Gender representation in obstetrics and gynaecology leadership.

BACKGROUND: Women in leadership in obstetrics and gynaecology in Australia and Aotearoa New Zealand have historically been underrepresented, despite forming a significant portion of the workforce. This study extends prior research from 2017, examining shifts in gender representation, attitudes, and perceived leadership barriers within the specialty. AIMS: The study aims to evaluate changes in gender diversity among leadership positions in the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and accredited training hospitals since 2017. Additionally, it seeks to understand current attitudes toward leadership and identify perceived barriers among RANZCOG consultants and trainees. MATERIALS AND METHODS: A cross-sectional approach was employed, utilising publicly available information, a survey distributed to RANZCOG members, and data from accredited training hospitals. Gender representation in leadership positions was analysed, and survey responses were collected from consultants and trainees to evaluate attitudes and perceived barriers. RESULTS: The study reveals an increase in women's representation in RANZCOG leadership, particularly on the council and in clinical leadership positions. While the proportion of women trainees remained stable, there was a noteworthy increase in women specialists. Survey responses revealed shared perceptions on leadership qualities but diverged on barriers, with more women expressing concerns about skillsets, caring responsibilities, and mentorship support. CONCLUSIONS: The findings underscore substantial progress in achieving gender equity in obstetrics and gynaecology leadership roles, attributed to RANZCOG initiatives, societal changes, and improved policies. Ongoing efforts, including structured mentorship and flexible arrangements, are recommended to sustain and further enhance gender representation and address specific barriers identified by women in the specialty.

Asymptomatic bacteriuria in pregnancy.

BACKGROUND: Asymptomatic bacteriuria (ASB) is associated with adverse maternal and neonatal outcomes and is routinely screened for and treated in the first trimester. Prevalence of ASB in the second and third trimesters of pregnancy is unknown. AIMS: The aim is to determine the prevalence of ASB in the second and third trimesters of pregnancy. METHODS: Prospective cohort study of 150 pregnant women. Mid-stream urine samples were tested for ASB in the second (24-28+6 ) and third (32-36+6 ) trimesters. Women were assigned to one of two groups: (i) ASB in any trimester of pregnancy and (ii) no evidence of ASB in pregnancy. Maternal and neonatal outcomes were compared between groups. RESULTS: Among 143 women included in the study, the rate of ASB was 4.9% (2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively). Of those with ASB, 14% had it in every trimester, whereas 43% had it on two or more samples. Of those with ASB in pregnancy, 43% were detected for the first time in the third trimester. Rates of maternal and neonatal outcomes were not statistically significantly different between the two groups. No women with ASB were induced for chorioamnionitis or growth restriction. CONCLUSION: The rate of ASB was highest in the third trimester of pregnancy, with rates of 2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively. This study was underpowered to assess maternal and fetal outcomes. Although numbers were small, the absence of ASB in the first trimester was a poor predictor of ASB in the third trimester.

Trends in early gestation stillbirths and neonatal deaths in New South Wales, Australia 2002-2019.

BACKGROUND: Little research has focused on understanding trends in early gestation (20-27 weeks) stillbirths and neonatal deaths. AIMS: To examine trends in early gestation stillbirths and neonatal deaths in New South Wales (NSW), Australia. MATERIALS AND METHODS: Population-based cohort study of all births ≥20 weeks gestation among female NSW residents during 2002 to 2019, induced pregnancy terminations excluded. Stillbirth rates by gestational age and birth year were calculated per 1000 fetuses-at-risk (FAR). Neonatal death rates by gestational age and birth year were calculated per 1000 live births. Linear regression was used to examine trends in stillbirth and neonatal death rates among all, singleton and twin births. RESULTS: Declining trends in early gestation stillbirth and neonatal death rates were found. Stillbirth rates decreased from 1.9 and 0.9/1000 FAR in 2002 to 1.6 and 0.7 in 2019 for 20-23 and 24-27 week groups, respectively. Neonatal rates decreased from 940 and 315/1000 live births in 2002 to 925 and 189 in 2019 for the 20-23 and 24-27 week groups, respectively. Among singleton births, declining trends in stillbirth and neonatal death rates across all age groups were observed, except for 37-38 week stillbirths. No trends in twin stillbirth rates were found across gestational age groups, although a decreasing trend was observed for 20-23 week twin neonatal deaths. CONCLUSIONS: Trends in early gestation stillbirth and neonatal deaths have declined in recent decades in NSW but further efforts are needed to reduce both early and late gestation stillbirth rates among twin births.

