This month’s Blue Journal Club

At what time point during a maternal code for cardiac arrest would you perform perimortem caesarean?

Wednesday 28th June 2017, 8pm BST

We will be discussing: ‘The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study’ by Beckett and colleagues.

The hosted discussion will take place on Twitter, with the discussion continuing for up to 7 days. Remember to use #BlueJC in all your Tweets!
Host: @bluejchost

Scenario

As the obstetrician in house, you are called to the emergency room to assist in the care of a pregnant patient who is “coding.” Upon arrival, you hear that the patient presented with hypoxia which led to cardiac arrest just moments before your arrival. The emergency medicine team is rapidly performing intubation and has begun chest compressions on the patient whose abdomen appears to indicate that she is full term. No return of spontaneous circulation (ROSC) is achieved after 2 minutes of CPR.

What do you do?

Description of research

Participants: Pregnant and recently-delivered women in the UK who
received basic life support (BLS) for cardiac arrest
Outcomes: Peri-mortem cesarean section, maternal death
Study design: Prospective descriptive study using the UK Obstetric
Surveillance system, a voluntary but widely-used reporting
system
Authors’ conclusion: 25% of cardiac arrests in pregnancy were associated with
anesthesia administration. Prognosis for out-of-hospital arrest
was poor despite rapid use of BLS. Women undergoing prompt
peri-mortem cesarean had better maternal and neonatal
outcomes.

Discussion points

• How did this study design differ from a retrospective chart review?
• What demographic characteristics and management factors were associated with maternal survival in this study?
• Among women who died, what causes of cardiac arrest and mortality were most common?
• List three specific biases inherent in this study’s design that limit the ability to make strong conclusions and recommendations regarding the management of maternal cardiac arrest.
• What conclusions can be drawn from this data about optimal timing of peri-mortem cesarean section?

Suggested reading

1. Mhyre et al. Cardiac arrest during hospitalization for delivery in the United States, 1998-2011. Anesthesiology 2014;120:810-818.
2. Drukker et al. Perimortem cesarean section for maternal and fetal salvage: concise review and protocol. Acta Obstet Gynecol Scand 2014;93:965-972.
3. Katz et al. Perimortem cesarean delivery. Obstet Gynecol 1986;68:571-576.
4. Katz et al. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol 2005;192:1916-1920.

What cervical cancer screening method would you recommend in a low resource setting?

Source: National Cancer Institute \ Winship Cancer Institute of Emory University
Creator: Scott Wilkinson, Adam Marcus

We will be discussing Accuracy of combinations of visual inspection using acetic acid or Iugol Iodine to detect cervical precancer: A meta-analysis.  Catarino et al. BJOG 2017 on Wednesday 27 September, 8pm BST.

Scenario

You have been asked to develop a screening system for cervical cancer in a low income country.    What method do you recommend?

 Description of research

 

Participants 101,273 women participating in 23 studies in India (11 studies), Africa (9 studies), Oceania (one study) and Latin America (two studies)
Interventions Four strategies of cervical screening:

(1) visual inspection of the cervix with acetic acid (VIA);

(2) visual inspection with Iugol’s iodine (VILI);

(3) cotesting;

(4) VILI as a triage test of a positive VIA result.

Comparison Histology if a cervical biopsy was performed; colposcopy when no sample was taken
Outcomes Sensitivity and specificity of testing strategy
Study Design Diagnostic test accuracy meta-analysis

 

Discussion Points:

  • What are the described screening strategies? Do they differ from what you do in clinical practice?
  • What are the properties of an ideal screening test?
  • What is the relationship between sensitivity and specificity, and positive predictive value?
  • Most of the studies included were cross-sectional and prone to bias. What kinds of bias are discussed in this meta-analysis? Are there others you can think of? (1)
  • What other information would you like in order to answer the question in the scenario?
  • Imagine that a funder, hearing of the need for cancer screening in this country and the paucity of evidence, offers research funding for a trial to evaluate different methods. How would you design such a trial?

Suggested reading

Leeflang MMG, Deeks JJ, Gatsonis C, Bossuyt PMM, Cochrane Diagnostic Test Accuracy Working Group. Systematic reviews of diagnostic test accuracy. Ann Intern Med. NIH Public Access; 2008 Dec 16;149(12):889–97.

How much physical activity is safe and healthy for pregnant women?

We will be discussing: Physical activity and the risk of preterm birth: a systematic review and meta-analysis of epidemiological studies by Aune and colleagues.

