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Background: Gestational trophoblastic disease (GTD) is an uncommon but highly treatable condition. There is limited local evidence to guide therapy., Aims: To report the experience of a statewide registry in the treatment of low-risk gestational trophoblastic neoplasia (GTN) over a 20-year period., Materials and Methods: A retrospective review of the prospectively maintained GTD registry database was conducted. There were 144 patients identified with low-risk GTN, of which 115 were analysed. Patient demographics, treatment details and outcomes, including development of resistance, toxicity or relapse were reviewed., Results: The incidence of GTD was 2.6/1000 live births. There was 100% survival. The mean time from diagnosis to commencing treatment was 1.9 days (range 0-29 days). Seventy-seven percent of patients treated with methotrexate achieved complete response. Thirteen patients (11.3%) required multi-agent chemotherapy, for the treatment of resistant or relapsed disease. There was a higher rate of treatment resistance in those with World Health Organization (WHO) risk scores 5-6 (odds ratio (OR) 6.56, 95% CI 1.73-24.27, P = 0.005) and those with pre-treatment human chorionic gonadotropin >10 000 (OR 4.00 95% CI 1.73-24.27 P = 0.007). Four patients (3.5%) were diagnosed with choriocarcinoma after commencing treatment. Nine patients (7.8%) had successful surgical treatment for GTN, both alone and in combination with chemotherapy. The relapse rate was 4.3%; all were treated successfully with a combination of chemotherapy and surgery, and 93.9% of patients completed follow up through the registry., Conclusions: Methotrexate is a highly effective treatment for low-risk GTN, especially with WHO risk score ≤4. The optimal treatment for those with risk scores of 5-6 requires further investigation., (© 2023 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Gestational diabetes (GDM) is one of the commonest pregnancy complications and is placing an increasing burden on diabetes and obstetric resources., Aims: To describe different antenatal models of care that have developed to address the increasing proportion of pregnancies complicated by GDM., Materials and Methods: Narrative review with thematic analysis from 15 volunteer antenatal diabetes in pregnancy services from Australia and New Zealand identified through a national diabetes organisation. Main outcomes were approaches to patient education, medical nutrition therapy (MNT), ongoing management and escalation of therapy for women with GDM., Results: All clinics provided at least one group education and one MNT session within 1-2 weeks of GDM diagnosis. Women from culturally and linguistically diverse communities usually required 1:1 education. Ongoing management of women with GDM was through either all women being seen in the GDM clinic, a step-up approach (ongoing management by the primary antenatal team with diabetes team referral if self-blood glucose monitoring (SBGM) or insulin therapy dosage criteria are reached) or step-down approach (ongoing management by the diabetes team with step-down to the primary antenatal team if SBGM criteria are reached). Telehealth was used to reduce the burden of clinic attendance, particularly in rural areas., Conclusions: Increasing numbers, earlier diagnoses, the need to provide care to women in rural, remote areas, and cultural/language differences, have generated a range of different antenatal models of care, allowed better workload accommodation and probably reduced costs. Randomised controlled trials of different models of care, with associated health economic analyses, are urgently needed., (© 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: The prognostic significance of oestrogen and progesterone receptors (ER/PR) in endometrial stromal sarcoma (ESS) has conflicting reports in the literature, and the routine use of adjuvant progestogen is of uncertain efficacy., Aims: To examine the prognostic significance of ER/PR positivity and of primary adjuvant progestogen use with outcome in ESS., Materials and Methods: All women with a diagnosis of ESS in our tertiary institution and associated private practices over the last 23 years were included. Primary variables were ER/PR positivity and adjuvant progestogen use. Other variables included high-grade disease and extrauterine disease. The primary outcome was survival, and the secondary outcome was recurrence-free survival (both overall and at 5 years). Survival was calculated using the Kaplan-Meier method. Univariate analyses were performed with t-test for means and chi-squared test for proportions, and multivariate analysis was used to control for age., Results: 35 women were included. ER/PR positivity was associated with a survival benefit (OR death 0.22, P = 0.02), but primary adjuvant progestogen was not. High-grade disease (OR 13, P = 0.02) and extrauterine disease (OR 8.7, P = 0.04) were associated with decreased survival. No variable significantly affected recurrence-free survival. Eight of ten cases of recurrence treated with progestogen have survived more than 3 years., Conclusions: ER/PR positivity appears to be useful for prognosis, but routine administration of primary adjuvant progestogen is not supported. There may be a role for progestogen in ER/PR positive tumours with recurrence or incomplete surgical clearance, but further research is required., (© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy., Aims: To evaluate the obstetric outcome and surgical morbidity of laparoscopic transabdominal cerclage., Methods: An observational study of consecutive women undergoing laparoscopic transabdominal cerclage from 2007 to 2013 by a single surgeon (AA). Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix. The primary outcome was neonatal survival. Secondary outcomes were delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated., Results: Sixty-four women underwent laparoscopic transabdominal cerclage during the study period. Three women underwent cerclage insertion during pregnancy; the remaining 61 were not pregnant at the time of surgery. Thirty-five pregnancies have been documented to date. Of those, 24 were evaluated for the study. The remaining cases were either early miscarriages, ectopic pregnancies or are still pregnant. The perinatal survival rate was 95.8% with a mean gestational age at delivery of 35.8 weeks. Eighty-three per cent of women delivered at ≥34 weeks gestation. There was one adverse intra-operative event (1.6%), with no postoperative sequelae., Conclusion: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. Success rates compare favourably to the laparotomy approach., (© 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: For select women with early endometrial cancer, particularly nulliparous women, nonsurgical options may be considered. There is increasing experience using progestogens, but little is known about the long-term outcomes and safety of such treatment., Aims: To present the cancer and pregnancy outcomes of women with greater than five years follow-up after progestogen treatment for early endometrial cancer., Methods: Ten women who underwent greater than six months of continuous progestogen therapy for early endometrial cancer were included in the study. All were managed by a gynaecological oncologist at a major tertiary centre in Melbourne, Australia. The histology of each subsequent curette was recorded, as was the timing and histology of hysterectomy (if relevant), and the results of any subsequent pregnancies., Results: All ten women showed histological regression of cancer with no cases of recurrence on follow-up curette. Four of ten women have undergone hysterectomy with one case of occult disease persistence in a woman noncompliant with therapy. The mean follow-up time was 89 months (range 62-142 months), there were no deaths and no woman was lost to follow-up. All four women attempting pregnancy were successful. There were eight pregnancies and five live births., Conclusions: This form of treatment appears to be successful and safe in the long term with good pregnancy outcomes. However, it is not standard and should be supervised in a specialised gynaecological oncology unit., (© 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: The gold standard for diagnosis of proteinuria in pre-eclampsia is traditionally a 24-h urine collection. Current Australian guidelines advocate use of the spot urine protein-to-creatinine ratio (PCR); however, there is controversy in the international literature about its accuracy and little recent Australian data exists., Aim: To clarify the accuracy of the spot urine PCR in a cohort of Australian women with pre-eclampsia., Methods: Women with pre-eclampsia over a 52-month period from a single obstetric unit were included in the study. Spot urine PCR, 24-h urine collection, gestation at delivery, severe hypertension in labour and magnesium sulphate requirement were recorded. Primary analysis of predictive values was performed on women who had had both a spot urine PCR and a 24-h collection. Continuous data were assessed using least squares analysis with Pearson correlation coefficient, Bland-Altman plot and receiver operator characteristics curve., Results: Two hundred and seventeen women had pre-eclampsia, and 121 of these underwent both tests. The two tests were highly correlated (r = 0.98, P < 0.0001). The urine PCR had a positive predictive value of 94% and a sensitivity of 95% for predicting proteinuria. There were no significant increases in the diagnosis of severe hypertension in labour nor the need for magnesium sulphate infusion in labour in those women in whom the 24-h collection was omitted., Conclusions: The urine PCR is highly accurate in predicting significant proteinuria in women with pre-eclampsia using the recommended cut-off of 30 mg/mmol. Our findings support current guidelines suggesting the use of a 24-h urine collection is now rarely required., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: Premenopausal women with early endometrial cancer may wish to maintain their fertility, and for some patients non-surgical treatment options may be attractive. We have examined our own experience with such patients, as there are limited published data so far to support clear guidelines in this area., Design: Retrospective analysis of a case series., Setting: Case series from a specialist gynaecological oncology unit in a major tertiary referral hospital., Sample: Sixteen patients receiving progestogen therapy for stage-1 endometrial cancer., Methods: We reviewed our experience of all patients receiving progestogen therapy for stage-1 endometrial cancer, and we particularly examined their cancer-free outcome and fertility potential., Main Outcome Measures: Response to treatment, duration of response, and subsequent pregnancies., Results: Of the 16 patients investigated, four received an oral progestogen, five received the levonorgestrel-releasing intrauterine system (Mirena), and seven received both forms of treatment. Ten patients (63%) responded to treatment, with a median time to response of 5.5 months. Six patients did not respond to treatment, but all were either early in treatment or opted for surgical management before the average time of response. No patient who responded had a later recurrence. The mean total follow-up time was 27 months (range 3-134 months), with no patient deaths. Three patients had successful pregnancies, with one patient having two children., Conclusions: This form of treatment appears to be a realistic treatment option in selected patients in the closely supervised environment of a specialist gynaecological oncology unit.