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Aims: To assess clinical outcomes and complications in women with ≥1 prior caesarean delivery (CS) during mid‐pregnancy medical abortion with misoprostol following mifepristone priming. Materials and Methods: Retrospective analysis of abortions at 13–28 weeks gestation using sequential mifepristone and misoprostol at a single centre from 1/2008–12/2018. Procedural outcomes were compared between cases with no prior CS, one prior and ≥2 prior CS. Results: There were 1399 consecutive women who underwent a medical abortion, with 304 (21.7%) having ≥1 prior lower segment CS (241 one, 49 two, 12 three, one four) and one a prior classical CS. Median gestation was 19 weeks (interquartile range (IQR) 17–21) among nulliparas, multiparas with no prior CS and multiparas with prior CS, P = 0.505. Compared with nulliparas (median procedural duration 10.8 h, IQR 7.5–16.5; adjusted hazards ratio (aHR) = 1.20 95%CI 1.04–1.40, P = 0.015), multiparas with prior CS had a shorter procedural duration (9.5 h, IQR 6.5–13.5) while multiparas with no CS had the shortest duration (7.0 h, IQR 5.0–9.8; aHR = 2.28 95%CI 2.01–2.58, P < 0.001). Complications were more frequent with prior CS: estimated blood loss (medians: 100 cc no CS vs 150 cc ≥1 CS, P = 0.002), blood loss >1000 cc (3.6% no CS vs 7.2% ≥1 CS; odds ratio (OR) = 2.11 95%CI 1.23–3.62, P = 0.007) and placental retention (17.3% no CS vs 25.3% ≥1 CS; adjusted OR = 1.44 95%CI 1.05–1.99, P = 0.024). Uterine rupture occurred in 4/304 women with ≥1 prior CS (1.3%). Conclusions: Mifepristone‐misoprostol abortion in women with prior CS is generally safe but associated with an increased risk of procedural complications. Lowering of the misoprostol dosage with prior CS may reduce uterine rupture, although this hypothesis requires ongoing research. [ABSTRACT FROM AUTHOR]

Background: Non‐invasive prenatal testing (NIPT) using cell‐free DNA (cfDNA) has expanded from detecting chromosome aneuploidy to testing for a variety of genetic conditions, including some select single gene disorders. As next generation sequencing/whole exome sequencing technology develops, it may be possible to expand NIPT of cfDNA to identify hundreds of single gene and chromosomal disorders in a fetus, thereby increasing the complexity of pretest counselling and parental decision‐making. Aim: The aim of this study was to assess the views of women on the phenotypes of genetic conditions potentially detectable with expanded NIPT that they would consider severe enough to warrant pregnancy termination. Materials and Methods: Using multiple clinical scenarios, we asked women via an online survey about the early detection of several well‐described genetic phenotypes in pregnancy that in theory could be detected by expanded NIPT. Results: Two hundred and nineteen women participated in this study. There was high support for early diagnosis and the option for termination of pregnancy in conditions perceived as severe (52–71%). Women expressed a preference for testing to be provided by general practitioners and assigned a high value to genetic counselling support (75–90%). In the case of a continuing pregnancy, women recognised the essential role of ongoing psychosocial counselling for family members and childhood early intervention programs. Conclusion: Women expressed clear preferences for termination of pregnancy for severe conditions and as early in gestation as feasible. Information and support from genetic counsellors are a highly valued resource in decision‐making following a prenatal diagnosis of a fetal genetic abnormality. [ABSTRACT FROM AUTHOR]

