more_vertWorldwide there is an alarming increase in caesarean section (CS) rates. The medical profession on its own cannot reverse this trend. Joint actions with governmental bodies, the health-care insurance industry, and women’s groups are urgently needed to stop unnecessary CSs and enable women and families to be confident of receiving the most appropriate obstetric care for their individual circumstances.
Preference: Obstetrics and gynaecology and women's health
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Stalwart of AMA and community passes away
OBITUARY
Dr David John Doidge ANDREW
RFD MBBS FRACGP Dip.Obst RCOG
1944 – 2018
Dr David John Doidge Andrew passed away unexpectedly on October 3, 2018.
A Fellow of the Australian Medical Association, his outstanding commitment to the organisation and the community in general stands as an inspiration to all.
Born, January 27, 1944, Dr Andrew graduated from The University of Melbourne in 1968 and joined the Australian Medical Association the following year.
On graduation, Dr Andrew worked in Auckland, New Zealand before working as a visiting medical officer at The Royal Children’s Hospital and The Royal Women’s Hospital. Dr Andrew also worked as an obstetrics and gynaecology Registrar in Wellington and Auckland in 1972 and 1973.
In 1971 Dr Andrew joined the Royal Australian Navy Reserve. He retired with the esteemed rank of Surgeon Commander in 2009.
Dr Andrew practised as a general practitioner for the Whittlesea and Epping Medical group from 1974 to 1975 before starting a solo practice in Epping in 1976. He retained this solo practice until 2009.
Since joining the AMA Victoria in 1969 and becoming an active member in the late 1970s, Dr Andrew has served as:
- Secretary and Chair of Northern Subdivision
- AMA Victoria Council representative for the Northern Division of General Practice
- AMA Victoria representative for the Department of Veteran Affairs on the Local Medical Officer Advisory Committee
- Member of the AMA Victoria Section of General Practice
- Treasurer of the Section of General Practice
- Member of the AMA-RACGP liaison Committee.
Throughout his career Dr Andrew has worked as a locum doctor intermittently in rural Victoria. He has been a strong advocate for doctors working in rural areas and for rural health.
One of Dr Andrew’s major concerns for the medical profession is the loss of obstetric skills in the new generation of doctors.
Outside of his active role with the AMA, Dr Andrew has also served as the Director of the Northern Division of General Practice.
Dr Andrew has been a long-time supporter and active member of the Australian Medical Association. Through his various roles, he has made an outstanding contribution to the organisation. He was a most worthy candidate for admittance to the Roll of Fellows.
Beloved husband to Vaoese, proud father of Jason, Bronwyn, Peter, Stephanie and David, and proud grandfather of Maximus, Austin, Celeste, Matilda, Alice and Wolfgang. He is sorely missed.
[Comment] Offline: It’s time to hold the private sector accountable
Once a central focus of global development goals, the field of women’s, children’s, and adolescents’ health has now been pushed to the margins of international concern. Maternal and child health advocates have been victims of their own success. Steep declines in under-5 mortality and steady progress in reducing maternal mortality have suggested the job is done. While advances in reproductive, maternal, newborn, and child health should be celebrated, this week’s report by the Independent Accountability Panel for Women’s, Children’s, and Adolescents’ Health (IAP) proves that such complacency is a grave mistake.
GPs urged to do more for pregnant women at risk of pre-eclampsia
A leading obstetrician has raised concern about the under-use of aspirin prophylaxis in pregnancy for women at high risk of pre-eclampsia.
Professor Shaun Brennecke, director of the Department of Maternal-Fetal Medicine at the Royal Women’s Hospital in Melbourne told doctorportal: “It seems to me that many pregnant women who should commence on low dose aspirin in the first trimester of pregnancy fail to do so.”
Professor Brennecke said the issue was an important one given the potential to reduce serious complications of pregnancy, including perinatal death.
“We are seeing women arriving for their first hospital-based pregnancy care visit at gestations beyond the ideal time for staring low dose aspirin,” he said. “They will have often seen their GP to arrange a referral to the hospital in time to start low dose aspirin, but the opportunity is missed, and by the time they reach hospital it may be too late to usefully start the treatment.”
Professor Brennecke said women at high risk – for instance, those with a past history of pre-eclampsia – should commence 150mg aspirin daily at night no later than 16 weeks gestation.
A randomized controlled trial in the New England Journal of Medicine last year found 150mg aspirin daily, commenced at 11-14 weeks gestation, significantly reduced the risk of preterm pre-eclampsia compared with placebo in 1620 high risk women (OR: 0.38; 95% CI, 0.20 to 0.74; P=0.004).
Who is ‘high risk’?
