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

Background

Endometriosis is a significant and prevalent health issue. Delayed diagnosis is common and the associated delay to treatment is associated with high socioeconomic and personal costs including chronic pain, infertility and reduced quality of life. There is a lack of studies documenting endometriosis pathways in Australia.

Aims

To explore lived experiences of individuals with endometriosis in South Australia and identify perceived barriers to timely diagnosis.

Materials and Methods

Semi-structured interviews were conducted with 50 participants aged over 18 years living in South Australia with a surgical diagnosis of endometriosis and data was analysed using reflexive thematic analysis.

Results

Participants reported significant delays between the onset of symptoms and their diagnosis. Barriers were identified at personal and systemic levels. Personal barriers include societal and self-normalisation of symptoms and stigma associated with discussing menstrual health. Systemic hurdles include symptom dismissal and insufficient endometriosis education within healthcare and community settings. These barriers significantly hinder equitable and empathetic healthcare access. Diagnosis delivery is a key point in the endometriosis care pathway and must be conducted thoroughly and empathetically by health professionals with a patient-centred focus.

Conclusions

This study highlights the need to improve care pathways for the timely recognition and management of persistent pelvic pain. In patients presenting with chronic pelvic pain, endometriosis should be considered as part of the differential diagnosis. Results call for multi-faceted improvements in technology, advocacy, and education for students and health practitioners to improve timely diagnosis and patient-centred outcomes. We suggest re-orientating the healthcare system to centre the individual as the expert in their own journey, fostering a more patient-centred approach.

Background

Intracytoplasmic sperm injection (ICSI) was first developed to overcome male factor infertility. ICSI has increased in uptake globally, including in cases where its use is non-essential for fertilisation.

Aims

To identify temporal trends in the use of, and indications for ICSI in an Australian context.

Materials and Methods

A statewide descriptive cohort study examining the trends in ICSI uptake and reported indication/s for ICSI use. The cohort included women undergoing IVF between 2005 and 2017 at IVF clinics across Victoria, Australia that resulted in a birth after 20 weeks' gestation.

Results

The dataset comprised 32 102 assisted reproduction cycles: 22 873 (71.3%) ICSI and 9229 (28.7%) conventional IVF. In 2005, ICSI accounted for 60.6% (1182/1952) of cycles, increasing to 79.5% (2344/2947) by 2017 (p_trend < 0.001). Testicular sperm retrieval as an indication for ICSI remained consistent over time (p_trend = 0.15). Male factor infertility as an indication decreased over time (p_trend = 0.007). Vitrified oocyte thaw (p_trend = 0.016) and ‘unexplained subfertility’ (p_trend = 0.30) cycles did not surpass 1.7% (39/2293) and 0.4% (9/2048), respectively of total cycles in any year. Donor sperm (p_trend = 0.001), pre-implantation genetic testing (p_trend = 0.004), female factors associated with poor IVF outcome (p_trend = 0.005) and advanced maternal age (p_trend = 0.005) all increased as indications for ICSI over time. ‘Unspecified’ indication accounted for the majority of ICSI cycles after 2008 (p_trend = 0.015).

Conclusions

During our study period, the total use of ICSI increased by 18.9%. Notably, most of these cycles were not medically indicated.

Background

During the coronavirus disease of 2019 (COVID-19) pandemic, pregnant women and new mothers in Australia experienced extreme pandemic societal responses but low SARS-CoV-2 incidence. This offers one of the few opportunities internationally to learn from the pandemic's indirect effects on maternal health, informing future policy.

Aims

To explore women's qualitative experiences of pregnancy to the 12 postpartum months during the COVID-19 pandemic in Australia.

Materials and Methods

A systematic search followed PRISMA guidelines. MEDLINE, Embase, Web of Science and PubMed were searched from 1 January 2020, to 13 August 2023, using four categories of terms: ‘COVID-19’, ‘perinatal’, ‘qualitative’, ‘Australia’. Studies were scored using the CASP checklist and common themes identified from thematic synthesis. The ENTREQ reporting statement was followed.