Pregnancy outcomes in women with endometriosis and/or ART use: a population-based cohort study.

STUDY QUESTION: What is the association between endometriosis and adverse pregnancy outcomes with ART use and non-use? SUMMARY ANSWER: Endometriosis and ART use are both associated with increased risk of preterm birth, antepartum haemorrhage, placenta praevia and planned birth (caesarean delivery or induction of labour). WHAT IS KNOWN ALREADY: There are contradictory findings on the association between endometriosis and adverse pregnancy outcomes, and many large studies have not considered the effect of ART use. STUDY DESIGN, SIZE, DURATION: Population-based cohort study of 578 221 eligible pregnancies during 2006-2015, comparing pregnancy outcomes across four groups (No endo/no ART, No endo/ART, Endo/no ART and Endo/ART). PARTICIPANTS/MATERIALS, SETTING, METHODS: All female residents of New South Wales, Australia aged 15-45 years and their index singleton pregnancy of at least 20 weeks gestation or 400 g birthweight. Linked hospital, pregnancy/birth and mortality data were used. Modified Poisson regression with robust error variances was used to estimate adjusted risk ratios (aRRs) and 99% CIs, adjusting for sociodemographic and pregnancy factors. MAIN RESULTS AND THE ROLE OF CHANCE: Compared to women without endometriosis who had pregnancies without ART use, there was increased risk of preterm birth (<37 weeks) in all groups [No endo/ART (aRR 1.85, 99% CI 1.46-2.34), Endo/no ART (aRR 1.24, 99% CI 1.06-1.44), Endo/ART (aRR 1.93, 99% CI 1.11-3.35)] and antepartum haemorrhage [No endo/ART (aRR 1.99, 99% CI 1.39-2.85), Endo/no ART (aRR 1.31, 99% CI 1.03-1.67), Endo/ART (aRR 2.69, 99% CI 1.30-5.56)] among pregnancies affected by endometriosis or ART use, separately and together. There was increased risk of placenta praevia [No endo/ART (aRR 2.26, 99% CI 1.42-3.60), Endo/no ART (aRR 1.66, 99% CI 1.18-2.33)] and planned birth [No endo/ART (aRR 1.08, 99% CI 1.03-1.14), Endo/no ART (aRR 1.11, 99% CI 1.07-1.14)] among pregnancies with endometriosis or ART use, separately. There was increased risk of placental abruption [No endo/ART (aRR 2.36, 99% CI 1.12-4.98)], maternal morbidity [No endo/ART (aRR 1.67, 99% CI 1.07-2.62)] and low birthweight (<2500 g) [No endo/ART (aRR 1.45, 99% CI 1.09-1.93)] among pregnancies with ART use without endometriosis. There was decreased risk of having a large-for-gestational age infant [Endo/no ART (aRR 0.83, 99% CI 0.73-0.94)] among pregnancies with endometriosis without ART use. LIMITATIONS, REASONS FOR CAUTION: Endometriosis is often under-diagnosed and women with a history of hospital diagnosis of endometriosis may represent those with more symptomatic or severe disease. If the effects of endometriosis on pregnancy are greater for those with more severe disease, our results may over-estimate the effect of endometriosis on adverse pregnancy outcomes at a population level. We were unable to assess the effect of endometriosis stage or typology on the study outcomes. WIDER IMPLICATIONS OF THE FINDINGS: These results suggest that women with endometriosis including those who used ART to achieve pregnancy are a higher-risk obstetric group requiring appropriate surveillance and management during their pregnancy. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Prevention Research Support Program, funded by the New South Wales Ministry of Health. The funder had no role in the design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit the manuscript for publication. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Maternal factors and risk of spontaneous preterm birth due to high ambient temperatures in New South Wales, Australia.