Objective: To determine the epidemiology, clinical management, and outcomes of women with gestational breast cancer (GBC). Methods: A population‐based prospective cohort study was conducted in Australia and New Zealand between 2013 and 2014 using the Australasian Maternity Outcomes Surveillance System (AMOSS). Women who gave birth with a primary diagnosis of breast cancer during pregnancy were included. Data were collected on demographic and pregnancy factors, GBC diagnosis, obstetric and cancer management, and perinatal outcomes. The main outcome measures were preterm birth, maternal complications, breastfeeding, and death. Results: Forty women with GBC (incidence 7.5/100 000 women giving birth) gave birth to 40 live‐born babies. Thirty‐three (82.5%) women had breast symptoms at diagnosis. Of 27 women diagnosed before 30 weeks' gestation, 85% had breast surgery and 67% had systemic therapy during pregnancy. In contrast, all 13 women diagnosed from 30 weeks had their cancer management delayed until postdelivery. There were 17 preterm deliveries; 15 were planned. Postpartum complications included the following: hemorrhage (n = 4), laparotomy (n = 1), and thrombocytopenia (n = 1). There was one late maternal death. Eighteen (45.0%) women initiated breastfeeding, including 12 of 23 women who had antenatal breast surgery. There were no perinatal deaths or congenital malformations, but 42.5% of babies were preterm, and 32.5% were admitted for higher‐level neonatal care. Conclusions: Gestational breast cancer diagnosed before 30 weeks' gestation was associated with surgical and systemic cancer care during pregnancy and planned preterm birth. In contrast, cancer treatment was deferred to postdelivery for women diagnosed from 30 weeks, reflecting the complexity of managing expectant mothers with GBC in multidisciplinary care settings. [ABSTRACT FROM AUTHOR]

Background: Routine cervical length (CL) measurement at the mid‐pregnancy ultrasound is a central recommendation of the Western Australian Preterm Birth Prevention Initiative (Initiative). Aim: To evaluate the perceptions and changes in practice of Western Australian obstetric care providers regarding routine CL screening for preterm birth (PTB) prevention following the Initiative introduction. Methods: Two self‐administered questionnaires were completed by providers from a range of practices. The first was during site visits with the Initiative Outreach team in 2015–2016. The questionnaire was re‐issued in 2021 via online dissemination. Participant demographic data and opinions on CL screening for PTB prevention were collected. Results: Two hundred and fourteen providers participated in 2015–2016 and 109 in 2021. In both surveys, providers were more likely to discuss transvaginal CL screening with high‐risk women (48.1%, 76.1%; P < 0.001) compared with low‐risk (7.5%, 18.3%; P = 0.002) and the importance of CL screening (13.5%, 40.4%; P < 0.001), in 2015–2016 and 2021, respectively. Responses relating to CL screening, including what constitutes a short cervix on ultrasound were varied. A transabdominal CL <35 mm was classified as short by 46.2% and 37.6% and <25 mm on transvaginal ultrasound by 49.1% and 64.2%, in the respective surveys. Most providers ceased progesterone (68.6%, 75.2%) at >28 weeks gestation. Conclusions: Providers focused on women with overt PTB risk factors, rather than a universal CL screening approach. Although there was improvement between the surveys, the definition of what constitutes a short cervix on ultrasound and how to treat and monitor women with a short CL remained varied. [ABSTRACT FROM AUTHOR]

Background: The Western Australian Preterm Birth Prevention Initiative was officially launched in November 2014. It demonstrated an initial decrease in the preterm birth rate in Western Australia. One of the key points of this initiative is the routine ultrasound measurement of the cervical length in mid‐pregnancy. Aim: The aim of this study was to evaluate the perceptions and attitudes of Western Australian women regarding transvaginal cervical length (TVCL) screening for preterm birth prevention. Materials and methods: Self‐administered questionnaires were completed by pregnant women before and after their mid‐trimester obstetric ultrasound. Maternal demographical and medical data were collected in addition to opinions of TVCL screening. Results: A total of 598 women participated with the maternal age range representative of the Western Australian obstetric population. There was a high rate of acceptance of TVCL imaging, with 2% of the 149 women declining a transvaginal ultrasound (TVU) offered in this study, 1.5% refusing a TVU in the past and 5.7% reporting that they would have a concern in having a TVU in the future. Women stated that they either had declined TVCL in the past (11%) or would decline in the future (30.7%) as they wanted to discuss the procedure with their clinician first, had been advised not to have a TVU by their clinician (11% in the past and 47.7% in the future) or felt uncomfortable with the operator (22% at a previous TVU and 34.4% in the future). Conclusion: Pregnant women participating in this study had a high acceptance of TVCL screening for preterm birth prevention. [ABSTRACT FROM AUTHOR]

