Acute abdomen with a parasitic smooth muscle tumor of uncertain malignant potential (STUMP) in pregnancy; a unique case report.

INTRODUCTION AND IMPORTANCE: Diagnosis of a smooth muscle tumor of uncertain malignant potential (STUMP) during pregnancy is rare. Furthermore; the investigation of an intra-abdominal mass during pregnancy is clinically challenging due to anatomical changes and additional considerations of the developing fetus and radiation exposure. The unusual nature and diagnostic dilemma of such a case warrants a case report to serve as an educational prompt to clinicians who may encounter pregnant patients with undifferentiated intra-abdominal masses and/or suspecting of STUMP. CASE PRESENTATION: We report a rare case of a parasitic STUMP diagnosed during pregnancy. The patient presented with a new umbilical hernia and deranged liver function tests (LFT's) during her third trimester. MRI reported a large mass in the left mid flank with intra-abdominal varices extending into the umbilical hernia. She went on to develop an acute abdomen requiring laparotomy where a parasitic fibroid adherent to the omentum was excised and a preterm infant was delivered via caesarean section. Histology was difficult due to pregnancy related changes but ultimately confirmed a diagnosis of STUMP. CLINICAL DISCUSSION: STUMP in pregnancy is rare and diagnosis is further complicated by histological challenges due to pregnancy related changes. Postoperative diagnosis is challenging due to lack of universally accepted diagnostic criteria and Uncertainty regarding prognostic factors makes management and follow-up of patients with STUMP challenging. Studies have shown that younger patients are more likely to demonstrate recurrence. CONCLUSION: Investigation and management of intra-abdominal masses in pregnancy is challenging. It requires timely multi-disciplinary team (MDT) input. Additional complications and considerations relate to the preterm fetus. Knowledge and understanding of these difficulties will better equip clinicians working with such patients to formulate a structured and well informed approach to the pregnant patient with a new intra-abdominal mass. Diagnosis of STUMP during pregnancy may be challenging for the pathologist and require further exert opinion.

Corticosteroids to safely reduce neonatal respiratory morbidity after late preterm and term planned caesarean section birth? A randomised placebo-controlled feasibility study.

OBJECTIVES: To assess the feasibility of conducting a randomised placebo-controlled trial of corticosteroids prior to planned caesarean section from 35+0 to 39+6 weeks. DESIGN: A triple-blind, placebo-controlled, parallel, trial randomised at the participant level (1:1 ratio). Additional feasibility data obtained by questionnaires from trial participants and women who declined trial participation, and focus groups with local site researchers and clinicians. SETTING: Three obstetric units in New Zealand including tertiary and secondary care; public and private care, and research active and non-active units. PARTICIPANTS: Women undergoing a planned caesarean section from 35+0 to 39+6 weeks; local site researchers and clinicians. INTERVENTIONS: Two doses of 11.4 mg betamethasone or saline placebo. Questionnaires and focus group meetings. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: trial recruitment rate of eligible women. SECONDARY OUTCOMES: trial recruitment by gestational age, site and delivery indication; proportion of babies who completed measurements of blood glucose concentrations as per protocol; overall incidence neonatal respiratory distress requiring >60 min of respiratory support; overall incidence of neonatal hypoglycaemia, and barriers and enablers to trial participation by participants, researchers and clinicians. RESULTS: The recruitment rate was 8.9% (88/987) overall and 11.2% (88/789) for those approached about the trial. Neonatal blood glucose concentrations were measured as per protocol in 87/92 (94.6%) babies. For potential participants, key enablers to participation were contributing to research, a feeling of relevance and a good understanding; key barriers were a lack of understanding and concerns over safety. For researchers and clinicians, themes representing enablers and barriers included relevance, communication and awareness, influences on women's decision-making, resource challenges and trial process practicalities. CONCLUSIONS: Some women are willing to participate in a randomised placebo-controlled trial of corticosteroids prior to a planned caesarean section birth at late preterm and term gestations. Participation in such a trial can be enhanced.

Anterior abdominal wall defects managed at a tertiary maternal-fetal medicine service in New Zealand: What counselling advice can we offer parents?

BACKGROUND: Anterior abdominal wall defects, including gastroschisis and omphalocoele, are common fetal anomalies. The management remains complicated, and their diagnosis may lead to significant parental distress. Effective parental counselling may impact on parental perceptions of the defect and help guide pregnancy management. AIMS: Using contemporary data, we aimed to describe clinical outcomes of patients with gastroschisis or omphalocoele in order to provide information for clinicians to assist in parental counselling. MATERIALS AND METHODS: We followed a case-series of patients with anterior abdominal wall defects referred to our regional Maternal Fetal Medicine services from 2011 to 2016. Outcomes of interest antenatally included details of diagnosis, associated anomalies and outcomes of pregnancy and postnatally included the nature of surgical repair, hospital stay and secondary complications until initial discharge. RESULTS: Eighty babies with gastroschisis were referred antenatally, and 72 were liveborn. Forty-nine babies with omphalocoele were referred antenatally, and 24 were liveborn. One further neonate with omphalocoele was postnatally diagnosed. Seventy-one neonates with gastroschisis progressed to operation, 30 developed complications post-surgery, and 68 survived until initial discharge. Twenty-two neonates with omphalocoele progressed to surgery, only two developed complications, and 21 survived until initial discharge. Eight of the surviving neonates with omphalocoele had associated structural abnormalities. The median hospital stay was 27 and eight days for gastroschisis and omphalocoele, respectively. CONCLUSION: Neonates with gastroschisis can have complex postnatal periods. Omphalocoele is associated with high antenatal mortality, especially in the presence of associated abnormalities; however, surviving neonates may have uneventful postnatal periods.

Opportunistically discovering usability requirements for a clinical handover system.

Clinical Handover in hospital is a process that can cause a major risk to patients, and be inefficient and time-consuming for staff. Software designed to support such processes needs to be used in a demanding and fast-moving environment. This work formulated Usability Design Requirements for such a handover software system. The requirements have been derived from a usability evaluation at Auckland City Hospital, where the handover was observed in two different environments during a handover improvement process. The requirements were produced using a multi-method, triangulated approach and they may be able to inform the design of systems to support clinical handover. The physical environment and the protocols adopted for handover were changed during this process, with software changes waiting for a larger project. Periods of change in work practice may be particularly favourable times to perform such studies, even if major software changes are not implemented. Staff engagement with the process may also be improved during times of change.