Journal of obstetrics and gynaecology [journal]
- '…a one stop shop in their own community': Medical abortion and the role of general practice. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 21.
The introduction to Australia of modern medical abortion methods, which require less specialist expertise and equipment than the more traditional surgical methods, have brought an as yet unrealised potential to improve access to abortion services.To investigate the potential for expanding the role of general practice in the provision of medical abortion in Victoria.In 2015, in-depth interviews were conducted with 19 experts in abortion service provision in Victoria. A semi-structured interview schedule was used to guide the interviews. Interviews were transcribed verbatim and transcripts analysed thematically.Participants were largely very supportive of the provision of early medical abortion in general practice as a way of increasing abortion access for women, particularly in rural and regional communities. Access to abortion was seen as an essential component of women's comprehensive health care and therefore general practitioners (GPs) were perceived as ideally placed to provide this service. However, this would require development and implementation of new service models, careful consideration of GP and nurse roles, strengthening of partnerships with other health professionals and services in the community, and enhanced training, support and mentoring for clinicians.The application of these findings by relevant health services and agencies has the potential to increase provision of medical abortion services in general practice settings, better meeting the health-care needs of women seeking this service.
- Clinicopathological study of ovarian carcinoid tumours. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 13.
To describe the clinical features, treatment, clinical course and survival rates of women diagnosed with ovarian carcinoid tumours.A retrospective chart review was performed of all patients diagnosed with primary ovarian carcinoid tumours who were managed by the Queensland Centre for Gynaecological Cancer from 1982 to 2015.Eighteen patients were identified with ovarian carcinoid tumours over the 32 years of the study period. Of the 18 patients, 14 were diagnosed with stage 1 disease, two were diagnosed with stage 3 disease and two were diagnosed with stage 4 disease. Carcinoid syndrome was present in two patients. All patients underwent surgical management. Follow-up strategies varied for early stage disease, but no patient with early stage disease received any adjuvant treatment and no patient developed recurrent disease. Patients with advanced stage disease were treated with cytoreductive surgery and chemotherapy. The five year survival was 100% for stage 1 disease, and 25% for stages 3 and 4 disease.The vast majority of carcinoid tumours are diagnosed as an incidental finding. Prognosis for early stage disease is excellent, whether conservative or more extensive surgery with staging was performed, and intensive follow up did not influence survival. Optimal treatment for advanced disease remains unknown and requires further study.
- Experiences of prenatal diagnosis and decision-making about termination of pregnancy: A qualitative study. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 12.
Advances in genetic technologies and ultrasound screening techniques have increased the ability to predict and diagnose congenital anomalies during pregnancy. As a result more prospective parents than ever before will receive a prenatal diagnosis of a fetal abnormality. Little is known about how Australian women and men experience receiving a prenatal diagnosis and how they make their decision about whether or not to continue the pregnancy.This qualitative study aims to describe parental experiences and examine how best to provide support after a prenatal diagnosis.Individual in-depth interviews were conducted with 102 women and men approximately six weeks post-diagnosis of fetal abnormality. Data were elicited using a narrative, chronological approach and women (n = 75) and a sample of male partners (n = 27) were separately interviewed. Thematic analysis, involving a rigorous process of qualitative coding, enabled iterative development and validation of emergent themes. Participants identified that the shock of the diagnosis can be lessened when good care is delivered, by provision of: clear, accurate and respectful communication; empathic, non-judgemental, professional support; timely access to further testing and appointments; seamless interactions with services and administration; appropriate choices about invasive testing; acknowledgment of the enormity and unexpected nature of the diagnosis, and of the subsequent decision-making challenges; and discussion of the myriad feelings likely to emerge throughout the process.This study has demonstrated the importance of providing timely access to accurate information and supportive, non-judgemental care for women and their partners following prenatal diagnosis of a fetal abnormality.
- Management of pregnancies complicated by hypertensive disorders of pregnancy: Could we do better? [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 11.
