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

Objectives

To audit outcomes of patients registered in the Queensland Trophoblast Centre (QTC) database who develop resistance to primary chemotherapy. To determine any risk factors that may predict first-line chemotherapy resistance in patients diagnosed with gestational trophoblastic neoplasia (GTN).

Methods

Patients within the QTC who were diagnosed with GTN between January 2012 and December 2020 were reviewed.

Results

Of 138 patients with GTN registered in the QTC, 22 (15.9%) patients developed resistance to first-line chemotherapy. Three had high-risk GTN and 19 had low-risk GTN. Of the three high-risk patients, one patient died. This patient had an epithelioid trophoblastic tumour (ETT). The remaining two high-risk patients had complete hydatidiform moles (CHM) with GTN. Both achieved complete remission with salvage therapy. Of the 19 low-risk patients, one patient had a partial hydatidiform mole (PHM). This patient achieved remission following third-line treatment. The other 18 low-risk patients had CHM with GTN. All but two of these 18 patients were successfully treated with second-line chemotherapy, with the remaining two patients achieving remission with third-line chemotherapy. Five of the 18 patients received either actinomycin-D or methotrexate as salvage therapy. Thirteen patients were given multi-agent chemotherapy for second-line treatment. One patient in this group died but this was not due to her disease. Initial β human chorionic gonadotropin levels were not predictive of number of chemotherapy cycles or number of lines of chemotherapy required to achieve remission.

Conclusions

GTN is a curable condition. If resistance to first-line chemotherapy occurred, most patients achieved remission with salvage therapy.

Background

Cannabis use during pregnancy is becoming more prevalent. While numerous studies have explored the relationship of cannabis use during pregnancy and outcomes for mothers and infants, uncertainty remains regarding the impact of cannabis use on pregnancy complications and later-life outcomes for offspring.

Aims

To produce a summary of the short and long-term effects of prenatal cannabis exposure on fetal growth and development, neonatal conditions, later-life, and maternal outcomes.

Materials and Methods

An overview of systematic reviews, an evidence and gap map, targeted updates of previous reviews, and de novo evidence synthesis was conducted. The databases searched include PubMed (National Center for Biotechnology Information); MEDLINE (Ovid); Embase (Ovid) and CINAHL with Full Text (EBSCO). Assessment of risk of bias was conducted in duplicate for all studies. Relevant studies were coded and are presented as an evidence and gap map. Where possible, meta-analyses were conducted with a narrative synthesis of the results. Primary studies and systematic reviews examining the relationship between cannabis consumption in pregnancy and the effect on fetal/child development, antenatal, and obstetric outcomes during pregnancy were eligible for inclusion.

Results

There were 89 studies/reviews eligible for inclusion in this review. There was a potentially harmful impact of prenatal cannabis exposure on all fetal growth and development outcomes, some neonatal outcomes, some later-life outcomes, and some maternal outcomes. The evidence regarding other neonatal conditions, later-life, and maternal outcomes was mixed.

Conclusions

The evidence suggests cannabis should be avoided during pregnancy.

Background

Menstrual cups offer a cost-effective and environmentally sustainable product for many young people. While clinical trials have shown their safety and effectiveness, no studies have investigated their performance in real-world use.

Aims

To describe the acceptability and functionality (continuation, discomforts, leakage, and adverse events) of menstrual cups and investigate the supportive role of product knowledge.

Materials and Methods

A cross-sectional online survey of 530 people aged 15–24 living in Australia who had ever used a menstrual cup, recruited via a menstrual cycle tracking application.

Results

More than half of participants (55%) were still using their first menstrual cup at the time of the survey, 16% had switched to an alternative cup, and 29% had discontinued use. In their first cycle of use, 54% of participants reported leakage and 25% reported pain or discomfort with the cup in place. Many participants (45%) reported being unable to remove the cup on their first attempt, with subsequently 17% requiring help to remove it, and 2% reported displacement of an intra-uterine device during removal. These figures decreased for subsequent cycles. Half of the participants were aware prior to using a cup that different cup models may offer a better fit for different individuals. This knowledge was associated with decreased odds of needing help to remove the cup (adjusted odds ratio 0.57, 95% CI 0.35–0.94) or discontinuing use (adjusted relative risk ratio 0.66, 95% CI 0.44–1.00).

Conclusions

Difficulties using menstrual cups are common in real-world use and higher than reported in clinical trials. Improved education provision may support more positive user experiences.

Background

Laparoscopy has often been considered a core part of the workup for pelvic pain. However, many of these laparoscopies find no pathology.

Aims

To evaluate the experiences of patients following laparoscopy for pelvic pain when there is no diagnosis found.

Materials and Methods

This descriptive qualitative study reviewed patients who underwent a diagnostic laparoscopy for persistent pelvic pain with no pathology found. Participants completed a written questionnaire and an in-depth semi-structured interview. Interview data were thematically analysed.

Results

Fifteen patients were interviewed with a median age of 30 years. Six themes were identified: desire for a diagnosis, hope as a coping strategy, inadequate communication, having ‘next steps’ of management offered, mental health impacts, and system issues. Participants wanted a diagnosis to help understand their condition, to enable connection with others, and believed that clinicians viewed pain with a diagnosis more seriously. Participants who were confident preoperatively that laparoscopy would lead to a diagnosis reported this contributing to poorer postoperative mental health. Participants discussed diagnoses not listed in the medical records, which provided hope for future management options. Participants reported worse mental health following the laparoscopy.

