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

Introduction: Ongoing advances in genetic technology may soon provide prenatal screening for multiple genetic conditions.

Aims: The aims were to investigate what prenatal screening test characteristics women prioritise and their willingness to pay for these tests.

Methods: We designed an online survey incorporating a series of discrete choice scenarios. Dimensions and levels were selected based on existing prenatal tests and a hypothetical prenatal test that could non-invasively detect multiple genetic disorders in pregnancy. Participants were recruited from social media platforms. Data were analysed using conditional logistic regression and latent class analysis (LCA).

Results: A total of 219 women completed the survey. Women with higher incomes and those with a tertiary education were willing to pay more than other groups. The maximum willingness to pay was AUD1870 (95% confidence interval: 1630, 2112) for a hypothetical non-invasive test to detect multiple genetic conditions in early pregnancy. An LCA demonstrated considerable heterogeneity in preferences, differing in both overall preference for testing and test characteristics considered most attractive. Among the participants, decision factors cited by 14.5% of participants were the risk of pregnancy loss, making them less likely to undergo testing; for 32.1% participants, accuracy was a major factor, and they were very likely to have testing; for 12.9%, test availability early in pregnancy was a decision factor.

Conclusions: If a non-invasive test that could detect the greatest number of genetic disorders in pregnancy was available, the priorities were test accuracy, risk of pregnancy loss and a test available early in pregnancy.

Background: Preterm birth (PTB) is a major pregnancy complication. There is evidence that a short cervical length in mid-pregnancy may predict women at increased risk of PTB.

Aims: To evaluate the utility of population-based, transabdominal cervical length (TACL) measurement screening in mid-pregnancy for PTB prediction in women.

Materials and methods: A transabdominal approach was initially performed, with a transvaginal (TVCL) approach offered when the TACL was <35 mm, could not be accurately measured, or the pregnancy had risk factors for PTB. TACL was compared to the directly related TVCL, when both were performed at the same assessment. Women with risk factors of PTB were included when they had both TACL and TVCL measurements performed at the same visit.

Results: Data were provided for 9355 singleton pregnancies from 13 participating imaging centres. A transabdominal approach was used in 9006 (96.3%), including 682 (7.3%) TVCL combined with TACL. There were 349 (3.7%) women who had TVCL only. The median TACL was longer (40 mm) than the TVCL (38 mm). In 682 paired TACL and TVCL measurements, TACL <35 mm correctly identified 96.2% of pregnancies with TVCL <25 mm, compared with 65.4% of cases when using a TACL <30 mm. A TVCL <25 mm occurred in 59 (0.6%) women. A TACL <35 mm was associated with birth <37 weeks of gestation in 12.1% of women and birth <32 weeks of gestation in 3.9%.

Conclusions: Universal TACL is a feasible option for population screening of cervical length in a low-risk population, progressing to TVCL if the TACL is <35 mm or the cervix cannot be transabdominally accurately measured.

Background: During the COVID-19 pandemic, mitigation measures were associated with a reduction in preterm birth rates; while not clearly proven, this observation has sparked significant interest.

Aim: To understand the cause of this reduction by exploring the characteristics of preterm birth cohorts.

Material and methods: We performed a retrospective cohort study where we compared women who delivered preterm in three Melbourne maternity hospitals and conceived between November 2019 and February 2020 (mitigation measures-exposed cohort) to women who delivered preterm and conceived between November 2018 and February 2019 (non-exposed cohort). We compared maternal characteristics, pregnancy complications, antenatal interventions, intrapartum care, and indications for delivery.