BACKGROUND: Exposure to high ambient temperatures has been shown to increase the risk of spontaneous preterm birth. Determining which maternal factors increase or decrease this risk will inform climate adaptation strategies. OBJECTIVES: This study aims to assess the risk of spontaneous preterm birth associated with exposure to ambient temperature and differences in this relationship between mothers with different health and demographic characteristics. METHODS: We used quasi-Poisson distributed lag non-linear models to estimate the effect of high temperature-measured as the 95th percentile of daily minimum, mean and maximum compared with the median-on risk of spontaneous preterm birth (23-36 weeks of gestation) in pregnant women in New South Wales, Australia. We estimated the cumulative lagged effects of daily temperature and analyses on population subgroups to assess increased or decreased vulnerability to this effect. RESULTS: Pregnant women (n = 916,678) exposed at the 95th percentile of daily mean temperatures (25ºC) had an increased risk of preterm birth (relative risk 1.14, 95% confidence interval 1.07, 1.21) compared with the median daily mean temperature (17℃). Similar effect sizes were seen for the 95th percentile of minimum and maximum daily temperatures compared with the median. This risk was slightly higher among women with diabetes, hypertension, chronic illness and women who smoked during pregnancy. CONCLUSIONS: Higher temperatures increase the risk of preterm birth and women with pre-existing health conditions and who smoke during pregnancy are potentially more vulnerable to these effects.

Training in obstetric anal sphincter injuries in Australia and New Zealand: A survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees.

BACKGROUND: Training in obstetric anal sphincter injuries (OASIS) in Australia and New Zealand relies upon consultant teaching and has not previously been assessed. AIMS: The aims of this study are to establish if training in OASIS is consistent and optimal in Australia and New Zealand and to evaluate trainee perspectives on supervision and teaching, along with confidence in repairing OASIS. MATERIALS AND METHODS: A descriptive cross-sectional study was performed. Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees were sent a 21-question survey. The survey was distributed to 725 trainees, and 132 trainees provided complete responses (18.2%). The main outcome measures were (i) comparison of confidence in performing a caesarean section versus OASIS repair and (ii) descriptive analysis of views towards training and suggestions for improvement. RESULTS: Trainees were significantly more confident in performing a caesarean section independently compared to OASIS repair (P < 0.05). This was the case for all year groups. Confidence increased with each year of training. Only 62% reported credentialing at their site. Whereas 50% reported training at the time of first unsupervised repair as good or excellent, 22.7% felt it was suboptimal and 2.3% unsatisfactory; 75.8% had attended a workshop; 38.6% requested mandatory workshops. Requests included that workshops be yearly, include video training and be required at consultant level. Trainees asked for supervision despite credentialing and for separate credentialing for 3A/B- and 3C/4th-degree tears. CONCLUSIONS: Trainees have increasing confidence in their ability to independently perform OASIS repairs throughout training. They requested that improvements be made to training and that there be an increase in structured teaching.

Place of birth and outcomes associated with large volume transfusion: an observational study.

BACKGROUND: Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. METHODS: The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission. RESULTS: Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells. CONCLUSIONS: Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.

A study of pregnancy after endometrial ablation using linked population data.

INTRODUCTION: Endometrial ablation encapsulates a range of procedures undertaken to destroy the endometrial lining of the uterus as a treatment for heavy menstrual bleeding in women who no longer wish to bear children. Pregnancy following ablation, while unlikely, can occur and may carry higher rates of complications. The aim of this study was to identify factors associated with post-endometrial ablation pregnancy and to describe pregnancy and birth outcomes for post-endometrial ablation pregnancies. MATERIAL AND METHODS: This population-based data linkage study included all female residents of New South Wales, Australia, aged 15-50 years with a hospital admission between July 2001 to June 2014 who birthed between July 2001 and June 2015. Cox proportional hazard regression was used to estimate associations between women's characteristics and post-endometrial ablation pregnancy of at least 20 weeks' gestation. Descriptive statistics were used to characterize pregnancy and birth outcomes. RESULTS: Of 18 559 women with an endometrial ablation, 575 (3.1%) had a post-ablation pregnancy of at least 20 weeks' gestation. Nulliparity (adjusted hazard ratio [aHR] 12.2, 95% confidence interval [CI] 9.1-16.2), older age (35-39 years: aHR 0.39, 95% CI 0.29-0.51; 40-44 years: aHR 0.06, 95% CI 0.04-0.11), marital status (single: aHR 0.67, 95% CI 0.55-0.83; widowed/divorced/separated: aHR 0.58, 95% CI 0.36-0.94) and a diagnosis of heavy menstrual bleeding (aHR 0.09, 95% CI 0.07-0.13) were associated with post-ablation pregnancy. There were high rates of cesarean delivery (43%), preterm birth (13%), twin or higher order pregnancies (9%) and stillbirth (13.3/1000 births) among these post-ablation pregnancies. CONCLUSIONS: Nulliparity at the time of endometrial ablation is associated with increased risk of post-ablation pregnancy, highlighting the importance of careful discussion and consideration of treatment options for heavy menstrual bleeding.

