Obstetrics and Gynaecology - Research Publications
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ItemPriorities for alleviating menopausal symptoms after cancer(LIPPINCOTT WILLIAMS & WILKINS, 2023-02-01)OBJECTIVE: To determine treatment priorities in women cancer patients attending a dedicated Menopausal Symptoms After Cancer service. METHODS: Cancer type and stage were abstracted from medical records. Women ranked up to three symptoms as treatment priorities from the list "hot flushes/night sweats," "mood changes," "vaginal dryness or soreness," "sleep disturbances," "feeling tired or worn out (fatigue)," "sexual problems and/or pain with intercourse," "joint pain," and "something else" with free-text response. For each prioritized symptom, patients completed standardized patient-reported outcome measures to determine symptom severity and impact. RESULTS: Of 189 patients, most had breast cancer (48.7%, n = 92), followed by hematological (25.8%, n = 49), gynecological (18.0%, n = 34), or colorectal (2.6%, n = 5). The highest (first-ranked) treatment priority was vasomotor symptoms (33.9%, n = 64), followed by fatigue (18.0%, n = 34), vaginal dryness/soreness (9.5%, n = 18), and sexual problems/pain with intercourse (9.5%, n = 18). Symptoms most often selected in the top three ("prioritized") were fatigue (57.7%, n = 109), vasomotor symptoms (57.1%, n = 108), and sleep disturbance (49.2%, n = 93). In patients who prioritized vasomotor symptoms, medians on the "problem," "distress," and "interference" dimensions of the Hot Flash Related Daily Interference Scale were, respectively, 6.0 (interquartile range [IQR], 5.0-8.0), 5.5 (IQR, 3.0-8.0), and 5.0 (IQR, 3.-7.0), indicating moderate severity. In patients who prioritized fatigue, the median Fatigue Scale score was 28 (IQR, 19-36), 37% worse than general population. CONCLUSIONS: Vasomotor symptoms, fatigue, sexual problems, and vaginal dryness/soreness were the leading priorities for treatment. Understanding symptom severity and patient priorities will inform better care for this growing population.
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ItemA single dose of quadrivalent HPV vaccine is highly effective against HPV genotypes 16 and 18 detection in young pregnant women eight years following vaccination: an retrospective cohort study in Fiji.(Elsevier BV, 2023-08)BACKGROUND: In 2008/9, Fiji vaccinated >30,000 girls aged 9-12 years with the quadrivalent human papillomavirus (4vHPV) vaccine coverage for at least one dose was >60% (one dose only was 14%, two dose only was 13%, three doses was 35%). We calculated vaccine effectiveness (VE) of one, two and three doses of 4vHPV against oncogenic HPV genotypes 16/18, eight years following vaccination. METHODS: A retrospective cohort study was undertaken (2015-2019) in pregnant women ≤23 years old, eligible to receive 4vHPV in 2008/9, with confirmed vaccination status. The study was restricted to pregnant women due to the cultural sensitivity of asking about sexual behavior in Fiji. For each participant a clinician collected a questionnaire, vaginal swab and genital warts examination, a median eight (range 6-11) years post vaccination. HPV DNA was detected by molecular methods. Adjusted VE (aVE) against the detection of vaccine HPV genotypes (16/18), the comparison group of non-vaccine genotypes (31/33/35/39/45/51/52/56/58/59/66/68), and genital warts were calculated. Covariates included in the adjusted model were: age, ethnicity and smoking, according to univariate association with any HPV detection. FINDINGS: Among 822 participants the prevalence of HPV 16/18 in the unvaccinated, one, two and three-dose groups were 13.3% (50/376), 2.5% (4/158), 0% (0/99) and 1.6% (3/189), respectively; and for the non-vaccine high-risk genotypes, the detection rate was similar across dosage groups (33.2%-40.4%, p = 0.321). The aVE against HPV 16/18 for one, two and three doses were 81% (95% CI; 48-93%), 100% (95% CI; 100-100%), and 89% (95% CI; 64-96%), respectively. Prevalence of HPV 16/18 was lower among women with longer time since vaccination. INTERPRETATIONS: A single dose 4vHPV vaccine is highly effective against HPV genotypes 16 and 18 eight years following vaccination. Our results provide the longest duration of protection for reduced dose 4vHPV schedule in a low- or middle-income country in the Western Pacific region. FUNDING: This study was supported by the Bill & Melinda Gates Foundation and the Department of Foreign Affairs and Trade of the Australian Government and Fiji Health Sector Support Program (FHSSP). FHSSP is implemented by Abt JTA on behalf of the Australian Government.