In the NEJM study, ‘high risk’ was determined using an algorithm that combined maternal factors, mean arterial pressure, uterine-artery pulsatility index, and maternal serum pregnancy-associated plasma protein A and placental growth factor.
However, Professor Brennecke said GPs need not rely on complex multi-parametric testing, which is not widely available and affordable.
“Given low dose aspirin is safe and cheap, it would be reasonable for general practitioners to rely on maternal history features – previous preeclampsia, family history of preclampsia, high BMI, co-morbidities such as pre-existing hypertension, diabetes, renal disease and lupus – as indicating a justification for offering pregnant women low dose aspirin therapy for the prevention of preeclampsia,” Professor Brennecke said.
Clinical Associate Professor Gregory Jenkins of the University of Notre Dame and Westmead Hospital, said a past history of pre-eclampsia was one of the strongest risk factors for subsequent pre-eclampsia.
“All women with a past history of pre-eclampsia should be recommended low dose aspirin from 12 weeks in subsequent pregnancies unless there is a reason to advise otherwise,” he said.
He added: “Whilst algorithms for detailed testing are under development and some have found their way into clinical practice, their role and application is probably still to be evaluated.”
Associate Professor Jenkins coauthored a recent study evaluating the effectiveness of UK and US guidelines for predicting pre-eclampsia to guide aspirin prophylaxis.
The guidelines use routinely collected maternal factors to identify women at risk for pre-eclampsia. High risk factors include autoimmune disease, chronic hypertension, pre-pregnancy diabetes mellitus, chronic renal disease and previous hypertensive disease in pregnancy. Moderate risk factors include age 40 or older, elevated BMI and multiple pregnancy.
Associate Professor Jenkins and colleagues regarded patients as “screen positive” if they had at least one high risk factor or two moderate risk factors.
Their study found that while the guidelines offered a “simple and specific approach for recommending aspirin prophylaxis”, they lacked adequate sensitivity – especially in nulliparous women. A better risk prediction tool is needed.
Minimal risk with aspirin
Professor Brennecke said there was likely to be minimal risk of starting low dose aspirin in the first trimester for the majority of women, even though higher doses (eg. 600mg) are contraindicated in pregnancy.
“Low dose aspirin has been used around the world for several decades now in this context, which provides considerable reassurance,” he said. “There are occasional cases of sensitivity to aspirin, but doctors can check for this before recommending the treatment. There is a potential risk that low dose aspirin may exacerbate bleeding in pregnancy, but this does not seem to be significant in practice.”
A 2007 Cochrane review of 59 trials, involving 37,560 women, found low doses of aspirin reduced the risk of pre-eclampsia by about a sixth (17%), with a similar lowering in the risk of the baby dying (14%) and a small lowering in the risk of being born too early (8%).
The Society of Obstetric Medicine of Australia and New Zealand states in its 2014 guidelines that in a population with a 20% risk of preeclampsia, the number needed to treat to prevent one case of preeclampsia is 50.
The guidelines state: “In view of this potential benefit, and the relative absence of maternal or neonatal complications, low dose aspirin is indicated for women with at least moderate to high risk of preeclampsia (ie secondary prevention of preeclampsia in women at increased risk and in women with significantly increased risk in their first pregnancy.”)
[Perspectives] Louise Kenny: pioneer in maternal and perinatal health
Louise Kenny started searching for early predictors of pre-eclampsia almost two decades ago. Today, her research offers the tantalising prospect of an early pregnancy screening test. “It’s biomarker based only, it’s done at 15 weeks, it doesn’t need any clinical or scan information, and if it’s as accurate as we think it is from our preliminary work, then it’s going to be a really useful tool in the antenatal clinic”, says Kenny, Executive Pro-Vice-Chancellor of the Faculty of Health and Life Sciences at the University of Liverpool, UK, and Consultant and Professor of Obstetrics and Gynaecology at University College Cork in Ireland.
“Extremely reassuring” studies back up vaccine safety assurances
Patients can be reassured about vaccine safety on the basis of two large studies that have directly tested claims about the potential harms of the human papillomavirus (HPV) and pertussis vaccines.
The first study, published in the journal Pediatrics this month, found no association between HPV vaccination and primary ovarian insufficiency (POI) among almost 200,000 female patients enrolled in the Kaiser Permanente health system in Oregon and Washington.
Claims of a link between HPV vaccination and POI have circulated widely on the internet on the basis of published case series. These include a case published in BMJ Case Reports in 2012 of a 16-year-old Australian girl whose menstrual cycle became scant and irregular following vaccination.
The report prompted a statement from the Therapeutic Goods Administration at the time saying there was no “plausibly biological basis” for the link.
