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

The first International Association of Diabetes and Pregnancy Study Groups Summit on the diagnosis of gestational diabetes in early pregnancy (Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) Summit) was held on the 17 November 2022 in Sydney, Australia. It sought to use the TOBOGM trial findings to scope the issues involved with early screening, to inform future discussions over possible approaches for diagnosing gestational diabetes mellitus (GDM) in early pregnancy. Most delegates supported testing for early GDM using a one-step 75 g oral glucose tolerance test approach with Canadian Diabetes Association criteria preferred, but highlighted the importance of considering resources, cost, consumer perspectives and equity in translating TOBOGM results into a clinical approach to screening for, and diagnosing, early GDM.

Welcome to the April 2024 issue of ANZJOG. Thank you to the many contributors to ANZJOG who have submitted manuscripts and contributed to the peer review process as this maintains the journal as a source of robust clinical science for clinicians and researchers in Australia and New Zealand and further afield.

This issue begins with two stimulating articles about severe maternal morbidity. Most of us are fortunate to live and work in locations with historically low rates of maternal mortality, although there remain lessons to be learned and improvements to be made from the rare but tragic maternal deaths that still occur. Although there are robust and well-resourced processes for review of maternal mortality, the recognition, review and reporting of severe maternal morbidity are much less systematic, resulting in missed opportunities for the detection and improvement of system-level weaknesses which underlie preventable severe adverse maternal outcomes. The review by Frost et al. provides an excellent overview of the current situation of maternal morbidity review in Australia. The authors conclude by outlining a number of key steps towards implementing a systematic maternal morbidity review jurisdictionally and nationally.¹ In their editorial, MacDonald et al. go further, calling upon us, clinicians and researchers, to make the case for progress in this area and to drive it.² Major change will require policy and resource attention from government, but we can take valuable action prior to that: to demonstrate why this is important, our willingness to work towards improvements in maternal and related health outcomes and to spur policymakers into action.

This issue also includes reports of two randomised controlled trials. Fahy et al. present their trial of placental cord drainage at caesarean section.³ This practice has been shown to reduce the duration of the third stage of labour at vaginal birth although without a clinically significant reduction in blood loss. The authors compared placental cord drainage to delayed cord clamping at planned caesarean section, finding no significant differences between the two groups, and concluded that this study supports the routine use of delayed cord clamping.

The second trial compared sonographer-performed ultrasound-guided embryo transfer versus standard embryo transfer, including rates of intrauterine air bubble visualisation, clinical pregnancy and live birth as outcomes.⁴ Of these, only air bubble visualisation was significantly different between the groups, with sonographer-performed ultrasound proving beneficial. Given the resource implications of sonographer assistance and the lack of impact on clinical outcomes, this study does not provide compelling evidence to change standard practice in routine cases.

Two groups present systematic reviews of gynaecological interes

Reviewing severe maternal morbidity (SMM) is considered a marker of the quality of maternity care, as in high income countries (HIC) maternal mortality is thankfully now rare.¹ SMM disrupts maternal (and wider family) wellbeing, causing considerable personal and public cost. SMM preventability review has the potential to reduce this and the associated harm. To do this, we must identify its occurrence, review these cases, and analyse findings to develop appropriate system improvements.

As Joanne Frost and her colleagues in this current Australian and New Zealand Journal of Obstetrics and Gynaecology state, there is currently no national consensus or agreement in Australia on terms to use, definitions to follow and therefore no ability to compare inter-state data on the rates and causes of SMM. There is also no defined process to assess preventability in Australia and without this at the outset it is difficult to see how change would be effected. While in Aotearoa (New Zealand), our Health Research Council has previously funded research to enable national SMM preventability reviews, across both countries there appears to be no will by our respective governments to provide ongoing funding to enable routine SMM preventability reviews to take place.² No funding is currently available at regional, state, or national levels, and there is no apparent plan for these reviews to become ‘business as usual’. This is regrettable, as opportunities are being missed to improve poor maternal and baby outcomes.

There is no global agreement on how to define and implement SMM or maternal near-miss (MNM) reviews. There is not even agreement on what to call it. Professor Marion Knight stated four years ago in an editorial for another equally high-quality journal, – ‘As we publish yet more studies (re)defining severe maternal morbidity, should we be questioning whether it is time to draw a line on this research waste and instead initiate a truly international consensus process?’³

And ‘ay, there is the rub’.⁴ How do we initiate a ‘truly international consensus process’? A systematic review of global practices in monitoring of MNM/SMM showed inconsistencies in monitoring with low /middle income countries (LIC/MIC) using predominantly the World Health Organization (WHO) definition of MNM and tools, and high-income countries (HIC) using the SMM definition tools such as the Geller tool for reviewing preventability. The authors concluded that global standardising was ‘not feasible at this time’.⁵ Even a good news recent systemic review and meta-analysis of the WHO MNM criteria uptake in LIC showed that despite good uptake in these countries enabling some intercountry comparisons, there was still the need in individual countries for contextual adaptations.⁶

Surely the conversation needs to change. A se

Bleeding after laparoscopic gynaecological surgery remains a potential complication. We assessed RADA16 (PuraStat®), a topical self-assembling peptide haemostatic agent, in a pilot study of 46 women undergoing laparoscopic gynaecological surgery. The primary outcome was intraoperative haemostatic efficacy for resection site bleeding. Haemostasis was achieved in all intraoperative bleeding situations (40/40 participants: 100%) with no clinically significant surgical bed bleeding or complications. Mean volume and time required to achieve haemostasis were 6 mL and 14 sec, respectively. This study suggests that PuraStat® is a safe, effective haemostatic agent in laparoscopic gynaecological surgery. Randomised controlled trials are warranted to confirm these findings.