Results

From eight peer-reviewed studies, four themes were identified: (1) ‘No one can give you any answers’: Provision of information was inadequate in supporting women to make health-related decisions; (2) ‘Very isolated’ or ‘It brought us closer’: Social distancing restrictions caused major changes within women's informal support networks; (3) ‘Have they seen enough of me?’: Women felt unsupported during disruptions in maternal health services; (4) ‘All you want to do is keep safe’: Safeguarding family from SARS-CoV-2 added cognitive strain to women's daily decision-making and routine. All studies were of a good or high quality.

Conclusions

Three lessons were highlighted. First, women need accurate, accessible health information to make informed decisions. Second, policies should support family bonding and social connections during government restrictions. Finally, health services must be strengthened to ensure continuous, high-quality, accessible care during global crises.

Background

Gestational diabetes (GDM) is currently diagnosed in approximately 18% of pregnancies in Australia. GDM may lead to infants being born large for gestational age (LGA), and other complications. There is currently no consensus on optimal treatment targets.

Aims

This study aims to compare perinatal outcomes in patients with GDM when treated according to tighter or less tight fasting blood glucose level (BGL) targets.

Methods

Our retrospective cohort study included data from all 12 metropolitan public hospitals providing maternity care in Victoria between January 2020 and December 2022. Women who gave birth to a term singleton infant and who had a diagnosis of GDM were included. Women were grouped according to their delivery hospitals' fasting BGL targets: ‘tighter’ (< 5.0–5.2 mmol/L) or ‘less tight’ (< 5.5–5.6 mmol/L). The primary outcome was LGA and a range of secondary outcomes were compared. Inverse probability treatment weights were calculated based on sociodemographic and socioeconomic factors. We then performed multilevel Poisson regression with delivery hospitals as random intercept.

Results

There were 25 041 births included, 12 423 (49.6%) in the ‘tighter’ target group, and 12 618 (50.4%) in the ‘less tight’ group. After adjusting for hospital and maternal demographics, there was no difference in LGA births (10.4% in ‘tighter’ vs. 9.5% in ‘less tight’ (p = 0.85)). More women received insulin treatment in the ‘tighter’ group (53%) compared to ‘less tight’ (35%, p < 0.001). There were no significant differences in secondary outcomes.

Conclusion

Tighter fasting BGL targets were not associated with improved perinatal outcomes but were associated with an increase in pharmacotherapy.

Background

Blood transfusion is an important treatment for obstetric haemorrhage. Transfusion also engenders significant short and long-term risks. Ensuring blood products are only given when necessary is a priority in improving outcomes.

Aims

To describe the population transfused at a single unit in New Zealand and identify the proportion of patients over and unnecessarily transfused via adjustment of haemoglobin per unit of blood given. To assess whether the rate of inappropriate transfusion was modified by demographic and treatment characteristics.

Materials and Methods

A retrospective cohort study inclusive of all people who gave birth from 20 weeks between 2018 and 2021 at one hospital was assembled. People who were administered red blood cell-containing products were identified. The pre-discharge haemoglobin was adjusted per unit of blood given with patients being considered over or unnecessarily transfused at a pre-discharge haemoglobin of ≥ 90 mg/dL.

Results

The transfused population comprised 694/25 915 pregnancies (2.7% of the cohort). Appropriate transfusion (pre-discharge haemoglobin < 90) occurred in 332/694 (47.8%) people. There were 325 (46.8%) patients who were over- or unnecessarily transfused. There was no difference in appropriateness of transfusion for any ethnicity compared to Māori, our referent group. Over-transfusion rates did not differ and were high in both acute (53%) and non-acute (45%) settings.

Conclusion

The rate of transfusion for obstetric haemorrhage was 2.7% in our study population. Approximately half of people receiving blood received either too many units or did not require a transfusion.

