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

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.

Sickle cell disease (SCD) is a hereditary haemoglobinopathy which causes multi-organ dysfunction. Pregnancies in SCD are high risk with significant maternal and fetal morbidity and mortality, including vaso-occlusive crises, thrombosis, anaemia, placental insufficiency, fetal growth restriction, preterm birth and medication effects. High level evidence on this topic is lacking. The Australian Sickle Cell Disease Working Group has reviewed international guidelines on this topic and provide an up-to-date and structured approach to the pre-conception, antenatal, birth and post-partum management of these women. Early and comprehensive multidisciplinary care involving experienced clinicians is recommended.

Background: Obstetric ultrasound is an important tool, aiding in screening, diagnosis, and surveillance throughout pregnancy.

Aims: To explore obstetric doctors', midwives', and sonographers' experiences and views of obstetric ultrasound in Victoria, Australia. To investigate the increasing role of obstetric ultrasound for clinical management, and the adequacy of resources and training for appropriate use of ultrasound in clinical management.

Materials and methods: This cross-sectional study forms part of a multi-national CROss-Country Ultrasound Study (CROCUS) exploring the views of consumers and health professionals from high-, middle- and low-income countries. Qualitative studies conducted in several countries informed the construction of a quantitative survey. These quantitative surveys were distributed to 16 hospitals across regional and metropolitan Victoria, Australia. Descriptive statistics were analysed from the responses.

Results: There were 354 questionnaires returned from 106 doctors, 222 midwives, and 26 sonographers. Overall, 72% of respondents held concerns about the potential loss of focus on clinical skills with increasing ultrasound use. Midwives were more concerned about the contribution of ultrasound to medicalisation of pregnancy than were doctors (P < 0.001). Many respondents noted that geographical factors (71%), rather than income levels (53%) influenced access to obstetric ultrasound. Over 90% of doctors and midwives believed additional training for their respective professions in ultrasound would enhance its reach and effectiveness.

Conclusions: Our survey findings confirm that clinicians place high levels of trust in the diagnostic findings of obstetric ultrasound antenatal care in Australia. Access to routine ultrasound could be improved for women in rural and lower-income areas.

Background: Miscarriage is a common medical occurrence which can be associated with significant psychological distress. Patients and partners are frequently disappointed by aspects of their care, especially with regard to emotional support. Although most published studies investigated the experiences of patients and partners in emergency departments (EDs) of public hospitals, miscarriage is also frequently diagnosed in non-emergency settings, such as during sonography or antenatal appointments, and approximately 25% of Australian women receive maternity care in private hospitals.

Aim: Because the experience of miscarriage is known to be setting-dependent, it is important to understand how patients and partners experience care outside the ED. Here, we addressed this gap by investigating the experiences of patients and partners who attended a private maternity hospital for miscarriage using a mixed-methods approach.

Materials and methods: Eighteen patients and six partners who had recently experienced a miscarriage were recruited at a private maternity hospital to take part in both semi-structured interviews and online surveys.

Results: Overall, patients and partners were highly satisfied with the emotional care they received. Thematic analysis of semi-structured interviews allowed us to identify a total of ten themes that contributed to satisfaction with emotional care.

Conclusions: We provide the first specific insights into the experiences of women and partners who received care for miscarriage in an Australian private hospital setting, and the first example of a healthcare setting that achieves high satisfaction with emotional care around miscarriage. The ten themes we identify provide a framework for improving satisfaction with care also in other settings.

Aims: The aim was to explore Endometrial cancer (EC) survivors' experiences of being offered nutrition and well-being advice.

Methods: This qualitative study was conducted at two tertiary centres in Aotearoa New Zealand. Semi-structured conversations with people who had completed treatment for EC in the past 12 months were undertaken to explore how they were offered nutrition and well-being advice as part of standard follow-up care. Interviews were analysed using reflexive thematic analysis.

Results: Fifteen people of Pacific, Māori and European ethnicity participated. Five themes were derived: (i) isolation and vulnerability, (ii) importance of language, (iii) inconsistent availability and relevance of nutrition and well-being information, (iv) competing priorities and influences and (v) holistic and culturally responsive support. People often experienced judgement associated with their weight as part of their care, with limited understanding of their lived realities. Nutrition and well-being advice was not widely available or accessible, and people had to explicitly ask for it. Social and environmental factors were barriers to making changes to health behaviours. A need for culturally safe holistic care was identified.

Conclusion: Enhancing survivorship after EC is ultimately premised on providing culturally safe and responsive care. Expanding workforce training in communication around high weight as well as education and self-assessment of cultural safety could enable aspects of this. A holistic care program could facilitate wider access to nutrition and well-being advice and better meet the needs of this population.