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ItemRisk factors for pre-eclampsia: Received wisdom versus reality(WILEY, 2022-11-22)
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ItemRisk factors for acute colonic pseudo-obstruction after caesarean section: A retrospective case-control study.(Wiley, 2023-02)BACKGROUND: Pregnancy and caesarean section are known to predispose to the development of acute colonic pseudo-obstruction (ACPO), a rare form of functional ileus of the distal large bowel. Pathogenesis of ACPO is likely influenced by pregnancy and childbirth and subsequent changes to hormonal, autonomic and metabolic physiology. Identifying pregnancy risk factors will assist with early identification, as the insidious onset postpartum often leads to delayed diagnosis and bowel ischaemia, perforation and sepsis. AIMS: To establish pregnancy risk factors associated with the development of ACPO after caesarean section. MATERIALS AND METHODS: A retrospective case-control study included 19 121 women undergoing caesarean between 1 January 2008 and 31 December 2016 at a tertiary referral hospital. Twenty-three cases of computerised tomography (CT)-diagnosed ACPO post-caesarean were identified from hospital medical records and imaging databases. Controls were matched for gestational and maternal age within one week of delivery with a ratio of 1:3. RESULTS: The incidence of ACPO was one in 800 caesarean sections. ACPO was significantly more likely to occur in women who had been administered opioid analgesia in labour (odds ratio (OR) 4.67, P = 0.04), and a trend for increased estimated blood loss (OR 1.01, P = 0.01). There was no increased risk associated with emergency or elective caesarean classification, previous abdominal surgery, type of anaesthesia, duration of labour, oxytocin augmentation, intrapartum fever, hypertensive disorders, diabetes in pregnancy, antepartum haemorrhage, multiple gestation, fetal presentation or birthweight. CONCLUSIONS: Risk factors for developing ACPO post-caesarean include opioid analgesia in labour and a trend for increased blood loss.
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ItemVirtual clinics in gynaecology - Can we shorten the wait? A randomised controlled trial implementing a novel care pathway for postmenopausal bleeding(WILEY, 2022-10)BACKGROUND: Postmenopausal bleeding (PMB), a common symptom of endometrial cancer, necessitates prompt clinical and sonographic assessment, often followed by hysteroscopy. Unfortunately, due to traditional gynaecology outpatient clinic paradigms, unnecessary patient-clinician encounters are common and may lead to delays in diagnosis. AIM: The aim was to assess a novel clinic model for the management of women with PMB based on virtual assessment and routine use of the outpatient hysteroscopy clinic. METHODS: An unblinded pragmatic randomised controlled trial was performed, comparing a 'virtual clinic' to routine outpatient clinical care. The primary outcome for assessment was time, measured as the interval (days) between referral triage and discharge for definitive management or to the general practitioner. Demographical and clinical data were collected. After discharge from the system, patients completed a satisfaction and feedback questionnaire. Log-rank tests were used to compare the equality of time-to-event functions across randomised groups. RESULTS: There were 96 participants, 46 in the intervention arm and 50 controls. The total time spent in the gynaecology system differed between groups (Χ2 (1) = 6.94, P = 0.008), with a median total time of 55 days (95% confidence interval (CI): 37-66 days) for the intervention group compared to a median of 84 days (95% CI: 54-101 days) for the control group. The number of in-person gynaecology encounters differed between those randomised to intervention (P < 0.001). Overall, 96% of respondents indicated a positive score for overall satisfaction. CONCLUSIONS: The proposed clinic model resulted in a significant reduction in the time between referral and discharge, without compromising patient satisfaction.