Latest HPV vaccine study “extremely reassuring”
Now Associate Professor Julia Brotherton, medical director of registries and research at the Victorian Cytology Service Registries said the latest study was “certainly significant and extremely reassuring”.
Out of 199,078 female patients aged 11 to 34 – 58,871 of whom received the HPV vaccine in adolescence – the study found 33 probable and 13 possible cases of primary ovarian insufficiency after follow-up averaging five years. Only one of the cases was vaccinated against HPV before symptom onset; a 16-year-old who received her third dose of HPV vaccine almost two years before estimated symptom onset.
This time lag was “not consistent with the authors of case reports who observed onset within 12 months of vaccination”, the authors noted.
They added: “although we did not formally test, we did not observe any temporal clustering of vaccine exposures among patients”.
More than half of the confirmed POI cases were patients who were diagnosed at age 27 or older, and only one patient was diagnosed under the age of 15.
The study could not adjust for contraceptive use, which the authors noted may mask the symptoms and onset of POI.
Nevertheless, they concluded: “We found no evidence of increased risk of POI after HPV vaccination, or other routine adolescent vaccination exposures, in this population-based retrospective cohort study with nearly 200,000 young women…We believe this study should lessen concern surrounding potential impact on fertility from HPV or other adolescent vaccination.”
Pertussis vacccine not linked to autism
A second study in Pediatrics investigated the potential association between prenatal tetanus, diphtheria, acellular pertussis (Tdap) vaccination and autism spectrum disorder (ASD) risk in offspring, using data from Kaiser Permanente Southern California.
The study followed up 81,993 pairs of pregnant women and their children for up to 6.5 years after birth. Almost half had received the prenatal Tdap vaccine.
ASD was diagnosed in 1,341 children, and incidence was greater in the unvaccinated than the vaccinated group; 3.78 per 1000 person years in the Tdap exposed versus 4.05 per 1000 person years in the unexposed (HR: 0.98, 95% CI: 0.88-1.09).
The authors concluded: “Prenatal Tdap vaccination was not associated with an increased ASD risk. We support recommendations to vaccinate pregnant women to protect infants, who are at highest risk of death after pertussis infection.”
[Correspondence] Saudi visa trainees called home from Canada in diplomatic dispute
Saudi Arabia’s decision to recall its students in response to the Canadian Minister of Foreign Affairs’ tweet1 about two women’s rights activists has sparked a crisis in hospitals and communities that rely on Saudi visa trainees. Canada is the third most popular destination for Saudi-sponsored medical trainees in resi-dences and fellowships, after the USA and the UK.2
Bridging the divide on water births
The water birth debate is back in the spotlight, as experts call for doctors and midwives to come to an agreement so that women can better make informed decisions
This comes after research found that most Australian midwives support the use of water immersion for labour and birth.
Lead author of the research and midwifery lecturer at the University of South Australia, Dr Megan Cooper, told doctorportal that “women need to be empowered to exercise choice and this requires full disclosure of all available options.”
She said there is mounting observational evidence on the safety and benefits of water births, but this is largely overlooked.
“Subsequently, midwives are finding it difficult to facilitate the option and women are unable to exercise choice around the option.”
The web based survey was completed by 234 Australian midwives. The results showed that not only do most midwives support the practice, but they reiterated its documented benefits.
This stands in contrast to the position statement of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), which highlights safety concerns and the need for more research.
University of Queensland Associate Professor Ted Weaver, an obstetrician and former president of RANZCOG, told doctorportal that given the limited evidence base, water birthing remains an issue of contention.
“The evidence so far such suggests that warm water immersion as a comfort measure during labour is useful. It helps women relax, reduces the number of epidurals, and reduces pharmacological pain relief.”
“Water birthing, where the baby is born in water, has its own potential risks – inhalation of water and the baby drowning, mothers collapsing in the bath, and post-partum haemorrhaging.”
Professor Weaver says that many doctors are not exposed to water births, because midwives largely perform them, and the women opting in are at low risk of complications.
“Certainly, in my institution, where there’s a bath in every room, we haven’t had any problems.”
Professor Weaver acknowledged there are obviously opposing views which complicate the discussion. “There are women who come and request water births, and there’s a lot of obstetricians who would say ‘absolutely not’. Midwives have an opposite view, feeling this is something women should be able to choose to do.”
Professor Weaver says that to resolve the disagreement and help women make more informed choices, professional bodies must cooperate.
“How policies are arrived at should be an exercise in collaboration. Doctors and midwives have to sit down and come to an agreement.”
He said that any policy must outline what criteria preclude women from having water births, and what to do when emergencies occur.
Dr Cooper said that women should be active in having conversations about their care.
