Feasibility of an asynchronous general practitioner-to-general physician eConsultant outpatient substitution program: A Queensland pilot study.

BACKGROUND AND OBJECTIVES: The use of an 'eConsultant' to support the family physician is an established outpatient substitution model in North America. This pilot study investigates the feasibility of the eConsultant model for complex chronic disease management within the Australian setting. METHOD: This pilot study was implemented in one urban and four rural/remote general practices in one state. The general practitioner (GP) sent a request for advice (RFA), a clinical summary with a specific clinical question/s, via secure messaging to a physician working remotely. Responses were required for GP/patient follow-up within 72 hours. RESULTS: The mean (standard deviation [SD]) time for general physician reply was 2.1 (1.2) days, and mean (SD) time from initial to subsequent GP/patient review was 14.8 (16.7) days. Only 13.3% of eConsultations required a subsequent face-to-face outpatient department appointment. DISCUSSION: The eConsultant model is feasible in Australia, with potential for improving access and reducing time to non-GP specialist input.

Negative predictive value of dobutamine stress echocardiography for perioperative risk stratification in patients with cardiac risk factors and reduced exercise capacity undergoing non-cardiac surgery.

BACKGROUND: Guidelines recommend functional testing for myocardial ischaemia in the perioperative setting in patients with greater than one recognised cardiac risk factor and self-reported reduced exercise capacity. AIM: To determine the clinical utility of dobutamine stress echocardiography (DSE) for perioperative risk stratification in patients undergoing major non-cardiac surgery. METHODS: Data on 79 consecutive patients undergoing DSE for perioperative risk stratification at a single centre were retrospectively reviewed to determine rates of major adverse cardiac events (MACE) during the index hospitalisation and 30 days post-discharge. Echocardiography and outcome data were obtained through a folder audit and echolab database. RESULTS: Out of the 79 DSE performed for perioperative risk stratification, 11 (14%) were positive (DSE +ve) and 68 (86%) were negative (DSE -ve). Management in the DSE +ve group included medical optimisation without invasive intervention (n = 7(64%)), diagnostic coronary angiography (n = 3(27%)) and coronary artery bypass graft (n = 1(9%)). None of the patients underwent percutaneous coronary intervention preoperatively. Perioperative MACE in the DSE +ve group was 36% compared to 4% in the DSE-ve group (P = 0.006). DSE +ve was a powerful predictor of perioperative inpatient MACE (OR 12.4, 95% CI 2.3-67, P = 0.003). The positive predictive value of DSE +ve status was 36%, whereas the negative predictive value of DSE-ve status for perioperative MACE was 96%. CONCLUSION: DSE for perioperative risk stratification had a high clinical utility in patients undergoing major non-cardiac surgery. In particular, a normal DSE had a high negative predictive value for perioperative MACE.

Role of telehealth in perioperative medicine for regional and rural patients in Queensland.

BACKGROUND: Australians living in regional, rural and remote areas face a myriad of complexities resulting in a trend to poorer health outcomes. Telehealth is being utilised as an alternative mode of service delivery to overcome such barriers. However, there is limited published information concerning the use of telehealth in perioperative medicine. AIMS: To review the performance of the telehealth preoperative assessment service at Mater Hospital Brisbane to determine last-minute cancellation rates secondary to medical reasons. METHODS: A retrospective chart audit of all patients referred to perioperative medicine telehealth consultation services was provided at Mater Hospital Brisbane. RESULTS: During a 1-year period, 229 patients across eight surgical subspecialties were referred for telehealth assessment (85 females, 144 males) with a median age of 67 years. Patients lived a median distance of 1597 km from Brisbane. Of the 229 patients included in the study, 7 (3.1%) experienced last-minute cancellations. From these data, the last-minute cancellation rate due to medical reasons was 1.3%, which is consistent with the international average. CONCLUSION: The Mater Hospital Perioperative Medicine Telehealth Programme is a means of providing comprehensive perioperative assessment to regional, rural and remote patients that result in reduced last-minute surgical cancellations and surgery within or below the national recommended guidelines.

Chronic kidney disease in pregnancy: Maternal and fetal outcomes and progression of kidney disease.

BACKGROUND: There is a paucity of Australian data regarding renal disease in pregnancy. We undertook a retrospective cohort study at a tertiary institution to examine the impact of renal disease on pregnancy outcomes and the effect of pregnancy on disease progression. METHODS: A total of 55 pregnancies of patients with renal disease admitted from 2003 to 2010 to the Royal Brisbane and Women's Hospital were analysed. Pre-conception variables, fetal/delivery and maternal outcomes were analysed in this group and in a control group of women with normal kidney function pre-pregnancy. RESULTS: Of the 55 pregnancies, 71% experienced pre-term delivery, 38% had intra-uterine growth restriction and 62% required caesarean section. Of all, 60% of neonates required neonatal intensive care unit (NICU) admission and six perinatal deaths occurred. Of all, 67% of women suffered preeclampsia, 47% anaemia and 3 patients required dialysis in pregnancy. Postpartum deterioration of renal function occurred in patients with pre-conception chronic kidney disease stage 3-5. CONCLUSIONS: Chronic kidney disease of all stages is a risk factor for adverse pregnancy outcomes. In a tertiary institution however, there is a high rate of successful pregnancy (84%).

