MIND MATTERS

Vol. 20 No. 3 | Spring 2018

a RANZCOG publication The College 5 From the President Steve Robson

Vol. 20 No. 3 Spring 2018 9 From the CEO Alana Killen O&G Magazine Advisory Group Dr Gillian Gibson Fellows Rep, New Zealand 11 Leaders in focus Dr Bernadette White Fellows Rep, VIC Dr William Milford Young Fellows Rep, QLD Kirsten Connan with Marilyn Clarke Dr John Schibeci Diplomates Rep, NSW Dr Brett Daniels Fellows Rep, TAS Dr Fiona Langdon Trainees Rep, WA Mind matters 14 Editorial O&G Magazine Editors Brett Daniels Rachel Corkery Lisa Westhaven 15 Perinatal mental health: an area of specialty Layout and Production Editor Renée Miller, Hettie Dubow & Klara Szego Rachel Corkery 18 Schizophrenia and psychotic disorders Designer Megan Galbally & Caroline Crabb Shay Colley Whitehart 21 Perinatal depression and anxiety Editorial Communications Rebecca Hill, Rosalind Powrie & Anne Sved Williams O&G Magazine Advisory Group RANZCOG 254–260 Albert Street 24 Antidepressants in East Melbourne, VIC 3002 Australia Lyndall White (t) +61 3 9417 1699 (e) [email protected] 26 Eating disorders in adolescents and young women Advertising Sales Danielle Pogos & Michele Yeo Bill Minnis Minnis Journals 29 Substance misuse and dependence in pregnancy (t) +61 3 9836 2808 Helen Winrow & Nicholas Walker (e) [email protected] 32 Personality disorders in clinical practice Jonathon Tremain Louise Newman Tremain Media (t) +61 2 9988 4689 (e) [email protected] 34 Psychosomatic disorders Bharat Visa, Yasaman Rezaei Adli & Louise Newman Printer Southern Colour 36 Postpartum psychosis: a practical management (t) +61 3 8796 7000 guide for obstetricians O&G Magazine authorised by Ms Alana Killen Marie-Paule Austin © 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). All rights reserved. No part of this 39 Mental health and pelvic pain publication may be reproduced or copied in Susan Evans & Tiffany Brooks any form or by any means without the written permission of the publisher. The submission of articles, news items and letters is encouraged. 42 Birth trauma and post-traumatic stress disorder Debra Creedy & Jenny Gamble For further information about contributing to O&G Magazine visit: ogmagazine.org.au 44 Finding meaning in bad news: critical The statements and opinions expressed in articles, conversations in medicine letters and advertisements in O&G Magazine are Catherine Campbell those of the authors and, unless specifically stated, are not necessarily the views of RANZCOG. 46 Are mothers convicted of infanticide mentally ill? Although all advertising material is expected to Anne Buist conform to ethical and legal standards, acceptance does not imply endorsement by the College. 48 PMT, PMS and PMDD: is there a difference? ISSN 1442-5319 Martien Snellen, Josephine Power & Gaynor Blankley Cover art ©RANZCOG 50 and mental health Annabelle Brennan 52 Obstetricians and mental health: more than RANZCOG Regional Committees delivering babies New Zealand Dr Celia Devenish Chair Vijay Roach Jane Cumming Manager Level 6 Featherson Tower 54 Mental health in medical practitioners 23 Waring Taylor Street/ PO Box 10611 Paula Fernandez & Alana Gilbee Wellington 6011, New Zealand (t) +64 4 472 4608 (f) +64 4 472 4609 (e) [email protected] Women’s health Australian Capital Territory 56 World Contraception Day: LARC in focus Dr John Hehir Chair Catriona Melville & Kirsten Black Lee Dawson Executive Officer (e) [email protected]

60 New guidelines for care during pregnancy New South Wales Debra Thoms A/Prof Gregory Jenkins Chair Lee Dawson Executive Officer 61 Comparing maternal mortality in the UK and Australia Suite 2, Ground Floor, 69 Christie Street St Leonards, NSW 2065 Gerald Lawson (t) +61 2 9436 1688 (f) +61 2 9436 4166 (e) [email protected] 66 Case report: antenatal management of anorexia nervosa Queensland Katherine Grove, Fiona Langdon, Shivanthi Senaratne, et al Dr William Milford Chair Sylvia Williamson Executive Officer 69 Case report: a brain in the pelvis: anti-NMDA-receptor Unit 22, Level 3, 17 Bowen Bridge Road encephalitis and ovarian teratoma HERSTON, Qld 4006 (t) +61 7 3252 3073 Myriam Girgis & Unine Herbst (e) [email protected]

72 Case report: acute abdomen in the third trimester South Australia/Northern Territory Dr Amita Singla Chair Sarah Luthy, Leeanne Panisi & Briley Pinau Tania Back Executive Officer Level 1, 213 Greenhill Road 74 The leg-up Eastwood 5063 Nicole Woodrow & Vinay Rane (t) +61 8 8274 3735 (f) +61 8 8271 5886 (e) [email protected]

76 Q&A: endometrial sampling in general practice Tasmania Natasha Trpkovska & Sue Tutty Dr Lindsay Edwards Chair Lisa Del Din Executive Officer 78 From the editor’s desk College House 254–260 Albert Street Caroline de Costa East Melbourne, Vic 3002 (t) +61 3 9412 2998 80 Journal Club (e) [email protected] Brett Daniels Victoria Dr Charlotte Elder Chair The College Lisa Del Din Executive Officer College House 81 College Statements update 254–260 Albert Street East Melbourne, Vic 3002 Yee Leung (t) +61 3 9412 2998 (e) [email protected] 81 Notice of deceased Fellow Western Australia Dr Robyn Leake Chair 82 RANZCOG 2018 Provincial Fellows/WA/SA/NT RSM Carly Moorfield Executive Officer 44 Kings Park Road PO Box 1645, West Perth, WA 6872 83 FRANZCOG Advanced Training Modules (t) +61 8 9322 1051 (f) +61 8 6263 4432 Michael Permezel (e) [email protected]

The Royal Australian and New Zealand 84 Queen’s Birthday Honours Awards College of Obstetricians and Gynaecologists College House 254–260 Albert Street 85 Letters to the Editor East Melbourne, Vic 3002 Margaret Sparrow, Carol Shand & Lisa Rasmussen (t) +61 3 9417 1699 (f) +61 3 9417 0672 (e) [email protected] (w) www.ranzcog.edu.au 86 Obituaries

Vol. 20 No. 3 Spring 2018 | 3 THE COLLEGE

Vol. 20 No. 3 Spring 2018 | 5 Vol. Prof Steve Robson with American College of College of Robson with American Steve Prof President, Obstetricians and Gynecologists (ACOG) Dr Lisa Hollier. 2018 Annual Scientific Meeting RANZCOG 2018 ASM is set On a local scale, the RANZCOG For the first time, to run in Adelaide in September. Health Meeting is being our Indigenous Women’s workshops the same time. The pre-meeting held at and the Adelaide organising look to be excellent recent of hoping to top the programs committee are many of meetings in Perth and Auckland. I hope as travel you as possible will have the opportunity to looks to be a fantastic to South Australia for what College event. Ministerial Advisory Committee on Costs Out-of-Pocket The Ministerial Advisory Committee on Out- Costs was set up by Health Minister of-Pocket to public concerns about Hunt in response Greg costs to out-of-pocket with regards transparency by the is chaired The group healthcare. in private O&G Magazine, in its addresses the vitally O&G Magazine addresses This issue of mental health. As usual, the important subject of outstanding together an editorial team have brought to write. It is difficult to overstate experts of group to health and it is gratifying mental the importance of so many clinical of see such a detailed examination conundrums in this issue. for 15 years has been going strong format, current to be better and more now and each issue seems than the last. informative FIGO and of Federation The International and somewhat (FIGO) will seem a remote The College you. to many of peripheral organisation and was successful in bidding for the FIGO scientific is held clinical meeting for 2021. FIGO’s meeting Janeiro, de Rio in hosted be will everyand years three The next meeting this year. Brazil, in October of is the in 2021. The FIGO congress will be in Sydney meeting. largest global women’s health scientific which RANZCOG (of FIGO’s member organisations obstetrics and national is one) comprise nearly every gynaecology society in the world. for our College to host honour It is a great honour comes this meeting, but with that I am chairing the local considerable responsibility. do so in organising committee and will continue to I have met my capacity as College past-President. Carlos Fuchtner Prof with the FIGO President-elect, 2021 FIGO Sydney Bolivia, and arrangements for of the College and the On behalf of well underway. are intending to arrange we are local organising group, you are all of the best FIGO meeting yet! I hope that time for this event in your diaries. able to make Prof Steve Robson Prof Steve President From the President the From THE COLLEGE 22/01/2018 12:17 PM Vol. 20 No. 3 Spring 2018 | 7 Vol. been incredibly rewarding. I hope I can impress upon impress I hope I can rewarding. been incredibly an honour it has been to work with so you what Board colleagues Councillors and many RANZCOG to over 12 tumultuous years. It would be impossible without the achieve anything as College President people. I should give a special thank many support of for the and Eleanor Bonikowski Grose you to Kylie things running in the amazing job they do in keeping to wish I would like CEO. President and of the office Dr Vijay Roach, and his Board all incoming President, will be, no doubt, a very memorable the best for what you. term ahead. Thank you so much to all of O&G-190-130-Starnberg-v3-print.indd 1 Dr Carlos Fuchtner (left), and Society of of (left), and Society , Dr Carlos Fuchtner Prof Steve Robson with FIGO President-elect Steve Prof (right). Lalonde Dr Andre Canada (SOGC) past-President, of Obstetricians and Gynaecologists Chief Medical Officer and has representatives from representatives Chief Medical Officer and has colleges, the Australian Medical the procedural and health insurers (AMA), private Association a working towards are We groups. hospital private will hopefully assist women model that transparency and their family doctors in selecting appropriate I am As with other Government endeavours, care. will either a heavy-handed response concerned that or potentially make do little to solve the problem, is ongoing and this group things worse. The work of when I am in the year, back to you later I will report allowed to speak publicly. Private maternity care obstetrics and gynaecology practice I have a private very is a matter close care private and the quality of I wanted to the main projects to my heart. One of to support has been pursue as College President has proven a model that care, maternity private despite holding a number Unfortunately, results. including groups, discussions with relevant of AMA, the the insurers, anaesthetists, private and Specialist Obstetricians of Association National others, Gynaecologists (NASOG), hospital bodies and appears to seem to be getting worse. There matters be a concerted media and social media campaign services in Australia. maternity against private have now been many forces I am pessimistic. Too However, the downward trend. unleashed to reverse a healthy we can again reach I live in hope that for women. and public care balance between private Officer Chief Executive the College CEO, that you will be aware Most of Alana Killen, has made a decision to complete her I was one 2018. the end of term with the College at the team who appointed Alana to the College and of in a decision. She came to RANZCOG it was a great a very at difficult time and has made leadership role her work on contribution. In particular, an incredible workplaces has been a major respectful promoting On a personal level, I step in the right direction. wise of have found Alana to be a wonderful source and on her professionalism counsel and I have relied It is very sad that enthusiasm to an enormous degree. a good Alana is leaving us, but I hope she will remain friend. I wish her well. A big thank you Council in 2006 when I first joined the RANZCOG served under I Chris Tippett was President. Prof Weaver, Ted A/Prof presidents: a further three Michael Permezel. Dr Rupert Sherwood and Prof big shoes to fill. My time with extremely They were Council and College leadership has the RANZCOG THE COLLEGE Vol. 20 No. 3 Spring 2018 | 9 Vol. has supplied birthing kits to and practical birthing kits to midwives has supplied General Hospital. Her most supplies to Port Moresby for Babies, which involved is Beanies project recent beanies for premature volunteers to knit recruiting babies in the Pacific. whom by all with and admired loved Carmel is greatly thank We RANZCOG. 32 years at over she has worked you well in your retirement. you, Carmel, and wish Accommodation update and consultation, Following much discussion to move forward with the Board have decided as one of option presented the joint venture College House for future the recommendations is the The next step in the process accommodation. (L to R) Angie Spry, Global Health and Provincial Fellows Provincial Global Health and (L to R) Angie Spry, College Wheeler, and Tracey Carmel Walker Coordinator, House receptionist. From the CEO the From In July, the College farewelled its longest-serving the College farewelled In July, and paid tribute to Walker, Carmel member, staff health and contribution to women’s her incredible Carmel began a moving ceremony. at to RANZCOG as Examinations the College in 1986, at her career RANZCOG, her time at and, throughout Secretary, positions, including the one held a number of for which she is most well known, as the Senior Health. Carmel for Global Women’s Coordinator Assistant of was appointed the inaugural Executive Health (PSRH) the Pacific Society for Reproductive upon an amazing journey in 1995 and embarked women and the health outcomes for to improve settings. in low-resource children to mention too numerous Her achievements are the of but have included: coordination here, Pacific Midwifery Leadership Fellowship Program; Membership program; the Associate establishment of the Brian Spurrett the development of facilitating and helping establish the continuing Foundation; for Pacific development program professional for women advocate O&G specialists. A tireless and families in the Pacific, Carmel also instigated which the College House annual charity program, Alana Killen CEO ASCCP August O&G.pdf 1 31/07/2018 5:05:24 PM

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CM CMY Different terms, fees or other loan amounts might result in a different comparison rate. istrue onlyforthe examples givenand may notinclude Thiscomparison rate all feesand charges. WARNING: arebased onaloan for$150,000 and atermof 25years. rates loan. upto70% ofthepropertyvalue withaprincipal and interestrepayment variablerate occupied loanswhenyou borrow fornewowner *The comparison applies †Rate Terms andmay changewithout notice. and conditionsapply You for you. shouldconsider whetheritis appropriate Finance criteria. issubjecttoour creditapproval needs. isprovidedbyMacquarie BankLimited This information AFSL and Australian CreditLicence237502anddoesnottake intoaccountyourobjectives, or financial situation THE COLLEGE gynaecologists#collection-records. new-zealand-college-of-obstetricians-and- net.au/organisations/royal-australian-and- collection. Pleasegoto:https://victoriancollections. visit thewebsitetobrowse through thisimportant Historical Collectiononline.Iencourageyouto This will allow College members to view the College’s use topromote theircollectionstoawideraudience. management systemthat anumberof organisations off site.VictorianCollectionsisafree collections a great manymore that are currently beingstored number of historicalartefactsondisplay, there are While visitorstoCollegeHouseare abletoviewa Historical Collection web-based videoconferencing. meeting rooms, trainingspacesandareas suitablefor facilities. Thenewbuildingaimstoincludeoffices, while providing improved accommodation and of thebuildingthat fronts ontoAlbert Street, the importantandsignificantheritagepresence take severalyearstocomplete.Thegoalisretain progress of thisproject, althoughitisanticipated to We willprovide regular updates regarding the planners, heritageadvisorsandquantitysurveyors. involve inputfrom (amongothers),architects, town development of adetailedbusinessplan,which will and advocacyforwhichitisrecognised. College maintainthehigh-qualitytraining,education for yourwillingnesstogiveuptimehelpthe you onbehalfof themembersandstaff of RANZCOG absolutely invaluable.Iwouldlike tosincerely thank Your contribution totheworkof theCollegeis or whomhavedecidednottostandforre-election. thank thoseCouncillorswhosetermshaveexpired for thecurrent Councilmembers.Iwouldlike to The CouncilMeetinginJulywasthefinalmeeting Council and HeHonoWāhine committees. and Torres Strait Islander, GlobalWomen’s Health representatives from theResearch Grants,Aboriginal Foundation willfocus.TheBoardalsoincludes projects uponwhichtheRANZCOG Women’s Health later intheyeartodiscussgoalsandspecific The Boardwillholdastrategic planningmeeting health, research, legalandsocialjusticeexpertise. skills tothegroup, includingfundraising,public members. Eachof thenewmembersbringsextensive held andtheBoardwelcomedfivenewexternal RANZCOG Women’s HealthFoundation Boardwas In July, thefirstmeeting of the‘reinvigorated’ RANZCOG Women’s Health Foundation THE COLLEGE Vol. 20 No. 3 Spring 2018 | 11 Vol. at Westmead Hospital during my residency, falling my residency, Hospital during Westmead at health. I then spent 12 months in love with women’s in Kavieng, New Abroad with Australian Volunteers every Papua New Guinea. Here, Province, Ireland with endemic malaria and mother was high risk, to domestic violence. This solidified my decision John I was based at commit to the O&G specialty. my training and Hunter Hospital for the majority of me to O&G, leading of I love every area soon realised Fellow. life as a Provincial been the mentors in your life? Who have She was an unsung hero. an my mother, Firstly, to me. Not many people would enormous inspiration but she was the first and only Aboriginal know, women’s health practitioner in NSW. Alison Bush. Alison was a truly skilled Secondly, for Aboriginal advocate and a passionate Islander women and babies. She Strait and Torres of us the essential foundations taught so many of ‘normal birth’. Did you aspire to leadership? people I was not looking for leadership. I think some qualities and have leadership born with natural are themselves the opportunity to use them. Others find is the My brother leadership and learn. in positions of leader. a natural former, Islander doctor Strait As an Aboriginal and Torres in many and trainee, I was expected to participate not held by my on roles extra committees and take as we needed advocacy peers. I did so willingly, Islander health, Strait for Aboriginal and Torres but it was certainly difficult juggling this with my years, I had work, training. During these registrar community responsibilities, Aboriginal family, study, Aboriginal land council commitments, and numerous most Like expectations. committee representative Islanders, I also had Strait Aboriginal and Torres happening in my family and sickness and death more my peers. community than most of as a leader? Do you now yourself Initially this happened without choice, but now Yes. Aboriginal it is a choice, a privilege and a pleasure. to likely more Islander trainees are Strait and Torres beyond training. No one hold further responsibilities was so there before, else had been in my situation to see this happen for no mentoring. I would like Strait Aboriginal and Torres of our next generation Islander trainees. What has been most challenging in your career? Balancing everything! I think even in households it is still hard. traditional roles, of with the reversal MBBS, Grad Dip Clin Epi, FRANZCOG from graduated (nee Kong) Dr Marilyn Clarke obtaining her in 1997, Sydney of the University doing so, she importantly In in 2007. FRANZCOG Today, became Australia’s first Aboriginal O&G. Fellows and five trainees who has three RANZCOG Islander. Strait identify as Aboriginal or Torres north of up in Port Stephens, grew Dr Clarke Dr Marlene with her twin sister, Newcastle, NSW, Kelvin A/Prof (GP) and younger brother, Kong her mother, credits (ENT surgeon). Dr Clarke Kong woman and passionate Grace Kinsella, a Woromi community nurse, for inspiring her and her siblings Malaysian-Chinese to become doctors. Her father, living is also a doctor, Cheok Seng (Tony) Dr Kong was the only until recently, in Malaysia. Dr Clarke, Along with her NSW. Fellow in Grafton, Provincial son, daughter and eight-year-old 12-year-old she is deeply engaged with her extended family and community. What led you to a career in O&G? to O&G as a medical real exposure I had my first King George V Memorial Hospital, where student at Aboriginal I befriended Sister Alison Bush, renowned and then Fellow, midwife and Honorary RANZCOG #CelebratingLeadership @RANZCOG @connankf @RANZCOG #CelebratingLeadership Clarke Marilyn Dr This feature sees Dr Kirsten Connan in This feature members with RANZCOG conversation leadership positions. range of in a broad you find this an interesting hope We and inspiring read. on Twitter Join the conversation Dr Kirsten Connan DDU MBBS(Hons), FRANZCOG, MMedEd (Gender and Leadership) THE COLLEGE us tofeelguilty. Iwishhadn’tfeltthat way. taking time off. We shouldn’t have a culture that leads employers whenIwaspregnant andfeltguiltyfor No regrets. Idoremember Iwasterrifiedtotellmy Do youhave anyregrets? at meetings. I wouldsaynoalotmore! Iwouldspendlesstime What wouldyoudodifferentlyinyourcareer? participate equallyinsociety. Yes. We shouldallbeadvocating forwomento Do youseeyourself asafeminist? barriers totheirhealthcare. conscious of thisforothersandworkhardtoremove provided adifferent perspective.Iam always greater degree thanmostof mypeers certainly Growing upandexperiencingdisadvantagetoa heritage influenced yourpractice ofmedicine? Has yourAboriginalandTorres StraitIslander practice. be oureveryday decisions abouttheirhealthcare. Thisshouldalways understand. Iwanttoempowerwomenmake options are, informing theminawaytheycan To empowerwomentounderstandwhat their roleasanO&G? What doyouseeasyourprimary Islander traineesandFellows. responsibility of thefewAboriginalandTorres Strait RANZCOG members.Advocacycan’tjustbethe cultural competencetrainingshouldoccurforall should occur. AboriginalandTorres Strait Islander incorporating thisintothemainstream curriculum should bepartof core businessforRANZCOG and Aboriginal andTorres Strait Islander women’shealth different, toothertrainees. very Strait Islandertraineesare boththesame,andalso mentoring program. IssuesforAboriginalandTorres it wouldbegreat ifwecouldestablishaformal For ourAboriginalandTorres Strait Islandertrainees, facilitate leadershiptraining? What doyoufeelRANZCOG coulddotofurther been invaluable. I have manyAuntiesandextendedfamily. Theyhave great meeting. their babiesandworktoimprove their care, inorderto‘close thegap’.PleasejoinDrMarilynClarke forthis professionals, wemustacknowledgethedisparity forAboriginalandTorres Strait Islandermothersand Women's Health MeetinginAdelaide,priortotheRANZCOG 2018AnnualScientificMeeting.Ashealthcare On 15–16September2018, RANZCOG willhost‘Turning Tides’,theAboriginaland Torres Strait Islander versus nineper1000births). per centversuseightcent),lowbirthweight(11.6 percentversus6.3 percent)andperinatal deaths (15 and theirbabies,includingincreased maternal mortality(fourtimesthat of other women), preterm birth(14 disproportionate burdenof adverseperinatal outcomes forAboriginalandTorres Strait Islandermothers or Torres Strait Islanderpeoples (5.2 percentof allregistered births).Againthestatistics revealed a In 2016, there were 16,479 birthsregistered inAustralia,where oneor bothparents identifiedasAboriginal Aboriginal andTorres StraitIslander women’s health Dr MarilynClarke. pursuing acareerasProvincialFellowinAustralia. and mentoring bytraineeswhoareinterested in Dr Clarke iswillingtobecontacted forcareeradvice Dr Clarke's mother. pursue acareerinwomen's health, inhonourof Aboriginal andTorres Strait Islandernurseto In 2018, ascholarshipwillbeestablishedforan Hectic andfulfilling! What wordsbestdescribeyourlife? time asaFellow. Torres Strait Islander women’shealthcare duringmy particularly prominent supportersof Aboriginaland Permezel andProf Steve Robsonhaveallbeen Dr Margaret O’Brien,DrJacqui Boyle,Prof Michael healthcare. Prof Mike O’Connor, DrChrisHughes, and AboriginalTorres Strait Islanderwomen’s There are now lots of Fellows investing into the IWHC Islander women’shealthcare. action initiated forAboriginalandTorres Strait and council,there ismore enthusiasmandmore Health Committee(IWHC).Witheachnewpresident They haveinvestedintheIndigenousWomen’s Torres StraitIslanderhealthcare? What rolehasRANZCOG playedinAboriginaland

Image by Brad Newton Photography. Copyright of the Australian Indigenous Doctors’ Association. Changes to RANZCOG CPD

What is changing? 1. Fellowship Certificates and Subspecialty Certifications with the original qualification date will be reissued. 2. Individual CPD transition plans will be sent to all Fellows. The plans will explain the CPD requirements needed to transition to the standard CPD triennium on 1 July 2019. 3. A draft of the revised CPD Framework based on the Medical Board of Australia’s Professional Performance Framework will be circulated for consultation.

Why is the College making changes? The Medical Board of Australia (MBA) has released the Professional Performance Framework (PPF) and is currently revising the CPD registration standards. RANZCOG Board approved changes to RANZCOG’s CPD program to ensure the College is proactively working towards meeting current and future MBA requirements, along with the requirements of the Medical Council of New Zealand (MCNZ). Consultations with members will be an important part of the process as the College works to align to the regulatory requirements. Consultation on the revised RANZCOG CPD Framework is now open and more information is available on the College website.

How will the College support Fellows through the transition? The College will contact all active Fellows via email and post to advise them on individual transition arrangements. The College will provide support to Fellows as they transition to the standard triennium. Information and FAQs about the transition will be published on the College website. The CPD team is available to assist with any CPD questions or concerns and can be contacted via email [email protected] or phone +61 3 9417 1699.

RAN003 FILLER ADVERT TEMPLATES A4 B.indd 4 10/08/2018 8:42:09 AM MIND MATTERS Editorial psychological distress intheprevious fourweeks. 7.6 percentof respondents reported experiencing Similarly, inthe2017–18NewZealand HealthSurvey, PhD, MBBS,FRANZCOG Dr BrettDaniels experienced acommonmentaldisorderin2015. estimates that fourmillionpeopleinAustralia from theAustralianInstituteof HealthandWelfare The mostrecent mentalhealthservicesreport and itsprofessional and personalimpactonhim, experienceofhis ownfamily’s postnatal depression psychosis. Vijay Roach provides a personal account of article onthemanagementof acutepostpartum approachesmultidisciplinary totreatment, andan on postnatal depression, includingscreening and of infanticide. There isacomprehensive article andtherare, buttragic,phenomenon pregnancy, topost-traumatic stress disorderin and psychoticillnessantidepressant usein subspecialty withinpsychologyandpsychiatry, the emergenceof perinatal mentalhealthasa in thisissueof O&GMagazine.Topics rangefrom pregnancy iswellknownandcovered extensively The interactionbetweenmentalillnessand role inwomen’s health. health issuesplayanincreasingly well-recognised and mentalillness,itisnotsurprisingthat mental With suchahighprevalence of psychologicaldistress 1

2

our colleagues. look after ourownmentalhealthandthewelfare of provide thebestcare forourpatients ifwedon’t other organisations. We cannotexpectthat wecan and tonotethesupportsoffered byRANZCOG and article onmentalhealthinmedicalpractitioners in themedia,Iwouldimplore allof youtoread the With suicidebydoctorsbeingreported more often their ownmentalhealthandthat of theircolleagues. increasingly takingstepstohelpdoctorsimprove indemnity providers andregulatory agencies,are career. RANZCOG, thegeneralmedicalprofession, mental healthproblems at sometimeintheir Zealand, manydoctorswill,themselves,experience psychological distress reported inAustraliaandNew With thehighprevalence of mentalillnessand perspective onbreaking bad news. in women’shealthandoffer avaluablepractical explicitly. Otherarticlesexplore personalitydisorders common, butat times,canappeardifficulttodefine therapeutic difficulties ofacomplaint,whichis al, are addressed inaninteresting articlebySnellenet mental health.Premenstrual psychological changes pelvic painandhowthemenopausecanaffect on eating disorders,thepsychologicalaspectsof Articles withagynaecologicalfocusincludethose abuse anddomesticviolence. consultation focusedonmentalhealth,substance new MBSitemnumberforanoptionalpostnatal part of routine antenatal care, andhasprovided a mental healthscreening shouldbecomeanintegral 2017, theAustralianGovernmentmandated that including hissupportof theGidgetFoundation. In 2. 1. References

whichdescribesthehistorical,diagnosticand August 2, 2018. key-results-2016-17-new-zealand-health-survey. Retrieved https://www.health.govt.nz/publication/annual-upda Retrieved August3, 2018. mental-health-services-in-australia/report-contents/summary. https://www.aihw.gov .au/reports/mental-health-services/ te- MIND MATTERS 1,9 1,9 tionship Vol. 20 No. 3 Spring 2018 | 15 Vol. t is ttuned parent-infant egnancy planned? after periods of and after the birth of and after infertility periods of after a baby The common changes to the partner rela The common changes an a The importance of tha emergency The psychiatric postpartum psychosis. relationship for the baby’s ongoing wellbeing relationship Was the pr Was • • and birth Pre-conception, pregnancy of and obstetric factors are Pre-conception by a mental requiring investigation significance, health clinician. History when planning is recommended Pre-conception disturbance. psychiatric current or is previous there in revised may need to be assessed and Medication period. and the postnatal for pregnancy preparation • History-taking is relevant for the pregnancy and the for the pregnancy History-taking is relevant period: postnatal • tric as well as harmful as well as harmful 5,6 This article ted with 8 2,4 Mental health 3 tion and fatigue on tion and fatigue Pregnancy and the Pregnancy 1 oblematic or traumatic oblematic influenced by biological, by influenced 2 es that impact new mothers es that Not only is the mother’s safety Not only is the mother’s safety 7 ession The effect of sleep depriva The effect mood stability The social pressur one’s of becoming a mother when The difficulties was pr own The impact of changes to the hormonal The impact of and the physical and emotional environment can be associa difficulties that the ‘baby blues’ and between The difference depr postnatal typical ‘new mother between The difference anxiety’ and clinical anxiety A heightened risk for pre-existing psychia A heightened risk for pre-existing conditions to re-emerge at risk, the infant’s physical and emotional wellbeing risk, the infant’s at but can be is rare, primaryis of concern. Infanticide or poorly untreated of complication a devastating mental illness. managed maternal Postnatal mental health disorders range from mild to mental health disorders range from Postnatal the leading causes with suicide being one of severe, death. maternal of Dr Renée Miller Dr Renée DPsych Principal Clinical Psychologist, Psychology Network Antenatal & Postnatal Clinical Advisor (Psychology), (COPE) Centre of Perinatal Excellence Hettie Dubow Health Mental MPsych, Grad Dip Infant Clinical Psychologist, Antenatal & Postnatal Psychology Network Dr Klara Szego MBBS, DPM, FRANZCP Principal Perinatal Psychiatrist, Perinatal Psychiatry Network and antenatal Medicare-funded of The introduction raises questions mental health screening postnatal qualified mental to appropriately referral around and health clinicians. The assessment, diagnosis specific requires patients perinatal of treatment training knowledge and expertise beyond the general other and by psychologists, psychiatrists received mental health practitioners. • • • • • outlines the essential components of mental health outlines the essential components of women. for perinatal care clinicians should know What mental health of mental health clinicians need to be aware Perinatal factors: a number of • • longer term effects on emotional, behavioural and longer term effects on emotional, behavioural cognitive development in children. disorders are associated with adverse pregnancy pregnancy with adverse associated disorders are restriction, outcomes such as intrauterine growth low birth weight and prematurity, psychological and social factors. postnatal period pose increased risk for manifesting period pose increased postnatal mental health problems, an area of specialty area an Perinatal mental health: health: mental Perinatal MIND MATTERS can havepsychologicalimplications forsubsequent Reproductive losscancausesignificantgrief, which Reproductive loss for postnatal mentalhealthproblems. complications of pregnancy, increasing therisk Antenatal depression andanxietyare common Pregnancy previous baby? attachment toababyfollowingthelossof a her relationship? Isthere internalconflict regarding stillbirth ortermination affected thewomanand How havereproductive lossessuchasmiscarriage, need toexplore theimplications of previous losses. a sensitivebirth, collaborating withobstetricpractitionerstoplanfor perinatal mentalhealthcliniciancanplayarole in When womenpresent priortogivingbirth,the • • • Issues tobeaware of followingbirth: Birth vulnerable women. on strategies forreducing postnatal stress inhighly • • • as thereof infertility, ahistory assisted • • • • • first presents), thefollowingfactorsmaybe relevant: pregnancy orafter (dependingonwhenshe delivery When assessingthewoman’semotionalstate during increase thetraumatic potentialof birth. Extreme painandasenseof lossof control can Pregnancy, labourandbirthare formidableevents. are alsocommonandcancausesignificantdistress. anxiety. Obsessivethoughtsaboutharmtothebaby pregnancy rather thansymptomsof depression or and appetitedisturbance,that maybesequelaeof such as increased heartrate, sleepdisturbance by over-representing confounding symptoms, non-trained clinician maypathologise pregnancy due tohormonalfluctuations. Conversely, the state canbedismissedasheightenedemotions pregnancy, awoman’saberrantpsychological to developingPTSDfollowingchildbirth. (PTSD) orsexualassaultmaybepredisposed ofwith ahistory post-traumatic stress disorder psychotic disorder? of antenatalhistory orpostnatal mood,anxietyor during birth? by healthpr Was adifficultbirthacknowledgedanddebriefed following thebirth? Did sheexperiencesevere sleepdisturbance W she feelouto How didthewomanexperienceherbirth?Did If ther childbirth (tocophobia)? W the ongoingimplications? reproduction ordonorconceptionandwhat are W a How didthewoman’smoodduringpregnancy eating disorders? body imageorweight?Isther Does shehaveconcernsaboutherchanging been diagnosedduringthepr Have fetalanomaliesormedicalcomplications psychiatric disturbance? Is ther ffect herbirthandpostnatal experience? as a history of sexualabusetriggeredas ahistory as/is there anextreme fearof e hasbeenaprevious pregnancy, isthere a e acurrent, previous of orfamilyhistory 10 andthepostnatal period. ofessionals? 13 f control ortraumatised? aswelladvisingobstetricstaff egnancy? e a history of e ahistory 11 During 3 Therapists 13 13,14 Women

12 dependent onherfunctioningasamother. mania at atimeinwoman’slifewhenherbabyis prescription of antidepressants caninducearebound factor forfuture postpartumepisodes. the postnatal of period.Ahistory PPPisastrong risk that mayincrease the likelihood of PPPdevelopingin risk factorsshouldbeidentifiedinawoman’shistory postpartum psychosis(PPP).Priortobirth,possible aware of therelatively rare, butacute,nature of Perinatal mental healthpractitionersneedtobe be conducted. planningandappropriatehistory), psychiatric review vital that (includingfamily prudenthistory-taking was discontinuedforpregnancy. disorder, especiallywhenmoodstabilisingtreatment represents significantriskforthe relapse of bipolar disorder withperinatal onset.Thepostnatal period Particular attention shouldbepaidtobipolar Bipolarity andpostpartumpsychosis for help? does thewomanhaveandisshecomfortable asking relationship? What functionalandemotionalsupport parenting past. to theattachment of history thewomaninherown between motherandchild.Links shouldbedrawn ruptures of attachment on theongoingrelationship understand attachment andtheimpactof theory outcomes. Thementalhealthpractitioner needsto by theparent hasconsequencesforthechild’slater an infant’s development.Thequalityof care provided The postnatal periodisahighlysensitivefor Mother-infant attachment promptly ifPPParises. emergency servicestoensure women are treated well acquaintedwithperinatal psychiatrists and Perinatal mentalhealthpractitionersneedtobe can befrighteningforthepatient andtherapist. disorder profile), which,althoughnotpsychotic, (typically associated withanobsessive-compulsive with awoman’sreports of intrusive thoughts practitioners shoulddiscernandbecomfortable postnatal adjustment. well establishedriskandprotective factorsfor partner andheravailablesocialsupportshavebeen The qualityof awoman’srelationship withher Relationship andsocialsupport risk forthemother. Co-morbid depression andanxietycanposefurther treatment plans forspecificsymptompresentations. depression) requires particularattention toidentify presence of anxietyandstress (asdistinctfrom the correct diagnosistobereached. unipolar depression, inmanycasestakingyearsfor to bipolardisorderbeingcommonlymisdiagnosedas first present withdepressive symptoms,contributing • • distress inthepostnatal period. of ‘postnatal depression’ tocapture emotional This hascontributedtoauniversaldiagnosis Postnatal literature focusesheavilyondepression. The postnatalperiod • require treatment at thisvulnerabletime. obsessive-compulsive disordermaymanifestand panic disorder, generalised anxietydisorder and contribute topostna In what waydidthewoman’sbirthexperience Did shedeliverpr W special care? ere herexpectations of birthmet? 16 PTSD, adjustmentdisorder, ematurely? Was thebabyin 3 What isthequalityof her tal adjustmentdifficulties? 15 17 However, the Patients typically 18,19 20 Inappropriate Inaddition, 12 18 Itis

MIND MATTERS

Am J BMC Am J Vol. 20 No. 3 Spring 2018 | 17 Vol. CMAJ 1997; 156(6):831-35. J Affect Disord 2003; 74(2):139-47. , Watson S. Traumatic childbirth. New childbirth. Traumatic S. , Watson , Negri L. Anxiety and stress in the postpartum: , Negri L. Anxiety and stress ondo L, Koukopoulos A, et al. Episodes of mood A, et al. Episodes of ondo L, Koukopoulos 2014; 10(4):359-71. 2014; Health Women’s . Post-traumatic stress disorder after childbirth: The childbirth: disorder after stress . Post-traumatic Adelaide Convention Centre , Sharma V, Mazmanian D. Bipolar disorder in the Mazmanian D. , Sharma V, , Rajput M. Misdiagnosis of bipolar disorder. Psychiatry bipolar disorder. , Rajput M. Misdiagnosis of om J, Gemmill A, Bilszta J, et al. Antenatal risk factors for risk factors for et al. Antenatal Bilszta J, Gemmill A, om J, tthey S, Barnett B, Howie P, Kavanagh D. Diagnosing Kavanagh D. Howie P, Barnett B, tthey S, ranzcogasm.com.au/atsiwhm2018 esseloo R, Kamperman A, Munk-Olsen T, et al. Risk of et al. Risk of T, esseloo R, Kamperman A, Munk-Olsen enzel A. Anxiety in childbearing women: Diagnosis and A. Anxiety in childbearing enzel For the first time, the 2018 RANZCOG AboriginalFor the first time, the 2018 RANZCOG Health Islander Women’s Strait and Torres Annual the RANZCOG Meeting will precede Turning Scientific Meeting. The meeting theme, Strait how Aboriginal and Torres Tides, explores health continues to ebb andIslander Women’s with advances and setbacks encounteredflow, on a daily basis. and includes workshops The diverse program discussion designed to provoke presentations and upskill in evidence-based obstetric and gynaecological issues specific to Aboriginal and Islander women. Strait Torres now to join us in riding a wave of Register optimism and change in Adelaide. phenomenon of traumatic birth. birth. traumatic of phenomenon Is there more to postnatal distress than depression? than depression? distress to postnatal more Is there Psychiatry 2006; 6(12):1-11. W Reynolds J J Beck C, Driscoll 272p. 2013. York:Routledge; Ma Whatever in mothers and fathers: postpartum depression happened to anxiety? Miller R, Pallant J Pope CJ and future strategies : Management directions. Viguera A, T postpartum periods. and disorders in 2252 pregnancies Psychiatry 2011; 168(11):1179-85. Singh T 2006; 3(10):57-63. W in bipolar disorder and postpartum postpartum relapse and meta-analysis. review psychosis: A systematic Psychiatry 2016; 173(2):117-127. Milgr J Affect Disord study. prospective A large depression: postnatal 2008; 108(1-2):147-57. 275p. Books; 2011. DC:APA Washington treatment. Saturday 15 - Sunday 16 September 2018

14. Resources (COPE) Excellence Perinatal of Centre Australia (PANDA) Anxiety & Depression Perinatal Support (SANDS) Death and Neonatal Miscarriage, Stillbirth Beyond Blue 17. 11. 15. 16. 19. 20. 12. 13. 18.

