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

Background: Effective analgesics with minimal side effects are imperative for patient and neonate wellbeing postpartum. Post-caesarean section ultrasound-guided transversus abdominis plane (TAP) blocks have proven safety and efficacy. Surgical TAP blocks appear effective and require little time and equipment. No previous examination of surgical TAP blocks in patients having undergone emergency caesarean section has been undertaken.

Aims: To investigate surgical TAP block and multimodal analgesic use during emergency caesarean section, the effect on surgical time, post-operative analgesia use, and admission length.

Materials and methods: We performed a retrospective review of 250 patients who underwent emergency caesarean in 2022. Surgical TAP blocks were performed with 20 mL of 0.375% ropivacaine either side. Primary outcomes included surgical time, length of admission, time to first request of rescue opiate, opiate use in first post-operative 24 h, total dose used during admission, and opiates prescribed on discharge.

Results: Ninety-six patients received surgical TAP blocks, and 154 did not. There were no statistically significant differences in the primary outcomes. Subgroup analyses were performed in patients who did not receive intrathecal morphine, body mass index over 30 kg/m², for patients whom this was their first caesarean, and for TAP blocks versus local infiltration to the wound. There were no significant differences in the primary outcomes in these subgroups.

Conclusions: Surgical TAP blocks did not prolong surgical time or decrease post-operative analgesia use or admission length in patients having undergone emergency caesarean. Patient-tailored multimodal analgesia is encouraged, although more research is needed.

Introduction: The public health response (PHR) to the COVID-19 pandemic significantly disrupted healthcare services worldwide. Our hospital, a major tertiary centre, is a unique two-state service across Queensland and New South Wales (NSW).

Objective: The primary objective is to describe changes in service demand and delivery in our hospital resulting from the COVID-19 PHR. The secondary objective is to investigate patient perceptions of this impact.

Materials and methods: We performed a retrospective interrupted time series analysis and a population-based survey to examine patient perceptions of the impact of the COVID-19 PHR. The study periods were demarcated by the initiation of the COVID-19 PHR on 1 March 2020 with the 'pre' and 'during' COVID-19 periods defined as the 12 months before and after this date respectively.

Results: More patients were seen during the COVID-19 PHR period. The number or stage of cancer diagnoses was not different (P > 0.05). There was evidence (P = 0.03) of an increase in overall occasions of service and fewer failed attendances (P = 0.005). Fewer surgeries were performed on NSW patients (P = 0.005). The survey response rate was 19.3% (n = 185) with 48% stating that COVID-19 had negatively affected their emotional wellbeing. More participants from NSW than Queensland identified border closures as the most significant impact of the COVID-19 PHR.

Discussion: The COVID-19 PHR resulted in an unexpected increase in unit service demand and delivery. The necessary implementation of telephone appointments, while less preferred by patients, sustained service requirements. Cross-border tertiary healthcare services should consider the significant impact of border restrictions on patient wellbeing.

Much focus has been placed on optimising training in obstetrics and gynaecology, with redesign of accreditation standards, expansion of training sites, curriculum reviews and the ever-present dilemma around appropriate surgical numbers for trainee logbooks. However, the time has come to consider the role of the unsung heroes of the training experience – the trainers. At the 2023 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Annual Scientific Meeting in Perth, a group of interested Fellows, Proceduralists, Trainees and College staff met to workshop what a RANZCOG Community of Practice for educators might look like. The discussion centred around the potential aims of such a group, its purpose, and of course – its name. Thus was born the RANZCOG Academy of Clinician Educators – the ACE. The ACE was formally launched by RANZCOG President Dr Gillian Gibson at the RANZCOG Symposium in the Sunshine Coast in July 2024, and will be hosting its opening webinar on the subject of ‘What makes a good medical teacher?’ on 22 August.

The aims of the ACE born out of that first meeting in Perth are fourfold: (1) to foster excellence in medical education; (2) to provide professional development opportunities for medical educators through RANZCOG; (3) to promote sharing of resources and collaboration between education providers and the College; and (4) to create networking and support opportunities for current medical educators and for those with an interest in the area (Fig. 1).

