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Join us for a Hatha based yoga session to start your day on the right foot! Jess will guide attendees through a series of movements, emphasising the body and breath, and balancing the nervous system to encourage a sense of flow and calm. This session is appropriate for anyone to join and Jess will provide scaled poses for health concerns (e.g., lower back tightness). Jess draws on her knowledge and skill as a clinical psychologist and yoga teacher to emphasise the psychological aspects of yoga practice. 

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The advent of non-invasive prenatal testing (NIPT) in 2010 as a screening test for the common trisomies was revolutionary, with sensitivity, specificity and detection rates unmatched by the combined first trimester screening programs. NIPT was found to achieve a detection rate for Down syndrome of 99.7%, with a false positive rate of 0.04%. However, some NIPT providers now additionally offer extended panels and low resolution whole genome sequencing (WGS) including sex chromosome aneuploidies, rare autosomal aneuploidies, and subchromosomal deletions, duplications and recurrent microdeletions. This comes at a cost of a higher false positive rate and lower positive predictive value. Moreover, the expanded panels and WGS NIPT raise issues of clinical utility and ethical concerns. NIPT after an NT scan documenting a live, structurally normal fetus would contextualize the results.

One of the most significant dilemmas in modern Obstetric care is managing extreme prematurity. The goal posts continue to change and each tertiary centre approaches this differently. In North Queensland, the geographical hurdles add a unique perspective to this Obstetric dilemma. 

As Obstetricians and Gynaecologists, our role is critical and the first review of a family faced with peri-viable dilemma is always challenging. 

This presentation will discuss a framework to guide clinicians who are faced with the imminent birth of a peri-viable baby. This includes a discussion around the current guidelines and the information required to counsel and navigate this challenging dilemma.

Risk of extreme pre-term (≤ 28 weeks) delivery is significantly higher in twin pregnancies than singletons. Improved survival has led to increased intervention, including caesarean section. Absence of a well-formed lower segment at early gestations can necessitate classical hysterotomy. Historically, classical incisions are associated with increased maternal morbidity, including haemorrhage, puerperal infection and ICU admission.

Aim: To evaluate short-term maternal outcomes in delivery of extreme pre-term twins via classical versus lower uterine segment caesarean section.

Mothers who delivered twins via caesarean section at ≤28 weeks between 1st January 2015 and 31st December 2019 were identified from the hospital birth register. A manual,  retrospective audit of each individual’s digital medical record was conducted.

We identified 28 mothers who delivered twins via caesarean section at-or-before 28-weeks during our study period. 28.5% were born before 26 weeks whereas the majority, 71.4%, were born between 26-28 weeks. 22 (or 78.5%) underwent lower uterine caesarean section and 6 (or 21.5%) had a classical caesarean section.  Baseline characteristics between both groups were comparable. Average parity in both groups was <1 (0.65 for LUCS versus 0.7 for CCS) and number of previous uterine scars was similar (2 for LUCS and 1 for CCS).

Postpartum haemorrhage greater than 1L occurred in 22.7% (n=5) women who had a lower uterine incision, compared to 33.3% (n=2) of those had a classical caesarean. 9% (or n=2) women who had a lower uterine incision developed sepsis, compared to 16.6% (or n=1) who had a classical caesarean. There was 1 ICU admission from the lower uterine caesarean section group, compared to none with classical caesarean. Conversion from spinal to general anaesthetic occurred in 33.3% of classical caesarean sections (n=2), compared to one case (4.5%) of lower uterine caesarean sections. No women from either group required hysterectomy or were diagnosed with venous thromboembolism in the post-partum period.

This audit demonstrates similar rates of maternal complications with CCS compared to LUCS. Decisions regarding mode of delivery in high-stakes scenarios, such as extreme pre-term delivery of twins, can be complex and challenging. Local, current data on maternal outcomes aids clinical decision-making.

