Australian & New Zealand Journal of Obstetrics & Gynaecology最新文献

Background: Infectious syphilis among women of reproductive age continues to rise in many countries including Australia, with a resultant increase in congenital syphilis. In response, new guidelines for management of syphilis in pregnancy were published in Queensland, Australia in 2018.

Aims: This study evaluates the management of women diagnosed with syphilis in pregnancy in South-East Queensland (SEQ) after release of this guideline.

Materials and methods: This retrospective review of notification data identified women in SEQ who had a positive syphilis serology during pregnancy, without evidence of adequate treatment prior to the pregnancy, between January 2019 and December 2021 inclusive. Maternal demographics and pregnancy details including syphilis staging, testing and management were extracted, with management assessed against the 2018 Queensland syphilis in pregnancy guideline.

Results: Of the 42 women identified, 79% were diagnosed in the first or second trimester, 69% had early-stage syphilis at the time of diagnosis and 86% were asymptomatic at the time of diagnosis. All, including the eight (19%) Aboriginal and/or Torres Strait Islander women identified, completed stage-appropriate treatment with penicillin, 83% completed treatment four weeks prior to delivery and 60% achieved a four-fold reduction in rapid plasma reagin at time of delivery.

Conclusions: Our findings suggest compliance with syphilis in pregnancy management recommendations has improved in SEQ since release of the 2018 guidelines. However, congenital syphilis rates continue to rise; further initiatives addressing barriers to timely testing and management of syphilis in pregnancy are urgently needed at both healthcare system levels and for individual women.

Background: Human papillomavirus (HPV) testing became the primary cervical screening modality in Aotearoa New Zealand in September 2023. To inform the national roll-out of HPV primary screening, a multiregion implementation study ('Let's Test for HPV') was undertaken in primary care in 2022-2023.

Aims: To explore participant perspectives and information needs following receipt of an HPV detected result.

Materials and methods: An online survey completed in 2023 by 921 Let's Test for HPV participants included 95 people with an HPV detected result (10.3%). Data collection included: adequacy of information provision, receipt of results, emotional response, views on HPV primary screening and needing cervical cytology and/or colposcopy, and intent to screen again.

Results: Receipt of an HPV detected result was worrying for most people and many had unanswered questions about HPV, how HPV testing fits with cytology, implications for follow-up and outcomes. Knowledge gaps and uncertainty appeared to be linked with feeling anxious about possible outcomes and fear of a cancer diagnosis. All survey participants received recommended follow-up (cytology and/or colposcopy). Having a choice of screening test and the ability to self-test were welcomed and the majority (88%) expressed intent to screen again.

Conclusions: These survey findings highlight the importance of giving clear information about potential outcomes at the time of screening and again when sharing results. Sensitive delivery of results, providing reassurance and answering questions are also important to mitigate fear and worry. Population-level education would help improve understanding of key messages about HPV testing and the changes to cervical screening.

Background: Intrapartum antibiotic prophylaxis (IAP) administration to group B streptococcal (GBS) positive pregnant women and other pregnant women with risk factors may reduce the rate of neonatal early-onset GBS infection (EOGBSI).

Aims: Our aims were estimating the current indications for IAP among women presenting in labour, evaluating compliance to the current local IAP guidelines and to provide recommendations for improving clinician compliance.

Materials and methods: We retrospectively analysed IAP data at our tertiary perinatal centre over a 16-month period. Our cohort included women, positive for GBS (± risk factors for EOGBSI), and a comparable number of randomly selected women with risk factors and GBS status negative or unknown.

Results: A total of 424 mother-baby pairs were included in this study. Forty-seven percent of the study cohort had IAP indication (n = 202/424). Of these, 72% (n = 145/202) received some form of IAP and 61% (n = 123/202) received 'adequate' IAP. IAP was adequately administered in 67% (n = 99/148) of women positive for GBS, 27% (n = 9/33) of women with unknown GBS status and 71% (n = 15/21) of women negative for GBS with IAP indication. Most frequent reason (30%, n = 125/424) for 'inadequate' IAP was less than four hours from birth for women positive for GBS despite spending more than 60 min in the hospital before birthing.

Conclusions: A substantial number of IAP were administered less than four hours before birth and were therefore 'inadequate' according to the current recommendations. These high rates could be reduced if those administered at least two hours prior to birth were redefined as 'adequate'.

Background: It remains unclear if there is an endometrial thickness (ET) threshold below which malignancy can be excluded. Guidance on whether endometrial biopsy is needed based on ET varies among regions in New Zealand and there is a desire to standardise guidance nationwide. This study evaluates the potential impact of limiting endometrial biopsy in pre-menopausal persons with abnormal uterine bleeding (AUB) to those with an ET of less than 12 mm.

Aims: To determine the number of pre-menopausal patients with AUB with an ET of less than 12 mm undergoing endometrial sampling annually and assess the prevalence of pathology among these patients.

Materials and methods: Endometrial samples from patients aged 18-50 years processed at a tertiary hospital between 15/06/2022 and 13/06/2023 were identified via a pathology lab search. Clinical, radiologic, and pathological data were obtained by case note review for those with AUB whose ET was less than 12 mm.

Results: Of 1271 endometrial samples, 355 patients met the eligibility criteria, and 2.2% of these were cancerous (three cases) or pre-malignant (five cases).