Archives of Women’s Women’s Archives of Archives of Women’s Women’s Archives of Arch Gen Psychiatry 2010; 2014; 384(9956): Lancet 2014; Aust Fam Physician 2016; 45(12):890-93. Aust Fam World Psychiatry 2007; 6(3):137-41. World , Buist A. Management of bipolar disorder over the , Buist A. Management of , Evindar A, Stewart DE. The effect of postpartum DE. The effect A, Stewart , Evindar , Watts J. Postnatal depression: A systematic review of of review A systematic depression: Postnatal J. , Watts Journal of Child Psychology and PsychiatryJournal of 2007; 48(3- tes M. Suicide: The leading cause of maternal death. Br J death. maternal tes M. Suicide: The leading cause of ote N, Bridge J, Gavin AR, et al. A meta-analysis of depression depression of Gavin AR, et al. A meta-analysis Bridge J, ote N, arland J, Warland M. Pregnancy after loss. Australia:Jane & after M. Pregnancy Warland arland J, tein A, Pearson R, Goodman S, et al. Effects of perinatal mental of perinatal et al. Effects tein A, Pearson R, Goodman S, riedman S, Resnick P. Child murder by mothers: Patterns and Child murder by mothers: Patterns Resnick P. riedman S, alge N, Neal C, Glover V. Early Stress, Translational Research and Research Translational Stress, Early V. Glover C, Neal N, alge especially for women with psychosis, bipolar especially for women 1800-19. Psychiatry 2003;183(4):279-81. F Boyce P W 160p. 1996. Michael Warland; 67(10):1012-24. Grace S on child cognitive development and behavior: A depression the literature. analysis of and critical review Oa prevention. period. perinatal disorders on the fetus and child. Pope S paper to 1999: An information published scientific literature Council; and Medical Research Health Australia: National 2000. 260p. 2000. Gr birth, low birth weight preterm and the risk of during pregnancy restriction. and intrauterine growth T Experience on Science Network: Fetal and Neonatal Prevention stress maternal Child and Adolescent Mental Health. Antenatal How and and long-term effects on child neurodevelopment: why? 4):245-61. 2003; 6(4):263-74. Health Mental Br mental (perinatal) paper on mother-infant international health, with guidelines for clinical practice. 2017; 20(1):113-20. Health Mental S 1

disorder or borderline personality disorder. disorder or borderline Medication and in pregnancy medication of The prescription fraught issue that postpartum is an emotionally and indecision for pregnant can cause stress Specialist perinatal women. and breastfeeding well-versed in helping women are psychiatrists with of medication benefits weigh up the costs and the fetus and the breastfed to the mother, regard on medication research current of Awareness infant. period is partly what and the postnatal in pregnancy general from psychiatrists distinguishes perinatal adult psychiatrists. Services and information mental health clinician needs to be The perinatal and child health well acquainted with maternal and other community services, supported playgroups support vulnerable families. Given the services that among childbearing women on seeking reliance the through and social connection information for the internet and social media sites, it is fitting good quality, with patients clinician to provide evidence-based information. Summary have highlighted some important considerations We mental health regarding for obstetric providers with the Along patients. support services for perinatal and the postnatal pregnancy general life upheaval of vulnerable to the emergence are period, patients with mental health problems, of and re-emergence and families. for infants implications far-reaching obstetricians consider that It is recommended of mental health and training the qualifications the effective assessment, practitioners to ensure patients. perinatal of diagnosis and treatment 3. 10. 8. 5. 9. 4. 6. 7. References 1. An N. ButterworthR,Glangeaud-Freudenthal ockington I, 2. Working through past attachment experiences experiences past attachment through Working in part, bonding difficulties, to current in relation practitioner mental health the perinatal distinguishes in parent-infant Training the generalist. from effectively with new is central to working attachment rupture, attachment cases of extreme mothers. In the baby is to determine whether clinicians need safe, MIND MATTERS psychotic disorders Schizophrenia and high rates of obstetriccomplications. schizophrenia andrelated psychoticdisordershave Sufficient evidenceshowsthat womenwith King EdwardMemorialHospital,Western Australia Women’s Health, GeneticsandMentalHealth MBBS, DRCOG, DCH, DipGrad(Arts),FRANZCP Dr CarolineCrabb King EdwardMemorialHospital,Western Australia Women’s Health, GeneticsandMentalHealth MBBS, MPM,FRANZCP, PhD Prof MeganGalbally next generation. maternal wellbeingandimprove thehealth of the disorder, there isanopportunitytooptimise managing apregnant womanwithapsychotic prevention of severe mentaldisorders.When complications are apotentialtargetforthefuture are unlikely tobemodifiable, obstetriccare and While riskfactorssuchasgenetic vulnerability to thefinaldevelopment of apsychoticdisorder. from geneticvulnerability, toenvironmental factors, there isamultifactorialdevelopmentalriskpathway psychotic disorders,there isnowconsensus that In anattempt tounderstand theaetiologyof severe lifelong outcomesforchildren. the risksinpregnancy are alsoassociated withpoor the role of treatment andlifestylefactors.Manyof can bemadetomentalillness,equallyimportantis poor neonatal outcomes.Whilesomeattribution increased rate of complications inpregnancy and hospitalisation. Itisunclearwhat underliesthis and increased riskof neonatal complications and low andhighbirthweightbabies,preterm delivery an association withhighrates of gestational diabetes, 1 Theseinclude • • • • disorders posesmanychallenges: The obstetricmanagementof womenwithpsychotic Obstetric management • • • • Sample clinicalbookingquestions: medication, includingantipsychoticmedications. psychotic disordersandanycurrent psychotropic antenatal shouldinclude assessment.Enquiry mental disordersbecomespartof theroutine recommended that intopastandcurrent enquiry but havepotentialimplications forpregnancy, itis disorders. Aspsychoticdisordersare lowprevalence depression andanxietybutdonotdetectpsychotic Postnatal Depression Scale(EPDS),screen for Universal screening measures, suchastheEdinburgh Antenatal assessment obstetrics, midwifery, andsocialwork. psychiatry approach,multidisciplinary integrating servicesfrom of childbearingwomenwithpsychosisrequires a Given thislevelof complexity, themanagement any womanof childbearingage. principles of pregnancy managementwhentreating Mental healthservicesare encouragedtoconsider community, therate of unplannedpregnancy ishigh. pre-conception; however, like manywomeninthe Ideally, consideration of thesefactorsoccurs • • • having ababy? nursing infant needtobeconsidered reach breastmilk, sotheirpotentialeffectsonthe bipolar disorder? or antipsychotics? valproate, lamotrigineorcarbamazepine) lithium, moodstabilisers(forexample,sodium detailed assessment. social circumstances andmayrequire may becompromised byherillnessand The qualityo preterm delivery including intrauterinegrowth retardation and and alcoholuse,withriskstotheunbornbaby, Ther associa The mothermayhavephysicalillnesses Most psychotr may beharmful totheunbornchild T be required the illnessandalterations intreatment may postpartum periods)canaffect thecourse of The peripartum(antena health pr Has anyoneinyourfamilyhadmental Have youhadmentalhealthpr Have youbeenpr health pr Have youbeenadmittedtohospitalforamental Have youeverhadmentalhealthpr reatment that maybeeffectiveforthemother e isahigherrate of cigarette smoking,drug ted withherpsychoticillness oblems, includingschizophrenia or oblem? f themother’sparenting opic agentstaken bythemother escribed medications suchas tal, delivery and tal, delivery oblems after oblems? MIND MATTERS

10,11 4 The research The research Vol. 20 No. 3 Spring 2018 | 19 Vol. 1,2 Frequently, the decision Frequently, 3 However, the overall number of number of the overall However, 9 into long-term child outcomes from exposure to exposure from into long-term child outcomes is currently in pregnancy antipsychotic medication too limited to draw conclusions. with serious is an antipsychotic associated Clozapine agranulocytosis side effects, such as neutropenia, it has a mandated and myocarditis. As a result, for and is usually reserved monitoring protocol these With schizophrenia. treatment-resistant guidelines do not risks, the national associated and advise in pregnancy clozapine of advise initiation with only to use it with caution in breastfeeding the infant. of monitoring appropriate is made to continue pharmacotherapy because the is made to continue pharmacotherapy because and hospitalisation illness (psychosis and associated concern than the treatment. greater suicidality) is of including the illness history, of review A careful is helpful in risks such as suicidality, associated management. making decisions around Medication dosage to maintain plasma levels The dosage required due to changes vary pregnancy, across will likely distribution metabolism and volume of in hepatic (particularly in the third trimester). to reference acute relapse, For management of local hospital guidelines is important, as well of the specific conditions of as consideration management such as avoidance of pregnancy, agents of in a supine position and the safety in pregnancy. Planning for delivery and the postnatal period doubts about whether a woman is are If there to obstetric interventions, the agreeing capable of this criteria for capacity need to be (re)examined; by the obstetrician should be done collaboratively The assessment includes whether and psychiatrist. the woman is able to believe the information and weigh up advantages and disadvantages of labour and (such as induction of procedures, arriving of the process section), as part of caesarean if a woman with psychosis is a decision. Even at may her mental state deemed to have capacity, If this is and she may lose capacity later. fluctuate may be helpful. an advance directive likely, Some women with psychotic disorders may be Mental Health Act as an involuntary under a state If order. or on a community treatment inpatient The general principle is to choose the lowest The general principle is to choose the lowest of an agent and monotherapy over effective dose possible. polytherapy where The risks associated with antipsychotic treatments treatments with antipsychotic associated The risks often based on limited research, are in pregnancy confounding of consideration by a lack of hampered alcohol and smoking, as obesity, variables such high rates at which occur use, all of illicit substance is there Currently, in pregnancy. risks and increase specific risk of with increased no clear association study a single of with the exception malformation, with risperidone and a small finding an association in risk. increase Studies have also found antipsychotic use to be have also found Studies low and high birth weight babies, with associated with adaptation neonatal delivery poorer and preterm admission. neonatal of higher rates studies across agents and participants is limited agents and participants studies across is no clear cautious. There are and any conclusions is There with miscarriage. an association of indication risk with increased to suggest an association research for specific antipsychotics, diabetes gestational of quetiapine and clozapine. including olanzapine, 2,4 essure checks essure include: 5,6 f full blood examination, f fetal growth zapine or quetiapine Recommendations for monitoring use Recommendations 4 oblems after their babies were born? If their babies were oblems after voidance of pharmacological agents for voidance of Close monitoring o assessment, including for Neonatal extrapyramidal side effects A suppression Regular monitoring o Regular weight and blood pr 16 weeks, Early glucose tolerance test at particularly if on antipsychotic agents such as olanzapine, clo urea and electrolytes, liver function tests, and electrolytes, urea and iron magnesium, calcium, folate, vitamin D, ECG Did your mother/sisters/aunts have any mental have any mother/sisters/aunts Did your health pr so, were they admitted to hospital? they admitted so, were • Antipsychotic medication antipsychotic drugs warn against of Manufacturers Clinicians must administer these use in pregnancy. according to the agents, against licensed indications, to mother and baby risk-benefit individual balance of published databases, with the available teratology guidelines. and national research • • • • • Drug, alcohol and smoking questions are are and smoking questions Drug, alcohol should which screening, into routinely incorporated and linguistically appropriate. be culturally Care pathways services psychiatric Referral to specialist perinatal before) (and preferably for assessment during for women with be considered should pregnancy not always possible, it is psychotic disorders. While in large hospital women deliver that recommended services on hand, paediatric settings with neonatal unit. intensive care neonatal including access to a Preconception pre-conception should be offered women Ideally, in order to psychiatrist counselling by a perinatal important options. It is weigh treatment carefully about the paucity to have an honest conversation in pregnancy. safety good evidence around of an opportunity to discuss other It also provides lifestyle and physical health factors associated may include This with the illness and medications. be modified (for can that exposures of consideration or alcohol and prescribed example, obesity, smoking, illicit drugs). Pregnancy For many women with psychotic illness, may medication prophylactic of discontinuation After discussion with the relapse. pose a risk of woman (and partner or other family members) risks and benefits to herself about the balance of continuing versus ceasing and the unborn baby of many will opt for ongoing the medications, pharmacological treatment. typical two groups: include, broadly, Medications antipsychotics, such as haloperidol; and atypical such as antipsychotics, second generation olanzapine, risperidone, quetiapine, aripiprazole orally or as administered They are and clozapine. given parenterally, depot medications long-acting fortnightly or monthly. Guidelines Health Mental Perinatal National latest The considering the use of for Australia recommend psychosis of for treatment antipsychotic medication in pregnancy. of these drugs in pregnancy of • MIND MATTERS that suppress lactation shouldbeavoided. mother andbaby. Useof pharmacological agents to care, ifrequired, iscrucialtoensure safety for clear planformonitoring,assessmentandpathways in theearlypostpartumperiodishighandhavinga anxieties duringthehospitalstay. Theriskof relapse state closelyanddiscussher(andfamilymembers’) a psychiatrist willmonitorthewoman’smental nursing staff care overnightduringadmission.Ideally, sedative antipsychoticandthebabyremaining in use of ashort-acting hypnoticmedication ora psychosis. Measures tomaintainsleepmayinclude pivotal inthedevelopmentof anacuteepisodeof of recurrence of maniaandsleepdeprivation canbe stay onthematernity ward.Insomniamaybeasign women willbenefitfrom asingle room andalonger problems andrequire extranursingattention. These confidence incaringfortheirnewborn,havesleeping Many womenwithapsychoticillnesswilllack breastmilk andmanyonlyhavelimitedsafety data. that mostpsychotropic medications dotransferinto health wardifnoMBUisavailable.Itshouldbenoted psychiatric motherandbabyunit(MBU)ormental possibility of electiveornon-electivetransfertoa requires discussionbefore delivery, asdoesthe documented inthemedicalfile.Breastfeeding perinatal mentalhealthcare planshouldbeclearly It isusefultoagree onpostnatal care inadvance;a Breastfeeding andearlypostnatalcare after delivery. of psychiatric nursingstaff helpfulduringlabourand staffobstetric andmidwifery mayfindthe presence do at itsonset.Ifthepsychoticillnessis severe, with theearlysignsof labourandknowwhat to The woman(andpartnerorcarer) shouldbefamiliar Preparation forlabour can bemanaged. neonatal toxicity, withdrawalorothercomplications woman’s psychotropic medications sothat signsof The neonatal paediatrician shouldbeinformed of the Paediatric input is essential. communication withthetreating mentalhealthteam consent totreatment undertheActisimportantand this isthecase,understandingprocesses for potentially devastating formotherandinfant. illness (affecting aboutonein1000women),but Postpartum psychosis(PPP)isa reasonably rare Postpartum psychosis child protective agencies. support and,ifrequired, coordinate involvementof worker maybeinvolvedtoorganisecommunity months whensheismostlikely tobecomeill.Asocial uninterrupted sleep,particularlyinthefirstthree and herpartner(orcarer) shouldensure sufficient vigilance forearlywarningsignsisvital.Thewoman andreduce stress.the womanidentify Continued general practitioner. Healthprofessionals shouldhelp mental healthprofessionals, childhealthnurseand follow-up psychiatric appointments, community This includescare followingdischarge,suchas include intrapartumandpostpartummanagement. mental healthplandevelopedinpregnancy to Ideally, thewomanwillhaveacollaborative perinatal Discharge or otherorganic cause.Itisimportanttoexclude be anacuteconfusional state causedbydelirium recurrence of achronic pre-existing illness, ormay may bethefirstpresentation of mentalillness,a 5 1 PPP encephalitis andotherrare causes. organic causes,includingdelirium,autoimmune both motherandchild. models of care andensure optimaloutcomesfor benefits of treatment options,sowecanimprove is anurgentneedtofurtherresearch therisksand psychotic disorderswillleadtoimproved care. There of thementalhealthof childbearingwomenwith Hopefully, growing awareness of theimportance Conclusion initiate lithiumimmediately after delivery. outside thepuerperalperiod,wouldgenerallybeto PPP, butnootherepisodesof seriousmentalillness Advice forwomenwhohaveaprevious of history 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References complications forthebaby. lithium, duetotherisksof toxicity andpotential most guidelinesadviseagainstbreastfeeding with Lithium isthegoldstandardtreatment. However, lithium andelectroconvulsive therapy(ECT). The evidence-supportedtreatments forPPPare woman improves. and supportof herrelationship withherbabyasthe environment, withsupervisedcontactherbaby specialised MBU. Thisprovides asafe treating Ideally, shewillbeadmittedwithherbabytoa episode requires urgentpsychiatric admission. or suicide.Awomanwithapostpartumpsychotic the riskof delusionalbeliefsleadingtoinfanticide Prompt psychiatric assessmentisessentialdueto of relapse, ifuntreated. previous of history PPP, there isa50–60percentrisk

org/10.1176/appi.ajp.2018.17040393. Published online:7May2018. Available at: https://doi. the riskof gestational diabetes. atypical antipsychoticmedication duringearlypregnancy and Y Opinion onDrugSafety 2014;13(12):1583-1590. antipsychotics andtheriskof gestational diabetes. Gentile S 2016;73(9):938-46. JAMA Psychiatry use inpregnancy andtheriskforcongenitalmalformations. Huybr alwaysbest? Galbally M,BerginkV 2015;172(9):901-8. Encephalitis inPostpartumPsychosis. Bergink V 2010;44(2):99-108. recommendations forantenatal care. antipsychotic andmoodstabilizer medication inpregnancy: Galbally M,SnellenW Gynaecol. 2016;56(4):336-40. postpartum psychosis:Asystematic review. AustNZJObstet lactation suppression withD2receptor agonistsandriskof Snellen M,PowerJ Centre of Perinatal Excellence, MelbourneGoogleScholar. 2017. the perinatal period:Australianclinicalpracticeguideline.COPE: Austin M,HighetN 2016;50(5):410-72. disorders. guidelines forthemanagementof schizophrenia andrelated New Zealand Collegeof Psychiatrists clinicalpractice Galletly C,CastleD Drug Saf . 2014;5(2):100-9. pregnancy: areview of theirmaternal andfetaleffects. Galbally M,SnellenPowerJ Pr Galbally M,SnellenLewisA.Psychopharmacologyand oonyoung Park,SoniaHernandez-Diaz, etal.Continuation of egnancy:Springer;2014. echts KF, Hernandez-Diaz S, Patorno E,etal.Antipsychotic . Pregnancy exposure tosecond-generation , ArmangueT, TitulaerM,etal.Autoimmune Australian andNewZealand Journalof Psychiatry , Group EW. Effective mentalhealthcare in , BlankleyG,GalballyM.Pharmacological , DarkF, etal.RoyalAustralianand 2018;5(7):534-6. Lancet Psychiatry , VigodS, etal.Breastfeeding andlithium:is alker S, Permezel M.Managementof 8 . Antipsychoticdrugsin . American Journalof Psychiatry Aust NZJPsychiatry Am JPsychiatry 1,7 Ifawomanhas 1 Expert Ther Adv MIND MATTERS

at 13 10 Vol. 20 No. 3 Spring 2018 | 21 Vol. 12 and for psychosocial stress, stress, and for psychosocial 9 11 In most jurisdictions, this is carried 11 with the AnteNatal Risk Questionnaire (ANRQ) Risk Questionnaire with the AnteNatal Screening for perinatal depression and anxiety Screening for perinatal settings, and some maternity Most Australian public for women antenatally screen in New Zealand, Postnatal and anxiety with the Edinburgh depression Scale (EPDS), Depression The National Perinatal Mental Health Guideline, Mental Health Perinatal The National Pregnant women, in general, welcome enquiry about women, in general, welcome enquiry Pregnant can bring their emotional wellbeing. This, in itself, as and isolation, stress feelings of and reduce relief to be happy and excited may be social pressure there discussion early as part of this time. Introducing at stigma and increases reduces obstetric care routine will be identified early and problems the chance that as they arise. with the EPDS is recommended screening Postnatal the birth, with further six to 12 weeks after scores assessment to be arranged for those with 13 or more. of out by maternal and child health nurses and GPs, out by maternal mental health obstetricians offering however, it a check will also find the six-week assessments at useful tool. in pregnancy Treatment to identify is firstly a woman The obstetrician’s role and/or anxiety and to understand with depression and close her pregnancy this in the context of Some women may initially find family relationships. a mental health diagnosis unacceptable and refuse encouraged but will feel more elsewhere, referral discussion and accept help. after their first booking visit. Screening, although not Screening, their first booking visit. support of extra women in need diagnostic, identifies assessment for mental health and further referral is sensitive to fluctuations The EPDS and treatment. and concerns about the stressors in environmental should be seen in or fetus, so the score pregnancy vulnerabilities this context, as well as pre-existing or stress and symptoms. If temporary environmental and the are suspected pregnancy difficulties with the the EPDS is worth repeating is 13 or above, it score available on how again in four weeks. Guidelines are to use the EPDS. approved by the National Health and Medical by the National approved best practice Council (NHMRC), articulates Research It advises assessment and treatment. for all aspects of selection needs to be founded upon a treatment that illness, the woman’s current assessment of thorough including the history, as well as any prior psychiatric any past suicidal past episodes, intensity of severity of particular and whether any or behaviour, ideation to be effective. has been proven medication The available options need to be clearly explained with the to the woman and her partner/family, about risks information open acknowledgment that her recovery is crucial is not complete, but that to her and her baby’s health, and efforts will be in the her preferences made to accommodate may improve Mild depression treatment approach. interventions, so these are with non-medication

1 Intervention 3 4,5 and there is increasing attention on the attention is increasing and there sometimes in response to the mother’s sometimes in response 8 6,7 Given the frequency of health system of Given the frequency 2 distress, especially when he is solely reliant on his on especially when he is solely reliant distress, of partner for emotional support, or he has a history or anxiety and work/life stress. depression provides an opportunity to prevent intergenerational intergenerational an opportunity to prevent provides mental health burden and cost. In transmission of Benefits Schedule changes to the Medicare 2017, the time to take obstetricians (MBS), allowing private to complete a mental health assessment, recognised in detecting obstetricians can take that role the key mental illness. perinatal episodes risks factors include: previous Underlying or anxiety (any anxiety disorder); a depression of birth; poverty; social or traumatic pregnancy stressful with a partner, support; conflict and lack of isolation physical, particularly domestic violence; previous sexual or emotional abuse, especially in childhood; or borderline loss; and perfectionistic pregnancy personality traits or disorders. Increasingly well-documented obstetric effects well-documented Increasingly birth and these conditions include preterm of admissions to special low birth weight, increased nurseries and disruption to the normal care for the mother and her transition to parenthood partner. Fathers matter, too. A father’s health affects obstetric health affects too. A father’s matter, Fathers outcomes, Perinatal depression and anxiety are common and anxiety are depression Perinatal co-occurring, with combined often problems, women in the first year 16 per cent of of rates postpartum and 10 per cent in pregnancy. Dr Rebecca Hill Dr Rebecca MBBS(Hons), FRANZCP Psychiatrist Consultant Network Health and Children’s Women’s Powrie Dr Rosalind BMBS, FRANZCP Child and Adolescent Psychiatrist Consultant Network Health and Children’s Women’s Dr Anne Sved Williams AM Dop Pscyhother MBBS, FRANZCP, Head, Helen Mayo House Medical Unit Network and Children’s Health Women’s mental health of fathers perinatally. Ten per cent Ten perinatally. fathers mental health of anxiety and can also develop perinatal fathers of depression, contact, there is ample opportunity to detect these contact, there significant personal and public health problems (PND) and anxiety depression Postnatal antenatally. and healthy parenting derail the development of due to the mother’s relationships, attachment cues and her infant’s impairment in reading and sensitive care responsive ability to provide risk of with subsequent increased to her infant, emotional and behavioural disorders in children mothers. depressed severely of and anxiety and Perinatal depression Perinatal MIND MATTERS accessibility at lowercost. be thewayof thefuture andwillperhapsprovide individually therapists are usingmindfulness-based approaches, effective treatment fordepression. Manyperinatal Mindfulness-based cognitivetherapyisan massage andaerobic exercise. for interpersonalpsychotherapy, peersupport, The guideline pregnancy thanothers. be selected,evenwhere ithaslessevidencein proven tobeeffectiveinthepastmaytherefore the timethat multipledrugtrialsmayrequire. Adrug relative brevity of pregnancy. Patients cannotafford antidepressants mustbeconsidered inlightof the lag toimprovement of uptosixweeksforall mandate forrapideffectivetreatment. Thetime risks tobothmotherandbaby, strong hasavery the firstoption.Severe depression, bynature of its sleep deprivation andtheurgentneedtomitigate Particularly relevant are deficientsocialsupport, present, new considerations developpostnatally. While manyfactorsidentifiedantenatally are still PND andanxiety consider takinganantidepressant. Only one-thirdof depressed pregnant womenwill causes and maydeterminedirection of referral. among manythat are aimedat theunderlying end withmedication. Rather, itmaybeoneelement which presupposes that treatment doesnotbegin or Overall, thebiopsychosocialmodelisrecommended, is stilllimited. depression, thoughresearch specificallyinpregnancy Psychotherapy canbeaneffectivetreatment for domestic violence. housing, legalorothersupportsinthecaseof assuring, where possible,basicaccesstoincome, Social workhasapowerfulrole toplayin professional withamentalhealthcare plan. refer toaMedicare-registered mentalhealth central tothisprocess and,inAustralia,theymay screening andclinicalassessment.GPsare often care andcanleadtoamore timelyresponse after health problems isanimportantpartof obstetric pathways toassistwomenwithperinatal mental psychiatrists. Findingandknowinglocalreferral to trainedperinatal mentalhealthcliniciansand specialised workers, often thecaseinruralareas, maternity hospitalsvariesgreatly, rangingfrom no The degree of mentalhealthsupportinpublic are somewhat disappointing,astreatment demonstrated positiveeffects,but results overall reduction of stress. Some group interventionshave is effectivein relapse prevention of depression and hypercholesterolaemia hasbeensuggested. for metaboliceffectssuchashyperglycaemiaand which caseanincreased scheduleof screening treat anxietyoraugmenttheantidepressant, in as quetiapineorolanzapineare often usedto risks formalformations. Adjunctiveagentssuch be importantifanyagentsare usedwithpossible indicated. The18–20weekmorphologyscanwill then anopinionfrom aperinatal psychiatrist is psychiatrist. orpresentation Ifthehistory iscomplex, appropriate professional, whetheraGPorgeneral warrant regular mentalhealthmonitoringbyan undertaking antidepressant therapyinpregnancy as prevention. 18 oringroups 5,17 14 21 furtherrecommends that women Internet-basedtreatments may There issomeevidenceforefficacy 19 22 , asthere isevidenceit 16 20 and 15 and/or co-morbidanxiety. agitation with prominent guiltandworthlessness can beexperiencedasastate of restless, numb that, rather thansadness,postnatal depression essential. We often findpatients maynotunderstand Education aboutthenature of depression is depression oranxietyinthepostnatal period. folate. Thisisespeciallytrueforthenewonsetof anaemia andvitamindeficiencies,suchas D, B12and contributory, suchasthyroid disorder, iron deficiency underlying organicdiseasethat maybecausalor Biological considerations includescreening for can offer information onbreastmilk drugexposure. pharmacy departmentsof majormaternity hospitals resources (seetheendof thearticle)and to commencingmedication inpregnancy. Online These risksshouldbediscussedwithwomenprior newborn exposedtoantidepressants inutero. adaption syndrome, ashort-livedresponse inthe through breastmilk andthepossibilityof neonatal risks of exposinginfants topsychotropic medication attachment. Itisalsoimportanttounderstandthe the impactof PNDonthenewborn’sdeveloping detection and treatment. well-positioned tofacilitate increased awareness, to accessingtreatment exist.Obstetriciansare available; however, socialandsystemicbarriers and fathers/partners. Effective treatments are long-term consequencesformothers,theirinfants are common, withpotentiallyseriousshortand In summary, perinatal depression andanxiety women asearlyinpregnancy as possible. and childdevelopment. positive impactonthemother-infant relationship discussed asasymptomof PND. Reassurance willbevaluedwhenthisisidentifiedand or shameinharbouringthesethoughts,iscommon. or deliberate harmtothebaby, accompanied byguilt unit where available.Intrusivethoughtsof accidental preferably amotherandbabyinpatient psychiatric mental healthteam,orinaward, at homewithfamilysupport,ahome-visiting dictates theappropriate levelof supervision,whether there isanyurgetoactuponthesethoughts.This infanticidal ideation assistsindistinguishingwhether A careful andtactfulassessmentof suicidaland be depressed becausetheylackthesefeatures. infant. Often,womenmistakenly thinktheycannot features, norisdisconnectionfrom ordislike of the ideation, whileimportanttoidentify, are notuniversal newsletter throughout pregnancy andthe postpartum. Information forwomen, whocansignuptoreceive aregular Centre forPerinatal Excellence (COPE): www.cope.org.au. Further reading cognitive development. developing attachment andfuture emotionaland been demonstrated tohaveimpactontheinfant’s as sustainedexposure tomaternal depression has provide emotionalcare whilethemotherrecovers, if there are otherlovingfamilymemberswhocan between motherandbaby. Itisidealfortheinfant mother, whilestillfacilitating positiveexperiences of reducing stress andmaximisingsleepforthe to rallyallpossiblesupportsassistinthetask The womanandherfamilyshouldbeencouraged high risk, and psychotherapymayprevent PNDinwomenat evidence that professional home-visitingsupport depression, psychosocial interventionsforreducing maternal for efficacy ofawiderange ofpsychologicaland 29 highlightingthevalueof such identifying 25 helpingpostpartumstress 17 5,17 There isalsosome There issomeevidence 23 Suicidalandinfanticidal 24 26 andfor

MIND MATTERS

Cochrane Cochrane Cochrane Cochrane J Obstet Birth 2009; Women Birth 2018 Women Vol. 20 No. 3 Spring 2018 | 23 Vol. ANZ J Psychiatry cimate.edu.aucimate.edu.au cimate.edu.aucimate.edu.au e F, et al. Internet delivered et al. Internet delivered e F, ofessionals-3/perinatal-mental- J Affect Disord. 2017 Oct 15; alker S, et al. Management of et al. Management of S, alker Ann Fam Med. 2016 Sep;14(5):463-72. Ann Fam . Psychosocial and psychological eating postpartum depression. postpartum depression. eating 2008 Jul; Health Ment Arch Womens es E, Duarte R.V Mindfulness-based Mindfulness-based es E, Duarte R.V ert J, Zimmerman C, et al. Early intervention Zimmerman ert J, Depress Anxiety 2017 Oct;34(10):928-966. , Dennis CL, Cosic N, et al. The effect of perinatal of perinatal et al. The effect , Dennis CL, Cosic N, J Affect Disord 2015 May 15;177:7-21. . Women’s attitudes, preferences and perceived and perceived preferences attitudes, . Women’s Mindfulness 2017;8(6):1421-1437. -P. Targeted group antenatal prevention of postnatal postnatal of prevention antenatal group Targeted -P. -P, Highet N, Expert Working Group. Mental Health Care Health Care Mental Group. Working Expert Highet N, -P, omen’s experiences with postpartum anxiety disorders: , Kim T, Ahn J. A systematic review of psychosocial of review A systematic Ahn J. , Kim T, , Gau M, Lee T, et al. Mindfulness-based programme on on programme et al. Mindfulness-based , Gau M, Lee T, .cope.org.au/health-professionals-3/perinatal-mental- ol L. A systematic review of the efficacy of cognitive the efficacy of review ol L. A systematic tt N, Levin L, Ziedonis D, et al. Enhancing participation et al. Enhancing participation Levin L, Ziedonis D, tt N, tephens S, Ford E, Paudval P, et al. Effectiveness of et al. Effectiveness Ford E, Paudval P, tephens S, airbrother N, Woody S. New mothers’ thoughts of harm related harm related New mothers’ thoughts of S. Woody N, airbrother interventions for women with postpartum stress. interventions for women with postpartum stress. Nurs. 2015 Mar-Apr;44(2):183-92. Gynecol Neonatal perinatal and preventing behavioral therapy for treating depression. antipsychotic and mood stabilizer medication in pregnancy: in pregnancy: medication antipsychotic and mood stabilizer care. for antenatal recommendations 2010;44(2):99-108. and meta- review a systematic interventions during pregnancy: analysis. women. pregnant the psychological health of May 8; pii S1871-5192(17)30717-5. 221:56-64. 2018; Health J Womens Int review. literature a narrative 29(10):237-249. F to the newborn. 11(3):221-9. Dennis C, Hodnett E. Psychosocial and psychological interventions for tr Rev. 2007 Oct 17;(4):CD006116. Syst Database Song J Sock Bya a settings: care perinatal in outpatient care in depression 2015 Nov; 126(5):1048-58. Obstet Gynecol review. systematic Austin M http://cope.org.au/health-pr health-disorders/decision-making-making-management/. Galbally M, Snellen M, W Goodman J depression. for perinatal barriers to treatment 36(1):60-69. Letourneau N and child for mothers on parenting treatment depression development. Dhillon A, Spark Pan W Bittner A, Peuk anxiety and depressive women with elevated in pregnant program. group of a cognitive-behavioral symptoms: efficacy Nurs. 2014;28(3):185-95. Neonatal J Perinat Austin M Scand. 2003 Apr; Acta Psychiatr a review. depression: 107(4):244-50. Forsell E, Bendix M, Hollandar a depression: cognitive behavioural therapy for antenatal trial. randomised controlled Ali E. W www health-disorders/calculating-score-epds/. Guideline . Australian Clinical Practice Period: in the Perinatal Excellence. Perinatal of Centre Melbourne (2017): S in primary depression psychological interventions for postnatal a meta-analysis. care: Dennis C, Dowswell T postpartum depression. interventions for preventing Database Syst Rev 2013;(2):CD001134. Syst Database

27. 16. 19. 20. 23. 24. 25. 26. 11. 13. 15. 17. 18. 21. 22. 12. 14. 28. 29. Acta Psychiatr Scand Acta Psychiatr 2018; Hum Reprod Update Lancet 2014;384:1775-1788. -L, et al. Non-psychotic -L, , et al. Neonatal outcomes in outcomes , et al. Neonatal Matern Child Health J. 2018; Child Health Matern Lancet Psychiatry 2016;3(10):973-962. Pavlovic D, Saint K, et al. Antenatal screening screening Saint K, et al. Antenatal Pavlovic D, oy S, Pawlby S, Pariante C. Identifying the women Pawlby S, oy S, on P, Cooper P. Postnatal depression, mother– depression, Postnatal Cooper P. on P, , Wennerholm U, Pinborg A, et al. The effect of Pinborg A, et al. The effect U, , Wennerholm , Bazemore S. Prenatal and postpartum depression in and postpartum depression Prenatal S. , Bazemore JAMA 2010;303(19):1961-9. JAMA Psychiatry 2016 Aug 1;73(8):826-37. , Rondon M, Araya R, et al. Epidemiology of maternal maternal , Rondon M, Araya R, et al. Epidemiology of Targeted resources aimed at aimed at resources Targeted who see women health professionals planning a pregnancy pregnant, are that or breastfeeding. , Groth S. Fathers Count: the impact of paternal risk paternal Count: the impact of Fathers S. , Groth Br J Psychiatry 1987;150:782-6. x J, Holden J, Sagovsky R. Detection of postnatal depression. depression. postnatal Sagovsky R. Detection of Holden J, x J, Targeted resources aimed at aimed at resources Targeted who see women health professionals planning a pregnancy pregnant, who are or breastfeeding. COMPANION COMPANION RESOURCES RESOURCES at risk of antenatal anxiety and depression: A systematic review. review. A systematic anxiety and depression: antenatal risk of at J Affect Disord. 2016;191:62-77. disorders in the perinatal period. disorders in the perinatal Depression the ten-item Edinburgh Postnatal Development of Scale. Austin M, Hadzi- a of validation depression: postnatal of for the prediction questionnaire. risk psychosocial pregnancy 2005;112(4):310-17. Meng Y 22(3):401-408. Paulson J a meta- depression: with maternal and its association fathers analysis. Co Biaggi A, Conr Howard L, Molyneux E, Dennis C Olderied, N outcomes: a and paediatric factors on perinatal paternal and meta-analysis. review systematic 1;24(3):320-389. factors on birth outcomes. Gelave B and risk factors and child outcomes in low-income depression, middle-income countries. Jarde A, Morais M, Kingston D Murray L, Fear women with untreated antenatal depression compared with compared depression antenatal women with untreated and meta- review a systematic women without depression: analysis. for and child development: prospects interactions infant editors. Gemmill AW, J, In: Milgrom and treatment. screening 2015. Identifying Depression and Anxiety. Wiley, Perinatal pp139-164.