Antenatal corticosteroid (ACS) administration is an effective strategy for improving neonatal morbidity and mortality outcomes in preterm birth. While ACS is recommended for women at risk of imminent preterm birth, they may prolong hospital stay, have short term side-effects for the women and potentially long-term effects for baby.[1] Babies who are not born preterm may have the risk of harm without benefit and thus it is important to appreciate the percentage of women who receive ACS who proceed to deliver preterm.
Aim: This study aims to review compliance of current practice of ACS administration with current guidelines and timing to delivery. We aim to identify antenatal presentations that have relatively high or low rates of delivery within 7 days of ACS that will allow more nuanced decision making about ACS.

A retrospective case-controlled study of patients who were admitted to the Mater Mother’s Hospital for ACS administration over a six-year period was performed with review of duration from steroid administration to delivery and indication for ACS. Patients with incomplete data and those who received ACS ahead of a scheduled term induction or caesarean section were excluded.
A total of 3382 patients who received antenatal corticosteroids were reviewed to identify 59.3% delivered within 7 days of ACS. Preterm birth within 7 days of ACS occurred within 22.7% in admissions for threatened preterm birth, 36.4% of cervical incompetence, 22.2% for antepartum haemorrhage, 49.6% for preterm pre-labour rupture of membranes and 63.2% of hypertensive disorders in pregnancy requiring elective preterm delivery.
This review will identify current ACS trends related to delivery timing to allow for more nuanced decision making for specific presentations. 

Chair – Dr Senaka Abeysundera.

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Dr Scott Peterson
Maternal CMV infection is associated with adverse outcomes. Recent studies have advanced our understanding and allow for a way forwarding in managing the threat of CMV infection in pregnancy.

 Alice will outline the significant public health implications of maternal depression or perinatal mood and anxiety disorders, whilst exploring the ethical complexities and possibilities of prescribing medications in this period.  There will be a brief review of the emerging use of transcranial magnetic stimulation, with an acknowledgement of the paucity of research for this population at this time.

Sponsored by:

This talk will provide an overview of trauma management in a pregnant patient, including an update of immobilisation, critical bleeding management and manual displacement of the uterus.

The management of trauma in pregnancy involves a systematic approach, incorporating the ABCDE of emergency management. It can be used as a framework for managing the critically ill pregnant patient, including women who are the victim of domestic or intimate partner violence

Pregnancy is a well-known risk factor of Venous Thrombus Embolism (VTE) events. To audit our department’s performance in VTE prevention, we looked into the records of 82 pregnant women who developed some symptoms of venous pathology, from thrombophlebitis, Deep Vein Thrombosis (DVT) to Pulmonary Embolus (PE) while receiving care at our hospital. We found that the risk identification, documentation and management during pregnancy care was inaccurate and incomplete and most of the confirmed VTE patients had no thromboprophylaxis prior to diagnosis. We recommend the use of a Performa by all clinicians to accurately identify risks to ensure proper risk management.

Placenta Accreta Spectrum (PAS) is broad term used to describe abnormal trophoblastic invasion into myometrium of the uterine wall. It includes placenta Accreta, Increta and Percreta. With ever increasing rates of cesarean sections, the incidence of PAS is likely to keep rising exponentially, which is of utmost clinical importance due to its potential morbidity and mortality.

We aim to highlight the importance of high index of antenatal suspicion for a potential complication, surveillance, diagnosis and delivery planning in this case. Inspite of appropriate tertiary Feto-maternal unit referral for ultrasound, the diagnosis was missed, leading to management at a non-tertiary unit in an emergency situation. We also enumerate challenges encountered in the management of undiagnosed placenta accreta (inspite of the most expected given antenatal scenario).

Retrograde case analysis of a 27 year old G4P3, previous 3 C-sections with DCDA twins, presented at 32+4 weeks gestation with severe antepartum hemorrhage and severe hypotension with live fetuses to our hospital. She warranted a Category 1 emergency cesarean section, sustained a cardiac arrest intraoperatively from massive hemorrhage, eventually complicated by urinary bladder injury and further extensive multidisciplinary involvement.