“It is important for women to ask about the risks of conventional options of pain relief such as epidural. They can then weigh up the benefits and risks, and choose what is right for them.”
Should pregnant women be offered inductions at 39 weeks?
Should all pregnant women be routinely offered induction of labour at 39 weeks? Although many women would prefer to wait for spontaneous labour, new research suggests being induced would substantially reduce their likelihood of requiring caesarean and could also be safer for the baby.
A multicenter US study published in the New England Journal of Medicine this month randomised 6,106 low-risk nulliparous women to either labour induction at 39 weeks or expectant management.
The relative risk of perinatal death or severe neonatal complications (the primary composite outcome) was 20% lower in the induction group than in the expectant management group (95% CI 0.64-1.00; p=0.049), the study found.*
The authors stated: “Labour induction is probably not associated with a higher risk of adverse perinatal outcomes than expectant management, and it may be associated with as much as a 36% lower risk than expectant management.”
Induction of labour was associated with a significantly lower frequency of caesarean delivery (18.6% versus 22.2%) and hypertensive disorders (9.1% versus 14.1%) compared with expectant management.
The authors wrote: “One caesarean delivery may be avoided for every 28 deliveries among low-risk nulliparous women who plan to undergo elective induction of labour at 39 weeks.”
Nevertheless, recruiting participants to the study was a major challenge, with only 27% of eligible women consenting to take part. Participants were younger than the average woman giving birth in the US, and also more likely to be African American or Hispanic.
An accompanying editorial said the recruiting problem was likely to reflect “deference to a perceived public preference for a less interventionist approach to the management of healthy pregnancies at full term.”
Dr Michael Gannon, former AMA president and a WA obstetrician has previously argued that routine induction at 39 or 40 weeks could reduce stillbirths and caesareans.
He told doctorportal: “One of the myths we have been trying to overcome is the notion that if you induce labour, you increase the rate of caesareans. This well-designed study shows that the very opposite is true.”
Dr Gannon said the induction of labour at 39-40 weeks should be discussed with all patients. Further, it should be offered and even recommended on a more regular basis.
“This evidence is completely at odds with the practice at a majority of public hospitals in Australia,” he said. “Private hospitals are often criticised for their higher rates of induction of labour, but scratch a bit deeper and the evidence shows why obstetricians are recommending it.”
He continued: “Whether women are giving birth in public hospitals or private hospitals, the city or the country, whether they are English speaking or not, they should be receiving the same evidence-based information that induction at 39-40 weeks reduces the requirement for caesarean and the risk of stillbirth.”
Dr Gannon acknowledged there would be “huge resource allocation issues” involved in increasing the induction rate. It would also likely precipitate an increase in epidurals.
He said the decision to induce at 39-40 weeks should take into account whether the woman’s cervix was favourable and whether epidural was available.
In the latest study, women in the induction group had a shorter overall hospital stay (owing to the lower rate of caesarean delivery). However, they spent longer in the labour and delivery unit compared with the expectant group.
Professor Hans Peter Dietz, Professor of Obstetrics and Gynaecology at Sydney Medical School is a vocal critic of the prevailing natural birth ideology. He said inducing babies at 39 weeks was a “no-brainer” if one wanted to reduce the risk of stillbirths and other perinatal complications. He said fetal lung maturity had been demonstrated at this stage.
“The risk of stillbirth is low in Australia but it’s not zero, and there is a very small additional risk with every day that goes by. So by delivering the baby at 39 weeks, you reduce the stillbirth risk,” he said.
Professor Dietz noted the study showed no increased risk of operative vaginal delivery with induction at 39 weeks compared with expectant management, adding there might be other benefits of having a slightly smaller baby earlier, such as a lower risk of pelvic floor trauma.
A Cochrane review concluded that a policy of labour induction at or beyond term compared with expectant management was associated with fewer perinatal deaths, fewer caesarean sections and more operative vaginal births. The timing of induction in the trials reviewed ranged from 37 weeks to 41 weeks.
*Although this finding would typically meet the standard for statistical significance (p≤0.05), in the present study it did not. This is because the authors raised the p value for statistical significance to 0.046 to compensate for having looked at the primary outcome once in the middle of the study (pre-planned interim analysis).
[Comment] Women making medical history: introducing A Woman’s Place
In December, 2017, The Lancet issued a call for papers for its special theme issue on women in science, medicine, and global health.1 The Comment outlined the gender inequalities in medicine that still persist, long after many overt barriers to women’s participation have fallen. While that theme issue will be forward-looking, I believe we can also gain insights from looking to the past for examples of women who have made their mark against the odds, and by asking what it was about their particular circumstances that enabled them to do so.