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Medicine, Australia

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AW W.,University of New South Wales | AW W.,Royal Hospital for Women
BMC Pregnancy and Childbirth | Year: 2013

Background: The obstetrical literature is dominated by Randomised Controlled Trials (RCTs), with the vast majority being analysed using an intention-to-treat (ITT) approach. Whilst this approach may reflect well the consequence of assignment to therapy and hence the 'trialists'perspective', it may fail to address the consequence of actually receiving therapy (the patient's perspective).Discussion: This review questions the ubiquitous adherence to the ITT approach, and gives examples of where this may have misled the maternity care professions. It gives an overview of techniques to overcome potential deficiencies in result presentation, using method effectiveness models such as 'Per Protocol' (PP) or 'As-Treated' (AT) that may give more accurate clinical meaning to the presentation of obstetrical results. It then proceeds to cover the added benefits, considerations and potential pitfalls of the use of Instrumental Variable (IV) models in order to better reflect the clinical context.Summary: While ITT may achieve statistical purity, it frequently fails to address the true clinical or patient's perspective. Though more complex and potentially beset by problems of their own, alternative methods of result presentation may better serve the latter aim. Each of the other methods may rely on untestable assumptions and therefore it is wisest that study results are presented in multiple formats to allow for informed reader evaluation. © 2013 AW; licensee BioMed Central Ltd.


Eden J.A.,University of New South Wales | Eden J.A.,Royal Hospital for Women
Maturitas | Year: 2012

Objective: To review the evidence that isoflavones are effective treatments for menopausal symptoms and to present the safety data. Methods: The databases Scopus, ScienceDirect and Primo Central Index were searched and preference was given to systematic reviews and meta-analyses. Results: The available evidence suggests that isoflavones do not relieve menopausal vasomotor symptoms any better than placebo. Long-term safety studies suggest that women who consume a diet high in isoflavones may have a lower risk of endometrial and ovarian cancer. Conclusions: Isoflavones cannot be recommended for the relief of hot flushes.


Awan N.,University of New South Wales | Bennett M.J.,University of New South Wales | Walters W.A.W.,Royal Hospital for Women
Australian and New Zealand Journal of Obstetrics and Gynaecology | Year: 2011

Background: There appears to be a rise in the rate of emergency peripartum hysterectomy (EPH) in the developed world. Aims: To determine the incidence, indications, risk factors, complications and management of EPH in our tertiary level teaching hospital, the Royal Hospital for Women (RHW) in Sydney, over the last decade. Methods: A retrospective analysis was conducted of all cases of EPH performed at the RHW between the years 1999-2008 inclusive. EPH was defined as one performed after 20 weeks gestation for uncontrollable uterine bleeding not responsive to conservative measures occurring at any time after delivery but within the first 6 weeks post-partum. Cases were ascertained via our hospital obstetric database. Results: There were 33 EPH among 38 998 births, a rate of 0.85 per 1000 births. Indications for EPH were morbid adherence of the placenta (54.8%), placenta praevia (19.4%), uterine atony (12.9%) and uterine rupture or cervical laceration (9.7%). A significant association between previous caesarean section (CS) and abnormal placentation was confirmed (P = 0.011), especially for morbid adherence of the placenta (P = 0.004). There was one maternal death. Maternal morbidity was significant, with disseminated intravascular coagulation and urinary tract injury among the most common complications. All women required blood transfusions, and over a quarter were admitted to the intensive care unit. Conclusions: In our series, abnormal placentation causing severe haemorrhage was the commonest indication for EPH. Previous CS is a risk factor for abnormal placentation and particularly for morbid adherence of the placenta. The morbidity associated with EPH is considerable. © 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.


Shand A.W.,University of Sydney | Shand A.W.,Royal Hospital For Women | Algert C.S.,University of Sydney | March L.,Royal North Shore Hospital | Roberts C.L.,University of Sydney
Annals of the Rheumatic Diseases | Year: 2013

Background: Systemic lupus erythematosus (SLE) is associated with adverse pregnancy outcomes overall. Objective To examine the outcomes for women with SLE in a pregnancy subsequent to a fi rst birth with an adverse outcome. Methods: A population-based cohort study was carried out of 794 577 deliveries to 532 612 women giving birth in New South Wales, Australia from 2001 to 2009. Data were obtained from longitudinally linked birth records and hospital records. Results: 675 women had a diagnosis of SLE in the study period (prevalence 127 per 100 000 childbearing women). Of 177 women who had a fi rst nulliparous birth and subsequent pregnancy, 10 (5.6%) had a perinatal death in the fi rst pregnancy, and of these women, 9 (90%) had a baby discharged home alive in the second pregnancy. Of the 167 women whose fi rst-birth infants survived, second pregnancy outcomes included: 18 (11%) admission for spontaneous abortion, 1 perinatal death (0.6%) and 148 (89%) infants discharged home. Two women had a thromboembolic event in their fi rst pregnancy but had no thromboembolic event in the second. Two women had thromboembolic events in second pregnancies only. Conclusion Women with SLE are at high risk of adverse pregnancy outcomes. However, those who have a perinatal death in their fi rst pregnancy can expect a live birth for a subsequent pregnancy.


