Showing papers in "Australian & New Zealand Journal of Obstetrics & Gynaecology in 2013"

Clinical evaluation of a first trimester algorithm predicting the risk of hypertensive disease of pregnancy

Abstract: Background: The aim of this study is to validate the Fetal Medicine Foundation (FMF) multiple logistic regression algorithm for prediction of risk of pre-eclampsia in an Australian population This model, which predicts risk using the population rate of pre-eclampsia, a variety of demographic factors, mean maternal arterial blood pressure (MAP), uterine artery PI (UtA PI) and pregnancy-associated plasma protein A (PAPP-A), has been shown to predict early-onset preeclampsia (delivery prior to 34 weeks) in 95% of women at a 10% false-positive rate Methods: All women who attended first trimester screening at the Royal Prince Alfred Hospital had their body mass index (BMI), MAP and UtA PI assessed in addition to factors traditionally used to assess aneuploidy (including PAPP-A MoM) After delivery, risks of early-onset (delivery prior to 34 weeks) pre-eclampsia, late pre-eclampsia and gestational hypertension were calculated using the FMF risk algorithm Results: A total of 3099 women were screened and delivered locally 3066 (989%) women had all data to perform preeclampsia screening available This included 3014 (983%) women with a live birth, where risks of early pre-eclampsia were calculated Twelve women were delivered before 34 weeks because of early pre-eclampsia with a prevalence of early pre-eclampsia of 1 in 256 pregnancies Risks generated through the use of maternal history, MAP, UtA PI and PAPP-A detected 417 and 917% of early pre-eclampsia at a false-positive rate of 5 and 10%, respectively Conclusions: This study shows that the FMF early pre-eclampsia algorithm is effective in an Australian population

Prevalence and determinants of complementary and alternative medicine use during pregnancy: results from a nationally representative sample of Australian pregnant women.

Abstract: Background Pregnant women have been identified as high users of complementary and alternative medicine (CAM). However, no research to date has provided a detailed analysis of the prevalence and determinants of CAM consumption amongst pregnant women. Aim To examine the prevalence and determinants of CAM use by pregnant women, utilising a national representative sample. Methods The study sample was obtained via the Australian Longitudinal Study on Women's Health. This paper is based on a sub-study of 1,835 pregnant women, administered in 2010. The women answered questions about CAM use, demographics, pregnancy-related health concerns and health service utilisation. Results Complementary and alternative medicine use was found to be high with 48.1% (n = 623) of pregnant women consulting a CAM practitioner and 52.0% (n = 842) of women using CAM products (excluding vitamins and minerals) during pregnancy. CAM practitioner visits were more likely for selected pregnancy-related health concerns, namely back pain or back ache, neck pain and labour preparation. Women were less likely to consult a CAM practitioner if they suffered with headaches/migraines. Employment was also found to be predictive of pregnant women's visits to a CAM practitioner. Significant health history and demographic predictors of CAM product use were tiredness and fatigue, embarking on preparation for labour and having a university education. Conclusion Most pregnant women are utilising CAM products and/or services as part of their maternity care and obstetricians, general practitioners and midwives need to enquire with women in their care about possible CAM use to help promote safe, effective coordinated maternity care.

Pelvic floor trauma in childbirth.

Abstract: The investigation of female pelvic floor function and anatomy is moving from the fringes to the mainstream of urogynaecology and female urology, and it is becoming increasingly relevant for obstetrics. We are coming to realise that pelvic floor trauma in labour is common, usually overlooked, and a major factor in the causation of pelvic organ prolapse. Modern imaging methods such as magnetic resonance and 3D/4D ultrasound have enabled us to diagnose such trauma reliably and accurately, most commonly in the form of an avulsion of the puborectalis muscle; that is, a disconnection of the muscle from its insertion on the os pubis. Such damage to the levator muscle is macroscopically evident and can also be palpated, a skill that is available to every clinician, requiring neither investment nor specialised equipment. In this review, I will describe pelvic floor assessment by palpation and ultrasound and illustrate the commonest abnormalities and their clinical consequences. This paper will not focus on magnetic resonance imaging due to technical restrictions, cost and access issues in most jurisdictions, and because several papers have recently shown that ultrasound is at least as effective in diagnosing such trauma. Anal sphincter trauma is generally well covered in the literature and hence not subject of this review.

