Menopause depression: Under recognised and poorly treated.

Menopause is a biological process experienced by all people assigned female at birth. A significant number of women experience mental ill health related to the major brain gonadal hormone shifts that occur in their midlife. There is poor understanding and management of the complex mental ill health issues, with the biological brain hormone changes receiving little formal attention. The current treatment advice is to manage this special type of mental ill health in the same way that all mental ill health is managed. This leads to poor outcomes for women and their families. Many women leave the workforce earlier than expected due to menopause-related depression and anxiety, with subsequent loss of salary and superannuation. Others describe being unable to adequately parent or maintain meaningful relationships - all ending in a poor quality of life. We are a large and diverse group of national and international clinicians, lived experience and social community advocates, all working together to innovate the current approaches available for women with menopausal mental ill health. Above all, true innovation is only possible when the woman with lived experience of menopause is front and centre of this debate.

The role of ultrasonography in the management of post-partum haemorrhage associated with retained products of conception: A case report.

BACKGROUND: Post-partum haemorrhage is a serious complication of vaginal and Caesarean deliveries, and a major cause of maternal morbidity and mortality. Retained products of conception (RPOC) are implicated in both primary and secondary post-partum haemorrhage, frequently leading to surgical interventions. Ultrasonographic diagnosis of RPOC gives a wide variation in accuracy due to significant overlaps between the normal and pathological features of the post-partum uterus. The inaccuracy of current diagnostic tools coupled with high rates of complications associated with surgical treatment poses a complex challenge to the physician. CASE: A 37-year old para 3 woman who had a vaginal delivery at term following an uncomplicated pregnancy. She had active management of the third stage of labour, and the placenta was delivered with missing fragments and ragged membranes. She had both primary and secondary post-partum haemorrhage with a total blood loss of 1140 mL. An ultrasonographic scan of the uterus on day 3 post-partum was suggestive of RPOC. Interventions included uterotonics, antibiotics, iron infusion, blood transfusion, and dilatation and curettage of RPOC, confirmed on histopathological analysis. She remained clinically stable post-operatively and was discharged 2 days later. CONCLUSION: Evidence currently promotes a combination of ultrasonography and clinical assessment in the diagnosis of RPOC. Each of these methods of assessments has significant shortcomings in terms of accuracy. When combined, determination of the most appropriate treatment and avoidance of unnecessary surgical interventions and associated complications become more feasible.

The legal status of the fetus in New South Wales.

The issue of how to define the legal status of the fetus is complex. Three clinical cases with fetal losses following motor vehicle accidents raise important issues regarding the legal status of the unborn child. Legislation was submitted to the New South Wales Parliament in the form of the Crimes Amendment (Grievous Bodily Harm) Bill 2005 (NSW) but was subsequently repealed. Medical technological advances make the viability of a fetus a shifting standard and encourage the comparison between newborns and late-term fetuses, offer increased fetal health status information and provide greater capacity to maintain the life of babies born prematurely. In view of the sophisticated state of medical care available in New South Wales, the three cases reviewed highlight the discrepancy between the medical recognition of the fetus as a patient and its lack of legal recognition.

Low PAPP-A: what are the clinical implications?

Ultrasound and pulsed Doppler can assist in confirming impaired placentation looking at fetal biometry and umbilical artery Dopplers. The authors recommend confirmation of fetal wellbeing at 28-30 weeks with a PAPP-A level below the first centile.

Ultrasound of ovarian dermoids - sonographic findings of a dermoid cyst in a 41-year-old woman with an elevated serum hCG.

Ovarian dermoid cysts are made up of solid, cystic and fat tissue. These components give rise to characteristic sonographic features such as a fat-fluid level, dermoid mesh and tip of the iceberg sign. The presence of two or more of these typical features can be used to confidently diagnose a dermoid cyst on ultrasound. This 41-year-old woman with a known cystic lesion on her right ovary which, on ultrasound, demonstrated two of these features, had the diagnosis of a dermoid cyst later confirmed on histopathology. She concurrently had an elevated serum human chorionic gonadotrophin (hCG), an unusual, but not unknown, finding in the presence of a dermoid cyst. The hCG resolved after removal of the ovarian cyst.

Spontaneous subcutaneous emphysema and pneumomediastinum during second stage of labour.

A 27-year-old healthy primigravida presented with spontaneous labour at 40 weeks gestation and proceeded to an unassisted vaginal delivery of a 3.2 kg infant. She immediately developed swelling in the neck and facial area associated with pleuritic chest pain. There was palpable crepitus throughout her anterior chest wall and neck. CT confirmed pneumomediastinum. She was managed with oxygen and analgesia in the intensive care unit and subsequently discharged with resolution of her symptoms. Postpartum pneumomediastinum with subcutaneous emphysema is treated conservatively after cardiac and embolic causes have been excluded; however, there is no consensus on the management of subsequent pregnancies.

RBC motion and the basis of ultrasound Doppler instrumentation.

Ultrasonography has become one of the most popular techniques for noninvasive body assessment. The advent of sophisticated Doppler imaging has added an "information about blood flow" dimension. However, searching for complex details, despite enhanced system design and capabilities, place an increased demand on the operator. Examination technique and equipment settings are potential sources of error and therefore to obtain and interpret Doppler indices well it is essential to understand the physics of the Doppler principle and the dynamics of blood flow.

Absent fetal hand: a case report.

Isolated congenital fetal hand malformation is a rare finding1. The prevalence of limb reduction deformities is about 3-8 per 20,000 births2. An isolated amputation of an extremity can be due to amniotic band syndrome, exposure to a teratogen or a vascular accident2. A comprehensive obstetric ultrasonographic assessment as well as genetic counselling are ideal when a fetal hand abnormality is detected, so as to determine whether a karyotype analysis is appropriate. We report a case of an absent left fetal hand and explore the parental distress with the diagnosis at almost 20 weeks of gestation. This case also highlights parental perception of medical inertia in terminating a pregnancy of this gestational age and complication.

Recurrent viable ectopic pregnancy in the salpingectomy stump.

Ipsilateral ectopic pregnancy after total salpingectomy is a rare occurrence and in theory should not happen. We report a case where a spontaneous ectopic pregnancy was found in the stump of the previously removed tube. This case highlights the need for further consideration of the diagnosis of an ectopic pregnancy in the setting of a previous ipsilateral salpingectomy.

Endoscopic ureterotomy for the treatment of ureteric stricture following laparoscopic oophorectomy.

We report a case of ureteric stricture formation in a 40-year-old woman after laparoscopic salpingo-oophorectomy and ureterolysis for removal of a large benign ovarian cyst. Ten days postoperatively, she was examined for gradually increasing loin pain and was found to have a short-segment ureteric stricture. She was initially treated conservatively by placement of a ureteric stent. The stent was removed after 6 weeks, and the ureteric obstruction reoccurred. She was subsequently successfully treated by endoscopic ureterotomy.