Rates of neonatal morbidity by maternal region of birth and gestational age in New South Wales, Australia 2003-2016.

INTRODUCTION: Research suggests that neonatal morbidity differs by maternal region of birth at different gestational ages. This study aimed to determine the overall and gestation-specific risk of neonatal morbidity by maternal region of birth, after adjustment for maternal, infant and birth characteristics, for women giving birth in New South Wales, Australia, from 2003 to 2016. MATERIAL AND METHODS: The study utilized a retrospective cohort study design using linked births, hospital and deaths data. Modified Poisson regression was used to determine risk with 95% confidence intervals (95% CI) of neonatal morbidity by maternal region of birth, overall and at each gestational age, compared with Australian or New Zealand-born women giving birth at 39 weeks. RESULTS: There were 1 074 930 live singleton births ≥32 weeks' gestation that met the study inclusion criteria, and 44 394 of these were classified as morbid, giving a neonatal morbidity rate of 4.13 per 100 live births. The gestational age-specific neonatal morbidity rate declined from 32 weeks' gestation, reaching a minimum at 39 weeks in all maternal regions of birth. The unadjusted neonatal morbidity rate was highest in South Asian-born women at most gestations. Adjusted rates of neonatal morbidity between 32 and 44 weeks were significantly lower for babies born to East (adjusted relative risk [aRR] 0.65, 95% CI 0.62-0.68), South-east (aRR 0.76, 95% CI 0.73-0.79) and West Asian-born (aRR 0.93, 95% CI 0.88-0.98) mothers, and higher for babies of Oceanian-born (aRR 1.11, 95% CI 1.04-1.18) mothers, compared with Australian or New Zealand-born mothers. Babies of African, Oceanian, South Asian and West Asian-born women had a lower adjusted risk of neonatal morbidity than Australian or New Zealand-born women until 37 or 38 weeks' gestation, and thereafter an equal or higher risk in the term and post-term periods. CONCLUSIONS: Maternal region of birth is an independent risk factor for neonatal morbidity in New South Wales.

Intrapartum fetal blood sampling performed at early cervical dilatation and delivery outcomes.

BACKGROUND: Intrapartum fetal blood sampling (FBS) is a fetal well-being diagnostic test for cardiotocogram abnormalities. AIM: The aim of this study was to determine whether women who had their first FBS at <4 cm cervical dilation had an increased risk of operative delivery (caesarean section, instrumental delivery) compared to those women who had their first FBS ≥ 4 cm dilation. MATERIALS AND METHODS: Retrospective cohort study involving labouring women who underwent FBS in a tertiary centre between 2015 and 2017. Women who had their first FBS at <4 cm dilation were compared to those who had their first FBS at ≥4 cm. The primary outcome was operative delivery (caesarean, instrumental delivery); secondary outcomes were neonatal complications. Univariate logistic regression was used to assess the association between degree of cervical dilation at first FBS and study outcomes. RESULTS: Among 591 women, 39 (6.6%) had their first FBS at <4 cm cervical dilation. Women in the ≥4 cm group were less likely to have a total of ≥2 FBS (P = 0.003). There was no difference in the primary outcome between the two groups. Women who had the first FBS at <4 cm dilation were twice as likely to have a caesarean section delivery (odds ratio 2.06, 95% confidence interval 1.06-3.98), although 41% had a vaginal birth (instrumental and spontaneous). There were no differences in rates of resuscitation or admission to nursery between groups. CONCLUSION: Women who had their first FBS < 4cm cervical dilation were twice as likely to have a caesarean section compared to women who had their first FBS ≥ 4 cm. However, 41% had a vaginal birth, and there were no differences in fetal outcomes.