Wednesday 30th August 2017, 8pm BST

Scenario
The first patient on the afternoon clinic schedule is seeing you for her first
obstetric visit. She is a healthy nulliparous 37-year-old business
administrator. She asks whether her morning workout routine will increase the
risk of preterm delivery.

What recommendations do you make about time and intensity of exercise during
pregnancy?

Description of research

Participants: Pregnant women in prospective studies of physical activity in
pregnancy.
Outcomes: Preterm birth <37 weeks
Study Design: Systematic review and meta-analysis of 41 studies from Europe, North America, South America, Asia, Australia and New Zealand
Authors’ conclusion: Higher leisure-time physical activity in pregnancy is associated
with a 14% relative risk reduction in preterm birth <37 weeks of gestation compared to lower physical activity. The data does not definitively answer the question of “how much” exercise is enough, or too much, but the lowest observed risk for preterm
birth was at 2-4 hours of activity per week.

Discussion points

  • How do you counsel women on physical activity in pregnancy?
  • Do you give the same advice about exercise to women who are underweight? How about those who are overweight or obese?
  • What is the most important conclusion of this study, from a patient-counselling standpoint?
  • Some of the forest plots (e.g Figure 4e) suggest that RCTs and cohort studies give different answers to a clinical question. Is this common in women’s health research? Can you name prominent examples where observational data gave an “opposite” or “wrong” answer to an important clinical question?
  • Describe the difficulties in studying this topic. How could you design the “perfect study” to answer the question of “how much” physical activity is safe and healthy for pregnant women?

Suggested reading

1. Perales et al. Exercise during pregnancy. JAMA 2017;317(11):1113-4.
2. Magro-Malosso et al. Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2017; 96:263-273.

 

A pill or a patch for a hot flush?

We will be discussing: Vasomotor symptoms due to natural menopause; systematic review and network meta-analysis (NMA) of treatment effects from the NICE Menopause Guideline by Sarri and colleagues.

Wednesday 26th July 2017, 8pm BST

Scenario
A 52 year old woman presents to your clinic with hot flushes and night sweats coinciding with the menopause. She does not wish to have an operation. What treatments do you recommend?

Description of research

Participants: 8326 women participating in 47 randomised controlled trials of medications and therapies to control
Interventions:
1) Transdermal oestradiol and progesterone
2) Oral oestradiol and progesterone
3) Isofavones
4) Black cohosh
5) Chinese herbal medicine
6) Multibotanicals
7) Acupuncture
8) SSRIs
9) SNRIs
Comparison: Placebo and sham acupuncture
Outcomes: Odds ratios and means ratios of vasomotor symptoms (hot flushes and night sweats)
Study Design: Bayesian network meta-analysis (NMA)

Discussion points

  • What advice do you currently give women in the situation above?
  • In your experience, do women find pills or patches (a) more acceptable and (b) easier to use?
  • What is a network meta-analysis?
  • What does it mean for such an analysis to be Bayesian? How would you explain the methods used to another clinician?
  • There are many interventions in this analysis and many possible interactions. What problems does this present?
  • Would you change your recommendations to the women you treat as a result of this analysis?
  • Papers such as this use innovative statistical methods to answer real-life clinical questions. Consider your answers to questions 4 and 6. Is your answer to question 6 dependent on your answer to question 4? If so, how and why?

Suggested reading

Ades AE, Caldwell DM, Reken S, Welton NJ, Sutton AJ, Dias S. Evidence Synthesis for Decision Making 7. Med Decis Making. 3rd ed. SAGE PublicationsSage CA: Los Angeles, CA; 2013 Jun 26;33(5):679–91.

 

What advice do you give about the risk of fetal abnormality and IVF conception?

We will be discussing: Maternal factors and the risk of birth defects after IVF and ICSI: a whole of population cohort study by Davies and colleagues.

Wednesday 31st May 2017, 8pm BST

The hosted discussion will take place on Twitter, with the discussion continuing for up to 7 days. Remember to use #BlueJC in all your Tweets!
Host: @bluejchost

Scenario

A 41-year-old nulliparous woman presents to your clinic wishing to get pregnant. What advice do you give her about her risk of fetal abnormality and IVF conception?

Description of research

Participants: 304 670 birth episodes in South Australia for the period January 1986 to December 2002.
Intervention: Assisted conception with IVF or ICSI.
Comparison: Natural conception.
Outcomes: Odds ratios of major birth defects.
Study design: Retrospective cohort study.

