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Journal of obstetrics and gynaecology [journal]
- Has the incidence of hypoxic ischaemic encephalopathy in Queensland been reduced with improved education in fetal surveillance monitoring? [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Mar 6.
Hypoxic ischaemic encephalopathy (HIE) is secondary to intrapartum asphyxia and the fifth largest cause of death of children under five. Incorrect use and interpretation of intrapartum cardiotocographs has been identified as a contributing factor to the development of HIE. Therefore, RANZCOG introduced the Fetal Surveillance Education Program (FSEP) to improve education and practice of intrapartum care.To investigate the incidence of HIE throughout Queensland between 2003 and 2011 during the introduction and implementation of RANZCOG FSEP.The incidence of HIE admissions at each hospital in Queensland (2003-2011) was collated from Queensland Health Statistics Centre. RANZCOG FSEP provided data regarding course attendees throughout Queensland (2006-2011). Hospitals were grouped into four regions. Statistical analysis was conducted using Stata(TM) (version 12.0) - data appeared to follow a damped harmonic model.The posteducation (2006-2011) HIE rate was significantly lower (P = 0.02) than the pre-education (2003-2005) rate. The final model predicted a stabilisation of HIE occurrence rate at approximately 160 events/100 000 live births by 2012. This rate was stable if the level of education was maintained but rose back to the initial rate of 250 events/100 000 live births if the education participation was discontinued.This study identified a significant reduction in the incidence of HIE - a potentially life-threatening newborn condition - between 2003 and 2011, during and following FSEP implementation. Notwithstanding the inevitable limitations of state-based data collection, these results are encouraging. For such improvements to be sustained, education must reach all staff engaged in intrapartum care and be regularly repeated.
- Evaluation of anti-Mullerian hormone in the first trimester as a predictor for hypertensive disorders of pregnancy and other adverse pregnancy outcomes. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Mar 3.
Prediction of pre-eclampsia and adverse pregnancy outcomes with biomarkers has been proposed. AMH is an ovary-specific growth factor, used to predict ovarian reserve, which changes with age similar to the change in age-related fertility.The aim of the study was to determine whether AMH tested in the first trimester of pregnancy was associated with pregnancy hypertension or adverse pregnancy outcomes.Retrospective cohort study of women who delivered singleton fetuses ≥20 weeks' gestation at Royal Hospital for Women, Sydney, Australia (n = 331). AMH was tested in 2011 via Beckman-Coulter Gen II ELISA method on frozen serum collected at the time of first trimester aneuploidy screening (10-13 + 6 weeks' gestation). Outcome data were obtained from the hospital database (ObstetriX). Main outcome measures were pregnancy hypertension (pre-eclampsia and gestational hypertension) and composite adverse pregnancy outcome.The median AMH level was 9.7pmol/L (interquartile range (IQR) 3.9-17.3). There was a trend towards women with pregnancy hypertension having lower AMH levels than women without pregnancy hypertension (median 5.1pmol/L, IQR 1.5-13.2 vs 9.4 IQR 3.9-17.3; P = 0.06). After adjusting for BMI ≥25, parity ≥1 and age ≥35, women with an AMH less than the 10th centile had a 3.3-fold increased risk of pregnancy hypertension (OR 3.3, 95% CI 1.2-8.7, P = 0.01). There were no other associations between low AMH concentration and adverse maternal or neonatal outcomes.Women with a very low AMH (1.5 pmol/L) in early pregnancy may have an increased risk of pregnancy hypertension. No other adverse pregnancy outcomes were identified.
- A randomised controlled trial of intra-uterine insemination versus in vitro fertilisation in patients with idiopathic or mild male infertility. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 28.
The cause of infertility is unexplained or poorly explained in 30-40% of couples undergoing standard investigations, and treatment ranges from expectant management to IUI and IVF.The aim of this study was to compare the clinical pregnancy rates and costs of intra-uterine insemination (IUI) and in vitro fertilisation (IVF) in women where the same ovarian stimulation led to the development of two or three mature follicles.A randomised controlled clinical trial compared the efficacy of IUI and IVF in a tertiary fertility centre (ISRCTN28780587). Primary outcome measures were fetal heart positive pregnancy rate and cost per live birth. The selection criteria were age: females 18-42 years and males 18-60 years, infertility for one year or more, no IVF or IUI for 12 months prior to the trial, and no coital, tubal or ovulatory disorders, oligospermia, untreated endometriosis or contraindication for multiple pregnancy. All women (n = 102) had the same dose FSH stimulation protocol. Those who developed two or three preovulatory follicles were randomised 3:1 to IUI (n = 33) or IVF (n = 10). IUI or IVF was performed 36 h after hCG administration with single or double embryo transfer on day two.Clinical pregnancy rates (40% vs 12%, P = 0.04) and live birth rate (40% vs 6%, P = 0.01) were higher for IVF than IUI. The cost per live birth was AU$8735 for IVF compared with $42,487 for IUI.This study provides evidence that IVF is more successful and cost-effective than IUI using the same doses of FSH. Further confirmatory studies are required.