Is mode of first birth a risk factor for subsequent preterm birth?

BACKGROUND: Previous preterm birth is a strong predictor of subsequent preterm birth, but less is known about the causes of preterm birth following a full-term first pregnancy. Recent research has highlighted previous caesarean section as a potential risk factor. AIM: To examine the relationship between mode of first birth and the risk of subsequent preterm birth in New South Wales (NSW), Australia. MATERIALS AND METHODS: A population-based record-linkage study of NSW women who had a live singleton first birth at ≥37 weeks gestation, followed by a singleton second birth between 2005 and 2017. Relative risk (RR) and 95% CI of preterm birth in the subsequent pregnancy was calculated using modified Poisson regression, with mode of first birth as the exposure. Spontaneous preterm birth and preterm prelabour caesarean were secondary outcomes. RESULTS: Women who had either an intrapartum (RR: 1.26, 95% CI 1.19-1.32) or prelabour caesarean (RR: 1.26, 95% CI 1.18-1.35) first birth had a higher risk of subsequent preterm birth (any birth <37 weeks gestation), than those who birthed vaginally. Women who had a previous instrumental birth (RR: 0.85, 95% CI 0.79-0.91) or prelabour caesarean (RR: 0.74, 95% CI 0.67-0.82) had lower risks of subsequent spontaneous preterm birth. However, prior prelabour caesarean also greatly increased risk of subsequent preterm prelabour caesarean (RR: 5.25, 95% CI 4.65-5.93). CONCLUSIONS: The mode of first birth has differing effects on the risk of subsequent spontaneous preterm birth and preterm prelabour caesarean. Awareness of the risk of subsequent preterm birth following caesarean section may help inform clinical decisions around mode of first birth.

Protocol for probiotic therapy vs placebo for preterm prelabour rupture of membranes to prolong pregnancy duration (Pro-PPROM) trial.

BACKGROUND: Preterm prelabour rupture of membranes (PPROM) is a common preterm birth antecedent. Preterm infants experience increased adverse newborn outcome risks. Infection is a risk factor for early birth in PPROM. Current management is antibiotic therapy, antenatal corticosteroids and to plan delivery at 37 weeks gestation. The microbiota and probiotics are potentially protective and may improve outcomes. AIMS: The primary aim is to evaluate whether oral probiotic therapy (Lactobacillus fermentum CECT5716) administered during PPROM between 24 and 34 weeks gestation prolongs pregnancy duration. The secondary aim is to evaluate maternal and neonatal outcomes. MATERIALS AND METHODS: This is a pragmatic, multicentre, double-blind, placebo-controlled randomised controlled trial in Australia. The population will be women with a singleton pregnancy and PPROM less than 34 weeks gestation. The intervention will be an oral probiotic therapy compared with a placebo control. The primary outcome will be the proportion of women still pregnant at seven days following PPROM. One-to-one randomisation will occur within 24 h of PPROM. The trial is powered (80%, alpha = 0.05) to detect an absolute percentage increase in the primary outcome of 30%, (from expected rate of 20% up to 50%). DISCUSSION: This trial will provide evidence for the effectiveness of the probiotic in prolonging pregnancy duration. Findings will inform the feasibility of a larger trial to examine the effect of oral probiotics on clinically important maternal and neonatal outcomes in PPROM.

Determining a strategy to reduce smoking in pregnancy.

