Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I.

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Australasian recurrent pregnancy loss clinical management guideline 2024, part II.

Part II of the Australasian guideline for the investigation and management of recurrent pregnancy loss (RPL) provides evidence-based guidance on the management of RPL provided. The implications of inherited and acquired thrombophilia with respect to RPL and suggestions for clinical management are provided. Autoimmune factors, including human leukocyte antigen, cytokines, antinuclear antibodies and coeliac antibodies, and guidance for management are discussed. Infective, inflammatory and endometrial causes of RPL are discussed in detail. Environmental and lifestyle factors, male factor and unexplained causes are outlined. Levels of evidence and grades of consensus are provided for all evidence-based statements.

Fertility preservation in gynaecology oncology patients: Experience from an Australian tertiary oncology centre.

BACKGROUND: Management for gynaecological cancers often includes removal of the reproductive organs and/or the use of gonadotoxic therapies resulting in sub-fertility. Oncofertility and discussion of fertility preservation in these patients is critical. AIM: To determine the rate of fertility preservation discussion among a cohort of patients with a gynaecological cancer and what determinants impact likelihood of a discussion. MATERIALS AND METHODS: A seven-year quantitative retrospective study was conducted at a single oncology centre, including 15-45 year old patients with a gynaecological cancer. The primary outcome was if a fertility preservation discussion occurred during a consultation. Secondary outcomes included if a referral was made and what fertility preservation services were undertaken. Determinants that impacted the likelihood of a fertility preservation discussion were analysed. RESULTS: One hundred and twenty-one patients were analysed. There were 84 (69%) patients who had a documented fertility preservation discussion, and 46% were referred to a fertility specialist for consultation. Age was a significant determinant, with patients aged 30-39 years of age more commonly having a fertility preservation discussion. Patients with a high-grade cancer compared to patients with a lower-grade cancer (grade one or two) were only a third as likely to have a discussion surrounding their fertility (odds ratio: 0.33, 95% CI: 0.13-0.86; P = 0.02). CONCLUSION: We conclude that rates of discussion around fertility options for patients with cancer are lower than the recommended guidelines. Oncofertility is an important discipline which we believe needs to be emphasised within the gynaecology oncology community and management of patients should include a multi-disciplinary team.

Surgical management of first-trimester bleeding in a heterotopic caesarean scar pregnancy: A case report and review of literature.

Heterotopic caesarean scar pregnancy (HCSP) is very rare, with only 24 cases reported in the literature. Optimal management is yet to be determined. We describe a 38-year-old woman, G2P1, who presented with vaginal bleeding and haemodynamic instability at 9 weeks of gestation in a HCSP. She was managed with ultrasound-guided lower-segment curettage and bilateral uterine artery ligation. The patient's pregnancy was complicated by preterm rupture of membranes and shortened cervix at 27 weeks of gestation. This necessitated preterm delivery, with subsequent neonatal death attributed to extreme prematurity. The patient later had a spontaneously conceived pregnancy, which was complicated by placenta percreta requiring elective caesarean hysterectomy at 34 weeks of gestation. This is, to our knowledge, the first case report describing preservation of the intrauterine pregnancy and future fertility in a patient with a HCSP and significant first-trimester bleeding. We suggest that ultrasound-guided lower-segment curettage may be a suitable management option for carefully selected patients with HCSP in a tertiary centre. All patients with HCSP require judicious counselling regarding the risk of morbidly adherent placenta and need for tertiary-level obstetric management in future pregnancies.

Fertility preservation in oncology patients: A literature review examining current fertility preservation techniques and access to oncofertility services in Australia.

