An audit of pregnancy outcomes in solid organ transplant recipients at a metropolitan hospital.

BACKGROUND: Pregnancies in patients with solid organ transplants have higher rates of complications and caesarean sections (CS). AIM: To perform an audit of the pregnancy outcomes in transplant recipients, to determine the rate of CS in our cohort, the appropriate skin incision for CS in these patients and to formulate recommendations for preoperative planning. MATERIALS AND METHODS: This is a retrospective cohort study. All patients who had a solid organ transplant were identified from the obstetrics database. The operation records of the transplant recipients who delivered by CS were reviewed and the de-identified data were evaluated for pregnancy outcomes. RESULTS: This cohort consisted of 22 women: six had simultaneous pancreas and kidney (SPK) transplants and 16 had kidney transplants. Over a ten-year period, four women had two pregnancies and one had a twin pregnancy, thus 27 babies were born. The rate of CS was 58% (n = 15) and the surgical approach in 13 of these patients was by Pfannenstiel incision. One patient had an elective midline incision at the first CS, which was repeated in the next pregnancy. Two CS were complicated by bladder injury, both occurring in SPK recipients. CONCLUSION: Patients with solid organ transplants have a higher rate of CS and SPK patients may be at a higher risk of bladder injuries during CS. Our data suggest that Pfannenstiel skin incision is still suitable for these patients. We recommend reviewing the operative details of the transplant operation and a pelvic magnetic resonance imaging for pre-operative planning.

Intravenous iron vs blood for acute post-partum anaemia (IIBAPPA): a prospective randomised trial.

BACKGROUND: Acute post-partum anaemia can be associated with significant morbidity including a predisposition for postnatal depression. Lack of clear practice guidelines means a number of women are treated with multiple blood transfusions. Intravenous iron has the potential to limit the need for multiple blood transfusions but its role in the post-partum setting is unclear. METHODS/DESIGN: IIBAPPA is a multi-centre randomised non-inferiority trial. Women with a primary post-partum haemorrhage (PPH) >1000 mL and resultant haemoglobin (Hb) 5.5-8.0 g/dL after resuscitation with ongoing symptomatic anaemia who are otherwise stable (no active bleeding) are eligible to participate. Patients with sepsis or conditions necessitating rapid Hb restoration are excluded. Eligible participants are randomised to receive a blood transfusion or a single dose of intravenous iron polymaltose calculated using the Ganzoni formula. Primary outcome measures include Hb, Ferritin and C-Reactive Protein levels on Day 7. Secondary outcomes evaluate (i) Hb, Ferritin and CRP levels on Day 14, 28, (ii) anaemia symptoms on Day 0, 7, 14 and 28 using structured health related quality of life questionnaires, (iii) treatment safety by assessing adverse reactions and infection endpoints and (iv) the quantitative impact of anaemia on breast feeding quality using a hospital designed questionnaire. DISCUSSION: If equivalence in Hb and ferritin levels, symptom scores and safety endpoints is demonstrated, intravenous iron may become the preferred treatment for women with acute post-partum anaemia to minimise transfusion reactions and costs. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12615001370594 on 16th December, 2015 (prospective approval).

Who is and isn't having babies with Down syndrome in western Sydney: a ten year hospital cohort study.

BACKGROUND: Screening for Down syndrome (DS) is a key component of antenatal care, recommended to be universally offered to women irrespective of age or background. Despite this, the diagnosis of DS is often not made until the neonatal period. AIMS: To retrospectively describe and compare the differences in populations with an antenatal diagnosis (AD) and neonatal diagnosis (ND) of DS and to explore why an antenatal diagnosis was not made. MATERIALS AND METHODS: The cohorts were women cared for at Westmead Hospital whose pregnancy received a diagnosis of DS between 2006 and 2015. The demographic variables of the AD and ND cohorts were examined and reasons why an antenatal diagnosis was not made in the ND cohort were analysed. RESULTS: There were 127 diagnoses of DS in the 10-year period, of which 41% were in the ND cohort (n = 52) and 59% in the AD (n = 75). Declaring a religious affiliation rather than Nil Religion was significantly more common in the ND cohort (88.5%) and especially the ND sub-cohort who declined DS screening/testing (95.8%) than the AD cohort (72%, P < 0.05). Women who were not offered screening were significantly younger (P < 0.001) than those who were, with 69% and 20% being ≤30 years, respectively. CONCLUSIONS: The proportion of DS pregnancies diagnosed in the antenatal period in western Sydney could be increased by ensuring younger women are not falsely reassured that DS screening is unnecessary for them. While religious affiliation may be a factor when women decline screening, ensuring appropriate counselling remains important.

Community management of lactational mastitis and/or breast abscess: a retrospective audit.

Lactational mastitis has an incidence of around 10 per cent in postpartum women, with breast abscess complicating some of these.The key principles of treatment include: supportive counselling, warm or cold compresses, effective milk removal, oral antibiotic therapy and symptomatic treatment. Patients can be managed in the community setting; however many present to hospital. The aim of this research was to establish which areas of clinical practice can be improved to reduce hospital admission rates. Sequential cases of lactation mastitis or breast abscess admitted to hospital over two years were reviewed, and it was found that the majority of patients attending the emergency department for management self-presented. There were low rates of utilisation of available community resources. There was poor patient knowledge of the natural history and simple management strategies for the condition. Midwives can play a vital role in educating new mothers and providing advice and support for non-pharmacological therapies.

Sublingual misoprostol for management of empty sac or missed miscarriage: The first two years' experience at a metropolitan Australian hospital.

BACKGROUND: Misoprostol management of miscarriage is only now becoming widely used in Australia. AIMS: To review the efficacy, safety and the popularity of outpatient sublingual misoprostol in empty sac/missed miscarriage management over its first two years of availability in a metropolitan Australian hospital. MATERIALS AND METHODS: A retrospective cohort review was undertaken of women choosing sublingual misoprostol 600 µg (three tablets) × three doses for miscarriage management. Principal outcomes assessed were miscarriage resolution without the need for curettage and complications. Additionally, the relative popularity of misoprostol versus surgery by place of birth and over time, and the return of pregnancy tissue for histology were analysed. RESULTS: Between 1 December 2012 and 30 November 2014, 279 women chose sublingual misoprostol for nonurgent miscarriage management, while 420 chose surgery (40 and 60%, respectively). Of the misoprostol cohort, 269 had complete data; 239 of 269 (88.8%) had resolution without curettage, nine (3.3%) had acute curettage, 21 (7.8%) had nonacute curettage, 30 (11.15%) had unplanned emergency department presentation, 11 (4.1%) had unplanned admission, three (1.1%) had blood transfusion and one (0.4%) had an infection requiring admission. Misoprostol was as popular with Australian-born as overseas-born women; 53.5% of patients returned histopathology specimens; one (0.7%) demonstrated partial hydatidiform mole. CONCLUSIONS: Outpatient management of missed/empty gestational sac miscarriage using sublingual misoprostol is associated with a high rate of avoiding curettage and the low rate of complication. It is equally popular with Australian-born and overseas-born women. Just over 50% returned pregnancy tissue for analysis.