Transverse position. Using rotation to aid normal birth-OUTcomes following manual rotation (the TURN-OUT trial): a randomized controlled trial.

BACKGROUND: The fetal occiput transverse position in the second stage of labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation in the second stage of labor is considered a safe and easy to perform procedure that has been used to prevent operative deliveries. OBJECTIVE: This study aimed to determine the efficacy of prophylactic manual rotation in the management of the occiput transverse position for preventing operative delivery. We hypothesized that among women who are at ≥37 weeks' gestation with a baby in the occiput transverse position early in the second stage of labor, manual rotation compared with a "sham" rotation will reduce the rate of operative delivery. STUDY DESIGN: A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 3 tertiary hospitals was conducted in Australia. The primary outcome was operative (cesarean, forceps, or vacuum) delivery. Secondary outcomes were cesarean delivery, serious maternal morbidity and mortality, and serious perinatal morbidity and mortality. Outcomes were analyzed by intention to treat. Proportions were compared using χ2 tests adjusted for stratification variables using the Mantel-Haenszel method or Fisher exact test. Planned subgroup analyses by operator experience and technique of manual rotation (digital or whole hand rotation) were performed. The planned sample size was 416 participants (trial registration: ACTRN12613000005752). RESULTS: Here, 160 women with a term pregnancy and a baby in the occiput transverse position in the second stage of labor, confirmed by ultrasound, were randomly assigned to receive either a prophylactic manual rotation (n=80) or a sham procedure (n=80), which was less than our original intended sample size. Operative delivery occurred in 41 of 80 women (51%) assigned to prophylactic manual rotation and 40 of 80 women (50%) assigned to a sham rotation (common risk difference, -4.2% [favors sham rotation]; 95% confidence interval, -21 to 13; P=.63). Among more experienced proceduralists, operative delivery occurred in 24 of 47 women (51%) assigned to manual rotation and 29 of 46 women (63%) assigned to a sham rotation (common risk difference, 11%; 95% confidence interval, -11 to 33; P=.33). Cesarean delivery occurred in 6 of 80 women (7.5%) in the manual rotation group and 7 of 80 women (8.7%) in the sham group. Instrumental (forceps or vacuum) delivery occurred in 35 of 80 women (44%) in the manual rotation group and 33 of 80 women (41%) in the sham group. There was no significant difference in the combined maternal and perinatal outcomes. The trial was terminated early because of limited resources. CONCLUSION: Planned prophylactic manual rotation did not result in fewer operative deliveries. More research is needed in the use of manual rotation from the occiput transverse position for preventing operative deliveries.

Grade 3 endometrioid adenocarinoma of the lower uterine segment diagnosed 6 weeks after a term delivery: A case report and literature review.

BACKGROUND: Endometrial cancer is the most common gynaecological malignancy in Australian women. Less than 5% of cases occur in women under 40 years of age and it is rarely associated with pregnancy. Most cases associated with pregnancy are diagnosed after first trimester loss. Only 14 cases of endometrial cancer diagnosed post-partum are reported in the literature. These cases were diagnosed up to 15 months post-partum. The histopathological classification was low grade in 12 patients and high grade in two patients. CASE: We describe a 37 year old woman, who presented after her second vaginal delivery (at 37 weeks of gestation) with suspected retained products of conception (RPOC). She had a dilation and curettage leading to the diagnosis of endometrial cancer six weeks post-partum. She underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and bilateral sentinel node biopsy. Histopathology confirmed a stage 1B grade 3 endometrioid adenocarcinoma located in the lower uterine segment with widespread lymph-vascular invasion and no other evidence of malignancy. She is planned to complete six cycles of adjuvant carboplatin/ paclitaxel chemotherapy, followed by pelvic external beam radiotherapy. DISCUSSION: We report the second case of a high-grade endometrial cancer diagnosed post-partum. The bulk of this tumour was in the lower segment of the uterus, which together with the fundal placenta, likely permitted the pregnancy progressing to term. Endometrial cancer should be considered a rare cause of abnormal post-partum bleeding. Curettage and histopathology examination is recommended in cases that do not resolve with conservative measures to exclude this rare complication.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial.