Conclusion

This study provides insight into the experiences of patients following a laparoscopy without an identifiable diagnosis. It highlights the importance of pre- and postoperative counselling, including discussing the potential for no findings at laparoscopy; the language used around other potential diagnoses; and the value in considering a patient's pre-existing mental health. The findings of this study are relevant for all clinicians counselling people with persistent pelvic pain where endometriosis is suspected.

Background

Pregnant and post-partum (collectively peri-partum) women may be at increased risk of severe COVID-19 disease.

Aims

To describe the characteristics, interventions, and outcomes of peri-partum patients admitted to intensive care units (ICUs) in Australia with COVID-19.

Materials and methods

We conducted a prospective, multicentre observational study using the SPRINT-SARI Australia database across 63 ICUs in Australia. All women <45 years of age, admitted to a participating Australian ICU, with laboratory-confirmed COVID-19 between 1 March 2020 and 1 June 2023 were included. Participants were categorised as either peri-partum, defined as pregnant or up to six weeks post-partum, or non-pregnant. The primary outcome was in-hospital mortality.

Results

A total of 737 eligible female patients were admitted to ICUs over the study period: 168/737 (23%) were peri-partum, while 569/737 (77%) were non-pregnant. The median age of peri-partum women was 31 (interquartile range (IQR) 27–36) years old, and median gestation was 28.0 (IQR 4–40) weeks. When compared to non-pregnant women, peri-partum women had lower rates of comorbidities (1.8% vs 14.4% P < 0.001), lower vaccination rates (27.4% vs 45.2%, P < 0.001), similar rates of mechanical ventilation, and greater use of tocilizumab (29.2% vs 4.0%, P < 0.001). Complications were low in both groups. In-hospital mortality was lower in peri-partum patients: 1/168 (0.6%) vs 24/569 (4.2%); P = 0.04.

Conclusions

Peri-partum patients made up ~25% of all women aged <45 years old admitted to Australian ICUs with COVID-19, and nearly 30% required mechanical ventilation. Despite lower vaccination rates in peri-partum patients, in-hospital mortality was lower than in non-pregnant patients.

Background

Maternity services in New Zealand are largely delivered by autonomously practising community midwives. This model of care is unique and may result in differences in the distribution of maternity healthcare utilisation and costs compared to other countries. New Zealand-specific cost data are needed to inform economic analyses, local policy and healthcare resource planning.

Aims

To provide estimates of the average total cost of maternity and neonatal healthcare for New Zealand women and infants, including cost impacts of multiple and preterm births.

Materials and Methods

A whole-of-population linked dataset, including 262 687 pregnancies resulting in a live birth (from 1 January 2016 to 30 June 2020), was created by combining several sources of healthcare data to calculate an average per-pregnancy cost of healthcare, taking a public health system perspective, during antenatal, intrapartum, and postnatal periods to one year after birth.

Results

The mean cost of public healthcare was NZ$19 795 for both maternal and infant care to one year post-birth. The bulk of this cost was incurred during pregnancy and birth. Mean total cost to one year was NZ$69 895 for twin and NZ$201 448 for higher order multiple compared to singleton pregnancies at NZ$19 098. Mean total healthcare cost decreased as gestation increased.

Conclusions

Most of the costs associated with pregnancy and childbirth were incurred during the birth and in the early neonatal period. Costs were disproportionately higher for multiple and preterm births.

These cost data can usefully inform policy and assist healthcare decision-making around reproductive and neonatal technologies.

Background

Assisted reproductive technology (ART) pregnancies are at greater risk of birth defects than non-ART pregnancies. Teratogenic medication exposure is a potential cause of birth defects that has not been compared between ART and non-ART pregnancies.

Aims

To determine whether the prevalence of exposure to teratogenic medicines during pregnancy varies by conception method (ART and three non-ART groups: ovulation induction (OI), subfertile untreated, and fertile naturally conceiving).

Materials and Methods

We linked state and commonwealth datasets for all live and stillbirths (≥20 weeks) in Western Australia with a conception date ≥1 July 2012 and date of birth ≤31 December 2014. We calculated the prevalence of exposure to teratogenic medicines (Therapeutic Goods Association Category D/X) across conception groups for the: (i) first trimester, and (ii) second and third trimesters.

Results

We identified 2041 ART, 590 OI, 2063 subfertile and 52 987 fertile pregnancies (57 681). The overall prevalence of exposure to Category D/X medicines was 0.8% in the first trimester, and 0.7% in the second and third trimesters. Category X medicines exposure was <0.5% for all conception groups and trimesters. The first trimesters of ART and OI pregnancies were more often exposed to Category D medicines than subfertile and fertile pregnancies, (ART = 4.9%, OI = 2.0% vs subfertile = 1.3%, fertile = 0.6%) as were later trimesters (ART = 3.4%, OI = 1.4% vs subfertile = 0.9%, fertile = 0.6%).

Conclusions

The overall prevalence of exposure to teratogenic medicines is low; however, exposure was greatest in pregnancies arising from ART and may be a modest contributing factor to the higher rate of birth defects observed among ART babies.