A review of placenta accreta spectrum and its outcomes for perinatal mental health.

OBJECTIVES: Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality of life and psychological wellbeing. Although the obstetric outcomes are well-known, further review is warranted to explore the psychological sequelae that may accompany these conditions. CONCLUSIONS: The occurrence of placenta accreta spectrum during pregnancy is a major life stressor that can contribute to the development of psychiatric co-morbidity including posttraumatic stress disorder, depression and anxiety disorders. Early recognition of psychological distress and symptomatic profile is recommended at all stages of perinatal care complicated by this rare spectrum of conditions.

Validating the Team Emergency Assessment Measure (TEAM) in obstetric and gynaecologic resuscitation teams.

BACKGROUND: Simulation-based training is an effective method of enhancing the knowledge, skill, and technical abilities of individuals and teams encountering obstetric and gynaecologic emergencies. Simulation may also enhance the non-technical performance of teams resulting in improved patient outcomes. Although simulation-based training is widely recognised as an effective educational approach, issues around feasibility - the lack of simulation experts and malleable outcome measures of team performance - remain critical barriers to their implementation. AIM: To evaluate the psychometric properties of the Team Emergency Assessment Measure (TEAM) when used by medical professionals in simulated obstetric and gynaecological emergencies. METHODS: There were 151 participants (63% female; 60% consultants; 69% no previous simulation-based training) who observed three live high-fidelity obstetric and gynaecological resuscitation simulations and completed the TEAM. RESULTS: Confirmatory factor analysis evaluated the construct validity of the TEAM, yielding a second-order structure identified by 'leadership', 'teamwork', and 'team management'. Convergent validity was supported by the average item-to-scale total correlation which was 0.75, P < 0.001 and the average analysis of variance extracted (AVE) 0.88. The individual factors also yielded high factor-to-scale total correlations (mean [M] = 0.87), and AVE (M = 0.89). The internal reliability was high for the whole scale (average alpha = 0.92) and across the sub-factors (average alpha = 0.80). The inter-rater reliability was excellent (inter-class correlation coefficient 1 = 0.98). Participants with differing levels of simulation training experience did not significantly differ. CONCLUSION: The TEAM is a viable instrument for the assessment of non-technical performance during simulated obstetric and gynaecologic emergencies, thus enhancing the feasibility of simulation-based training.

Spontaneous vaginal birth following induction with intravenous oxytocin: Three oxytocic regimes to minimise blood loss post birth.

BACKGROUND: No evidence was identified in relation to the downward titration/cessation of intravenous oxytocin post spontaneous vaginal birth, in the absence of postpartum haemorrhage (PPH); suggesting clinicians' management is based on personal preference in the absence of evidence. AIM: To determine the proportion of induced women with a spontaneous vaginal birth and PPH, when intravenous oxytocin was utilised intrapartum and ceased 15, 30 or 60minutes post birth. METHODS: This three armed pilot randomised controlled trial, was undertaken on the Birth Suite of an Australian tertiary obstetric hospital. Incidence of PPH was assessed using univariable and adjusted logistic regression, which compared the effect of titrating intravenous oxytocin post birth on the likelihood of PPH, relative to the 15minute titration group. FINDINGS: Postpartum haemorrhage occurred in 26% (30 of 115), 20% (23 of 116), and 22% (30 of 134) of women randomised to a 15, 30 and 60minute titration time post birth, with no statistically significant differences between groups. CONCLUSION: There was no difference in the incidence of PPH between the three groups. Therefore, we question the benefit of delaying cessation of intravenous oxytocin for 60minutes post birth. Further investigation in this cohort is recommended, to compare the incidence of PPH when intravenous oxytocin is ceased either immediately, or 30minutes post birth. This research is warranted, as an evidence-based framework is lacking, to guide midwives globally in relation to their management of intravenous oxytocin post an induced spontaneous vaginal birth, in the absence of PPH.

Experience of Bakri balloon tamponade at a single tertiary centre: a retrospective case series.