- Pregnancy after definitive treatment for Graves' disease - Does treatment choice influence outcome? [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 27.
Women requiring thyroid hormone replacement after definitive therapy (surgery or radioiodine) for Graves' disease who later conceive require an early increase in levothyroxine dose and monitoring of thyroid hormone levels throughout pregnancy. In addition, as TSH receptor antibodies (TRAb) can cross the placenta and affect the fetus, measurement of these antibodies during pregnancy is recommended.To review the management of pregnancies following definitive treatment for Graves' disease in order to assess the rates of maternal hypothyroidism and TRAb measurement.Retrospective chart review of women who had undergone definitive treatment for Graves' disease at a tertiary hospital and subsequently had one or more pregnancies.A total of 29 women were identified, each of whom had at least one pregnancy since receiving definitive treatment for Graves' disease: there were a total of 49 pregnancies (22 in the surgical group and 27 in the radioiodine group). Both groups had high rates of hypothyroidism documented during pregnancy (47 and 50%, respectively). The surgical group was more likely to be euthyroid around the time of conception. Less than half of the women were referred to an endocrinologist or had TRAb measured during pregnancy. Neonatal thyroid function was measured in one-third of live births. One case of neonatal thyrotoxicosis was identified.Adherence to the current American Thyroid Association guidelines is poor. Further education of both patients and clinicians is important to ensure that treatment of women during pregnancy after definitive treatment follows the currently available guidelines.
- A comparison of two different mesh kit systems for anterior compartment prolapse repair. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 25.
Mesh reinforcement is considered an effective method for anterior compartment prolapse repair. Two common methods of mesh reinforcement involve either transobturator fixation (eg Perigee™) or lateral and apical anchoring (eg Anterior Elevate™). The aim of this study was to assess subjective and objective outcomes after Anterior Elevate and Perigee mesh kit surgery.This was a surgical audit of patients after anterior colporrhaphy (AC) with mesh reinforcement, undertaken at three tertiary urogynaecological centres. All patients were assessed for prolapse recurrence, which was defined as either (i) symptoms of prolapse (vaginal lump/dragging), (ii) ICS POPQ ≥ Stage 2, or (iii) bladder descent ≥10 mm below the symphysis pubis on transperineal ultrasound. Mesh co-ordinates and organ descent on Valsalva were determined relative to the inferior symphyseal margin.Two hundred and twenty-nine patients with anterior compartment mesh (138 Perigee, 91 Elevate) were assessed at a median follow-up of 1.09 years (IQR 0.65-2.01). On assessment, 24% (n = 55) had symptoms of prolapse recurrence, 46% (n = 106) had a clinical recurrence, and 41% (n = 95) a recurrent cystocele sonographically. All objective results favoured the Perigee group. The superiority of the Perigee kit remained highly significant (P < 0.0001 for all clinical and ultrasound measures of prolapse recurrence) on multivariate analysis.This retrospective analysis suggests that apical anchoring such as Anterior Elevate mesh system does not necessarily confer an advantage over the original transobturator mesh fixation technique for anterior compartment reconstruction.
- Surgical anatomy in obstetrics and gynaecology: The trainees' perspective. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 25.
The aim of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Integrated and Elective Training Program is to ensure trainees have both clinical and surgical competence. The capacity to recognise important anatomical structures underpins this aim; however, quantification of RANZCOG trainees' anatomical knowledge and their training and assessment is not available.To survey trainees at all levels relating to applied anatomy, training and assessment within the RANZCOG training program.All accredited RANZCOG trainees were invited to participate in an online survey relating to anatomy knowledge, application, assessment and means of improving anatomical training.At the commencement of training, 11% of trainees perceived their anatomical knowledge as adequate and this increased to 77% by the final year of training. For final-year trainees, 78% perceived their anatomy knowledge as sufficient to perform a total abdominal hysterectomy and 87% an ovarian cystectomy or salpingectomy. Eighty-four per cent of trainees perceived the RANZCOG training programme as providing inadequate anatomy teaching. 100% of respondents supported a RANZCOG approved anatomy training course.This is a survey-based study and therefore subjective. Consequently, accurate determination of anatomical knowledge for RANZCOG trainees is inexact.Trainees perceive limitations in their anatomical knowledge. A formalised RANZCOG anatomy course would be of value in providing structured education and assessment of trainees' knowledge and establishing whether there are improvements in surgical competencies.