BACKGROUND: Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries. OBJECTIVE: This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation. STUDY DESIGN: A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed. RESULTS: Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval, -1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval, -0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval, -3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes. CONCLUSION: Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

How do the M4 and M6 models perform in an Australian pregnancy of unknown location population?

BACKGROUND: The diagnosis of a pregnancy of unknown location (PUL) is made when there is an elevated serum ß human chorionic gonadotropin (ßhCG) and no pregnancy on transabdominal and transvaginal ultrasound. Most of these pregnancies end as intra-uterine pregnancies or unsuccessful pregnancies and can be safely managed expectantly. However, up to 20% of these women will have an ectopic pregnancy. Several mathematical models, including the M4 and M6 protocols, have been developed using biochemical markers to triage PUL presentations. This rationalises numbers of tests and visits made without compromising safety and allowing timely intervention. AIMS: We aimed to externally validate the M4 and M6 models in an Australian tertiary early pregnancy assessment service (EPAS). MATERIALS AND METHODS: We performed a retrospective single-centre cohort study across five years. Our study population included all women attending our EPAS with a PUL who had at least two serum ßhCG levels and one progesterone level measured. The M4 and M6 models were retrospectively applied. RESULTS: Of the 360 women in the study population, there were 26 confirmed ectopic pregnancies (7.2%) and six persisting PULs (2%). The M4 model had a sensitivity and specificity of 72%. The M6P model had a sensitivity of 91% and specificity of 63%. The M6P misclassified two ectopic pregnancies into the low-risk group, compared with seven in the M4 model. CONCLUSIONS: The M6P model has the highest sensitivity of the three models and a negative predictive value of 99%. These numbers are comparable to the original United Kingdom population. Further prospective validation is planned.

A Multicenter International Temporal and External Validation Study of the Ultrasound-based Endometriosis Staging System.

STUDY OBJECTIVE: The aim of this study was to validate temporally and externally the ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis. DESIGN: A multicenter, international, retrospective, diagnostic accuracy study was carried out between January 2016 and April 2018 on women with suspected pelvic endometriosis. SETTING: Four different centers with advanced ultrasound and laparoscopic services were recruited (1 for temporal validation and 3 for external validation). PATIENTS: Women with pelvic pain and suspected endometriosis. INTERVENTIONS: All women underwent a systematic transvaginal ultrasound and were staged according to the UBESS system, followed by classification of laparoscopic level of complexity according to the Royal College of Obstetricians and Gynaecologists (RCOG) levels 1 to 3. MEASUREMENTS AND MAIN RESULTS: UBESS I, II, and III were then correlated with RCOG levels 1, 2, and 3, respectively. A comparison between temporal and external sites (skipping "A") and between each site was performed in terms of the diagnostic accuracy of UBESS to predict RCOG laparoscopic skill level. A total of 317 consecutive women who underwent laparoscopy with suspected endometriosis were included. Complete transvaginal ultrasound and laparoscopic surgical outcomes were available for 293/317 (92.4%). At the temporal site, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of UBESS I to predict RCOG level 1 were 80.0%,73.8%, 94.9%, 97.2%, 60.2%, 14.5%, and 0.3%, respectively; of UBESS II to predict RCOG level 2 were 81.0%, 70.6%, 82.0%, 26.7%, 96.8%, 3.9%, and 0.3%, respectively; of UBESS III to predict RCOG level 3 were 91.0%, 85.7%, 92.4%, 75.0%, 96.1%, 11.3%, and 0.2%, respectively. At the external sites, the results of UBESS I to predict RCOG level 1 were 90.3%, 92.0%, 88.4%, 90.2%, 90.5%, 7.9%, and 0.1% respectively; UBESS II to predict RCOG level 2 were 89.2%, 100.0%, 88.5%, 37.5%, 100.0%, 8.7%, and 0.0%, respectively; and UBESS III to predict RCOG level 3 were 86.0%, 67.6%, 98.2%, 96.2%, 82.1%, 37.8%, and 0.3%, respectively. When patients requiring ureterolysis (i.e., RCOG level 3) in the absence of bowel endometriosis were excluded (n = 54), the sensitivity of UBESS III to correctly classify RCOG level 3 increased from 85.7% to 96.7% at the temporal site (n = 42) and from 67.6% to 96.0% at the external sites (n = 12) (p <.005). CONCLUSION: The results from this external validation study suggest that UBESS in its current form is not generalizable unless there is either or both bowel deep endometriosis and cul-de-sac obliteration present. The major limitation appears to be the misclassification of women who require surgical ureterolysis in the absence of bowel endometriosis.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve.