The effects of an increasing gradient of maternal obesity on pregnancy outcomes

Abstract: Background Maternal obesity is becoming more prevalent in obstetrics and has been linked with pregnancy complications and perinatal outcomes. The gradient of association of increasing maternal obesity and pregnancy outcome is less well studied. Aims To determine the influence of an increasing gradient of obesity, categorised by the body mass index (BMI), on pregnancy outcomes and to determine the BMI thresholds at which pregnancy complications occur. Materials and Methods Secondary analysis of an observational study on pregnancy and obesity. The BMI at the first prenatal visit was grouped into BMI categories (<18.5, 18.5–24.9, 25–29.9, 30–34.9, 35–39.9, 40–44.9, and ≥45) and compared with the normal category (BMI 18.5–25) for pregnancy outcomes and adjusted for known cofounders. Results A total of 4,490 women were stratified into the pre-pregnancy BMI categories: <18.5 (n = 276), 18.5–24.9 (n = 1965), 25–29.9 (n = 1072), 30–34.9 (n = 551), 35–39.9 (n = 317), 40–44.9 (n = 167), and ≥45 (n = 142). The maternal demographics were significantly different between BMI groups (P < 0.001). Compared to women with a normal BMI, different BMI thresholds convey an increased risk for specific pregnancy complications: BMI≥25 for gestational diabetes (P < 0.001), induction of labour (P < 0.001), caesarean delivery (P < 0.001) and large for gestational age neonate (P < 0.001); BMI≥30 for pre-eclampsia (P < 0.001), wound infection (P = 0.001), shoulder dystocia (P < 0.001) and meconium (P = 0.006); BMI≥35 for urinary tract infection (P < 0.001) and postpartum haemorrhage (P < 0.001); BMI≥40 for endometritis (P < 0.001). Conclusions Body mass index thresholds exist at which pregnancy complications significantly increase and they vary depending on outcome ranging from BMI ≥25 to a BMI ≥40.

Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009.

Abstract: Background Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. Aims To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 – 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. Methods Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. Results The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. Conclusion In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS.

Emergency obstetric simulation training: how do we know where we are going, if we don't know where we have been?

Abstract: Background Obstetric emergencies contribute significantly to maternal morbidity and mortality. Current training in the management of obstetric emergencies in Australia and internationally focusses on utilising a multidisciplinary simulation-based model. Arguments for and against this type of training exist, using both economic and clinical reasoning. Aims To identify the evidence base for the clinical impact of simulation training in obstetric emergencies and to address some of the concerns regarding appropriate delivery of obstetric emergency training in the Australian setting. Methods A literature search was performed to identify research undertaken in the area of obstetric emergency training. The initial literature search using broad search terms identified 887 articles which were then reviewed and considered for inclusion if they provided original research with a specific emphasis on the impact of training on clinical outcomes. Results Ninety-two articles were identified, comprising evidence in the following clinical situations: eclampsia, shoulder dystocia, postpartum haemorrhage, maternal collapse, cord prolapse and teamwork training. Evidence exists for a benefit in knowledge or skills gained from simulation training and for the benefit of training in small units without access to high-fidelity equipment or facilities. Conclusions Evidence exists for a positive impact of training in obstetric emergencies, although the majority of the available evidence applies to evaluation at the level of participants’ confidence, knowledge or skills rather than at the level of impact on clinical outcomes. The model of simulation-based training is an appropriate one for the Australian setting and should be further utilised in rural and remote settings.

Prenatal screening for Down syndrome in Australia: Costs and benefits of current and novel screening strategies

Abstract: Objective To analyse the cost-effectiveness and performance of noninvasive prenatal testing (NIPT) for high-risk pregnancies following first-trimester screening compared with current practice. Methods A decision tree analysis was used to compare the costs and benefits of current practice of first-trimester screening with a testing pathway incorporating NIPT. We applied the model to 32 478 singleton pregnancies screened between January 2005 and December 2006, adding Medicare rebate data as a measure of public health system costs. The analyses reflect the actual uptake of screening and diagnostic testing and pregnancy outcomes in this cohort. Results The introduction of NIPT would reduce the number of invasive diagnostic procedures and procedure-related fetal losses in high-risk women by 88%. If NIPT was adopted by all women identified as high risk by first-trimester combined screening, up to 7 additional Down syndrome fetuses could be confirmed. The cost per trisomy 21 case confirmed, including NIPT was 9.7% higher ($56 360) than the current prenatal testing strategy ($51 372) at a total cost of $3.91 million compared with $3.57 million over 2 years. Conclusion Based on the uptake of screening and diagnostic testing in a retrospective cohort of first-trimester screening in Western Australia, the implementation of NIPT would reduce the number of invasive diagnostic tests and the number of procedure-related fetal losses and increase the cost by 9.7% over two years. Policy planning and guidelines are urgently required to manage the funding and demand for NIPT services in Australia.

Clinical and psychological impact after surgical, medical or expectant management of first-trimester miscarriage – a randomised controlled trial

Abstract: Background The management of first-trimester miscarriage has been studied extensively in recent years. However, relatively little attention has been focussed on woman's satisfaction and psychological impact from different treatment modalities. Aim To investigate the clinical and psychological outcomes of surgical, medical and expectant management of first-trimester miscarriage. Materials and Methods A prospective randomised controlled trial of 180 women suffering miscarriage managed by either surgical evacuation, medical evacuation or expectant management was conducted in a university-affiliated, tertiary referral hospital. The complete miscarriage rate, clinical symptomatology, complications, women's satisfaction and the psychological impact were evaluated. Results Women in surgical evacuation (98.1%) had a significantly higher complete miscarriage rate when compared with medical evacuation (70%) and expectant management (79.3%). Women who had surgical evacuation had significantly shorter duration of vaginal bleeding, but higher rate of infection. Women who had medical evacuation had significantly more gastrointestinal symptoms. Despite differences in efficacy and complication profile, there was no significant difference in satisfaction among groups. There were no significant differences in terms of psychological well-being, depression scores, anxiety level, fatigue symptoms as measured in General Health Questionnaire-12, Beck Depression Inventory, Spielberger's State Anxiety Inventory and fatigue scale at treatment and four weeks after treatment. However, women with active intervention had greater post-traumatic stress symptoms as measured in Chinese version of Impact of Event Scale – Revised at the time of treatment when compared with women in expectant management. Conclusion Without substantial differences in the clinical and psychological impact between different treatment modalities, a more conservative approach with expectant management for miscarriage may be an option for women.