- Pelvic inflammatory disease in women with endometriosis is more severe than in those without. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 20.
To determine the incidence and severity of acute pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA) in hospitalised women with and without a history of endometriosis.Retrospective analysis of hospital records retrieved for all women hospitalised with PID or TOA between January 2008 and December 2011 in a tertiary referral centre. Women were compared with regard to a history of endometriosis for demographic, clinical and fertility data.26 (15%) of the 174 women hospitalised due to PID or TOA were excluded because of age older than 45 years, leaving 148 for analysis. The mean age was 35.7 ± 9.3 years and mean duration of hospitalisation was 5.9 ± 3.7 days. The women were divided into two groups: Group 1 with endometriosis (n = 21) and Group 2 without endometriosis (n = 127). Women in Group 1 as compared with Group 2 were significantly more likely to have undergone a fertility procedure prior to being admitted to the hospital with PID (9/27 (45%) vs 22/121 (17%), P < 0.001); particularly in vitro fertilisation (IVF) (7/ 27 (33%) vs 12/121 (9%), P < 0.006); Women in Group 1 more frequently experienced a severe and complicated course involving longer duration of hospitalisation (8.8 ± 4.7 vs 4.4 ± 2.3 days, P < 0.0001) and antibiotic treatment failure (10/27 (48%) vs 8/121 (6%), P < 0.0001).Pelvic inflammatory disease in women with endometriosis is more severe and refractory to antibiotic treatment, often requiring surgical intervention. It is likely that endometriosis is a risk factor for the development of severe PID, particularly after IVF treatment.
- Effect of body mass index on latency periods after history-indicated cervical cerclage. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 8.
The impact of maternal body mass index (BMI) on cervical cerclage outcomes is not clear in the literature.We sought to investigate the impact of BMI on history-indicated cervical cerclage outcomes in our unit.We retrospectively reviewed 196 history-indicated cervical cerclage procedures. The results were analysed according to the BMI groups <25, 25-30 and ≥30 kg/m(2) .A total of 122 cases were available for the final analysis. Thirty-two (26.1%) of the women had normal BMI (BMI < 25), 69 (56.5%) were overweight (BMI = 25-30) and 21 (17.4%) were obese (BMI ≥ 30). The mean gestational age of delivery according to BMI groups <25, 25-30 and ≥30 were 37.2 ± 3.1, 36.0 ± 5.3 and 36.0 ± 4.9 weeks (P = 0.591), respectively. The mean latency periods according to BMI groups <25, 25-30 and ≥30 were 24.3 ± 3.2, 21.1 ± 5.1 and 21.4 ± 4.9 weeks (P = 0.171), respectively. We found no correlation between the BMI and latency periods (Spearman's rho = -0.252). The multivariable logistic regression model found no variable to affect preterm birth rates.The BMI has no impact on history-indicated cervical cerclage procedure outcomes. Normal weight, overweight and obese women had similar latency periods after history-indicated cervical cerclage. This high percentage of preterm birth risk necessitates close surveillance of these women for preterm birth.
- Why group & save? Blood transfusion at low-risk elective caesarean section. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 8.
Women undergoing elective caesarean section (CS) routinely have a group and save ordered as part of their preoperative assessment, whereas women with expected vaginal birth do not. Our aim was therefore to determine the rate of blood transfusion at elective CS compared with vaginal birth in a large Australian maternity hospital. A retrospective cohort study was performed using routinely collected de-identified data of 35 477 women, over 4 years, who delivered at the Mater Mothers' Hospital, Brisbane, Australia. After excluding women with established risk factors for transfusion, the likelihood of blood transfusion following elective CS was significantly lower compared to vaginal birth (aOR 0.47 (0.29, 0.77)).
- Vitamin D concentrations in pregnant women with diabetes attending for antenatal care in Far North Queensland. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Feb 8.
Serum concentrations of vitamin D were measured in 101 pregnant women with diabetes, both pre-existing and gestational, who attended for antenatal care in Cairns Base Hospital. Eighty-two (81.2%) had sufficient concentrations of vitamin D, 12 (11.9%) had levels indicating insufficiency and 7 (6.9%) were deficient. These findings contrast with those in the general population of pregnant women in the region, among whom 93.1% have been shown to have sufficient levels. The study contributes to the ongoing debate around the need for universal antenatal vitamin D screening in Australia.