5. 6. 9. 10. 8. 7. 1. References 2. 3. 4. For professionals, the NHMRC-approved Perinatal Mental Health Mental Perinatal the NHMRC-approved For professionals, mental for perinatal online training in best practice Guideline and health disorders. any can be downloaded onto platform, screening iCope, a web-based and depression of and autoscoring rapid screening device to allow and professionals. factors by patients psychosocial risk (PANDA):www.panda.org.au. Australia Anxiety and Depression Perinatal phone counselling. PANDA and how to access resources Information, online to the phone counselling patients can refer Professionals request training sessions. and service, find information Lactmed: toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. in breastfeeding, chemical and drug exposure of Online database Medicine. Library of maintained by the US National Sms4dads.com about their baby’s information sign up to receive can Expectant fathers Prof they wish, from as well as online support, if development via SMS, Richard Fletcher’s team in Newcastle. Mummoodbooster.com Institute Research led by the Parent-Infant project An online research who sign Women Institute (USA). Research (Australia) and the Oregon program. an eight-week online treatment up receive MIND MATTERS Belmont PrivateHospital,Queensland Consultant Psychiatrist MBBS, FRANZCP Dr Lyndall White in pregnancy Antidepressants pain disorders.Antidepressants may, at times, conditions, includingdepressive, anxietyand Antidepressants are prescribed foranumberof occurring bythesecondtrimester. women suffera relapse of depression, often confirming pregnancy. Up to68percent of these discontinue antidepressant medication upon However, more thanhalfof womenabruptly Pregnancy isnotprotective formentalhealth. • • • the past12months,shemayelectto: If awomaniscurrently euthymicandhasbeenfor state andpsychosocialcircumstances. a comprehensive assessmentof thewoman’smental continue orwithholdmedication iscompletewithout and duration of depressive episodes.Nodecisionto admission wasrequired andthefrequency, severity successful. Importantfactorsincludewhether and what treatments were required, tolerated and condition, whethertheconditionhasremitted history, includingtheseverityof herpastandcurrent infant. Itshouldbebasedonthemother’spsychiatric risk andbenefittomother, fetusand,later, the This decisionshouldbeasensiblebalancebetween her doctor. consultation withthewoman,herpartnerand ideally shouldbemadepriortoconception,by to continueorceaseantidepressants inpregnancy on thismedication. There are rare exceptions to this. the sake of a pregnancy ifthewomanhasbeenwell Antidepressants should notberoutinely changedfor should becontinuedthroughout thepregnancy. or recurrent depression inthepast,thenmedication If awomanisdepressed orhassuffered seriousand/ • • Continue curr Change toalterna Reduce dose(notr symptoms recur Cease andr Cease medica eintroduce medication if tion duringpregnancy ent medication te medication ortherapy ecommended) 1 Thedecision 1 the UStake antidepressants. Approximately eightpercentof pregnant womenin hypomanic swing. other thymolepticmedications mayriskamanicor antidepressants withouttheco-prescription of also beprescribed inbipolardisorder. Theuseof pregnancy) islowbutnotzero. for anynegative outcomeforthefetus(and associated withantidepressants. Theabsoluterisk barrier. There are potentialpregnancy complications amniotic fluidandthecrossing of thebloodbrain Fetal exposure toantidepressants isviatheplacenta, Fetal exposure changes includingdiet,exercise andsleep patterns. behavioural andinterpersonaltherapies)lifestyle successfully treated withpsychotherapies(cognitive and anxietydisorders.Milddepression maybe are commonlyprescribed forsignificantdepression selective noradrenaline reuptake inhibitors(SNRIs) serotonin reuptake inhibitors(SSRIs).SSRIsand prescribed andresearched medications are selective blood volume,reduced gutmotility, increased antidepressants through increased maternal Pregnancy affects thebioavailability of Bioavailability ultrarapid metaboliser). higher doses of anantidepressant (extensiveor (possible poormetaboliser),ornobenefitfrom either tohavesignificantsideeffects atlowdose tool, itmayassist,especiallyifawomanappears depression. Whilethisisstillarelatively newclinical selecting thebestmedications intreatment-resistant Pharmacogenomics are becomingmore usefulin Pharmacogenomics potentially fatal inoverdose. contraindication tousingTCADs, astheyare Suicidalideationdrugs (TCADs). isasignificant in pregnancy, particularlyof tricyclic antidepressant be unwantedsideeffects of antidepressant agents hypotension, oversedation andconstipation mayall in hyperemesis withSSRIorSNRIagents.Postural especially inpregnancy. Nauseamaybeexaggerated Tolerability of antidepressant agentsisimportant, Tolerability recall biasare further complications. on prescriptions supplied.Patient adherence and Observational studiesmayinvolvedatabases relying be theresult of low-ormedium-qualitymethods. psychotropic medication useinpregnancy may Distortions inanystudyregarding outcomesfor Outcome studies neurobehavioural andgrowth challenge. third trimesterexposures maybeassociated with in congenitalmalformation, whilesecondand trimester exposure todrugsmaybeimplicated of medication inpregnancy isalsoimportant.First 3 2 Themostcommonly 3 4 Thetiming 5 MIND MATTERS JAMA BMJ 2012; Vol. 20 No. 3 Spring 2018 | 25 Vol. JAMA 2006;295(5):499-507. tion of the literature: Understanding Understanding the literature: tion of -Díaz S, Huybrechts K, et al. Use Huybrechts S, -Díaz , Brain U, et al. Maternal and foetal factors and et al. Maternal , Brain U, , Mamisashvili L, et al. Selected pregnancy , Mamisashvili L, et al. Selected pregnancy Gen Hosp Psychiatry 2013;35:265. Pathways to care for all pregnant for all pregnant to care Pathways 10 printstore.ranzcog.edu.au -P, Highet N and the Expert Working Group. Mental Group. Highet N and the Expert Working -P, , Galbally M, Snellen M, et al. Pharmacological , Artama M, Engeland A, et al. Selective serotonin , Artama M, Engeland A, et al. Selective serotonin L, Altshuler L, Harlow B, et al. Relapse of major depression depression major of Relapse al. et B, Harlow L, Altshuler L, BMJ 2013;347:f4877. echts K, Palmsten K, Mogun H, et al. National trends in trends National et al. H, echts K, Palmsten K, Mogun Written by experts. Written RANZCOG RANZCOG Patient Information Pamphlets f taking an antidepressant medication during pregnancy? during pregnancy? medication f taking an antidepressant that influence prenatal exposure to selective serotonin reuptake reuptake to selective serotonin exposure prenatal influence that In: Galbally M, Snellen M, Lewis A, inhibitor antidepressants. Berlin: Springer; editors. Psychopharmacology and Pregnancy. 2014:33-46. In: Galbally research. observational the complexities of M, Snellen M, Lewis A, editors. Psychopharmacology and Berlin: Springer;2014:19-31. Pregnancy. Palmsten K, Hernández Kieler H persistent and risk of inhibitors during pregnancy reuptake pulmonary hypertension in the newborn: population-based the five Nordic countries. cohort study from 334:d8012. Boyce P In: Galbally in pregnancy. major depression management of M, Snellen M, Lewis A, editors. Psychopharmacology and Berlin: Springer; 2014:67-85. Pregnancy. Austin M period: Australian clinical practice in the perinatal health care 2017. Excellence; Perinatal of guideline. Melbourne: Centre Cohen Huybr among publicly insured treatment medication antidepressant women. pregnant Shea A, Thi Nguyen T Einarson A. Critical evalua Conover E, Forinash A. How do I weigh the risks and benefits o Primer 3rd Edition. The Teratology [Internet]. In: Teratology www. from: Society; 2018 [cited 2018 July 20]. Available teratology.org/primer/. Ross L, Grigoriadis S to antidepressant exposure and delivery outcomes after and meta-analysis. review a systematic medication: Psychiatry 2013;70:436. postpartum near delivery and risk of antidepressants of United low income women in the hemorrhage: cohort study of States. during pregnancy in women who maintain or discontinue in during pregnancy treatment. antidepressant

women should include access to comprehensive access to comprehensive women should include teams. mental health perinatal 4. 5. 9. 10. References 1. 3. 6. 7. 8. Conclusion mother and infant risks to the are While there the in pregnancy, antidepressants of with the use major mental an untreated impact of negative overstated. cannot be in pregnancy health disorder the Medicare of Clinical Committee The Obstetrics have Taskforce (MBS) Review Benefits Schedule the with the launch of this us of reminded recently mental recommending new MBS item numbers in pregnancy all women, both health assessments of and postnatally. 2. 5

3 9 8 8 Persistent 7 The medication The medication 9 Postnatal growth growth Postnatal 6 3 This condition is usually self-limiting and 9 minor. Admission to NICU may be warranted. minor. impairment, delayed fine or gross motor skills, and impairment, delayed fine or gross not cognitive and intellectual impairment have been shown conclusively to be a consequence in the fetus to antidepressants of exposure of a remains in the mother Major depression pregnancy. serious consideration. of SSRIs The only significant potential risk for use and SNRIs obstetrically appears to be postpartum haemorrhage. This risk seems small, but clinically significant (four per cent in exposed women versus per cent in non-exposed women). three may clear the maternal compartment, thereby thereby compartment, may clear the maternal in depressive the mother to an increase predisposing a time when she is most vulnerable. It symptoms at does not necessarily clear the fetal compartment and to It is best PNAS. may still suffer from the neonate team prior to delivery. engage the neonatology Despite the risk of PNAS, the practice of reducing reducing the practice of PNAS, Despite the risk of third mid to late from antidepressants the dose of trimester is not recommended. Poor neonatal adaptation syndrome (PNAS) syndrome adaptation Poor neonatal in taken are can be a risk when antidepressants may be jittery and suffer Infants pregnancy. late hypoglycaemia and distress, hypotonia, respiratory PNAS varies, but incidence of The reported seizures. in the exposed late appears to be higher in infants infant variables include Confounding pregnancy. genotype. The studies relating to preterm delivery and low birth to preterm The studies relating fraught with discrepancies weight with SSRIs are unlikely These outcomes are in methodology. to be clinically significant. Negative outcomes made between have been many associations There antidepressants outcomes and the use of negative causality is yet to be but direct in pregnancy, depression, the mother’s of established. The severity other medications use of any co-morbidities and the outcome. An untreated and substances all affect in poor episode may result major depressive severe clinic, poor diet and low antenatal at attendance with substances self-medication The risk of self-care. aside is also significant. Suicide is the final risk, poor depression, postnatal high incidence of from poor risk of and long-term to the infant attachment neglect. child developmental outcomes through SNRIs and SSRIs to SSRIs, the major concern for With respect to congenital cardiac defects. relates malformation is here significantly implicated The only medication and even in these studies, the prevalence paroxetine, risk. background than the was only minimally greater renal function and reduction in plasma protein protein in plasma and reduction function renal may antidepressant dose of The concentrations. in advanced to be increased need therefore P450 enzymes in later in hepatic Changes pregnancy. Smoking, required. doses may also affect pregnancy foods may and chargrilled vegetables cruciferous of antidepressants. therapeutic levels further affect Proton pump inhibitors, dexamethasone and pump inhibitors, Proton may affect that among medications nifedipine are therapeutic altering thereby certain P450 enzymes, levels. antidepressant pulmonary hypertension of the newborn (PPHN) has pulmonary hypertension of to SSRIs, exposure pregnancy in late been reported is low (increase The incidence SNRIs and TCADs. 1.2 to 3 per 1000 in SSRI exposure). from MIND MATTERS physical activity. of obesity withafocusonweightreduction and factor, especially inthecontextof increasing rates young women in adolescentsand Eating disorders reports, reaction. Firstdescribedby19thcentury medical nervosa (AN)are unlikely tohavesucharelaxed the dietat anothertime.Individualswithanorexia enjoy it,perhapswithahalf-heartedplantoresume still reach forthechocolate on astressful dayand Dieting isnotunusual,althoughmanyof uswill Royal Children’sHospital Dept ofAdolescentMedicine Paediatrician/Adolescent Physician MBBS FRACP PhD Dr MicheleYeo such asperfectionism. country, geneticheritabilityandpersonalitytraits include femalegender, residence inadeveloped and environmental factors at play, asriskfactors there are likely tobebiological,psychosocial atypical AN. Whilethecauseof ANisunknown, are notunderweight,adiagnosisreferred toas a significantamount of weightinashorttime,but symptoms canalsooccurinindividualswholose loss drivenbyanintensefearof weightgain.These Royal Children’sHospital Dept ofAdolescentMedicine Clinical EvaluationCoordinator(EatingDisorders) BSc(Hons),MPsych(ClinNeuro) BA, Danielle Pogos 1 ANischaracterisedbysignificantweight 3 2 Dietingisalsoamajorrisk and polycysticovariansyndrome. can alsobeassociated withirregular oestrogen levels.Ontheotherhand,BNandBED hypothalamic-pituitary-ovarian axisandlow AN and amenorrhoea,withsuppression of the weight loss,excessive exercise and low BMIin There isaclearrelationship betweensignificant Menstrual concernsandpubertaldevelopment concerns about . to theO&Gincludemenstrualdisturbanceand systems are discussedbelow. Typical presentations long-term health.Theimpactsonthemajororgan multiple organsystemsandimpactingshort malnutrition oroverweight/obesity, affecting Disordered eating behaviourscanleadto a significanttimeforgrowth anddevelopment. they commonlypresent intheadolescentyears, While eating disorderscanoccurinadulthood, Complications ofeatingdisorders these disordershasseriousmedicalconsequences. studied. Despitethedifferent aetiologies,each of in malnutritionaffect boneformation, aswell changes ingrowth ,andIGF-1 occurring years. Oestrogen deficiency, hypercortisolaemia, bone mineraldensityoccursduring theadolescent to long-termbonehealth,asthe greatest increase in Restrictive eating disorderspose asignificantthreat Bone health early adolescence. ARFID occurduringtheperipubertalperiodand when restrictive eating disorderssuchasANand and delayedpubertyare commonfeatures, especially eating disorders. Table 1showsthediagnosticcriteriaforthese issues, lackof interest, orfearof chokingorvomiting. food intake foravarietyof reasons, suchassensory AN orBN. AdolescentswithARFIDrestrict their driven byconcernoverbodyshapeorweight,unlike refers toasignificanteating disturbancethat isnot avoidant restrictive foodintake disorder(ARFID), A newlydescribedheterogenous eating disorder, without thecompensatory behaviours. characterised byrecurrent episodesof bingeeating not loseweight.Bingeeating disorder(BED)is and restriction, exercise orpurging,buttheydo (BN) experiencerecurrent episodesof bingeeating In contrasttoAN, adolescentswithbulimianervosa at muchhigherrates. cent forBED. Subthreshold eating disordersoccur per cent,0.8–0.9 percentforBN, and1.6–2.3 per lifetime prevalence rates forANrangefrom 0.3–1.7 clinic-based samples.Recentstudiessuggestthat on whether theyare population, communityor The rates of eating depending disordersvary 4 5,6 ARFIDhasnotbeenaswell 7 Delayedgrowth MIND MATTERS Vol. 20 No. 3 Spring 2018 | 27 Vol. clusively during the course of ted culturally sanctioned practice Bisphosphonates have been effective have been Bisphosphonates f lack of control over eating during the over eating control f lack of 11 ttributable to a concurrent medical ttributable to a concurrent ed interference with psychosocial functioning with ed interference ting, in a discrete period of time (for example, period of ting, in a discrete oestradiol) may be useful in increasing bone may be useful in increasing β oestradiol) episode Is not better explained by lack of available food or Is not better explained by lack of by an associa Does not occur ex a disturbance of is no evidence AN or BN and there is in the way in which one’s body weight or shape experienced Is not a the When condition or another mental disorder. another of context the in occurs disturbance eating the eating of the severity condition or disorder, with associated routinely that disturbance exceeds the condition or disorder and warrants additional clinical attention. Ea food within any two-hour period), an amount of most individuals what is definitely larger than that time under similar in a similar period of would eat circumstances A sense o Significant weight loss/failure to achieve expected Significant weight loss/failure weight gain Significant nutritional deficiency Dependence on enteral feeding or oral nutritional supplements Mark in improving bone density in adults, however, bone density in adults, however, in improving half-lives and potential for concerns about long limit its use in adolescents and women teratogenicity age. childbearing of health and obstetric concerns Reproductive by eating on how fertility is affected Research with is mixed, in remission) disorders (even when and vitamin D. Studies suggest that oestrogen oestrogen that suggest Studies D. and vitamin contraceptive the combined oral using replacement AN is not effective and adults with pill in adolescents research is some There bone density. in improving oestrogen transdermal physiologic that suggesting (17 up does complete catch although mineral density, not occur. Marked distress regarding binge eating is present. binge eating regarding distress Marked least once a week occurs, on average, at Binge eating months. for three use of with the recurrent is not associated Binge eating compensatory behaviours as in BN and inappropriate BN or during the course of does not occur exclusively such as for overeating, AN methods to compensate self-induced vomiting. The eating disturbance: The eating • • disorder (BED) Binge eating An episode of binge eating. of episodes Recurrent by: is characterised binge eating • • An eating or feeding disturbance manifested by An eating nutritional and/ to meet appropriate persistent failure the of with one (or more) or energy needs associated following: • • • • • Avoidant restrictive food intake disorder (ARFID) food intake restrictive Avoidant fluence of body fluence t interferes with weight gain t interferes 10 f energy intake, leading to a f energy intake, Fifty per cent of adolescents with adolescents of Fifty per cent Up to 30 per cent of adolescent to 30 per cent of Up f lack of control over eating during the over eating control f lack of 8 ting/purging type: during the last three 9 Diagnostic criteria for AN, ARFID, BN and BED. ARFID, AN, Diagnostic criteria for ting, in a discrete period of time (for example, period of ting, in a discrete cessive exercise within any two-hour period), an amount of food within any two-hour period), an amount of most individuals what is definitely larger than that time under similar in a similar period of would eat circumstances episode Ea A sense o weight or shape on self-evaluation, or persistent weight or shape on self-evaluation, current the of seriousness the of recognition of lack low body weight Binge-ea months, the individual has engaged in recurrent or purging behaviour binge eating episodes of laxatives, (self-induced vomiting or the misuse of or enemas) diuretics Restricting type: weight loss is accomplished dieting, fasting and/or primarily through ex Restriction o of age, significantly low body weight in the context health sex, developmental trajectory and physical or persistent gaining weight Intense fear of behaviour tha or Disturbance in the way in which body weight shape is experienced, undue in • compensatory behaviours inappropriate Recurrent, weight gain, such as: self-induced in order to prevent or other diuretics laxatives, vomiting; misuse of exercise. fasting; or excessive medications; compensatory and inappropriate The binge eating least once a on average, at behaviours both occur, months. week for three by body shape and is unduly influenced Self-evaluation weight. during The disturbance does not occur exclusively AN. episodes of Bulimia nervosa (BN) An episode of binge eating. of episodes Recurrent by: is characterised binge eating • Specify whether: • • • • Anorexia nervosa (AN) Anorexia • Table 1. Table girls and adult women report having sustained a having women report girls and adult normal weight with In addition, women of fracture. found to have lower spinal bone mineral BN were suggesting to their healthy peers, density compared other than weight loss influence that factors bone metabolism. Treatment of amenorrhoea and low bone density amenorrhoea and low bone density of Treatment of gain and restoration should focus on weight calcium of optimisation as well as function, menstrual playing a role in bone resorption. The best predictive predictive The best bone resorption. in a role playing of is the duration bone density decreased factor of amenorrhoea. AN have bone mineral density values of greater greater of mineral density values AN have bone SD) below their (1 deviation than one standard healthy peers. MIND MATTERS but relapse mayalsobetriggered. disorders. pregnancy are commoninwomenwitheating of FBT havebeenadaptedforuseinadults. the successof FBTinadolescent AN, modifiedforms snacks toenableweightgainormaintenance.Due and supervisetheadolescentineating mealsand The FBTtherapistcoachestheparents tosupport by taskingtheparents withtherole of re-feeding. aim of FBTistoremove control from theadolescent and BEDriskexcessive gestational weightgain. syndrome, obesityandinfertility. association betweenBN, BED, polycysticovary normal population. ofin womenwithahistory ANcompared tothe between rates of pregnancy andinfertility treatment population-based studiesindicate nodifference the disorder. currently littledata onefficacygiventhenewness of success inachievingweightgain, althoughthere is also usedforadolescentswithARFID becauseof its Apgar scores andfeedingdifficulties. born prematurely, havelowerbirthweights, mothers withaneating disorderare more likely tobe postnatal depression andrelapse. Infants bornto experience increased perinatal problems, including Studies alsoshowthat womenwitheating disorders menstrual disturbance. with ANandBN, despitethehighprevalence of the riskof unplannedpregnancy ishigherinwomen A numberof largecohortstudieshaveshownthat compared tomatched controls. clinical samplesreporting lowerrates of pregnancy evidence basefortreatment of adolescentAN. Family-based hasthestrongest treatment (FBT) inrestrictiverecovery disorders. nutritional status inalleating disordersandweight eating disorders,treatment must focusonimproved Given thesignificantlong-termcomplications of Treatment contributing topredisposition forarrhythmias. or purgingcanleadtoelectrolyte abnormalities, and cardiacfailure. Misuseof laxatives, diuretics cardiovascular causes,suchastachyarrhythmias About halfof deaths inANcanbeattributed to conduction abnormalitiesoccurmore frequently. progressive malnutrition,structural,functionaland hypotension andposturalhypotension.With include bradycardia,posturaltachycardia, Common findingsin restrictive eating disorders Cardiac The impactof BEDonthebrainisstillbeingstudied. cognitive control, reward andemotionprocessing. also shownchangesinneuralcircuitry related to pronounced. Functional brainimagingstudieshave similar findingsinpatients withBN, althoughless were reversible withweightgain.There were matter. Studies showthat manyof thesechanges with AN, report areduction inbothgrey andwhite styles. Neuroimaging studies,mostlyinpatients psychomotor retardation andinflexible thinking increasing malnutrition,theycanpresent with headaches anddifficultiesinconcentration. With Patients witheating disordersoften complainabout Neurological disease are complications of obesity asaresult of BED. Metabolic complications andriskof cardiovascular may haveagreater riskof miscarriage. 15 Remissioncanoccurduringpregnancy, 13 There isalsoacomplex 12 Negative feelingsregarding 12 14 However, 16 Women withBED Women withBN 18 12 22 FBTis 19 21 17

The 20 based therapy(CBT). First-line treatment forBNinadultsiscognitive multidisciplinary teamsfor treatment.multidisciplinary for pregnancy andrefer to,orcollaborate with, eating andweight-related behaviours,counsel O&Gs are well placedtoenquire aboutdisordered disturbance orfertilityconcerns.Thismeansthat Young womenoften present toO&Gsformenstrual outcomes foryoungwomenandtheiroffspring. identification andtreatment iscrucialforbetter and highrates of morbidityandmortality. Early are associated withmultiplemedicalcomplications adolescents andyoungwomen.Thesedisorders can present at anyage,butmostcommonlyin Eating disordersare seriousmentalillnessesthat Conclusion electrolyte abnormalitiesorsuicidality. for managementof haemodynamicinstability, Inpatient treatment hasbeengenerallyreserved may exacerbate restriction, bingeeating andpurging. weight control measures suchasdietandexercise to betaken intoaccount,however, focusonlyon The managementof co-morbidobesityalsoneeds SSRIs andtopiramate mayconfer additionalbenefit. BEDs inadults.Pharmacologicalmeasures include There isempiricalevidencefortheuseof CBTin 14. 10. 7. 6. 5. 4. 3. 2. 1. References 13. 12. 11. 9. 8. treatment modalities. In adolescentBN, bothFBTandCBTare effective eating patterns andreduce binge-purgeepisodes. with BN. may alsobeusedasanadjuncttotherapyinpatients (SSRIs), particularlyhighdose(60mg)fluoxetine, unobtainable. Selectiveserotonin reuptake inhibitors through self-helpbookswhenprofessional therapyis

A fulllistofreferences isavailableonlineat: www.ogmagazine.org.au. ovaries. McClusk 2014; 121:408-416. disorders: findingsfrom apopulation-based birthcohort. twin birthsandunplannedpregnancies inwomenwitheating Micali N Linna M,RaevuoriA,HaukkaJ Misra M,Ka Robinson L,AldridgeV 2004; 114:1574-1583. parameters incommunitydwellingadolescentgirls. on clinical,hematologic, biochemicalandbonedensity Misra M,AggarwalA,MillerK,etal.E T disturbance ineating disorders. Poyastr adolescents. severity of DSM-5 eating disordersinacommunitycohortof Smink F 2011;68:717-723.Pysch comorbidity surveyreplication adolescentsupplement. of eating disorders inadolescence.Resultsfrom thenational S 2013 May22. manual of mentaldisorders(DSM-5®). AmericanPsychiatric Pub. American Psychia 165-168. disorders: population basedcohortover3years. Pa Epidemiology 2014; 6:89. genetic, environmental andsocietalfactors. Mitchison D Clinical Societyof London.1874; 7:22-28. Gull W 46:826-833 outcomes ineating disorders. anorexia nervosa. replacement increases bonedensityinadolescentgirlswith bone density. OsteoporosisInt 2016;27:1953-1966. meta-analysis of theassociation betweeneating disordersand In JEndocrinol2013;2013:897-19. of lowbonemineralmassinadultwomenwithanorexia nervosa. 40:424-434. rombetti A,RichertL,HerrmannF, etal.Selectivedeterminants wanson S, Crow S, LeGrangeD, etal.Prevalence andcorrelates tton G,Selzer R,Coffey C,etal.Onset of adolescent eating 23 . Apepsiahysterica,norexia nervosa.Transactions of the o A,ThorntonL,PlotonicovK,etal.Patterns of menstrual , Van Hoeken D, Oldehinkel A,etal.Prevalence and , dosSantos-Silva I, Stavola B, etal.Fertilitytreatment, Lancet 1992;340:723. ey S, LaceyJ, Pearce J. Bingeeating andpolycystic tzmann D, MillerK,etal.Physiologicestrogen , HayP. Theepidemiologyof eating disorders: Int JEat Disord2014; 47:610-619. tric Association. Diagnosticandstatistical J BoneMinerRes2011;26:2430-2436. 23 24 , ClarkE,etal.Asystematic review and CBTaimstonormalise CBTcanalsobedelivered , etal. Am JObstetGynecol2013; Int JEat Disord2007; ffects of anorexia nervosa Clinical BMJ 1999;318: Pediatrics

Arch Gen BJOG 23

MIND MATTERS 7,8 Psychiatric Psychiatric 6 Vol. 20 No. 3 Spring 2018 | 29 Vol. 13 Agonist treatment, Agonist treatment, 11 Increased monitoring of monitoring of Increased 12 Patients who use drugs during Patients 9,10 illness is strongly associated with increased suicide with increased associated illness is strongly Suicide is the leading single risk during pregnancy. and mortality in New Zealand maternal cause of in death of maternal cause the fifth most common significantly higher among are Australia. These rates Islander women. Strait Torres Maori, Aboriginal and Abrupt cessation of some substances, particularly of Abrupt cessation is not recommended and benzodiazepines, opiates spontaneous due to the risk of during pregnancy, birth. miscarriage and preterm Among those with dependence syndrome, rates of of rates syndrome, Among those with dependence up to 70 per cent. illness are psychiatric Antenatal care of for treatment and referral screening Universal women for drug and alcohol misuse is pregnant visit. Several the first antenatal at recommended to identify scoring systems have been validated high risk for ongoing substance use women at in pregnancy. fetal growth is recommended, due to the increased the increased due to is recommended, fetal growth Other sequelae low birth weight. incidence of on the fetus include birth defects and of addiction delay. long-term neurodevelopmental women with It is not uncommon for pregnant hours to out of dependence disorders to present emergency departments or obstetric units with acute withdrawal, social issues and intoxication, obstetric emergencies, such as placental abruption. hours, the pregnancy out of For presentations plan should be easily accessible and its care followed as closely as possible. recommendations such as methadone, is recommended during such as methadone, is recommended time for conversion being with the safest pregnancy, the second trimester. pregnancy represent a diverse group and there may and there a diverse group represent pregnancy of the likelihood increase that present be features include substance misuse and dependence. These in labour, unbooked booking or presenting late on antenatal blood-borne infection detection of itinerant lifestyle and pre-existing screening, child illness. The involvement of psychiatric is also pregnancies services in previous protection substance of common for women with a history misuse. It is important to perform a comprehensive to look for the long-term clinical examination liver disease drug misuse, such as chronic sequelae of and valvular heart disease. for women and families with care to providing Key team dependence disorders is a multidisciplinary (MDT) involving midwives, obstetricians, approach, primary and support counsellors specialists, addiction should be care Continuity of or social workers. and provided the pregnancy maintained throughout and culturally non-judgemental in a confidential, agreement care A pregnancy sensitive manner. and the should be drawn up between the patient and postpartum period, for the pregnancy MDT maternity discharge from at care and for transfer of should agreement services. Compliance with the care every at visit, particularly if the woman is be reviewed withdrawal treatment. receiving

4 is a cluster of is a cluster of 5 1 It has been defined as a 1 In 2010, the New Zealand Zealand New the 2010, In 3 2 Ministry of Health (MoH) estimated that 12.3 per cent that Ministry Health (MoH) estimated of would encounter population the New Zealand of a substance use disorder during their lifetime. In 2011, the New Zealand National Committee for National In 2011, the New Zealand alcohol and described (NCAT) Addiction Treatment drug misuse as the sixth highest contributor to the disease. of burden national Dependence syndrome, which has replaced the which has replaced Dependence syndrome, Statistical in the International term ‘addiction’ Health Diseases and Related of Classification (ICD-10), 10th revision Problems, physiological, behavioural and cognitive phenomena on a much a substance takes in which the use of higher priority for an individual than other behaviours value. once had greater that primary chronic disease of brain reward, motivation, motivation, brain reward, primary disease of chronic syndrome Dependence circuitry. memory and related involves an inability to abstain, coupled with cycles or Without treatment and remission. relapse of efforts, dependence engagement with recovery in permanent and can result is progressive syndrome disability and death. The Australian National Drug Strategy Household Drug Strategy The Australian National the per cent of 15.6 that reported in 2016, Survey, 12 had used an illicit drug over the age of population and over 17 per cent of 12 months, in the previous consumed alcohol in quantities that the population lifetime risk guidelines. exceeded Dr Helen Winrow MBBCh, DTMH trainee FRANZCOG Hospital, Auckland National Women’s Dr Nicholas Walker FRANZCOG dependence in pregnancy dependence Substance misuse and and misuse Substance MIND MATTERS analgesia inlabourorpostpartum. to control withdrawalsymptomsdonotprovide continue theseinlabour, however, dosagesused long-term opioidmedications shouldbeadvisedto access andplanforadequate analgesia.Women on admission toreview potentialissueswithvenous The anaesthetistshouldbecontactedearlyinthe of intoxication. need tobemadepostpartumreduce therisk period. Reductionsinmaintenancedosingmay postpartum psychosisintheimmediate postpartum high riskof drugrelapse, postpartumdepression and transition of care. Women withdependenceare at end of thepostnatal periodtoensure asmooth alcohol services,shouldbeintroduced before the Ongoing communitysupport,includingdrugand practice andthismustbesensitivelyaddressed. to bearinmindthat co-sleepingmaybeacultural recommended safe sleepingpractices.Itisimportant discussed andwomentheirfamiliesinformed of sudden infant death syndrome (SIDS)shouldbe Table 1. and needforFinneganscoring. depending onthedrugof misuse,socialfactors with theirmothers,often forat leastaweek, and baby. Neonates at riskof NASshouldbeadmitted indicated toensure safety andwellbeing of mother Planned postnatal admissiontohospitaliscommonly Postnatal care use andconfirm fetalwellbeing. to reduce self-medication, monitorsubstance Early attendance tohospitalinlabourisimperative Labour andbirth support workers. admitted, there mustberapidnotification of their key stabilisation andsupport,however, iftheyare not It isoften toadmitwomen tohospitalfor necessary unit shouldbeconsidered whentimingdelivery. syndrome (NAS)requiring admissiontoaneonatal labour isindicated, theriskof neonatal abstinence Benzodiazepines Cannabis Opiates Alcohol Substance Stimulants Recommendations formanagementof substancemisuseinpregnancy andpostpartum. 13 13 • • • • • • • • • • Recommendations • • • • serum. Amphetamine levelsinbr and unsafe sleeping. Advise againstbr prepared. Advisewomennot tobreastfeed for24–48 hoursafter use. on howtominimiseneonatal exposure. feedingplanshouldbe Asupplementary not recommended. The AustralianNa Substitution canbecommencedwhilebreastfeeding. Ideally outweigh thebenefits. For heavyusers,withoutintentiontocutdown,theriskso Associa If unstableonwithdrawaltr S Levels o Passage o If stableonsubstitutiontr above recommended levels. Expr A maximumo Abstinence isideal advise againstbreastfeeding, duetoharmful neonatal effects. top ifthere isevidenceof oversedation 13,14 13 essing priortodrinking,withformulasupplementation, isanoptionifintake is Ifinductionof Riskfactorsfor 13 , thewomanwillhaveundergonesupervisedwithdrawalduring pregnancy. 18 ted withneonatal agitation, irritabilityandlong-termdevelopmentaldelay f buprenorphine are considered insignificant Women whochoosetobreastfeed whileusingmust be carefully counselled f methadoneintobreastmilk isminimal f twostandarddrinksdailyisrecommended eastfeeding immediately after use,duetoriskof maternal sedation tional HealthandMedicalResearch Council(NHMRC)andNZMoH 13,16 11 13,18

13,16 eastmilk canreach seven timesthelevelsinmaternal eatment, breastfeeding isencouraged eatment orusingshort-acting opiates, breastfeeding is 13 of neuroadaptation tothesubstance,evidenceof assessed byapproved specialists,lookingforfeatures medically managedwithdrawal.Individualsare to provide individualisedtreatment that includes from harm,allowassessmentof specificneeds, and Act cameintoeffect.Itaimstoprotect individuals 2018,February theNewZealand SubstanceAddiction Australia, are consideringimplementation. In treatment programs, whileothers,includingWestern capacity. SeveralAustralianstates havecompulsory to haveasevere substancedependenceandtolack treatmentundergo compulsory if they are considered exists that allowsthosewithsevere addictionto to voluntarilyentertreatment programs, legislation While itisidealforthosewithdependencedisorders be emphasised. cases, theimportanceof skin-to-skincontactmust not berecommended, however, eveninsuch For asmallnumberof women,breastfeeding may Breastfeeding maternity services. which shouldbeinusebythetimeof dischargefrom contraception, ideally a long-acting reversible option, There shouldbeanantenatal planforpostpartum or earlyinterventionprograms maybeappropriate. syndrome), referral tocommunitypaediatric services drug andalcoholmisuse(forexample,fetal be monitored. Forchildren significantly affected by safety, aswellmilestonedevelopment,needsto program mustbeensured. Forthenewborn,home to theMDT agreement andwithdrawaltreatment engagement withcommunityservicesandadherence are dischargedfrom maternity services.Ongoing A formalhandovershouldtake placewhenthefamily Discharge encouraged tobreastfeed. In theabsenceof HIVinfection, mostmothersare be tailored totheneedsof eachmotherandbaby. specialist isof utmostimportanceandadvicemust 13 Consultation withalactation 15 11 f breastfeeding may 11,16 13 13 MIND MATTERS

ranzcog.edu.au edicting addiction Paediatrics 2012; Paediatrics Vol. 20 No. 3 Spring 2018 | 31 Vol. Obstet Gynecol. 2016; eport of the Perinatal and Maternal and Maternal the Perinatal eport of JAMA 2000;284(13):1689-1695. f Health and Welfare. National Drug Strategy Strategy Drug National and Welfare. f Health in Deaths Maternal f Health and Welfare. , O’Brien C, et al. Drug dependence, a f Health. Clinical Guidelines for the f Health. Clinical Guidelines Future Neurology 2011;6(4):459-480. Future Obstet Gynecol. 2010 Oct;116(4):827-33. an R. Neonatal drug withdrawal. drug an R. Neonatal y of Health. Introductory Guidelines on the Substance Guidelines Health. Introductory y of ff I, Wells A, McGourty R, et al. Validation of the 4P’s Validation et al. Wells A, McGourty R, I, ff . Medications and Mother’s Milk: a manual of lactational lactational and Mother’s Milk: a manual of . Medications tua Raki. Substance Withdrawal Management: Guidelines for tua Raki. Substance Withdrawal tional Health and Medical Research Council. Infant Feeding Council. Infant tional Health and Medical Research u C-S, Jew C, Lu H-C. Lasting impacts of prenatal cannabis prenatal Lasting impacts of Jew C, Lu H-C. u C-S, COG Committee Opinion No 711. Opioid use and opioid use Committee Opinion No 711. Opioid use and opioid COG postpartum Immediate Committee Opinion No. 670. COG onkers K, Gotman N, Kershaw T, et al. Screening for prenatal for prenatal et al. Screening T, Kershaw Gotman N, K, onkers odd F. Te Ariari o te Oranga: the Assessment and Management o te Oranga: the Assessment Ariari Te odd F. 13(5):398-405. Household Survey 2016: detailed findings. Drug Statistics series Statistics Drug 2016: detailed findings. Household Survey 2017. Canberra: AIHW, no. PHE 214. no. 31. Cat. 2015. Committee: Reporting Mortality Mortality Review Commission, 2017. Safety Health Quality and Wellington: 2017. Canberra: AIHW, No. PER 92. Cat. Australia 2012–2014. Journal of for substance abuse in pregnancy. Plus screen 2007 Dec;27(12):744-8. Perinatology Obstet Gynecol. 2017;130:e81-94. disorder in pregnancy. contraception. reversible long-acting 17ed, 2017. pharmacology. NZ Ministr Act. Addictions (Compulsory Assessment and Treatment) Health, 2017. Ministry of Wellington: Sinha R. New findings on biological factors pr Psychiatry Current 2011; Reports vulnerability. relapse McLellan A, Lewis D insurance for treatment, medical illness: implications chronic and outcomes evaluation. T Health and Substance Use with Co-existing Mental People of 2010. Health, Wellington, Ministry of Problems. annual r PMMRC. Eleventh Australian Institute o Y the Substance Use Risk Profile- of substance use: development Scale. Pregnancy Chasno Ma health, specialist in primary medical and nursing practitioners Raki, hospital settings. Matua addiction, custodial and general 2011. Wellington, A NSW Department o birth and the substance use during pregnancy, management of Health, 2014. period. NSW Department of postnatal Hudak M, T 129:e540-60. A 128:e32-7. Na Research Health and Medical Guidelines. Canberra: National Council, 2012. W endogenous cannabinoids in the of and the role exposure developing brain. Hale T Australian Institute o Australian