Results: In the exposed cohort, 252/3129 women delivered preterm (8.1%), vs 298/3154 (9.4%) in the non-exposed cohort (odds ratio (OR) 0.84, 95% CI 0.70-1.00, P = 0.051). The baseline characteristic of two cohorts were comparable. Rates of spontaneous preterm labour (sPTL) without preterm pre-labour rupture of membranes (PPROM) were lower in the exposed cohort (13.1% vs 24.2%, OR 0.47, P = 0.001) while PPROM occurred more often (48.0% vs 35.6%, OR 1.67, P = 0.003). With a non-statistically significant prolongation of pregnancy in the cohort exposed to mitigation measures for both sPTL without PPROM (35.4 vs 34.9 weeks, P = 0.703) and PPROM (35.6 vs 34.9 weeks, P = 0.184). The rate of spontaneous labour after PPROM was higher in the exposed cohort compared to the non-exposed cohort (40.1% vs 24.1%, OR 2.09, P < 0.001).

Conclusion: The reduction in preterm delivery during mitigation measures may have been driven by a reduction in spontaneous labour without PPROM, which seemed to result in more PPROM later in pregnancy.

Background: The barriers to comprehensive abortion care in Australian metropolitan tertiary hospitals are under-researched. Previous work has suggested that negative practitioner attitudes and lack of training may play a large role; however, this remains poorly understood.

Aim: The aim was to survey doctors practicing obstetrics and gynaecology to better understand their views, training experience and confidence in abortion care.

Method: The method involved a cross-sectional study via an anonymous survey at a single metropolitan tertiary hospital not providing substantive abortion services in Melbourne, Australia. Inclusion criterion was obstetric and gynaecology medical staff working at that hospital. Data were collected regarding views, training experiences and confidence in first-trimester medical and surgical abortion, and second-trimester surgical abortion. Data were analysed according to levels of training, categorised as RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) Fellows, prevocational/vocational trainees and general practitioner specialists.

Results: Sixty-one valid responses were received from 90 eligible participants (response rate 68%). An overwhelming majority (96%) supported abortion services. The majority of RANZCOG Fellows felt confident performing first-trimester surgical abortion (89%) and first-trimester medical abortion (71%); however, only half felt confident performing second-trimester surgical abortion (50%). Prevocational/vocational trainees were overall less confident but overwhelmingly expressed interest in gaining further experience in abortion.

Conclusion: Doctors are generally confident in providing first-trimester abortion services (medical or surgical) in the metropolitan tertiary setting. However, further work is required to understand ongoing barriers to comprehensive abortion care. There may also be a skills shortage for second-trimester surgical abortion, requiring significant improvements in abortion training.

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Part II of the Australasian guideline for the investigation and management of recurrent pregnancy loss (RPL) provides evidence-based guidance on the management of RPL provided. The implications of inherited and acquired thrombophilia with respect to RPL and suggestions for clinical management are provided. Autoimmune factors, including human leukocyte antigen, cytokines, antinuclear antibodies and coeliac antibodies, and guidance for management are discussed. Infective, inflammatory and endometrial causes of RPL are discussed in detail. Environmental and lifestyle factors, male factor and unexplained causes are outlined. Levels of evidence and grades of consensus are provided for all evidence-based statements.

Persistent pelvic pain is a significant healthcare concern among adolescents; however adolescents often have poor health literacy regarding their pain. Current school curricula fail to specifically address pelvic pain and management strategies. This review aims to summarise current pelvic pain education programs in Australian and New Zealand schools. These programs have successfully strengthened the understanding of the psychosocial impact of periods and pelvic pain, instilled greater confidence in managing persistent pain and have allowed for prompt detection and treatment of pelvic pain in adolescents. An outcomes-driven, collaborative, and coordinated approach is needed to improve pelvic health educational interventions for adolescents.

Background: Thyroid axis dysregulation during controlled ovarian hyperstimulation (COH) is more pronounced in hypothyroid-treated women. Whether or not this leads to compromised thyroid hormone levels within the ovarian follicular fluid is not known.

Aims: To determine whether ovarian follicular thyroid hormone levels are compromised in adequately replaced hypothyroid women undergoing controlled ovarian hyperstimulation (COH), and/or influence cycle/pregnancy outcomes.

