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

Background: Clinical practice guidelines recommend additional monitoring in pregnancy for women post-bariatric surgery, to reduce the risk of maternal and infant complications.

Aim: To examine if pregnancy care post-bariatric surgery at an Australian quaternary public hospital is consistent with guidelines and to report on perinatal outcomes.

Materials and methods: A retrospective audit of medical records and perinatal outcomes from post-bariatric surgery pregnancies from June 2016 to February 2021 was completed. Micronutrient monitoring and supplementation practices, gestational diabetes mellitus (GDM) screening, gestational weight gain (GWG) and fetal growth (FG) monitoring were compared with guidelines. Perinatal outcomes were compared with Queensland and Australian population data.

Results: Eighty-three women meeting the inclusion criteria delivered 86 infants. Twenty percent (n = 16) had recommended GDM screening, 86% (n = 71) recommended FG monitoring at 12-weeks and 98% (n = 81) at 20-weeks, but only 24% (n = 20) had monthly monitoring from viability. GWG monitoring was 95% (n = 79) in the second trimester and 94% (n = 78) in the third trimester. Monitoring rates were highest for iron, and lowest for copper and selenium. Adverse infant outcomes for length of stay, neonatal intensive and special care admissions and caesarean section were significantly higher than the Queensland and Australian populations (all p < 0.05).

Conclusion: Adherence with consensus recommendations aligning to standard antenatal monitoring for the general population was high, but additional monitoring for post-bariatric surgery specific care was lower. The evidence suggesting increased rates of adverse perinatal outcomes highlights the importance of consistency and adherence with post-bariatric surgery specific care for this group during pregnancy.

Background: Infertility is a global public health concern, and as a result, fertility treatments continue to evolve. Uterus transplantation is a novel procedure where a healthy donor uterus is transplanted into an individual without a functioning uterus who desires pregnancy, allowing them to participate in the genetic, gestational and social components of parenthood. Previous studies in several countries have investigated their population's views regarding uterus transplants to aid in awareness and understanding. However, Australians' views have not been explored outside the absolute uterine factor infertility community.

Aims: We aimed to examine Australians' support for uterus transplantation and the factors associated with higher support for the procedure's availability, Medicare subsidisation and ethical acceptance.

Materials and methods: Participants (N = 349, aged 17-68) completed an online cross-sectional survey comprising demographics, fertility and transplant history and perceptions of uterus transplantation.

Results: Most Australians supported uterus transplantation availability (84.5%), subsidisation (67.3%) and ethical acceptance (73.3%). Male gender, non-university education, younger age, high parenthood importance and higher beliefs that the procedure is safe for the recipient, donor and infant/child predicted higher support for availability. Higher beliefs in uterus transplantation being safe for the recipient predicted higher support for subsidisation. Male gender and increased parenthood importance predicted higher levels of ethical acceptance.

Conclusions: Despite ethical complexities surrounding the procedure, Australians were generally supportive of uterus transplantation. While our findings may inform future policies about uterus transplantation, research examining public perceptions over time, with the birth of more children and health professionals' perceptions, would be beneficial.

Background: Caesarean section surgical site infections (SSIs) have the potential to cause major complications however there remains a paucity of data on its microbiology and causative organisms.

Aims: The aim of this study was to identify the organisms causing SSIs in hospitalised patients after lower uterine caesarean section (LUCS). Secondary aims included investigating the differences in organisms isolated from elective versus emergency caesarean sections, and to compare the microbiology of superficial and deep SSIs.

Materials and methods: This was a large retrospective study reviewing all SSIs after LUCS in Western Australian (WA) public hospitals from 2001 to 2021 with data obtained from the Healthcare Infection Surveillance of Western Australia (HISWA).

Results: There were 687 patients identified with an SSI following LUCS over this twenty-year period. The five most common organisms or organism groups isolated were methicillin-susceptible Staphylococcus aureus (MSSA) (30.4%), methicillin-resistant Staphylococcus aureus (MRSA) (14.7%), Enterobacterales (9.5%), Pseudomonas aeruginosa (9.3%), Staphylococcus lugdunensis (5.7%). Group A and B Streptococcus were isolated cumulatively in more than 5% of cases. There were a significantly higher number of superficial SSIs than deep SSIs, and SSIs were significantly more common post emergency LUCS.

Conclusions: Current Australian guidelines may not be appropriate in a considerable proportion of patients with LUCS SSIs, and patients with systemic features of infection should receive antibiotics with activity against P. aeruginosa and MRSA. Critically ill patients with features of sepsis or septic shock should be administered a carbapenem agent which has activity against AmpC/ESBL producing Enterobacterales, instead of piperacillin/tazobactam. Staphylococcus lugdunensis may be an under recognised pathogen in LUCS SSIs. This study also highlighted the importance of wound site sampling in SSIs to establish appropriate directed antimicrobial therapy.

Background: Preterm prelabour rupture of membranes (PPROM) is a common obstetric complication with significant maternal and foetal consequences. There is a lack of contemporary evidence regarding the optimal management of PPROM, including the best antibiotic regimen and management at previable gestations.