BACKGROUND: In Australia, between the years 2010 and 2014, over 4500 adolescents and young adults (15-25 years old) were diagnosed with cancer. Treatment regimens are often gonadotoxic and are well known to induce ovarian and testicular failure. Oncofertility is an emerging discipline in obstetrics and gynaecology which seeks to preserve and restore the reproductive future of cancer patients. AIM: To perform a systematic literature review to assess the current fertility preservation techniques available to patients and examine access and uptake of fertility preservation in Australia. MATERIALS AND METHODS: Electronic databases, including Medline, Cochrane Review, SCOPUS and CINHAL, were searched for peer-reviewed publications and national guidelines examining oncofertility practices from 2008 to July 2018. Three hundred and seventy-five articles were initially screened, with 158 articles for full text review and an additional five clinical guidelines were identified. RESULTS: There is a paucity of Australian data on oncofertility with <50% of data included for analysis reflecting the Australian experience. The majority of primary research included retrospective papers with small cohort numbers. Key areas addressed included live birth outcomes, uptake of services and patient and physician perspectives on fertility preservation. Few articles sought to examine the positive and negative side effects of fertility preservation in oncology, social challenges of oncofertility and access to services worldwide. CONCLUSION: Oncofertility is an emerging discipline which seeks to provide safe, efficient and effective fertility preservation options for young adults and adolescents diagnosed with cancer. A multi-disciplinary approach with collaborative communication with oncologists is key to providing this service within Australia.

Success rates and outcomes of laparoscopic mesh sacrohysteropexy.

BACKGROUND: Uterovaginal prolapse is a prevalent gynaecological issue, which can have a negative impact on the quality of life of women. Hysterectomy and vaginal repair are conventional treatments to address apical prolapse; however, women are increasingly requesting uterine-preserving alternatives. AIMS: This study aimed to evaluate the impact of laparoscopic mesh sacrohysteropexy on symptomatic prolapse from an Australian experience. MATERIALS AND METHODS: This retrospective cohort study presents outcomes of 157 patients who underwent laparoscopic mesh sacrohysteropexy at a private practice in South Australia during 2007-2017. Primary outcome is the success rate according to the pelvic organ prolapse quantification (POP-Q) system. Secondary measures included complication rates and patients identified as having Stages III-IV prolapse and their outcomes. RESULTS: The median age was 58 years (27-86 years), median parity was 2 (0-6), and median body mass index was 26.8 (23-29.9). One hundred and thirty-four women had a laparoscopic hysteropexy and concurrent vaginal prolapse repair and four women had an isolated laparoscopic hysteropexy. The mean pre-operative point C was 0.60. The mean change from pre-operative point C to post-operative point C was 7.6 cm (P < 0.01). Of the 136 patients (98.6%) seen at post-operative 4-6 weeks, all had Stage 0 POP-Q scores. Prolapse recurrence was observed in 22 patients, while 116 patients remained cured at their last follow-up. Prolapse recurrence was associated with anterior vaginal mesh, previous prolapse surgery, pre-operative Stage III-IV disease and number of vaginal deliveries. CONCLUSIONS: Laparoscopic mesh sacrohysteropexy is an effective and safe procedure with a high success rate comparable to available international data.

Persistent omental trophoblastic implantation following salpingostomy, salpingectomy and methotrexate for ectopic pregnancy: A case report.

2% of all pregnancies are ectopic. Optimal surgical management is currently salpingectomy over salpingostomy, secondary to the risks of persistent trophoblastic tissue or omental implants (15%). However, rare cases of omental trophoblastic implants following laparoscopic salpingectomy have been noted in the literature. Current practice dictates that serial determinations of human chorionic gonadotropin (beta-hCG) levels after salpingectomy are not required, as it is considered a definitive treatment. However, given that these cases are hard to interpret through ultrasound and are almost always detected via sudden-onset abdominal pain and acute haemoperitoneum (33%), an argument can be made for post-operative beta-hCG assessment.

Obstetric and perinatal outcomes for twin pregnancies in adolescent girls.

This was a nine-year retrospective cohort study to investigate obstetric and perinatal outcomes in a cohort of adolescent girls with twin pregnancies from a major Australian tertiary centre in Brisbane, Australia. The adolescent cohort was aged <19 years and the control group was aged 20-24 years. The total study cohort comprised of 183 women. Of these, the adolescent cohort contained 29 girls (15.8%) and the control group comprised of 154 women (84.2%). Adolescent girls were less likely to delivery via an elective caesarean section compared to women in the control group (10.3% vs. 25.7%, p < 0.001). There were no differences in duration of labour, post-partum haemorrhage or perineal trauma rates. After controlling for the confounding effects of parity, chronicity and birth weight, birth <28 weeks remained significant (aOR 11.20, 95% CI 2.97-42.18, p < 0.001) for the adolescent cohort. There was a higher proportion of adolescents whose babies had an adverse composite perinatal outcome (87.9% vs. 69.5%, OR 3.20 95% CI: 1.40-7.31, p = 0.01) however significance was lost after adjusting for parity, chorionicity, birthweight and gestation at birth (aOR 3.27 95% CI: 0.95-11.31, p = 0.06). Our results show that obstetric and perinatal outcomes for twin pregnancies in teenagers were broadly similar compared to controls although the risk of extreme preterm birth was increased after controlling for confounders.