To foster excellence in education we need to know what that looks like: what are the essential competencies for a medical educator in our speciality? The literature identifies multiple competency domains, with good concordance between different authors on the subject.^1-3 The consensus is that excellence in medical education comprises skills or attributes in the following five areas: teaching and facilitating learning, designing and planning learning, assessment and feedback, educational research and scholarship, and educational leadership. If the ACE are to accept and promote those five competencies, we must first understand them, including understanding how they are applicable to clinician educators in our own speciality of obstetrics and gynaecology. Let us consider them in turn, starting with the most obvious competency area for an educator – that of teaching and facilitating learning.

How to define competency in teaching is surprisingly difficult within the medical field, as there seem to be opposing views on whether clinical expertise is more important than the non-clinical skills associated with teaching when it comes to medical education. In 2008, Sutkin et al published a literature review on the subject ‘What makes a good clinical teacher in medicine?’.⁴ Sutkin identified 49 separate themes arising from analysis of the literature. The dominant theme was ‘Medical/clini

Potassium-wasting syndromes, including Gitelman or Bartter syndrome, require close medical and biochemical review during pregnancy to reduce potentially severe complications, morbidity and mortality. We report a case of severe potassium-wasting syndrome managed successfully in pregnancy with extremely high oral potassium intake.

Background: Universal mismatch repair immunohistochemistry (MMR IHC) tumour testing in endometrial cancer (EC) for Lynch syndrome (LS) was introduced in Auckland, New Zealand, in January 2017. Identifying patients with LS allows them and their families to access risk reduction strategies. Universal MMR IHC testing aids in the molecular classification of EC and has prognostic and therapeutic implications.

Aim: We aimed to determine the incidence of LS in women with EC in Auckland, New Zealand, following the introduction of MMR testing and the impact of universal screening on local genetic services.

Materials and methods: This is a retrospective clinicopathological evaluation of women with a new EC diagnosis referred to the Auckland Gynaecological Oncology Unit from 1/1/17 to 31/12/18. Patient data were extracted from the Gynaecological Oncology Unit database and electronic records, and analysed using descriptive statistics.

Results: During the study period, 409 patients were diagnosed with EC, with an over-representation of Pacific Islanders (32.5%). Of these, 82.6% underwent MMR IHC testing, 20% were MMR-deficient (MMRd), and 71% had somatic hypermethylation. The Pacific Islander population had a 64% (odds ratio 0.36, P = 0.005) reduction in the odds of having MMRd tumours compared with Europeans. Of the patients who underwent MMR IHC testing, 5.5% were referred to a genetic clinic for germline testing. LS was confirmed in eight patients (2.3%).

Conclusion: LS was diagnosed in 2.3% of patients. There was an over-representation of Pacific Islanders in the EC group but not among those diagnosed with LS.

Background: Symptoms like vaginal bleeding or abdominal pain in early pregnancy can create anxiety about potential miscarriage. Previous studies have demonstrated ultrasonographic variables at the first trimester transvaginal scan (TVS) which can assist in predicting outcomes by 12 weeks gestation.

Aim: To validate the miscarriage risk prediction model (MRP) in women who present with a viable intrauterine pregnancy (IUP) at the primary ultrasound.

Materials and methods: A multi-centre diagnostic study of 1490 patients was performed between 2011 and 2019 for retrospective external and 2017-2019 for prospective temporal validation. The reference standard was a viable pregnancy at 12 + 6 weeks. The MRP model is a multinomial logistic regression model based on maternal age, embryonic heart rate, logarithm (gestational sac volume/crown-rump length (CRL)) ratio, CRL and presence or absence of clots.

Results: Temporal validation data from 290 viable IUPs were collected: 225 were viable at the end of the first trimester, 31 had miscarried and 34 were lost to follow-up. External validation data from 1203 viable IUPs were collected at two other ultrasound units: 1062 were viable, 69 had miscarried and 72 were lost to follow-up. Temporal validation with a cut-off of 0.1 demonstrated: area under the curve (AUC) of 0.8 (0.7-0.9), sensitivity 66.7%, specificity 83.9%, positive predictive value (PPV) 35.7%, negative predictive value (NPV) 94.9%, positive likelihood ration (LR+) 4.1 and negative LR (LR-) 0.4. External validation demonstrated: AUC 0.7 (0.7-0.8), sensitivity 44.9%, specificity 90.4%, PPV 23.3%, NPV 96.2%, LR+ 4.6 and LR- 0.6 (0.4-0.7).

