Award-winning Abstracts from the SOGC Annual Clinical Meeting 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST GYNAECOLOGY PAPER A RANDOMIZED COMPARISON OF GOSERELIN VERSUS SUCTION CURETTAGE PRIOR TO THERMACHOICE II® BALLOON ABLATION George A. Vilos, MD, FRCSC, Emily C. Vilos, BEd Department of Obstetrics and Gynaecology, St. Joseph's Health Care, The University of Western Ontario, London ON

Objectives: To evaluate the clinical outcomes following the use of goserelin and suction curettage prior to ThermaChoice II balloon ablation to treat menorrhagia.

Study Methods: Qualified patients (n = 100) randomized to goserelin 3.6 mg 1 month prior or suction curettage before balloon ablation. Uterine bleeding was documented by menstrual diary scores at baseline (Higham> 150), and 3, 6, and 12 months. The ThermaChoice II system circulated the fluid within the silicone balloon for 8 minutes at 180 mm Hg pressure and 87°e.

Results: The mean age, weight, and duration of menorrhagia were 40.6 yr, 73 kg, and 8.8 yr, respectively, with no differences between the groups. No safety issues related to the device were noted. At 1 yr the median reduction in Higham score was from 286 to 10 (97%) and from 272 to 14 (95%) for the goserelin (n = 47) and curettage (n = 45) groups, respectively. The combined amenorrhea/hypomenorrhea rates (Higham 0-35), eumenorrhea rate (Higham 36-75), and menorrhagia rate (Higham >75) were 85%, 9%, and 6% (goserelin) and 76%, 16%,9% (curettage), respectively. The patient self-assessment dysmenorrhea was reported as none (51 %), mild (30%), moderate (10%), and severe (9%) by both groups. Patient satisfaction was 89% goserelin versus 95% curettage. There was 1 hysterectomy for pain and 4 resectoscopic ablations in the goserelin, and 2 resectoscopic ablations in the curettage group. The overall success rates were 88% for goserelin and 89% for curettage.

Conclusions: (1) Following ThermaChoice II treatment the success rate at 1 year was 88.5%. (2) There was a trend toward goserelin superiority (lower Higham) but it was not statistically significant.

JOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST OBSTETRICS PAPER PATIENTS' ACCEPTANCE OF SECOND-TRIMESTER PREGNANCY TERMINATION METHODS H. Akoury, MD, FRCSC, I R. Windrim, MD, FRCSC, I M. Hannah, MSc, MDCM, FRCSC,4

L. Ferris, PhD,s A. Willan, PhD,6 D. Chitayat, MD, FRCPC,2 G. Seaward, MD, FRCSC, I E. Winsor, PhD, 3 T. Einarson, PhD, 7 M. Thomas, PhD 8 I Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, 2The Prenatal Diagnosis and Medical Genetics Program, 3Pathology and Laboratory Medicine; Mount Sinai Hospital, University of Toronto, Toronto ON 4Department of Obstetrics and Gynaecology, 5public Health Sciences; Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto ON 6Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON 7Pharmacology Department, University of Toronto, Toronto ON 8Department of Political Science, York University, Toronto, ON

Objective: On reviewing the English literature, little work has been published about questionnaires assessing patients' acceptability or satisfaction during second-trimester pregnancy termination methods. This research evaluates patients' acceptance of alternative methods of second-trimester pregnancy termination associated with fetal anomalies. It is part of a randomized clinical trial to evaluate the effectiveness of these alternative methods: misoprostol administered orally (OM), misoprostol administered vaginally (VM), and PGF2-alpha administered by intra-amniotic injection (lAPG).

Study Design: A questionnaire was developed with input from an interest group formed for that purpose. Thorough pretesting helped to establish the validity of questionnaire items. Patient preferences were measured using Likert scales. Patients completed questionnaires, in private, during third-week postpartum physician visits. Results: The overall response was 78% (1651211), with only slight variation among groups. Patients perceived that duration, from the procedure's start to the onset of labour pain, was shorter for VM than for lAPG (p < 0.039) or OM (p < 0.002). Prostaglandin injection was more painful to patients than misoprostol administration (p < 0.001). VM patients reported less nausea than either lAPG (p < 0.003) or OM patients (p < 0.05), less vomiting than lAPG patients (p < 0.002), and less diarrhea than OM patients (p < 0.01). VM patients experienced less pain than OM (p < 0.05) and slightly less than lAPG. Not surprising, given these data, VM patients were more willing to use the same procedure in the future (p < 0.001). Conclusion: Patients who received vaginal misoprostol for second-trimester pregnancy termination were more positive about their experiences than were those patients who received oral misoprostol or intra-amniotic injection ofPGF2-alpha.