Background Increasingly couples are travelling overseas to access assisted reproductive technology, known as cross border reproductive care, although the incidence, pregnancy outcomes and healthcare costs are unknown. Aims To determine obstetric and neonatal outcomes for multiple pregnancies conceived through fertility treatment overseas, and estimate cost of these pregnancies to the health system. Materials and methods Retrospective study of women receiving care for a multiple gestation between July 2013 and June 2015 at Western Australia's sole tertiary obstetric hospital, where conception was by overseas fertility treatment. Obstetric and neonatal outcomes were recorded and cost estimates calculated. Results Of 11 710 births, 422 were multiple pregnancies. Thirty-seven pregnancies were conceived with fertility treatment, with 11 (29.7%) conceived overseas. Median antenatal clinic attendances, ultrasound examinations, and fetal assessments for the overseas fertility cases were six, 10, and nine, respectively. The gestational age at delivery ranged from 30 to 38 weeks (median 34 + 1). Median neonatal admission duration was 18 days (range 0-47). Cost for obstetric care was estimated between $170 000 and $216 000, and cost of neonatal care was estimated as $810 000, giving a combined total cost of between $980 000 and $1 026 000. Conclusion At the sole tertiary obstetric centre in WA, approximately one-third of all multiple pregnancies conceived with fertility treatment resulted from treatment overseas. The Australian healthcare cost for these 11 women and their infants exceeded $1 000 000. This study suggests that overseas fertility treatment has a significant health-related cost to the mother and infant, and the local healthcare system. [ABSTRACT FROM AUTHOR]

Background Contingent screening for trisomy 21 using non-invasive prenatal testing has the potential to reduce invasive diagnostic testing and increase the detection of trisomy 21. Aim To describe the diagnostic and economic performance of prenatal screening models for trisomy 21 that use non-invasive prenatal testing as a contingent screen across a range of combined first trimester screening risk cut-offs from a public health system perspective. Methods Using a hypothetical cohort of 300 000 pregnancies, we modelled the outcomes of 25 contingent non-invasive prenatal testing screening models and compared these to conventional screening, offering women with a high-risk (1 > 300) combined first trimester screening result an invasive test. The 25 models used a range of risk cut-offs. High-risk women were offered invasive testing. Intermediate-risk women were offered non-invasive prenatal testing. We report the cost of each model, detection rate, costs per diagnosis, invasive tests per diagnosis and the number of fetal losses per diagnosis. Results The cost per prenatal diagnosis of trisomy 21 using the conventional model was $51 876 compared to the contingent models which varied from $49 309-66 686. The number of diagnoses and cost per diagnosis increased as the intermediate-risk threshold was lowered. Results were sensitive to trisomy 21 incidence, uptake of testing and cost of non-invasive prenatal testing. Conclusion Contingent non-invasive prenatal testing models using more sensitive combined first trimester screening risk cut-offs than conventional screening improved the detection rate of trisomy 21, reduced procedure-related fetal loss and could potentially be provided at a lower cost per diagnosis than conventional screening. [ABSTRACT FROM AUTHOR]

Aim To describe the potential impact of using noninvasive prenatal testing ( NIPT) as a second-tier test, on the diagnosis and outcomes of pregnancies identified as high risk through first trimester screening ( FTS) in a cohort of real pregnancies. Materials and Methods Western Australian FTS and diagnostic data (2007-2009) were linked to pregnancy outcomes. Karyotype results from invasive prenatal testing in high-risk women were analysed. The outcomes of abnormal results that would not be detected by NIPT, assuming a panel of trisomy 21/18/13 and sex chromosome aneuploidies, and the likelihood of diagnosis in a screening model using NIPT as a second-tier test are described. Results Abnormal karyotype results were reported in 224 of 1488 (15%) women with high-risk pregnancies having invasive diagnostic testing. NIPT potentially would have identified 85%. The 33 abnormalities unidentifiable by NIPT were triploidies ( n = 7, 21%), balanced ( n = 8, 24%) and unbalanced rearrangements ( n = 10, 30%) and level III mosaicisms ( n = 8, 24%). For conditions not identifiable by NIPT, fetal sonographic appearance was likely to have led to invasive testing for 10 of 17 (59%) pathogenic abnormalities. If a policy was adopted recommending invasive testing for FTS risk >1:50 and/or ultrasound detected abnormality, the residual risk of an unidentified pathogenic chromosomal abnormality in those without a diagnosis would have been 0.33% (95% CI 0.01-0.65%). Conclusions A screening model with NIPT as a second-tier for high-risk pregnancies would be unlikely to have changed the outcome for the majority of pregnancies. Optimising the diagnosis of rare pathogenic abnormalities requires clear indicators for invasive testing over NIPT. [ABSTRACT FROM AUTHOR]