Does occiput posterior position in the second stage of labour increase the operative delivery rate

Abstract: Objectives To assess the impact of occipito-posterior position in the second stage of labour on operative delivery. Methods Double-blinded prospective cohort study of ultrasound determined occiput-posterior position during the second stage of labour compared with occiput-anterior position. The primary outcome was operative (caesarean section, forceps or vacuum) delivery. Results A total of 68% (13/19) women in the occiput-posterior group, and 27% (39/141) in the occiput-anterior group had an operative delivery (unadjusted: P < 0.001). Caesarean section was performed in 37% and 5%, respectively (P < 0.001). The occiput-posterior group had a longer second stage (mean 2 h 59 minutes vs 1 h 54 minutes; P = 0.001) and larger infants (mean 3723 g vs 3480 g, P = 0.024). In the logistic regression, occiput-posterior position, nulliparity, abnormal second stage cardiotocograph and epidural analgesia were independent predictors for operative delivery. Conclusions Occiput-posterior position early in the second stage of labour is strongly associated with operative delivery. There is potential to explore interventions such as manual rotation.

Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect?

Abstract: Aim This study was undertaken to investigate whether female pelvic organ prolapse repair changes levator hiatal biometry. Methods Retrospective analysis of clinical and translabial ultrasound volume data of women who underwent prolapse surgery at a tertiary urogynaecological unit between March 2005 and April 2009. Data sets of 81 women were analysed who had undergone an interview, clinical assessment using POP-Q staging and 3D translabial ultrasound before and after prolapse surgery. Imaging data were obtained preoperatively and 3–12 months postoperatively to determine potential changes in levator hiatal dimensions. Type of surgery, mesh use, symptoms of recurrent prolapse, age, significant recurrent prolapse and length of follow-up were tested in linear regression as potential confounders. Results The mean preoperative hiatal area on Valsalva was 31.9 cm2 (range 13.5–58.1 cm2, SD 10.0 cm2). Mean postoperative hiatal area on Valsalva was 28.9 cm2 (range 13.9–47.4 cm2; SD 7.3 cm2), which implies a significant reduction of 9% (P = 0.001). None of the tested potential confounders were found to be significantly associated with a perioperative change in hiatal area on Valsalva on linear regression analysis. Conclusions Surgery for female pelvic organ prolapse is associated with a small but significant reduction in hiatal area, but abnormal hiatal distensibility persists in most cases. This suggests that excessive hiatal distensibility is more likely the cause rather than the effect of prolapse.

Noninvasive prenatal testing for trisomy 21: Challenges for implementation in Australia

Abstract: The term ‘Non invasive prenatal testing’ is used to describe the rapidly emerging molecular technologies related to cell free DNA assessment that are being applied to prenatal screening for Down syndrome and other chromosomal abnormalities. This technology is now available to Australian women through a number of off-shore laboratories. We review the basis of this method of testing, the literature describing the effectiveness of NIPT in screening for trisomy 21 and the potential methods by which this tool could be incorporated into current screening strategies.

Subclinical hypothyroidism as a risk factor for placental abruption: evidence from a low-risk primigravid population.

Abstract: Background Subclinical thyroid hypofunction in pregnancy has been shown to have an association with neurodevelopmental delay in the offspring. It is unclear whether obstetric factors may account for this observation. Aims To establish the prevalence of subclinical hypothyroidism (SCH) in a low-risk primigravid population and to explore its association with obstetric sequelae. Materials and Methods Nine hundred and fifty-three primigravid women had thyroid hormone indices analysed in the early second trimester. Delivery and neonatal outcomes were available for 904 women who met the criteria for inclusion in the study. Women with subclinical hypothyroidism (thyroid-stimulating hormone (TSH) values at or above the 98th percentile with a normal free thyroxine (fT4)) or isolated maternal hypothyroxinaemia (fT4 level at or below the second percentile with a normal-range TSH) were compared with biochemically euthyroid controls. Chi-squared test and analysis of variance were used for statistical analysis. Results The prevalence of SCH or isolated maternal hypothyroxinaemia was 4%. Positivity for antithyroid peroxidase (TPO) or antithyroglobulin (ATG) antibodies correlated with SCH status (P = 0.02). Placental abruption was observed more commonly in the setting of either SCH or isolated maternal hypothyroxinaemia when compared with euthyroid controls (P = 0.02 and 0.04, respectively). Conclusions Subclinical hypothyroidism and isolated maternal hypothyroxinaemia are associated with placental abruption. The observation of these effects in this healthy low-risk population lends weight to the case for antenatal screening for diminished thyroid reserve.