Intrauterine balloon tamponade (IUBT) is an established fertility-sparing and life-saving treatment for postpartum haemorrhage. However, high-level evidence is lacking for specific aspects of its use. Our aim was to evaluate a large case series of IUBT to inform evidence-based clinical practice. 296 cases of IUBT over a three-year period at a tertiary obstetric referral centre were identified and reviewed. Demographic, clinical, and procedural outcome measures were collected; including rates of success and failure of IUBT, duration of tamponade, and complications. IUBT was successful in 265 (90%) of women and failed in 18 (6%). All failures occurred within six hours of balloon insertion. Once deemed stable and successful at six hours, no women required return to theatre or further intervention. The mean duration of intrauterine balloon tamponade was 18.5 hours. A large variance in clinical practice exists including duration of intrauterine balloon tamponade, and method and timing of removal. A number of changes informed by the results will be introduced and prospectively audited to improve IUBT use.Impact statementWhat is already known on this subject? Intrauterine balloon tamponade (IUBT) is an important second-line treatment option in severe postpartum haemorrhage (PPH). IUBT is easy to use, is effective especially in the setting of uterine atony, and is associated with minimal complications.What the results of this study add? This study confirms the high rate of success for IUBT in controlling PPH. We found that after six hours, if deemed successful, it is rare that further intervention is required. In addition, tamponade beyond 12 hours, gradual or incremental deflation of the balloon, and antibiotic cover beyond the duration of tamponade are unlikely to yield any further safety benefit.What the implications are of these findings for clinical practice and/or further research? Our findings suggest that women should not be required to fast for balloon removal; removal of the balloon should occur by 12 hours if deemed stable and adequately resuscitated; deflation and removal of the balloon can occur at once; and antibiotics should be ceased after balloon removal. These will allow women to mobilise and recover sooner, and improve flow and throughput in our high-acuity care areas.

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.

Impact of elective caesarean section on neonatal retrieval in Western Australia during a 12-year period.

OBJECTIVE: To determine whether 2006 Australian national guidance to delay elective caesarean section until 39 weeks' gestation would reduce the need for neonatal retrieval for respiratory compromise following elective caesarean. STUDY DESIGN: This is a retrospective cohort study comparing infants born by elective caesarean section who required retrieval for respiratory distress in Western Australia before and after the national guidance (2003-2006 vs. 2008-2014). RESULTS: The proportion of infants born by elective caesarean section who required retrieval for respiratory distress was reduced in the later cohort (0.77% (153/19 780) vs. 0.55% (227/40 875); p = 0.0012). The diagnosis of surfactant-deficient lung disease amongst retrieved infants was also reduced (26% (40/153) vs. 17.4% (40/227); p = 0.04). CONCLUSION: A reduction in the proportion of elective caesarean sections before 39 weeks in Western Australia was associated with a reduction in retrieval for respiratory compromise related to surfactant deficiency in infants born by elective caesarean section.

Emergency peripartum hysterectomy in a Western Australian population: Ten-year retrospective case-note analysis.

BACKGROUND: Emergency peripartum hysterectomy (EPH) is a life-saving obstetric procedure reserved for conditions where medical treatment and conservative surgery have failed. EPH is associated with significant morbidity and mortality. AIM: To examine the incidence, indications, risk factors, maternal and neonatal outcomes of EPH in a tertiary hospital in Western Australia (WA). METHODOLOGY: A retrospective case-note analysis of all cases of EPH performed at King Edward Memorial Hospital in WA between the years 2006 and 2016. The incidence, indications, risk factors, maternal and neonatal outcomes were reviewed. All cases were ascertained via our hospital obstetric database. RESULTS: A total of 72 cases of EPH were identified among 64 999 births. The incidence of EPH in WA was 1.1 per 1000 deliveries. Abnormal placentation was the main indication for EPH accounting for 66.7% of cases. Among women undergoing an EPH, 22.2% had a history of one previous caesarean section and 33.3% had two or more caesarean sections, respectively. Maternal morbidity was significant. There was one cardiac arrest secondary to hypovolaemia, and 84% of the women received blood transfusions with more than half of these women meeting the criteria for massive transfusion protocol (≥4 units of packed red cells). Urinary tract injury and venous thromboembolism were some of the other complications among our cohort of women. CONCLUSION: EPH is associated with significant morbidity. Our study identifies abnormal placentation as the leading cause of EPH.