Complex management of near miss mortality due to missed antenatal diagnosis.

We reinforce utmost clinical importance on antenatal diagnosis. We also present the available literature on prenatal screening, possible laboratory aids, and surveillance. We further discuss signs of intraoperative recognition as well as highlight the significance of quick and crucial surgical interventions for management in undiagnosed and/or unexpected placenta accreta situations.

Chair - Dr Emma Inglis 

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Session 3 : Gynaeoncolgy

Neoadjuvant chemotherapy, Sentinel lymph node biopsies and targeted therapies have reduced the radicality and morbidity of gynaecological oncology surgery with no effect, or in some cases, improved outcomes.
This presentation will aim to review some of these newer techniques and treatments currently being adopted in Gynaecological Oncology.

Sponsored by:

There is a broad interface and indeed overlap between gynaecological oncologists and general gynaecologists.  The most essential element in managing this is good communication. With ovarian lesions, every effort should be made to exclude cancer prior to surgery.  This will entail not just utilisation of decision tools such as ROMA or RMI, but careful examination of the patient, personal review of imaging studies and consideration of the global picture.  Prophylactic surgery for ovarian cancer is much more than just the surgery, including indication for procedure, post op requirements, implications for family and technical details of the surgery itself.  Always exclude occult cervical cancer before hysterectomy.  For management of HSIL or AIS aim for crisp clean margins, and consider the place of cold knife cone biopsy.  For fibroids – consider the possibility of leiomyosarcoma.  Try to avoid myoma screws and open morcellation.  For vulval lesions – need a low threshold for biopsy.  VIN/HSIL can certainly be managed by general gynaecologists.  If obvious vulval cancer – take biopsy and instigate imaging work up and refer.  For difficult benign surgery, the retroperitoneum is your friend.  For obstetrics haemorrhage – good communication and one designated leader in the surgery.  The single most important principle for all aspects of the interface, is communication.

 Lymph node (LN) evaluation in endometrial cancer is controversial. The status of LNs provides crucial information for prognosis and adjuvant therapy. Greater than 30% women with a pre-operative indication of complex hyperplasia with atypia (CAH) have concurrent endometrial cancer, hence there is rationale to justify assessment of the LNs in these women. Sentinel lymph node biopsy (SLNB) allows for an accurate nodal assessment while minimising the risks of a full pelvic lymph node dissection (PLND). Robotic-assisted hysterectomy (RAH) has several advantages compared to laparoscopic surgery, including more LNs dissected, shorter hospital admission and less blood loss.

 Aims:To examine the characteristics and peri-operative outcomes of women with CAH or endometrial cancer undergoing RAH +/- SLNB or PLND.
To examine the utilization, feasibility and role of SLNB and compare their peri-operative outcomes.

Materials and Methods:
Retrospective cohort study from December 2018 – February 2021 of women who underwent RAH+/-LN assessment for endometrial cancer or CAH. SLNB was performed using indocyanine green dye and fluorescence detection. Intention to treat analysis was performed.

115 women had RAH with or without LN assessment. Mean age was 61.9 +/- 10.3 years and mean BMI 34.3 +/- 10 .5 kg/m2. 45% were born in Australia. 59% had SLNB, 29% had no LN assessment and 12% had PLND.  41.9% of women with a preoperative indication of CAH had a final diagnosis of cancer.   35.7% of the PLND cohort had positive LNs.  76.4% of women in the SLNB cohort had a preoperative diagnosis of EAC, mostly Grade 1 (54.4%). The final diagnosis was mostly early stage low grade disease (Stage 1A - 50%, Grade 1 EAC- 56%). The detection rate was 90%.  There was a statistically significant trend towards performing SLNB over time (47% December 2018 to December 2019 versus 75% January 2020 to February 2021, p value 0.004). 
There was a statistically shorter length of stay, less estimated blood loss and shorter surgical duration in the SLNB cohort, compared to the no LN assessment cohort (p values 0.02, 0.01 and 0.03 respectively).
There was statistically significant less estimated blood loss and surgical duration in the SLNB compared to the PLND cohort (p values 0.03 and 0.001 respectively).