Demographic characteristics and pregnancy outcomes in adolescents - Experience from an Australian perinatal centre.

BACKGROUND: Adolescent pregnancy is defined as pregnancy in girls aged 10-19 years and can be associated with increased risks. AIM: To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre. MATERIALS AND METHODS: This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital (MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19 years and the control group was aged 20-24 years. RESULTS: Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage. CONCLUSIONS: Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes.

Synchronous colorectal liver metastases in pregnancy and post-partum.

BACKGROUND: Metastatic colorectal cancer (mCRC) in pregnancy and post-partum is rare, but represents significant diagnostic and therapeutic challenges for clinicians. A multidisciplinary team (MDT) approach is essential. This study reports the first series in the Australasian literature, describing our experience with and management of pregnant and post-partum patients diagnosed with synchronous colorectal liver metastases (sCRLM). METHOD: A retrospective review of prospectively collected data for patients with sCRLM diagnosed during pregnancy or post-partum, presenting to a tertiary referral hospital between 2009 and 2014, was performed. Data regarding patient presentation, imaging, management, histopathology and survival were analysed. Patient characteristics and outcomes were reviewed, including age, presenting complaint and median survival. RESULTS: Five patients were identified with sCRLM: three patients were diagnosed antepartum and two post-partum. Median age was 31 years (range 26-34). All patients were diagnosed with colorectal primary and synchronous liver lesions. All patients received folinic acid, fluorouracil, oxaliplatin chemotherapy, two intrapartum. One patient had both the primary lesion and liver metastases excised early post-partum. Second-line chemotherapy with folinic acid, fluorouracil, irinotecan and other biological agents was used in some cases post-partum. One patient suffered a fetal loss, while the other four had uncomplicated live births. Median survival was 7.6 months, with two patients dying shortly after delivery. CONCLUSION: The diagnosis of mCRC in pregnancy is challenging and survival is poor. A MDT approach to management is essential. Chemotherapy remains the mainstay of treatment from the second trimester. Rapid confirmation of diagnosis and early chemotherapy, followed by post-partum colorectal and liver resection may improve survival.

Retrospective Analysis of Motor Development in Infants at High and Low Risk for Autism Spectrum Disorder.

OBJECTIVE: To measure upper-extremity and gross motor skill development in infants with and without risk factors for autism spectrum disorder (ASD). METHOD: Data were coded retrospectively from 39 infants who participated in longitudinal structured early developmental assessments. Twenty-five infants were at high risk for ASD, and the remaining 14 infants were classified as low risk. Upper-extremity and motor skill development were coded at ages 2, 4, and 6 mo. Five infants went on to receive an ASD diagnosis at age 2-4 yr. RESULTS: Infants at high risk for ASD demonstrated fewer midline behaviors with the upper extremities and delayed motor skill development than the low-risk group. Differences in motor skills were most apparent at age 4 mo. CONCLUSION: Early monitoring for motor delay in infants at high risk for ASD is warranted. Midline control and play with the upper extremities and overall motor skill development are possible assessment and therapeutic targets.

Feeding and eating behaviors in children with autism and typically developing children.

Mothers of children aged 2-12 years completed an exhaustive questionnaire assessing feeding and eating behaviors for both themselves and their children with autism, and typically developing siblings of children with Autism Spectrum Disorder (where available), or typically developing children with no sibling with a disability. Results indicate that children with autism were only marginally more likely to exhibit picky eating behavior (overall style) than their siblings or matched typically developing children. Rates of ritualistic feeding behaviors were equivalent in all groups of children although children with autism were more likely to be currently exhibiting problematic eating and feeding behaviors. The implications of these results for the treatment of feeding difficulties exhibited by children with autism will be discussed.