The conundrum of eclampsia and fitness to drive.

BACKGROUND: Australian Fitness to Drive guidelines suggest that anyone who has had a seizure of any kind in the context of a 'metabolic' disorder should avoid driving for a period of 6 months. The special case of eclampsia is not mentioned. AIMS: In this study, we aimed to assess what advice healthcare professionals involved in the peripartum care of women provide to women who have an eclamptic seizure, what investigations they would conduct to exclude other causes of seizures and their level of awareness of whether eclampsia was addressed in the Australian Fitness to Drive guidelines. MATERIALS AND METHODS: A survey of 165 healthcare professionals attending the 2012 Society of Obstetric Medicine of Australia and New Zealand annual scientific meeting. Participants included registered nurses, midwives, consultant obstetricians, consultant physicians, doctors in training and others, interested in medical disorders of pregnancy. RESULTS: One hundred and nine conference attendees completed the survey (response rate 66.1%). 58 respondents (53.2%) had cared for 5 or more women with peripartum seizures, and 23 respondents (21.1%) had cared for 10 or more women with peripartum seizures. 46 respondents (42.2%) had never considered the issue of driving after an eclamptic seizure. For those who had considered the issue, advice ranged from no restriction (n = 5, 4.6%), no driving for 1-2 weeks (n = 14, 12.8%), no driving for 3 months (n = 20, 18.4%) or no driving for 6 months (n = 6, 5.5%). CONCLUSIONS: Many healthcare professionals caring for women with peripartum seizures have not considered issues relating to fitness to drive after an eclamptic seizure. There is a wide range of advice provided. Better prospective data are required regarding the risk of subsequent seizure after eclampsia, to inform clear fitness to drive guidelines.

Susac syndrome and multifocal motor neuropathy first manifesting in pregnancy.

Susac Syndrome (SS) and multifocal motor neuropathy (MMN) are rare autoimmune neurological conditions which can affect women of childbearing years. The effect of pregnancy on these disorders is poorly characterised. We report a case of SS first manifesting in pregnancy with challenges in diagnosis and management and a poor clinical outcome, and a case of MMN manifesting in pregnancy then relapsing in a subsequent pregnancy. A summary of other cases in the literature and the postulated underlying immune mechanisms is presented.

Pregnancy-induced Cushing's syndrome in recurrent pregnancies: case report and literature review.

Pregnancy in women with Cushing's syndrome (CS) is uncommon. It is associated with significant maternal and fetal complications. Pregnancy-induced Cushing's syndrome is exceptionally rare with fewer than ten cases reported in the world literature and none in Australia or New Zealand. We describe a woman with possible recurrent pregnancy-induced CS complicating five pregnancies over a 7-year period. We discuss the changes in the hypothalamic-pituitary-adrenal axis during normal pregnancy together with the diagnosis, aetiology and management of CS in pregnancy.

Moyamoya disease in pregnancy: maintenance of maternal blood pressure.

Moyamoya disease is a rare cerebrovascular occlusive disorder characterized by stenosis in the circle of Willis with the development of a compensatory circulation. It has been associated with significant morbidity in pregnancy including intracranial haemorrhage, ischaemic stroke and epilepsy. We present the case of a 26-year-old woman with a previous diagnosis of moyamoya vasculopathy with bilateral superficial temporal to middle cerebral artery bypass grafting. During the second trimester, she developed significant neurological symptoms related to postural hypotension in the presence of a stenosis of the right-sided graft. The hypotension was treated with fludrocortisone therapy with improvement in blood pressure and symptoms. Moyamoya vasculopathy poses unique challenges to obstetric care. This is the first report of use of fludrocortisone for maintenance of blood pressure during pregnancy in this condition.

A fifteen-year retrospective review of obstetric patients requiring critical care.

BACKGROUND: Maternal mortality is a rare occurrence in developed nations. Given the low maternal mortality rate, other markers must be used to assess maternal risk and quality of obstetric care. One such is admission to critical care. AIMS: To determine the rate of admission, diagnosis and management of women from conception and up to 6 weeks postpartum to critical care units including coronary care (CCU), high dependency unit (HDU) and intensive care units (ICU). METHODS: We performed a retrospective review of obstetric patients requiring critical care admission from January 1995 to August 2010. Demographic details, obstetric history, place of admission (CCU, HDU or ICU) and fetal/neonatal outcomes were examined as were initial indication for critical care admission, final diagnosis and treatment administered. RESULTS: Data were available from 308 admission incidents. There were 259 (84%) admissions to ICU and 49 (15.9%) to CCU. More than a third of women were transferred from another institution. Those women transferred were more unwell and had a higher mortality rate than local women. Primary diagnoses: obstetric haemorrhage (ICU 30.9%), hypertensive disorders of pregnancy (ICU 16.2%, CCU 12.2%), infection (ICU 14.2%, CCU 6.1%), pre-existing cardiac disease (ICU 9.3%, CCU 55.1%). CONCLUSIONS: The obstetric population represents only a small percentage of critical care utilisation and overall morbidity and mortality. However, this population is an important and growing group. Increased surveillance peripartum in a critical care facility allows earlier detection of maternal compromise and detailed management. Analysis of these 'near misses' in obstetrics aims to improve pregnancy outcomes.