Aims: To understand the contemporary management of PPROM among clinicians in Australia and Aotearoa New Zealand.

Materials and methods: An anonymous web-based survey was designed and distributed, consisting of 31 questions about individual clinicians' routine management of PPROM across a range of different gestations.

Results: The survey was completed by 235 clinicians from across Australia and Aotearoa New Zealand. The majority (225/232, 97%) routinely prescribed prophylactic antibiotics after PPROM, with 90 different antibiotic regimens documented. The most commonly prescribed prophylactic antibiotics were erythromycin (198/225, 88%) and penicillins (103/225, 46%). There was variation in practice regarding the timing of birth after PPROM, with 62% (147/235) routinely delaying birth until after 37 weeks of gestation, and 61% (143/235) expediting birth after 34 weeks of gestation if Group B Streptococcus was cultured antenatally. For previable PPROM (< 22 weeks of gestation), 74% (171/232) of women were routinely admitted to hospital at the time of diagnosis and 77% (173/225) were routinely offered antibiotics. There was significant variation in the earliest gestational ages at which antenatal corticosteroids and resuscitation are offered.

Conclusions: We observed wide variation in clinical practice of management of PPROM. With a lack of national consensus regarding optimal management of this common pregnancy complication, contemporary clinical trials to define best practices are required.

Background: Although there is ongoing debate, the current consensus is that vaginal breech birth carries a marginal increase in perinatal morbidity and mortality. Due to these risks there have been decreasing numbers of vaginal breech births and subsequently clinical exposure to hands-on training has declined. However, to confidently care for women who plan a vaginal breech birth or those presenting in advanced labour with an unexpected breech presentation, education in vaginal breech birth remains necessary.

Aims: This pilot study aimed to assess the ability of a multimodal teaching program consisting of high-fidelity physical models, educational videos and a 360° virtual reality video to increase the confidence of maternity staff in their theory and management skills regarding vaginal breech birth. A secondary aim was to determine whether the virtual reality video enhanced learning alongside established techniques.

Materials and methodology: A multimodal teaching program was administered to 20 maternity health staff. They were given a self-reported pre- and post-intervention scales to assess changes in their confidence. They also provided feedback on the virtual reality video.

Results and conclusion: The teaching program significantly increased maternity staff's confidence in their knowledge and management skills whilst decreasing their anxiety surrounding vaginal breech birth. However, participants did not perceive the 360^o virtual reality being of added value. Further studies should examine whether this program leads to objective change in vaginal breech birth knowledge and management skills and ultimately improved clinical outcomes. Additional studies should explore which types of virtual reality technology benefit breech birth education.

Background: Gestational diabetes mellitus (GDM) is associated with short- and long-term adverse health outcomes for women and their infants. Antenatal diet and/or physical activity interventions have not been effective at preventing GDM, and currently, it is not clear whether intervening similarly prior to pregnancy is beneficial.

Aims: This review aims to evaluate the impact of pre-pregnancy diet and/or physical activity interventions on rates of GDM and other maternal and infant health outcomes.

Methods: A systematic literature search of the online databases Embase, Pubmed, Cochrane Central Register of Controlled Trials, Ovid MEDLINE and CINAHL was conducted from inception to 7 February 2023. All randomised controlled trials comparing pre-pregnancy diet and/or physical activity interventions with standard care or control were included. Data were extracted by two reviewers independently, and meta-analysis was performed using random-effects models to calculate summary effect estimates and 95% confidence intervals. The primary outcome was GDM. Five randomised trials assessing pre-pregnancy diet and/or physical activity interventions (n = 1924 women) were included.

Results: Pre-pregnancy diet and/or physical activity interventions were not associated with a significant difference in rates of GDM (2 studies; n = 214; RR 1.19, 95% CI 0.81, 1.75). There were no statistically significant differences for any of the secondary maternal or infant outcomes reported. There was significant heterogeneity between studies with regard to type, duration and intensity of the pre-pregnancy diet and/or physical activity interventions.

Conclusions: There was no evidence that pre-pregnancy diet and/or physical activity interventions reduced the risk for GDM or other adverse maternal and infant outcomes.

Background: Persistent pelvic pain (PPP) affects 5%-27% of women of reproductive age. The calls for earlier and improved access to surgery to diagnose endometriosis do not address the requirement for symptom management and exclude the 50% of women who undergo a laparoscopy for identical pain symptoms but do not have endometriosis identified. Moreover, current evidence for the management of pelvic pain almost exclusively focuses on patients diagnosed with endometriosis.

Aims: To investigate the pain scores and overall satisfaction with symptom control in participants with PPP who utilised the levonorgestrel-intrauterine device 52 mg (LNG-IUD), to explore the association between time since last menstrual period (LMP) and other potential factors, including the impact of surgery and surgical findings, on pain outcomes.

Materials and methods: This prospective cohort study recruited participants between February 2015 and December 2017 following outpatient clinic referral for pelvic pain symptoms (dysmenorrhea, non-cyclic pelvic pain, dysuria, dyspareunia or dyschezia). Over 18 months, 72 participants had an LNG-IUD (52 mg) inserted, with 51 completing a follow-up questionnaire 6-18 months after insertion to assess pain outcomes.