Harpham M.,Royal Hospital for Women | Abbott J.,Royal Hospital for Women
Journal of Minimally Invasive Gynecology | Year: 2014

Uterine curettage may result in formation of intrauterine adhesions, which can predispose to recurrent miscarriage [1]. Herein is presented a video case report of a 24-year-old woman with recurrent miscarriages and recurrent intrauterine adhesions after treatment of non-progressive pregnancies. Targeted intrauterine pregnancy tissue removal using a hysteroscopic morcellator was performed to reduce the risk of adhesion recurrence. Successful removal of products of conception, without subsequent adhesion formation, and an ongoing viable pregnancy followed. Selective targeted removal of products of conception mayoffer some advantage to women with a predisposition to recurrent Asherman's syndrome. © 2014 AAGL.


The primitive breast develops in utero and during infancy breast growth largely parallels the growth of the child. At puberty, the GnRH pulse generator starts up, initially with just 1-2 pulses daily. This results in very small amounts of unopposed estrogen being secreted by the ovary. As the GnRH pulse generator matures, ovarian secretion of estrogen increases. The pubertal breast responds to this increasing estrogen drive. Breast glandular increase in size is mostly due to growth and division of the primary ducts. Eventually, the terminal buds give rise alveolar buds which tend to cluster around a terminal duct. Lobule formation begins in the first 2 years that follow menarche. With the onset of ovulation, breast mitotic activity increases and is usually maximal in the luteal phase. The final stage of breast maturation occurs during the first full-term pregnancy. The breast undergoes marked changes in preparation for breast feeding. There is evidence that breast SC number decreases during that first pregnancy. Also, the remaining SC undergo significant change which seems to render them less likely to undergo malignant change. These alterations to breast SC number and function may explain, at least in part, why early first pregnancy reduces the risk of breast cancer later in life. Copyright © 2010 Published by Elsevier Ireland Ltd. All rights reserved.


Eden J.A.,Royal Hospital for Women
Maturitas | Year: 2010

Like other organs, the breast contains rare somatic stem cells (SCs) that are long-lived and slowly dividing. In the adult breast, they are closely regulated in areas located along the breast ducts called SC niches. Breast SCs can produce offspring that become ductal, alveoli or myoepithelial cells. In fetal life, SCs form the primitive breast ducts and up to 30 weeks of gestational age, this process appears to be largely independent of estrogen. Early life risk factors for breast cancer include birth weight, rapid growth during infancy and diet. The impact of these risk factors may be mediated through SC number. These somatic breast SCs persist into adult life and so they are exposed to oncogenic influences for much longer than the short-lived differentiated breast ductal and alveolar cells. As such, it is likely that the breast SC is a prominent target for carcinogenesis and so SC number may be an important determinant of breast cancer risk later in life. © 2010 Elsevier Ireland Ltd.


Atchan M.,Royal Hospital for Women
Breastfeeding review : professional publication of the Nursing Mothers' Association of Australia | Year: 2011

Breastfeeding is the biological feeding norm for human babies. Encouraging breastfeeding is a primary health promotion strategy, with studies demonstrating the risks of artificial baby milks. Each year approximately 10% of the women who give birth in New South Wales decide not to initiate breastfeeding, and the demographic characteristics of this group of women have previously been identified. This paper reviews the literature to explore the factors that influence women's decisions about breastfeeding, and their reasons for not initiating breastfeeding. The review revealed there are relatively few studies that explore the experiences of women who decide not to initiate breastfeeding, especially in the Australian context.


Won H.R.,Royal Hospital for Women | Abbott J.,Royal Hospital for Women
International Journal of Women's Health | Year: 2010

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem.Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management. © 2010 Won and Abbott.


Collier C.B.,Royal Hospital for Women
International Journal of Obstetric Anesthesia | Year: 2010

Background: Considerable uncertainty exists regarding accidental injection of local anaesthetic into the 'subdural space' during attempted epidural block. A whole range of clinical findings, from excessively high to failed blocks has been reported although many of these findings appear difficult to explain on the basis of our current knowledge of the anatomy. The existence of another, adjacent space, the intradural space, is postulated. Methods: Our study of atypical epidural blocks using contrast injection and radiographic screening has now obtained data on 130 patients, and results were reviewed retrospectively, searching for contrast flowing into the subdural region. Results: Radiographic studies have revealed 10 patients with an unusual dense localised collection of contrast in a space previously unrecognised by anaesthetists. Clinical presentation was of inadequate neuraxial block, which could eventually be corrected by top-up doses, but with the possible risk of developing a high block. Late radiographic pictures revealed contrast escaping from the mass into the epidural, subdural or subarachnoid spaces. Conclusions: A review of electron microscopy studies suggested that a 'secondary' subdural space could be opened up by trauma in the distal layers of the dura. Our findings suggest that injection into this 'intradural' space can occur, resulting in an initially inadequate neuraxial block with limited spread. Further volumes of local anaesthetic can be expected to produce satisfactory block, probably as a result of escape to the epidural space. However, late spread to the subdural or subarachnoid space may occur. © 2009 Elsevier Ltd. All rights reserved.

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