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21 19 However, relapse is relapse However, 20 f Addiction Medicine, 2011. Accessed at: f Addiction Medicine, 2011. Accessed at:

. International Statistical Classification of Diseases and Classification Statistical . International ey Brown M, Wells E, Scott K. (Eds) Te Rau Hinengaro: Rau Hinengaro: E, Scott K. (Eds) Te M, Wells ey Brown tional Committee for Addiction Treatment New Zealand 2011. New Zealand tional Committee for Addiction Treatment Addiction treatment is everybody’s business. Where to from is everybody’s to from business. Where Addiction treatment http://ncat.org.nz/wp-content/uploads/ Accessed at: here? addiction-treatment-is-everybodys-business.pdf. Oak Ministry Health, of Mental Health Survey. The New Zealand 2006. Wellington, WHO Version 10th Revision (ICD-10)-WHO Health Problems Related http://apps.who.int/classifications/icd10/ Accessed at: for 2016. browse/2016/en#/F10.2. American Society o www.asam.org/education/live-online-cme/fundamentals-of- addiction-medicine. Na

also considered a normal part of the process of of the process part of a normal also considered failure. recovery indicate and does not necessarily It is important that, as clinicians, we recognise as clinicians, we recognise It is important that, an opportunity to identify presents pregnancy that their dependence and engage an individual and has that program treatment family in a rehabilitative the potential to bring about long-term change. 4. References 1. 2. 3. Substance dependence is a complex disease that is is is a complex disease that Substance dependence is, in part, due to the persistent This treat. difficult to circuitry control and impulse to reward alterations process a pathophysiological in the brain, leading to Underlying psychological is difficult to undo. that in health play a pivotal role and social aspects of By the the disease process. the development of has addiction treatment, time most people enter they once the things over their lives, replacing taken communities their from them enjoyed, isolating life-long illness and risk of and putting them at high, with some are relapse of Rates poverty. to cent will return 85 per studies suggesting that drug use within 12 months. craving, previous unsuccessful attempts to control to control attempts unsuccessful previous craving, effects, harmful ongoing use despite usage, and for the act to apply. present which two must be of made according to capacity is of An assessment The regularly. and reviewed NZ MoH guidelines but stands for eight weeks, order initially treatment by the courts. may be extended 6 – 9 June 2019 Save the date Sheraton Grand Mirage Resort Grand Mirage Resort Sheraton Gold Coast, Queensland RANZCOG 2019 RANZCOG QLD/NSW/Provincial Fellows Scientific Meeting Regional MIND MATTERS in clinical practice Personality disorders Disorders (DSM-5) The DiagnosticandStatistical Manualof Mental Classification morbidity andmortality. have highlevelsof serviceuseandexcess medical with thechallengesof treating theseindividuals,who healthy relationships. Manycliniciansare familiar use othersforsupport,avoidconflict andmaintain with interpersonalfunctioningaffect one’sabilityto as aresult of limitedcopingstrategies. Difficulties risk of experiencing anxiety, depression anddistress terms of engagementandrapport.Theyare alsoat treatment, presenting challengesforcliniciansin stressful experiences,suchasillnessandclinical vulnerable personalitiesare lessabletocopewith neurodevelopmental factors.Individualswith early attachment experiencesandparenting, and development are influenced bygeneticfactors, and emotionalcontrol. Disturbancesinpersonality influence interpersonalfunctioning,self-concept PD refers toenduringqualitiesof apersonthat morbidity, mentalillnessandmortality. of clinicalservices,withincreased rates of medical adult population. Affectedindividualsare highusers relationships. PDoccursin4–12 per centof the persistent difficultiesinfunctioningandsocial Individuals withapersonalitydisorder(PD)have Royal Women’s Hospital,Melbourne BA(Hons), MBBS(Hons),PhD, FRANZCP Prof LouiseNewmanAM • • features maypresent inchildhood.Thediagnosis adolescence andyoungadulthood, althoughearlier with severalearlyriskfactors,usually evidentin Personality disordersare developmentaldisorders • • following domains: norms. Theseconditionsimpactat leasttwoof the that isinflexible, pervasiveandnotwithincultural enduring pattern of innerexperienceandbehaviour classification givesadefinition ofgeneralPDasthe Impulse contr Interpersonal functioning appr Affectivity –therange,intensity, labilityand Cognition –wayso self, othersandevents opriateness of emotional response ol 2 systemof psychiatric f perceiving andinterpreting 1 • of inadequacyand hypersensitivitytonegative Cluster Cdisordersinclude:patterns of feelings Cluster Cdisorders major challengesintransitionto parenthood. risk duringpregnancy andtheperinatal period,with interpersonal crises.Thesewomen are particularlyat emotional states, outburstsanddemands, angry managing borderlinePDrelate totherapidshiftsin psychopharmacological treatment. Clinicalissues terms of aetiologyandresponse topsychologicaland general population andisoneof the moststudiedin Borderline PDoccursinaround twopercentof the and attention seeking(histrionic). (narcissistic); andpatterns of excessive emotionality grandiosity, needforadmiration andlackof empathy regulation andimpulsivity(borderline);patterns of instability inrelationships, self-image,emotional for andviolation of therightsof others(antisocial); Cluster Bdisordersincludeindividualswith:disregard Cluster Bdisorders health settings. general population, withincreased rates inmental Cluster Adisordersare foundin0.5–3 per cent of the avoiding familiarity, maybeahelpfulapproach. and suspicious.Clearformalcommunication, these individuals,whomaybeanxious,guarded difficult toestablishatherapeutic relationship with and eccentricities(schizotypal). Cliniciansfindit and discomfort inrelationships, cognitivedistortions restricted range of emotionalexpression (schizoid); pattern of detachmentfrom socialrelationships and interpreting motivesasmalevolent(paranoid);a pervasive distrustandsuspiciousnessof others, Cluster Adisordersincludeindividualswith:a Cluster Adisorders • • clinical setting: discrete typesare sometimesdifficulttodefineina overlaps are commonbetweenthegroups andthe PD, withthree clustersof themes.Similarities and The DSMsystemdescribes11specifictypes of or asylum-seeking. individuals experiencing difficultyinacculturation avoided whenseeingdistress anddisturbancein and emotionalexpression. PDasalabelshouldbe differences inthemanagement of self, relationships also take intoaccountculturalinfluences and mental illnessorsubstanceabuse.Diagnosisshould may beanacuteresponse tostress, theimpactof important toexclude transientdifficultiesthat particular features of personalitydifficulty. Itis of functionandaclearhistoryof earlyonsetof of PDrequires anevaluation of long-termpatterns borderline, histrionic, nar Cluster B:Emotional schiz Cluster A:Eccentric obsessive compulsive,passiveaggr Cluster C:Anxious oid, schizotypal –avoidant,dependent, –paranoid, –antisocial, cissistic essive MIND MATTERS 10 Journal of Journal of Current Opinion in Current Vol. 20 No. 3 Spring 2018 | 33 Vol. Australian and New Zealand Australian and New Zealand There is clear evidence There 7,8 Clinical Psychology Review 2016; 9 tric Association, Diagnostic and statistical Diagnostic and statistical tric Association, es S. Recent advances in the theories of and Recent advances in the theories of es S. tevenson C, Bergman L, Boyce P. Borderline tevenson C, Bergman L, Boyce P. Women’s Health Issues 2016;26:190-5. Health Women’s G, Galbally M, Snellen M. Borderline personality disorder personality Borderline M. Snellen M, Galbally G, , Bennett C, Midgley N, et al. Parent-infant et al. Parent-infant , Bennett C, Midgley N, ollm B, Rucker G, Timmer A, Stoffers J. G, Timmer A, Stoffers Rucker ollm B, e-Miron V, Czuzoj-Shulman N, Oddy L, et al. Effect of Oddy L, et al. Effect N, Czuzoj-Shulman V, e-Miron tional Health and Medical Research Council. Clinical practice tional Health and Medical Research yden J, Winsper C, Dieter W, et al. A systematic review of the of review et al. A systematic Winsper C, Dieter W, yden J, Reproductive and Infant Psychology 2016;34:5,464-482. Reproductive and Infant borderline personality disorder on obstetrical and neonatal borderline personality disorder on obstetrical and neonatal outcomes. the evidence for of review psychotherapy: a systematic mental health. and infant parental improving disorders. interventions with attachment Psychiatry 2007;20(4):343-8. personality borderline guidelines for the management of Council, Health and Medical Research National disorder. Melbourne 2012. Pharmacotherapy for borderline personality disorder. Rev 2010:8:CDO7667. Base Syst Cochrane Data Y Br J Psychiatry 2010;97:193-9. survey. severity: national American Psychia mental disorders .5th ed. American Psychiatric manual of Publishing, 2013. Par Blankley Newman L, S interaction and parenting mother-infant personality disorder, findings. preliminary perceptions: PsychiatryJournal of 2007;41(7):598-605. E of mothers by offspring and outcomes experienced parenting potential mechanisms with borderline personality pathology: and clinical implications. 47:85-105. Barlow J Newman L, Mar Na Lieb K, V in the perinatal period: early infant and maternal outcomes. and maternal period: early infant in the perinatal Australasian Psychiatry 2015;23:688-92.

8. 4. 9. 10. References 1. 2. by recorder Personalitypathology P. Tyrer ang M,CoidJ, 3. 6. 7. Overall, these approaches promote emotional promote Overall, these approaches in function and reduction relationship regulation, interventions Psychopharmacological impulsivity. symptoms, specific severe may be useful to target and include mood agitation, and such as depression usually These are stabilisers and antipsychotics. assessment. psychiatric following prescribed Principles of management PD management of The general principles of aim to maintain a clear and consistent treatment support for the individual, who plan and provide may be anxious, angry or emotionally volatile. vulnerability and the personality, Recognition of to an overreaction and avoidance of anxiety, therapeutic difficult behaviour helps to maintain the It is important to clarify emergency relationship. of and crisis supports for women with a history and to or self-harming behaviours decompensation Consistent liaise with existing mental health services. and available supports, with clear parameters contain anxiety and contact, help to for regular community and across should be coordinated hospital services. for the effectiveness of structured psychological psychological of structured for the effectiveness therapy, dialectical behaviour therapies, including and cognitive based treatment mentalisation National in the as reviewed analytic therapy, Council (NHMRC) Medical Research and Heath clinical guidelines. improve the parent’s emotional understanding of the of understanding emotional the parent’s improve as an attachment role them in their child and support parent’s placed on building the Emphasis is figure. well as supporting focus on the child, as capacity to early trauma. recovery from 5. While 6 The broad The broad 4 Rates of postnatal postnatal of Rates 5 3 depression are elevated in women with histories of in women with histories of elevated are depression difficulties and child abuse, contributing to parenting insecurity in the infant. attachment resulting there is limited evidence for the efficacy of clinical is limited evidence for the efficacy there aim to approaches current interventions for BPD, Australian data found a similar range of obstetric found a similar range of Australian data outcomes, including low issues and poor neonatal nursery and need for special care Apgar scores found 30 per cent the data admission. Importantly, to be traumatic, pregnancy the women reported of to end the pregnancy request of rates increased care. engagement in antenatal and low levels of early, PD raise concerns around with severe Women capacity and child protection. parenting evaluation (avoidant); preoccupation with with preoccupation (avoidant); evaluation (obsessive perfectionism and control orderliness, submissive, clinging of and patterns compulsive); care to be taken need with an excessive behaviour in found C disorders are (dependent). Cluster of the general population. of 0.5–2.4 per cent disorder in everydayPersonality practice relationship, PD impacts the doctor-patient recommendations compliance with treatment Commonly described and clinical outcomes. with borderline patients PD, as severe seen as frequently are personality disorder (BPD) and emotionally self-defeating chaotic, crisis-prone, and may tolerance stress unstable. They have poor People suicidal behaviour. engage in self-harm and anxiety clinical depression, with PD can develop with BPD Women problems. and substance abuse childhood abuse and trauma are and a history of in current to experience abusive patterns likely more and parenting difficulties. relationships Maternity care and BPD difficulties in with significant BPD is associated emotional maintaining healthy relationships, Many women and poor impulse control. fluctuations child abuse and attachment describe histories of on disruptions, which have a long-term impact post-traumatic risk of function and increase Pregnancy symptoms and difficulties in parenting. by significant anxiety and may be complicated is more child abuse. The pregnancy memories of assault. sexual of to be unplanned or the result likely may be limited, increasing Supportive relationships psychosocial stress. women diagnosed with BPD in Cohort studies of smoking, drug of higher rates report pregnancy and co-morbid and alcohol use, financial stress are obstetric complications of Rates mood disorder. diabetes, premature including gestational elevated, membranes, chorioamnionitis, caesarean of rupture delivery birth. and preterm range of complications highlights the need for complications range of multidisciplinary management, involving integrated setting. Early mental health services in the maternity discussion with women about the psychological supportive and involvement of pregnancy of stress interventions is an important preventive strategy. the concerns underlie protective of High rates particularly challenges for women in parenting, child abuse and/or current is a history of when there PD may with severe trauma. Women relationship difficulties in transition to parenthood have core figure and in function as a consistent attachment They may also have difficulty for their infant. and communication in understanding infant in the infant, emotional responses tolerating negative themselves. becoming distressed MIND MATTERS prevalent in females. settings andthedisorderisrecognised asmore present inmedical (asopposedtopsychiatric) pain, thiscanalsobespecified. Individualstypically symptoms. Ifthepredominant somatic symptomis or excessive timeandenergydevoted tothese high levelsof anxietyrelated tosymptoms,and/ thoughts abouttheseriousnessof symptoms, concerns, suchasdisproportionate andpersistent or behavioursrelated tothesymptomsorhealth Associated withthisare excessive thoughts,feelings actual nature of overtime. thesymptommayvary (greater thansixmonthsduration), althoughthe disruption todailyfunctioning,andare persistent problems) that are distressing orresult insignificant symptoms (suchaspain,fatigue andgastrointestinal Psychosomatic disorderischaracterisedbysomatic ‘factitious disorder’. ‘illness anxietydisorder’,‘conversion disorder’and disorders’ andinclude‘somatic symptomdisorder’, umbrella of ‘somatic symptomandotherrelated such disordersare captured underthediagnostic Statistical Manualof MentalDisorders(DSM-5), fifth andcurrent version of theDiagnosticand disruption tolifecreated bythecondition.In with greater emphasisplacedonthedistress and psychological inoriginandmedicallyunexplained, has beenashiftawayfrom symptomsbeing Royal Women’s Hospital,Melbourne Director oftheCentreforWomen’s MentalHealth Psych. RANZCP BA(Hons), MBBS(Hons),PhD, FRANZCP, Cert.Child Prof LouiseNewmanAM Royal Women’s Hospital,Melbourne Centre forWomen’s MentalHealth MD Dr Yasaman Rezaei Adli Royal Women’s Hospital,Melbourne Centre forWomen’s MentalHealth MBBS, BMedSc,MPHTM,MPsych Dr BharatVisa disorders Psychosomatic hysteria’. as Freud, describingthephenomenaas‘conversion unexplained symptoms’andearlierclinicians,such iterations overtime,suchas‘somatisation’, ‘medically This isnotanewconceptandhashadnumberof to have,at leastinpart,apsychologicalorigin. because theypresent physically, butare thought Psychosomatic illnesseschallengethisparadigm among specialtiesandhowhospitalsare structured. dualism isevidentinhowdiseasesare separated either themind(psyche)orbody(soma).This Medicine hashistoricallyseparated diseaseinto and/or gynaecological settings. of particular interest tocliniciansworkinginobstetric 1 However, inmore recent times,there 2 Giventhis,thedisordermaybe are estimated tobebetweenfoursixpercent, Rates of psychosomatic disorderintheUnited States Epidemiology many outpatient andinpatient servicesascontrols. the annualmedicalcare expenses andutilisetwiceas Patients withpsychosomatic disordershavetwice female-to-male ratio of 10:1). it affects manymore womenthanmen(approximate of alcoholandsubstanceabuse. neglect, sexualabuse,chaoticlifestyle,andahistory factors havebeenidentified,including:childhood presentation andaetiology. Nevertheless,certainrisk diagnoses are heterogeneous inboththeirclinical patterns. Itislikely that thepopulation withthese have beenproposed basedonobservedandstudied of psychosomatic disorders,anumberof theories Although wehavenotidentifiedtheexactaetiology Aetiology prevalence of 38per1000womenaged15–73. is often difficulttomanage.Ithasanestimated Chronic pelvicpainisacommondisorder that a complex way. psychological andphysicalpathology canpresent in pelvic painprovides agoodexampleof howboth period andchronic pelvicpain.Inparticular, chronic disorder, mooddisordersintheperimenopausal Some examplesinclude:premenstrual dysphoric with bothphysicalandpsychologicalfeatures. that commonly present ingynaecologicalsettings, There are anumberof establishedclinicalsyndromes Gynaecological context ole: • • • • develop apsychosomatic disorder: explanations forwhyandhowcertainindividuals There are anumberof proposed modelsthat provide management of thisconditionintheNational Health An estimated £158millionisspent annually onthe symptoms willdevelopachronic somatic illness. per centof patients whopresent withacutesomatic expressed inphysical symptoms. are repressed andtransferred inwards,and mechanism) todistress. Thoughtsoremotions lesser-developed psychologicaldefence(coping postpone unwelcomechallenges. means of avoidingnoxious obligations and increased sensitivitytominimalstimulation. system painpathways overtime,andaneventual describes anup-regulation of centralnervous conditions, thecentralsensitisation hypothesis Psychodynamic theor Sick r Cognitive theor Neur cognitive scheme. woulddescribethisasafaulty Cognitive theory symptoms asthepresence of amedicalillness. bodily functionsandare likely tomisattribute often haveanincreased awareness of theirown obiological theory: obiological theory: Anunconscious(withoutawareness) y: Peoplewiththesedisorders 1 y: ‘Somatisation’ isseenasa In chronic pain 2 Anestimated 20–25 2 1 1 6 5

3 2 and

4 MIND MATTERS Psychiatr Psychiatr

Vol. 20 No. 3 Spring 2018 | 35 Vol. , Scherrer G, et al. Cellular and molecular G, et al. Cellular , Scherrer 2009;139(2):267-84. Cell tes D. Somatization increases medical increases Somatization tes D. tic approaches to obstetrics, gynaecology to obstetrics, gynaecology tic approaches tric Association. Diagnostic and statistical Diagnostic and statistical tric Association. 2010;57(1):35-48. Urology European , Sadock V, Ruiz P. Kaplan and Sadock’s synopsis of of Kaplan and Sadock’s synopsis Ruiz P. , Sadock V, on R. Somatization in the primary care setting. in the primary care on R. Somatization ogmagazine.org.au tthe P, Mignin L, Gray R, et al. Factors predisposing women to predisposing Mignin L, Gray R, et al. Factors tthe P, Am Fam Am Fam symptom disorder. M. Somatic Maffei urlansik S, all M, Baranowski A, Elneil S, et al. EAU guidelines on chronic guidelines on chronic et al. EAU all M, Baranowski A, Elneil S, K American Psychia Barsky A, Orav E, Ba medical and psychiatric and costs independent of utilization Arch Gen Psychiatry 2005;62(8):903-10. comorbidity. Basbaum A, Bautista D pain. mechanisms of Lal M. Psychosoma La F pelvic pain. McCarr Sadock B 11th ed. psychiatry behavioural sciences/clinical psychiatry. Kluwer; 2015. Wolters Philadelphia (PA): Physician 2016;93(1):49-54. American Psychiatric mental disorders (DSM-5®). manual of Pub; 2013. . 2009;29(1):1-12. J Obstet Gynaecol and . 2006; BMJ review. pelvic pain: systematic chronic 332(7544):749-55. Times 2006;23(6):32-34. ant to read more ant Find similar articles when online. you explore

5. 9. References 1. 2. 3. 4. 6. 7. 8. biological, psychological and social aspects of the and social aspects of biological, psychological with patients find treating Doctors often disorder. these diseases challenging because the presentations of illness and fit into our paradigms do not neatly often disorders are Psychosomatic treatment. rehabilitation disabling and require chronically life and social of quality of improvement aiming at It is important to try and shift our participation. is a what thinking, work together and help manage many people (especially affecting significant disease women) in our community.

2 7

7

2

Furthermore, Furthermore, 6 It was developed 9 8 Of course, treating Of course, treating 2 9 9 Follow the CBT treatment plan developed between the patient and therapist. and the patient plan developed between CBT treatment Follow the depression/anxiety. co-morbid illness, treat Rule out medical symptoms and distress alliance, listen to the patient’s Form a trusting therapeutic and discomfort. sessions, acknowledge the distress during ‘counselling’ and the connection between physical complaints self-discover Help the patient all psychological’. symptoms are comments such as, ‘Your Avoid emotional stressors. specialists (when not to other or referrals No unnecessary diagnostic procedures indicated). CARE MD framework. CARE interface psychiatry/cognitive therapy behavioural (CBT) A Assess R Regular visitsE Empathy M Medical-psychiatric medical care. to stop overuse of consults, agreement regular Short D Do no harm C with Consultation the persisting pain in the context of treatment treatment the persisting pain in the context of options being exhausted can lead to frustration, hopelessness, and possible development or the In cases where depression. worsening of to the pain thoughts, feelings or behaviour related and disabling, psychosomatic appear excessive disorder may be diagnosed. General principles of management management is the cornerstone of Collaboration It is ideal to have a disorders. psychosomatic of biological, targets the that multidisciplinary approach to psychological and social factors contributing the illness. of the development and perpetuation evidence-based include cognitive behavioural therapy and mindfulness-based therapies. Specific psychological methods that are are Specific psychological methods that The CARE MD model provides an effective framework The CARE MD model provides with presenting patients for the management of disorders (Table 1). psychosomatic Chronic pelvic pain is often thought to have a pelvic pain is often Chronic component because organic psychosomatic is not established in many cases, or the pathology the organic of pain persists despite the treatment found that by a study This is exemplified pathology. as endometriosis or such organic pathology, that the cases in only half of reported adhesions, were was performed. diagnostic laparoscopy where Service (NHS) in the UK, and $881.5 million a year on Service (NHS) in the UK, States. in the United management its outpatient Table 1. Table co-morbid mental illness is important. Conclusion with medically unexplained presenting Patients physical symptoms should be assessed and treated manages the that with a multidisciplinary approach Psychological therapies should be tailored to Psychological therapies should be tailored Pharmacological presentation. the patient’s include evidence the greatest treatments with inhibitors (SSRIs) and reuptake selective serotonin (TCAs). tricyclic antidepressants for people working in primary care settings, however, settings, however, care for people working in primary in other settings. The relevant the principles remain mental health framework suggests collaboration with treating approach, practitioners, having an empathic understanding an encouraging illness, and co-morbid the mind-body connection. of A multidisciplinary approach is also suggested with is also suggested A multidisciplinary approach pelvic pain management. chronic Psychosocial factors recognised in patients with in patients Psychosocial factors recognised similar to psychosomatic pelvic pain are chronic disorders, and include sexual abuse, physical abuse and co-morbid mental illness. Figure 1. 600 400 200 300 500 100

0 MIND MATTERS Rates of postpartum guide forobstetricians a practicalmanagement Postpartum psychosis: disorder andmore than50percentinwomenwitha to 30percentof of womenwithahistory bipolar in theparturientpopulation, increasing dramatically postpartum psychotic episodes is 1–2/1000 deliveries was developed.Inthe21stcentury, therate of the conceptof non-organicpostpartumpsychosis there were nounderlyingmedicalriskfactorsand of bloodlossorsepsis.However, insomecases, time, manycaseswere likely organicasaresult was firstcharacterisedinthe19thcentury. At that of severe psychiatric symptomsearlypostpartum, Postpartum or‘puerperal’psychosis,theacuteonset RoyalPerinatal Psychiatry, HospitalforWomen Director, StJohnofGodMotherBabyUnit St JohnofGodHospital&University ofNSW Chair, Perinatal&Women’s MentalHealth, MD, FRANZCP, MBBS Prof Marie-Paule Austin EPISODES PER 1000 DEIERIES POSTPARTUM PSYCHOSIS PREVIOUS psychosisinwomen. BIPOLAR WOMEN past postpartumpsychosis(Figure 1). three weekspostpartum. 30-fold increased riskforacutepsychosisinthefirst Both suicidalityandpossiblethoughtsof harmto with significantlyimpaired abilitytocare forthebaby. as theepisodeworsens,symptomsare associated symptoms andinsightoften fluctuate daytoday, and, insight intotheirdisturbedmentalstate. Psychotic delusions. Thesewomenmayhavepartialorno especially ifdistressed ordepressive bypersecutory welfare. Theymayexperiencesuicidalthoughts, can’t betrustedorconcernsabouttheirbaby’s express vaguesuspicionsthat closefamilymembers persecutory, guilt). More often, thesewomenmay experience frankdelusions(forexample,grandiose, be illogicalanddifficulttofollow, andtheymay Depending onsymptomseverity, theirspeechmay to engage,restless, distractableordisorganised. they present aspreoccupied, suspicious,difficult undiagnosed earlyon.At mentalstate examination, Women likely are very tominimisesymptomsandgo will beremoved becausetheyare a‘bad’mother). longer betrusted;theyare ‘going mad’;orthe baby them, theirfamilyorinfant; closefamilycanno frightening beliefs(forexample,harmwillbefall As psychosisevolves,womendevelopirrational and review at regular intervalsforsymptomevolution. are commoninparturientwomen,itisimportantto (independent of babywaking).Asthesesymptoms increasingly anxiousaffect andpoorsleep Very earlysignsof postpartumpsychosisinclude Clinical features POPULATION GENERAL 2 postpartum psychosis of bipolar affective previous episode who havesu ereda bipolar omen andwomen in theeneral population deliveries for omen psychosis per1000 Rates ofpostpartum 1 Awomanhasa MIND MATTERS Vol. 20 No. 3 Spring 2018 | 37 Vol. while the antipsychotic takes effect within one to within effect takes the antipsychotic while needs to the antipsychotic weeks. Response three and well, reduction and, all going close monitoring first (if this is the woman’s six months after cessation undertaken. psychosis) can be episode of of diagnosis woman has a pre-existing a Where or develops bipolar disorder or schizophrenia longer-term such a diagnosis, appropriate mood stabilisers will need to be antipsychotic and/or is to be commenced while If lithium re/commenced. it is best to seek a second opinion, breastfeeding, psychiatrist. a perinatal possible from where Psychoeducation between the difference It is important to explain and postpartum psychosis. depression postnatal and her family about the overall the woman Reassure postpartum psychosis, while of good prognosis monitoring for psychiatric emphasising the need and months. Women in subsequent and medication signs of their families need to learn about the early commonly: insomnia, psychosis, most of relapse baby’s waking; racing thoughts; independent of anxiety; distractibility; mood shift or severe erratic or with the baby preoccupation or unfounded family’s welfare. planning pregnancy Future but is not contraindicated, Subsequent pregnancy of until the woman has been free best deferred also need to be Families symptoms for over a year. having had one postpartum psychosis that aware to about a recurrence chance of a woman’s increases postnatal 50 per cent, but early management of mental health and close insomnia with medication relapse the chance of to reduce monitoring is likely a clear mental It is important to devise substantially. and her family plan with the woman healthcare this plan Copies of for any subsequent pregnancy. all key need to be made available to the woman and providers. healthcare Prognosis fairly Postpartum psychosis usually responds to antipsychotic weeks) quickly (within two to three some However, and sleep restoration. medication and it is possible much longer to resolve cases take developing a longer-term these women are f zopiclone e ‘more severe e ‘more . Again, try to reduce t sleep deprivation is a key risk is a key t sleep deprivation y to destigmatise the mental health y to destigmatise e to psychiatry and the local mental e the safety of infant and mother. infant of e the safety As soon as possible, seek advice from and hand As soon as possible, seek advice from over car health team. Discuss possible admission to a mother and baby Discuss possible admission to a mother and the MBU unit (MBU). Emphasise the value of for support with the baby the mother’s/family’s stigma with a psychiatric admission. Discuss the diagnosis in broad terms: avoid the Discuss the diagnosis in broad term psychosis; use terms lik depression’. postnatal Emphasise tha factor and highlight the need to urgently commence a hypnotic. Consider a hypnotic with a long half-life. For example, half to one tablet o is Temazepam (Restavit). doxylamine or (Imovane) safe relatively to be useful. Hypnotics are unlikely is minimal secretion as there in breastfeeding, into breastmilk. Engage both the woman and her significant Engage both the woman other/s and tr while highlighting the issues as much as possible need for urgent care. Ensur Case vignette one several admissions in her teens, responded requiring married woman with bipolar disorder, A 35-year-old well 20s. She remained follow-up in her and psychiatric the time, but ceased all medication fully to lithium at alcohol or of cessation and partner relationship, sleep, supportive work situation regular of on a regimen mood lability lasting a few days would resolve Occasional bursts of life stressors. drug use; and minimising of a relationship after bit depressed’ having been ‘a she reported enquiry in pregnancy, At sleep. with improved in her teens, but did not mention the bipolar disorder. breakup severe 26 weeks for management of was uneventful until she was admitted to hospital at Pregnancy of her husband and the structure She missed the support of hypertension. In hospital, sleep was broken. worsened and had to stay as her blood pressure anxious about the delivery work. She became increasingly staff, and suspicious of sleep deprived section, she became severely in hospital to term. Following caesarean she was By day three, labile in mood, wanting to go home against medical advice, and declining a hypnotic. poison her with wanting to delusions (staff in speech, irritable, voicing persecutory chaotic and pressured unit. psychiatric to a locked ward and was transferred unable to be contained on the postnatal medication), therapy (ECT), she finally accepted lithium which antipsychotic and electroconvulsive After several trials of she was functioning optimally though it took another year before recovery, rapidly led to full symptomatic which was managed planning took place for her second pregnancy, deal of to work. A great and able to return to guarantee good sleep while her husband did and postpartum pregnancy in late with low-dose seroquel remained lithium and, two years later, or need to recommence night. She did not relapse feeds at expressed stress. sleep hygiene and managing but vigilant around well unmedicated, Short and longer-term management Medication a Once the woman is engaged with psychiatry, antipsychotic, such as quetiapine (Seroquel), sedating this is to will need to be commenced. Initially, and insomnia distress agitation, symptoms of reduce • • • • • • baby, as part of a psychotic belief system or severe or severe belief system a psychotic part of as baby, need to be specifically explored. depression, Diagnosis psychosis is very acute straightforward Diagnosis of in milder cases However, severe. are when symptoms symptom minimisation, is commonly there where these fluctuation, partial insight and day-to-day cross-sectional well at women may present critical to obtain corroborative assessment. It is thus history and, if possible, to significant others from intervals. If close regular, the woman at review essential. is consultation urgent psychiatric unsure, plan: management An obstetrician’s immediate • MIND MATTERS presentations requiring antipsychotictreatment, restoration, through tomore severe andflorid range from mildsymptoms,resolving withsleep Acute postpartummentaldisturbancecan however unlikely that mightbe. the needtoroutinely exclude organicpathology, for postpartumpsychosis.Casethree emphasises symptoms at night.However, italsomet criteria hallucinations, disorientation totimeandworsening of anacuteconfusional state, withfleetingauditory case two.Casethree hadsomefeatures suggestive was associated withdifficultyearlydetectionin The fluctuating nature andsubtlety of symptoms regular intervals. Symptoms medication andtheneedtoreview symptomsat very sleep deprivation, withlackof useof hypnotic demonstrate alackof response bystaff tosevere this maybedeniedorunderstated). Allcases seek pastorfamilypsychiatric (though history The firsttwocasesillustrate theneed tocarefully Conclusions with anemergingbipolardisorder. sometime inthenext15ormore years, go ontodevelopamanicordepressive episode relapse into psychosis later inlife,14 percentwill the majorityof womenwithadenovoepisodedon’t less commonly, aschizophrenia-like illness.While psychiatric condition,eitherabipolardisorderor, settled backtonormaloverthenextthree days,confirming thediagnosis of acute confusional state. of postpartumpsychosis.Hbthat dayreturned as5.3. Aftertransfusionandregular hypnotic,hermentalstate A workingdiagnosisof acuteconfusional state wasmade,pendinginvestigations, withdifferential diagnosis breastfeed Shelacked as‘babytoldmeitwasnothungry’. insightintoherdisturbedmental state. (ASIO). Shewasintermittentlyconfused aboutthedate andtimeof andwhethersheshould delivery welfare andabeliefthatbaby’s hehadbeenkidnappedbytheAustralianSecurityIntelligenceOrganisation her affect wasalittleoddandfearful.Itdifficulttofollowhertrain ofthought.Sheexpressed fearsforher was notedtobewalkingupanddownthecorridorvaguely‘lookingformybaby concerned that herbabymightnotbesafe onthewardunlessshewatched overitdayandnight.At times,she labour andhadnotsleptfortwonightsbecauseof highanxietylevels.Nohypnotichadbeenoffered. Shewas was available).At review 36hourslater, staff reported shehadbeen‘inappropriate’ during thesecondstage of induction andforceps delivery, withmoderate postpartumhaemorrhageof 700mlandHb9.5 (nopriorlevel A 40-year-old marriedwomanwashavingherfirstbabyanddidnot report apsychiatric history. Shehadan Case vignettethree on amoderate doseof quetiapine. the baby. Shewasscheduledtothepsychiatric unitanddischargedhomethree weekslater, muchimproved afternoon of dayfive,sheshovedthebabyasidewhenitwasbrought intofeedandnarrowly misseddropping had taken adislike toher. That afternoon, however, shewassettledandnotvoicinganyconcerns.Onthe camerasinthehospital,waswantingbabytostaywithstaff,presence of andworriedthat CCTV somestaff but declinedahypnotic.Onthemorningof postpartumdayfour, sheexpressed vagueconcernsaboutthe baby andnotwantingtobreastfeed orcare forherbaby. Shewasfindingsleepdeprivation challenging, very traumatic emergencycaesarean sectionforfetaldistress. Shereported asenseof notbeingconnectedtothe but hersisterhadsuffered severe postnatal depression. Anunremarkable pregnancy wasfollowedbya A 40-year-old marriedwomanwasambivalentabouthavingachild.There wasnopastpsychiatric history, Case vignettetwo often rapidlyevolve. 3 consistent 3. 2. 1. References of Obstetriciansand Gynaecologists. President-elect of the RoyalAustralianandNewZealand College I gratefully acknowledgefeedbackfrom DrVijayRoach, Acknowledgement unit, shouldbeconsidered. transfer toapsychiatric facilityormotherandbaby or antipsychoticmedication, andalowthreshold for the thirdtrimester, earlyinterventionwithhypnotic plan, attention toavoidanceof sleepdeprivation in teamapproach,multidisciplinary amanagement of apsychiatrist. Inpatients withapriorhistory, a rapid escalation, withtheneedforearlyinvolvement possibility of postpartum psychosisandtheriskof Obstetricians andmidwivesmustbemindfulof the much corroborative aspossible. history intervals, ideallyafter sleeprestoration andwithas incipient casesneedtobeassessedat closerepeated considered apsychiatric emergency, whilepossible and often hospitalisation. Severe casesare

69(4):428-434. of bipolaraffective disorders. disorders withpostpartumonset:possibleearlymanifestations Munk Dec 06;296(21):2582-2589. mental disorders:apopulation-cased register study. JAMA2006 Munk period. psychosis, andschizophrenia inpregnancy andthepostpartum Jones I -Olsen T, Laursen T, Meltzer-Brody S, etal.Psychiatric -Olsen T, Laursen T, PedersenC,etal.Newparents and , ChandraP, DazzanP, etal. Bipolar disorder, affective Lancet 2014 Nov15;384(9956):1789-1799. ’. At mentalstate examination, 2012April; Arch GenPsychiatry