Overweight and obesity knowledge prior to pregnancy: a survey study.

BACKGROUND: Overweight and obesity are associated with increased risk for pregnancy complications. Knowledge about increased risks in overweight and obese women could contribute to successful prevention strategies and the aim of this study is to assess current levels of knowledge in a pregnant population. METHODS: Cross sectional survey of 412 consecutive unselected women in early pregnancy in Brisbane, Australia: 255 public women attending their first antenatal clinic visit and 157 women at private maternal fetal medicine clinics undergoing a routine ultrasound evaluation prior to 20 weeks gestation. The cohort was stratified according to pre pregnancy BMI (< 25.0 or ≥ 25.0). The main outcome measure was knowledge regarding the risks of overweight and obesity in pregnancy. RESULTS: Over 75% of respondents identified that obese women have an increased risk of overall complications, including gestational diabetes and hypertensive disorders of pregnancy compared to women of normal weight. More than 60% of women asserted that obesity would increase the risk of caesarean section and less than half identified an increased risk of adverse neonatal outcomes. Women were less likely to know about neonatal complications (19.7% did not know about the effect of obesity on these) than maternal complications (7.4%). Knowledge was similar amongst women recruited at the public hospital and those recruited whilst attending for an ultrasound scan at a private clinic. For most areas they were also similar between women of lower and higher BMI, but women with BMI < 25.0 were less likely to know that obesity was associated with increased rate of Caesarean section than those with higher BMI (16.8% versus 4.5%, P < 0.001). Higher educational status was associated with more knowledge of the risks of overweight and obesity in pregnancy. CONCLUSIONS: Many women correctly identify that overweight and obesity increases the overall risk of complications of pregnancy and childbirth. The increased risks of maternal complications associated with being obese are better known than the increased risk of neonatal complications. Maternal education status is a main determinant of the extent of knowledge and this should be considered when designing education campaigns.

Use of imaging for investigation of suspected pulmonary embolism during pregnancy and the postpartum period.

Pulmonary embolism (PE) is recognized as a leading cause of maternal mortality in the developed world; however, it is a very difficult diagnosis to make on clinical grounds, and in most cases imaging is required. Pregnancy is a recognized risk factor for venous thromboembolism, and symptoms of normal pregnancy including shortness of breath, tachycardia and leg swelling are included in clinical tools for risk stratification for PE in the non-pregnant population. This results in a very low threshold for imaging, despite concerns regarding the risk of exposure to ionizing radiation both for the fetus and the maternal breast. We reviewed the results of all ventilation/perfusion scans and computed tomography pulmonary angiograms performed in pregnant women at a single institution to identify how many of these tests were positive for PE, and which clinical features may identify a low-risk group. A total of 386 scans were performed to investigate 375 episodes of suspected PE, representing 1.3-1.5% of pregnant women. Fifteen patients were diagnosed with PE, giving an incidence of one in 2000 maternities. The only statistically significant factors associated with PE were smoking or the presence of multiple risk factors. Clinical features of tachycardia and leg swelling did not provide significant diagnostic value; however, the absence of pleuritic chest pain had a negative predictive value of 97.8%. Arterial blood gas and D-dimer were statistically different between those with and without PE but not to a clinically useful degree. Currently available clinical and laboratory tools are not adequate to exclude a diagnosis of PE in a pregnant patient, thus imaging is justified to exclude PE. Further longitudinal studies to identify a low-risk group who do not require imaging is vital.

Illicit drug use in late pregnancy associated with stillbirth and eclampsia.

We present the case of a 20-year-old student with an undiagnosed pregnancy who had taken ecstasy and LSD (lysergic acid diethylamide). Twenty-four hours later she delivered a stillborn term infant, and subsequently developed eclampsia with seizures, hypertension and proteinuria. Illicit drug use is relatively common in women of child-bearing age in Australia, and is a risk factor for adverse obstetric outcomes. Ecstasy (MDMA [3,4-methylenedioxymethamphetamine]) is a sympathomimetic amine, similar to amphetamine in its cardiovascular effects. LSD is a hallucinogen with complex pharmacology and has potential for significant compromise of placental blood flow. We propose that the combined vasoconstrictive effects of MDMA and LSD caused placental ischaemia, contributing to the fetal death and precipitating a cascade of endothelial dysfunction which resulted in an eclamptic syndrome.