Diagnosis and management of arrhythmias in pregnancy.

Arrhythmias are the most common cardiac complications occurring in pregnancy. Although the majority of palpitations in pregnancy may be explained by atrial or ventricular premature complexes, the full spectrum of arrhythmias can occur. In this article, we establish a systematic approach to the evaluation and management of arrhythmias in pregnancy. Haemodynamically unstable arrhythmias warrant urgent cardioversion. For mild cases of benign arrhythmia, treatment is usually not needed. Symptomatic but haemodynamically stable arrhythmic patients should first undergo a thorough evaluation to establish the type of arrhythmia and the presence or absence of structural heart disease. This will ultimately determine the necessity for treatment given the potential risks of anti-arrhythmic pharmacotherapy in pregnancy. We will discuss the main catalogue of anti-arrhythmic medications, which have some established evidence of safety in pregnancy. Based on our appraisal, we provide a treatment algorithm for the tachyarrhythmic pregnant patient.

Increasing the adoption of ambulatory hysteroscopy in Australia - cost comparisons and patient satisfaction.

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact StatementWhat is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia.What the results of this study add? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it.What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

Ovarian cysts in pregnancy: a narrative review.

Most adnexal masses are benign, incidental findings of pregnancy which resolve spontaneously. They may present clinically due to haemorrhage, rupture, torsion and mass effect. Aetiological classification includes ovarian benign, ovarian malignant, non-ovarian, gynaecological, non-ovarian non-gynaecological and an additional subset of pathologies unique to pregnancy. Ultrasound is the first-line imaging modality for the evaluation of adnexal masses. This may be supplemented with magnetic resonance imaging. Tumour markers support evaluation of malignant potential, but interpretation of results in pregnancy is challenging. Surgical intervention requires consideration of gestation, lesion characteristics and presence of complications. Laparoscopy is preferred owing to shorter operative time, quicker recovery and resultant lower thrombotic risk. Post-viability, fetal wellbeing and assessment must be considered. Management of the pregnancy may include cardiotocography, steroids, non-teratogenic antibiotics and tocolytics. In rare cases, particularly related to malignancy, termination of pregnancy may be required to enable immediate management where there are concerns for maternal wellbeing.

Laparoscopic Port-Site Hernia: An Underrecognized Iatrogenic Complication of Laparoscopic Surgery.

IMPORTANCE: Port-site hernia is an iatrogenic complication with a documented incidence between 0.65% and 2.8%. However, the true incidence could be higher because of delayed onset, asymptomatic nature, and loss to follow-up. Port-site hernia could be further complicated by incarceration or strangulation leading to small bowel obstruction requiring emergent surgical intervention, thus imposing significant financial and emotional burden to patients. OBJECTIVE: This article aims to provide a summary of the available literature concerning port-site hernia and explore preventive strategies for future clinical practice. EVIDENCE ACQUISITION: This review was formulated through electronic literature searches in Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The reference lists of the included studies were hand searched to identify other relevant articles to capture all available literature in this narrative review. RESULTS: Following screening for eligibility based on relevance to the topic under consideration, 28 studies were identified. This included 5 original articles, 1 case series, and 22 review articles, including 4 systematic reviews. Included studies were critically appraised in formulating this review. CONCLUSIONS: Port-site hernia is an underrecognized yet preventable complication with careful consideration of predisposing technical and host factors, thorough attention to surgical technique, or use of a fascial closure device. RELEVANCE: With the widespread and increasing use of laparoscopic methods to treat surgical pathologies, knowledge of this complication is imperative to encourage prevention strategies and facilitate early recognition and management should it occur.

Cervical Cerclage: A Review and Rethinking of Current Practice.

IMPORTANCE: Cervical insufficiency (CI) is a serious complication of pregnancy, which can cause preterm birth. Identifying how to most effectively treat CI has the potential to maximize neonatal survival in this population of women. OBJECTIVE: To determine whether transabdominal cervical cerclage should be offered as a first-line treatment option in high-risk women. EVIDENCE ACQUISITION: An electronic literature search for relevant studies was conducted using keywords (CI, cervical cerclage) on the MEDLINE database. RESULTS: Although transabdominal cerclage (TAC) is reserved as a second-line treatment option over transvaginal cerclage (TVC), it has some advantages over TVC: a higher placement of the suture at the level of the cervicoisthmic junction; avoidance of placement of foreign material in the vagina, in turn, reducing risk of infection and inflammation, which can propagate preterm labor; and the option to leave the suture in place for future pregnancies. Systematic review evidence offers TAC as a more effective procedure to TVC in reducing preterm birth and maximizing neonatal survival. Although TAC is a slightly more complex procedure compared with TVC, advances in minimally invasive surgery now allow gynecologists to perform this more effective procedure laparoscopically and therefore without the added morbidity of open surgery but with the same if not better outcomes. CONCLUSIONS: Laparoscopic TAC can provide a more effective treatment option for CI without the added burdens of open abdominal surgery. RELEVANCE: Our article highlights future directions for study in the area of cervical cerclage and refinement of existing practices.