Time to delivery: Transfers for threatened preterm labour and prelabour rupture of membranes in Western Australia.

OBJECTIVE: To describe the outcomes of patients transferred to King Edward Memorial Hospital (KEMH) with signs of labour at preterm gestations. DESIGN: A retrospective observational study of the 69 cases transferred to KEMH during 2015. SETTING: Patient transfers from all locations across Western Australia (WA) to the sole tertiary perinatal centre in Perth. PARTICIPANTS: Pregnant women within WA with threatened or actual preterm labour (PTL) or preterm prelabour rupture of membranes (PPROM) between 23 and 32 weeks gestation. MAIN OUTCOME MEASURES: The occurrence of delivery during the admission and time-to-delivery as well as length of admission and association between clinical factors and time-to-delivery. RESULTS: The percentage of the study population delivered during the admission following transfer was 72.5%. Eighty-six per cent of those who delivered did so within 72 hours of transfer. The median time from transfer to delivery was 1 day. Sixty-three per cent of those who did not deliver during the admission progressed to 36 weeks gestation. Patients transferred with PPROM were less likely to deliver during the admission compared to those with uterine activity (50% versus 19.6%, P = 0.007) and nulliparas were more likely to deliver (93.5% versus 55.3%, P < 0.001). CONCLUSION: The majority of women transferred with signs of PTL progress to delivery during the same admission with the highest risk of delivery being the first 72 hours following transfer. If the pregnancy is ongoing at 72 hours, there is a reasonable chance of progression to late preterm gestation supporting the return of woman to their place of origin for antenatal care following discharge.

An unexpected presentation of haemoperitoneum in a pregnant woman.

In the majority of tertiary centres the Emergency Room or Assessment Unit is the gateway to the rest of the hospital. It is the location where critical decisions are formulated depending on whether a patient's condition is serious enough to warrant admission and, at times, emergency surgery. On occasion this decision can be straightforward based solely on the patient's presentation, observations, and basic investigations. This case highlights that although the decision and initial management may be apparent, often the diagnosis can be unexpected and that the diagnostic challenge is often outside the scope of a brief Emergency Room assessment. Corpus luteal cyst rupture is a common phenomenon but often not the cause of significant morbidity as it was in this case, especially in the absence of any associated risk factors.

Diagnosis and treatment of ectopic pregnancy.

The most common site of localisation of an ectopic pregnancy is the fallopian tube. Rarely an ectopic pregnancy can be found in the ovary, a caesarean section scar, the abdomen or the cervix. Risk factors are previous ectopic pregnancy, PID, endometriosis, previous pelvic surgery, the presence of a coil and infertility. However, a third of women with an ectopic pregnancy have no known risk factors. NICE recommends a low threshold for offering a pregnancy test to women of childbearing age when they attend the surgery. Symptoms and signs appear when the tube starts to tear. When the tube ruptures, the woman will quickly become unwell and haemodynamically unstable because of rapid intra-abdominal blood loss. The most common symptoms of ectopic pregnancy are pelvic or abdominal pain, amenorrhoea, missed period or abnormal period and vaginal bleeding. A positive diagnosis of a urinary tract infection or gastroenteritis does not exclude an ectopic pregnancy. Signs of suspected ectopic pregnancy include pelvic, abdominal, adnexal or cervical motion tenderness, rebound tenderness and abdominal distension. Women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, should be referred directly to A&E, irrespective of the result of the pregnancy test. Stable patients with bleeding who have pain or a pregnancy of six weeks gestation or more or a pregnancy of uncertain gestation should be referred immediately to an early pregnancy assessment (EPA) service, or out-of-hours gynaecology service if the EPA service is not available. Diagnosis is confirmed by transvaginal ultrasound scan to identify the location of the pregnancy.