SLNB at RAH was utilised & feasible with a statistically significant trend towards increased utilisation over time and high detection rate. SLNB at RAH was safe with a low complication rate comparable to No LN sampling cohort and had advantages compared to PLND cohort. SLNB should be considered in suitable selected women undergoing surgery for endometrial cancer or CAH.

Placenta accreta spectrum (PAS) is a rare disease of abnormal placental attachment and is associated with high risk of massive haemorrhage. Management of PAS is variable, but usually involves caesarean hysterectomy (CH).
To compare maternal and perinatal outcomes of women with PAS managed with interventional radiology (iliac artery balloon inflation or uterine artery embolisation) and CH (staged procedure) versus CH alone (non-staged procedure).

 A retrospective cohort study of women who had a CH for PAS (2001-2020) was performed at a Sydney tertiary maternity hospital. Women who delivered after 24 weeks’ gestation and had histologically-confirmed PAS were included. Descriptive statistics were used to present data.

Forty-six women were included (30 staged and 16 non-staged). Mean blood loss was reduced in the staged versus non-staged procedure group (1794 vs. 3731 mL) and the staged group had fewer blood transfusions (12/30 [40%] vs. 15/16 [94%]; p<0.01). There was no difference in major surgical complications between the staged and non-staged groups (13/30 [43%] vs. 5/16 [31%]; p=0.45). There was no difference between the staged and non-staged groups in 5-minute Apgar <7 (13/30 [43%] vs. 4/16 [25%]; p=0.24), neonatal resuscitation (22/30 [73%] vs. 10/16 [63%]; p=0.47 and NICU admission (14/29 [47%] vs. 10/16 [63%]; p=0.33).

 Combined, staged obstetric and interventional radiological management of PAS reduces mean blood loss and need for blood transfusion without any increase in maternal or perinatal morbidity.

Large numbers of women undergo hysterectomy each year with up to 70% for benign indications, including endometriosis. Endometriosis affects 5-10% of women in their reproductive years and symptoms are variable. Surgical treatment is used when there are features of severe disease or medical therapy is insufficient.

To determine if women with endometriosis are at higher risk of complications associated with TLH, compared with women without endometriosis, at Waitemata District Health Board (WDHB).

Retrospective analysis of all women undergoing TLH at WDHB from January 2015 to June 2020. Data was obtained from the medical record including patient and procedural characteristics, length of hospital stay and complications occurring within 3 months of surgery. Data was analysed by chi square test.

Forty three of 146 women undergoing TLH had endometriosis reported in the operation note. Women with endometriosis were more likely to have a complication (32.6% vs 28.2%) including; Conversion to laparotomy (4.7% vs 1%), bladder/ureteric injury (2.3% vs 1%), haemorrhage 500mL or more (4.7% vs 2.9%), vault haematoma (7% vs 4.9%), postoperative infection requiring IV antibiotics (16.3% vs 7.8%), any postoperative infection (27.9% vs 22.3%) and unplanned readmission (18.6% vs 12.6%).

Women with endometriosis undergoing TLH were more likely to experience an associated complication, however this was not found to be statistically significant. Limitations include the retrospective design and small sample size.