MIND MATTERS Vol. 20 No. 3 Spring 2018 | 39 Vol. seriously. She may spend much of her consultation her consultation She may spend much of seriously. and severe. her pain is real explaining that be established quickly with A positive rapport can for example, ‘Thankspain validation, initial prompt really I hear you’ve had a today. for coming to see me she knows that This ensures difficult time with pain’. the Allowing is severe. you understand her pain first few minutes, describing woman to speak for the to the the consultation her main concerns, guides she is most anxious about. areas imply that Sentences with two phrases joined by ‘but’ and are you do not believe the first phrase to be true but I pain is real, best avoided. For example, ‘Your that think you should see a psychologist’, suggests phrases Joining you do not believe her pain is real. effective. is more with ‘and’ Previous sexual assault sexual events may be distressing While a history of this important, not all women will wish to discuss to their pain. with you or consider it relevant possible item with a range of A questionnaire allows the woman answers, such as the one below, It is time her consultation. to decide the focus of readiness to discuss the a efficient and demonstrates assault if she wishes to. you experienced distressing sexual events Have Yes/No during your life, including sexual assault? to answer this question. I prefer not my appointment. to discuss this during I would like to discuss this during my appointment. I prefer not Motivational interviewing and reflective listening pain may have left your patient Prolonged emotionally and physically exhausted, with limited options. Building on new treatment energy to take momentum for change is enhanced by ‘reflective listening’ and a psychologist may use this technique. been on For example, the woman explains: ‘I’ve ‘So, despite reply: opioids for pain for ten years’. You it’s not saying that using opioids for ten years, you’re do you ask: ‘What helping your pain?’ She nods. You think would help with this pain?’ involves listening and then reflecting This process by motivated more are back her findings. Patients on the is less pressure their own thinking and there practitioner to come up with solutions for complex an opportunity issues. When listening reflectively, suggestions. For example, when will come to make stabbing pelvic pain: listening to a description of do pelvic muscle spasm. What ‘That sounds like You: she you think would help your muscle spasm?’ Where you have the opportunity to suggest doesn’t know, accord with her own thinking. options that Mobilisation for pain, is the best non-drug treatment Exercise but it is also highly advantageous for mental health conditions. As many women with persistent pelvic internus muscle spasm, pain will have obturator Tiffany Brooks MAPS BPsych(Hons), MA Psych (Health), Psychologist Health to in O&G we committed When we chose a career the last caring for girls and women with pain. Over have laid decade, rapid changes in neuroscience pelvic pain is just in the the concept that to rest for more pelvis. Once any pain has been present in the to six months, central sensitisation than three Pain becomes spinal cord and brain will be present. symptoms will complex and the spectrum of more While pain is include anxiety or depression. often our working lives, coping with distressed part of may seem overwhelming. This article patients support your suggestions to enhance and provides pain, anxiety with chronic patients management of and depression. Streamlining the consultation questionnaire Pre-appointment to complete a questionnaire Asking your patient a history and brief their appointment provides before a glance. Suggested mental health assessment at include the Pelvic available questionnaires freely (www. for Girls and Women Pain Questionnaire for questionnaire pelvicpain.org.au) and the DASS-21 (https://headspace. anxiety and stress depression, org.au/assets/Uploads/Resource-library/Health- professionals/Clinical-Toolkit/DASS-21-with-Scoring- Sheet.pdf). Early pain validation and tests, disappointing past treatments Negative in a community misunderstanding may result her pain will not be taken feeling fearful that patient Dr Susan Evans FFPMANZCA GAICD, MBBS, FRANZCOG, Gynaecologist Pain Medicine Physician and pelvic pain Mental health health Mental MIND MATTERS Figure 1. and mentalillness,often withinspecificareas works withinthespecificoverlapbetweenhealth psychologist hasundertaken furthertraining and registration asapsychologist. However, ahealth Masters of Psychologygraduates are eligiblefor How referral toapsychologistworks your pain.’ psychology hasarole inassistingyoumanage has arole, yourthinkinghasarole, andtherefore is real andpainisacomplexillness.Your brain her pain.Usefulphrasesmightinclude:‘Your pain a psychologistwillnotreduce youreffortstomanage be of benefit.Itisimportanttoexplainthat including be sensitivetothesuggestionthat psychologycould • • • and willworkwithyourpatient on: A psychologistoffers aseries of longconsultations Referral toapsychologist pain byinducingcentralsensitisation. Unfortunately, regular opioiduseincreases chronic strategy andthere isnoexpectation of anormallife. palliative care, where death provides anexit The regular useof opioidsforpainbeganwith Avoid opioids as salsa. a dailywalk,orfree-flowing dancingstyles,such the core’ worksbest.Thesemayincludestretches, pacing andchoosinganexercise that is‘away from After yearso • o Pacing behaviourstoavoidtheboom/bustcycle chr Thinking andbehaviourpatterns forpeoplewith psychology andthebrain Educa with healthservices pain conditionstoimprove theirengagement The managementof co-morbidmentalhealth CognitiveBehavioural Therapy(CBT). f energyandfatigue onic healthconditions tion aboutpainprocesses andthelinkto f negative experiences,yourpatient may 5 thinking patterns, and adjusting unhelpful behaviours. of thiscycle,challengingdysfunctionalbeliefsand providing accurate information, buildingawareness CBT worksbytargetingeachaspectof thiscycle,by catastrophising andworsementalhealthoutcomes. chronic painitcanleadtomore pain,disability, is functionalandnormalforacutepain,but avoidance of that painandfear(Figure 1).This responses to painleadtomore fearandconsequent the fear-avoidance model,where fearandanxiety workswith Cognitive behaviouraltherapy(CBT) Psychology therapies patient attends theirpsychologist. two weekstoobtain,dependingonhowoften your information. Unless urgent,thismaytake oneto informed consentbefore providing youwith to meetwithyourpatient toobtaintheirwritten referring doctor, thenthepsychologistwillneed earlier feedbackifrequired. Ifyouare notthe report after sixandtensessions,canrequest the referring doctor, whoshouldexpectaprogress operative consent.Specialprivilegeisprovided to similar importanceonthisasweplaceinformed information toathirdparty. Psychologistsplace to obtaininformed consentpriortodivulgingany Confidentiality limitations require apsychologist for consultations privately. for herworkplace,somewomenmayprefer topay of eitheranxietyordepression mayhaveimplications frequently co-exist.Asacknowledgingthepresence a current indication foraMHCP, theseconditions for anxietyordepression. Whilepainaloneisnot a psychologistwhere yourpatient hasbeenreferred GP, provides tenMedicare-subsidised sessionswith A mentalhealthcare plan(MHCP),prescribed bya with feedback. it goes’,orenquiring‘Did itgowell?’provides you treatment. Askingyourpatient to‘Let meknowhow finding therightpsychologist,aswell such aschronic pain.Effective treatment means MIND MATTERS O&G Pharmacol Medication Medication Vol. 20 No. 3 Spring 2018 | 41 Vol. Pain 2000;85(3):317-332. oimmunopharmacology of oimmunopharmacology of 3 Lancet Neurol. 2015 Feb;14(2):162–173. Starting with a lower dose makes with a lower dose makes . Starting . Pharmacotherapy for neuropathic pain in adults: . Pharmacotherapy for neuropathic CT made simple: an easy to read primer of Acceptance primer of CT made simple: an easy to read . Fear-avoidance and it’s consequences in chronic and it’s consequences in chronic . Fear-avoidance Harris R. A Hutchinson M. Exploring the neur Vlaeyen J E Finnerup N NeuPSIG and updated meta-analysis review, systematic recommendations. Oakland, CA, New Harbinger 2009. and Commitment Therapy. immune central mechanisms of of review opioids: an integrative for opioid analgesia. signaling and their implications 2011 Sep;63(3):772-810. Rev. the art. of pain: a state musculoskeletal Magazine 2014;16(3).

References 1. pelvicpain. chronic managementof Medication vans S. 3. 4. 5. a serotonin noradrenalin reuptake inhibitor (SNRI) reuptake noradrenalin a serotonin These medications or venlafaxine. such as duloxetine of anxiety or depression the dual benefit offer and pain receptor management via the serotonin receptor. management via the noradrenaline is usually started with 30mg in While duloxetine the morning (mane) for two weeks, then 60mg at a may find starting mane, young female patients lower dose easier initiate acceptable. To more treatment initiating a 30mg capsule, with a 15mg dose, open treatment discard half the contents and close the capsule. Amitriptyline is the drug with the lowest number for any medication (NNT=2.1) of needed to treat 5–10mg in the early A dose of central sensitisation. reduce sleep, pain, improve evening can reduce background vulval pain, reduce reduce bloating, 10–25mg A dose of headaches and slow the bladder. or further for bladder overactivity may be required headache. These doses are chronic of reduction compliance and improved ineffective for depression amitriptyline has been that an explanation requires than depression. for pain rather prescribed for women on prescribing Detailed information with pelvic pain is outlined in the article, chronic pelvic pain, available at of management www.pelvicpain.org.au. 2. (St Vincent’s Hospital, (St (Macquarie University) is a (Macquarie University) particularly useful for any person The six domains of Acceptance and Commitment Therapy (ACT). Acceptance and Commitment Therapy The six domains of These bring together pain education, . These bring together pain education, Figure 2. onic Pain Reboot ee online course with five weekly lessons that with pain associated with anxiety or depression. with pain associated www.ecentreclinic.org.au. at: register Patients teaches neuroscience and pain self-management teaches neuroscience techniques. It is Chr The Pain Course fr and education is a comic-based Sydney) course with eight weekly lessons mobilisation weekly GP feedback. It costs and the option of A$59 for four month’s access and is suitable for pain. Patients mobility or chronic any level of https://thiswayup.org.au/how-we- at: register can-help/courses/chronic-pain. • While improvement in absolute pain scores following in absolute pain scores While improvement these courses may be modest, they completion of reduce the impact have been shown to significantly lives. pain on patients' of Medications for central sensitisation already our care arrive at our patients Many of inhibitor reuptake using a selective serotonin with effective choice, A more (SSRI) medication. would be pain improvement, of higher likelihood Acceptance and commitment therapy (ACT) works 2) the six domains (Figure each of on increasing aspects such as mindfulness, in order to facilitate and values-based activities pain tolerance, increased functioning. in order to improve activities, facilitate Pacing is used to breakdown pain sensitisation, levels, reverse activity increased and enhance pain management in strength improve the long term. courses for patients Online pain and mental health and successful Over the last few years, validated patients online courses have become available for with anxiety or pain associated with chronic depression and pain mental health support, mobilisation self-management techniques. These courses are unable to who are particularly useful for patients or access pain psychology services: afford attend, • MIND MATTERS threatened death, orsexualviolation’. seriousinjury criterion, whichnowrequires exposure to‘actual or changes includedmodification of theA1stressor the diagnosticcriteriaforPTSDwere made. These and stress-related disorders’. (DSM-5) placedPTSDintoanew classof ‘trauma Diagnostic and Statistical Manualof MentalDisorders of anxietydisorders,thelatest editionof the Although PTSDsymptomsare characteristic disorder (PTSD). associated withsymptomsof post-traumatic stress to poormaternal mentalhealthandhavebeen childbirth eventshavebeenfoundtocontribute her infant andrelationships withothers.Stressful and havelong-termconsequencesforthemother, recur inother pregnancies, canbecomechronic than often thought.Suchdifficulties are likely to depression, anxietyandtraumaare more common Perinatal mental healthdifficulties related to Griffith University, Brisbane Head ofMidwifery RN, RM,MHealth, PhD Prof JennyGamble Griffith University, Brisbane Perinatal MentalHealth RN, BA(Hons),MEd,PhD Prof DebraCreedy childbirth events canbeexperiencedastraumatic. However, numerous studies showthat evencommon is traumatic maybeahighlysubjectiveprocess. role). Determiningtheextenttowhichastressor indirect (through thecourseof one’sprofessional that asignificantotherwasexposedtotrauma, or Such exposure maybedirect, witnessing, learning stress disorder and post-traumatic Birth trauma 1 Severalchangesto 1 when attending maternity appointments.Conversely, suicidal thoughtsandpanicattacks, particularly pregnant again report sleepdifficulties, depression, obstetric intervention. woman’s choiceand/orcontrol, andhighlevelsof attitudes andbehavioursof caregivers that inhibita include, disrespect orneglectbymaternity staff, with perceived poorcare duringlabourandbirth for subsequentbirths. children orrequest anelective caesarean section Some womenmaychoosetonot havemore tend to‘reframe’ birth asfrighteninganddangerous. Women who haveexperiencedatraumatic childbirth infertility.partners, andvoluntary contributes toalackof intimacyandconflict with women alsoreport fearof becomingpregnant, which symptoms. and interpersonalcare anddevelopmentof trauma relationship betweenperceptions of poortechnical psychological traumaafter childbirth foundadirect outcomes. Longitudinalstudiesexamining to interpersonalfactors,painandadverseclinical experiences duringlabourandbirthoften relate of childbirthmaycontributetotrauma.Distressing Differences betweentheexpectation and reality Factors contributingtotrauma symptoms co-morbid anxietyanddepressive symptoms. women experiencing traumaare alsolikely toreport support are replaced withactualorperceived harm. shaken whenexpectations of constancy, fidelityand in theNetherlands, Rates of traumasymptomsrangefrom 21 percent report symptoms of trauma followingchildbirth. PTSD followingchildbirth.However, manywomen six per cent of women meet the diagnostic criteria for While themajorityof birthsare nottraumatic, twoto women whoexperiencedadistressing birth. and socialwithdrawalare consistentlyreported by nightmares, hypervigilancewithregard tothebaby, answers aboutthetraumatic episode,flashbacksand detachment from thebaby. Obsessionwithseeking breakdown, sexualdysfunction,andemotional depression andsuicidalthoughts,maritalfamily debilitating anxietysymptomsandpanicattacks, Consequences of birth-related traumainclude Consequences other causes. or functionalimpairmentandnotbedueto to persistforat leastonemonth,create distress concentrating (Criterion E).Thesesymptomsneed such asirritability, hypervigilanceordifficulty feelings (Criterion D);ortrauma-related arousal, (Criterion C);haveworseningnegative thoughtsor flashbacks (Criterion B);avoidtrauma-related stimuli re-experience theeventthrough nightmares or As aconsequence,womenmay:persistently 34 percentinaUSsample. 5 Negative birthexperiencesassociated 1 2 33percentinAustralia 7 6 Women whodobecome Thewoman’sworldviewis 4 Ahighproportion of 3 and 7 Some 6 MIND MATTERS Birth Midwifery 2009; Women & Birth Women Psychological Medicine Vol. 20 No. 3 Spring 2018 | 43 Vol. thereby minimising minimising thereby 15 f the beholder. Nurs Res. 2004; f the beholder. J Psy Obstet Gyne 2006; Cochrane Database Syst Rev. Syst Database Cochrane 2006; Health Ment Arch Womens trick J, et al. A prospective et al. A prospective trick J, , Filippi F. PTSD, risk factors and PTSD, , Filippi F. , et al. Post-traumatic stress following stress , et al. Post-traumatic meta-analysis of 15 of meta-analysis Cochrane tric Association (2013). Diagnostic and tric Association The new Mental Health Care in in Health Care The new Mental 13 Midwifery 2012;29(3):217-224. utura M, Small R, et al. Debriefing interventions for Cochrane Database of Systematic Reviews 2015; Issue Systematic of Database Cochrane , Gamble J, Creedy D, et al. Women’s perceptions perceptions et al. Women’s D, Creedy , Gamble J, experiences L. Women’s Barclay D, Creedy , Gamble J, , Creedy D. A counselling model for postpartum D. , Creedy , et al. Midwife-led continuity models vs other models -P, Highet N, Expert Working Group. Mental Health Care Mental Health Care Group. Expert Working Highet N, -P, aims to improve prevention and early prevention aims to improve . Towards a conceptual framework for understanding . Towards 14 , Brack G, DiIorio C. Prevalence and predictors of women's of and predictors , Brack G, DiIorio C. Prevalence tthey S, et al. Variability in use of cut-off scores and formats and formats scores cut-off in use of et al. Variability tthey S, orld Health Organization. Depression and Other Common Depression orld Health Organization. expectations among women having a baby: a two-wave expectations J Psy Obstet & Gyne. 2006;27(2):81-90. longitudinal study. emotional support following childbirth: a qualitative of investigation. PRIME midwifery counselling intervention. of 1):s11-12. 2011;24(Supp W 2017 WHO: Geneva. Mental Disorders: Global Health Estimate. Ma for Scale – implications Depression on the Edinburgh Postnatal practice. clinical and research Austin M Period: Australian Clinical Practice Guideline. in the Perinatal Excellence. Perinatal of 2017; Centre Sandall J for childbearing women. care of 2016;4:CD004667. American Psychia Washington DC. mental disorders (5th ed.). manual of statistical Olde E, van der Hart O Clin Psychology Review 2006;26(1):1-16. childbirth: a review. Alcorn K, O’Donovan A, Pa stress post-traumatic of the prevalence longitudinal study of childbirth events. from disorder resulting 2010;40(11):1849-59. Soet J psychological trauma during childbirth. experience of 2003;30:36-46. Maggioni C, Margola D Beck C. Birth trauma: In the eye o 53(1):28-35. Fenwick J Gamble J birth experiences. women following distressing 25(2):e21. Bastos M, F psychological trauma in women following of the prevention childbirth. DOI:10.1002/14651858.CD007194.pub2. Art. No.:CD007194. 4. Fenwick J Slade P symptoms following childbirth and stress post-traumatic for further research. implications 27(2):99-105. 9(6):309-315.

detection of antenatal and postnatal depression, depression, and postnatal antenatal detection of better psychosocial risk through anxiety and and for expectant treatment and referral screening, care maternity we argue that new mothers. However, to establish a therapeutic relationship need providers undertake with women in early pregnancy, mental health assessments at psychosocial risk and to the changing needs multiple points, and respond period. Providing perinatal the women throughout of caseload midwife has the women with a ‘known’ childbirth trauma. Caseload potential to minimise mental health and midwifery integrates routinely and support for women psychosocial risk screening, birth labour, pregnancy, and families throughout and postpartum. A unequivocally participants, with over 17,000 RCTs, caseload women receiving that demonstrated to have a likely more midwifery were care and less pain relief spontaneous vaginal birth, require have fewer adverse outcomes, 6. 8. 11. 13. 15. References 1. 2. 3. 4. 5. 7. 9. 10. 12. 14. psychosocial and physiological changes of pregnancy pregnancy of changes physiological and psychosocial and postpartum. the likelihood of a traumatic birth. of the likelihood Childbirth trauma is complex and multifactorial. and potentially a fresh Caseload midwifery offers and detecting to preventing cost-effective approach mental perinatal risk for trauma and development of frames the health disorders. Caseload midwifery mental health challenges women may experience birth and early motherhood as a in pregnancy, A midwife physiological and psychosocial transition. health who is known and trusted can detect mental and psychosocial risk in a timely way and respond care. a woman’s maternity within the context of the Perinatal Period: Australian Clinical Practice Period: Australian the Perinatal Guideline

9 Given the 10 8 Furthermore, psychological psychological Furthermore, 11 recommends the integration of maternal maternal of the integration recommends of ‘debriefing’ to prevent to prevent ‘debriefing’ Review of Cochrane 12 mental health into all health services received by mental health into all health services received the attempted childbearing women. However, health mental specialised perinatal of integration has met with mixed care services into maternity in increase is a reported Although there results. based to these services, assessment may be referrals risk factors. of or presence on a single screening et al argue, mental health symptoms As Matthey and diagnostic identified by various screening the significant tools cannot be easily distilled from inconclusive nature of research to date, but potential to date, research of inconclusive nature in this research of outcomes, further significance is needed. area The transition to motherhood is complex. trauma symptoms may be exacerbated Birth-related by by the complex intersecting issues experienced and postpartum. Sensitive women during pregnancy conflict, personal issues, such as relationship sexual assault and a domestic violence, previous in addressed rarely history childhood abuse, are of women’s abilities and may adversely affect pregnancy to cope during labour. Of the seven included studies, not all specifically Of the seven included is risk. Although ‘debriefing’ targeted women at such as anxiety disorders intended to prevent outcome the main and PTSD, reactions acute stress Debriefing depression. in many studies was measure for women with also not effective interventions are or serious mental reactions serious post-traumatic women may authors suggest that The distress. their distress. considerable time to process require counselling and A major challenge in offering emotional support to new mothers is the availability the feasibility Our work has evaluated trained staff. of with new a midwife-led counselling intervention, of counselling or mothers randomly assigned to receive months three At support group. an active parenting postpartum, PTSD total symptom and depressive for women in the reduced were symptom scores but, overall, there counselling support group, groups. between no significant differences were either counselling or parenting Mothers receiving with high or very high satisfaction support reported by midwives. the interventions offered Psychological and psychosocial interventions Psychological and psychosocial into research has been little systematic There acute or prevent reduce early interventions to childbearing women. A trauma symptoms in recent variable outcomes. reported postpartum depression becoming pregnant again can provide opportunities opportunities provide again can pregnant becoming Some women have new coping strategies. to develop strategies pregnancy, in a subsequent that, reported and a birth plan planning, use of such as proactive providers, care and empathetic seeking supportive during control a sense of to regain helped them labour and birth. pregnancy, issues – such as grief and loss associated with fetal issues – such as grief and loss associated a loss of illness or disability, death, or neonatal the birth hoped-for normal birth, and processing in fragmented experience – can be overlooked present the health professional service models where during labour and birth is not the person providing fragmented Current or postpartum care. immediate diminish the likelihood care maternity models of and ‘knowing’ a woman health professionals of Even effectively to her needs over time. responding assistance, more though many women would like not frequently childbirth are arising from problems the mental health discussed and few women receive help they need. WHO MIND MATTERS conversations inmedicine bad news:critical Finding meaningin reflections onthemeaning of badnews andhowthis One of myseniorneonatal colleaguesoffers her reproductive assistance. of a terminalcancerdiagnosis,orof thelimitsof unit, orof thosewhohaveinformed theirpatient likely tograduate from ourneonatal intensivecare doctors andparents of infant patients whoare not It reminds meof otherconversations between acting empathically andgenuineempathy isobvious. is skilled,butnotrehearsed. Thedifference between safe. Thisdoctorhashadthisconversation before; he the softness of histoneas hereminds herthat sheis reassurance heoffers whenhetouchesherhandand the intensityof eyecontactbetweenthem,the It isconveyedverbally, of course,butmostlyInotice notice, isbidirectional: totrustandbetrustworthy. conversations already they’ve had.Thisrelationship, I How theirconversations onthisdayreflect previous and herdoctorhavecometonavigate thissadday. to ‘watch, waitandwonder’abouthowthispatient life-limiting abnormalities,Ihavetheopportunity pregnancy just afewdaysafter learningherbabyhas the medicalprocedures that willinterrupther As Isitwithmypatient, supportinghertowards – PaulKalanithi,WhenBreath BecomesAir one mustsometimesgetcrushedbytheweight.’ and whollyimpossible:intakingupanother’s cross, guilt. Thoseburdensarewhat make medicineholy the ineluctablefailuresbrought menearlyunbearable The costof mydedication tosucceedwashighand devastation makes itreasonabletoletthat lifeend. values, what makes hislifeworthlivingandwhat I mustfirstunderstandhismind:identity, his Before operating onapatient’s brain,Irealised, another’s identity –wasobviousinitssacredness. calltoprotect life–andnot merelylifebut ‘The King EdwardMemorialHospital,Perth Dept ofPsychologicalMedicine UWA CentreforNeonatalResearch &Education BPsych, MPsych(Clin),PhD Dr CatherineCampbell 1 patient’s fear andthedoctor’sownexperience of compassion andhope,allinthe contextof the how todelivertheirknowledge while maintaining that concernourtrainees.Theyare concernedwith about particularconditions,diagnosis orprognosis and peerconsults,that itisrarely alackof knowledge observation andinvolvement in simulation training sufficient. Itseems from theoutside,through contexts, initself, structure andcontentisnot the pitchof ‘illness’conversations across clinical While there seemstobeacommonstructure to of meaning. medicine (givingfacts)andgivesplacetotranslation reflects adeparture from amore lineartransaction of ‘holding’ intheirhelpingrelationship. Thisapproach before themandplaceahigherordervalueonthe consciousness, istheircapacityto‘see’theperson these vignettesdemonstrate, perhaps withoutself- between doctorandpatient. What mycolleagues in the interpersonaltexture of theconversation person-centred practiceoffer away of organising in healthcare, therapeuticprinciplesof CarlRogers’ postureauxiliary of theclinicalpsychologistworking unfolding of meaninganditisinescapable.From the can causeintensepain.Itisamomentby relationships, future, valuesandhope.Thisdisruption Bad newsrisksinterruptingapatient’s senseof self, offer, always, iskindnessandcompassion.’ conversations. Ihave cometovaluethat what Ican Patients rememberdifferent thingsaboutthese the mosthonestpictureof the condition that Ican. decisions that fallinlinewiththeirvaluesbypainting values, helpingthemtodraw meaning andmake and openstancetowardthefamily’sbeliefs over time,Ihave foundithelpful to developaclear and unabletooffer that strong,calmface.However, my juniorsmustthinkof me,possibly that Iamweak leader of theseconsults andoften thinkaboutwhat and doctor Iamhumantoo.have beenobserver this isthepurestformof human emotion andasa tear withmypatients, sharingintheirpain.Ibelieve emotionally drained,andIhave, onoccasion,sheda now withmorecompassion.EachtimeIcomeaway of self-reflection, Icometotheseconversations empty life’. Sincethisfirst attempt, and after plenty I lovehimasheis.At leastheisheretofulfil my you,doctor.as mum’s onlycomment was,‘Thank must have putalot of numbersinto mymonologue, reassuring tone,thoughmythoughts wereracing.I to mumgently andtothebestof myability, witha of herbabyafter somanylosses.Istartedtalking 21] withmum,whowasoverjoyedbythelivebirth to bestbroachthis[dysmorphicfeatures of trisomy ‘IrememberdistinctlyhowanxiousIfelt abouthow for eachpatient: meaning isrepresented inconversations differently MIND MATTERS Vol. 20 No. 3 Spring 2018 | 45 Vol. Cancer Journal for . Available Times. Available New York The doctor’s duty is Guidance App RA , et al. Approaching difficult , et al. Approaching . Communication skills training in paediatrics. skills training in paediatrics. . Communication 2017; 14: 87. Available from: from: Available 87. 2017; 14: Reproductive Health . When breath becomes air. United Kingdom: Random United becomes air. . When breath . How long have I got left? , Menichetti J, Barusi L, et al. Breaking bad news Barusi L, et al. Breaking , Menichetti J, he go-to app resource go-to app resource he T for obstetricians and gynaecologists. in assisted reproductive technology: a proposal for technology: a proposal in assisted reproductive guidelines. https://reproductive-health-journal.biomedcentral.com/ articles/10.1186/s12978-017-0350-1. Kalanithi P House; 2016. Kalanithi P www.nytimes.com/2014/01/25/opinion/sunday/how- from: long-have-i-got-left.html. Back A, Arnold R, Baile W CA: in oncology. tasks communication https://doi. from: Available Clinicians. 2005; 55(3):164-77. org/10.3322/canjclin.55.3.164. Kier A, Wilkinson D 2013;49:624-28. and Child Health Paediatrics Journal of Leone D

References 1. 2. 3. 4. 5. sense of trepidation, as I am acutely aware that the that acutely aware as I am trepidation, of sense learned changed. I have lives will be forever parents’ is silence of silence. A period of to be afraid not enormity of respect for the as it conveys “right” often what to explore with parents time the news. Taking as getting for them is as important the news means to be made This allows decisions the facts correct. without rushing.’ power to transform lives. Any suffering has the many forms. Suffering comes in instead, life, but to a previous patient a not to return the person’s of to hold and contain projections up the space to they take unbearable feelings, while up their makes and understand what think through will come to carve what experience; and ultimately, out their new normal. Hope exploring hope. Through a patient’s Never destroy Hope for possibility. we widen our lens perceptions face of may be found in many places, even in the view hope through despairing odds. Doctors often as an expression their patients, lens from a different of than an expression rather likelihood, statistical of the living; of wishing. Hope is found in the quality of a relational a motherhood story (however short); of about the life reflections experience, in broader despair is a for hope in the face of lived. Searching ‘meaning-making’ and central art form of delicate in medicine. While conversations to illness-related of denial as the patient a period hope may reflect stance, as they seeks to maintain a protective to ‘hear’ the bad news, it can also develop readiness new beginning, a wish a be about the emergence of the ground Hope prepares future. for a different and, for healing, movement, change, acceptance growth. ultimately,

5 formation into two to three formation formation clearly and slowly formation e a plan to follow-up. ess responses tient’s life epare the setting, the message and yourself epare tart by assessing the patient’s existing tart by assessing the patient’s key points Mak Give patients permission to ask questions, invite permission to ask questions, Give patients their family the illness on Be curious about the impact of pa Summarise in Pr S situation their understanding of Deliver in and Become familiar with common emotional str • More broadly, communication skills training communication broadly, More through encouraged for senior trainees are experiential-led training options. Conceptual skills has emerged in micro-counselling of distillation For example, Back et al recommend literature. recent habits, avoiding ‘blocking, dismissing or redirecting’ reassurance. lecturing, colluding and premature • • • • • feeling vulnerable. It can be helpful to think about think about helpful to It can be vulnerable. feeling development of skills as stages these communication In early professional the doctor. in the life of and structure teaching about content development, the interpersonal In advanced trainees, priority. takes focus. comes into sharper process news Delivering unsettling literature and evidence-based The practice-informed for strategies contains useful communication that information delivering sad and illness-related all healthcare for up mandatory reading makes or supportive whether they fulfil direct professionals, you will find structural Within this literature roles. conversations: guidelines for critical • Instead, these authors encourage their reader to Instead, these authors encourage their reader expansive skills such as ‘ask-tell-ask’, cultivate and naming questioning (for example, tell me more), emotional responses. validating The relationship and counselling techniques are structure Whatever of followed, or the clinical context, the best examples characterised by something are critical conversations sits between a doctor special in the space that the words between the lines of and their patient, This human binding agent might be best spoken. dynamics. It involves empathy, described as relational and a capacity to be authentic and wholly present, to see the world an unconditional preparedness this at facilitate you. To the person before view of level, we must be available to ‘see’, conversational understanding, as wholly as possible, the patient’s emotions, decisions, intentions and proposals, beliefs and thoughts. The bad news consult is not a time to defend a diagnosis or expertise, but to bear form) by in whatever pain (expressed the patient’s illness transforms lives. Indeed, the that recognising adjustment to doctor’s capacity to support a patient’s curiosity a position of bad news is best served from the than from rather about the person being treated, and knowing. This reflective closed position of more offers the opportunity interpersonal process reflexive that the patient to consider the unique qualities of enable and extend themselves to serve to potentiate, cope with bad news and its meaning. Learning to feel in with the ‘holding’ space is reflected comfortable my colleague’s comments about the role another of silence: of 20 years working in neonatal after now, ‘Even with a medicine, I approach these conversations • MIND MATTERS step-parents. one, men and womenare bothrepresented, asare in thefirstyear, mostlybywomen.Aftertheage of filicides occurinthefirstweek oflifeand30percent is thehighestriskof beingmurdered. Ten percentof ourselves that infancy isstilltheageat whichthere mentally ill? of infanticide Are mothersconvicted depression and anxiety bothhaveastrong psychosis. Theoriginof thelawand postpartum mental illnessbeingbiological,except postpartum There islittleevidence,however, forpostpartum biological mother. offence andadefencethat canonlybeusedbythe is reduced asinmanslaughter(fiveyears).Itisan lactation. Themaximumsentenceforinfanticide to havebeenaffected bytheact of givingbirth or being basedinscience:thebalanceof mindisseen legal ramifications, aswellbeingsuggestive of included inthelawandwheninvoked, hasspecific validity. Infanticide ontheotherhand,where age byaparent –isadefinitionthat hasnolegal Filicide –thekillingof achildunder18yearsof History and ownershipof thechildandpartner. can beparticularlyviolentandimplybeliefof rights to dealwithemotions,especiallyanger. Thecrimes high levelsof stress. For men,manyhaveneverlearnt include mentalillness,drugs,history of abuseand evil’ (psychopathic). Issuesthat leadtothetragedy male orfemalefamilyperpetrators are rarely ‘pure Culturally, there isrepugnance forchildmurders,yet (0.8/100,000). as theninthlowestworldwideforchildhomicides biological mother–israre. Australiacurrently ranks age of 12months(ortwoyearsinVictoria)bythe Infanticide –thekillingof aninfant underthe Austin Health, University ofMelbourne Dept ofPsychiatry MBBS, MMed,MD, FRANZCP Prof AnneBuist 2 1 However, itissoberingtoremind mental illness Act. The15percentof womenwhohaveperinatal Many countries,notablynottheUS, adoptedthis 1922 prevented thesewomenfrom beinghanged. babies were left;theInfanticide Act intheUKof options toraiseachild,andifwithoutfamilysupport, women pregnant outof wedlockhadnofinancial psychosocial basis.Inthe19thcentury, workingclass do havefurtherpregnancies theydeny. be arisktoanyoneelse,althoughoccasionally, they the casecomestolight,thesewomenare unlikely to One infant wenthomewith the mother. Providing six casesIhavebeeninvolvedwith,three survived. claims eachyear), notifications andmore than60,000 substantiated families where abuseisprevalent (more than350,000 always perpetrated bythemother. killing of aninfant undertheageof 24 hours),almost important toseparate asubvariety, (the For thepurposesof makingsenseof infanticide, itis Classification though theactwassimultaneous. to beaffected inonecase,butnottheothers,even murder. Itiscuriousthat herstate of mindwasseen older children alsodiedandshewasconvictedof 20-year sentence.Althoughshekilledaninfant, her In arecent Victorian case,thewomanwasgivena orders, whilejailtimehasbeencommoninNSW. women onbailandgavethemcommunitytreatment Until recently, the state of Victoria generally put these law, andevenwhentheydo,itisnotalwaysused. Australian states donotallrecognise theinfanticide cases doesthechilddie. Xinran Characteristics levels of stress. They alsohavelowerlevelsof supportandhigher psychiatric (suggestingageneticcomponent). history are often leftoroccasionallybashedbrutally. ‘alien’ who hastornthrough theirbody. Theinfants Thebabyisunplannedand notwanted,an terrifying. these youngwomen,labourissudden,dramatic and to spotorhaveperiods,anddenyitfamily. For partial lackof knowledgeof their state, maycontinue or religious upbringings.Theymayhavecompleteor have hadlimitedsexeducation, andoften rigidand/ are often young(orat leastnaiveandimmature), association withdenialof pregnancy. Thesewomen differs from infanticide, demonstrating astrong their families. psychologically andwithinthesocial contextof but theneonaticide casesare generallyunwanted Australia, thesameculturalissues are notinplay, socio-cultural phenomenaechoed inIndia.In of unwanted femalebabiesinChina,aprimarily 9 writesaboutthehorrificimpact of disposal 3 haveahigherrate of pastandfamily 4 Overlappingwiththisgroup are 5 butinonlyasmallnumberof 6 Neonaticide 8 7 Inthe MIND MATTERS

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. Fatal child maltreatment and child maltreatment . Fatal , et al. Postnatal mental health of of mental health , et al. Postnatal f Family Studies. Available from: https:// from: Available Studies. f Family om an unknown Chinese mother: stories of stories of om an unknown Chinese mother: fanticide: Psychosocial and Legal Perspectives fanticide: Psychosocial and Legal International Review of Psychiatry of Review 1996; International Am J Psych 1970;126(10):1414-20. wain A. Rates and risk of postpartum depression - a postpartum depression and risk of wain A. Rates . Murder of the newborn: a psychiatric review of of review the newborn: a psychiatric . Murder of of review a psychiatric . Child murder by parents: . Punishing Karen. In: Everywhere I Look. Text I Look. Text In: Everywhere . Punishing Karen. Am J Psych 2005;162(9):1578-87. Am J Psych 1970;126:325-34. Clarify expectations for trainees for Clarify expectations sites for Clarify expectations of consistency in preparation Promote as antrainees to commence a career O&G consultant For more information, go to information, For more ranzcog.edu.au/Specialist-Training/ATM The College is introducing compulsory The College is introducing With Modules (ATMs). Advanced Training the same minimum all trainees will have ATMs, to undertake training requirements procedural during Advanced Training. are to: The aims of the ATMs • • • FRANZCOG FRANZCOG Modules Advanced Training who trainees For FRANZCOG commenced training on or after 1 December 2014 est, S. An overview of filicide. Psychiatry (Edgmont). 2007 Feb; (Edgmont). Psychiatry filicide. An overview of est, S. reidman S, Horowitz S, Resnik P. Child murder by mothers: a Resnik P. S, Horowitz S, reidman W M, Hayes B Buist A, Austin O’Hara M, S Australian Institute o aifs.gov.au/cfca/publications/child-abuse-neglect-statistics. Accessed May 12th 2018. Resnick P Garner H B01B0SZACS. ASIN Publishing 2016; pp121-125. Spinelli M (ed). In Xinran. Messages fr F knowledge and a research of state current critical analysis of agenda. Resnick P Meyer C, Oberman M. Mothers who kill their childr Mom’. 2001. New to the ‘Prom Susan Smith from moms minds of Press. University New York NY: York, Damask A, Nelson M, Bonner B Damask A, Nelson abuse versus neglect. physical from deaths of characteristics Neglect 2013;37(10):735-744. Child Abuse and 4(2):48-57. meta-analysis. 8(1):37-54. neonaticide. Publishing 2002; Psychiatric on Mothers Who Kill. American 1585620971. ISBN-10 1451610949. 2012; ISBN-10 loss and love. Scribner. filicide. women giving birth in Australia 2002-4: findings from the from birth in Australia 2002-4: findings women giving program. depression Beyondblue postnatal 42(1):66-73.