JOGC

AUGUST

2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST GYNAECOLOGY JUNIOR MEMBERS PAPER ENDOMETRIOID CARCINOMA OF THE UTERINE CORPUS WITH A MYXOID STROMAL REACTION; A PATTERN OF MYOMETRIAL INVASION ASSOCIATED WITH A MORE AGGRESSIVE CLINICAL COURSE T. Newhook, MD, FRCSC, I S. Murray, MD, FRCPC, 2 R. Grimshaw, MD, FRCSC l I Department of Obstetrics and Gynaecology, 2Department of Pathology, 3Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology Dalhousie University, Halifax NS

Objectives: Numerous studies have demonstrated depth of myometrial invasion is an important prognostic factor in endometrial carcinoma, independent of tumour grade. Less is known about the histologic pattern of myometrial invasion and its impact on prognosis. We have noted that in some endometrioid carcinomas of the uterus, the invasive glands are associated with a prominent myxoid stromal reaction. We undertook a study of endometrioid carcinomas to determine the frequency of this pattern of invasion and its prognostic significance. Methods: A laboratory database search of the files of the Department of Pathology, Queen

Elizabeth II Health Sciences Centre, Dalhousie University, was undertaken for endometrioid carcinomas of the endometrium between January 1, 1995, and December 31. Clinical followup and staging data was obtained from a clinical database kept by the Division of Gynaecologic Oncology. Invasive cases lacking a myxoid reaction were used as the control group. Histochemical stains were used to determine the nature of the stromal reaction.

Results: 118 patients with invasive endometrioid carcinomas were identified (FIGO stage IA cases were excluded). 31 cases were identified as having a prominent myxoid reaction (26%). Average follow-up in the myxoid group was 31.1 months (range 6-65.2) and 41.8 months in the control group (range 1.1-70.6). The myxoid group had a higher proportion of advanced stage tumours (p = 0.01) and a lower proportion of early stage tumours (p = 0.001). Patient age and tumour grade were similar. The myxoid group had a higher incidence oflymphatic vascular space invasion (p = 0.001) and a higher overall death rate (p = 0.01). When controlled for stage and grade a higher incidence of death or recurrent disease was found in the myxoid group (stage 1 p = 0.04, stage 2 p = 0.02). Conclusions: We have identified a pattern of myometrial invasion in endometrioid carcino-

ma in which invading tumour is associated with a prominent myxoid stromal reaction. Analysis of data in this group of patients suggests that this is associated with a more aggressive clinical course including a significantly higher proportion of cases with lymphatic vascular space invasion and higher rates of death and recurrent disease in early stage disease.

JOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST GYNAECOLOGY JUNIOR MEMBERS PAPER RUNNER-UP MISOPROSTOL OFFERS NO COST ADVANTAGE OVER INTRA-AMNIOTIC PGF2-ALPHA FOR SECOND-TRIMESTER PREGNANCY TERMINATION A.Y. Black, MD, FRCSC,' K. Fung Kee Fung, MD, MHPE, FRCSC2 I Department of Obstetrics and Gynaecology, Queen's University, Kingston ON 2Department of Obstetrics and Gynecology, Ottawa Hospital, Ottawa ON

Objective: Both intra-amniotic PGF2-alpha and misoprostol are safe and effective methods of second-trimester pregnancy termination. A perceived advantage of misoprostol is its lower cost; however, there have been no detailed cost analyses comparing the two methods to date. Our objectives were to (1) determine the cost of second-trimester pregnancy termination for PGF2-alpha and misoprostol, (2) determine factors influencing cost and areas of greatest cost, (3) identifY areas where costs could be reduced. Methods: Using the hospital's patient database, 80 patients undergoing second-trimester pregnancy termination with either PGF2-alpha or misoprostol from April 1993 to June 2000 were identified. Costs were calculated using the Sunrise Decision Support Manager system. Costs included nursing, operating room time, pharmacy, lab, social work, and imaging. Statistical analysis was performed using StatView. The student's t-test was used to compare continuous variables.

