Therese McGee

Acute Appendicitis in Pregnancy

Summary: Acute appendicitis is the commonest nongynaecological surgical problem occurring during pregnancy. Almost 10 years experience at a large teaching hospital is supplemented with an extensive review of the literature to offer guidelines for diagnosis and management. Symptoms, signs and investigations are unhelpful in diagnosis. The overwhelming message is that because perinatal mortality rises from less than 3% in both uncomplicated appendicitis and negative laparotomy, to 20% in perforated disease, the maxim regarding acute appendicitis — if in doubt, take it out — is never more true than in pregnancy.

βhCG monitoring after single‐dose methotrexate treatment of tubal ectopic pregnancy: Is the Day 4 βhCG necessary? A retrospective cohort study

In ectopic pregnancy (EP) management, failure of βhCG to fall more than 15% between Days 4 and 7 after methotrexate administration indicates the need for a second dose. Regimens preferring a 25% fall in βhCG between methotrexate administration and Day 7 have been proposed.

Readmissions for surgical site infections following caesarean section

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n = 42). Thirty‐seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co‐morbidities that predisposed them to infection.

Response to: Confounding factors in readmissions due to surgical site infections after caesarean section

Dear Editor, We would like to thank the author of this letter for their interest in readmissions for surgical site infections following caesarean section surgery and their comments on our paper. Firstly, regarding readmissions of patients to other hospitals, we agree that this information would have given us a more complete dataset; however, we do not believe that significant numbers were missed. Most patients (90%) are public and the majority live very close to the hospital with birthing restricted to those in nominated local government areas. Tracking readmissions in the small number of highrisk outofarea women, including those from the country, who presented to other hospitals rather than coming back to Westmead would have been difficult due to the large catchment area. Ideally, a statewide database would allow the identification of all patients for future studies. Secondly, readmissions for acute pain were uncommon – they were detected as International Classification of Diseases – 10 categories of ‘Other and unspecified abdominal pain’ or ‘Pain localised to other parts of lower abdomen’ which accounted for <3% of readmissions. Of course, many of the women being readmitted with pyrexia, endometritis, secondary postpartum haemorrhage, migraine, severe hypertension or mastitis may have had pain, but the diagnostic category allocated to each case is the underlying cause, rather than the pain itself. From the time of caesarean section, women are given regular paracetamol and a nonsteroidal antiinflammatory drug supplemented with oxycodone as required. They are strongly encouraged to continue with adequate regular analgesia at home. This, together with an active midwifery discharge program, probably contributes to low rates of readmission for acute abdominal pain as a diagnosis in itself. Finally, previous studies have identified emergency surgery as a risk factor for surgical site infections postcaesarean section.1,2 Our study was an observational study, which was not designed or powered to determine risk factors. Therefore, we could not conclude that emergency surgery was a risk factor for wound infection, rather that surgical site infections were the most common reasons for readmissions following caesarean section.

Documentation of instrumental vaginal deliveries

Background: Instrumental vaginal deliveries (IVDs) account for approximately 11% of births in Australia. Complications resulting from IVD can occasionally be the subject of litigation. The Royal College of Obstetricians and Gynaecologists suggests a standardised pro forma in their guidelines as an aid to accurate and complete IVD documentation. Many units, including ours, use less structured reporting, which is probably also less adequate. Aim: To assess whether the introduction of a dedicated IVD form improves the quality of IVD documentation. Method: Analysis of the quality of IVD documentation before and after the implementation of a new dedicated IVD form. A survey to evaluate clinicians’ opinion on the new standardised form. Results: Significant improvement was found in documentation of key information including the documentation of caput (p < 0.05), type of instrument, number of ventouse cup detachments, moulding of specific sutures, abdominal palpation (number of fifths of foetal head palpable), liquor colour and total time of instrument application (p < 0.001). A majority of clinicians believed the form to be beneficial in terms of completeness and that it reduced the amount of time required for documentation. Conclusions: IVD documentation is enhanced by the use of a dedicated form. Clinical judgement may also be enhanced by the discipline involved in the formal assessment required by the form.

Sublingual misoprostol for management of empty sac or missed miscarriage: The first two years’ experience at a metropolitan Australian hospital

Misoprostol management of miscarriage is only now becoming widely used in Australia.

Blood pressure profile in pregnancy: The impact of its duration on results and patients' well‐being

A blood pressure profile (BPP) is often used to diagnose and manage hypertension in pregnancy. However, there is no consensus on the number and interval of blood pressure (BP) readings required.