Independent risk factors for infants who are small for gestational age by customised birthweight centiles in a multi‐ethnic New Zealand population

Abstract: Background: Infants born small for gestational age (SGA) by customised birthweight centiles are at increased risk of adverse outcomes compared with those SGA by population centiles. Risk factors for customised SGA have not previously been described in a general obstetric population. Aim: To determine independent risk factors for customised SGA in a multi-ethnic New Zealand population. Methods: We performed a retrospective cohort analysis of prospectively recorded maternity data from 2006 to 2009 at National Women’s Health, Auckland, New Zealand. After exclusion of infants with congenital anomalies and missing data, our final study population was 26,254 singleton pregnancies. Multivariable logistic regression analysis adjusted for ethnicity, body mass index, maternal age, parity, smoking status, social deprivation, hypertensive disease, antepartum haemorrhage (APH), diabetes and relevant pre-existing medical conditions. Results: Independent risk factors for SGA included obesity (adjusted odds ratio 1.24 [95% CI 1.11–1.39] relative to normal weight), maternal age 35 years (1.16 [1.05–1.30] relative to 20–29 years), nulliparity (1.13 [1.04–1.24] relative to parity 1), cigarette smoking (2.01 [1.79–2.27]), gestational hypertension (1.46 [1.21–1.75]), pre-eclampsia (2.94 [2.49– 3.48]), chronic hypertension (1.68 [1.34–2.09]), placental abruption (2.57 [1.74–3.78]) and APH of unknown origin (1.71 [1.45–2.00]). Gestational diabetes (0.80 [0.67–0.96]) and type 1 diabetes (0.26 [0.11–0.64]) were associated with reduced risk. Conclusions: We report independent pregnancy risk factors for customised SGA in a general obstetric population. In contrast to population SGA, obesity is associated with increased risk. Our findings may help identify pregnancies that require increased fetal growth surveillance.

Outcome following selective fetal reduction in monochorionic and dichorionic twin pregnancies discordant for structural, chromosomal and genetic disorders.

Abstract: Background To investigate the indications for offering selective fetal reduction in monochorionic (MC) and dichorionic (DC) twins and to correlate obstetric outcome with the antenatal procedure. Methods All cases of MC and DC twins discordant for structural anomalies and for chromosomal/genetic abnormalities were included. Selective reductions performed for twin-to-twin transfusion syndrome or growth restriction were excluded. For DC twins, feticide was achieved using intracardiac injection of potassium chloride (KCl). For MC twins, bipolar cord occlusion (BCO), interstitial laser or radiofrequency ablation (RFA) was used. Results There were 121 twin pregnancies discordant for structural and chromosomal abnormalities. Only 88 (56 were MC twins and 32 were DC twins) had selective reduction. For both MC and DC twins, the leading indication for selective reduction was structural anomalies with CNS malformations the most common. For all MC fetal reduction techniques, the overall pregnancy loss rate ( 87% and 100% for DC twins. Conclusions Selective reduction in MC pregnancies carries an increased procedure-related and preterm delivery rate compared with DC pregnancies. The main indication for selective reduction was structural malformations, with a predominance of CNS anomalies. © 2013 The Authors ANZJOG

Prevention of mother-to-child transmission of hepatitis B virus (HBV) during pregnancy and the puerperium: Current standards of care

Abstract: Background Mother-to-child transmission (MTCT) of hepatitis B virus continues to occur despite the interventions of hepatitis B vaccination and immunoglobulin. The most significant risk factor in transmission is high maternal viral load. Being aware of viral replicative activity permits risk stratification and allows the opportunity for additional preventative measures such as antiviral therapy. Methods Retrospective audit of investigations and clinical management among hepatitis B surface antigen–positive pregnant women from three maternity services across Victoria over a five-year period from 2006 to 2011. Results Over the study period at the three institutions, there were 46,855 births, and 398 hepatitis B-positive pregnant women. 87% of the women were non-Australian-born. Viral load testing was performed in 90%). Conclusion There is scope for considerable improvement in referral and assessment of pregnant women with hepatitis B infection. Guidelines addressing the issue of maternal viral replicative status and the need for antiviral therapy may assist in guiding clinical management.

A prospective longitudinal study on rotation thromboelastometry in women with uncomplicated pregnancies and postpartum.

Abstract: BACKGROUND: Rotation thromboelastometry (ROTEM) is an easy, fast and complete method of measuring coagulation. AIMS: Our goal was to obtain longitudinal values on ROTEM in uncomplicated pregnancies and in the puerperium. MATERIALS AND METHODS: Healthy women, who visited our outpatient clinic for antenatal checks and who accomplished an uncomplicated pregnancy were tested three times during pregnancy and one time postpartum. Intrinsic and extrinsic pathway tests were carried out. RESULTS: In total, 62 women were analysed, and 298 measurements were taken. With increasing gestational age, there are significant changes towards hypercoagulability. CONCLUSION: This study provides a better knowledge about physiological changes in ROTEM measurements during pregnancy. These normative data may serve as assistance for future studies and interventions.

