Welcome to Edition Five

Spring is here with the promise of warmer weather. School holidays are upon us again, and hopefully the end of the tsunami of viral infections that have characterised this winter.

At Hobart OBGYN we are proud to provide private obstetric care for both high and low risk pregnancies by a group of experienced obstetricians.We have the support of a dedicated team of midwives, high quality point-of-care ultrasound and a friendly administrative team, and provide our services at a reasonable cost. Our rooms are happy to provide nancial estimates of any out-of-pocket costs, including estimates for women who wish to deliver uninsured in a private hospital.

Vaccinations in Pregnancy

As you may be aware,the recommendation for PertussisVaccination in pregnancy changed earlier this year. Due to increasing evidence of the effectiveness and safety of the dTpa vaccination during pregnancy, it is now recommended as a single dose during the third trimester of each pregnancy. The optimal time is early in the third trimester between 28 and 32 weeks.This is regardless of the timing of the last immunisation. Transplacental transfer of pertussis antibodies from the vaccinated women to the foetus gives passive immunity to the newborn more effectively than postpartum immunisation. Antibody levels peak two weeks after immunisation and the most effective placental antibody transfer is from 30 weeks. Family members do not need to be re-immunised with each pregnancy if they are already up to date.

New: We are very pleased to be able to offer a vaccination service to our antenatal patients.We are now able to provide in our rooms the In uenza and Pertussis vaccinations suggested by the National Immunisation Program for all pregnant women, through the Immunise Australia Program.We have found that being able to provide the vaccinations on the day they are suggested has greatly increased our vaccination rates.The convenience of the service has been very much appreciated by our patients. 

Gynaecological Services

As well as the full range of consultations for general gynaecology, we have a range of specific expertise in areas such as pelvic floor defects, adolescent gynaecology, infertility and advanced laparoscopic and hysteroscopic procedures. Colposcopy and urodynamics are both performed in our well equipped procedure rooms. Our gynaecologists are all certified colposcopists.

If women without private insurance wish to choose their surgeon, when they have their gynaecologial procedure and avoid the waiting lists, having their procedure as an uninsured patient in the private system is an option.We are happy to provide advice and our rooms can arrange nancial estimates.

We aim to provide an affordable, high quality service for you and your patients. If we can be of any assistance please feel free to contact our rooms on 6228 3331.

Hobart OBGYN Scholarships

We were pleased this year to support some talented young Tasmanian women through the inaugural Hobart OBGYN Scholarship at the Southern Tasmanian Dancing Eisteddfod. The scholarships will support these women to explore vocational training opportunities in dance. Bethany Reece and Anaya Latham were the first two recipients.

Reducing Ovarian Cancer Risk with Salpingectomy

Some women having a hysterectomy or pelvic surgery for benign causes may have returned to you also having had a bilateral salpingectomy. In recent times there has been the suggestion that some ovarian cancer may arise in the fallopian tubes.This has gained momentum due to the finding of lesions with “pre-malignant” potential in the fallopian tubes of BRCA mutation carriers having prophylactic surgery to reduce their risk of ovarian cancer. It has also been known for a long time that a tubal ligation reduces the relative risk for ovarian cancer. Over the last couple of years more and more literature has been published supporting the concept of prophylactic bilateral salpingectomy in the hope of reducing the risk of ovarian cancer.

A Swedish group looked at the incidence of ovarian malignancy in women who had tubal surgery (250,000 women) compared with the general population (5.5 million controls). Overall some form of tubal occlusion or removal gave a hazard risk of 0.65 (CI 0.52-0.81).Unilateral salpingectomy had a HR of 0.71 (CI 0.56-0.91) and a bilateral salpingectomy halved the risk to 0.35 (CI 0.17-0.73).

During open or laparoscopic surgery a bilateral salpingectomy adds little to the operating time and to the risk of the procedure. There is a theoretical concern about compromise to the blood flow to the remaining ovary – however this has not been seen to date in the literature. Hence it seems with mounting evidence of bene t and minimal risk with no evidence of harm, it is important to offer women already having surgery the opportunity of possibly reducing their risk of ovarian cancer.With no screening test as yet, ovarian cancer remains a disease characterised by late diagnosis and poor prognosis.Women choosing permanent contraception by tubal occlusion should also be given the opportunity to discuss bilateral salpingectomy along with other methods.

Quick Fact: A large Taiwanese Cohort Study has recently confirmed the association of ovarian endometriosis with ovarian cancer. Their study showed a four times risk of ovarian cancer and interestingly a 4-5 times risk of ovarian and endometrial cancer in women with adenomyosis.

Oral Contraceptive and VTE

We all know there is an association between oral contraceptive use and the risk of venous thromboembolism.There has also been a lot of ‘bad press’ about the newer progestogen based OCP’s (desogestrel, gestodene, drospirenone or cyproterone) having a significantly increased risk. A case-matched study of over 10,000 cases of VTE collected from UK medical records over the last 10 years was recently published in the BMJ.

In absolute numbers per year, a woman’s risk of VTE was:

Per 10,000
%
Those not using the OCP
4 0.04
Those using OCP containing older progestogens
10 0.10
Those using OCP containing newer progestogens
16 0.16

 

This has to be compared to:

Per 10,000 %
The risk of VTE whilst pregnant

29

0.29
The risk of VTE in the immediate postpartum period
300 3.00

 

It must be noted that in many trials the VTE rates between the progestogens is essentially the same.

The newer progestogens have been developed to avoid androgenic side effects and some have been designed with additional potential bene ts such as drospirenone which is a spironolactone analogue that has a mild diuretic effect. Certainly some of the progesterone related side effects such as headache, breast tenderness and weight changes are improved with the newer preparations. Break through bleeding may also respond to a preparation change.

The risk of VTE is increased in the rst 12 months of OCP prescription.With a break of treatment, the risk of VTE increases even after a short break of four months, and increases with increasing length of the break. Thus stopping and starting the OCP increases the risk of VTE. Other factors that in uence the risk of VTE with the OCP are age, smoking and BMI >30. For example a woman aged in her forties with a BMI >30 has a RR of 40 for VTE.

We need to remember that for most women the bene ts of the OCP regardless of whether they contain a new or old progestogen, outweigh the risks.