Conclusion: The MRP model is not able to be used in real time for counselling, and management should be individualised.

Background: Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery.

Aims: To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital.

Materials and methods: Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes.

Results: The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m² (27.8-38.3 kg/m²). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases.

Conclusions: VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

Background: Despite clinical and economic benefits, pain during outpatient hysteroscopy (OPH) remains a barrier to use. There is a lack of evidence to support routine use of one analgesic over another versus no analgesic.

Aims: To study the efficacy and safety of methoxyflurane analgesia during OPH.

Materials and methods: A single-centre, randomised, double-blind, placebo-controlled experiment was performed; 90 patients were randomly assigned (1:1). Participants allocated to the treatment group (cases) received 3 mL of methoxyflurane through an inhaler. The control group received a placebo. The primary outcome was a mean difference in pain, via a change in Visual Analog Scale (VAS) score from baseline at diagnostic hysteroscopy. Secondary outcomes were a mean difference in VAS score with any subsequent operative procedures; a mean difference in VAS score at 15 min post-procedure; participant and clinician-reported adverse effects and events; and participant-reported procedure acceptability, adjuvant nitrous oxide (N₂O₂) use and a composite of 'distress'.

Results: During diagnostic hysteroscopy, there was a mean difference of 11.5 mm/100 (95% confidence interval (CI) 0.08-22.95), P = 0.05, with the lower score in the cases, compared with controls. During subsequent operative procedures, there was a mean difference of 15 mm/100 (95% CI 2.71-28.22), P = 0.02, with the lower pain score in the cases, compared with controls. There was no significant difference in pain 15 min post-procedure, participant- and clinician- reported adverse effects and events, procedure acceptability and the 'distress' composite.

Conclusions: Methoxyflurane significantly reduced pain during OPH compared with placebo, for diagnostic as well as operative procedures. Furthermore, methoxyflurane was well tolerated, with no adverse events.

Welcome to the June issue of the Australian and New Zealand Journal of Obstetrics and Gynaecology.

This issue begins with a thought-provoking editorial by Boothroyd et al¹ which explores the declining fertility rate in the Australian population and its implications for society. Australia is not alone among similar countries in this situation, it being a common challenge faced by virtually all high-income countries. While we have been able to maintain population growth due to net immigration, this is unlikely to remain the case in the longer term, and at some point we are likely to find ourselves in the situation where supporting the growing elderly population is reliant upon a shrinking working age population. This is clearly economically unsustainable. The authors identify contributors such as higher levels of female education and employment and extended educational and career development pathways coinciding with peak fertility ages. In suggesting areas for public policy changes which could address the fertility decline, the authors make a call for this to become part of the political agenda.

The issue continues with a wide-ranging selection of papers from across our specialty.

Endometriosis continues to be topical. Fang et al² present a systematic review of multidisciplinary teams for the care of people with endometriosis. They find the models studied varied in professional composition, with little clear evidence to demonstrate which is the superior model in terms of clinical and important non-clinical outcomes. They speculate that multidisciplinary teams are likely to be valuable but that further research is required to show which models are most effective. Frayne et al³ present a mixed methods study of the acceptability of using the Raising Awareness Tool for Endometriosis (RATE) in a general practice setting. They found that general practitioners found RATE valuable, particularly in facilitating discussion about symptoms and their management, but identified uncertainty about the identification and management of people with chronic pain syndromes. Pelvic pain was highly prevalent, with a significant impact on quality of life in a substantial proportion of those participants. Paterson et al⁴ present the first published data on endometriosis surgery in Aotearoa New Zealand. This retrospective review of over 400 surgeries performed for known or suspected endometriosis found pain to be the most common indication for surgery, with 68% of surgeries confirming this condition. These findings are broadly comparable to international data, but the authors call for further research into endometriosis in a New Zealand-specific context.

McGinn et al⁵ present their study of sexual and reproductive health services in New Zealand. They report that these services are fragmen