Background

While endometrial ablation (EA) offers a minimally invasive alternative to a hysterectomy for women suffering from abnormal uterine bleeding (AUB), clinicians currently lack reliable predictive tools to identify which patients will experience treatment failure, leaving both providers and patients to make treatment decisions with incomplete prognostic information.

Aims

The aim of this study is to identify factors that are associated with failure of EA, and use these to develop and internally validate a model predicting failure after EA.

Materials and Methods

Design

Retrospective cohort study.

Results

Of the 646 patients who underwent an EA between 2015 and 2021, 21% required ongoing treatment. A model for predicting the failure of endometrial ablation was developed. The presence of fibroids and increasing BMI was associated with failure of EA. Increasing age and insertion of the Mirena at the time of EA made failure less likely.

Conclusions

Despite many years of evidence supporting different factors that are associated with failure after an EA, this is the first study to develop a predictive model using Australian data and the first model incorporating the use of Mirena. Ongoing research is suggested to improve model performance and then validate the model externally prior to using it in a clinical context. The nomogram is a demonstration of a possible application of a predictive model.

Background

An estimated 73.3 million abortions occur annually worldwide. Second-trimester abortion is known to carry a higher risk of complications than first-trimester abortion, though the absolute risk is thought to be low. There is limited Australian data about second-trimester surgical abortions and no studies have looked at surgical complications.

Aims

This study aimed to determine the complication rate of second-trimester surgical abortions at an Australian tertiary maternity hospital across a 5-year period.

Materials and Methods

A retrospective audit was conducted from 1 January 2019 to 31 December 2023. Inclusion criteria were women and pregnant people with a gestation of 14 + 0 to 23 + 6 weeks who underwent dilation and evacuation for termination of pregnancy. The primary outcome was the rate of complications.

Results

Two thousand, one hundred and sixty-four D&Es were performed for termination of pregnancy across the study period. Forty-seven of these women experienced complications, equating to a complication rate of 2.17%. The major complication rate was 0.55% (n = 12). The overall complication rate was significantly lower in women under 20 weeks' gestation compared to women over 20 weeks (1.71% vs. 4.19%, p = 0.007). This difference was significant when comparing minor complication rates only (RR 0.32, 95% CI 0.16–0.61); major complication rates demonstrated no significant difference between gestation groups (RR 1.12, 95% CI 0.25–5.15).

Conclusions

This study demonstrates that surgical second-trimester abortions are safe. Increased complication risk with increased gestational age is evident, highlighting the importance of timely access to abortion care.

Background

Every woman who books into a public hospital for antenatal care in Australia is assessed for risk factors for adverse outcomes. However, no study has examined empirical patterns of risk stratification, subsequent models of care and their relationship to perinatal outcomes.

Aims

This study aims to describe patterns of risk stratification and their intersection with allocated models of care and subsequent perinatal outcomes.

Materials and Methods

This is a multi-centre retrospective cohort study of all pregnancies booked in and delivered at the three maternity units in western Sydney between 1 January 2018 and 31 December 2022. Women were classified into one of three risk categories (A, B or C) as defined by the Australian College of Midwives' guideline. Variables measured include allocated models of care, maternal and fetal risk factors, birth outcome, and pregnancy morbidity and mortality.

Results

At time of both booking-in and birth admission, most women were classified as Category C (‘high risk’). During antenatal care, the number of women classified as Category C grew by 70.7% from 21,847 at booking in to 37,290 at birth admission. Between booking-in and admission for birth, there was an over 25% increase in women allocated to medical models of care during the study period. There was higher perinatal morbidity in women classified as ‘high risk’.

Conclusions

Current antenatal risk stratification methods appear to detect women with a higher chance of adverse perinatal outcomes, but in doing so classify over three quarters of women as ‘high-risk’. This has important ramifications for model of care, perceived patient risk, and resource allocation.