Australian and New Zealand Journal of Obstetrics and Gynaecology

ELLWOOD, David

doi: 10.1111/j.1479-828X.2008.00964.xpmid: 19133036

BOYLE, Jacqueline; RUMBOLD, Alice R.; CLARKE, Marilyn; HUGHES, Chris; KANE, Simon

doi: 10.1111/j.1479-828X.2008.00962.xpmid: 19133037

This paper summarises the recent RANZCOG Indigenous Women's Health Meeting with recommendations on how the College and its membership can act now to improve the health of Aboriginal and Torres Strait Islander women and infants.

BRAMELD, Kate J.; DICKINSON, Jan E.; O’LEARY, Peter; BOWER, Carol; GOLDBLATT, Jack; HEWITT, Beverley; MURCH, Ashleigh; STOCK, Rosanne

doi: 10.1111/j.1479-828X.2008.00912.xpmid: 19133038

Aim: To identify first trimester indicators of adverse pregnancy outcomes. Method: Data were obtained from the statewide evaluation of first trimester screening for Down syndrome in Western Australia which included 22 695 pregnancies screened between August 2001 and October 2003. Screening data were linked with pregnancy outcome information from the Hospital Morbidity Database and the Birth Defects Registry. The odds ratios (OR) of adverse outcomes were analysed for combined risk incorporating maternal age, nuchal translucency (NT) and biochemical parameters and then separately for each parameter (pregnancy‐associated plasma protein‐A (PAPP‐A), free beta human chorionic gonadotropin (β‐hCG) and NT). Results: Risk assessments for first trimester combined screening are derived from maternal age, ultrasound measurement of fetal NT, maternal serum free β‐hCG and PAPP‐A. Increased combined risk for Down syndrome was significantly (P < 0.01) associated with spontaneous loss at or before 24 weeks gestation (OR 13.51), birth defects (OR 6.58) and preterm birth at or before 32 weeks gestation (OR 3.2). Maternal serum PAPP‐A below the 5th centile was associated with Down syndrome (OR 8.43), spontaneous loss before 24 weeks (OR 5.04) and later than 24 weeks (OR 4.50), preterm delivery before 32 weeks (OR 3.11) and before 37 weeks (OR 2.24). NT above the 95th centile was associated with Down syndrome (OR 43.91), birth defects (OR 4.02) and spontaneous loss before 24 weeks (OR 6.24). Low levels of free β‐hCG and increased NT were less consistently associated with adverse outcomes and high levels of free β‐hCG showed limited use as an indicator. The detection rates for all outcomes other than Down syndrome were less than 40%. Conclusion: Biochemical indicators and NT that are measured during first trimester screening for Down syndrome show a number of associations with adverse outcomes, but do not show appropriate performance characteristics for screening tests. These data are consistent with the view that the individual components, specifically low PAPP‐A levels alone, do not provide an effective screening tool for adverse pregnancy outcomes.

SAID, Joanne M.; BRENNECKE, Shaun P.; MOSES, Eric K.; WALKER, Susan P.; MONAGLE, Paul T.; CAMPBELL, Janine; BRYANT, Valerie J.; BORG, Anthony J.; HIGGINS, John R.

doi: 10.1111/j.1479-828X.2008.00919.xpmid: 19133039

TURNER, Catherine E.; YOUNG, Jane M.; SOLOMON, Michael J.; LUDLOW, Joanne; BENNESS, Christopher; PHIPPS, Hala

doi: 10.1111/j.1479-828X.2008.00923.xpmid: 19133040

Background: Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible. Aims: To ascertain the proportion of primiparas and clinicians who would participate in a hypothetical randomised controlled trial comparing vaginal delivery with elective caesarean section. Methods: Pregnant women (mean 22 weeks gestation) recruited from public and private antenatal clinics at a major tertiary referral centre were interviewed to ascertain their willingness to participate in a hypothetical randomised controlled trial. A self‐administered questionnaire was mailed to midwives, obstetricians, urogynaecologists and colorectal surgeons, and results between groups were compared. Results: One hundred pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons participated. Only 14% (95% confidence interval (CI), 8–22) of pregnant women and 31% (95% CI, 26–36) of clinicians indicated that they would participate in a randomised controlled trial. Conclusions: A randomised controlled trial comparing vaginal delivery and elective caesarean section may not be feasible due to low levels of willingness to participate, particularly among pregnant women.

BOMBELL, Sarah; McGUIRE, William

doi: 10.1111/j.1479-828X.2008.00924.xpmid: 19133041

Background: The guanine to adenine transition at position ‐308 nucleotides in the tumour necrosis factor promoter region (TNF ‐308A) is a putative genetic risk factor for pre‐eclampsia/eclampsia (PE/E). However, association studies have reported conflicting findings and have generally been underpowered to exclude modest effect sizes. Aim: To assess and synthesise the available evidence for the association of the TNF (‐308A) polymorphism with PE/E. Methods: Systematic review and random effects meta‐analysis of genetic association studies. Results: Sixteen eligible case–control studies in which a total of 1919 patients with PE/E and 2374 controls participated were identified. The studies were generally small but of reasonable methodological quality. Random effects meta‐analysis improved the precision of the estimate of effect size but did not detect a statistically significant association: pooled relative risk 1.02 (95% confidence interval 0.86 to 1.20). Conclusions: The available data are not consistent with more than a very modest association between the TNF (‐308A) allele and PE/E. Screening pregnant women for this allele in order to guide antenatal surveillance or treatment is unwarranted. Future research efforts should focus on alternative candidate genes.