BACKGROUND: Further efforts, informed by current data, are needed to reduce smoking during pregnancy. AIMS: To describe trends in smoking during pregnancy and identify regions most likely to benefit from targeted smoking cessation interventions, in New South Wales (NSW), Australia. MATERIALS AND METHODS: All women who gave birth in NSW between 1994 and 2016 were included. Smoking status was identified from the Perinatal Data Collection. For births between 2012 and 2016, women were grouped into Local Health District (LHD) of residence, and smoking rates calculated. The impacts of a hypothetical smoking cessation intervention in four LHDs with (i) high smoking rates and (ii) high numbers of smokers, were compared. RESULTS: The overall smoking rate during pregnancy decreased from 22.1% in 1994 to 8.3% in 2016. [Correction added on 13 August 2020, after first online publication: the overall smoking rate during pregnancy in 1994 has been corrected from 14.5% to 22.1%.]. The decrease was lowest among women living in the most socioeconomically disadvantaged areas (41%) and highest among those living in the most advantaged areas (83%). Between 2012 and 2016, over half the women who smoked during pregnancy lived in one of four LHDs. Only 1% of women reporting smoking during pregnancy resided in the LHD with the highest smoking rate (34.7%). A simulated intervention targeting only four regions showed greater effect on the statewide smoking rate when targeting LHDs with high numbers of smokers rather than high smoking rates. CONCLUSIONS: Despite decreases in rates of smoking during pregnancy, there was evidence of geographic clustering of smokers. The greatest reduction in overall smoking may come from interventions targeting the four LHDs with the highest number of smokers.

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004-2015.

BACKGROUND: Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth. AIMS: We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015. METHODS: Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand-born (AUS/NZ-born) women. Intervention rates (induction or pre-labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004-2011 and 2012-2015). RESULTS: There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24-1.62), Oceanian (aOR 1.45, 95% CI 1.17-1.80) and African (aOR 1.46, 96% CI 1.19-1.80) born women had significantly higher odds of stillbirth that AUS/NZ-born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian-born women (18.1% and 19.6% respectively) than AUS/NZ-born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian-born women in the all-births model, with their stillbirth rates becoming closer to AUS/NZ-born women in the later period. CONCLUSION: South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW.

Childhood health and education outcomes following early term induction for large-for-gestational age: A population-based record linkage study.

INTRODUCTION: There is debate about optimal management of pregnancies with a large-for-gestational age baby. A recent randomized controlled trial reported that early term induction of labor reduced cesarean section rates and infant morbidity. However, long term childhood outcomes have not been assessed. The aim of this study was to assess maternal, neonatal and child health and education outcomes for large-for-gestational age babies induced at 37-38 weeks' gestation. MATERIAL AND METHODS: Population-based record linkage study of term (37+ weeks), cephalic-presenting singleton pregnancies with a large-for-gestational age baby in New South Wales, Australia, 2002-2006. Linked birth, hospital, mortality and education data were used with at least 9 years follow up from birth. Exposure was induction of labor at 37-38 weeks, compared to expectant management (spontaneous birth at ≥37 weeks and planned births at ≥39 weeks). Relative risks and 95% confidence intervals were estimated using Modified Poisson regression with robust variance. RESULTS: Among 10 174 eligible pregnancies, 412 (4.0%) had an induction at 37-38 weeks. Women in the induction group were less likely to have a cesarean section (RR: 0.65, 95% CI: 0.51-0.82). Infants had higher rates of: low Apgar scores, birth trauma, neonatal jaundice and phototherapy use, and admission to special care nursery or neonatal intensive care than their expectantly managed counterparts. As children, they had higher rates of hospital admission (RR: 1.16, 95% CI: 1.04-1.30) and special needs (RR: 1.98, 95% CI: 1.12-3.50). However, by age 8 there was no difference in overall literacy and numeracy achievement. CONCLUSIONS: Although women who had an early term labor induction with large-for-gestational age were less likely to have a cesarean section, the increased risk of neonatal morbidities and additional healthcare utilization suggests the need for caution in early induction of large-for-gestational age babies before 39 weeks' gestation.

Appendicectomy during pregnancy and the risk of preterm birth: A population data linkage study.

