Spiders and mushrooms: Reporting bowel endometriosis shape on preoperative MRI to flag surgical complexity.

INTRODUCTION: Preoperative imaging of patients with endometriosis allows adequate counselling, referral to appropriate centres of expertise and workforce planning. The objective of this study was to assess the feasibility of simplified three-category preoperative endometriosis MRI morphological descriptors to predict subsequent surgical management. METHODS: A single-centre observational study in 76 patients (median age 38 years, range 18-55) with preoperative endometriosis mapping MRI between 1 Jan 2015 and 31 Dec 2019. MRI studies were prospectively re-read blind-to-surgical outcome to categorise rectosigmoid morphology as normal, spider-shaped (linear T2-dark fibrotic bands) superficial endometriosis or typical crescentic or mushroom-shaped deep infiltrating endometriosis (DIE). Bowel motility was similarly categorised as normal, tethered or distorted/fixed. The reference standard was subsequent surgery within 3 years of MRI, categorised as no bowel surgery, adhesiolysis only or more complex surgeries. RESULTS: Despite three-quarters of surgical cases having normal bowel morphology on preoperative MRI (72%, 55/76; 12% linear superficial endometriosis, 10% crescentic and 5% mushroom-shaped DIE) more than half showed bowel tethering (54%, 41/76) or distortion/fixation (10%, 8/76) and most patients underwent adhesiolysis (79%, 60/76). Complex surgery such as bowel resection, laparotomy conversion or complex adhesiolysis is predicted by morphology (crescentic or mushroom-shaped DIE, P < 0.001) and motility (tethered or distorted bowel, P = 0.002) descriptors. CONCLUSIONS: Comprehensive and clinically relevant diagnostic reporting does not have to be convoluted to have clinical impact: in our study population, categorising bowel morphology as normal, spider-shaped (superficial) or crescentic/mushroom-(DIE) shaped and motility as normal, tethered (superficial) or distorted/fixed (deep endometriosis) correlates to subsequent surgical complexity.

Pretreatment With Mifepristone Compared With Misoprostol Alone for Delivery After Fetal Death Between 14 and 28 Weeks of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of pretreatment with mifepristone before misoprostol, compared with misoprostol alone, for termination of pregnancy after a fetal death in the second trimester. METHODS: This prospective, double blind, placebo-controlled trial randomized women requiring a termination of pregnancy after fetal death between 14 and 28 weeks of gestation to placebo or 200 mg mifepristone orally 24-48 hours before the termination of pregnancy with misoprostol (400 micrograms every 6 hours vaginally for women at 24 weeks of gestation or less, and 200 micrograms every 4 hours vaginally for women at 24 weeks of gestation or more). Based on a median labor with misoprostol alone in the second trimester of 13 hours, a sample size of 116 women per group was planned to compare the primary outcome of time from administration of misoprostol to delivery. The trial was ceased after 66 women were enrolled secondary to prolonged time to achieve recruitment. RESULTS: From April 2013 to November 2016, 66 women were randomized (34 to placebo and 32 to mifepristone). There were no differences in the characteristics between the two groups. The median time for the primary outcome of administration of misoprostol to delivery in the placebo group was 10.5 hours, compared with 6.8 hours in the treatment group (hazard ratio 2.41 95% CI 1.39-4.17, P=.002). Women in the placebo group required more doses of misoprostol (3.4 vs 2.1, P=.002) and more misoprostol overall (1,181.8 micrograms, vs 767.7 micrograms, P=.003). There was no difference in maternal complications between the two groups. Women in the mifepristone group reported improved perception of the procedure. CONCLUSION: The sequential use of mifepristone and misoprostol for the termination of pregnancy after fetal deaths between 14 and 28 weeks of gestation reduces the time to delivery, compared with the use of misoprostol alone, with no worsening of maternal complications. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12612000884808.

Surgery in pregnancy: Identifying factors contributing to variation and delay in diagnosis and management of appendicitis in pregnancy.

BACKGROUND: Suspected appendicitis is the most common indication for surgery for non-obstetric conditions during pregnancy. Delay in management increases the risk of appendiceal perforation and pregnancy loss. Stand-alone specialty obstetric hospitals often don't have surgical teams on site. It has been suspected that this may be a factor that leads to delayed diagnosis and management of non-obstetric surgical conditions in pregnancy. AIMS: To assess the differences in time to diagnosis, imaging, surgical management and outcomes between a stand-alone tertiary obstetric hospital and a tertiary general hospital for pregnant patients presenting with suspected appendicitis who underwent an appendicectomy. MATERIALS AND METHODS: A retrospective study of all women who underwent appendicectomy in pregnancy for suspected appendicitis over a four-year period. RESULTS: Women who attended the specialist hospital were later in gestation (medians 29 weeks vs 18 weeks, P = 0.004) and less likely to have imaging (84% vs 56%, P = 0.047) with no difference in the rates of confirmation of diagnosis of appendicitis using imaging. Women who presented to the specialist hospital were more likely to be managed with a laparotomy, admitted to high dependency unit, have a longer hospital stay and tended to be later in gestation. There was no difference in rates of positive appendicectomies, appendiceal perforation or management in under the recommended 24 h. CONCLUSIONS: The specialty obstetric hospital has a much higher rate of laparotomy and longer length of stay. The majority of patients presenting to both hospitals did not undergo surgery within 24 h and delay in imaging was a major contributor.

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 effect of a multidisciplinary obstetric emergency team training program, the In Time course, on diagnosis to delivery interval following umbilical cord prolapse - A retrospective cohort study.

BACKGROUND: Cord prolapse is an uncommon obstetric emergency, with potentially fatal consequences for the baby if prompt action is not taken. Simulation training provides a means by which uncommon emergencies can be practised, with the aim of improving teamwork and clinical outcomes. AIMS: This study aimed to determine if the introduction of a simulation-based training course was associated with an improvement in the management of cord prolapse, in particular the diagnosis to delivery interval. We also aimed to investigate if an improvement in perinatal outcomes could be demonstrated. MATERIALS AND METHODS: A retrospective cohort study was performed. All cases of cord prolapse in the designated time period were identified and reviewed and a comparison of outcome measures pre- and post-training was undertaken. RESULTS: Thirty-one cases were identified in the pre-training period, and compared to 64 cases post-training. Documentation improved significantly post-training. There were non-significant improvements in use of spinal anaesthetic, and in the length of stay in the special care neonatal unit. There was a significant increase in the number of babies with Apgar scores less than seven at 5 min. There were no differences in the diagnosis to delivery interval, or in perinatal mortality rates. CONCLUSION: Obstetric emergency training was associated with improved teamwork, as evidenced by the improved documentation post-training in this study, but not with improved diagnosis to delivery interval. Long-term follow-up studies are required to ascertain whether training has an impact on longer-term paediatric outcomes, such as cerebral palsy rates.