free.

Videos and illustrations

We engaged two gynecologists, Jørgen Præst for video editing and Lotte Clevin who is also a professional illustrator. The use of good colleagues ensured the relevance of the products.

Formalities

We hired a law firm to elaborate collaboration agreements. That was necessary with these international stakeholders.

Language revision

An obstetrician/gynecologist (Reynir Tómas Geirsson, former AOGS Chief Editor) delivered text editing.

Multiple-choice questions

- A medical student (Thomas Jensen) established a platform for MCQ. Authors, professors, associate professors, and medical students are encouraged to add new MCQ to this collection. We publish them as soon as the authors have approved the suggestion.