6. 8. 11. References 1. 2. 3. 5. 7. 9. 10. 12. 4. 140 height x 70 width p43 ATM.indd 1

12 elated to elated of the diagnoses of men and the diagnoses of of 11 y to child abuse 10 ticide with potential denial of pregnancy ticide with potential denial of eoccupation (which could be psychotic) eoccupation  Secondar  Women who kill in conjunction with their violent Women or abusive partners  Neglect secondary to distraction or pr  Purposeful, which could be r mental illness.  Neona and dissociation at birth at and dissociation The women I see, mostly, rather than being ‘bad’ rather The women I see, mostly, have done a or ‘mad’ (psychotic), (psychopathic) both was involved in recently, bad thing. In a case I (as did and I agreed psychiatrist the prosecution the woman loved her) that many people who knew such a of sense one make her child. How then can Does the psychiatric murder unless it is madness? of the at the time need for her, diagnosis fit the legal To not was doing? she not know what to offence, was against the law? know killing your child illness Association with mental In Resnick’s study Uniting characteristics beyond the neonaticide group group the neonaticide beyond characteristics Uniting and retrospective are establish. Studies hard to are links are The strongest have small numbers. often suicidality and use of psychosis, with a history of identified Other common factors services. psychiatric abuse of history domestic violence, isolation, were and unmarried status abandonment, and maternal drug abuse. 3. 4. cases I have dealt with, six were Of the 14 infanticides Four were (or attempted). neonaticides only; one psychosis, two abuse and domestic and one complex mental health violence-related, issues. One case was an with cultural and isolation an older child) suicide, which (of infanticide-murder cases were was almost certainly psychosis. Three which one was of (older children), infanticide-murder complex cultural and psychotic and the other three personality issues. Outcomes, prevention and intervention available contraception are and readily neonaticides. to prevent strategies the key probably of group the broader these tragedies, like However, of need better community awareness infanticides, motherhood, and the psychological costs and risks of family and community support. the importance of Beyondblue has achieved a significant change in screening and in routine community awareness the screening but after depression, for risk of intervention needs to be timely and include repeated needed. The woman where assessments and respite, I mentioned earlier who loved her baby had scored Scale Depression high on the Edinburgh Postnatal (EPDS), but was never followed up. While it was the were (isolation) her circumstances assumed that the deeper psychological the score, cause of root It is went undiagnosed and untreated. problems we want to identify early and treat these problems Loneliness and is not easy. Parenting assertively. harder still. parenting make isolation classification of maternal filicide: of maternal classification 1. 2. 5. women who commit filicide, while nearly half had women who commit filicide, while nearly (psychosis and mental illness severe a diagnosis of did not. Drug use, the remainder depression), severe family relationships, personality disorders, disordered for the tragedy up the ‘reason’ and poverty make charged were occurring, and the perpetrators included however, The research, with murder. different cases going back to the 1800s with very and his classification play at social circumstances which involved is unhelpful for infanticide, useful is Meyer and Oberman’s only women. More MIND MATTERS this category. treatment forpremenstrual symptomsare in that asignificantpercentage of womenwhoseek treatment non-responsive. Ithasbeensuggested undiagnosed anduntreated, partiallytreated, or anxiety disorderoreating disorderthat maybe as amajordepressive disorder, bipolardisorder, exacerbation of anunderlyingcondition(PME),such many women,symptomsrepresent apremenstrual from theoutset,itneedstoberecognised that for or adisorder, dependingontheirimpact.However, behavioural componentsandconstituteasyndrome and includephysical,emotional,psychological menstruation begins.Thesymptomsmaycluster of themenstrualcycleandendshortlyafter symptoms, whichbegininthelate lutealphase experience apredictable, cyclicpattern of moliminal It haslongbeenrecognised that manywomen any confusion that hasarisen. part of thehumancondition?We aimtodisentangle separate entities?Are theyafflictions atall,orjust same orvariantsof thesameaffliction, or are they premenstrual dysphoricdisorder(PMDD)oneandthe premenstrual syndrome (PMS)and tension (PMT), The namesaysitall.Ordoesit?Are premenstrual Heidelberg Head ofUnit, MercyHospitalforWomen Perinatal Psychiatrist MBBS, MPM,FRANZCP Dr GaynorBlankley Mercy HospitalforWomen Perinatal Psychiatrist FRANZCP MBBS, MMed(Psychiatry), Dr JosephinePower Prahran, Victoria Mercy HospitalforWomen &PrivatePractice Perinatal Psychiatrist MBBS, MPM,FRANZCP Dr MartienSnellen is thereadifference? PMT, PMSandPMDD: women globally. reported tobeexperiencedbyup50per cent of only requires andis oneortwosymptoms toqualify diagnostically, itisalooseandinformal label,asit symptoms impliedintheterm‘tension’. Overall, de-emphasising theemotionaland psychological the symptomcluster, withtheterm‘syndrome’ many arguethat thelatter labelbetterdescribes and tearfulness.PMSisthesamething.However, swings, depression, clumsiness,lethargy, insomnia concentration, reduced libido,aggression, mood tension, lowered copingability, impairmentof food cravings,emotionalirritability, anxiety, nervous retention, weight gain, constipation and/or diarrhoea, and bloating, backache,acneoutbreaks, fluid headaches and/ormigraines,abdominalcramping of thefollowingsymptoms:tender swollenbreasts, PMT issaidtoinvolvetheexperienceof oneormore 1 2 had beenidentified worldwide. or theresearch unusable,andthat thecondition interest concernsdidnotrender thediagnosisinvalid domestically orlegally, that financial conflict of does notharmwomeneconomically, politically, regarding thisintroduction, finding that such alabel 2014, apublishedreview addressed reservations a formaldiagnosticcategory. Soonafterwards, in introduction of DSM-V, PMDDwasintroduced as fluoxetine soldinEurope. However, withthe2013 remove PMDDfrom thelistof indications for for themanufacturer of Prozac (fluoxetine) to MedicinalProductsfor Proprietary requirement was furthersupportedin2003bytheCommittee to keep theconditioninappendix.Thisview The DSM-IV-TR, published in2000, againdecided affect men. that wasonly poorlystudiedbecauseitdidn’t Others arguedthat itrepresented avalidcondition impairment. occupational functioning,tothepointof transient affect theirquality of lifeanddailyinterpersonal experience multiplesymptomsthat cansignificantly recognised that three toeightpercentof women impairs psychosocialfunctioning,ithasbeen While PMSisgenerallymanageableandminimally . sometimes onlyoccurduringthelutealphaseof the first to recognise that depressive moodsymptoms rates andevenmurder. for decreased worker productivity, increased divorce Dalton, whofeltthat theconditionwasresponsible term PMSwaslater introduced in1953byGreen and restore orderinthehomeandworkplace.The oophorectomy orradiation therapy inorderto ovarian functioningneededtobeobliterated with and hecoinedthephrasePMT. symptoms wasfirstdescribedby Frank in1931 The clusteringof more severe premenstrual disorder aimstocapture thissub-group. women withsymptomrelief. inhibitor (SSRI)fluoxetine assisted60 per cent of Lilly, suggestedthat theselectiveserotonin reuptake further study. In1995, alargestudy, subsidised byEli with anelaboration of diagnosticcriteriatoaid eradicated. Theydecidedtokeep itintheappendix distinct diagnosis,kept intheappendix,orentirely to whetherthecategory shouldbeelevated toa of theDSM-IV in1994, there wasmuchdebate as needingfurtherstudy.category Priortotherelease disorder intheappendixasaproposed diagnostic diagnostic category of late lutealphasedysphoric of MentalDisorders(DSM-III-R) introduced the In 1987, theDiagnosticandStatistical Manual important asjobpromotions orchildcustodycases. ill, leadingotherstomistrusttheminsituations as could leadtowomenbelievingthat theyare mentally diagnostic category potentiallybeingharmful, asit pathologising of cyclicalchangesinwomen’,withthe syndrome andrepresented ‘an unnecessary argued that suchsymptomswere aculture-bound 3 Thetermpremenstrual dysphoric 6

5 Later, Mortolawasthe 7 Inreaction, some 4 9 Hisviewwasthat TheInternational 8

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BMJ 1953; Vol. 20 No. 3 Spring 2018 | 49 Vol. New England Journal of New England Journal of Current PsychiatryCurrent Reports. 2015 Harv Rev Psychiatry 1996 Jan-Feb; . 2014 Feb; J Clin Diagn Res. 2014 emenstrual Dysphoric Disorder: Am J Obstet Gynecol. 2010 Mar; World World validity and utility. tric classifications: , Tiwari D, et al. Prevalence of premenstrual premenstrual of et al. Prevalence , Tiwari D, Am J Obstet Gynecol 1989;161(6,Pt1):1682-1687. . Premenstrual Dysphoric Disorder: Controversies Dysphoric Disorder: Controversies . Premenstrual , Breaux C, Yonkers K. Addressing concerns about the K. Addressing C, Yonkers , Breaux , Girton L, Yen S. Depressive episodes in premenstrual episodes in premenstrual Depressive S. , Girton L, Yen The disorders PMT, PMS and PMDD, to PMS and PMDD, The disorders PMT, 12 ekvand-Moghadam A, Sayehmiri K, Delpisheh A, Kaikhavandi ekvand-Moghadam eene R, Dalton K. The premenstrual syndrome. syndrome. eene R, Dalton K. The premenstrual teiner M, Steinberg S, Stewart D, et al. Fluoxetine in the et al. Fluoxetine D, Stewart S, teiner M, Steinberg onkers K, O’Brien P, Eriksson E. Premenstrual syndrome. syndrome. Eriksson E. Premenstrual K, O’Brien P, onkers rank R. The hormonal causes of premenstrual tension. premenstrual rank R. The hormonal causes of Neurolog Psychiatry 1931;26:1053. (4818):1007-14. syndrome. dysphoria. premenstrual of treatment Medicine 1995;332(23):1529-34. the diagnosis. surrounding 3(5):293-295. Raval C, Panchal B Hantsoo L, Epperson C. Pr Jablensky A. Psychia Psychiatry 2016 Feb;15(1):26-31. Pink disease. of exacerbation 202(3):221-231. Dir (PMS) – a systematic syndrome premenstrual Epidemiology of S. and meta-analysis. review 8(2):106-109. Y 2008 Apr 5;371(9619): 1200-1210. F Gr Mortola J S Severino S Hartlage S J Clin dysphoric disorder in DSM-5. premenstrual inclusion of Jan;75(1):70-76. Psychiatry 2014 dysphoric disorder among college and premenstrual syndrome Indian J Psychiatry Gujarat. 2016 Bhavnagar, students of Apr-Jun;58(2):164-70. Epidemiology and Treatment. Nov;17(11):87.

The aetiology of PMS and PMDD remains an active an remains and PMDD PMS of The aetiology symptom While the timing of research. of area sex suggests that and disappearance occurrence no demonstrable are relevant, there is hormone flux levels in hormone reproductive in differences symptoms. do or don’t experience women who 5. 6. 7. 8. 9. References 1. 2. Menstrualcycle-related H. C,Taylor Guico-Pabia erton J, 3. 4. 10. 11. 12. Some women may thus have an abnormal central Some women may thus to normal hormone levels nervous system response considered no longer are Symptoms and variation. to be simply cultural or psychological phenomenon, with but biologically based occurrences, genetic and epigenetic hormonal, neurobiological, aetiological components. ‘there Jablensky suggests that publication, In a recent recognised the majority of is little evidence that boundaries by natural separated mental disorders are defined by their diagnostic categories and that as ‘valid’ should be regarded clinical syndromes only if they have been shown to be truly discrete entities’. Thus, hormone levels and flux alone appear to be levels and flux Thus, hormone and neurobiological the relevant however, irrelevant, an underlying may represent physiological changes that is evidence There sensitivity to such changes. with diverse acts as a neuro-modulator, oestrogen its nervous system through effects on the central and dopaminergic on the serotonergic, influence systems, as well as exerting GABA neurotransmitter responsiveness and on the expression influence and prolactin progesterone, androgens, of which have all of hormone, gonadotropin-releasing on immunomodulation. been shown to have effects date, have not met such a standard. However, they have not met such a standard. However, date, the information may possess ‘utility’ by virtue of symptoms, outcome they convey about presenting understanding A greater response. and treatment we commit to these aetiology is essential before of Hopefully, unconditionally. diagnostic categories into genetics, epigenetics, neurobiology research a conceptual epidemiology will allow and population between the emerging continuum and reconciliation in symptomatology, the variation dimensional view of embodied in current approach and the categorical and DSM-5. such as ICD-10 classifications tion of In Australia, 10 tion f control tion ed lack of energy ed lack of f being overwhelmed or out of control f being overwhelmed or out of , easy fatigability or marked lack or marked , easy fatigability tion of ‘bloating’ and weight gain). and ‘bloating’ tion of ed change in appetite, overeating or specific ed change in appetite, overeating ed anxiety, tension and/or feelings of being tension and/or feelings of ed anxiety, ed affective lability (for example, mood lability ed affective anger or increased ed irritability, mood, feelings of ed depressed ed anxiety and tension ed lability (for example, mood swings) ed irritability or anger mood edly depressed eased interest in usual activities (for eased interest eased interest in usual activities eased interest eating or specific food cravings) eating ‘bloating’ or weight gain. ‘bloating’ example, work, school, friends, hobbies) food cravings Hypersomnia or insomnia A sense o tenderness Physical symptoms, such as breast or swelling, joint or muscle pain, a sensa Decr Subjective difficulty in concentra Lethargy of energy Mark swings, feeling suddenly sad or tearful, or sensitivity to rejection) increased interpersonal conflicts thoughts hopelessness or self-deprecating Mark up’ or on edge. ‘keyed Mark Mark Mark Feeling overwhelmed or out o Physical symptoms (for example, breast a tenderness or swelling, joint or muscle pain, sensa Mark Decr Difficulty in concentra Lethargy and mark change in appetite (for example, Marked over Hypersomnia or insomnia Mark Mark Mark • • • • • • • • • Criterion C the following symptoms must of One (or more) five a total of to reach additionally, be present, symptoms when combined with symptoms from Criterion B above: • Criterion B the following symptoms must of One (or more) be present: • • • • • • • • • • • the Therapeutic Goods Administration recognises recognises Administration the Therapeutic Goods the however, PMDD, the diagnosis of the validity of reimburse Scheme does not Pharmaceutical Benefits SSRIs used for its treatment. the cost of a of PMDD, definition In order to meet the DSM-V meet the following specific criteria. must patient Criterion A at during the past year, For most menstrual cycles at of the following 11 symptoms (including least five in the final the first four) must be present least one of menses, start to improve the onset of week before menses, and the onset of within a few days after become minimal or absent in the week post-menses: • Classification of Diseases, 10th revision (ICD-10), (ICD-10), revision 10th of Diseases, Classification diagnostic the introduced in 2010, first published with tension syndrome, premenstrual category of with criteria compared and easily endorsed broad specific criteria. This and narrow the DSM-V’s research criteria has impaired in diagnostic difference as the guideline development, and therapeutic the female per cent of 91.4 former criteria captures per cent, when only 3.7 and the latter population college students. applied to a sample of MIND MATTERS mental health Menopause and conflicting. Bromberger etalandMulhall etalhave Data regarding thepostmenopausalperiodis that maybeashigh40 per cent. ofof depression, a history with anoverallprevalence compared to the premenopausal period, independent twice aslikely toexperienceadepressive disorder, that womeninthemenopausetransition are upto symptoms. Severallongitudinalstudieshaveshown between themenopausetransitionanddepressive There isextensiveevidenceof theconnection Potential causes menopause-specific toolsformentalhealth. symptoms andthepotentialclinicalvalueincreating it highlightsthebroad nature of menopausal and monitoringresponse totreatment. Furthermore, patient-focused care, guidingmanagementdecisions distinction isclinicallysignificantfortheprovision of menopause independentof mooddisturbance. This and lowlibido,are common experiencesof depressive symptoms,includingsleepdisturbance to amountadepressive disorder. However, some Depressive symptomsmaybeof significantseverity loss of interest inusualactivities. appetite, lowlibido,feelingsof worthlessnessand may includelowmood,sleepdisturbance,lossof Scale Revised(CESD-R) symptoms,which toclassify as theCenterforEpidemiologicStudies Depression Studies inthissettingoften usescreening toolssuch transition maypresent withavarietyof symptoms. Mood disturbanceassociated withthemenopause Symptoms in themenopausesetting. for clinicalpracticeinproviding comprehensive care menopause transitionandoutlinesimportantpoints overview of thementalhealthimplications of the and reproductive changes.Thisarticleprovides an loss of identityassociated withfamily, employment experience significant psychosocial change, including disturbance andvaginaldryness.Women may wellbeing, includingvasomotorsymptoms,sleep time forwomen,bringingaboutchangesinphysical The menopausetransitioncanbeachallenging Royal Women’s Hospital,Melbourne O&G Registrar MBBS, LLB(Hons) Dr AnnabelleBrennan 1-4 disorder duringthepostmenopausalperiod. demonstrated increased riskof havingadepressive current guidelines advise againsttheuseof hormonal used forthetreatment of vasomotorsymptoms, offer additionalbenefittomooddisturbancewhen menopause transition. any depressive symptomsassociated withthe depression thanwomenwhohadnot disorder hadnohigherriskof postmenopausal who experiencedaperimenopausaldepressive contrast, womenwithnopriorhistory of depression more likely tohavepostmenopausaldepression. In ofwith ahistory depression, whowere eighttimes showed that thiswasonlythecaseforwomen However, observational data from Freeman etal hormone treatment. perimenopausal depression following withdrawalof of depressive symptomsinwomenwith replacement therapy depressive symptomswiththeuseof hormonal data demonstrating significantimprovement in depression. and noradrenaline, knowntobeimplicated in pathways, particularlythoseinvolvingserotonin involvement of ovariansteroids inneuroregulatory both animalandhumanstudiesdemonstrating the of mentalillness.Therehistory isextensivedata from transition remain prevalent intheabsenceof a disorder. Depressive symptomsinthemenopause factors clearlysuggestingahormonalbasistothe and symptomonset.However, there are several clear relationship betweenbasalhormonelevels There isnohigh-levelevidencedemonstrating a symptoms inperimenopausalwomen. been showntobeeffectiveinimproving depressive mood disturbance.Oestrogen hormonaltherapyhas treatment inthemanagementof perimenopausal Antidepressants remain first-linepharmacological address theindividualhistory andclinicalexperience. transition are multifactorialandtreatment should Depressive symptomsduringthemenopause Management vasomotor symptoms. sleep qualityoccursduringthistimeindependentof However, evidencehasbeenconflicting and reduced predispose todepression by reducing sleepquality. has alsobeenimplicated. Vasomotor symptomsmay Poor sleepqualityduringthemenopausetransition increased theprevalence of vasomotorsymptoms. depressive symptomsanddepressive symptoms symptoms increased theriskof developing menopause transition.Thepresence of vasomotor depressive andvasomotorsymptomsduringthe review that demonstrated therelationship between symptoms. Worsley etalundertookasystematic transition involvedinthedevelopmentof depressive There are severalotheraspectstothemenopause depressive symptoms. uterus, whichhasbeenshownto potentiallyworsen progesterone therapyforwomenwithanintact a clinicalconsideration istheneedforconcomitant 7 There are alsorandomisedcontrolled 10 8,9 17 12-15 2 and,moreover, recurrence Whilehormonaltherapymay 8,9,16 However, 5,6

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Arch Gen 10/08/2018 8:45:11 AM Vol. 20 No. 3 Spring 2018 | 51 Vol. . The 2012 Hormone -Moul TA, et al. Efficacy et al. Efficacy TA, -Moul Psychoneuroendocrinology JAMA Psychiatry 2018;75(2):149-157. JAMA Psychiatry 2015;72(7):714-726. Maturitas 2014;77:93-110. Maturitas 2016;94:137-142. Maturitas Annals of the New York Academy of Sciences Academy of the New York Annals of Kantola P, Polo O, et al. Sleep in midlife women: et Polo O, Kantola P, esranta T, et al. Predictors of sleep disturbance in sleep disturbance of et al. Predictors esranta T, Menopause 2014;21(11):1217-1224. Menopause 2009;16(4):671-9. J, Dor RB, et al. Effects of Estradiol Withdrawal on et al. Effects Dor RB, J, J, et al. Sex and mood in the hormones and mood in the et al. Sex J, Danaceau MA, et al. Estrogen Nieman L, J, , Andel R, Anstey KJ. Variation in symptoms of symptoms of in Variation R, Anstey KJ. , Andel 2000;183:414-420. Am J Obstet Gynecol. Taylor J, Hickey M. Menopause and depression: Is there a Is there depression: M. Menopause and Hickey J, Taylor 2014;79:142-146. Maturitas een L, Nyberg S, Turkmen S, et al. Sex steroid induced et al. Sex steroid S, Turkmen een L, Nyberg S, es CD, Almeida OP, Joffe H, et al. Efficacy of estradiol for the of estradiol Efficacy H, et al. Joffe Almeida OP, es CD, ffe H, Soares CN, Thurston RC et al. Depression is associated is associated Thurston RC et al. Depression CN, H, Soares ffe orsley R, Bell R, Kulkarni J, et al. The Association Between et al. The Association J, orsley R, Bell R, Kulkarni élez Toral M, Godoy-Izquierdo D, et al. Psychosocial D, M, Godoy-Izquierdo élez Toral Mood in Women With Past Perimenopausal Depression Mood in Women of menopause, vasomotor symptoms and depressive effects symptoms. the North American Menopause of Therapy Position Statement Menopause 2012;19(3):257-271. Society. perimenopause. perimenopause. 2009;1179:70-85. preliminary a depression: in perimenopause-related replacement report. V a interventions in perimenopausal and postmenopausal women: randomised and non-randomised trials and of review systematic studies. non-controlled Schmidt P Schmidt P Soar Schmidt P W During Perimenopause: A and Depression Symptoms Vasomotor 2014;77:111-117. Maturitas review. systematic Jo sleep, but measured with worse objectively and subjectively in women with vasomotor awakenings, frequent not more symptoms. Lampio L, Polo- Vivian- link? Lampio L, Saar Gordon JL, Rubinow DR, Eisenlohr in the progesterone transdermal estradiol and micronized of symptoms in the menopause transition, depressive of prevention clinical Trial. a randomized Andr effect mood may be explained by the paradoxical negative by GABAA modulators. mediated 2009;34(8): 1121-32. North American Menopause Society Mulhall S Mulhall depression and anxiety in midlife 2018;108:7-12. Maturitas women by menopausal status. women: a disorders in perimenopausal depressive of treatment trial. placebo-controlled double-blind, randomized, Psychiatry 2001;58:529-534. Trial. Clinical Randomized menopausal transition.

14. 19. 8. 9. 12. 13. 15. 17. 18. 6. 7. 10. 11. 16. For Supervisors Email: [email protected] Phone: 61+ 3 9412 2933 JAMA Arch Gen 19 18 Arch Gen Psychiatry 2006;63:375-382. Psychol Med. 2011;41(9):1879-88. , Soares CN, Vitonis AF, et al. Risk for new onset Vitonis AF, CN, , Soares Menopause 2010;17(3):545-51. , et al. The prevalence of depression symptoms and depression of , et al. The prevalence omberger JT, Kravitz HM, et al. Major depression during and Kravitz HM, et al. Major depression omberger JT, reeman EW, Sammel MD, Boorman DW. Longitudinal pattern Longitudinal pattern Boorman DW. Sammel MD, EW, reeman Cohen LS Timur S among perimenopausal and postmenopausal factors influencing women. Br Health Across Women’s the menopausal transition: study of after (SWAN). the Nation F mood in women with no with depressed and menopausal status history depression. of F menopause. natural symptoms around depressive of during the menopausal transition. depression of Psychiatry 2014;71(1):36-43. Psychiatry 2006;63: 85-390. For Trainees Email: [email protected] Phone: +61 3 9412 2918 Learn more by accessing these College resources. available via the website and Guidance app:College Statements 48) (C-Obs Anxiety and Depression Perinatal Women in Perinatal Screening Psychosocial Assessment and Depression Pamphlets information Patient Birth and following and Anxiety during Pregnancy Depression via www.climate.edu.au Resources depression postnatal Counselling and management of ASM 2017 - Plenary Jo Black, RANZCOG Mental Health Strategy: Perinatal Developing a National ASM 2017 Mental Health: Jo Black, RANZCOG Clinical Issues in Perinatal Support Unit Training https://www.ranzcog.edu.au/Training/TSU Mental health

5. References 1. hormones of etal.Associations LinH, SammelMD, EW, reeman 2. 3. 4. Conclusion involves a challenging The menopause transition change for physical and psychological period of should be mindful of many women. Clinicians for developing perimenopausal factors predisposing depressive of as a history mood disturbance, such and depression disorders, including postnatal disturbance. Comprehensive, mood premenstrual an understanding of requires care patient-focused and menopause and depression the symptoms of to managing the individual a targeted approach both. experience of therapy for the primary treatment of perimenopausal perimenopausal of for the primarytherapy treatment symptoms. depressive use also be given to the should Consideration the to address psychological management of the menopause issues arising during biopsychosocial therapy has been Cognitive-behavioural transition. both physical in improving shown to be effective menopause of and psychological symptoms to or adjunct and is an important alternative pharmacological treatment. RAN003 FILLER ADVERT TEMPLATES HALF PAGE HORIZONTAL.indd 1 MIND MATTERS screening formentalhealth disorders,substance representation from RANZCOG, recommended that Benefits Schedule(MBS)Review Taskforce, with Obstetrics ClinicalCommitteeof theMedicare than deliveringbabies mental health: more Obstetricians and Mental HealthGuideline. recommendation of theAustralianNational Perinatal has beendemonstrated tobeeffectiveandis a key Screening formentalhealthdisordersinpregnancy practice that ‘youwon’tknowifyoudon’task’. It isself-evidentineveryotheraspectof medical maternal death. and NewZealand, suicideisaleadingcauseof or psychosis.Inmanycountries,includingAustralia post-traumatic stress disorder, adjustmentdisorder the ‘babyblues’toovertmentalillness,depression, a continuumof symptomsfrom mildanxietyand distressing emotionalturmoil.Thismaymanifestin pregnancy, birthandearlyparenting canleadto with minimaldisruption.Forasignificantminority, social change.Formany, thispathway isnegotiated of great adjustment–biological,psychological and a pre-existing illness.Theperinatal periodisatime disease may arise denovoorbeanexacerbation of perinatal anxietyand/ordepression. The One infivewomenandonetenmenexperience always so. particular, that theiremotionalhealthisstable.Itisn’t father) are isgood, happy, that everything and,in societal expectations of anewmother(and love andadoration byparents, familyandfriends.The all communities.Anewbornisasource of wonder, Pregnancy andthearrivalof ababyare celebrated in great joy, ajourneyof excitement andhappiness. For manywomenandtheirpartners,itisatimeof between conceptionandoneyearpostpartum. The perinatal period maybedefinedasthetime Mater Hospital North ShorePrivateHospital Royal NorthShoreHospital Visiting MedicalOfficer MBBS, MRCOG, FRANZCOG Dr VijayRoach 1 InNovember2017, the Depression Scale(EPDS), screening toolsincludetheEdinburghPostnatal pathways forthosewhoscreen positive.Validated There mustbeclearlydefinedandaccessible successful, there needstobeadequate training. Mandating screening isafirststep.Forthistobe item numbersandtheintroduction of new ones. conditions in pregnancy, with modification of existing legislate therequirement toscreen formentalhealth of ourknowledge,Australiaisthefirstcountry to now recognised intheMBSSchedule.To thebest after womenwithmentalhealthdisordersisalso care. Theimportanceandcomplexityof looking misuse anddomesticviolencebepartof routine psychological screen, theANRQ, is demonstrated by: pregnancy, duringpregnancy orpostpartum)that mentalhealthdisorder(whetherarisingpriorto (m) Complex birthitem16522 Box 1. ChangestotheMBSSchedule claimed onceperpregnancy. will notbedisadvantaged.Thisitem canonlybe chooses nottoundertake theassessment,they be offered patient, however, toevery ifthepatient domestic violence.Thementalhealth servicewill including screening fordrugandalcohol useand include amentalhealthassessment of thepatient, four andeightweeksafter birth.Theitemwillalso attendance lastingat least20minutes between A newitemwillbeintroduced forapostnatal Postnatal consultation (newitem)16407 the assessment,theywillnotbedisadvantaged. however, ifthepatient choosesnottoundertake health servicewillbeoffered patient, toevery alcohol useanddomesticviolence.Themental assessment, includingscreening fordrugand The itemwillalsoincludeamentalhealth attend thebirth doctor intends(16590)/doesnotintend(16591)to Planning andmanagementof pregnancy where the disclosure orevidenceof domesticviolence (n) (ii) thepatient requiring hospitalisation; or (i) (iii) (iv) tr the patient havingaGPmentalhealth  pr the patient havingamanagementplan  symptoms of amentalhealthdisorder;or psychologist orpsychiatrist totreat the the pa eatment plan;or epared inaccordancewithitem291. tient receiving ongoingcare bya 2 andanantenatal 3 whichassesses .. MIND MATTERS Acta Psychiatrica Acta Psychiatrica offering offering 4 Vol. 20 No. 3 Spring 2018 | 53 Vol. Aust N Z J Obstet Gynaecol. -P, Hadzi-Pavlovic D, Leader L, et al. Antenatal Leader L, et al. Antenatal D, Hadzi-Pavlovic -P, -P, Highet N and the Expert Working Group. Mental Group. Highet N and the Expert Working -P, British Journal of Psychiatry British Journal of 1987;150(6):782-786. x J, Holden J, Sagovsky R. Detection of Postnatal Depression: Depression: Postnatal Sagovsky R. Detection of Holden J, x J, ohlhoff J, Hickinbotham R, Knox C, Roach V, Barnett A. C, Roach Knox J, Hickinbotham R, ohlhoff Austin M Period: Australian Clinical Practice in the Perinatal Health Care Excellence. Perinatal of Guideline. (2017) Melbourne: Centre Co Depression the 10-item Edinburgh Postnatal Development of Scale. doi:10.1192/bjp.150.6.782. Austin, M validation depression: postnatal of for the prediction screening risk questionnaire. a psychosocial pregnancy of 2005;112:310-317. Scandinavica K in screening and depression psychosocial assessment Antenatal hospital. a private doi:10.1111/ajo.12418. 2016;56(2):173-178.

References 1. 2. 3. 4. free consultations with psychologists, psychiatrists psychiatrists with psychologists, consultations free and via both face to face and social workers, events to raise hold numerous telehealth. We has hitherto received a disease that of awareness insufficient attention. your obstetric part of mental healthcare Make every practice. Ask about emotional wellbeing at can identify high You visit. Then listen to the answer. and delivery perform an instrumental blood pressure, or birth. FRANZCOG manage a complex pregnancy qualify but being a you for that, and DRANZCOG You can doctor qualifies you for so much more. manage and support women with mental identify, the care and beyond. If we make illness in pregnancy our practice, the emotional wellbeing integral to of will birth and parenting pregnancy, around culture all. change, for the betterment of midwives. It is the responsibility of obstetricians and obstetricians of responsibility It is the midwives. not be outsourced. GPs. It should now have five children. and and I recovered Cathie permanently scarred and content, but happy are We could have been 26 years ago. It of by the events our passion into the have channelled We better. a charity to raise awareness Gidget Foundation, early and wellbeing in pregnancy emotional of a loving woman with Gidget was a real parenting. took her own husband and friends. She family, undiagnosed from life 17 years ago, suffering now runs The Foundation depression. postnatal hospitals, in private programs screening Gidget Foundation Australia exists to promote the importance of emotional wellbeing among the importance of Australia exists to promote Gidget Foundation that and the wider community to ensure their health providers expectant and new parents, and supportive care. appropriate timely, those in need receive Australia, with a Sydney, based in not-for-profit is a registered The Foundation national footprint. or an appointment, go to http://gidgetfoundation.org.au/ or to make information For more call 1300-851-758. a woman in the context of her personality, life her personality, context of in the a woman environment. and social and community experiences, territoryThis is new many practitioners, often for be so. but it needn’t to midwifery staff, outsourced the will change screening routine that The hope is mental that recognising obstetric practice, of culture obstetric care. integral part of health is an In 1991, a matter? Does mental health really While woman gave birth to her first son. 32-year-old it was wanted. She was unplanned, the pregnancy intelligent economically secure, was happily married, was and pregnancy She embraced and healthy. birth experience. an intervention-free to have keen pressure 34 weeks, her blood wasn’t to be. At That and hospitalised, medicated went up and she was term and was induced at told to stop work. She an epidural and a forceps had tonic contractions, born to two deeply A beautiful baby boy was delivery. The doctors and midwives parents. traumatised They saved the woman’s life … but amazing. were fact, she had her how she felt. In they never asked She developed an anxiety disorder during pregnancy. the birth and disorder after stress had post-traumatic and depression spent the next two years with anxiety, Her husband didn’t understand. He suicidal ideation. when he left that went back to work, not realising rocking herself, she would sit on the kitchen floor, self-harm. paralysed by anxiety and thoughts of was made by depression postnatal The diagnosis of included admission chance. The journey to recovery to a mother and baby unit for six weeks, medication, the psychotherapy and couple counselling over because of damage was done next five years. A lot nobody asked. was man and that Cathie, woman was my wife, That It can discriminates. me. This is not a condition that and the implications woman any pregnant affect is our in pregnancy Mental healthcare profound. are and should be as integral to obstetric responsibility diabetes and the gestational as blood pressure, care and vaginal birth. Your caesarean complexities of your daughter, your sister, is your mother, patient is not the sole domain of Mental healthcare yourself. MIND MATTERS the generalpopulation. practitioners havehigherlevelsof depression than months inNSW. reported on the suicideof fourdoctorsinfive profession comesat great cost.In2017, themedia The problem of poormentalhealthinthemedical at particularrisk. population. Younger doctorsandfemaleare and thoughtsof suicidethanthat of thegeneral significantly greater levels of psychologicaldistress commitments, canbechallenging. knowledge, aswellbalancingfamilyandpersonal busy profession. Developingskillsandbuilding are long,whilecopingwiththedemandsof a hard work,determination andsacrifice.Thehours Being anO&Gspecialistisrewarding, butittakes RANZCOG Senior Coordinator, Training SupportUnit Training Liaison Supervisor RN, MHPE Alana Gilbee RANZCOG Senior Coordinator, Training SupportUnit Trainee Liaison Dip. Counselling Paula Fernandez medical practitioners Mental health in their professional integritycouldbecompromised. career development couldbeinjeopardy, orthat mental health.Doctorsare concernedthat their coupled withthegeneralstigma of compromised a culture of silenceamongmedical practitioners, mental healthconcerns.There are manyreasons for medical practitionerstoseekassistance fortheirown A possibleexacerbating factoristheresistance of perform at anoptimumstandard. be scheduledandencouraged,toensure allstaff such traumaandthat mentalhealthbreaks should systematic mentalhealthchecksonstaff exposedto with. Ithasbeensuggestedthat there shouldbe and recovering from thetraumatheyregularly deal training andresources, toassisttheminprocessing exposed totragedycanbenefitfrom readily available ‘sex-related stressor’ RANZCOG Fellowship traineesare female,apotential Statistics from 2017showthat 83percentof organisations. may beleftfeelingunsupportedbytheirprofessional clinical practice,includingadverseevents,trainees In additiontopersonalfactorsandthedemandsof employed populations (6.4 versus2.8 per100,000). themselves at agreater rate thanwomeninother in Australia,femaledoctorswere reported askilling published studyof suicidebyhealthprofessionals themselves between2007and2016. Inthefirst declare that hisrecords show20doctorskilled 6 Peopleinhigh-riskjobswhoare 3 TheState coroner wentonto 5 forcurrent trainees. 2 Theyalsoexperience 7 1 Medical 4

their registration topractise medicine cancelled. More concerningisthefearthat doctorswillhave • • • wellbeing andthat of yourcolleagues? What canyoudotofurtherpromote yourhealthand warning signs. best approach toavoidingescalation of these a colleagueyouare worriedaboutthemisthe Early interventionandnotbeingafraid totell • • • • • yourself orothersincludethefollowing: Warning signsof potentialmentalhealthchangesin Warning signsofmental health changes of response foratraineeorsupervisorinneed. put inplacewell-definedprograms andpathways TSU demonstrates a systematic approach and has formation of theTraining The SupportUnit (TSU). workforce. RANZCOG hasresponded withthe an interest inthehealth of thewholemedical been urgedtoexaminetheirpracticesandtake Medical colleges,amongotherstakeholders, have RANZCOG's response • • • supervisors togetintouchat timesof difficulty. TSU encouragestrainees,consultants andtraining to assistandsupportRANZCOG members. The education andclinicalpractice,havebeenemployed backgrounds inmental health,counselling,medical Trainee LiaisonandTraining SupervisorLiaison,with collegiality andcanprotect againstburnout. Access supervisorsupport,asitpromotes are experiencing. open discussionaboutthedifficultiesyou Meet regularly withpeersandencourage becoming overwhelmed. to developawareness of whenyouare of highanxietyorstress, While doctorscanperformduringperiods too stressed or havereached yourthreshold? stressors? Howdoyouknowwhenare Become self-aware. What are yourparticular Eating disordersordrugalcoholdependence. Acute stress reactions Withdrawal orself-neglect Absenteeism orpresenteeism Extreme tiredness burnout. reduce theriskof emotionalexhaustionand Consider activities,suchasmindfulness,to or region. Service websiteandhelplinesineachstate be foundthrough theDoctors’HealthAdvisory importance of doctorwellbeing.SuchGPscan Refer yourselftoaGPwhopromotes the your workplace. be discussedandmutuallyagreed uponwithin orareductionleave isnecessary inhourscould For yourself, acceptthat at times,aperiodof 12 9 10 itisimportant 13 A 11 8 MIND MATTERS J Am Medical ofession: not a ofession: . Melbourne (AUST): Vol. 20 No. 3 Spring 2018 | 55 Vol. Internal Medicine Journal 2018 Internal et’. Yahoo 7 News. 2017 Mar 18;cited 7 News. 2017 Mar 18;cited et’. Yahoo , McGorry P. Depression and suicide among Depression , McGorry P. , Bismark M, Spittal M. Suicide by health ANZJOG 2014;54:30-35. , Pellicano R, et al. Medical student tional Mental Health Survey of Doctors and Doctors of tional Mental Health Survey MJA 2018 Jun;208(11):471-472.el. y retching everyy retching Monday: Australia’s most eaking the culture of mental health stigma: the of eaking the culture MJA 2016 Sep 19;205(6):260-265. nderstanding the stresses and strains of being a doctor. doctor. being a and strains of nderstanding the stresses es C, Guvva E, Ascher N, et al. Burnout and stress among among et al. Burnout and stress es C, Guvva E, Ascher N, arughese E, Janda M, Obermair A. Can the use of quality arughese E, Janda M, Obermair A. Can the use of tatistical Snapshot 2017. Melbourne (AUST): RANZCOG 2018. 2018. Melbourne (AUST): RANZCOG Snapshot 2017. tatistical [Updated 2017; cited 2018 Jul 12]; [2 screens]. Available from: from: Available 2017; cited 2018 Jul 12]; [2 screens]. [Updated www.ranzcog.edu.au/about. from: Available jobs. News.com.au. 2017 Nov 23. traumatic www.news.com.au/finance/work/at-work/dry-retching-every- monday-australias-most-traumatic-jobs/news-story/77c131d81 881accd4d26e8d3d432b62e. Connelly E. Br challenges physicians face when seeking help. Medicalbag.com. www.medicalbag.com/lifestyle/ from: 2018 May 2. Available physician-mental-health-stigma-challenges/article/762882/. A guide to supporting trainees in difficulty www.ranzcog.edu.au/Training/ from: Available 2018. RANZCOG Specialist-Training/Support-Resources. Dendle C, Baulch J and academic performance. psychological distress 2018 Jan;21:1-7. Teacher Baigent M, Baigent R. Burnout in the medical pr passage. rite of Lebar and resilience. US surgery psychological distress residents: Surg. 2017 Jan;226(1):80-90. Coll Riley G. U Oct 4;181(7):350-353. MJA 2014 Beyondblue. Na Oct;1-156. Final Report. 2013 Medical Students. Bailey E, Robinson J doctor’s suicide exposes Buttigieg M. Fourth young NSW medicine’s ‘shameful secr https://au.news.yahoo.com/fourth- from: Available 2018 Jul 08. young-nsw-doctors-suicide-exposes-medicine-s-shameful- secret-34695413.html. Milner A, Maheen H S V on surgical complications the impact of assurance tools reduce obstetricians and gynaecologists in Australia the well-being of and New Zealand? Reynolds E. Dr medical practitioners in Australia. medical practitioners in Australia. Mar;48(3):254-258. professionals: a retrospective mortality study in Australia, mortality a retrospective professionals: 2001-2012.

