Caesarean scar ectopic pregnancy: Evolution from medical to surgical management.

BACKGROUND: Caesarean scar ectopic pregnancy (CSP) is defined as blastocyst implantation occurring in a uterine scar. The incidence of CSP continues to rise with increasing caesarean section rates; prevalence is estimated to be 1:1800 to 1:2226 of all pregnancies. To date, over 30 treatment regimens have been published. The Royal College of Obstetricians and Gynaecologists guidelines (2016) state there is insufficient evidence to support one specific intervention over another. AIM: To review outcomes of medical and surgical management of CSP cases at a single tertiary centre over a nine-year period, in order to establish the safest and most effective management approach. MATERIALS AND METHODS: An audit was undertaken of patients treated for CSP between January 2009 and March 2017 at King Edward Memorial Hospital, Western Australia. Patient demographic and treatment outcome data were extracted from medical records. RESULTS: Fifty-one patients were identified as having CSP diagnosed during this time period, of which five were excluded due to lack of data, leaving a total of 46 cases. The majority of patients (52%, n = 24) elected for initial surgical management, while 41% (n = 19) trialled medical management. Seven percent (n = 3) opted for conservative management. Success rates of surgical, medical and conservative management were 100%, 53% and 0% respectively (P < 0.001). Medical management was associated with prolonged follow-up; there was no difference in complication rates between surgical and medical managements. CONCLUSIONS: In this audit, surgical management was the most effective way to manage CSP. There was no significant difference in complication rates between the two groups.

Accuracy, interpretability and usability study of a wireless self-guided fetal heartbeat monitor compared to cardiotocography.

Fetal Cardiography is usually performed using in-hospital Cardiotocographic (CTG) devices to assess fetal wellbeing. New technologies may permit home-based, self-administered examinations. We compared the accuracy, clinical interpretability, and user experience of a patient-administered, wireless, fetal heartbeat monitor (HBM) designed for home use, to CTG. Initially, participants had paired HBM and CTG examinations performed in the clinic. Women then used the HBM unsupervised and rated the experience. Sixty-three women had paired clinic-based HBM and CTG recordings, providing 6982 fetal heart rate measures for point-to-point comparison from 126 min of continuous recording. The accuracy of the HBM was excellent, with limits of agreement (95%) for mean fetal heart rate (FHR) between 0.72 and -1.78 beats per minute. The FHR was detected on all occasions and confirmed to be different from the maternal heart rate. Both methods were equally interpretable by Obstetricians, and had similar signal loss ratios. Thirty-four (100%) women successfully detected the FHR and obtained clinically useful cardiographic data using the device at home unsupervised. They achieved the required length of recording required for non-stress test analysis. The monitor ranked in the 96-100th percentile for usability and learnability. The HBM is as accurate as gold-standard CTG, and provides equivalent clinical information enabling use in non-stress test analyses conducted outside of hospitals. It is usable by expectant mothers with minimal training.

Accuracy, Clinical Utility, and Usability of a Wireless Self-Guided Fetal Heart Rate Monitor.

OBJECTIVE: To evaluate the accuracy, clinical utility, and usability of a wireless fetal and maternal heartbeat monitor to monitor fetal heart rate (FHR). METHODS: We conducted a prospective, single-center study of a convenience sample of women aged 18 years or older with a singleton pregnancy of at least 12 weeks of gestation. Fetal heart rate recordings were performed using both the heartbeat monitor and cardiotocography to evaluate accuracy. Clinicians used the heartbeat monitor in the clinic. Women used the device, unassisted, during a clinic visit or at home. Obstetricians assessed the clinical utility of FHR traces. Women rated the heartbeat monitor using the System Usability Scale. RESULTS: A total of 81 participants provided 126 recordings. The accuracy of the heartbeat monitor was excellent compared with cardiotocography, with limits of agreement (95%) for mean FHR between -1.6 (CI -2.0 to 1.3) and +1.0 (CI 0.7-1.4) beats per minute (bpm), mean difference -0.3 bpm, intraclass coefficient 0.99. The FHR was detected on all occasions. Clinicians took a median (interquartile range) of 0.5 (0.2-1.2) minutes to detect the FHR, obtaining a continuous trace of longer than 1 minute in 95% (39/41) of occasions. Home users took a median of 0.5 (0.2-2.0) minutes to detect the FHR, obtaining a continuous trace of longer than 1 minute in 92% (24/26) of occasions, with a median total trace time of 4.6 (4.4-4.8) minutes. The traces were deemed clinically useful in 100% (55/55) of clinician and 97% (31/32) of home recordings. The heartbeat monitor ranked in the 96-100th percentile for usability and learnability. CONCLUSION: The heartbeat monitor was accurate and easy for clinicians and participants to use. Data recorded at home were equivalent to those obtained using current assessment protocols for low-risk pregnancies, potentially allowing the device to be used in telehealth consultations. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry, ACTRN12620000739910. FUNDING SOURCES: The HeraBEAT devices used in this study were loaned by HeraMED Pty Ltd (HeraMED, Netanya, ISRAEL). The study was supported by PHI Research Group (not-for-profit), which was responsible for Statistician fees and Research Assistants' salaries. Joondalup Health Campus provided infrastructure support, and IT services in-kind to the PHI research group.