BACKGROUND: Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy. AIM: To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve. MATERIALS AND METHODS: Women aged 18-44 years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy. RESULTS: Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6 ± 4.6 years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00 pmol/L (range 5-67 pmol/L) vs 15.25 pmol/L (range 3-96 pmol/L), P = 0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40 pmol/L (range 3.9-37.8 pmol/L) vs 13.67 pmol/L (range 2.8-30.5 pmol/L), P = 0.185). CONCLUSION: Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Delivery in the second stage in theatre: Does consultant presence make a difference? A pilot study.

Complex operative obstetrics encompasses a range of clinical acumen, decision-making and surgical skill requiring training, supervision and practise. A period of mandated consultant presence in theatre in the second stage was prospectively audited at our institution to assess the impact of improved senior supervision on mode of delivery and maternal and neonatal morbidity.

Rupture of a caesarean scar ectopic pregnancy: A case report.

BACKGROUND: Caesarean scar pregnancy is an uncommon form of ectopic pregnancy characterized by implantation into the site of a caesarean scar. Common clinical features include vaginal bleeding and abdominal pain; however, a significant proportion of cases are asymptomatic. The primary diagnostic modality is transvaginal ultrasound. There is no current consensus on best-practice management. CASE PRESENTATION: A 36-year-old woman, G7P2, presented to an early-pregnancy service with vaginal spotting and an ultrasound scan demonstrating a live caesarean scar ectopic pregnancy at 8 + 5 weeks' gestation. On examination she was hemodynamically stable with a soft abdomen. She was advised to have dilation and curettage (D&C) under ultrasound guidance; however, she was concerned that she might require more extensive surgery, such as a hysterectomy and so requested non-surgical management. On day 1 she underwent ultrasound-guided embryocide with lignocaine followed by inpatient multi-dose systemic methotrexate. Her beta-human gonadotrophic hormone level decreased. Repeat ultrasound on day 18 demonstrated a persistent caesarean scar ectopic pregnancy with increased vascularity, and so uterine artery embolization (UAE) was performed with a view to D&C the following day. This plan was altered to expectant management with ongoing follow-up by a different clinician who had had previous success with UAE alone. On day 35 the patient presented with life-threatening vaginal bleeding that required an emergency total abdominal hysterectomy. CONCLUSIONS: Caesarean scar pregnancies are uncommon. Multiple treatment strategies have been employed, with variable degrees of success. Further research into risk stratification and management are needed to guide clinician and patient decision making.

Predicting Pouch of Douglas Obliteration Using Ultrasound and Laparoscopic Video Sets: An Interobserver and Diagnostic Accuracy Study.

OBJECTIVES: To investigate the diagnostic accuracy and interobserver agreement among sonologists when assessing offline ultrasound (US) video sets of the "sliding sign" and among gynecologic surgeons when assessing corresponding laparoscopic video sets to predict pouch of Douglas (POD) obliteration and to compare the performance of the groups. METHODS: A diagnostic and reproducibility study was conducted, including 15 observers in 4 groups: (1) senior sonologists, (2) junior sonologists, (3) general gynecologists, and (4) advanced laparoscopists. The sonologists viewed 25 offline preoperative US video sets of the sliding sign, and the surgeons viewed the corresponding intraoperative laparoscopic videos of the same patients. Each observer was asked to classify POD obliteration in the video sets and was compared to the reference standard POD state determined at real-time laparoscopy by a single investigator (G.C.). The interobserver correlation and diagnostic accuracy were evaluated among the 15 observers and 4 groups. The Cohen κ coefficient and Fleiss κ coefficient were used for the analysis. RESULTS: The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for senior sonologists were 93.3%, 100%, 89.6%, 84.4%, and 100%, respectively; for junior sonologists, 70.0%, 88.9%, 59.4%, 55.2%, and 90.5%; for general gynecologists, 75.2%, 88.1%, 78.1%, 69.8%, and 91.9%; and for advanced laparoscopists, 82.4%, 91.9%, 90.8%, 82.9%, and 95.8%. The overall agreement between senior sonologists was almost perfect (Fleiss κ = 0.876); for junior sonologists and general gynecologists, it was moderate (Fleiss κ = 0.589 and 0.528); and for advanced laparoscopists, it was substantial (Fleiss κ = 0.652). CONCLUSIONS: Interobserver agreement was superior among senior sonologists. Prediction of POD obliteration using offline US videos by senior sonologists is comparable to offline assessments of laparoscopic videos by advanced laparoscopists for prediction of POD obliteration.