Discussion points

  • How does this study define birth defects? How would you explain this to a patient?
  • This study used linked data. What routine data sets did it link between? Do these data sets exist in your healthcare system?
  • Why is linked data of use? Can you think of other areas where this sort of linkage would be helpful?
  • Does this study attain the standards for reporting studies using linked routine data (the RECORD statement)?
  • Do you agree with the authors’ conclusion that this study refutes the assumption that the known risk between assisted conception and birth defects is linked to age, or is more investigation needed?
  • Can you briefly summarise the results of this study? How would the results of this study influence your counselling of the woman in the scenario?

Suggested reading

Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. PLoS Med 2015;12:e1001885. https://doi.org/10.1371/journal.pmed.1001885

How would you help a colleague dealing with the stress of an adverse outcome?

We will discuss ‘Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey by Wahlberg and coauthors on the 26th April 2017. This paper is free to view from 17th April.

Start date: 26 April 2017. The discussion will continue for 7 days until 2nd May 2017.

First hosted discussion session(s) on Twitter starts at BST 8pm (3pm EST/12 noon PST) on 26 April 2017 (using hashtag #BlueJC).

Host: @BlueJCHost

Follow us: Twitter

The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues.

The discussion points are below:

Scenario

A colleague working in another part country calls to tell you that she delivered a patient whose full term baby died in the NICU a few days after delivery. During the course of the hospital safety committee’s review of the case, it was determined that a delay in delivery likely contributed to complications leading to the neonate’s death.  Your colleague asks for advice and help “sorting it all out”.

How will you help?

Description of Research:

Participants 1,459 midwives and 706 obstetricians from Sweden. Mostly women.
Exposure A serious and potentially traumatic event on the delivery unit, such as (1) a child died or had severe asphyxia, (2) maternal near-miss or death during delivery, or (3) other difficult event such as violence or threat.
Outcomes Provider experience of probably post-traumatic stress disorder (PTSD) or partial PTSD.
Study design Cross-sectional survey.
Authors’ conclusion A substantial proportion of obstetricians and midwives experiences PTSD-like symptoms after serous traumatic events related to delivery.

Discussion Points:

  • Describe a time when you have been the “second victim” of an adverse event. How did it affect you? Did it have an effect on your other patients?
  • Did the authors have an adequate response rate to their survey? What means could they have used to improve response rates?
  • The authors cite probable selection bias and recall bias as limitations of the study. How would you design a study addressing the same objective, but with less potential for these biases?
  • In what ways might non-responders have biased this study?
  • What were the main differences between obstetrician responders and midwife responders in this study?
  • Obstetricians reported negative experiences with debriefings (or reassembly) in this study. In your experience, what are the ways debriefings can be helpful or harmful?
  • How would you use the results of this study in your own practice?

Suggested reading

  1. Scott et al. The natural history of recovery for healthcare provider “second victim” after adverse patient events. Qual Saf Health Care Care 2009;18:325-330.
  2. Schroder et al. Guilt without fault: a qualitative study into the ethics of forgiveness after traumatic childbirth. Social Science & Medicine 2017;176:14-20.
  3. Grimes and Schulz. Descriptive studies: what they can and cannot do. Lancet 2002;359:145-49.

Is induction of labour at term a cost-effective option for nulliparous women over 35?

We will discuss Labour induction near term for women aged 35 or over: an economic evaluation by Walker and coauthors on the 29th March 2017This paper is free to view from 20th March.

Start date: 29 March 2017. The discussion will continue for 7 days until 5th April 2017.

First hosted discussion session(s) on Twitter starts at BST 8pm (3pm EST/12 noon PST) on 29 March 2017 (using hashtag #BlueJC).

Host: @BlueJCHost

Follow us: Twitter

The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues.

The discussion points are below:

Scenario

Recent evidence has suggested that there may be some benefit in inducing nulliparous women at 39 weeks if they are 35 years of age or older.  Do you think your health system should change to a policy of offering this routinely?

Description of Research:

Participants 380 nulliparous women aged 35 years or older with an ongoing singleton pregnancy at 39 weeks, with the fetus in cephalic position.

Women were excluded if they had any contraindication to labour, vaginal delivery or expectant management; if they had known fetal abnormality; if they had not had an ultrasound before 22 weeks (no anomaly scan); or if they had undergone IVF with the use of donor eggs.

Intervention Induction between 39+0 and 39+6 weeks of gestation.
Comparison Expectant management of pregnancy.
Outcomes Resource utilization was captured through routine health service data collection, verified by reseach staff, and patient questionnaires at one month postnatal.
Study design Cost-utility analysis: secondary economic analysis of subset of paricipants in a randomised controlled trial.