BACKGROUND: Suspected appendicitis is a common non-obstetric indication for emergency abdominal surgery during pregnancy. AIMS: Assess the risk of preterm birth and other maternal and neonatal adverse birth outcomes following appendicectomy during pregnancy. MATERIALS AND METHODS: Population-based data linkage study of women with singleton births in New South Wales, Australia, 2002-2014. Pregnancies with appendicitis and appendicectomy were compared to pregnancies without appendicitis. Crude and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for preterm birth were estimated. Modified Poisson regression with robust variance was used to estimate crude and adjusted risk ratios (aRR) with 99% CI for other outcomes. RESULTS: Of 1 124 551 eligible pregnancies, 1024 (0.9/1000 pregnancies) had appendicitis and appendicectomy. Of these, 566 (55.3%) had laparoscopic and 458 (44.7%) had open appendicectomy. Appendicectomy at later gestational ages was associated with increasing rates of preterm birth. After adjustment for maternal and pregnancy factors, appendicectomy was associated with increased risk of preterm birth (overall aHR 1.73, 95% CI 1.42-2.09; planned aHR 2.08, 95% CI 1.60-2.72), maternal morbidity (aRR 2.68, 99% CI 1.88-3.83) and neonatal morbidity (aRR 1.42, 99% CI 1.03-1.94). However, there was no difference in perinatal mortality rates. CONCLUSION: Appendicectomy during pregnancy is associated with increased risk of spontaneous and planned preterm birth, maternal and neonatal morbidity. Availability of resources to prevent or manage preterm labour should be considered when appendicectomy is performed at gestational ages of 20 weeks or more.

Outcomes associated with transfusion in low-risk women with obstetric haemorrhage.

BACKGROUND AND OBJECTIVES: Obstetric haemorrhage is associated with increased blood transfusion, morbidity and health service usage in women. While the use of transfusion in actively bleeding patients is supported, there is little evidence for the use of blood as treatment in the nonbleeding patient following obstetric haemorrhage. Transfusion may expose women to increased morbidity. This study aims to compare outcomes between low-risk women receiving no or 1-2 units of blood in the context of obstetric haemorrhage. MATERIALS AND METHODS: The study population included women giving birth in hospital in New South Wales, Australia, between July 2006 and December 2010, with a diagnosis of obstetric haemorrhage. Women with medical or obstetric conditions making them high risk were excluded, as were women receiving more than 2 units of blood. Data were obtained from linked hospital, birth and blood bank databases. Propensity score matching was used to compare outcomes between transfused and nontransfused women in order to estimate the impact of the transfusion itself on outcomes. RESULTS: There were 14989 women with obstetric haemorrhage, of whom, 1702 received a transfusion, including 1069 receiving a transfusion of 1-2 units. Women receiving transfusion were more likely to experience severe maternal morbidity (relative risk 7·0, 95% Confidence interval (2·8, 17·8)), be admitted to intensive care (RR 2·1 95% CI(1·2, 3·8)), and have a length of stay >5 days (RR 2·0, 95% CI (1·6, 2·5)). CONCLUSIONS: Small volume transfusion in the context of obstetric haemorrhage among low-risk women is associated with poorer maternal outcomes and increased healthcare utilisation.

Assessing the effect of risk factors on rates of obstetric transfusion over time using two methodological approaches.

BACKGROUND: While red blood cell transfusion rates have declined in most Australian medical specialties, obstetric transfusion rates have instead been increasing. Obstetric transfusions are mostly linked to postpartum haemorrhage, the rates of which have also increased over time. This study used two methodological approaches to investigate recent trends in obstetric transfusion in New South Wales (NSW) and the extent to which this was influenced by changing maternal and pregnancy characteristics. METHODS: Linked birth and hospital records were used to examine rates of red blood cell transfusion in the postpartum period for mothers giving birth in NSW hospitals from 2005 to 2015. Logistic regression models were run to examine the contribution of maternal and pregnancy risk factors to changing rates of transfusion. Risk factors were divided into "pre-pregnancy" and "pregnancy related". Crude and adjusted estimates of the effect of year of birth on obstetric transfusion rates were compared to assess the effect of risk factors on rates over time using two approaches. The first compared actual and predicted odds ratios of transfusion for each year. The second compared the observed increase in transfusion rate with that predicted after controlling for the risk factors. RESULTS: Among 935,659 births, the rate of obstetric transfusion rose from 13 per 1000 births in 2005 to 17 in 2011, and remained stable until 2015. From 2005 to 2015, postpartum haemorrhage increased from 74 to 114 per 1000 births. Compared with the rate in 2005, the available maternal and pregnancy characteristics only partially explained the change in rate of transfusion by 2015 (Method 1, crude odds ratio 1.39 (95% CI 1.25, 1.56); adjusted odds ratio 1.29 (95% CI 1.15, 1.45)). After adjustment for maternal and pregnancy characteristics, obstetric transfusion incidence was predicted to increase by 10.3%, but a 38.7% increase was observed (Method 2). CONCLUSION: Rates of obstetric transfusion have stabilised after a period of increase. The trend could not be fully explained by measured maternal and pregnancy characteristics with either of the two approaches. Further investigation of rates and maternal and clinical risk factors will help to inform and improve obstetric blood product use.