Medical management of miscarriage: Predictive factors of success.

Medical management of miscarriage is an acceptable option available to women, and has advantages of providing timely treatment, while avoiding exposure to surgery and anaesthesia. This retrospective cohort study aimed to determine factors predictive of successful medical management, utilising a single dose protocol of 800 µg vaginal misoprostol. In this cohort, the success rate was 67% (199/296), and smaller mean gestational sac diameter independent of gestational age predicted success (P = 0.046). Success is not significantly related to parity, miscarriage type, pelvic pain or vaginal bleeding at the outset of treatment.

Vertical transmission of hepatitis C: Testing and health-care engagement.

AIM: To investigate hepatitis C virus (HCV) testing patterns and engagement with health care for women positive for HCV antibodies (anti-HCV) in pregnancy and their children through pregnancy and the first 2 years of the child's life. METHODS: At a large inner-city Australian hospital from 2010 to 2012, anti-HCV positive pregnant women were recruited into a cohort study from pregnancy to 2 years post-delivery. Maternal and child data were collected by questionnaire and medical record extraction. RESULTS: During the study 29 women participants delivered 31 children. HCV RNA was detected in 64% (18/28) of pregnancies, with injecting drug use, the most likely route of maternal infection. Relatively high maternal health-care engagement during pregnancy reduced after delivery. There was evidence of ongoing illicit drug use in the majority of women. Of the children, 58% (18/31) had some HCV testing confirmed but complete testing was confirmed for only 10% (3/31). Largely, testing was incomplete or unknown. No vertical transmission was identified. Forty-two percent (13/31) of children were placed in out-of-home-care. CONCLUSIONS: Potentially, there is a high risk of inadequate or incomplete HCV testing of vulnerable children. Ongoing maternal drug use, poor maternal health-care engagement and placement in out-of-home-care may increase the risk. Complete testing of all children at risk of vertically acquired HCV needs to be ensured.

Does previous caesarean section at full dilatation increase the likelihood of subsequent spontaneous preterm birth?

BACKGROUND: There is emerging evidence that caesarean section at full dilatation is associated with an increased risk of subsequent spontaneous preterm birth. AIM: To investigate the association between caesarean section at full dilatation and spontaneous preterm birth in subsequent pregnancies. MATERIALS AND METHODS: This was a retrospective cohort study of women who had two consecutive births at Royal Prince Alfred Hospital, 1989-2015. Our main comparison group was women who had emergency caesarean sections during the first stage of labour. Secondary comparison groups were women who had elective caesarean sections, instrumental deliveries and unassisted vaginal deliveries. The primary outcome was spontaneous preterm birth (<37 weeks gestation) in a subsequent pregnancy. RESULTS: There were 2672 women who had an emergency caesarean section, with 2142 (80%) performed during the first stage of labour and 533 (20%) at full dilatation. The rates of spontaneous preterm birth in a subsequent pregnancy were 1.7% and 3.8%, respectively (odds ratio 2.2 (95%CI 1.3-3.8), P = 0.003). The hazard ratio for spontaneous onset of labour at any given gestation from 20 weeks until full term was 1.4 (95%CI 1.2-1.6) and did not change after adjusting for maternal age and body mass index. CONCLUSION: There is a significantly higher rate of subsequent spontaneous preterm birth in women who had a caesarean section at full dilatation compared with women who had a caesarean section during the first stage of labour. Awareness of this as a risk factor may warrant referral to a high-risk obstetric or preterm birth clinic.

