A retrospective cohort study of the impact of In Time obstetric simulation training on management of vaginal breech deliveries.

BACKGROUND: Following the Term Breech Trial, vaginal breech deliveries are rarely undertaken in Australia. Some women choose to have a breech delivery following counselling, while others will present in labour with an undiagnosed breech. Clinicians need to be skilled in vaginal breech delivery despite this being a rare clinical situation. Simulation training provides a means by which uncommon clinical situations can be practised. AIM: This study aims to determine if the introduction of a simulation-based training course is associated with an improvement in the management of vaginal breech delivery and neonatal outcomes. METHODS: Cases of term vaginal breech delivery five years prior to introduction of In Time training (2001-2005) and five years after In Time training (2007-2011) were identified in a tertiary obstetric hospital (King Edward Memorial Hospital, Perth). There were 136 women identified in the pre-training (2001-2005, n = 56) and post-training (2007-2011, n = 80) groups. Case note review was undertaken to gather information. RESULTS: Apgar scores of <7 at five minutes were higher in the post-training cohort (8.8% vs 0%, P = 0.041). Arterial and venous pH readings were similar between cohorts, with a non-significant trend toward improvement in the post-training cohort. Special care nursery admissions and length of hospital stay were unchanged. The primary accoucheur was more likely to be a consultant (35.0% vs 16.4%) in the post-training cohort. Appropriate manoeuvres were more likely to be used in the post-training cohort (52.5% vs 44.6%). CONCLUSIONS: Obstetric In Time simulation training improved seniority of accoucheur and documented appropriate manoeuvres in the management of term vaginal breech delivery.

The prone position in healthy pregnant women and in women with preeclampsia - a pilot study.

BACKGROUND: The prone position is rarely used in medical settings in pregnancy. There is no published information about the prone position in women with preeclampsia. This study examined the feasibility and acceptability of the prone position in pregnant women, and the short-term effect of the prone position on blood pressure (BP) in term healthy pregnant women and in women with preeclampsia. METHODS: After ethics approval, written consent and trial registration (ACTRN:12615000160538 registered 18/02/2015, date of first participant enrolled 03/03/2015), 50 healthy term pregnant women and 15 women with preeclampsia had BP, heart rate (HR), oxygen saturation (SpO2), respiratory rate (RR), fetal heart rate (FHR) and comfort levels measured in two positions: left lateral, and prone. Measurements were after five minutes rest in each position. RESULTS: Mean ± SD age, gestation and body mass index for healthy pregnant women was 33 ± 4.1 years, 38 ± 1.0 weeks and 27 ± 3.2 kg.m- 2 and for women with preeclampsia was 32 ± 4.7 years, 36 ± 3.4 weeks, 31 ± 5.6 kg.m- 2 respectively. No clinically significant changes occurred in healthy pregnant women in the prone position. Systolic BP was reduced in the prone position in women with preeclampsia (P = 0.019, mean difference - 6.6 mmHg, 95% confidence interval - 11.9 to - 1.3 mmHg). 33% of women with preeclampsia experienced a 10 mmHg or greater reduction in systolic BP in the prone position. 42% of healthy pregnant women and 47% of women with preeclampsia preferred the prone position to lateral. CONCLUSIONS: This is the first study to examine the prone position in women with preeclampsia. For short periods of time the prone position is feasible and comfortable in pregnant women including those at term. The prone position may reduce systolic BP in women with preeclampsia without obvious adverse effects. Larger studies with women lying for longer periods in the prone position are required. Pregnancy should not be a contraindication to the prone position for short periods of time. TRIAL REGISTRATION: ACTRN:12615000160538.

Invasive cervical adenocarcinoma arising from extension of recurrent vulval Paget's disease.

An 83-year-old woman with a long-standing history of both invasive and vulval extramammary Paget's disease (EMPD) was referred to a tertiary gynaecological oncology service for suspicion of contiguous extension to the vagina and cervix. Vaginal biopsies confirmed EMPD; however, a loop excision of the cervix demonstrated invasive adenocarcinoma arising from Paget's disease. The patient subsequently underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy and radical upper vaginectomy, confirming FIGO stage 1B1 cervical adenocarcinoma. She was recommended but declined to have adjuvant pelvic external beam radiotherapy. To our knowledge this is the second case of invasive cervical adenocarcinoma arising from vulval Paget's disease in the literature.