Immediate post‐partum initiation of intrauterine contraception and implants: A review of the safety and guidelines for use

Abstract: Women are particularly susceptible to unintended pregnancies in the first year after birth, with 10-44% of pregnancies being unintended. In many settings, post-partum birth control is initiated at the six-week post-partum visit but most women are sexually active by this time, and ovulation can occur as early as day 28. There are many potential advantages of initiating intrauterine contraception (IUC) and implants use in the immediate post-partum period, including their high efficacy and reversibility which rivals sterilisation as well as ease of access to providers trained in their insertion. This review aims to describe the benefits and risks of use of IUC and implants in the immediate post-partum period. It discusses the maternal and infant health safety issues of early initiation of the progestogen containing methods and provides a critical review of existing international guidelines. Overall low rates of adverse effects such as pain, bleeding, infection and perforation, are documented to occur in all studies regardless of the timing or route of IUC insertion. Expulsion rates are significantly higher immediately after vaginal delivery compared to interval insertions, but are no higher after insertion at caesarean section. Post-partum implants appear to have the same side effects as interval insertions, and to date, no adverse impact on breast milk or infant growth has been demonstrated. Most international evidence-based guidelines support the initiation of IUC and progestogen containing contraceptive methods in the immediate post-partum period as they regard the advantages of provision at this time to outweigh the risks.

Lymphovascular space invasion is highly associated with lymph node metastasis and recurrence in endometrial cancer.

Abstract: Background Lymphovascular space invasion (LVSI) has been evaluated as a predictor for nodal metastasis or poor survival in endometrial adenocarcinoma. Aims To evaluate whether LVSI is a prognostic factor for lymph node metastasis and relapse of disease in endometrial adenocarcinoma. Materials & Methods We retrospectively analysed the medical records of 438 women with endometrial adenocarcinoma treated by surgical staging, including pelvic and paraaortic lymph node dissection, between January 1996 and July 2011. Results One hundred sixty-three women (37.2%) were LVSI-positive and 275 (62.8%) were negative. LVSI-positive women were significantly older and showed more advanced stage, poorer differentiation, and a higher frequency of non-endometrioid histology type, myometrial invasion, and positive peritoneal cytology than LVSI-negative women. Surgeries by laparotomy rather than laparoscopy and more adjuvant therapies were conducted in LVSI-positive women. The median number of pelvic and paraaortic lymph nodes removed were not different, but LVSI-positive patients showed more lymph node metastases. The LVSI-positive group also showed a higher recurrence of disease and lower survival rates than the LVSI-negative group. Negative predictive values of LVSI for lymph node metastasis and recurrence of disease were 96.4 and 97.1%, respectively. In multivariate analysis, LVSI did not influence overall or disease-free survival after adjusting for several confounding factors. Conclusions In the cases that the nodal status has not been assessed in endometrial adenocarcinoma, the presence of LVSI may be a reasonable surrogate in addition to other risk factors, in determining the need for adjuvant therapy.

Risk of postpartum uterine synechiae following uterine compression suturing during postpartum haemorrhage.

Abstract: Background Uterine compression suturing is considered a successful, safe, inexpensive and simple ‎method for the conservative treatment of atonic postpartum haemorrhage (PPH). However, insufficient data are available about the potential risk of subsequent intrauterine ‎synechiae (IUS). Aim To determine the risk of postpartum uterine synechiae in women who received isolated uterine compression suturing for the management of major uncontrolled PPH. Materials & Methods All women with major PPH from May 2005 to June 2011 were reviewed retrospectively. Diagnostic hysteroscopy was performed to assess the uterine cavity in the 27 women who successfully underwent isolated uterine compression suturing for major atonic PPH and fulfilled the study inclusion and exclusion criteria. Results Among the 27 women who underwent isolated uterine compression suturing, 5 (18.5%) were found to have IUS on hysteroscopic examination. The mode of delivery for all women who developed IUS was caesarean section. Among these five women, three had mild IUS, one had moderate IUS and one had severe IUS. All adhesions were later successfully resected by hysteroscopy, except for one case with dense IUS. Conclusions Uterine compression suturing was found to be associated with a risk of postpartum uterine synechiae formation, which may subsequently affect future fertility.

Delivery at 37 weeks' gestation is associated with a higher risk for child behavioural problems

Abstract: BACKGROUND: Advances in obstetric care have been accompanied by increasing rates of intervention which often involve elective delivery at 37 weeks, soon after term gestation has been achieved. AIM: The aim of this study was to examine the behavioural sequelae for children born at this early term gestational age compared with those born at later weeks. METHODS: The Western Australian Pregnancy Cohort (Raine) Study provided comprehensive obstetric data from 2900 pregnancies. Offspring were followed up at ages two, five, eight, 10, 14 and 17 years using the parent report Child Behaviour Checklist (CBCL) with clinical cutoffs for overall, internalising (withdrawn, somatic complaints, anxious/depressed) and externalising (delinquent, aggressive) behaviour (T-score ≥ 60). We used longitudinal logistic regression models incorporating generalised estimating equations (GEE) with step-wise adjustment for ante-, peri- and postnatal confounding factors. RESULTS: Approximately 9% of our cohort was born within the range of 37(0/7) and 37(6/7) weeks. Those born at 37 weeks' gestation were at increased risk for overall (OR = 1.43, 95% CI = 1.02, 2.01) and externalising (OR = 1.42, 95% CI = 1.01, 2.01) behavioural problems in the fully adjusted model when compared with infants born from 39 weeks onwards. Infants born late preterm (34-36 weeks) and at 38 weeks did not show a significantly increased risk for behavioural problems. CONCLUSION: Infants born at 37 weeks' gestation are at increased risk for behavioural problems over childhood and adolescence compared with those born later in gestation. We suggest that 37 weeks' gestation may not be the optimal cutoff for defining perinatal risk as it applies to behavioural development. Language: en

Risk of malignancy in women who underwent hysterectomy for uterine prolapse.