The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage.

BACKGROUND: Medical management of miscarriage allows women to avoid the risks associated with surgical intervention. In 2011 the early pregnancy assessment service (EPAS) at the Royal Prince Alfred Hospital (RPAH) in Sydney, Australia introduced medical management of miscarriage with single-dose 800 µg vaginal misoprostol. AIMS: We sought to investigate the impact of the introduction of medical management had on the proportion of women having surgery and conservative management and to examine the success and complication rates of medical management. MATERIALS AND METHODS: We undertook a retrospective cohort study that included all women diagnosed with a miscarriage from 12 months prior to and 18 months after the introduction of medical management. Successful management was defined as the absence of retained products of conception or endometrial thickness less than 15 mm on ultrasound at two weeks. The change in management choices over time, the success rates and complication rates were measured. RESULTS: Of 1102 women in the final analysis, 446 were in Group A (before medical management) and 656 in Group B (after medical management). Primary surgical procedures fell significantly for missed miscarriages from 68 to 48% (P < 0.001) and primary conservative management reduced for incomplete miscarriages (63-44%; P = 0.01). Overall 89 of 108 (82.4%) patients managed medically had a resolution within two weeks. One in ten presented with a complication. DISCUSSION: The introduction of medical management led to a statistically significant reduction in the proportion of women undergoing primary surgical management of missed miscarriage. Success and complication rates were similar to other studies.

Transverse occiput position: Using manual Rotation to aid Normal birth and improve delivery OUTcomes (TURN-OUT): A study protocol for a randomised controlled trial.

BACKGROUND: Fetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate. METHODS/DESIGN: Eligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity. Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410). DISCUSSION: This trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies. TRIAL REGISTRATION: This trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752 ) on 4 January 2013.

Caesarean section at full cervical dilatation.

BACKGROUND: Caesarean section at full cervical dilatation has many implications for maternal and neonatal morbidity as well as subsequent pregnancy outcomes. However, increasing trends are reported internationally for second-stage caesarean delivery. OBJECTIVES: To review the rate and indication for a caesarean section at full dilatation over a 5-year period at a tertiary referral obstetric centre in Sydney. MATERIALS AND METHODS: Retrospective cohort review of all women with a singleton, cephalic presenting fetus at ≥37(0)  weeks' gestation delivered by caesarean section in the second stage of labour between 1 January 2009 and 31 December 2013 at Royal Prince Alfred Hospital. Medical records were reviewed, and demographic, maternal and fetal outcome data were obtained. Consultant supervision and documentation standards were recorded. The main outcome measures were the rate of caesarean section at full cervical dilatation, maternal and fetal morbidity. RESULTS: During the study period, 8449/26063 (32.4%) babies were born by caesarean section. Of these surgical births, 476 (5.6%) were performed at full cervical dilatation at >37 weeks' gestation. There was no observed trend over the 5 years. The majority of women delivered by caesarean section at full dilatation were nulliparous and in spontaneous labour. More than half of these women were delivered without a trial of instrumental delivery. Consultant obstetricians were present for 7% of public second-stage caesarean deliveries. CONCLUSION: We report a 5-year experience with caesarean delivery at full dilatation at a tertiary unit. The rate was variable over the 5 years. Secondary outcome measures suggest that consultant supervision is uncommon and documentation standards require improvement.

Persistent Occiput Posterior position - OUTcomes following manual rotation (POP-OUT): study protocol for a randomised controlled trial.

BACKGROUND: Occiput posterior position is the most common malpresentation in labour, contributes to about 18% of emergency caesarean sections and is associated with a high risk of assisted delivery. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and to the neonate, respectively. There is level 2 evidence that prophylactic manual rotation reduces the caesarean section rate and assisted vaginal delivery. But there has been no adequately powered randomised controlled trial. This is a protocol for a double-blinded, multicentre, randomised controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate. METHODS/DESIGN: Eligible participants will be (greater than or equal to) 37 weeks' with a singleton pregnancy and a cephalic presentation in the occiput posterior position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 68%, then for a reduction to 50%, an alpha value of 0.05 and a beta value of 0.2, 254 participants will need to be enrolled. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, and protocol number X110410. Participants with written consent will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery (defined as vacuum, forceps and/or caesarean section deliveries). Secondary outcomes will be caesarean section, significant maternal mortality/morbidity and significant perinatal mortality/morbidity. Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. The results of the trial will be presented at one or more medical conferences. The trial will be submitted to peer review journals for consideration for publication. There will be potential to incorporate the results into professional guidelines for obstetricians and midwives. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry ACTRN12612001312831 . Trial registered 12 December 2012.