Introduction Approximately 10-15% of term babies may require admission to neonatal special care units. This level of care is frequently an unexpected event for parents. Aims To review the frequency and obstetric risk factors associated with the admission of term neonates to a tertiary hospital special care unit ( SCN). Materials and Methods All babies born ≥37-weeks gestation admitted to the SCN at King Edward Memorial Hospital between 2004 and 2006 were identified from the institutional maternity and neonatal databases. Maternal and obstetric factors were reviewed to identify potential predictors of admission to the SCN. Results During the study period, 1671 term neonates born to 1624 women were admitted to the SCN (14.4% of term deliveries). Neonatal intensive care unit admissions accounted for 10.6% of the term admissions. The most common reasons for SCN admission were respiratory complications ( n = 421, 25.2%), observation postresuscitation ( n = 402, 24.1%) and hypoglycaemia ( n = 152, 9.1%). Elective caesarean delivery was significantly associated with admission to the special care unit for respiratory complications compared with all other delivery modes (37 vs 23%, P < 0.001), particularly if the birth occurred at <39-weeks gestation (38 vs 24%, P < 0.001). Conclusions In our population of women delivering at a tertiary maternity facility, approximately 1:8 term babies were admitted to the neonatal special care unit. Elective caesarean delivery was associated with a significant risk of admission for respiratory complications compared with other birth modes, especially when <39-weeks gestation. [ABSTRACT FROM AUTHOR]

Background Fetal and neonatal alloimmune thrombocytopenia ( FNAIT) is the most common cause of severe perinatal thrombocytopenia, arising from the transplacental passage of maternal antibodies directed at paternally inherited antigens on fetal platelets. Aim To review the occurrence, management and perinatal outcomes of pregnancies complicated by FNAIT from a single tertiary obstetric hospital in Western Australia. Materials and Methods The study was conducted as a retrospective review of cases with prenatally recognised FNAIT between 2001 and 2011, with the treatment modalities and outcomes analysed. Results Over the 10-year period, 20 cases of clinically significant FNAIT in 13 women were managed at our centre. Three cases were complicated by antenatal intracranial haemorrhage (15%), and in all 3, this was the presenting feature leading to diagnosis. In 17/20 (85%) cases, anti- HPA 1a was the responsible antibody, with the remainder being anti- HPA 5b. In 16/17 cases with pre-pregnancy recognition, intravenous gammaglobulin ( IVGG) was administered antenatally (gestation at commencement ranging from 13 to 26 weeks) with adjuvant prednisolone in three cases. Postnatal treatment ( IVGG or platelet transfusion) was provided in 4/16 cases. There was no intracranial haemorrhage or demise in any case receiving prenatal therapy. Conclusions FNAIT is a rare and serious condition. In our small single-centre study, there was variability in the therapeutic strategies, although IVGG was central to all prenatally managed pregnancies. None of the treated pregnancies was complicated by intracranial haemorrhage or fetal death. There is a need for ongoing refinement of FNAIT management protocols, both in the prenatal and in the postnatal period. [ABSTRACT FROM AUTHOR]

Introduction: The introduction of an audience response system (ARS) in the obstetrics and gynaecology course for medical students at The University of Western Australia provided an opportunity to measure knowledge gain by ARS lecture formats compared with didactic lectures. Methods: The study was conducted over four obstetrics and gynaecology terms, alternating the ARS and didactic format between two selected lectures each term. Students completed multiple-choice quizzes immediately post-lectures and 5 weeks later. Results: Immediate post-lecture quiz mean scores for the ARS lectures were significantly higher compared with scores for the didactic lectures (7.5 vs. 6.7, p < 0.001). Pairwise comparisons between ARS and didactic lectures for each lecture topic showed significantly higher quiz scores for ARS lectures (preterm labour 8.3 vs. 7.4, p == 0.032; and prenatal diagnosis 6.9 vs. 6.0, p == 0.014). Quiz scores for the didactic preterm labour lecture were significantly higher than scores for the didactic prenatal diagnosis lecture (6.0 vs. 7.4, p < 0.001). Quiz results at 5 weeks showed no differences in scores between the ARS and the didactic lectures and no differences between lecture topics. Conclusions: Use of the ARS in lectures appeared to improve knowledge gain immediately post-lecture but no difference was found after retesting at 5 weeks. [ABSTRACT FROM AUTHOR]