Abstract: Aims: To evaluate the risk of missing a malignancy in surgical specimens following hysterectomy for uterine prolapse ifroutine pathological examination is not performed. Additionally, information on the risk of missing an hithertounsuspected malignancy if uterine preservation is the preferred management option will be provided.Materials and Methods: A retrospective study was performed on all cases of surgery performed for uterine prolapse in atertiary referral institution from 2003 to 2011. Those with confirmed malignancy before operation were excluded. Thestudy subjects had their clinical history, investigations, the type of operations and histopathology report analysed. Theywere classified into symptomatic or asymptomatic, depending on whether they reported symptoms that were suggestive ofuterine malignancy.Results: A total of 640 women were studied. Three cases of hitherto unsuspected uterine malignancy were found, givingan incidence of 0.47%. Among the 456 asymptomatic women, both pre- and postmenopausal, the risk of incidentalmalignancy was 0.22%. Within the postmenopausal group, risk of incidental malignancy was 0.26%. Another 3 cases ofuterine premalignant conditions were identified, giving an overall risk of premalignant and malignant uterine condition of0.94%. Five cases of cervical intra-epithelial neoplasia were found, contributing to a risk of 0.78%.Conclusions: The risk of missing an uterine malignancy in patients with uterine prolapse is low if appropriateinvestigations are carried out prior to surgery. If hysterectomy is to be performed, we recommend that all surgicalspecimens be subjected to histopathological examination.Key words: Chinese, malignancy, menopausal, uterine conservation, uterine prolapse.

Corona mortis: Anatomical data and clinical considerations

Abstract: Background Minimally invasive procedures, such as the TVT-Secur™, have been linked to injury to the corona mortis. Injury during the insertion of the TVT-Secur™ happens due to the vessel's position close to the place of the margin (25–30 mm from the symphysis pubis). Aims Systematic description of the aberrant vessel anatomy so as to help gynaecologists determine the risk of peri- and postoperative complications during the TVT-Secur™ and related procedures. Methods In a cadaver study, the lesser pelvis of ten female cadavers with venous or arterial coronae mortis was dissected. The origin, diameter and course of the aberrant vessels, as well as the distance from the symphysis pubis, were documented. Results Arterial coronae mortis were found in eight hemipelvises. All vessels originated from the ipsilateral inferior epigastric artery and all crossed over the superior pubic rami. Average distance from the symphysis pubis was 52.4 mm. Average vessel diameter was 3 mm. Venous coronae mortis were identified in ten hemipelvises. Eight drained into the external iliac and four into the inferior epigastric artery. Nine vessels crossed over the superior pubic rami. Average distance from the symphysis pubis was 46.7 mm. Average vessel diameter was 3.13 mm. Conclusion Although individual variation makes direct contact with the vessel possible, in most cases there is a window of eight millimetres at least between the margin of the TVT-Secur™ and most aberrant veins. Possible aberrant arteries seem to lie even further.

Role of postmenopausal bleeding pattern and women's age in the prediction of endometrial cancer

Abstract: Background Women with postmenopausal bleeding should be evaluated efficiently to exclude endometrial carcinoma Aims To estimate the risk of endometrial cancer using individual case characteristics among women with postmenopausal bleeding in whom the endometrial thickness is >4 mm Methods Women with postmenopausal bleeding underwent clinical evaluation followed by transvaginal ultrasonography and endometrial biopsy Clinical evaluation included age, body mass index, duration of menopause, number of bleeding episodes and amount of bleeding Results This study included 142 women, and endometrial carcinoma was found in 18 (127%) Older age, higher body mass index, longer duration of menopause, longer lasting bleeding episodes, higher amount of bleeding and recurrent bleeding episodes were the clinical characteristics associated with endometrial cancer However, multivariate analysis revealed >55 years of age during postmenopausal bleeding, history of recurrent bleeding episodes and bleeding exceeding 5 pads per day in each episode as significant parameters, which predicted the presence of endometrial cancer among women with postmenopausal bleeding Conclusions Prompt evaluation is required in women with postmenopausal bleeding to exclude endometrial cancer Transvaginal ultrasonography is a reasonable first-line approach, and invasive sampling is required when ultrasonographic endometrial thickness is above 4 mm However, about 90% of women with postmenopausal bleeding will finally be found to have a nonmalignant condition Therefore, women who are at increased cancer risk should further be distinguished This may be achieved using individual patient characteristics that result in a more accurate evaluation strategy with lower rates of unnecessary invasive procedures

Pelvic floor muscle training improves quality of life of women with urinary incontinence: a prospective study.