Discussion Points:

  • How do you currently manage a woman aged 35 or over in her first pregnancy?
  • Why measure economic outcomes? What is the difference between economic outcomes and a cost-utility analysis?
  • Healthcare spending is not normally distributed, as a small number of people will have very high costs. What steps did the researchers take to mitigate this? Are these adequate?
  • What is a Quality Adjusted Life Year (QALY)?
  • A prospective economic evaluation of the intervention (induction for primparous mothers over 35 at 39 weeks) was embedded into the trial design. How did the authors do this?
  • This study was conducted from the perspective of the NHS in England, which is a universal coverage system that is free at the point of need. How might this translate to another healthcare system (your own, if not in the UK?
  • Can you briefly summarise the results of this study? How would the results of this study influence your practice?

Suggested reading

National Institute of Care Excellence. Guide to Methods of Technology Appraisal, 2013.

Cranberry capsules to prevent bacteriuria after pelvic surgery. #BlueJC

We will discuss Cranberry capsules to prevent nosocomial urinary tract bacteriuria after pelvic surgery: a randomized controlled trial by Letouzey and co-authors on the 22nd February for 7 days. This paper is open access

Start date: 22 February 2017. The discussion will continue for 7 days until 1st March 2017.

First hosted discussion session(s) on Twitter starts at GMT 8pm (3pm EST/12 noon PST) on 22 February 2017 (using hashtag #BlueJC).

Host: @BlueJCHost

Follow us: Twitter

BJOG_BlueJC_160x600WebBanner_Mar15_(reoriented)_3The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues.

The discussion points are attached below:

Scenario

A 43 year-old woman is scheduled to undergo a vaginal hysterectomy. After a previous hysteroscopy she developed a bothersome urinary tract infection (UTI). She wonders if cranberry capsules could help prevent another UTI during her upcoming surgery. Would you recommend cranberry capsules to prevent postoperative bacteriuria?

cranberry-capsulesopt

 

 

 

 

 

 

 

Description of Research:

Participants Women undergoing pelvic surgery requiring urinary catheter for at least 24 postoperative hours.
Intervention Prophylactic cranberry juice capsule proanthocyanidins (PAC) 36 mg from day 0 to day 10.
Comparison Placebo from day 0 to day 10.
Outcomes Postoperative culture-proven bacteriuria within 15 days after surgery.
Study design Double-blind, Randomized Controlled Trial (RCT)
Authors’ conclusion PAC prophylaxis does not reduce the risk of postoperative bacteriuria in patients undergoing pelvic surgery.

 

Discussion Points:

  • What are your current practices for reducing urinary tract infections after pelvic surgery?
  • Do you think the primary outcome (bacteriuria within 15 days of operation) is a valid surrogate for urinary tract infection? Why, or why not?
  • This study was, in the end, underpowered to detect a difference in the primary outcome. List the reasons why.
  • Many participants were excluded or dropped out after randomization, how might a high dropout rate (1) affect power, and (2) introduce bias?
  • If you were asked to design this trial, what effect size (reduction in bacteriuria) would you say is sufficient to consider routine use of cranberry capsules for prevention of postoperative UTIs? (10%? 25%? 50%?)
  • How do you interpret these results, considering the totality of evidence in the literature as outlined by the authors?
  • Summarise this trial’s results in the form of a tweet. (140 characters)
  • Will your practice change because of this study?

Suggested reading

  1. Newgard CD and Lewis RJ. Missing Data: How to Best Account for What is Not Known. JAMA 2015;314(9):940-941. DOI: 10.1001/jama.2015.10516 – Link
  2. Pocock SJ and Stone GW. The Primary Outcome Fails – What Next? N Eng J Med 2016;375:861-870. DOI: 10.1056/NEJMra1510064 
- Link

 

Induction of labour: should we prefer balloons to prostaglandins?

We will discuss Double-balloon catheter versus prostaglandin E2 for cervical ripening and labour induction by Du and co-authors on the 25th January for 7 days.

This paper is open access: http://bit.ly/2j9ZmNY

We are now on LinkedIn too: http://linkd.in/1BVrpad (simply ask to join)!

Start date: 25 January 2017 (the discussion will continue for 7 days between 25th January and 1st February 2017.

First hosted discussion session(s) on Twitter starts at GMT 8pm (3pm EST/12 noon PST) on 25 January 2017 (using hashtag #BlueJC).

Host: @BlueJCHost

Platforms: Twitter, Facebook and LinkedIn 

BJOG_BlueJC_160x600WebBanner_Mar15_(reoriented)_3The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues.