Hypertensive disorders are among the most common medical problems in pregnancy. Compliance with clinical practice guidelines has potential to translate to significant maternal and perinatal health benefits.To evaluate compliance with Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) clinical guidelines for management of hypertension during pregnancy.Inclusion criteria: women with hypertension in pregnancy who gave birth at a tertiary obstetric centre in 2010. Compliance with SOMANZ guidelines was assessed, as well as uptake of findings from the 'Induction of labour versus expectant monitoring for mild gestational hypertension/pre-eclampsia after 36 weeks' gestation' (HYPITAT) trial.Of 5624 women, 516 (9.2%) were identified with hypertension (49 chronic hypertension (CH); 457 gestational hypertension (GH) or pre-eclampsia (PE)). Thresholds to diagnose hypertension and initiate anti-hypertensive treatment were consistent with SOMANZ recommendations. Among women with CH, only 12.2% were prescribed aspirin prior to 16 weeks as PE prophylaxis. Of women with PE, 37 (18.6%) had known risk factors for development of PE at the initial visit yet only nine (24.3%) received aspirin. Of the 244 women who met HYPITAT inclusion criteria at 36 weeks, 174 (77.7%) were managed expectantly; nine (5.2%) developed severe adverse outcomes.Current management guidelines for hypertension treatment were generally followed, although aspirin prophylaxis was frequently overlooked, resulting in up to 19 excess PE cases. Uptake of recommendations from the HYPITAT trial was low; however, severe complications were fewer than expected. Overall, this suggests that clinicians appropriately weigh up the likely maternal risk compared to infant benefits of deferred delivery in each case, a key recommendation of HYPITAT-II.
- Knowledge, advice and attitudes toward women driving a car after caesarean section or hysterectomy: A survey of obstetrician/gynaecologists and midwives. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 11.
Women are given variable information about when to recommence driving after surgery.To assess obstetrician/gynaecologists' and midwives' knowledge, attitudes and advice about car driving after abdominal surgery including hysterectomy or caesarean section (CS).An anonymous Surveymonkey(™) survey was distributed to accredited trainees and Fellows of the Royal Australian New Zealand College of Obstetricians and Gynaecologists and midwives registered with the Australian College of Midwives by email in November 2013. Demographic information, recommendations about driving, and reasoning behind these recommendations were collected.Nine hundred and seventy-seven clinician responses (15.8%) were analysed: 555 midwives, 92 trainees and 330 Fellows. Ninety-six percent gave advice about driving after surgery. Respondents considered pain (85.6%), medication (73.2%) and mobility (70.5%) the most important factors when advising on resumption of driving. After uncomplicated CS, 19% said they would advise a well woman that she could drive <4 weeks, 18% advised four weeks, 33% advised five to six weeks and 27% did not give a specific timeframe. Similar timeframes were given following hysterectomy. Of each professional group, trainees (49%) and midwives (48%) were more likely to advise waiting five to six weeks to resume driving compared with Fellows (9%) (P < 0.001). Although 71.5% of respondents thought that most women drove before four weeks, only 33.9% of respondents thought driving earlier than advice given was unsafe.Clinicians frequently give advice about driving after surgery. This advice is inconsistent and many advise women not to drive for significant time periods. This study highlights the need for education and research about driving after surgery.
- Ovulatory disorders are an independent risk factor for pregnancy complications in women receiving assisted reproduction treatments. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 11.
Conception using assisted reproduction treatments (ART) has been associated with an increased risk of pregnancy complications. It is uncertain if this is caused by ART directly, or is an association of the underlying factors causing infertility.We assessed the relationship between assisted conception (AC) and maternal or fetal complications in a large retrospective cohort study. In a nested cohort of women receiving infertility treatment, we determined if such risk rests predominantly with certain causes of infertility.Retrospective database analysis of 50 381 women delivering a singleton pregnancy in four public hospital obstetric units in western Sydney, and a nested cohort of 508 women receiving ART at a single fertility centre, in whom the cause of infertility was known.A total of 1727 pregnancies followed AC; 48 654 were spontaneous conceptions. Adjusted for age, body mass index and smoking, AC was associated with increased risk of preterm delivery (OR 1.73, 95% CI 1.50-2.02), hypertension (OR 1.55, 95% CI 1.34-1.82) and diabetes (OR 1.51, 95% CI 1.30-1.75). In the nested cohort, ovulatory dysfunction was present in 145 women and 336 had infertility despite normal ovulatory function. Ovulatory dysfunction was associated with increased risk of diabetes (OR 2.94, 95% CI 1.72-5.02) and hypertension (OR 2.40, 95% CI 1.15-5.00) compared to women with normal ovulatory function.Assisted conception is associated with increased risk of pregnancy complications. This risk appears greatest for women whose underlying infertility involves ovulatory dysfunction. Such disorders probably predispose towards diabetes and hypertension, which is then exacerbated by pregnancy.
- Consanguinity and associated perinatal outcomes, including stillbirth. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 11.