Abstract: Background: Women suffering from urinary incontinence have impaired quality of life (QoL). Pelvic floor muscletraining (PFMT) has been recommended to be the first-line treatment for them.Aims: This study evaluated the role of (PFMT) in women with urinary incontinence.Materials and Methods: All women suffering from urinary incontinence without pelvic organ prolapse who attended theurogynaecology unit of a university hospital from January 2009 to June 2010 were recruited. Urinary symptoms andimpact on QoL were assessed using the Chinese validated Urogenital Distress Inventory short form (UDI-6) andIncontinence Impact Questionnaire short form (IIQ-7) before and after PFMT. Urodynamic studies (UDS) were used todifferentiate the diagnoses of urinary incontinence.Results: Three hundred and seventy-two women, aged 52.3 10.8 years and practised PFMT for 9.9 7.3 months,completed the study. Over 65% recorded improvement in both UDI-6 and IIQ-7. Stratified for urodynamic diagnosis,stress incontinence group and those who had no UDS abnormality had significant improvement in their urinary symptomsand QoL after PFMT. UDI-6 and IIQ-7 also improved significantly after PFMT in groups where the clinical presentationwas stress incontinence, overactive bladder symptoms or mixed urinary incontinence. Age was not associated with asignificant difference in the response to PFMT.Conclusions: Pelvic floor muscle training appears to be an effective first-line intervention for improving urinary symptomsand QoL of women presenting with urinary incontinence. Future studies on long-term effectiveness and cost-effectivenessare also required.Key words: Chinese women, Incontinence Impact Questionnaire short form, pelvic floor muscle training, urinaryincontinence, Urogenital Distress Inventory short form.

Multiple daily injections of insulin versus continuous subcutaneous insulin infusion for pregnant women with type 1 diabetes.

Abstract: Aims The aim was to evaluate the outcome of pregnancies with type 1 diabetes (T1DM) treated from the first trimester with continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI). Methods In a retrospective, observational study, we matched 64 CSII patients for age, age at onset and duration of diabetes and HbA1c in the first trimester with 64 MDI pregnancies. We analysed carbohydrate metabolism, insulin requirements, development of PIH, progression of retinopathy and fetal outcome. Results In CSII group, we found a significantly smaller insulin requirement both at the beginning of pregnancy and before delivery, significant decrease in HbA1c levels and significantly smaller number of hypoglycaemic episodes in the second trimester and significantly more hyperglycaemic episodes in the first trimester. In both groups, maternal, fetal and perinatal outcomes were similar and the number of hypo- and hyperglycaemic episodes decreased throughout pregnancy. Conclusion Continuous subcutaneous insulin infusion (CSII) treatment in pregnant women with type 1 diabetes is associated with a reduced number of hypoglycaemia and decreased insulin requirement. We noted no difference in perinatal outcome comparing women on multiple insulin injections with those on continuous insulin infusion.

Perceived changes in the knowledge and confidence of doctors and midwives to manage obstetric emergencies following completion of an Advanced Life Support in Obstetrics course in Australia.

Abstract: Background The Advanced Life Support in Obstetrics (ALSO) course is an internationally recognised interprofessional course to support health professionals to develop and maintain the knowledge and skills to manage obstetric emergencies. Aims This study investigated changes in confidence and perceived changes in the knowledge of doctors and midwives to manage specific obstetric emergency situations following completion of an ALSO course in Australia. Methods A prospective repeated-measures survey design was used to survey 165 course attendees from four Australian states pre- and postcourse and at six weeks (n = 101). Data were analysed using a Friedman two-way repeated-measures analysis of variance and the Wilcoxon signed rank test. Results There was a significant improvement in confidence and perceived knowledge of the recommended management of all 17 emergency situations immediately postcourse (P < 0.001) and at six weeks postcourse (P < 0.001) when compared to precourse levels for both groups of health professionals. However, a significant decrease in knowledge and confidence for many emergency situations from immediately postcourse to six weeks postcourse (P < 0.05) was also observed in both groups. Conclusions Completion of the Australian ALSO course in Australia has a positive effect on the confidence and perceived knowledge of doctors and midwives to manage obstetric emergencies. However, there needs to be some means of reinforcing the effects of the course for longer term maintenance of knowledge and confidence.

A threefold increase in gestational diabetes over two years: review of screening practices and pregnancy outcomes in Indigenous women of Cape York, Australia.

Abstract: Background: Australian Aboriginal women have a high prevalence of type 2 diabetes (T2DM) in pregnancy and gestational diabetes (GDM). Aims: To review how screening practice affects the pregnancy data of all Indigenous women and their newborns living in Cape York, Queensland. Methods: All medical charts of mothers and their neonates delivered in the regional hospital over two-one-year periods (2006 and 2008) were reviewed. Universal testing with an oral glucose tolerance test (OGTT) was introduced in 2007. Results: Gestational diabetes (GDM) increased from 4.7 to 14.2%, and T2DM was similar (2.4 and 2.3%). There were 127 deliveries in 2006 and 134 in 2008. Testing rates with OGTT improved from 31.4% in 2006 to 65.6% in 2008. Mothers with diabetes in pregnancy (DIP) were older and heavier than non-DIP mothers. Caesarean section rates were significantly higher in the DIP group compared with the non-DIP group (66 vs 25%) in both time periods. The booking weight of DIP mothers decreased 16 kg, their babies normalised their weight, length and head circumference; respiratory distress and Apgar scores improved comparing the two periods. In DIP, infants >40% had hypoglycaemia; however, rates of serious complications were low. Rates of breastfeeding were similar between groups. Follow-up rates for GDM improved from 16.6% in 2006 to 31.6% in 2008. Of those tested one-third were diagnosed with T2DM. Conclusion: The rate of GDM tripled after implementation of universal testing. Outcomes improved. There is still need for improvement in testing and follow-up practices in relation to DIP.

