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

Background: Vaginal swab microbiological testing is commonly performed as routine clinical management for various obstetric and gynaecological presentations. The clinical utility and cost-effectiveness of vaginal swab microscopy, culture and susceptibilities (MCS) in altering empirical management is ill-defined.

Aims: To describe the clinical use of vaginal swabs in a tertiary women's hospital emergency department (ED), measure the impact of vaginal swabs on altering empirical clinical management, and to determine the economic cost of vaginal swab MCS.

Materials and methods: Retrospective case-series of vaginal swabs collected at a single, tertiary women's ED between January 2021 and July 2021. Symptomatology, clinical diagnosis, test results, and pre-swab and post-swab clinical management were determined upon medical record review. Economic costs of vaginal swab MCS were retrospectively determined via internal accounting records, permitting unit-level activity-based costing.

Results: A total of 660 vaginal swabs from 584 clinical episodes were included. Vulvovaginitis was the most common indication for swab collection (34.5%, 167 samples). Altered empirical management was observed in 9.8% of all swabs (95% CI 7.4-12.2%), with marked variability between clinical indications. Antimicrobial initiation was the most common alteration in management (8.9%, 95% CI 8.7-9.1%). The estimated cost of vaginal swab MCS was $29.71 AUD; labour, consumables and disposal costs accounted for 69.3, 29.8 and 0.9%, respectively.

Conclusions: The impact of vaginal swab MCS on empirical clinical management is context-specific and variable. The majority of swabs performed do not impact upon empirical management. Antimicrobial initiation is appreciably more common than antimicrobial cessation with vaginal swab results.

Background: Women with substance use disorders (SUD) use less contraception, and experience higher rates of unintended pregnancy, compared to women without SUD. Contraception is discussed at the six-week postnatal appointment, which many women with SUD do not attend. Therefore, it is important women have the opportunity to formulate contraception plans before discharge from the birth admission.

Aims: To assess postpartum contraception plans, including initiation and method of interest, among women with SUD and compare these to women without SUD.

Materials and methods: All births from January 2011 to September 2019 from one New South Wales local health district were analysed. Data included maternal demographics, SUD, and contraception plans. Chi-squared statistics and multivariate multinomial regression analyses were used to compare outcomes for women with and without SUD.

Results: Of 59 195 mothers, 429 (0.7%) had a SUD. There were 50.1% of women with SUD and 56.2% without SUD (P = 0.03) who had no documented plan for contraception. There were 37.3% of women with SUD and 42.4% without SUD (P = 0.06) who had a prescription for contraception or a referral to discuss contraception. There were 12.5% of women with SUD and 1.4% without SUD (P < 0.001) who initiated contraception in hospital.

Conclusions: Although postpartum contraception initiation was higher among women with SUD, half of all women (with or without SUD) were discharged without a plan for contraception initiation. Embedding provision of postpartum contraception into maternity care, or investigating other opportunities, may improve access for all women, including those with SUD.

Introduction: Borderline ovarian tumours (BOT) are a common epithelial ovarian tumours. Typically diagnosed at an early stage with a good prognosis, many BOT are treated conservatively. Recurrence is common. This update to our last audit in 1997 represents one of the largest audits of BOT to date.

Materials and methods: All patients with BOT managed at 'the hospital' from 1984 to 2021 were included. Expert pathology review was available.

Results: There were 549 cases included. The recurrence rate was 5% (n = 29/549) with 1.4% (n = 8/549) undergoing malignant transformation. Three of the eight women who recurred as cancer died from their disease. Frozen section was predictive of histologic diagnosis in 92% (n = 55/60) of serous tumours (SBOT), but only 62% (n = 54/87) of mucinous tumours (MBOT). In MBOT where the appendix appeared normal intra-operatively, it was histologically benign in all cases (n = 63). In SBOT, the recurrence rate was 5/23 (22%), 12/52 (23%), 1/29 (3%) and 3% (P = <0.01) for unilateral cystectomy, unilateral oophorectomy ± cystectomy, bilateral oophorectomy, and bilateral oophorectomy with hysterectomy, respectively, as index procedure. In MBOT this correlated to 2/20 (10%), 3/93 (3%), 0 and 1/58 (2%), respectively.

Discussion: This study describes important information correlating first surgical procedure and fertility-sparing surgery to recurrence and malignant transformation. For all BOT subtypes, fertility-preserving surgery increased the risk of recurrence and hysterectomy was not superior to removal of both ovaries. In MBOT, frozen section is of limited utility and the macroscopically normal appendix is very unlikely to be anything but benign, if MBOT is the true histologic diagnosis.

Background: Pregnant women have historically been excluded from participation in medication trials, in part due to the perceived risks of drug exposure to mothers and fetuses. However, little is known about pregnant women's attitudes toward risk and participation in such trials.

Aims: To address this knowledge gap and to identify factors that influence trial participation.