Conclusions: If sampling thresholds would change to not perform biopsies in those with an ET of less than 12 mm, eight cases of treatable disease would be missed in pre-menopausal people. This represents 13.6% of all endometrial cancers diagnosed in pre-menopausal people in the same time period. There is no ET cut-off to reliably exclude high-risk pathology and endometrial sampling should be performed in all cases of AUB with risk factors.

Background: Infertility is a prevalent issue worldwide. Current investigation of female pelvic infertility uses transabdominal laparoscopy, exposing patients to its associated risks. An alternative method is fertiloscopy, comprising hysteroscopy, tubal dye studies, and transvaginal hydrolaparoscopy (TVHL), falling under the broader category of VNOTES. This study reviews fertiloscopy cases in Australia to assess its role in managing infertility.

Materials and methods: Retrospective analysis of 76 cases was performed with review of imaging results, fertiloscopy findings and interventions, and fertility outcomes. Statistical analysis was conducted via R Studio v4.1 with means and averages used for descriptive data and a Kruskal-Wallis analysis of variance test used to evaluate differences in continuous variables. Kaplan-Meier curves were constructed to describe cumulative pregnancy incidence, with differences evaluated using log-rank tests. Statistical tests were two-tailed, and a P-value < 0.05 was considered significant.

Results: Of 76 cases, 70 underwent fertiloscopy and 35 an intra-operative intervention. Of the cohort, 53 conceived, 18 spontaneously. The highest chance of spontaneous conception was 44% by day 283. The failure rate of fertiloscopy was 5.3%, and complications occurred in 1.3% of cases.

Discussion: The highest chance of spontaneous conception post-fertiloscopy was 44% by day 283, possibly indicating the time between the procedure and referral to reproductive therapies. This study identified a low associated failure and complication rate, supporting fertiloscopy as a low-risk procedure.

Conclusion: Despite limitations, this study highlights spontaneous pregnancy outcomes and associated low complication and failure rates, emphasising fertiloscopy's role in managing infertility in Australia as a lower risk surgical alternative to standard laparoscopy.

Background: While uterus transplantation offers a promising treatment option for women with uterine factor infertility (UFI), the potential for graft failure and lack of organ availability could have subsequent psychological repercussions for women. Exploring baseline psychological well-being for women with UFI who could become uterine transplant recipients is essential to identify specific psychological challenges to be considered prior to transplantation. UFI can be congenital uterine absence, namely Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), or acquired uterine absence (hysterectomy).

Objective: To analyse baseline psychological well-being among women with UFI.

Design and setting: A survey including demographic data and two internationally validated psychological questionnaires, Depression, Anxiety and Stress Scale (DASS-21),¹³ and Fertility Quality of Life (FertiQoL), was disseminated to women with UFI. Data from these instruments was compared between groups and then to data that uses these tools in the general infertility population.

Results/outcomes: The study included 39 women (mean age 29.54 years). Higher scores for moderate symptoms of depression, anxiety, and stress were reported for the entire UFI cohort. More women with congenital UFI showed 'severe' symptoms for depression/anxiety, compared to women with acquired UFI. Women with acquired UFI showed poorer FertiQoL scores compared to both women with congenital UFI and to the general infertility population scores in previously published data.

Conclusion: Clinicians should consider accessing increased psychological support for women with UFI when discussing fertility options including uterine transplant, and they may need to tailor this support depending on whether the patient has congenital or acquired UFI.

Australia has transitioned to primary Human Papillomavirus (HPV) screening; however, high-risk HPV (hrHPV)-negative high-grade squamous intraepithelial lesions and adenocarcinoma in situ have been reported. HPV in situ hybridisation (ISH) testing has been proposed to reclassify these cases. This study identified hrHPV-negative lesions and assessed HPV-ISH. A total of 89 of 1468 patients (6.06%) had hrHPV-negative lesions, and HPV-ISH revealed five (5.75%) reclassified positive cases. No demographical differences were found between groups. Current population-level screening is effective. HPV-ISH was not effective for reclassification. This small, significant population requires further study to assess the phenomenon and augment detection given the implications of misidentification.

Background: Anticoagulant therapy prevents thrombosis and thromboembolic events in patients with mechanical heart valves. Bridging anticoagulation around the time of birth represents a unique challenge. Few retrospective reviews or case series exist examining peripartum outcomes with bridging anticoagulation.

Aims: Review of peripartum and postpartum anticoagulation management, with a focus on postpartum complications.

Materials and methods: Design: case series, single centre.

Setting: Royal Brisbane and Women's Hospital, Australia between 1 January, 2000, and 1 August, 2022.

Population: all pregnant women with mechanical heart valves (any type) who birthed.

Main outcome measures: intrapartum and postpartum haemorrhage, thrombosis, thromboembolic complications, cardiac events, readmission, and maternal death.

Results: There were 18 women, with 23 births. Sixteen births were via caesarean section (70%). Fourteen women (61%) experienced at least one significant haemorrhagic complication, one woman required a peripartum hysterectomy, one woman experienced atrial fibrillation, and one had a valvular thromboembolic complication. No maternal cerebral thromboses or maternal deaths were recorded.

Conclusions: Women with mechanical heart valves who undergo bridging anticoagulation are associated with significant maternal morbidity. Most postpartum haemorrhagic complications were associated with bridging unfractionated heparin infusions in the first postnatal week. Bridging anticoagulation practices varied widely. Ongoing pooled data are required to inform evidence-based guidelines for postpartum anticoagulation management.