Results: There was no significant difference in mean cost between misoprostol termination, $1031.3 ± 484.5, and intra-amniotic PGF2-alpha termination, $1068.9 ± 400.3 (p = 0.743). Cost of termination was not significantly affected by gestational age, indication for termination, or experience with the medication. There was no significant difference in length of stay with misoprostol, 2.00 ± 0.74, compared to intra-amniotic PGF2-alpha, 2.21 ± 0.96 (p = 0.128). Nursing was the greatest cost associated with induction in both groups, $789.98 ± 440.88 for misoprostol and $639.26 ± 252.43 for PGF2-alpha, but there was no significant difference in nursing cost between the two groups (p = 0.128). Operating costs and pharmacy costs were significantly higher for PGF2-alpha than for misoprostol (p = 0.028, P = 0.020), respectively.

Conclusion: Misoprostol offers no cost advantage over intra-amniotic PGF2-alpha for second-trimester pregnancy termination, The area of greatest cost is nursing time. Reducing nursing time by starting terminations as an outpatient may help reduce overall cost. Reduced cost should not be cited as a reason to use misoprostol over PGF2-alpha for second-trimester pregnancy termination.

JOGe

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST OBSTETRICS JUNIOR MEMBERS PAPER FOLATE LEVELS IN PREGNANT SMOKERS: AN IMPORTANT GENE/ENVIRONMENT INTERACTION Sarah D. McDonald, MD, FRCSC, Sherry L. Perkins, PhD, Carol Ann Jodouin, MLT, Mark C. Walker, MD, FRCSC Department of Obstetrics and Gynecology, University of Ottawa, Ottawa Hospital, Ottawa ON

Objective: The objective of this study was to determine if serum and RBC folate levels were decreased in pregnant smokers and if total plasma homocysteine levels were elevated. Study Design: In this cross-sectional study, serum folate, RBC folate, and homocysteine were measured in pregnant first- and early second-trimester smokers (cases) and non-smokers (controls). In addition, vitamin B 12 , albumin, creatinine, cotinine, hematocrit, and MTHFR status were determined and compared between groups.

Results: Smokers had significanrly lower concentrations of serum folate (22.7 vs. 29.4 nmol/L, p = 0.001), and lower concentrations ofRBC folate (766 vs. 900 nmol/L, p = 0.038) than nonsmokers. Dietary folate concentrations were not significantly different between smokers and non-smokers. Homocysteine levels were also not significantly different between the groups. For each genotype of MTHFR, lower levels of serum folate were observed in smokers, with the lowest folate levels seen in homozygous MTHFR 677TT (18.6 nmol/L in smokers vs. 24.2 nmol/L in non-smokers).

Conclusions: Both serum folate and RBC folate are lower in pregnant smokers than in pregnant non-smokers, while homocysteine levels are not significantly different. There is an important gene/environment interaction between MTHFR gene activity and tobacco exposure on serum folate levels. Lower levels of serum folate may account for the higher rate of miscarriage, stillbirth, placental abruption, and fetal anomalies observed in smokers. Pregnant smokers may benefit from higher doses of periconceptual folic acid.

JOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST OBSTETRICS JUNIOR MEMBERS PAPER RUNNER-UP THE INTERDELIVERY INTERVAL AND THE RISK OF UTERINE RUPTURE E. Bujold, MD, FRCSC,.·2 S. H. Mehta, MD,2 C. Bujold, OT,. R.J. Gauthier, MD, FRCSC' I Department of Obstetrics and Gynecology. Hapital Ste·Justine. Montreal QC 2Department of Obstetrics and Gynecology. Wayne State University. Detroit MI

Objectives: To determine the effect of the interval between the previous Caesarean section and the subsequent trial oflabour on the likelihood of successful VBAC and symptomatic uterine rupture.

Study Methods: The medical records of all women with a history of one prior Caesarean were reviewed. Patients with a previous vaginal delivery or with more than one Caesarean were excluded. Patients were divided into 4 groups according to the interval between their prior Caesarean and their subsequent delivery: <12 months, 13-24 months, 25-36 months, and >36 months. Rates of uterine rupture were compared for these 4 groups. Potential confounders were controlled using logistic regression analyses.