Results: Dysmenorrhoea (coefficient = -0.142, p < 0.001) and overall satisfaction with symptom control (coefficient = 0.079, p = 0.020) scores improved linearly with increased months since LMP in LNG-IUD users. In multivariate analysis, the age of onset of symptoms, laparoscopies prior to study entry or during the study period, and a histological diagnosis of endometriosis did not have a significant relationship with pain outcome or overall satisfaction with symptom control.

Conclusions: This study demonstrates that menstrual suppression with the LNG-IUD, regardless of a diagnosis of endometriosis, significantly improves a woman's overall satisfaction with PPP management. The LNG-IUD is an effective first-line medical management option for patients presenting with PPP.

Background: Genomics has improved etiological diagnosis for foetal structural anomalies. It is being increasingly utilised in prenatal investigation both in Australia and internationally. To date, literature reporting diagnostic yield according to indication has been available. There is limited literature around the challenges of implementation and other aspects of utility.

Aims: We aimed to explore the experiences and perspectives of clinicians involved with the delivery of a state-wide public prenatal exome sequencing (pES) service in Australia.

Materials and methods: This qualitative study was developed using a pragmatism framework. A multidisciplinary cohort of clinicians across all tertiary foetal medicine units in Victoria was interviewed. Inductive content analysis was used to understand the experiences, impact, and utility of pES.

Results: Eight clinician interviews were analysed. The impact of pES on clinicians included: increased pressure, higher emotional toll, and balancing the benefits with resource limitations. PES was most useful when it provided prognostic information. The clinicians felt that pES had the most utility for patients when the result informed their decision about whether or not to continue a pregnancy. Clinicians acknowledged their 'gatekeeper' role and valued a collaborative, multidisciplinary approach. The main perceived harm for patients was the anxiety associated with waiting times for results.

Conclusions: This study provides insights into the delivery of a publicly funded pES program. Our findings highlight the importance of the multidisciplinary team in the successful implementation of genomic technologies in reproductive health.

Background: In patients with diabetes, antenatal glucocorticoids can induce transient maternal hyperglycaemia for approximately 72 h. This may be associated with adverse outcomes, including neonatal hypoglycaemia, prompting recommendations for prophylactic increases in insulin by some expert groups; however, there are no validated protocols. A review of our institutional practice of empiric dose escalation (Day 1:25%, Day 2-3:40%, Day 4:20%, Day 5:10%) determined it was inadequate to prevent hyperglycaemia.

Aim: To investigate the efficacy of an intensified insulin escalation protocol in achieving time in target range (3.9-7.8 mmol/L) following antenatal betamethasone.

Materials and methods: Following implementation of the intensified insulin escalation protocol at Western Health (Day 1 and 2: 50% increase, Day 3:30% increase), a prospective cohort study was conducted for women with gestational diabetes or type 2 diabetes managed with insulin requiring betamethasone. Data was collected from the electronic medical record and expressed as mean ± SD or median (IQR).

Results: 29 women (82.8% GDM, 17.2% T2DM) were included with median gestation 33 + 2 (31-34⁺⁴) weeks and median BMI 30 kg/m² (27-38IQR). In the 72 h post first-dose betamethasone, the proportion of readings in target range (< 5.1 mmol/L fasting and < 6.8 mmol/L post prandial) was 35.3%. There was no maternal hypoglycaemia. Median increase in insulin requirement was 50% (22.6%-100% IQR) on Day 1, 106% on Day 2 (33%-297% IQR) and 133% on Day 3 (23%-543% IQR).

Conclusions: A significant increase in insulin requirement, exceeding current guideline recommendations, occurs following antenatal betamethasone in women with diabetes, and further prospective evaluation of optimal dosing is required.

Background: Australian lawyers, researchers and unions are advocating for the implementation of national paid menstrual leave legislation. The scarce research in this emerging field has not thoroughly explored women's attitudes towards such leave.

Aim: To explore Australian women's attitudes towards paid menstrual leave.

Materials and methods: Participants (n = 923, female sex assigned at birth currently or previously menstruating; 18+ years; resident in Australia; fluent in English) primarily recruited via social media, including accounts of Australian women's health and menstruation support groups for conditions such as adenomyosis and endometriosis, using a passive snowball sampling frame, completed an online cross-sectional mixed-methods survey.

Results: Most (85%) expressed being somewhat to definitely in favour of paid menstrual leave, 4% were unsure and 11% were somewhat to definitely not in favour. Younger age and history of missing work due to menstrual pain were significant independent predictors of support for paid menstrual leave. Women preferred menstrual leave to be paid (rather than unpaid or reimbursed as additional income if unused), available monthly, with a once-off doctor's approval required to access leave. Overall, 73% of participants reported positive impacts on employees in response to open-ended questions about potential impacts (positive, negative and unintended). The most common categories were better workplaces and productivity and improved work outcomes.

Conclusion: Research such as this is essential for informing considerations about menstrual leave legislation. Further research investigating the attitudes of a wider range of stakeholders, such as men, colleagues, employers, employment lawyers and economists, is needed to develop an inclusive understanding of menstrual leave.