Redesigning antenatal care: Prospective use of an implementation framework to establish a population-based multidisciplinary first-trimester screening, assessment and prevention service.

BACKGROUND: Australian rates of adverse obstetric outcomes have improved little despite guidelines recommending history-based screening and intervention. The first trimester provides a unique opportunity to predict and prevent complications, yet population-based screening has failed to be translated into broad clinical practice. AIMS: This study aimed to redesign antenatal care within an Australian public healthcare centre to align with evidence-based maternity care, including population-based first-trimester screening with early initiation of preventative strategies in high-risk pregnancies. METHODS: A five-phase action-process model, sharing key elements with implementation science theory, was used to explore barriers to change in antenatal care, co-design a novel service with consumers and establish a population-based antenatal pathway commencing with a multidisciplinary first-trimester screening, assessment and planning visit. RESULTS: The case for change and associated barriers were defined from the perspective of antenatal care stakeholders. Key needs of each group were established, and solutions were created using co-design methodology, allowing the team to create a novel approach to antenatal care which directly addressed identified barriers. Implementation of the service was associated with a fall in the median gestation at first specialist maternity care provider visit from 20 to 13 weeks. CONCLUSIONS: This study confirms the feasibility of establishing a comprehensive first-trimester screening program within a public Australian healthcare setting and highlights a co-design process which places individualised assessment at the forefront of antenatal care. This framework may be applicable to most public maternity settings in Australia, with expansion aimed at providing equity of care, including in rural and remote settings.

Adherence to a selective antenatal haemoglobinopathy screening policy within a tertiary level obstetric unit in Australia.

BACKGROUND: Haemoglobinopathies represent the most common single gene disorder worldwide; however, significant centre to centre variations in antenatal screening practices exist. AIMS: To assess performance of a selective antenatal haemoglobinopathy screening policy within a presumed low-prevalence Australian population. Primary outcome was the failure to screen rate for women with at least one identifiable risk factor. Secondary outcomes included outcomes of maternal screening and rates, gestations and outcomes of paternal, prenatal and neonatal testing. MATERIALS AND METHODS: A two-year retrospective cohort study identifying all women attending for public antenatal care with at least one identifiable risk factor for haemoglobinopathy. RESULTS: At least one risk factor for haemoglobinopathy was identified in 8.8% of the entire pregnant cohort; however, the failure to screen rate was high at 83.7% overall. Screening was significantly more likely to be undertaken in multiparous women, those with multiple risk factors and women originating from the Middle East. Twenty percent of screened women returned an abnormal result; however, this led to paternal haemoglobinopathy screening in only 66.6%. Where completed, the addition of partner screening reclassified offspring to low-risk status in 85.7% of cases. CONCLUSIONS: This study demonstrates an 83.7% screen failure rate within a selective screening model raising concerns regarding the clinical utility and health equity of this approach. This major drawback of selective screening suggests that institution of a universal antenatal screening system for haemoglobinopathies, even in anticipated low-prevalence areas, will improve detection rates and ensure families receive appropriate and timely counselling.

Pregnancy and lactation during long-term total parenteral nutrition: A case report and literature review.

There is a paucity of clinical data regarding the management of pregnancy and lactation in women requiring long-term total parenteral nutrition with complex nutritional needs. This case report and literature review highlights common challenges in care and presents evidence which can guide the obstetrician's approach to care.

Can Routine Histopathology Distinguish Between Vulvar Cutaneous Candidosis and Dermatophytosis?