6. 8. 9. 10. 11. 12. 13. References 1. 2. 4. 7. 3. recommendation is adopted, it will be another step in step will be another adopted, it is recommendation who need help. for doctors the right direction Summary and yet they caregivers inherently Doctors are for themselves. care difficult to find it increasingly mounting to the response has acted in RANZCOG health and wellbeing in the poor mental evidence of forming the TSU as a means by medical profession, This support to trainees and supervisors. providing of includes employers, net that a safety is one aspect of easily accessible resources. and a range of insurers 5. f Australia receives around f Australia receives tions (around 80 per cent) will result tions (around t a notification is made does not is made t a notification e than half of the notifications received the notifications e than half of For more information, go to: www.ranzcog.edu.au/Training/TSU. information, For more For advice and support, contact the Training Support Unit: For advice and support, contact the Training Trainees Paula Fernandez (t)9412 2918 +61 3 (e) [email protected] Supervisors Alana Gilbee (t)9412 2933 +61 3 (e) [email protected] are closed at assessment, the first stage in closed at are are under which all notifications the process medical practitioners of by a group considered and community members to decide if further The average length is required. information about medical time to assess notifications of practitioners in 2017–18 was 49 days. This is getting faster each year. process The fact tha Most notifica Mor The Medical Board o each year. 3500 notifications action will follow. mean that action being taken. in no regulatory RANZCOG’s submission to the Australian Health submission RANZCOG’s while Ministers’ AdvisoryCouncil in 2017 is that, under a all practitioners and employers remain impairment and other report to mandatory obligation notifiable conduct, practitioners treating forms of said doctors would have a complete exemption If this to report. the statutory requirement from • • • The TSU has also put in place an external assistance assistance an external put in place has also The TSU This program Converge International. program, and can to all trainees and supervisors is available can be times. The service up to three be accessed seven days a week and hours a day, 24 contacted the individual. the needs of to meet tailored authorities Medical registration with personal many doctors in dealing A concern of their colleagues, of and that mental health issues, by medical registration is the potential response seeking help, or the that boards. Doctors fear colleagues, may place of mandatory reporting on their practice. restrictions such as the Australian Medical Organisations, Medical the New Zealand (AMA), Association professional and a host of (NZMA) Association can be consulted and provide indemnity insurers, support services and education doctor-focused for members. Health In Australia, doctors can call the Australian Agency (AHPRA) for Practitioner Regulation if they have concerns or queries advice confidential about voluntary AHPRA has or mandatory reporting. on reporting: some information provided • WOMEN’S HEALTH Figure 1. 10 12 0 2 4 6 8 LARC infocus LARC World ContraceptionDay: and theirfamilies. social andpsychologicalconsequencesforwomen pill. methods, suchascondomsortheoralcontraceptive contraception. Manyare relying onuser-dependent in AustraliaandNewZealand are using a methodof Fifty percentof womenwhopresent forabortion incidence of adversebirthoutcomes than thosethat havebeenplanned,withahigher mayresult inpoorer pregnancy outcomes an in their lifetime one-third toahalfof Australianwomenexperience of all pregnancies globallyare unplanned.Around elusive inmanycountries,asanestimated half to ensure pregnancy that iswanted,remains every fewer unwantedpregnancies. Thevisionof WCD, and theirpartnershavegreater informed choiceand awareness of contraceptiveoptionssothat women This annualworldwidecampaignseekstoincrease World ContraceptionDay(WCD) ison26September. Camperdown, NSW Royal PrinceAlfred Hospital University ofSydney Obstetrics, GynaecologyandNeonatology MBBS, MFSRH, FRANZCOG, DDu, PhD A/Prof KirstenBlack Senior MedicalOfficer, MarieStopesAustralia MBChB, MSc,FRCOG, MFSRH, DipGUM Dr CatrionaMelville third of Australianwomenwillundergoanabortion. Long-acting reversible contraceptive LARC 3,4 Comparison of unintended pregnancies bycontraceptivemethod. Unintended pregnancies that donotresult in

PARTICIPANTS WITH CONTRACEPTIVE FAILURE (%) YEAR 1 5 andserious Depot-medroxyprogesterone acetate DMPA 1 and up to a 2

YEAR 2 methods, suchastheoralcontraceptivepill. pregnancy thanshort-acting user-dependent are significantlylesslikely to result inunintended (IUC) andsubdermaletonogestrel (ENG)implants, inparticular,(LARC), intrauterinecontraception Long-acting reversible contraceptivemethods LARC Evidence forthesuperiorefficacyof the contraceptivepill,evenat oneyearof use. are morecontraception. LARC cost-effectivethan have highercontinuation rates thanshort-acting and forget’contraceptionforthree totenyearsand intrauterine system)andENGimplantsprovide ‘fit (copper intrauterinedevicesandthelevonorgestrel to reduce therate of repeat abortion. initiation after abortionhasbeenshown of LARC pill, patch orring) compared tocombinedhormonalmethods(the 20 timeslesslikely toresult inunintendedpregnancy, large cohortstudy, thesemethodswere foundtobe autonomy overtheircontraception. a yearlysupply, offering greater choiceandmore of thiscontraceptiveenableswomentobegiven is availableintheUSandEurope. Self-administration depot-medroxyprogesterone acetate, Sayana Press®, A self-administered, subcutaneous formulation of as asecond-tieroption,duetoitslowerefficacy. Provera®, fitsthedefinition LARC,itis regarded of the progestogen-only injectablecontraceptive,Depo women in Sweden use a LARC method. women inSweden useaLARC In contrast,24 percentof reproductive-aged with only11per centof womenusingthem. remains low compared tootherdevelopedcountries, Despite this,theuptake methodsinAustralia of LARC 6 PPR Short-acting hormonal contraceptive: hormonal pill,Short-acting patch, ring 6 (Figure 1).Inaddition,immediate YEAR 3 16,17 8-10 14 IUC Although 12,13 6,7 Ina 11

15

WOMEN’S HEALTH A 32 16,17 which 28,29 was Many health 33 A range of 34 Vol. 20 No. 3 Spring 2018 | 57 Vol. 23,24 31 was accepted by sexual 36 e: Action Plan. tional standards and guidance The increased use of FAMs may be may FAMs use of The increased 30 ff as having relevance to Scotland, as ff as having tionships Strategy, Respect and tionships Strategy, This contradicts Australian and This contradicts Objectives for effective contraception 35 23-25 f overcoming barriers to LARC One f overcoming provision. fter abortion were included in these standards. fter abortion were  Scotland’s first National Sexual Health Sexual Scotland’s first National and Rela and Action Responsibility: Scotland’s Strategy Sexual Health, Plan For Improving actions were set out in this strategy to enhance set out in this strategy actions were and service education sexual health promotion, Health Service Quality National provision. Scotland (NHS QIS) developed Improvement clinical sexual health standards for services NHS Scotland. NHS by, or secured by, provided QIS also set standards for measuring the uptake their LARCof methods and targets for increasing use. launched in 2005 with £15 million of funding launched in 2005 with £15 million of years. This funding was extended over three by the Scottish government within the Better Health, Better Car a Institute for the 2005 National Additionally, guidance (NICE) Effectiveness Clinical and Health LARCon the use of The NHS QIS standards and guidelines clinicians to consider novel ways empowered o health sta the same contraceptive its findings addressed women and professionals affected issues that in Scotland.  employed in many settings simple strategy in Scotland was to abolish the necessity for a reduced This fitting consultation. pre-LARC the time and inconvenience experienced by with multiple associated women and providers  Developing na associated with increased availability of smartphone smartphone availability of with increased associated these such as Clue and Kindara. Users of applications, with typical use, FAMs that, methods should be aware only 76 per cent effective. are advocate the use of IUC in women of all ages and of IUC in women the use of advocate may be Another barrier to accessing IUC parity. and multiple separate mandating the custom of devices. appointments for inserting The cost implications of LARC of must also be The cost implications system. in the Australian healthcare considered financial barriers has been shown to Removal of LARC States. of in the United uptake increase barriers Overcoming 1. International research indicates a professional a professional indicates research International IUC, of provision gap in familiarity with knowledge misperceptions major issues being the with one of this method. women for suitability of the around recommend to still reluctant are Some providers or nulliparous IUC methods for young or provide women. services still initially offer a contraceptive counselling a contraceptive services still initially offer the woman return that and then request consultation for an insertion appointment. However, date a later at suitable for same-day insertion. many women will be User barriers young women for is a continued trend There and barrier to use short-term hormonal LARC. than rather methods of contraception international evidence-based guidelines, international cross-sectional survey of more than 1500 men and more survey of cross-sectional despite age found that, reproductive women of of highly effective methods the availability of proportion contraception in Australia, a considerable low effectiveness, used methods of respondents of such as withdrawal and -based methods (FAMs). 2. barriers Empowering clinicians to address

and 21 6

25 26 A recent mixed mixed A recent 26 Informing women Informing 22 If immediate insertion is not If immediate 19 27 20 Providing balanced information about balanced information Providing 23,24 18 methods study from the UK highlighted a number of the UK highlighted a number of methods study from issues, including a discordance between practitioner medical eligibility for IUC and the knowledge of training, to access of lack guidelines, criteria eligibility and risk aversion to undertaking procedures. Conveying the facts to women can be challenging, adverse media coverage recent especially in light of LARCof methods in Australia. Barriers among Australia primary care providers providers Barriers among Australia primary care of: training in LARC identified included a lack effective funding models for insertion and removal, pathways nurses to perform them, and availability of for rapid referral. dispel misconceptions about their suitability. the benefits of LARC, along with free provision, can of provision, the benefits LARC, along with free women choosing in as many as 70 per cent of result methods IUC or an implant over other reversible possible, greater likelihood of follow up is achieved if of likelihood possible, greater weeks of the appointment is scheduled within a few the abortion. Provider-based barriers Provider-based LARC providers Gaps in knowledge and training of barrier. have been found to be a key Barriers to LARC Knowledge and training professionals for women, healthcare As advocates women have access to a wide that must ensure for contraceptive options appropriate range of the their needs. A detailed understanding about of risks and benefits LARC methods is paramount, and consumers. both for contraceptive providers All LARC methods can be initiated immediately after after immediately All LARC methods can be initiated at surgical abortion. ENG implants can be inserted for medical mifepristone administration the time of after abortion and IUC can be inserted any time has been confirmed. the pregnancy expulsion of choosing medical abortion women are Increasingly, telemedicine, with the or accessing services through early makes home, which occurring at procedure have LARC challenging. Women of more initiation for a LARC interval non-attendance of high rates only half insertion following abortion. In one study, to a contraceptive clinic after women fast-tracked of with the authors medical abortion actually attended, medical insertion after immediate concluding that abortion is preferable. Recommendations for initiation of LARC for initiation Recommendations delayed providers healthcare Historically, method until a contraceptive of commencement to menstrual period, a normal of the beginning that and pregnancy was no risk of there ensure immediately. would become effective the method at providers to their present women However, requesting cycle of their menstrual times different her chosen of initiation contraception. Delaying an the woman to risk of method potentially exposes time. This in the intervening unintended pregnancy visits adds an additional layer for repeat requirement when, in many cases, taking a ‘quick complexity of at a contraceptive method initiating start’ approach, will the menstrual cycle start of a time other than the pregnancy In cases where and appropriate. be safe levonorgestrel quick starting the cannot be excluded, and the not recommended intrauterine system is should only be used if the copper intrauterine device emergency contraceptive criteria for its use as an are met. of the advantages of LARC the advantages of methods can be of women’s that demonstrating research difficult, with contraception is suboptimal knowledge regarding side effects are misconceptions regarding and that common. WOMEN’S HEALTH 3. LARC provision after LARC pregnancy 3. Table 1. * GTD =gestational trophoblastic disease LNG-IUS ehdTaenm Activeingredient Trade name Method Copper-IUD TT380 Standard TT380 Copper-IUD LNG implant Thesinglerod ImplanonNXT ENG implant outcomes. short inter-pregnancy intervalsonperinatal on concernabouttheadverseimpactof has alsobeenafocusof intervention,based postnatal provision of subdermalimplants methods.Accesstoimmediateprovide LARC abortion care inScotlandhavebeentrainedto viewed bywomenpriortotheirappointment. Ther Scotland, inlinewithNHSQISstandards provision intheabortionsetting of LARC whichareof replenished LARCs, asrequired. overcome thisobstaclebystoringsmallsupplies prescriptions. due to time constraints and the need for advance provision remainssame-day LARC achallenge, However, inmanygeneralpracticesettings, contraception, itiscrucialthat midwivesand to beengagedinproviding qualitypostpartum States. approach isalsorecommended intheUnited and reproductive servicesinScotland.This appointment isnowavailableat arangeof sexual fitting consultations.at theinitial LARC unplanned pregnancy intheperiodbetween appointments, andlessenedtheriskof an (APPLES) pr Partum ContraceptioninEdinburghSouthEast implants, aswelladministerDepoProvera. as 'contraceptivechampions',abletoinsert where midwiveswere trainedandidentified approach topostpartumcontraceptiveprovision, elective caesarean section. consultations the introduction of pre-appointment telephone guidelines. F is notalwayspossible. of thefactthat immediate postpartumprovision intr A homeENGimplantinsertionservicewasalso  aculty of SexualandReproductive Health Summary of LARC methods:components,duration, of LARC Summary efficacyandabsolutecontraindications. oduced forvulnerablewomen,inrecognition e hasbeenastrong focusonthe 37,38 Otherinnovative approaches were 42,43 41 oject isanexampleof acollaborative Doctorsandnursesproviding 39 26 IUCisoffered at thetime of Mirena Load-Cu 375 short TT380 (available inNZ) Jadelle andtheuseof information DVDs Somegeneralpracticeshave 46 Ifmaternity services are 44 # PID =pelvicinflammatory disease TheAccesstoPost 52mg Levonorgestrel etonogestrel the progestogen contains 68mgof (4cm) implant from 375–380mm Copper surfacearea levonorgestrel containing 75mg 2 rods, each 35 and 45 40

2 er 98 Unexplained vaginal 99.8% 5 years er 99%Breast cancer 99.95% 3 years of action Duration er 99%Breast cancer 99.95% 5 years years 5–10 2. Developmentof trainingmodulesandguidance 1. RANZCOG initiative uptake inincreasing LARC

made of thevaluableresources, to thesystemandensures that betteruseis for midwiveshasaddedenormouscapacity this service.ContraceptiveENGimplanttraining are provided withtrainingandsupporttooffer other membersof themultidisciplinaryteam ongoing challenges. pressures andadequate knowledgeremain clinical leadership. develop high-levelskillsandbeabletoprovide module. Thesemoduleswillenabletraineesto abortion care and asexualhealthonline Training Module(ATM) incontraceptionand learning outcomesforimplantinsertion. Alliance, includescompetenciesandexamplesof which hasbeenendorsedbytheFamily Planning care professionals inAustralia. Thedocument, insertion andremoval of ImplanonNXTbyhealth of aguidancedocument:Thesafe andeffective however, beeninstrumentalinthedevelopment by thepharmaceuticalcompany. Theyhave, Implant trainingisnolongerbeingpr guidance forIUCmethods. php). Thesemodulesprovide andclinical theory portal (https://shop.ranzcog.edu.au/index. non-RANZCOG membersthrough theshop members through Climate andfree to These modulesar three modules: Thetrainingpackagecontains modules inLARC. and reproductive healthhasdevelopedonline RANZ RANZ  Introduction toLARC •    Insertionandmanagementof IUC. • Intr • and reproductive health Development o  COG hasdevelopedanAdvanced COG’s specialinterest group insexual oduction toIUCinsertion Efficacy 92 Unexplained vaginal 99.2% f apathway fortraininginsexual e availabletoRANZCOG reproductive tracttumours symptomatic untreated STIs, tumours STIs, reproductive tract PID, symptomatic untreated malignant disease),current elevated BHCG levelsor sepsis, GTD(persistently postpartum orpostabortal bleeding, breast cancer, contraindications Absolute GTD bleeding, puerperalsepsis, disease), current PID BHCG levelsormalignant 48 * (persistentlyelevated 47 althoughtime 49 ovided # , WOMEN’S HEALTH BMJ Sex Acta Obstet J Fam Plann J Fam BMJ Sexual & Vol. 20 No. 3 Spring 2018 | 59 Vol. egnancy. FSRH, 2017. 2017. FSRH, egnancy. , 2015. BMJ Sexual & Reproductive J Fam Plan Reprod Health Care Plan Reprod Health J Fam on S. Routine provision of of Routine provision on S. acting reversible methods of methods of acting reversible J Fam Plan Reprod Health Care 2016; Plan Reprod Health J Fam on S. ‘One-stop’ visits for insertion of visits for insertion of ‘One-stop’ on S. 2013;88:629-35. Contraception Journal of & Reproductive Planning & Reproductive Family Journal of , Madden T, et al. The Contraceptive , Madden T, , Heathcote J. Telephone counselling for Telephone J. , Heathcote on S. Midwives’ experiences and views of Midwives’ experiences and views of on S. Medical Journal of Australia 2011;194(6):324. Australia of Medical Journal on S, Briggs R, et al. Postpartum contraception: a on S, American Journal of Obstetrics and Gynecology Obstetrics American Journal of ecutive Health Department. Respect and er J, Bigrigg A. Attitudes of women in Scotland to in Scotland women of Bigrigg A. Attitudes er J, BJOG 2017;124:2009-15. ons A, Turner R, Brindis C. Same-day LARC insertion ons A, Turner . Better Health, Better Care: Action Plan. In: Scotland . Better Health, Better Care: wareness Methods. FSRH, 2015. 2015. Methods. FSRH, wareness omoting Health Service. NHS Scotland. Long-Acting omoting Health Service. NHS Scotland. Long-Acting L, Walker S, Newton V, Parker M. Provider-based barriers Provider-based M. Parker V, Newton S, Walker L, , Bateson D, Frearson M, et al. Current barriers and barriers M, et al. Current Frearson D, , Bateson on S, Craig A, Sim J, et al. Feasibility and acceptability Craig A, Sim J, on S, tional Institute for Clinical Evidence. Long-acting reversible reversible Long-acting tional Institute for Clinical Evidence. teson D, Harvey C, Williams J, Black K. Intrauterine Black K. Intrauterine Harvey C, Williams J, teson D, oan L, Craig A, Scott L, et al. Increasing access to oan L, Craig A, Scott L, et al. Increasing alker S, Newton V, Hoggart L, Parker M. 'I think maybe 10 years think maybe 10 years M. 'I Hoggart L, Parker V, Newton S, alker COG Committee. Increasing use of contraceptive implants and contraceptive implants use of Committee. Increasing COG tandards for sexual health services. Healthcare tandards for sexual health services. Healthcare reilich K, Holton S, Rowe H, et al. Sociodemographic et al. Rowe H, K, Holton S, reilich aculty of Family Planning and Reproductive Health Planning and Reproductive Family aculty of amily PLanning NSW, Family PLanning Victoria, Health. TRaR. PLanning Victoria, Health. Family amily PLanning NSW, contraception: unified training. long- giving postpartum contraceptive advice and providing Plan J Fam study. contraception: a qualitative acting reversible Care 2014;40:177-83. Reprod Health Hormonal and intrauterine Summary Table UKMEC Care. 2016. contraception. London: FSRH; attitudes and practices. attitudes intrauterine contraception using online resources. Care 2015;41:300-2. Reprod Health and short unintended pregnancy missed opportunity to prevent intervals. inter-pregnancy 42:93-8. Case care. and postnatal Reversible Contraception in antenatal www.healthscotland.com/ at: Available 2013. number 8, Study uploads/documents/21436-HPHSCaseStudy8LongActingReversi bleContraception.pdf. Gynecol Scand 2017;96:1144-51. Britton A, Connolly A. Long- 2014;40:80-1. McCance K, Camer F Contraception: an Australian clinical practice handbook, 4th Contraception: an Australian NSW 2014. edition. Ashfield, ed. Edinburgh: The Scottish Government; 2007. H, on pdf via: www. Available Scotland, 2008. Improvement healthcareimprovementscotland.org/previous_resources/ standards/sexual_health_services_final_s.aspx. Na A Obstetrics unintended pregnancy. intrauterine devices to reduce & Gynecology 2009;114:1434-8. Biggs M, Ar Gorman C, Dennis J subdermal implants and intrauterine contraceptives. 2018;44:136-8. Reprod Health Gunn C, Gebbie A, Camer FSRH Guideline Contraception After Pr Heller R, Camer Health Pr Heller R, Johnstone A, Camer in a section elective cesarean intrauterine contraception at public health service: a service evaluation. national Camer contraceptive counselling antenatal routine introducing of delivery: the APPLES pilot contraception after of and provision evaluation. Cr period via a home contraceptive implants in the postnatal insertion service by community midwives. 2018;44:61-4. Reproductive Health contraception: a qualitative study to explore the acceptability of of the acceptability to explore study a qualitative contraception: methods. long-acting Care 2008;34:213-7. Health Ba W never women who had of Beliefs and attitudes seems a bit long.' used intrauterine contraception. 2018;44:90-6. Health Hoggart intrauterine contraception in general practice. of to provision 2018;44:82-9. Health BMJ Sexual & Reproductive Mazza D reversible long-acting the use of to increase potential strategies unintended of contraception (LARC) rate the to reduce discussion. roundtable in Australia: An expert pregnancies ANZJOG 2017;57:206-12. F FSRH Intrauterine Contraception. F effective and with the use of characteristics associated from the less effective contraceptive methods: findings Australia Fertility Management in Contemporary Understanding & Reproductive Contraception Journal of European survey. Care 2017;22:212-21. Health Fertility A Secura G, Allsworth J reversible barriers to long-acting reducing CHOICE Project: contraception. 2010;203:115.e1-.e7. The Scottish Ex sexual and action plan for improving Strategy responsibility. ed. Edinburgh 2005. health. In: Department TSEH, Scotland N S contraception. 2005. Glasier A, Scor Glasier this so few Australian women using why are contraception: effective method?

49. 39. 41. 43. 44. 45. 48. 29. 32. 35. 36. 38. 40. 42. 46. 47. 23. 24. 25. 26. 27. 28. 30. 31. 33. 34. 37. egnancy. egnancy. Human PLoS One 2012; ena long-acting ena long-acting J Fam Plann Reprod Health Plann Reprod Health J Fam 2012;85:458-64. Contraception New England Journal of Medicine; New England Journal of wareness and knowledge of long acting and knowledge of wareness , Gissler M, Suhonen S. Age, parity, history of Age, parity, , Gissler M, Suhonen S. 2016;94:548-55. Contraception , Zhao Q, Secura G, et al. Preventing unintended , Zhao Q, Secura G, et al. Preventing , Silva M, Xu S. Post abortion contraception and S. , Silva M, Xu , Fitzadam S, Yeung A, et al. Contraceptive practices Yeung , Fitzadam S, 2008;78:149-54. Contraception ouli I. The cost-effectiveness of long-acting reversible of long-acting The cost-effectiveness ouli I. , Peipert J, Zhao Q, et al. Effectiveness of long-acting of long-acting Zhao Q, et al. Effectiveness , Peipert J, , Koenig M, Hindin M, et al. The effects of unintended M, Hindin M, et al. The effects , Koenig , Jolly K, Scott J, et al. Pregnancy Outcome in South et al. Pregnancy , Jolly K, Scott J, , Harrison C, Taft A, et al. Current contraceptive A, et al. Current , Harrison C, Taft , Holton S, Kirkman M, et al. Prevalence and distribution et al. Prevalence Kirkman M, , Holton S, on S. Subcutaneous depo-medroxyprogesterone acetate. acetate. Subcutaneous depo-medroxyprogesterone on S. home self- Glasier A, Johnstone A. Pilot study of on S, A, Glasier A. Assessment Johnstone Berugoda N, on S, on S, Glasier A, Chen Z, et al. Effect of contraception Glasier A, Chen Z, et al. Effect on S, , Stephansson O, Gemzell-Danielsson K. Early versus Gemzell-Danielsson O, , Stephansson eisberg E, Goldstone P, Heckenberg M. A profile of women M. A profile Heckenberg eisberg E, Goldstone P, opp Kallner H, Thunell L, Brynhildsen J, et al. Use of al. Use of et Thunell L, Brynhildsen J, opp Kallner H, aculty of Family Planning and Reproductive Health Care. Health Care. Planning and Reproductive Family aculty of russell J. Contraceptive failure in the United States. States. in the United Contraceptive failure russell J. reversible contraceptives, as women report severe side-effects severe as women report contraceptives, reversible ABC News; 2017. Sydney: Branley A. Spotlight on Implanon and Mir Journal of Family Planning and Reproductive Health Care 2013; Health Planning and Reproductive Family Journal of 39:75-7. depo-medroxyprogesterone subcutaneous of administration for contraception. acetate Contraception London: FFPRHC Guidance: Quick Starting FSRH; 2017. Camer service for intrauterine contraception a ‘fast-track’ referral of following early medical abortion. Care 2012;38:175-8. Saav I medical intrauterine contraception after delayed insertion of trial. controlled abortion – a randomized 7:e48948. NHS Health Scotland. A in women and professionals what contraception: reversible Edinburgh: Research. Qualitative Scotland need. Feedback from NHS Health Scotland; 2009. contraception and attitudes towards contraceptive use in towards contraceptive contraception and attitudes PLoS One 2015; survey. women – a nationwide Swedish 10:e0125990. 2011;83:397-404. Contraception Camer Camer F its effect on repeat in Auckland, New Zealand. in Auckland, New abortions repeat its effect on 2010;82:260-5. Contraception contraceptive methods in the UK: Analysis based on a decision- Institute for Health and analytic model developed for a National (NICE) clinical practice guideline. Clinical Excellence Reproduction 2008;23:1338-45. health and among women: the second Australian study of relationships. Mazza D management in Australian general practice: an analysis of Australia 2012;197:110-4. Medical Journal of data. BEACH K T 366:1998-2007. repeat of the risk abortion and contraceptive choices affect abortion. Roberts H Mavranez Richters J reversible contraception. reversible Birgisson N Journal in review. the Contraceptive CHOICE Project pregnancy: 2015;24:349-53. Health Women’s of Camer and incidence of pregnancy of termination at provided BJOG 2012;119:1074-80. pregnancy. of subsequent termination Heikinheimo O Australia 2015. In: Health S, ed. Adelaide: Government of South ed. Adelaide: Government of In: Health S, Australia 2015. Australia; 2015. W Sexual & First National in NS. pregnancies terminating Melbourne: Public Health Health Conference. Reproductive Australia; 2012. Association Gipson J the of health: a review child, and parental on infant, pregnancy Planning 2008;39:18-38. in Family Studies literature. Winner B Rowe H Fertility the Understanding unintended pregnancy: of Aust N Z J Public Survey. Management in Australia National 2016;40:104-9. Health Scheil W and unplanned pr Real choices: women, contraception www. at: Available 2008. Australia, International Marie Stopes mariestopes.org.au/research/australia/.

18. 17. 19. 20. 21. 22. 15. 16. 10. 11. 12. 13. 14. 7. 8. 9. 3. 5. 6. 1. 2. 4. Ongoing challenges Ongoing general training of Ensuring adequate challenge, particularly a remains practitioners not providing are for IUC. Increasingly, hospitals training services and the community contraceptive family planning in state-based opportunities being are care of limited. New models clinics are design, such as a hub and spoke considered, and some GP practices are whereby hospitals and develop of excellence identified as centres as training centres. recognition References WOMEN’S HEALTH now discouraged,unlessthere isaspecificindication. antenatal visit.Routinetesting forvitaminDstatus is encourage routine Hepatitis Ctestingat the first Among thechangesisanewrecommendation to health professionals. and Torres Strait Islanderhealthworkers andallied including midwives, obstetricians,GPs,Aboriginal professionals caringforpregnant women, The guidelinesare designedfor all health considered andrespected. psychological, spiritualandculturalneedsare care, toensure that hersocial,emotional,physical, considered inplanningandproviding pregnancy to ensure thebroad contextof awoman’slifeis The guidelinesencouragehealthprofessionals mental illness. migrant andrefugee womenandwithsevere for AboriginalandTorres Strait Islanderwomen, focus onimproving theexperienceof antenatal care to pregnancy care forarangeof groups, witha environment. Theyhighlightspecific approaches latest scientificevidenceandchangesinthehealth be completednextyear. Theguidelinesreflect the review of theguidelines,withsecondstageto The 2018editioncomprisesthefirstpart of a rolling requirements forguideline development. Health andMedicalResearch Council(NHRMC) for thisedition,inaccordancewiththeNational of chapterswere reviewed andupdated in2016–17 published in2012and2014 respectively. Anumber One andTwo of theAntenatal Care Guidelines, The 2018editionof theguidelinescombinesModule of thePregnancy Care ClinicalPracticeGuidelines. Department of Healthhasreleased arevised version current recommendations forpractice,theAustralian To assisthealthprofessionals instayingabreast of practice reflects current research andbestpractice. of services,itisimportanttoensure that clinical mothers andbabies.Inmaintaininghighquality Our healthsystemprovides excellent care for and thebirthitself. the postnatal period,itis alsoaboutthepregnancy outcomes formotherandbaby. Itisnotjustabout during pregnancy isvitaltoensure thebestpossible for ourchildren. Best-practicecare formothers Getting agood,healthystartinlifeisessential Australian Government Officer Chief NursingandMidwifery Debra Thoms during pregnancy New guidelinesforcare at: www.health.gov.au/pregnancycareguidelines. The Pregnancy Care Guidelines can be downloaded obstetrics itemswithclinicalbestpractice. items andintroduction of sixnewitemstoalignMBS resulted inchangestoanumberof MBSobstetrics the Medicare BenefitsSchedule(MBS),whichhasalso benefit wasintroduced asa result of the review of and withintwomonthsof givingbirth.Thenew mental healthassessmentsduringtheirpregnancy women havebeeneligibleforMedicare-funded In addition,sinceNovember2017, allpregnant be finalisedbymid-2019. National Strategic Approach toMaternity Serviceswill forward toworkingwiththemonthisnextstage.The level of engagementacross thesectorandIlook themes identified.Ithasbeengreat toseethehigh and discussingpotentialstrategies toaddress thekey territories, willbeconsideringthefeedbackreceived key stakeholder group, aswellthestates and and organisations. Inthecomingmonths,our contributions from consumers,health professionals have received aconsiderablenumberof thoughtful The first stage of consultation has now closed and we Maternity Services. development of aNational Strategic Approach to and territories,aswellstakeholders, onthe to beworkingwithmycolleaguesinthestates maternity care forAustralianwomen.Iampleased just oneaspectof acommitmenttoimproved Revision of theguidelinesforpregnancy care is with worktocommencelater thisyear. physical activityandweightwillalsobereviewed, carrier screening. Guidelinesrelating tonutrition, consider newinformation onvaccinesandgenetic on anaemia,prolonged pregnancy anddiabetes, guidelines, publishedin2019, willincludeupdates The secondstageof review of thepregnancy care women tomonitortheirweightat home. antenatalweighed at visit,andencourage every all pregnant women,offer theopportunitytobe discuss weightgain,dietandphysicalactivitywith and babies.Theyrecommend healthprofessionals as importantdeterminantsof healthformothers to pregnancy andweightgainduringpregnancy The guidelinesrecognise bodymassindexprior WOMEN’S HEALTH In 5 Vol. 20 No. 3 Spring 2018 | 61 Vol. was released covering the years was released 6 and from 2013–2015, there were were there 2013–2015, and from 4 2,305,920 maternities. In Australia, as of June 2015, June 2015, In Australia, as of maternities. 2,305,920 to be 23,781,200. was estimated the population 2008–2012. As these reports overlap, it was not 2008–2012. As these reports of causes the of details exact the ascertain to possible was a decision Accordingly, for the year 2011. death the covering made to use the two Australian reports The total number years 2006–2010 and 2012–2014. women giving birth in Australia in these two time of which allows a reasonable periods was 2,368,540, comparison with the UK experience. women died between 2013 pregnant In the UK, 240 were these women 38 of of The deaths and 2015. to the pregnancy, to be coincidental considered motor vehicle accidents, leaving 202 such as from there In the two Australian reports, deaths. maternal women who died. The 198 pregnant was a total of to be coincidental in was considered death cause of deaths. 36 cases, leaving 162 maternal divided into a number of are deaths I), as outlined by the World (Table categories 1992). (WHO, classification Organization included in the UK are deaths pregnancy Late are deaths pregnancy in Australia late report, but not identified. women in each pregnant The demographics of In both countries, country the reports. is outlined in the women who of three-quarters approximately The UK’s study. born in the country of died were South Asia, comes largely from immigrant population immigrant Australia’s while Europe, Eastern and Africa and New Zealand comes mainly from population Jamaica, Asian countries. In the UK, women from Australia, apart from the reports mentioned above, the reports Australia, apart from an additional report The formula for the calculation of the frequency of of the frequency of The formula for the calculation differ slightly in and the terminology deaths maternal mortality the UK, the maternal the two countries. In divided by deaths maternal is the number of rate at (women who were ‘maternities’ the number of In multiplied by 100,000. weeks pregnant), least 24 is the number mortality ratio Australia, the maternal divided by women who gave birth deaths maternal of a or delivered least 20 weeks pregnant, at (who were least 400g), multiplied by 100,000. fetus weighing at mortality the maternal In the years 2013–2015, per 100,000 as 8.76 in the UK was calculated rate the overall In the two Australian reports, maternities. per 100,000 was 6.83 mortality ratio maternal UK the it is generally accepted that births. However, within identifying deaths of all maternal processes than the systems comprehensive the country is more in place in other countries. the UK was estimated of the population In June 2015, as 65,110,000, highlight 2,3 and Australia for 1 the years 2006–2010 and 2012–2014, Recent reports on maternal mortality from the UK mortality from on maternal Recent reports covering the years 2013–2015 and Australia mortality in the UK the in mortality Comparing maternal maternal Comparing slight differences in the cause of maternal mortality of maternal in the cause slight differences and in the two countries. Although the populations reviewing significantly different, demographics are gives additional insights into together the reports It is important deaths. maternal causes of the current in both the rare are deaths maternal that to stress should be the data UK and Australia. Accordingly, small with caution due to the relative interpreted and the different numbers, which can fluctuate, data collection. methods of to reported in the UK are deaths Maternal Mothers and Babies: Reducing Risk through the UK Enquiries across Audits and Confidential program who run the national (MBRRACE-UK), maternal conducting surveillance into the causes of the National It is based at deaths. and perinatal of the University at Epidemiology Unit Perinatal to MBRRACE-UK provided Oxford. The information concerned, caring for the women the staff is from including coroners, other sources or through and media pathologists Scottish procurators, is cross-checked of deaths Identification reports. The certificates. such as death records, with national is highlighted these additional sources importance of alone certificates death the use of by the fact that of 202 of the final total only identified 110 cases out deaths. maternal and the quality of sources In Australia, the data and territory. vary reporting by state death maternal collection is through for data The initial process Mortality Committees Maternal and Territory State a number of is obtained from (STMMC). The data including clinicians, midwives, coronial sources, and Births, Deaths and the Registry of reports, the STMMCs is passed on from Marriages. The data Health and Welfare, to the Australian Institute of Mortality Maternal into a National for compilation Data Collection. deaths on maternal data Australia, only In Western available, due to the health and privacy legislation are the Australian report In addition, state. in that and ‘for some states for 2006–2010 noted that mortality committees and territories, the maternal not active for periods during subcommittees were was no committee 2006–2013’. As an example, there 2006 between active in the Northern Territory and 2014. Dr Gerald Lawson FRANZCOG O&G Former Consultant NSW John Hunter Hospital, WOMEN’S HEALTH Table 1. coincidental death. In theUKreport, homicideisclassifiedonlyasa domestic settingisclassifiedasacoincidentaldeath. indirect death, whilehomicideoccurringoutsidea situation of domesticviolenceisclassifiedasan on thecircumstances. Ahomicideoccurringina as eitheranindirect orincidentaldeath, depending with externalevents,suchashomicide,are classified In addition,inAustralia,maternal deaths associated as direct deaths. development of apuerperalpsychosisare classified classified asindirect deaths, whilesuicidesduetothe associated withaprevious psychiatric illnessare as direct deaths. Accordingly, suicidesinAustralia diagnosed mentalhealthillnessshouldberegarded whereas suicidesinthesettingof nopreviously disorder shouldberegarded asindirect deaths, there wasevidenceof apre-existing mentalhealth rare. Thecommitteeconcludedthat suicideswhere came totheconclusionthat puerperalpsychosisis Australian andNewZealand Collegeof Psychiatrists, Committee,withadvicefromAdvisory theRoyal However, theAustralianNational Maternal Mortality This classification wasadoptedintheUK report. In theUK,maternal mortalityrate from largely duetocardiacconditionsandsepsis. times that of non-indigenousAustralianwomen, and Torres Strait Islandersisapproximately three hand, thematernal mortalityrate amongAboriginal than that of womenborninAustralia.Ontheother of womenwhowere bornoverseasisactuallylower However, inAustralia,thematernal mortalityratio among thewomenwhodiedduringpregnancy. Pakistan andBangladeshwere over-represented all maternal suicidesasdirect maternal deaths. suicide. In2012,WHOrecommended classifying There are differences intheclassification of overweight orobese. whose BMIwascalculated, 70percentwere either report of 2012–2014, of the33womenwhodiedand age, andforAboriginalwomen.IntheAustralian higher forwomenover35andunder20yearsof In Australia,theincidenceof maternal death was women whodiedwere eitherobeseoroverweight. women of Africandescent.Fifty-three percentof the and womenfrom ethnicminoritygroups, especially women, thoselivinginthemostdeprivedareas, 2013–2015 wasfoundtobehigheramongolder Late death Unclassified death Coincidental death Indirect death Direct death Maternal death Definitions of maternal deaths (WHO, 1992). result of direct orindirect maternal causes. A death occurringbetween42daysandoneyearafter theendof pregnancy that isthe labour, or thepuerperium. delivery A maternal death from unspecifiedorundetermined cause,occurringduringpregnancy, such asmotorvehicleaccidents. A death from unrelated causesthat happenstooccurinpregnancy orthepuerperium, the physiologicaleffects of pregnancy. pregnancy andwhichwasnottheresult of direct obstetriccauses,butwasaggravated by A death resulting from previous existingdisease,ordiseasethat developedduring resulting from anyof theabove. puerperium), from interventions, omissions,incorrect treatment, orfrom achainof events A death resulting from complications of thepregnant state (pregnancy, labourandthe incidental causes. ectopic pregnancy, miscarriageortermination of pregnancy, butnotfrom accidentalor from anycauserelated to,oraggravated by, thepregnancy oritsmanagement,including The death of awomenwhilepregnant orwithin42daysof theendof thepregnancy