Materials and methods: Australian women over the age of 18, currently pregnant or within six months of delivery, were recruited to participate in an online survey (n = 623) and follow-up interviews (n = 11). The survey investigated willingness to participate in five hypothetical drug trial scenarios of varying risk. Demographic and obstetric information, including COVID-19 vaccination status, was also collected. The impact of these factors on trial participation was analysed using ordinal regression. Interviews were subjected to thematic framework analysis using a priori and emergent themes.

Results: Nearly half of the respondents (48%) indicated a willingness to participate in at least one of the hypothetical trials. As trial risk increased participation likelihood decreased, especially if the risk was to the fetus, regardless of benefits to the mother. COVID-19 vaccination status and medication hesitancy were predictors of an unwillingness to participate. Three broad themes emerged from the qualitative data: risk-benefit analysis, quality of evidence, and trust.

Conclusions: Overall, participants expressed a positive attitude toward research and medication trials during pregnancy, but were concerned about fetal risk. The findings of this study may help enhance trial design and the participation of pregnant women in medication trials.

Background: Current understanding of clinical practice and care for maternal kidney disease in pregnancy in Australia is hampered by limitations in available renal-specific datasets.

Aims: To capture the epidemiology, management, and outcomes of women with significant kidney disease in pregnancy and demonstrate feasibility of a national cohort study approach.

Materials and methods: An Australian prospective study (2017-2018) using a new kidney disease-specific survey within the Australasian Maternity Outcomes Surveillance System (AMOSS). Women who gave birth with acute kidney injury (AKI), advanced chronic kidney disease (CKD), dialysis dependence or a kidney transplant were included. Demographic data, renal and obstetric management, and perinatal outcomes were collected.

Results: Among 58 case notifications from 12 hospitals in five states, we included 23 cases with kidney transplant (n = 12), pre-existing CKD (n = 8), newly diagnosed CKD (n = 2) and dialysis (n = 1). No cases of AKI were reported. Reporting rates were better in states with study investigators and, overall, cases were likely under-reported. Nearly 35% of women had a non-delivery-related antenatal admission. Nephrology involvement was 78.3% during pregnancy and 91% post-partum. Adverse events were increased, including pre-eclampsia (21.7%), and preterm birth (60.9%). Women had high rates of aspirin (82.6%) and antihypertensive (73.9%) use, indwelling catheter for labour/delivery (65.2%), caesarean delivery (60.9%), and blood transfusion (21.7%).

Conclusions: This first-ever Australian prospective study of significant kidney diseases in pregnancy provided novel insights into renal-specific clinical patterns and practices. However, under-reporting was likely. Future studies need to overcome the challenges of case identification and data collection burden.

Objective: This study aimed to evaluate the costs and consequences of a new midwife-navigator-facilitated care pathway for reduced fetal movements.

Materials and methods: This study was conducted at a tertiary obstetric centre in Queensland, Australia and modelling occurred for this and smaller services. Two months of data from pre (n = 112 in 2019) and post (n = 141 in 2020) implementation of the care pathway were analysed with T-tests and logistic regression models to evaluate maternal and neonatal outcomes. A Markov model was built to estimate the costs and consequences of the intervention. Sensitivity analysis was conducted to test various scenarios including modelling for smaller centres.

Results: There were no statistically significant differences in clinical outcome between the intervention and usual care groups. Intervention patients spent one hour and eight minutes less time in hospital (P < 0.001). This resulted in a saving to the centre of AU$135 per patient (AU$159 083 annually). One-way sensitivity analysis suggested that cost savings would be found in all scenarios except for smaller units providing services for less than 1900 births per annum.

Conclusion(s): To our knowledge, no other care pathway involving acute obstetric care has been economically evaluated to date. Our model based on real-world presentations for reduced fetal movements confirms that midwife-navigators may be an economically beneficial implementation strategy for dealing with common obstetric conditions.

Background: Choice, a fundamental pillar of woman-centred maternity care, depends in part on the right to decline recommended care. While professional guidance for midwives and obstetricians emphasises informed consent and respect for women's autonomy, there is little guidance available to clinicians or women about how to navigate maternity care in the context of refusal.

Aim: To describe the process and outcomes of co-designing resources to support partnership between the woman who declines recommended maternity care and the clinicians and health services who provide her care.

Materials and methods: Following a participatory co-design process involving consumer representatives, obstetricians, midwives, maternal fetal medicine specialists, neonatologists, health service executives, and legal and ethics experts, implementation of the resources was trialled in seven Queensland Health services using Improvement Science's Plan-Do-Study-Act cycles.

Results: Resources for Partnering with the woman who declines recommended maternity care have now been implemented statewide, in Queensland, including a guideline, two consumer information brochures (available in 11 languages), clinical form, flowcharts, consumer video, clinician education, and culturally capable First Nations resources. Central to these resources is an innovative shared clinical form, that is accessible online, may be initiated and carried by the woman, and where she can document her perspective as part of the clinical notes.

Conclusion: Queensland is the first Australian jurisdiction, and perhaps internationally, to formally establish this kind of guidance in clinical practice. Such guidance is identified as an enabler of choice in the national Australian strategy Woman-centred care: Strategic directions for Australian maternity services.