Materials and methods: Prospective cohort study involving 46 euthyroid (anti-thyroid peroxidase antibody negative) and 16 levothyroxine-replaced women with baseline thyroid-stimulating hormone (TSH) <2.5 mIU/L attending their first COH cycle. Follicular fluid TSH, free triiodothyronine (T3) and free thyroxine (T4) were recorded at oocyte pick-up. Serum levels were measured at: (i) baseline; (ii) human chorionic gonadotropin trigger day; and (iii) cycle conclusion. The number of mature oocytes retrieved, fertilisation, early pregnancy loss and live birth rates were compared.

Results: Median serum TSH levels were similar at baseline (1.76 vs 1.24 mIU/L, P = 0.053), but free T3 levels were lower (4.5 vs 4.8 pmol/L, P = 0.029) in levothyroxine-replaced compared to euthyroid women, with serum TSH levels increasing across ovarian stimulation (P = 0.006) into pregnancy testing (P = 0.030). Follicular fluid free T3 levels were lower in levothyroxine-replaced women (median 4.3 vs 4.6 pmol/L, P = 0.032). Fertilisation rates were lower (52% vs 71%, P = 0.043) in women requiring levothyroxine replacement, but numbers of mature oocytes retrieved, early pregnancy loss and live births did not differ.

Conclusion: Adequately replaced hypothyroid women achieve lower ovarian follicular fluid free T3 levels and poorer fertilisation rates compared to euthyroid women undergoing COH. Optimising T3 levels may be pivotal in improving COH outcomes in hypothyroid women.

Background: The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static.

Aims: To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis.

Materials and methods: A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement.

Results: This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes.

Conclusion: Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.

The effects of the COVID-19 pandemic on Australia's health system, the economy and social cohesion of the country are still felt but effect on birth rates and future generations is of profound significance. During the first year of the pandemic the news was particularly grim: Australian Bureau of Statistics (ABS) data¹ revealed that 3 00 000 babies were born for the first time since 2007, and the estimated total fertility rate (TFR—the total number of children born to each woman if she were to live to the end of her child-bearing years) had fallen to 1.58, the lowest in Australia's history and representing a fall of 56% from the peak in 1961 (when the TFR reached 3.55).

A slight rebound in the number of babies born was observed in 2021—perhaps the result of people delaying pregnancy rather than abandoning the idea altogether—the situation again appeared grim with the release of the 2022 birth statistics. Australia's TFR has remained below 1.7 since before the pandemic, the longest period in the nation's history.² The results prompted calls from former Australian Federal Treasurer Peter Costello—architect of the ‘Baby Bonus’ initiatives of the early 2000s—to call for new policy measures to increase Australia's birth rate.³ Yet while the pandemic appears to have exacerbated the ‘baby bust,’ the pre-pandemic year 2019 also had an historical low TFR of 1.66 babies per woman. Indeed, Australia's birth rate had been in established decline well before the pandemic (Fig. 1). Putting this in a global context, too, the fall in fertility rates seen in Australia is hardly unique: across the globe birth rates and resulting TFR estimates have been in decline since the 1960s (Fig. 2).

Population is influenced by births, life-expectancy and immigration. Immigration has boosted the availability of human capital, and stimulated the economy in Australia but the contribution of immigration to long-term population growth remains uncertain. Studies suggest that migrants commonly have, as a group, higher TFRs,⁴ yet this has not proven to be the case in Australia: ABS data reveal that the fertility rates of overseas-born mothers have been lower than those of Australian-born mothers since 2007 (Fig. 3).

Estimates of the TFR allow comparison with a second important metric—the replacement fertility rate (RFR): the TFR at which newborn girls would have an average of exactly one daughter over their lifetime. The RFR is important because it represents the rate at which a population exactly replaces itself from one generation to the next. In high-income countries replacement-level fertility requires an average of 2.1 children per woman. In countries with high infant and child mortality rates, the average number of births may need to be much greater. Replacement-level fertility rates will keep a country's population steady but will not lead to population growth i