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ItemThe 5-minute Apgar score and childhood school outcomes(WILEY, 2022-10)AIM: To examine the association between Apgar score at 5 min and childhood developmental and educational outcome. METHODS: A population-based data linkage study of births ≥37 weeks' gestation linked to developmental outcomes at preparatory school and educational outcomes at school grades 3, 5 and 7 in Victoria, Australia. Multivariable logistic regressions and generalised estimating equations were used. RESULTS: There were 167,126 singleton infants with developmental results and 392,933 singleton infants with at least one educational result. There was an inverse relationship between Apgar score at 5 min and poor developmental and educational outcomes, with the worst outcomes among Apgar scores of 0-3. Apgar scores of 7, 8 and 9 were all associated with poorer developmental outcomes (aOR = 1.31, 95% CI: 1.12-1.54; aOR = 1.17, 95% CI: 1.05-1.29; aOR = 1.08, 95% CI: 1.02-1.13 respectively), while Apgar scores of 7 and 8 were associated with poorer educational outcomes at grades 3, 5, and 7. With progression through grades 3, 5, and 7, the extent of the difference in educational outcomes diminished (e.g. for Apgar scores of 0-3: aOR = 3.33, 95% CI: 1.85-6.00 in grade 3 and aOR = 1.49, 95% CI: 0.75-2.96 in grade 7). CONCLUSION: Apgar scores below 10 at 5 min are associated with poorer developmental and educational outcomes in school.
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ItemMedical management of secondary postpartum haemorrhage: A prospective cohort study(WILEY, 2022-06-14)BACKGROUND: Secondary postpartum haemorrhage (PPH) complicates ~1% of pregnancies and can cause serious maternal morbidity. However, evidence guiding optimal management is scarce and often based on case series and expert opinion. AIMS: To measure the success of primary medical therapy in managing secondary PPH and to identify factors associated with need for surgical management. MATERIALS AND METHODS: Postpartum patients presenting to a tertiary women's hospital emergency department between July 2020 and October 2021 with secondary PPH were recruited. Data from the acute presentation were prospectively collected. Antenatal and intrapartum data were collected from medical record review. The primary outcome was the success of medical management for secondary PPH, defined by the implementation of medical or expectant measures without subsequent need for surgical intervention. RESULTS: One-hundred and twenty patients underwent primary medical management for secondary PPH. Ninety-eight (82%) were managed successfully with medical management and 22 (18%) required surgery. Medical management involved misoprostol (n = 33; 27.5%), antibiotics (n = 108; 90%), and less commonly other uterotonics (n = 6; 5%). Factors associated with lower rates of successful medical management included: antecedent manual removal of placenta (MROP) (odds ratio (OR) 0.2, P = 0.047), primary PPH ≥500 mL (OR 0.39, P = 0.048) or ≥1 L (OR 0.24, P = 0.009), >200 mL blood loss at presentation (OR 0.17, P = 0.015), increasing time post-delivery (OR 0.84, P = 0.044), retained products of conception (RPOC) on ultrasound (OR 0.024, P = 0.001) and vaginal birth (OR 0.27, P = 0.027). CONCLUSION: Medical management was highly successful. Vaginal birth, MROP, primary PPH, RPOC on ultrasound and increasing time post-delivery were associated with increased need for surgical management.
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ItemThe role of social media in management of individuals with endometriosis: A cross-sectional study(WILEY, 2022-04-18)BACKGROUND: To better understand the potential role of social media (SM) as a self-management tool for individuals with endometriosis and to assess its current use by endometriosis patients. AIMS: The primary outcome was use of SM for health in patients with endometriosis. Secondary outcomes included preferred SM platforms for health information sharing and factors that influenced use, positive and negative experiences and reported impacts on health. MATERIALS AND METHODS: A single-centre, cross-sectional study performed within benign gynaecology units at a tertiary hospital in Melbourne, Australia. One hundred patients with a confirmed diagnosis of endometriosis participated. Individuals did not have to be users of SM. Data were collected through an electronic third-party survey tool (SurveyMonkey® ). Analysis methods included descriptive statistical analysis, frequency counts, as well as cross-tabulation to examine statistical association between variables. Free-text responses were qualitatively analysed using deductive-inductive semantic thematic analysis. RESULTS: Social media was used for health by 76% of patients with endometriosis in this study. SM users were younger, had pelvic pain for more than six months and reported higher rates of psychosocial impact and symptoms from endometriosis. Respondents reported overall positive impacts on psychological, social and cognitive health outcomes (76%) from SM use. CONCLUSION: In our cohort, a high number of people with endometriosis are using SM for health. These individuals are more likely to suffer both physical and psychosocial impacts from endometriosis. Hospitals and health organisations may consider support of the endometriosis community through SM.