Professor Ajay Rane 
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Session 4 : Pelvic Pain

The Clinical Guidelines on the diagnosis and management of endometriosis were a key deliverable of the 2018 National Action Plan on Endometriosis launched by the Federal government.   A working group made up of consumers, clinicians, administrators, college staff and writers was established and evaluated existing guidelines, making a decision to build on the existing NICE guidelines, to avoid duplication.  Key questions were proposed and systematic reviews conducted and this is the basis for the technical report  - an accompanying document to the guidelines.  The guidelines utilise the GRADE program to determine quality of evidence.   There were 75 recommendations made with a determination of overall low quality evidence.   Accessibility of the guidelines for general practitioners as well as specialists was an important outcome for the documents.  The guidelines highlight areas of concern with regards to the local Australian populations and directions for future research.   

Non-suicidal self injury is common among young adult population. Self harm to the genitals is uncommon, but can include injuries such as cutting, burning, insertion of foreign bodies, and chemical burns.
There is documented guidelines in relation to unintentional ingestion or insertion of button batteries predominantly in children. This has resulted in mandated changes in the manufacture and packaging of this item. However the majority of literature focuses on injury related to ingestion and insertion in ears or nose. Following an increase in presentations to a local hospital among three adult women; a targeted review using search terms “vagina” and “button battery” revealed only one other case report worldwide.
 When there is sufficient retained battery charge, hydrolysis and creation of hydroxide ions in adjacent tissues leads to mucosal burn at the battery’s negative pole and secondly by direct pressure at insertion site (QLD guidelines). There is risk of perforation and erosion causing fistulas.
 Due to an increase in repeated presentations, there was concern that vaginal battery button insertion could lead to serious long term morbidity in terms of erosion and fistula formation into the abdominal cavity, rectal or vesical spaces.
Aim: To establish data on the outcomes of vaginal button battery insertion. 
Retrospective review of multiple cases at the Caboolture hospital with insertion of lithium batteries in the vagina. Cases were selected from 2019 to 2021. Data collection from both them local ED system and operating theatre system.

 In 2020 there was 14 theatre cases that required removal of lithium batteries in the operating theatre. These cases were all related to three specific patients, with known mental health issues and well known to the local mental health service. Operative findings described superficial erosion. Nil evidence of fistula or perforation in all 14 cases. 8 of the cases were classed as Priority C, and the remaining 6 cases were Priority B.
Following an increase in presentations among these specific patients at Caboolture hospital a Multidisciplinary was held in September 2020. This involved the local emergency department, gynaecology team and mental health team. Education was performed by psychiatry team to help aid approach and management of these cases while in hospital.

International research supports follow-up after early medical abortion (EMA) using a patient questionnaire and low sensitivity urine pregnancy (LSUP) test however this has not been evaluated in the Australian setting, where follow-up  has traditionally been undertaken via an in-clinic consultation using ultrasound or quantitative serum human chorionic gonadotropin (hCG) levels. Australia’s first LSUP test was registered with the Therapeutic Goods Administration in November 2019. In March 2020 we launched a new telephone follow-up protocol using a patient questionnaire and an LSUP test.

To evaluate outcomes for patients with a positive LSUP test and compare to accepted benchmarks

Data was collected for patients who underwent the telephone follow-up protocol from 26/03/2020-30/04/2020 and had a positive LSUP test necessitating an in-clinic review appointment.  Outcomes of these patients were ascertained and analysed.

441 patients underwent telephone follow-up after EMA with the new protocol between 26/03/2020 – 30/04/2020 and of these 31 (7%) had a positive LSUP test necessitating an in-clinic review. On review, 15 patients were found to have a complete EMA, 13 were diagnosed with an incomplete abortion and 3 had a continuing pregnancy. 

Transition to a telephone LSUP test follow-up protocol resulted in 93% of patients not requiring an in-clinic review appointment. The complication rates were within accepted benchmarks. This protocol reduces the burden of unnecessary clinic visits for both patients and clinical services and has been especially useful during the COVID-19 pandemic in reducing travel and face-to-face contact.  This model offers another step towards self-managed abortion care. 

Chair - Dr Benjamin Bopp