Evaluation of the frequency and obstetric risk factors associated with term neonatal admissions to special care units

Abstract: Introduction Approximately 10–15% of term babies may require admission to neonatal special care units. This level of care is frequently an unexpected event for parents. Aims To review the frequency and obstetric risk factors associated with the admission of term neonates to a tertiary hospital special care unit (SCN). Materials and Methods All babies born ≥37-weeks gestation admitted to the SCN at King Edward Memorial Hospital between 2004 and 2006 were identified from the institutional maternity and neonatal databases. Maternal and obstetric factors were reviewed to identify potential predictors of admission to the SCN. Results During the study period, 1671 term neonates born to 1624 women were admitted to the SCN (14.4% of term deliveries). Neonatal intensive care unit admissions accounted for 10.6% of the term admissions. The most common reasons for SCN admission were respiratory complications (n = 421, 25.2%), observation postresuscitation (n = 402, 24.1%) and hypoglycaemia (n = 152, 9.1%). Elective caesarean delivery was significantly associated with admission to the special care unit for respiratory complications compared with all other delivery modes (37 vs 23%, P < 0.001), particularly if the birth occurred at <39-weeks gestation (38 vs 24%, P < 0.001). Conclusions In our population of women delivering at a tertiary maternity facility, approximately 1:8 term babies were admitted to the neonatal special care unit. Elective caesarean delivery was associated with a significant risk of admission for respiratory complications compared with other birth modes, especially when <39-weeks gestation.

The case for retaining severe perineal tears as an indicator of the quality of obstetric care.

Abstract: Background The incidence of severe perineal tears acquired during vaginal childbirth varies considerably across hospitals but its use as a safety and quality indicator is in jeopardy because of problems associated with accurate detection and recording. Aim To understand and interpret time trends in the incidence of third- and fourth-degree perineal tears among women giving birth vaginally in 18 public maternity hospitals in South Australia, taking into account individualised risk factors for each birth. Methods The risk-adjusted probability of a third- and fourth-degree tear was estimated for each of 65,598 singleton vaginal births (2002–2008), using a previously published regression model. The risk factors for each birth included maternal age; parity and ethnicity; assistance with instruments and episiotomy; shoulder dystocia; and infant birthweight. Plots of ‘excess’ tears were generated to help identify maternity services where the observed incidence of severe trauma differed from the expectation estimated from the risk profiles. Results Three hospitals were identified at which there were systematically more tears than expected (given their risk profiles), and five hospitals were identified at which there were fewer tears. However, increased tearing at two hospitals coincided closely with improved advocacy for better detection and treatment of perineal tears (especially partial third-degree tears). Conclusion Statistical process control methods provide a powerful means of investigating temporal variations in the incidence of outcomes like severe perineal tears. Third- or fourth- degree tears should be retained as a quality indicator of maternity services, but it is likely that many third-degree tears currently go undetected.

Outcomes of monochorionic diamniotic twin pregnancies: A comparison of assisted and spontaneous conceptions

Abstract: Background The widespread use of assisted reproductive technologies has led to an increase in the prevalence of monozygotic twins. Twinning after blastocyst transfer results in monochorionic placentation; a form of placentation that is associated with higher risks of mortality and morbidity. Aims This study describes complication rates of monochorionic diamniotic (MCDA) twin pregnancies and examines whether they differ between spontaneous and assisted conceptions. Methods A five-year retrospective review of 294 MCDA twin pregnancies that had no evidence of structural abnormality on ultrasound at 12 weeks' gestation. Outcomes of spontaneous and assisted conceptions Day 3 (D3) cleavage stage embryo or Day 5 (D5) blastocyst transfer) pregnancies were compared. Results Two hundred and eighteen (74.1%) MCDA twin pregnancies were conceived spontaneously, whilst 14 (4.8%) resulted from D3 cleavage stage embryo and 62 (21.1%) resulted from D5 blastocyst transfer. Fetal and whole pregnancy loss rates were high, affecting 11.4% and 8.8% of cases, respectively. 16.2% of pregnancies were delivered <32 weeks' and 66% <37 weeks' gestation. 36.2% of infants were small for gestational age and selective intrauterine growth restriction (IUGR) affected 7.5% of pregnancies. There was no significant difference in the prevalence of complications between spontaneous and assisted conceptions. Conclusions Assisted conception with either D3 cleavage stage embryo or D5 blastocyst transfer does not increase the risk of complication in a MCDA twin pregnancy. Mortality in monochorionic twins remains high despite early recognition and heightened surveillance throughout pregnancy. Information describing the risks of monochorionic twinning and of subsequent complications may be of value to women undergoing assisted conception.