Primary mixed large cell neuroendocrine and high grade serous carcinoma of the endometrium.

Endometrial large-cell neuroendocrine carcinoma admixed with a high-grade serous (HGS) adenocarcinoma is extremely rare with only one reported case in the literature. We present the second reported case in a 47-year-old woman who presented with abdominal pain, distension and loss of weight. On examination she had a fixed pelvic mass and vascular left vaginal mass. Imaging confirmed a 13 cm solid cystic rectouterine pelvic mass, omental disease and retroperitoneal lymphadenopathy. She underwent a modified posterior exenteration, partial posterior vaginectomy, omentectomy and Hartmanns procedure with suboptimal debulking. Histopathology revealed a stage 4B mixed carcinoma with large cell neuroendocrine (70%) and HGS carcinoma (30%). Eight cycles of adjuvant cisplatin and paclitaxel were given with a complete radiological and biochemical response after 7 months. Unfortunately, she developed widespread recurrence at 9 month and was offered second line chemotherapy.

Can the blood gas analyser results be believed? A prospective multicentre study comparing haemoglobin, sodium and potassium measurements by blood gas analysers and laboratory auto-analysers.

Blood gas analysers are point-of-care testing devices used in the management of critically ill patients. Controversy remains over the agreement between the results obtained from blood gas analysers and laboratory auto-analysers for haematological and biochemistry parameters. We conducted a prospective analytical observational study in five intensive care units in Western Australia, in patients who had a full blood count (FBC), urea, electrolytes and creatinine (UEC), and a blood gas performed within 1 h of each other during the first 24 h of their intensive care unit admission. The main outcome measure was to determine the agreement in haemoglobin, sodium, and potassium results between laboratory haematology and biochemistry auto-analysers and blood gas analysers. A total of 219 paired tests were available for haemoglobin and sodium, and 215 for potassium. There was no statistically significant difference between the results of the blood gas and laboratory auto-analysers for haemoglobin (mean difference -0.35 g/L, 95% confidence interval (CI) -1.20 to 0.51, P = 0.425). Although the mean differences between the two methods were statistically significant for sodium (mean difference 1.49 mmol/L, 95% CI 1.23-1.76, P < 0.0001) and potassium (mean difference 0.19 mmol/L, 95% CI 0.15-0.24, P < 0.0001), the mean biases on the Bland-Altman plots were small and independent of the magnitude of the measurements. The two methods of measurement for haemoglobin, sodium and potassium agreed with each other under most clinical situations when their values were within or close to normal range suggesting that routine concurrent blood gas and formal laboratory testing for haemoglobin, sodium and potassium concentrations in the intensive care unit is unwarranted.

Uterocutaneous fistula as the primary presentation of a gynaecological malignancy.

We report a case of high-grade gynaecological carcinoma presenting as a uterocutaneous fistula. A 59-year-old woman presented with a discharging abdominal wall wound. Imaging confirmed a large solid pelvic mass forming a sinus tract with the anterior abdominal wall. The tract tunnelled through a previous caesarean section scar. Biopsy indicated a high-grade gynaecological carcinoma, with features suggestive of endometrioid adenocarcinoma. The patient underwent two cycles of chemotherapy. Despite this, the mass increased in size and was complicated by abdominal wall wound breakdown. Chemotherapy was ceased. Surgical and palliative options are under consideration.

Is FCH PET able to identify foci of infection superiorly to FDG PET?

We report a case of a brain abscess identified on fluorine-18 choline (FCH) positron emission tomography (PET) scan, which was not identified on fluorodeoxyglucose (FDG) PET scan. To our knowledge, there are no previous case reports of incidental brain abscess identified by FCH PET imaging. A 51-year-old man, with liver cirrhosis complicated by hepatocellular carcinoma (HCC) was enrolled in a research trial comparing HCC detection in FCH PET versus FDG PET. During the course of the trial, he underwent radiofrequency ablation (RFA) for HCC. A repeat FCH PET scan post-RFA incidentally revealed a 2.5 cm lesion with avid uptake in the left occipital area of the brain. The patient was asymptomatic. MRI suggested this was an abscess. A craniotomy and drainage was performed, with culture of Streptococcus intermedius (Smilleri group) from the thick-walled collection, a causative organism for previous episode of pneumonia. He successfully completed a 6 week course of antibiotics.