The discussion points are attached below:

 

 

Scenario

A 26 year old woman in her first pregnancy requires induction of labour at term for reduced fetal movements.   She has a normal CTG, normal scan with normal umbilical artery Doppler studies, and no other risk factors.

What method of induction of labour would you recommend? 

Description of Research:

Participants Women with singleton pregnancies with live fetuses in vertex presentation, intact membranes, and unfavourable cervices, requiring induction of labour.
Intervention Transcervical double balloon catheter
Comparison Locally applied prostaglandin E2 analogues
Outcomes Primary:  (1) proportion of women achieving vaginal delivery within 24 hours, (2) proportion of women delivering by Caesarean

Secondary: (1) Uterine hyperstimulation; (2) Neonatal unit admission; (3) Maternal adverse events (PPH, uterine rupture).

Study design Metanalysis of randomised controlled trials

 

 

Discussion Points:

  • How do you currently counsel women similar to the one in the scenario?
  • Have you used double-balloon catheters? Do you find that they are well tolerated?
  • How did the authors assess the quality of individual studies?
  • What were the problems identified by their quality assessment of individual studies?
  • Critically appraise this meta-analysis using the PRISMA checklist (http://prisma-statement.org/PRISMAStatement/Checklist.aspx)
  • Can you briefly summarise the results of this study as a one-sentence take-home message?
  • Would the results of this study influence your management of the woman in the scenario?
  • How would the results of this study influence your daily practice?

 

Suggested reading

Scottish Intercollegiate Guidelines Network. Critical Appraisal: notes and checklists. Methodology checklist 1: Systematic reviews and meta-analyses. http://www.sign.ac.uk/methodology/checklists.html (Last access 20 July 2016)

Heavy periods and bleeding between periods in pre-menopausal women: is it OK to wait and see without biopsy?

We will discuss “Premenopausal abnormal uterine bleeding and risk of endometrial cancer” by Pennant and co-workers from 30 November 2016 for 7 days.

*This paper is open accesshttp://bit.ly/2fEA3TV.

We are now on LinkedIn too: http://linkd.in/1BVrpad (simply ask to join)!

Start date: 30 November 2016 (the discussion will continue for 7 days between 30 November – 7 December 2016)

First hosted discussion session(s) on Twitter starts at GMT+1 (British Summer Time) 8pm on 30 November 2016 (using hashtag #BlueJC)

Host: @BlueJCHost

Platforms: Twitter, Facebook and LinkedIn 

BJOG_BlueJC_160x600WebBanner_Mar15_(reoriented)_3The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues.

The discussion points are attached below (quoted from the published Journal Club guide)

 

Scenario

A 32-year-old nulliparous woman presented to your clinic with bleeding in between her periods for the past 6 months.

Her periods had been regular prior to her new symptom. She had an up-to-date and normal smear, and recent tests for genital tract infections were negative. She had no other medical history.

How would you manage this woman?

 

Description of research

Participants Studies reporting rates of endometrial carcinoma and/or atypical hyperplasia of women with pre-menopausal abnormal uterine bleeding
Intervention Endometrial biopsy and histological analysis
Comparison Prevalence of endometrial malignancy
Outcomes Risk of endometrial cancer or atypical hyperplasia
Study design Studies reporting rates of endometrial carcinoma and/or atypical hyperplasia of women with pre-menopausal abnormal uterine bleeding
Authors’ conclusion The combined risk of endometrial cancer is low (0.34%; 95% CI 0.28 to 0.42%, n=28,162; 96 cases)

Discussion Points

  • Which additional factors would you consider when you manage the woman in the above scenario?
  • How do you currently manage the women in the clinical scenario?
  • What is the best way to determine the prevalence of a disease in different subgroups of the population?
  • What are the strengths and weaknesses of this meta-analysis for this research question? (see suggested reading)
  • In particular, do you have additional comments with regards to the search strategy and selection criteria?
  • What is the prevalence (with confidence intervals) of endometrial cancer and atypical hyperplasia identified in this study?
  • Are the results of the existing study consistent with published guidelines?

Suggested reading

Scottish Intercollegiate Guidelines Network. Critical Appraisal: notes and checklists. Methodology checklist 1: Systematic reviews and meta-analyses. http://www.sign.ac.uk/methodology/checklists.html (Last access 20 July 2016)

For those who want to understand hashtags, this may be a useful guide. For an introduction to #BlueJC, please refer to BJOG 2013;120:657–60. Follow @BlueJCHostthis blog and our Facebook page to receive news about #BlueJC.