OBJECTIVES: This study aimed to determine if vulvar cutaneous candidosis and dermatophytosis can be distinguished by routine histopathology. MATERIALS AND METHODS: Twenty-four cases of periodic acid-Schiff-stained vulvar biopsies with a diagnosis of cutaneous mycosis were reviewed and histopathological characteristics on both periodic acid-Schiff and hematoxylin and eosin were recorded. Data were collected on age, clinical impression, microbiological results, and treatment, and all specimens underwent multiplex polymerase chain reaction analysis. RESULTS: The mean age was 60 years, and all but 3 women had at least 1 risk factor for mycosis including 15 (62.5%) with lichen sclerosus and/or planus managed with topical corticosteroids. A clinical suspicion of tinea or candidosis was documented in 12 (50%) of the cases. Vulvovaginal swabs showed Candida species in 9 women; one skin scraping was positive for Trichophyton rubrum. Microbiology was not obtained in 8 patients, 5 had a negative swab, and 1 had negative skin scrapings. No histopathological or morphological features distinguished Candida species from dermatophytes. Organisms appeared as basophilic structures in the stratum corneum in 15 (62.5%) hematoxylin and eosin-stained slides. Polymerase chain reaction results were positive for Candida species in 5 (21%) and for dermatophytes in 3 (13%), negative in 13, and unassessable in 3 cases. CONCLUSIONS: Vulvar cutaneous candidosis and dermatophytosis cannot be reliably distinguished by routine histopathology or specific polymerase chain reaction. A high index of suspicion combined with adequate microbiological testing remains the best approach to differentiating between the 2, which impacts on counseling, treatment, and prognosis.

Lessons to be learnt in managing the breech presentation at term: an 11-year single-centre retrospective study.

BACKGROUND: The 2000 publication of the Term Breech Trial significantly impacted obstetric practice in Australia with a rapid increase in delivery of term breech singletons by caesarean section. More reassuring data from European centres who continued to offer vaginal breech deliveries to carefully selected women have led to a softening of international guidelines which now support an individualised approach to management. The application of this principle to an Australian population, particularly in the wake of such a major change in obstetric practice, has not previously been demonstrated. AIM: To compare short-term neonatal and maternal morbidity for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. MATERIALS AND METHODS: Eleven-year single-centre retrospective study with intention-to-treat analysis based on intended mode of delivery. RESULTS: Two hundred and forty-three of 766 (31.7%) eligible women elected for planned vaginal breech delivery. The overall success rate in this group was 58%. Morbidity rates were low and compare favourably with similar international studies. However, there was a nonsignificant trend towards higher rates of short-term serious neonatal and maternal morbidity in the planned vaginal delivery group (1.6 vs 0.4%, P = 0.08 and 8.2 vs 4.8%, P = 0.06, respectively). CONCLUSIONS: Attempted vaginal delivery for breech presentation remains an option in carefully selected women under strict obstetric protocols.

A comparative study of efficacy and outcomes of large loop excision of the transformation zone procedure performed under general anaesthesia versus local anaesthesia.

BACKGROUND: Although Australian National Health and Medical Research Council (NHMRC) guidelines do not specify targets for mode of anaesthesia for large loop excision of the transformation zone (LLETZ) procedures, UK NHS Cervical Screening Programme (NHSCSP) guidelines recommend that >80% of LLETZ procedures be performed under local anaesthesia. There is a paucity of clinical data regarding both the proportion of women receiving general anaesthesia for treatment, factors underpinning this choice and the impact of mode of anaesthesia on treatment outcomes. AIMS: To identify the proportion of women who have a LLETZ under general anaesthesia and to establish the impact of mode of anaesthesia on outcomes including treatment efficacy, overtreatment (negative histology), short-term morbidity and attendance for follow-up. METHODS: Single-centre retrospective analysis of all women treated with LLETZ for suspected cervical dysplasia between 1, May 2005 and 1, May 2009. RESULTS: Thirty-three percent of a total 465 LLETZ procedures were carried out under general anaesthesia, although the reason for anaesthesia choice was not recorded in 52% of cases. There were no significant differences in the primary outcomes of unclear LLETZ margins or negative LLETZ histology, or in the secondary outcomes of depth and surface area of LLETZ specimen, short-term morbidity or rates of incomplete follow-up. CONCLUSIONS: Although reasons underpinning selection of anaesthesia mode remain elusive, at this centre, outcomes following LLETZ procedure for the management of suspected cervical dysplasia are not affected by the mode of anaesthesia used.