Results: 1527 patients were included. The rate of successful VBAC was comparable in each group: 13121 (62%),275/372 (74%), 310/436 (71%),488/698 (70%), p = 0.43. The rate of uterine rupture was significantly higher in the first two groups (p = 0.036; see figure). In a logistic regression analysis controlling for seven confounding variables, the odds ratio of uterine rupture in those patients with an interdelivery interval less than 24 months was 2.65 (95% CI = 1.08,6.46).

Rate of uterine rupture 4.76 %

<12

13-24

25-36

>36

Interdelivery interval (months)

Conclusion: A short interdelivery interval is associated with an increased risk of uterine rupture.

lOGe

AUGUST

2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST GYNAECOLOGY POSTER HYSTERECTOMY TRENDS IN NOVA SCOTIA: 1992-2000 T. F. Baskett, MB, FRCSC,· C. D. Skedgel,2 M. Pennock2 J Department of Obstetrics and Gynaecology and 2The Population Health Research Unit. Dalhousie University. Halifax NS

Objective: To review the trends in hysterectomy for benign disease in the province of Nova Scotia during the 1990s.

Methods: Using the CIHI database for the nine years 1992-2000, the numbers and route of hysterectomy, type of surgeon (ob/gyn, gen. surgeon, other), length of stay, and hospital type were reviewed. For the five years, 1996-2000, rates of hysterectomy, age group, region, and income quintile were analyzed.

Results: Over the nine years, 1992-2000, there were 19,404 hysterectomies performed with the trends shown below: Route Abd Vag No (%) No (%)

1992 2000

1646 (65) 1130 (59)

Hospital Length of Stay Surgeon Teaching Regional (days) Gyn Gen Surgl other

931 1579 862(35) 779(41 ) 602 ("35%) 1307 ("17%)

6.6 3.7

85% 96%

15% 4%

For the five years 1996-2000, the 40-44-year age group and one of the four regions had significantly higher hysterectomy rates. The highest income quintile had a significantly lower rate.

Conclusion: Over the nine years the total number of hysterectomies has decreased 24%, with the reduction in teaching hospitals twice that of regional hospitals. The proportion of vaginal hysterectomies has risen by 6%. Age group, region, and income are related to the rate ofhysterectomy.

lOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST OBSTETRICS POSTER OUTCOMES AT 3 MONTHS FOR WOMEN IN THE TERM BREECH TRIAL Mary E. Hannah, MD, MDCM, FRCSC, for the Term Breech Trial Collaborative Group Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Maternal Infant and Reproductive Health Research Unit, University ofToronto,Toronto ON

Objectives: Caesarean section may have beneficial and adverse outcomes for women. We compared the policies of planned Caesarean section and planned vaginal birth for breechpresentation pregnancies in terms of maternal outcomes at 3 months postpartum. Study Methods: In a randomized controlled trial of2088 women, women completed a structured questionnaire at 3 months postpartum, in selected centres. The outcomes were breastfeeding, ease of caring for baby and adjusting to being a new mother, sexual relations, relationship with husband/partner, pain, incontinence, depression, and the mother's views regarding her childbirth experience and her participation in the study.

Results: Of the 1940 women randomized in centres participating in the 3-month follow-up, 1596 (82.3%) returned completed questionnaires. Baseline information was similar for both groups. The rate of Caesarean section was 725/798 (90.9%) in the planned Caesarean section group; the rate of vaginal birth was 456/798 (57.1 %) in the planned vaginal birth group. Women in the planned Caesarean section group were less likely to report urinary stress incontinence than the planned vaginal birth group (36/798 [4.5%] vs. 58/797 [7.3%]. P = 0.02). Incontinence of flatus was not different between groups, but was less of a problem in the planned Caesarean section group, ifit occurred (p = 0.006). There were no differences between groups in other outcomes. Conclusions: Planned Caesarean section for pregnancies with breech presentation at term results in a lower risk of incontinence and no increased risk of other problems for women at 3 months postpartum.

JOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE SOGC ANNUAL CLINICAL MEETING

2002

BEST GYNAECOLOGY JUNIOR MEMBERS POSTER THE PREDICTIVE VALUE OF URINALYSIS FOR UTI

W. A. Silva, MD, S. Farrell, MD, FRCSC Department of Obstetrics and Gynaecology, IWK Health Centre, Halifax NS

Objectives: To examine the predictive value of the components of urinalysis (dipstick and microscopy) separately and in combinations for urinary tract infection (UTI).