Knowledge, experience and attitudes towards skin-to-skin contact following Caesarean sections among health professionals in Vietnam.

AIM: This study explored knowledge, experience and attitudes of health professionals towards early essential newborn care and skin-to-skin contact following Caesarean sections in a tertiary hospital in Central Vietnam. METHOD: We conducted a cross-sectional descriptive study using an anonymous questionnaire in March 2016. Health professionals from obstetrics, anaesthesiology and neonatology departments were surveyed. RESULTS: All of the 204 surveys were returned, accounting for 82% of total staff involved in the care for women and newborns with Caesarean sections. Correct knowledge of early essential newborn care was lowest among anaesthesiology staff. Health professionals reported that ≥90% of Caesarean section births they attended in the preceding week had skin-to-skin contact. Approximately 16% obstetricians, 71% midwives, 49% anaesthesiology and 76% neonatology staff considered the current frequency of skin-to-skin contact to be about right. The remainder considered the current rate too high. All professional groups identified the main difficulties of conducting skin-to-skin contact as the temperature in the operating theatre and the need for additional staff. Other concerns included increasing the risk of the baby of falling off, prolonging the operation and difficulty to monitor mothers. CONCLUSION: The study identifies issues where improvements can be made in the implementation of skin-to-skin contact following Caesarean sections.

Outcomes of Gallstone Disease during Pregnancy: a Population-based Data Linkage Study.

BACKGROUND: Gallstone disease is a leading indication for non-obstetric abdominal surgery during pregnancy. There are limited whole population data on maternal and neonatal outcomes. This population-based study aims to describe the outcomes of gallstone disease during pregnancy in an Australian setting. METHODS: Linked hospital, birth, and mortality data for all women with singleton pregnancies in New South Wales, Australia, 2001-2012 were analysed. Exposure of interest was gallstone disease (acute biliary pancreatitis, gallstones with/without cholecystitis). Outcomes including preterm birth (spontaneous and planned), readmission, morbidity and mortality (maternal and neonatal) were compared between pregnancies with and without gallstone disease. Adjusted risk ratios (aRRs) and 99% confidence intervals were estimated using modified Poisson regression and adjusted for maternal and pregnancy factors. RESULTS: Among 1 064 089 pregnancies, 1882 (0.18%) had gallstone disease. Of these, 239 (12.7%) had an antepartum cholecystectomy and 1643 (87.3%) were managed conservatively. Of those managed conservatively, 319 (19.0%) had a postpartum cholecystectomy. Gallstone disease was associated with increased risk of preterm birth (aRR 1.3, 99% CI 1.1, 1.6), particularly planned preterm birth (aRR 1.6, 99% CI 1.2, 2.1), maternal morbidity (aRR 1.6, 99% CI 1.1, 2.3), maternal readmission (aRR 4.7, 99% CI 4.2, 5.3), and neonatal morbidity (aRR 1.4, 99% CI 1.1, 1.7). Surgery was associated with decreased risk of maternal readmission (aRR 0.4, 99% CI 0.2, 0.7). CONCLUSIONS: Gallstone disease during pregnancy was associated with adverse maternal and neonatal outcomes. Most women with gallstone disease during pregnancy are managed conservatively. Surgical management was associated with decreased risk of readmission.