Single-dose methotrexate treatment for ectopic pregnancy and pregnancy of unknown location and progesterone as a predictor of success.

BACKGROUND: The use of single-dose intramuscular administration of methotrexate in the treatment of ectopic pregnancies (EP) is a well-established practice. This study evaluates its use at a novel dose of 40 mg/m(2) body surface area (BSA). OBJECTIVE: To evaluate the efficacy and safety of single-dose methotrexate treatment 40 mg/m(2) for tubal EP and persistent pregnancies of unknown location (PUL) and determine whether serum progesterone is a predictor of treatment success. MATERIALS AND METHODS: Retrospective cohort study of patients receiving intramuscular methotrexate 40 mg/m(2) for the treatment of EP or PUL at Royal Prince Alfred Hospital over five years. RESULTS: One hundred and eighteen women received single-dose methotrexate with an overall success of 84%. Surgical intervention was needed in 16.6%. Pretreatment beta-hCG level and ectopic diagnosis were independent variables predictive of the need for surgery (P = 0.003 and 0.02, respectively). Serum progesterone level was not predictive of the need for a second dose or surgery. The sensitivity and specificity at pretreatment beta-hCG of 1202 IU/L were 84% and 74%, respectively. Commonly reported side effects included nausea, abdominal pain and heavy vaginal bleeding. Significant treatment-related adverse effects were rare. CONCLUSION: Single-dose IM methotrexate at a novel dose of 40 mg/m(2) is a safe and effective treatment for selected EP and persistent PUL. The risk of surgery was positively correlated to serum beta-hCG level and the diagnosis of EP. Progesterone was not a risk factor for surgery. Further studies are required to confirm the efficacy of this dose regimen and explore the safety of expectant management as an alternative to methotrexate treatment.

Persistent occiput posterior: OUTcomes following digital rotation: a pilot randomised controlled trial.

AIM: To determine the feasibility of a multicentre randomised controlled trial (RCT) to investigate whether digital rotation of the fetal head from occiput posterior (OP) position in the second stage of labour reduces the risk of operative delivery (defined as caesarean section (CS) or instrumental delivery). METHODS: We conducted the study between December 2010 and December 2011 in a tertiary referral hospital in Australia. A transabdominal ultrasound was performed early in the second stage of labour on women with cephalic, singleton pregnancies to determine the fetal position. Those women with a fetus in the OP position were randomised to either a digital rotation or a sham procedure. In all other ways, participants received their usual intrapartum care. Data regarding demographics, mode of delivery, labour, post natal period and neonatal outcomes were collected. RESULTS: One thousand and four women were consented, 834 achieved full dilatation, and 30 were randomised. An additional portable ultrasound scan and a blinded 'sham' digital rotation were acceptable to women and staff. Operative delivery rates were 13/15 in the digital rotation (four CS and nine instrumental) and 12/15 in the sham (three CS and nine instrumental) groups, respectively. CONCLUSION: A large double-blinded multicentre RCT would be feasible and acceptable to women and staff. Strategies to improve recruitment such as consenting women with an effective epidural in active labour should be considered. This would be the first RCT to answer a clinically important question which could significantly affect the operative delivery rate in Australia and internationally.

Clinical case presentation: life threatening Group A sepsis secondary to HyCoSy.

Hysterosalpingo contrast sonography (HyCoSy) is a commonly performed procedure in the investigation of infertility. Infection is an uncommon complication of this procedure. Should it occur, it is generally mild and amenable to outpatient treatment with oral antibiotics. We present a case of an immunosuppressed woman who underwent HyCoSy for investigation of secondary infertility and developed life-threatening sepsis with Group A streptococcus.