Study Methods: Prospectively, 378 patients being evaluated at a tertiary care urogynaecology unit for urinary incontinence collected urine specimens. Specimens were sent for both urinalysis and culture and sensitivity. Data collected included age and presenting symptoms. Components of the urinalysis included dipstick analysis (blood, protein, nitrite, and leukocytes), microscopy for cellular findings (WBC and RBC), and microorganisms (bacteria). Positive urine cultures were reported as 105 CPU/mL of isolated organisms.

Results: The predictive values of the individual components of the urinalysis for the whole group are shown in the table below: Predictors

Sensitivity Specificity Positive Negative Positive Negative Relative predictive predictive likelihood likelihood risk value value ratio ratio

Blood (moderate 0.12 or large)

0.94

0.08

0.96

1.85

0.94

1.88

Protein

0

0.97

0

0.95

0

1.03

N/A

Nitrite (positive)

0.29

0.99

0.71

0.96

38.40

0.71

16.13

Leukocyte (> 125 celis/lJL)

0.18

0.97

0.19

0.96

4.90

0.85

4.85

WBC (>5/hpf)

0.59

0.85

0.15

0.98

3.86

0.49

6.88

RBC(> 10/hpf)

0.12

0.96

0.12

0.96

2.83

0.92

2.83

Bacteria (moderate, many or large)

0.47

0.92

0.22

0.97

5.86

0.58

8.19

0.15 0.31

0.98 0.97

0.61 0.50

0.82 0.94

6.24 12.03

0.88 0.71

3.38 9.00

(>0.3 gIL)

Combinations of bacteria, WBC, nitrite: Any I positive Any 2 positive

Conclusion: A positive nitrite or the presence of any two positive indicators out of a combination of three (bacteria, WBCs, and nitrite) are highly predictive for a urinary infection.

JOGC

AUGUST 2002

AWARD-WINNING ABSTRACTS FROM THE

2002

SOGC ANNUAL CLINICAL MEETING

BEST OBSTETRICS JUNIOR MEMBERS POSTER A SYSTEMATIC REVIEW OF ADVERSE OBSTETRICAL OUTCOMES IN PREGNANT WOMEN WITH ACTIVATED PROTEIN C RESISTANCE AND FACTOR V LEIDEN J. Dy, MD,I S. Mayank, MBBS,2 M. Rodger, MD, FRCPC,3 G.Wells, PhD,2 M.Walker, MD, FRCSCI I Department of Obstetrics and Gynecology. 2Department of Epidemiology. JDepartment of Medicine. The Ottawa Hospital. Ottawa ON

Objective: This study aims to conduct a meta-analysis of case control studies ofFVL and quantifY its association with adverse perinatal outcomes including recurrent pregnancy loss (RPL), intra-uterine fetal death (IUFO), intra-uterine growth restriction (IUGR), preeclampsia, and abruptio placentae.

Methods: A systematic review of the literatute on electronic databases was performed. The key words used were: FactorY, APCR', pregnancy loss', abortion*, pregnancy induced hypertension*, preeclampsia*, placental infarction', abruptio', IUGR*, IUFO*. Cross-referencing of the bibliography of all papers was done. Case-control studies were subjected to the study selection criteria established a priori. Two reviewers independently analyzed each paper. Summary odds ratio for each outcome was calculated by summary chi-square test. The New Castle-Ottawa Quality Assessment Scale (NOS) for case control studies was used to score the quality of each study and sensitivity analysis was performed.

Results: There are 37 published case control srudies with a total of8952 patients included in this review. Combined odds ratios were 2.91 (95% CI 2.16-3.93) for RPL, 3.36 (95% CI 1.80-6.28) for IUFO, 2.47 (95% CI 1.09-5.58) for IUGR, 2.32 (95% CI 1.77-3.03) for preeclampsia, and 3.42 (95% CI 1.65-7.08) for abruptio placentae. Overall, the pooled odds ratio for having anyone adverse perinatal outcome with the FVL mutation is 2.73 (95% CI 2.27-3.29).

Condusions: FVL significantly increases the risk for poor obstetrical outcomes. However, large prospective trials are needed to determine the true relative risk for these adverse perinatal outcomes and management options for patients known to carry the FVL mutation.

JOGC

AUGUST

2002