Welcome to Dr. Naomi Saunder

We are very pleased to have Naomi join our experienced team of Gynaecologists.

Dr Saunder is a recently elevated FRANZCOG fellow, finishing in 2012 with the Gynaecological Oncology Team at the Royal Hobart Hospital.  Originally from Melbourne, where she completed her MBBS at the University of Melbourne, Naomi undertook a post-fellowship position at Monash Medical Centre as a Urogynaecology fellow in 2013.

After Naomi and her family fell in love with Tasmania during their time in 2012, they have decided to return and resettle in Hobart, with Naomi working as a Staff Specialist at the Royal Hobart Hospital with a special interest in the pelvic floor.

Naomi is excited to join Hobart OBGYN, providing general gynaecology  services.  Her main interest is in the management of pelvic floor dysfunction including urinary incontinence, bladder pain, sexual dysfunction and prolapse.  She undertakes urodynamics, prolapse and incontinence surgery, laparoscopy, open surgery and operative hysteroscopy.

She is a member of the Urogynaecological Society of Australia (USGA) and actively participates in annual meetings and is looking forward to the combined international meeting in Washington later in the year.  Naomi is married with one daughter, and enjoys spending time with her family exploring Tasmania and trying to keep warm.

She is taking referrals now.  It is a pleasure to be able to reduce our waiting time for women waiting for gynaecological review.

 

Jane Barker (Pelvic Floor Physiotherapist) Consulting from Hobart OBGYN

Providing a comprehensive service to women with Pelvic Floor concerns is very important to us at Hobart OBGYN.  Physiotherapy is a vital component of treatment for incontinence, prolapse, dyspareunia and pelvic pain as well as issues that arise during pregnancy.

Jane graduated as a physiotherapist in 1988 and has worked in a variety of settings.  In 2001-2004 she worked on Calvary’s maternity ward.

As a result of the fulfilment she gained from this, she went on to complete postgraduate qualifications in the management of continence and pelvic floor rehabilitation.  Since then she has worked as the principle of her own practice with a caseload exclusively in the provision of women’s health services and pelvic floor management.  Her special interests include optimizing bladder, bowel and sexual function as well as guiding women into safe forms of exercise and fitness.  She is passionate and focused on improving the lifestyle of women in their childbearing years and beyond.

 

The “Blood Test for Down’s Syndrome”

Non invasive prenatal testing (NIPT) for fetal aneuploidy via maternal blood sampling sounds ideal, and is now available in Hobart through Hobart Pathology (Verifi©).

What is NIPT and how good is it?

The placenta sheds small fragments of fetal DNA into the maternal circulation called cell-free fetal DNA.  It is enough to be detected and analysed by massive parallel sequencing, and register a “chromosomal dosage imbalance” or aneuploidy.  It is a highly accurate screening test.  The sensitivity of this test for detecting Trisomy 21 is 99.5% and the specificity is 99.8%.  The negative likelihood ratio for a negative result is 0.005.  It is therefore the most efficient screening tool available for Down’s Syndrome.  The numbers are almost as good for Trisomy 18, 13 and sex chromosome anomalies (Turner’s Klinefelter, Triple X Syndrome).  False positives rates are significantly lower (<1%) compared to standard testing (5% for traditional combined first trimester screening).

So Where does NIPT fit in with our practice?

Currently it is regarded as a highly effective screening test – NOT a diagnostic test.  Abnormal results still require confirmation with an invasive test—preferably amniocentesis.

The excellent specificity of the test allows women with an increased risk of Down’s Syndrome (eg. High background risk or a high risk combined first trimester screening result) to confidently decline invasive testing and its’ associated risk.  And indeed we offer this test for all of these high risk women prior to an amniocentesis or CVS.  We still encourage women with a high background risk to have combined first trimester screening as well

What are the Problems with NIPT?

It does not provide the same information as the current tests.  Trisomies 21, 18, 13 and sex chromosome abnormalities make up only 70% of the abnormal results found after abnormal first trimester screening.  Therefore this test will miss atypical chromosomal abnormalities.  The bottom line, there is a 2.5% risk of missing a clinically relevant undetected atypical chromosomal anomaly.

Invasive testing is still recommended in the presence of a fetal structural anomaly detected on ultrasound or a very high risk result (>1:10) on combined screening as these cases are more likely to have an atypical result.

Other things to consider—there is around a 2% sample failure rate.  The ideal time for the test to reduce sample failure is around 11-13 weeks gestation.  Failure rates are higher in women with an increased BMI.  There are limitations with those who have had an organ transplant, stem cell therapy and using donor eggs.

As the free DNA is placental (trophoblast) in origin, false positives can be reported in the case of maternal tumours and placental mosaics.  Fetal mosaics can also be missed.  The test analyses maternal DNA as well—so it may diagnose a maternal condition eg. Maternal 47 XXX which will be an unintended result from the test.

The advantages of combined first trimester screening go beyond detection of Down Syndrome—it gives a biochemical measure of placental function (and can help identify pregnancies at risk of pre-eclampsia, IUGR etc), an early ultrasound assessment of major structural anomalies, accurate dating, early diagnosis of multiple pregnancy and determination of chorionicity.  NIPT does not replace the 12 week ultrasound.

We can however take advantage of the negative predictive value of this blood test to reduce invasive testing in high risk women.  Samples are sent overseas and results take around 10 days to return.

Last, but not least, the test currently costs the patient $700 and is completely out of pocket (not covered by Medicare or Private Health insurance rebate).  This therefore puts it out of reach of a lot of our patients.

How it will be formally integrated into the Aneuploidy Screening program in Australia is yet to be seen.

Review article: Noninvasive prenatal testing for trisomy 21: Challenges for Implantation in Australia L Hui and J Hyett ANZJOG 2013; 53:416-425,

Dating Scans

All of our obstetricians can perform first trimester dating scans in our rooms.  This can save your patients the extra cost and inconvenience of attending an extra ultrasound prior to their first visit.  If there is concern about unknown LMP, bleeding or pain, previous miscarriage or ectopic please note this on your referral and our first visit will be scheduled at the appropriate clinical time.  Please note our routine visit is usually scheduled around 8—10 weeks gestation.