FLENADY, Vicki; MACPHAIL, Julie; NEW, Karen; DEVENISH‐MEARES, Paul; SMITH, Julie

doi: 10.1111/j.1479-828X.2008.00907.xpmid: 19133042

Background: Despite high level evidence showing that antenatal smoking cessation programs are effective in reducing the number of women who smoke during pregnancy and the number of low birthweight and preterm births, few Australian hospitals have adopted a systematic approach to assist pregnant women to stop smoking. Aims: The aim of this study was to assess the effectiveness of a smoking cessation guideline, developed specifically for clinicians providing antenatal care in public maternity hospitals, combined with an implementation program on the uptake of evidence‐based practice. Methods: A clinical practice guideline was developed and an implementation strategy was tested, using a prospective before‐and‐after study design, at the Mater Mothers’ Hospital in Brisbane. Women were surveyed in late pregnancy, pre‐ and post‐implementation. The primary outcome measures were women's report of appropriate smoking cessation support received, specifically, information brochures and referral to Quitline. Secondary outcome measures included women's report of smoking status in late pregnancy and relapse rates. Results: Post‐implementation, more women reported receiving written materials on smoking cessation (76% vs 35%; relative risk (RR) 3.4; 95% confidence interval (CI) 2.7, 4.2) and referral to Quitline (67% vs 14%; RR 4.9; 95% CI 3.0, 8.0). While not statistically significant, fewer women post‐implementation reported smoking in late pregnancy (19.5% vs 16.7%) and fewer reported smoking > 10 cigarettes per day (38% vs 25%). Conclusions: Clinical practice guidelines specifically designed for a public maternity care setting combined with an implementation program resulted in an increase in evidence‐based practice with some indication of improved smoking behaviour for women.

KHOO, Nee Scze; VAN ESSEN, Phillipa; RICHARDSON, Malcolm; ROBERTSON, Terry

doi: 10.1111/j.1479-828X.2008.00915.xpmid: 19133043

Aims: To report on the efficiency of fetal echocardiography, outcome after prenatal diagnosis of congenital heart disease (CHD) and the effectiveness of South Australia's obstetric screening program in detecting CHD. Methods: A retrospective audit of our institutional cardiac database, the South Australia Birth Defects Register and the South Australia Pregnancy Outcome Unit from 1999 to 2003. Results: CHD was present in 10.7 per 1000 births and was potentially detectable in 5.2 per 1000 births. Of these, only 22.5% were referred for fetal echocardiography. Prenatal detection of transposition of the great arteries occurred in four of 27 (14.8%), atrioventricular septal defect in five of 21 (23.8%), tetralogy of Fallot in seven of 28 (25.0%) and hypoplastic left heart syndrome in 20 of 33 (60.6%). Fetal echocardiography had 95.2% sensitivity, 99.5% specificity, 99.0% positive predictive value and 97.6% negative predictive value for CHD. A prenatal diagnosis of CHD resulted in termination in 30.1%, stillbirth in 7.8% and neonatal death in 3.9% of cases. Conclusion: Routine obstetric ultrasound detects CHD infrequently. Outflow tract lesions are most commonly missed. Fetal echocardiography is an accurate tool for prenatal diagnosis of CHD. Pregnancy outcomes after prenatal diagnosis are comparable to other Australasian and western countries, suggesting uniformity in parental counselling and population behaviour. Strategies that improve routine obstetric ultrasound detection of CHD are likely to yield the greatest impact.

JANSSENS, Sarah; WALLACE, Karen L.; CHANG, Allan M. Z.

doi: 10.1111/j.1479-828X.2008.00920.xpmid: 19133044

Aim: To document the rise in prepartum and intrapartum caesarean section and the demographic and medical factors contributing to the rise. Methods: Data from 52 423 deliveries between January 1997 to May 2005 were analysed for yearly change in caesarean section rates and multiple demographic and medical factors. Results: The prepartum caesarean section rate increased by 1.6% per year and the intrapartum caesarean section rate by 0.8% per year. There was no increase in the overall prevalence of obesity, short stature, advanced maternal age, medical complications or previous caesarean section. There were significant increases in nulliparity, private care, induction of labour and the use of electronic monitoring, but these were insufficient to explain the magnitude of the rise. Conclusion: The increase in prepartum and intrapartum caesarean section displayed was not fully explained by medical and demographic changes in the population.

ORJI, E. O.; OLALEYE, A. O.; LOTO, O. M.; OGUNNIYI, S. O.

doi: 10.1111/j.1479-828X.2008.00902.xpmid: 19133045

Background: There is not enough information to evaluate the routine use of exteriorisation of the uterus for repair of the uterine incision and further studies are needed to examine the value of exteriorisation of the uterus at caesarean section as against non‐exteriorisation. Aims: To assess intraoperative and postoperative morbidity following exteriorisation of the uterus at caesarean section as compared to those with non‐exteriorisation. Methods: A randomised controlled trial at Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria. Two hundred and ten women were randomised to either exteriorisation (N = 105) or non‐exteriorisation group (N = 105). Statistical analysis using SPSS compared intraoperative and postoperative outcome. The outcome measures include intraoperative blood loss, number of analgesic dose, difference in operating time, febrile morbidity, intraoperative complications, and duration of hospital stay. Results: There were significant reductions in intraoperative blood loss (P < 0.05), number of analgesic dose (P < 0.05) and duration of hospital stay (P < 0.05) in the uterine exteriorisation group as compared to those in the non‐exteriorisation group. There was no significant difference in operating time, febrile morbidity, intraoperative complications and operating time. The period for return of bowel function was significantly longer in the exteriorisation group. Conclusion: Exteriorisation of uterus at caesarean section is associated with less intraoperative blood loss, less number of analgesic dose and shorter hospital stay.