Consanguinity defined as the sexual union between two related individuals has been previously an infrequent practice in Australia, but recently there has been migration from countries with widespread practice of consanguinity. There is limited and conflicting evidence in the literature that suggests consanguinity to be associated with adverse obstetric outcomes.To assess the effect of consanguinity on perinatal outcomes.A retrospective analysis of singleton births over a ten-year period at an Australian tertiary hospital. The data were extracted from the hospital obstetric database and analysed for an association between consanguinity and perinatal outcomes, including stillbirth. Main outcome measures were stillbirth, threatened premature labour, fetal congenital abnormality, perinatal mortality and neonatal outcomes.There were 46 399 singleton births recorded over the ten-year study period, and 44 004 had consanguinity data available. The overall consanguinity rate was 5.5% (n = 2565), which remained consistent over the study period at our institution. Consanguinity was associated with higher rate of threatened premature labour (5.6% vs 4.7%, P = 0.003), fetal congenital abnormality (4.2% vs 3.1%, P = 0.004), perinatal mortality (2.4% vs 1.0%, P < 0.001) and reduced risk of hypertension in pregnancy (5.3% vs 3.4%, P < 0.001). Consanguinity was an independent risk factor for stillbirth with a relative risk of 2.88 (P < 0.001, 95% CI 1.98, 4.18).Women from consanguineous relationships are at higher risk of adverse perinatal outcomes, including stillbirth. Given the 5% prevalence of consanguinity in our obstetric population, these findings have significant implications for preconception counselling, obstetric care and health resource allocation.
- Combined Foley's catheter with vaginal misoprostol for pre-induction cervical ripening: A randomised controlled trial. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 7.
Pre-induction cervical ripening greatly influences the outcome of induction of labour (IOL).To compare the efficacy of combined Foley's catheter and vaginal misoprostol with Foley's catheter or low-dose vaginal misoprostol alone for cervical ripening.Women with a singleton pregnancy admitted at term for cervical ripening and IOL based on clinical indication were randomised into three groups. Oxytocin augmentation was done in the groups as indicated. Significant tests were done using chi square, Fisher's exact and analysis of variance tests.A total of 210 women were randomised into the study. Women in the combined group (Foley's catheter and vaginal misoprostol) had significantly higher postcervical ripening Bishop's score than the women in the other two groups; P = 0.001. Cervical ripening time, induction-delivery time and cervical ripening-delivery interval were significantly shorter in the combined group compared to the other two groups; P = 0.001. Also, women in the combined group required significantly lesser oxytocin augmentation than the other two groups; P = 0.001. There was no difference in Apgar scores at 1 or 5 minutes or in special baby care unit admission among the groups. There were no reported cases of uterine contractile abnormalities or rupture in this study.Combined Foley's catheter and vaginal misoprostol provide a shorter duration to the achievement of cervical ripening.
- Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding? [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jul 1.
This observational case series in 65 premenopausal women with abnormal uterine bleeding evaluated whether transvaginal ultrasound followed by saline infusion sonohysterography (SIS) prevented unnecessary hysteroscopy. Although SIS indicated that hysteroscopy was unnecessary in eight women, this benefit was offset by the invasive nature of the scan, the number of endometrial abnormalities falsely detected by SIS and the cost of the additional investigation.
- Intrauterine anaesthetic after hysteroscopy to reduce post-operative pain - A double blind randomised controlled trial. [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2016 Jun 30.
Pain after hysteroscopy is usually minimal but some women need additional analgesia while in the recovery ward and some require overnight hospital admission to control pain. Intrauterine installation of an anaesthetic after hysteroscopy may reduce pain.To see if intrauterine levobupivacaine reduces post-procedure pain, need for analgesia and allow earlier return to normal activity.This was a double-blind randomised controlled trial. Women having hysteroscopy under general anaesthesia were allocated to receive intrauterine instillation of levubupivacaine or normal saline at the end of the procedure. Women were assessed in the recovery ward by a verbal descriptor pain scale and need for additional analgesia and followed up on day 3 to further assess pain and return to normal activity.There were no significant differences in demographic characteristics or indication for surgery between the 224 women in the study group or the 214 women in the control group. At two hours post-procedure, 156/224 (70%) study women versus 119/214 (56%) control women had no pain; (relative risk (RR) 0.68 and 95% confidence interval (CI) 0.53-0.87). There were 182/224 (81%) study women versus 154/214 (72%) control women with a pain score < 5 (RR 0.67; 95% CI 0.47-0.95). Fewer women in the study group required additional analgesia 54/224 (24%) versus 88/214 (41%) (RR 0.58; 95% CI 0.44-0.78). There was no significant difference between groups with regards to pain at 24 h post-procedure or return to activity.Intrauterine instillation of levobupivacaine reduced post-procedure pain and need for additional pain relief.