7

a chapter such deaths were recorded. TheUKreport included obstetric haemorrhage.IntheAustralianreports, 13 In theUK,between2013–2015, 21womendiedfrom both countries. in thewomenwhodiedfrom thisconditionin smoking andoperative delivery, were prevalent risk factors,suchasobesity, oldermaternal age, time periods,there were 15deaths. Therecognised deaths between2013and2015. InthetwoAustralian deaths inbothcountries.IntheUK,there were 26 Thrombo-embolism istheleadingcauseof direct for 68outof 88deaths (77percent). from thesecauses,whileintheUK,theyaccounted report, 57out of 71direct deaths (80percent)were maternal deaths inboth countries.IntheAustralian continue tomake upthemajorityof casesof hypertension, sepsisandamnioticfluidemboli) deaths (thrombo-embolism, obstetrichaemorrhage, The traditional‘bigfive’causes of direct maternal Results deaths intheUKandAustraliaare listedinTable 2. Ireland. Thecausesof direct andindirect maternal chapters alsoincludedata from theRepublicof that cancausematernal death. Someof these includes chaptersthat review someof theconditions included under‘Other causes’.TheUKreport also or epilepsy. Deaths duetoepilepsyinAustraliaare comprise mainlypatients whodiedfollowingstrokes in theAustralianreports. Theseneurological cases entitled ‘Neurological conditions’,whichisnotused Among indirect deaths, theUKreport hasacategory indirect causes’. are includedinthecategoryaneurysm, of ‘Other in theUK,suchasfrom aruptured splenicartery Patients whodiedfrom non-obstetrichaemorrhages the termnon-obstetrichaemorrhageisnotused. considered an indirect death. IntheUKreports, haemorrhage withoutassociated hypertension is is categorised asadirect death, whileacerebral haemorrhage associated withsevere pre-eclampsia from asiteotherthantheuterus.Acerebral A non-obstetrichaemorrhageisbleeding either obstetric ornon-obstetrichaemorrhage. haemorrhage are categorised asdyingfrom In theAustralianreports, womenwhodiedfrom obstetric haemorrhageinboththeUKand 8 that reviewed thedetailsof deaths from WOMEN’S HEALTH 19.8 14.0 3.5 3.5 4.6 – – 23.3 27.9 % 100% – 1.4 5.6 2.8 14.1 7.0 15.5 11.3 2.8 18.3 100% 21.1 – % 2.3 1.2 & 2012–14 & 2012–14 Vol. 20 No. 3 Spring 2018 | 63 Vol. Australia, 2006–10 Australia, 2006–10 # 1 17 12 3 3 4 – – 20 24 No. 71 – 1 4 2 10 5 11 8 2* 162 13 91 15 5 No. 2 – – – 0.9 2.6 3.5 6.1 16.7 22.8 47.4 % 100% 2.3 – – 2.3 3.4 4.5 9.1 11.4 13.6 23.9 100% 29.5 – % – UK UK 2013–15 2013–15 – – – 1 3 4 7 19 26 54 No. 88 2 – – 2 3 4 8 10 12 202 21 114 26 – No. – There were 11 deaths from emboli in fluid amniotic from deaths 11 were There Among and eight in the UK. reports, the Australian induction two women undergoing were the UK cases who received intra-uterine deaths, because of collapsed and misoprostol doses of excessive women, multiparous Two following hyperstimulation. developed also labour, establish to induced were who and prostaglandins the use of after hyperstimulation fluid emboli. amniotic died from was 12; in report UK the in suicides of number The the in However, was 14. it reports, Australian the six weeks and between 46 suicides were there UK, as many times four almost postpartum, 12 months patients these of Many pregnancy. the as during It appeared histories. psychiatric pre-existing had psychiatric postpartum with women many that were suicide of risk at placed them that conditions one any by ‘owned’ not were and recognised, not team. healthcare woman’s the of group eight women in the UK with epilepsy In 2013–2015, or in the immediate died during pregnancy 9 Causes of direct and indirect maternal deaths in the UK and Australia. deaths maternal and indirect direct Causes of Obstetric haemorrhage Non-obstetric haemorrhage Suicide Sepsis (H1N1 flu) Sepsis Psychosocial Cancer Neurological causes Neurological Other causes Cardiovascular Indirect deaths Total Unclassified Cardiovascular Non-obstetric haemorrhage Anaesthetic Hypertension Early pregnancy death Early pregnancy Amniotic fluid embolism Sepsis Suicide Total maternal deaths Total Obstetric haemorrhage Total Thrombo-embolism Unclassified Early pregnancy death Early pregnancy Direct deaths * In the Australian reports, 12 cases of suicide were classified as indirect deaths. All suicides in the UK report were considered direct deaths. direct considered report were in the UK All suicides deaths. classified as indirect suicide were 12 cases of * In the Australian reports, blunt trauma to the uterus. from # The haemorrhage resulted Table 2. Table In both the UK and Australia, there were 14 deaths deaths 14 were there In both the UK and Australia, deaths indirect which four were following sepsis, of deaths the Australian of in both countries. Three was (swine flu), and there influenza due to H1N1 were Most case among the British deaths. one confirmed postpartum. obstetric sepsis occurred direct cases of was the streptococcus A beta haemolytic Group with maternal associated most common pathogen with five cases in Australia and two in mortality, the UK. Republic of Ireland. The breakdown of 22 cases was: 22 cases of The breakdown Ireland. of Republic nine deaths placental abruption; from deaths three from deaths nine praevia/accreta; from post-caesarean five were which (of atony postpartum trauma. genital tract from one death section); and was a total there Australian reports, In the two hypertensive disorders, such from ten deaths of from deaths only three were as eclampsia. There the UK. Hypertensive deaths hypertensive causes in 1985–1987, in the UK. From now much reduced are 27 such cases. were there WOMEN’S HEALTH pain’. woman whopresents withsevere upperabdominal inanypregnanta ruptured aneurysm splenic artery other front-line staff canentertainthediagnosis of awareness of thiscondition,sothat obstetriciansand argued that ‘itistherefore importanttoincrease reduced mortality. Anearlierreport from 2003 early involvementof ageneralorvascularsurgeon medical conditionsinpregnancy. obtain anopinionfrom aphysicianexperiencedin disorders, theappropriate management wouldbeto obstetricians. Inthefaceof atypical symptomsand conditions wouldbeproblematic formost lympho-histiocytosis. Managing theseunfamiliar from ethnicminoritiesdiedfrom haemophagocytic thombo-cytopenic purpura.FourwomenintheUK Addison’sdisease,pancreatitiserythematosus, and cystic fibrosis, sicklecellanaemia,systemic lupus during theircareer. Theseincludedeaths from obstetricians wouldprobably notencounter of maternal death from medicalcausesthat most report alsolistedasmallnumberof rare causes associated withtermination of pregnancy. TheUK pregnancies andonedeath followingcomplications In Australia,there were fivedeaths duetoectopic pregnancies. There were four deaths in the UK report. Most earlydeaths were from ruptured ectopic cardiac conditionsinpregnancy. by physicianswithparticularexperienceintreating pre-existing cardiacconditionsshouldbereviewed reports recommended that pregnant womenwith and whosubsequentlybecomepregnant. Both following surgicaltreatment, surviveintoadultlife, of womenwithcongenitalheartdefectswho, maternal age,obesityandtheincreasing number main contributingfactorsappeartobeincreasing the Australianreports, there were 25deaths. The the UK,between2013–2015, 51womendied.In indirect deaths, butof maternal deaths overall.In is currently themostcommoncause,notjustof In developedcountries,cardiovasculardisease The UKreport includedachapter epilepsy deaths. delivery. ThetwoAustralianreports recorded four epilepsy diedbetweensixweeksandoneyearafter postpartum period.Afurtherfivewomenwith rupture inpregnancy, publishedin2009, review of reported casesof aneurysm splenicartery embolism oranamnioticfluidembolism.Aliterature focused onotherdiagnoses,suchasapulmonary had already collapsed,emergencystaff were often abdominal painwasmisdiagnosed.Where patients rupture. Inmanycases,theaccompanying acute condition. Mostcasesare asymptomatic priorto and Republicof Ireland, ninewomendiedfrom this this cause.TheUKreport Australia, from 2006–2010, fivewomendiedfrom which isnotontheradarof manyobstetricians.In death isfrom aruptured aneurysm, splenicartery One of theleastappreciated causesof maternal such casewasreported intheUK. two womeninAustraliadrowned inthebath andone woman withepilepsyisdrowning. Inthesereports, specialist advice.Anotherriskfactorforapregnant discontinued theiranti-epilepticmedication without Among theUKcaseswere severalwomenwho during pregnancy. Thecauseisnotunderstood. toxicological oranatomical causeof death detected pregnancy of awomanwithepilepsy, withouta defined asthesuddenandunexpecteddeath during unexplained death inepilepsy(SUDEP).SUDEPis 14 That sentimentremains validtoday. 12 notedthat intheUK 11 onsudden 13 foundthat birth from approximately 90per100,000 womengiving that time,maternal death rates intheUKhavefallen Deaths inEnglandandWales beganin1952.Since In theUK,Confidential EnquiriesintoMaternal longer haveamother. a devastated familyand,often, otherchildren whono that amaternal death isacatastrophe, leavingbehind Beyond thestatistics, itisstating theobvioustosay Conclusions perimortem operations andfourbabiessurvived. caesarean section.Ofthese,six(26 per cent)were report for2012–2014, 23womenwere delivered by caesarean sections,14 survived.IntheAustralian procedures. Ofthebabiesbornfollowingperimortem 35 (38percent)were performedasperimortem delivered bycaesarean section.Ofthese operations, Ninety-three of thewomeninUKreport were three percentof theAustralianpopulation. Aboriginal communityconstitutesapproximately ten percentof theoveralltotalof 162deaths. The among theIndigenouspopulation. Thiswasalmost The twoAustralianreports recorded 16deaths for theyears1964–1966. Maternal mortalitydata wasfirst recorded inAustralia 4. 3. 2. 1. References draft of thisarticle. I wouldalsolike tothankProf RogerPepperell forreviewing anearlier the UKandAustralia. editors, authorsandcontributorstothematernal mortalityreports in the National Perinatal EpidemiologyandStatistics Unit, aswellall In Australia,Iwouldlike toacknowledgeProf GeorginaChambersof Knight of theNational Perinatal Epidemiology Unit/MBRRACE-UK. I wouldlike togratefully acknowledgetheassistanceof Prof Marian Acknowledgements. late pregnancy deaths. direct thesameenergytoaddressing indirect and direct obstetricdeaths. Theongoingchallengeisto understandably focusedonaddressing the‘bigfive’ Over thelasthalf-century, obstetricianshave pregnancy (n=46),asduringthepregnancy (n=12). as manywomenintheUKcommittedsuicidelate pregnancy. Asmentionedabove,almostfourtimes more thanthe202womenwhodiedduring weeks and12monthspostpartum,over60percent UK, from 2013–2015, 326womendiedbetweensix situation appliestodeaths inlate pregnancy. Inthe healthcare teamsremains apriority. Asimilar care coordinated andsecondary across primary the numberof indirect deaths, multidisciplinary been asimilarreduction inindirect deaths. To reduce due toareduction indirect deaths. There hasnot welcome. However, thedecrease is predominantly and Australiaoverthelast50yearsis,of course,very The reduced numbersof maternal deaths intheUK 6.8 per100,000 womengivingbirth. report, using thesamedefinitions,incidencewas as 30.3 per100,000 confinements. Inthe2012–2014 maternal mortality rate for direct deaths was reported

15 Available at: www.ons.hov.uk/ population andcommunity. England andWales, ScotlandandNorthernIreland: mid2015. Office o in Australia2012–2014. Cat. no.PER92.Canberra:AIHW. Australian Instituteo Cat. no.PER61. Canberra:AIHW. deaths inAustralia2006–2010, Maternal deaths seriesno.4. Johnson S National Perinatal EpidemiologyUnit, University of Oxford2017. Enquiries intoMaternal Deaths andMorbidity2013–15. Oxford: to inform maternity care from theUKandIreland Confidential UK. SavingLives,Improving Mothers’Care -Lessonslearned Knight M,NairT toaround nineper100,000 currently. f National Statistics. Population estimates forUK, , BonelloMR,LiZ,HilderL,SullivanEA.2014. Maternal uffnell D, etal(Eds.)on behalf of MBRRACE- f HealthandWelfare 2017. Maternal deaths 16 Inthat report, the WOMEN’S HEALTH Vol. 20 No. 3 Spring 2018 | 65 Vol. into Maternal Deaths and Morbidity Deaths into Maternal Piercy C on behalf of the Medical and C on behalf of Piercy tional Health and Medical Research Council) Council) tional Health and Medical Research y of Health. (1957). Report on Confidential Enquiries (1957). Report on Confidential Health. y of , Phillips M, Faulkner K. Splenic artery aneurysm rupture , Phillips M, Faulkner Ojeme DO, Welch CC: Review: spontaneous rupture of of Review: spontaneous rupture CC: Welch Ojeme DO, elso A, Wills A, Knight M on behalf of the MBRRACE-UK the MBRRACE-UK M on behalf of Wills A, Knight elso A, European Journal of Obstetrics Gynecology and Journal of European in pregnancy. Reproductive Biology 2009;146:133-7. Knight M & Nelson- of Lessons for the care Group. Surgical Chapter-writing surgical disorders chapter women with medical and general on D, et al (Eds.) In Knight M, Nair M, Tuffnell writing group. Mothers’ Improving Saving Lives, MBRRACE-UK. behalf of the UK from care maternity to inform Lessons learned Care: and Deaths into Maternal Enquiries Confidential and Ireland Epidemiology Perinatal Oxford: National Morbidity 2013–15. Oxford 2017:50-58. of University Unit, Ha JF Selo- J Obstet Gynecol Eur splenic artery aneurysm in pregnancy. Reprod Biol. 2003;109(2):124-7. Ministr 1952–1954. in England and Wales Deaths into Maternal NHMRC (Na Australia, in the Commonwealth of deaths Maternal 1966. Council. Health and Medical Research National 1964–1966. Canberra: NHMRC. K Lessons on epilepsy and Group. Chapter-writing Neurology of D, et al (Eds.) on behalf M, Nair M, Tuffnell In Knight stroke. Lessons Mothers’ Care: Saving Lives, Improving MBRRACE-UK. UK and Ireland the from care maternity learned to inform Enquiries Confidential Epidemiology Unit, Perinatal Oxford: National 2013–15. Oxford 2017:24-36. of University 14. 11. 13. 15. 16. 12. f the MBRRACE-UK f the MBRRACE-UK tatistics, June 2015. Available at: www. at: Available June 2015. tatistics, ternal Mortality in the UK: Surveillance ternal Mortality in the UK: Surveillance tion of ICD-10 to deaths during pregnancy, during pregnancy, to deaths ICD-10 tion of terson-Brown S on behalf of the Haemorrhage the Haemorrhage S on behalf of terson-Brown : Humphrey MD, Bonello MR, Chughtai A, et al. Maternal Maternal MR, Chughtai A, et al. Bonello MD, : Humphrey and AFE Chapter-writing Group. Messages for care of women of care Messages for Group. and AFE Chapter-writing fluid embolism. In Knight M, with haemorrhage or amniotic Saving of MBRRACE-UK. al (Eds.) on behalf D, et Nair M, Tuffnell learned to inform Lessons Mothers’ Care: Lives, Improving Enquiries Confidential the UK and Ireland from care maternity Oxford: National and Morbidity 2013–15. Deaths into Maternal Oxford 2017:74-81. of University Unit, Epidemiology Perinatal al (Eds.) D, et M, Tuffnell In Knight M, Nair and Epidemiology. Mothers’ Saving Lives, Improving MBRRACE-UK. on behalf of the UK from care maternity to inform Lessons learned Care: and Deaths into Maternal Enquiries Confidential and Ireland Epidemiology Perinatal Oxford: National Morbidity 2013–15. Oxford 2017:6-21. of University Unit, M on behalf o Cantwell R, Gray R & Knight Knight P & Pa Nair M & Knight M. Ma Caring for women with Group. Psychosis Chapter-writing of D, et al (Eds.) on behalf M, Tuffnell psychosis. In Knight M, Nair Lessons Mothers’ Care: Improving Saving Lives, MBRRACE-UK. the UK and Ireland from care maternity learned to inform and Morbidity Deaths Maternal Enquiries into Confidential Epidemiology Unit, Perinatal Oxford: National 2013–15. Oxford 2017:37-49. of University Australian Demographic S Demographic Australian abs.gov.au/absstats/abs@nsf/mf/3101.0. AIHW series no. deaths Maternal 2015. in Australia 2008–2012. deaths AIHW. Canberra: no. PER 70. Cat. 5. The WHO applica 2012. puerperium: ICD MM. WHO, childbirth and

9. 10. 5. 6. 7. 8. For further information visit: For further information www.ranzcog.edu.au/Training/TSU : Support Unit or contact the Training or [email protected] Email: [email protected] Phone Paula: +61 3 9412 2918 or Alana: +61 3 9412 2933 RANZCOG is committed to supporting trainees and is committed to supporting RANZCOG training supervisors and has established the Training and impartial professional Support Unit. This is a safe, Supervisors to contact and Training Trainees service for and be guided and supported along the most effective pathway. response encouraged to contact Ms Paula are Trainees Liaison in Trainee Fernandez, Senior Coordinator, anxiety or poor health. Supervisors stress, times of encouraged to contact Ms Alana Gilbee, Senior are concerned Supervisor Liaison if they are Coordinator, supervising. about a trainee they are The TSU also manages trainee training complaints in a manner. fair and responsive RANZCOG recognises that trainees may that recognises RANZCOG and personal professional experience periods of of the demands coping with and that difficulty, developing skills, building a busy profession, and knowledge as well as balancing family personal commitments can be challenging. the importance of The College also recognises work to supporting training supervisors as they vital training and learning trainees have ensure new procedures through taken opportunities; are time to develop their skills and given adequate under supervision. Training Support Unit Support Training WOMEN’S HEALTH of anorexia nervosa Antenatal management Case report in pregnancy. assessment andmanagementof eating disorders Perinatal Mental Healthprovide nomentionof the The mostrecent AustralianNational Guidelinesfor little guidanceandresearch intoANandpregnancy. depression, anxietyandpsychoticdisorders,there is However, thisisnotalwaysthecase.Unlike pregnancy tooccur, ANneededtobeinremission. and lessthan15extreme. Ithadbeenthought,for considered mild,16–17moderate, 15–16severe determines diseaseseverity, withaBMIof 17–20 and purgingbehaviours.Bodymassindex(BMI) It canbeassociated withrestricting and/orbinging fear of weightgainanddisturbanceinbodyimage. by restriction of intake andlowbodyweight,intense and recovery. ANisaneating disordercharacterised are considered aspartof assessment,management approach toensure bothphysicalandmentalhealth of mentalhealth,requiring amultidisciplinary team Managing anorexia nervosa(AN)isachallengingarea King EdwardMemorialHospital,Perth MBBS, MPM,FRANZCP, PhD Prof MeganGalbally University ofWestern Australia, Perth Dept ofO&G MBBS, MD, FRANZCOG, DDU, CMFM Prof JanDickinson King EdwardMemorialHospital,Perth MBBS, FRACP Dr ShivanthiSenaratne King EdwardMemorialHospital,Perth MBBS Dr FionaLangdon King EdwardMemorialHospital,Perth BSc, MBBS Dr KatherineGrove booking visit.Following theroutine administration unremarkable, despite noting her low BMI of 15 at the generalhospital.Herantenataltertiary care appeared she wasbooked intoamaternity servicewithin a Following thediagnosisof her secondpregnancy, she hadreceived minimaltreatment inthepast. The patient of hada15-year history ANforwhich to fortnightlyreview. midwifery, psychiatry, physiciananddieteticsweekly involvement, includingmaternal-fetal medicine, care. Thisentailedintensivemultidisciplinary team ongoing managementof hercomplex obstetric weeks gestation. Transfer occurred tofacilitate the medicine unitof O&Ghospitalat atertiary 24 generalhospitaltothematernal-fetala tertiary The patient wasa30-year-old G2P1transferred from Case description 1 corrected throughout theadmission. diet. Unstable calciumlevelswere monitored and eventual successfulintroduction of mealsand full intake were complicated byhypoglycaemia,with attempts totransitionfrom nasogastrictooral on re-feeding requiring replacement. Initial evident withthedevelopmentof hypophosphataemia progression to bolus feeds. Re-feeding syndrome was continuousfeedsinitially,(NGT) withgradual admission bloods.Shereceived nasogastrictube Hypokalaemia (2.7mmol/L) waspresent onthe 23 dayswhere herphysicalhealthwasstabilised. she wasadmittedtoageneralmedicalwardfor Following herinitialassessmentbyapsychiatrist, anxiety anddepression. unremarkable. There of wasafamilyhistory both suicide attempts. Drugandalcoholassessmentwas once andfoundthishelpful.There of was nohistory treatment. Shewaspreviously trialledonfluoxetine and neverreceived anyintensiveeating disorder She hadneveraninpatient psychiatric admission had norecent contactwithmentalhealthservices. The patient hadpreviously seenapsychiatrist, but she otherwisefelthelpless. intakeher dietary gaveherasenseof control when significant stress forherfamily. Strict restriction of she wasinherteenageyearsduringaperiodof The patient’s eating disordercommencedwhen psychotic disorder. criteria foranyothermood,anxiety, trauma-basedor on achievement.Shedidnotmeetthediagnostic construct wasnotableforself-criticismandafocus characterised byexcessive worry. Herpersonality She describedlong-standinggeneralisedanxiety being generallyoverwhelmedandunabletocope. insomnia, passivesuicidalideation, andfeelingsof mood, irritability, demotivation, lowenergy, initial symptoms characterisedbypervasivelylow The patient alsopresented withsignificantdepressive body weight. gain, withherself-worthheavilyinfluenced byher other compensatory behaviours.Shefeared weight not uselaxatives, exercise excessively orengagein behaviour around three timesperweek.Shedid She describedpurginguptotwicedailywithbinging intakedietary towellbelownormalrequirements. postural symptoms.Shehadbeenrestricting her postural tachycardia,resting bradycardia,and risk. Onphysicalexamination, shehadsignificant had significantlylowered mood withassociated weight gainoverthe20weeksof pregnancy, and pregnancy associated withAN, hadinsufficient at 17, shehadactivesymptomsthroughout her it wasrecognised that herBMIremained low 20 weeksgestation. At thispsychiatric consultation, she wasreferred foramentalhealthconsultation at of theEdinburghPostnatal Depression Scale(EPDS), WOMEN’S HEALTH AN is associated AN is associated 4 Vol. 20 No. 3 Spring 2018 | 67 Vol. Furthermore, Furthermore, 3 5,6 However, despite a low despite a low However, 2 These include: 5 Ensuring there is a mental health referral to is a mental health referral Ensuring there co-morbidity of disorder, assess both the eating and anxiety and also any impact on depression with the fetus/infant the developing relationship particularly electrolytes, Regular monitoring of for active purging behaviours the fetus, monitoring of Regular growth behaviours particularly for active restrictive are prior to delivery if there ECG Maternal disorder has impacted on an eating concerns that cardiac function multidisciplinary care, of Ensuring coordination mental health, including obstetrics, midwifery, obstetric medicine dietetics and, when necessary, for admission based on Having a clear threshold health and fetal wellbeing maternal parameters of by an eating to be affected likely are that hypoglycaemia, maternal which include disorder, restrictive syndrome, bradycardia, Long QT bone cardiac atrophy, from cardiac failure etc dysfunction, especially neutropenia marrow Long-term health, including assessing for peripartum osteopenia/osteoporosis. • • • • • • • This case report illustrates the risk of untreated AN untreated the risk of illustrates This case report morbidity and the potential for impact on maternal with a that it illustrates Equally, on fetal growth. disciplines, a the key across approach coordinated was able to good outcome for mother and infant only be achieved. This positive outcome was not parameters, but equally and neonatal pregnancy and depression of mental health, with a remission and awareness anxiety symptoms and a growing disorder. for her eating commitment to treatment beyond these tangible that This case also illustrates but clinical outcomes was the less measurable, engagement, support equally important, aspects of together a team This brought care. and collaborative maternal care, expertise in midwifery on drew that and fetal medicine, obstetric medicine, dietetics mental health. perinatal Conclusion are there woman with AN, In managing a pregnant principles. key poorer growth in offspring have been shown to in offspring growth poorer of life. the first year continue across with a higher rate of depression and anxiety, and anxiety, depression of with a higher rate and is also associated depression, including perinatal breastfeeding. of with low rates prevalence, there have been several large studies there prevalence, risks in pregnancy increased have confirmed that For women with disorders. for women with eating with slower fetal this has included associations AN, gestational low birth weight and small for growth, neonatal and higher risk of age, lower Apgar scores, death. and perinatal resuscitation with 10 days of midwifery home practice group days of with 10 she was reviewed discharge, after weeks visits. Two the hospital. by a psychiatry and midwifery team at depression of no symptoms reported She was well, baby was weight and her had stable or anxiety, then ceased had commenced but thriving. She supported by her she felt however, breastfeeding, decision. She also felt well visiting midwife in this dietetics around plans from equipped with adapting follow Her postpartum intake. her diet and nutritional clinical practice, psychiatry, up will include general psychology and dietetics. Discussion is uncommon, with prevalence AN in pregnancy per 0.05–0.5 the UK and Norway at from estimates women. pregnant cent of A full list of references is available online at: www.ogmagazine.org.au. A full list of references is available online at: Given the concerns about prolonged low weight over low weight prolonged about the concerns Given and physiological associated with her pregnancy, on and the potential effects disturbances electrolyte to a tertiary transferred was her care the fetal growth, medicine with a maternal-fetal women’s hospital and an inpatient initially assessed as unit. She was each review, At for weekly review. then discharged psychiatry, midwifery, she was seen by obstetrics, with close collaboration physicians and dietetics, Despite those involved in her care. between all of the distance about initial concerns expressed the at attendance overall home, the patient’s from very clinic was reliable. antenatal Her obstetric history included an uncomplicated, two years earlier delivery term spontaneous vaginal investigations antenatal Routine baby. a 3.8kg of first including a low probability all normal, were second and an unremarkable trimester screen ultrasound. trimester morphology were the pregnancy throughout studies Electrolyte the nasogastric tube of normal following removal Low albumin, low total weeks gestation. 24 at with treated and low calcium levels were protein with well tolerated, and were oral supplementation to near normal ranges by the end improvement of pregnancy. appeared dietary intake Her tendency to restrict psychosocial increased during times of greatest the fetus revealed scans of Serial growth stress. between the 26th and 28th fetal growth plateauing with the abdominal circumference week, gestational the 50th to the 10th centile. This falling from in the stress increased with a period of correlated in clinic reduction an associated family environment, weight gain. As maternal and lack of attendance abdominal in the third trimester, nutrition improved continued to track along the 10th circumference studies. fetal Doppler centile with reassuring with extensive psycho- was provided The patient with the potential risks associated around education on the developing fetus. dietaryrestricted intake to 150mg, with good effect Sertraline was up-titrated Towards and anxious symptomatology. on depressive she was further engaged her pregnancy, the end of to facilitate clinical psychologist with a perinatal and support in the postpartum period. treatment anxiety she reported the pregnancy, Throughout to meal times and the occasional desire around to the bodily sensations purge, particularly related and fullness. These sensations nausea, bloating of the third part of the latter during exacerbated were weight maternal of with subsequent lack trimester, this, the In view of 34 weeks gestation. gain after stay was admitted for a two-day inpatient patient The admission provided 37 weeks gestation. at physiological stability an opportunity to ensure for in preparation and optimised nutritional intake all monitoring were and ECG Electrolyte delivery. hypocalcaemia and with ongoing unremarkable, recorded. but acceptable blood sugar levels low, third trimester was in the late ECG A maternal support cardiac function would performed to ensure showed normal vaginal delivery and reassuringly and function. ventricular size at labour occurred induction of An uncomplicated had age and the patient gestational 38+2 weeks of a live male infant of a spontaneous vaginal delivery (35th centile). She was assessed weighing 3.2kg prior to delivery by the mental and postpartum health team. After discharge, she was supported WOMEN’S HEALTH Vol. 20 No. 3 Spring 2018 | 69 Vol. Case one with a two-week woman presented A 23-year-old involuntary emotional lability, history lethargy, of forgetfulness and falls. movements, increasing acutely was alert but the patient On examination, and initial investigations Examination confused. was admitted for empiric normal. The patient were lumbar intravenous antibiotics for meningitis, as the cell count, but her a high white revealed puncture and brain MRI An EEG clinical condition deteriorated. the abdomen and pelvis was normal. A CT scan of an pelvic mass, likely a 12cm multi-loculated revealed 1). (Figure ovarian teratoma detected antibodies were After anti-NMDA-R fluid (CSF), the in serum and cerebrospinal a right gynaecological oncology team performed admission. on day eight of salpingo-oophrectomy cystic mature was consistent with Histopathology 2). (Figure teratoma continued to experience patient the After surgery, and psychosis with ideation suicidal depression, with and was treated auditory hallucinations This syndrome This syndrome 2 CT abdomen/pelvis (Coronal and Sagittal): A 12x7x11cm multi-loculated solid and Sagittal): A 12x7x11cm multi-loculated CT abdomen/pelvis (Coronal and is associated with long-term and is associated 3 Figure 1. keeping with a large density foci in calcified and fat and cystic pelvic mass, with punctate or bony disease, lymphadenopathy ascites, peritoneal or pulmonary No ovarian teratoma. Hospital Radiology Department. Liverpool lesions. Courtesy of which causes neuronal dysfunction and which causes neuronal 1 loss by altering the neuronal cell-surface NMDA NMDA cell-surface loss by altering the neuronal in the limbic system. receptors presents with a range of psychiatric, neurological and neurological psychiatric, with a range of presents autonomic features Anti-N-methyl-D-aspartate receptor (NMDA-R) (NMDA-R) receptor Anti-N-methyl-D-aspartate encephalitis is a paraneoplastic limbic syndrome Neural tissue in a caused by ovarian teratomas. anti-NMDA-R of can trigger the production teratoma antibodies, Dr Myriam Girgis trainee FRANZCOG MWomHMed, MBBS, DCH, Dept of O&G Liverpool Hospital, Sydney Herbst Dr Unine FRANZCOG MMed (O&G)(UP), MBChB, FCOG(SA), Dept of Gynaecology Oncology Liverpool Hospital, Sydney morbidity and mortality. We will review the three the three will review We morbidity and mortality. to our institution over a period presented cases that 12 months. of teratoma encephalitis and ovarian ovarian and encephalitis anti-NMDA-receptor anti-NMDA-receptor A brain in the pelvis: pelvis: in the brain A Case report Case WOMEN’S HEALTH reported asmallrightovarian teratoma forwhich movements. Apelvicultrasound andCTscan demonstrate focal rhythmiceyeandupperlimb she wasintubated andsedated, butcontinued to Due toafluctuating GlasgowComaScale(GCS), tachycardia andpyrexia. autonomic dysfunction,causing severe hypertension, and serum.Itbecameapparent that shehad Anti-NMDA-R antibodieswere foundintheCSF sodium valproate, levetiracetamandmidazolam. had tonic-clonic andfocalseizures, requiring and quetiapine.DespiteanormalEEG, thepatient disinhibition andhyperactivity, requiring olanzapine disturbances withaggression, violentoutbursts, The patient continuedtohavebehavioural tomultipledrugs. refractory grade temperatures. Herbloodpressure remained tazocin forsuspectedsepsis,asshedevelopedlow encephalitis andtheantibioticswere changedto methylprednisolone wasaddedforautoimmune benzylpenicillin, ceftriaxone and acyclovir. Soon after, started forsuspectedmeningitis/encephalitiswith cell countonlumbarpuncture andtreatment was and imagingwere normal.Shehadahighwhite was 184/126. Theinitialexamination, investigations On review, shewasacutelydisorientedandherBP was knowntohavehypertensionandtype2diabetes. lethargy, acute confusion andasubjectivefever. She A 25-year-old womanpresented withheadache, Case two on IVIGandmycophenolate. discharged onday27of admission.Sheiscurrently She slowlyimproved neurologically andwas methylprednisolone, rituximabandoralprednisone. She received intravenousimmunoglobulin(IVIG), to bradycardia,dueautonomicdysfunction. also experiencedrecurrent syncopesecondary haloperidol, risperidoneandmidazolam. She [H&E stain].Imagecourtesyof Liverpool HospitalAnatomical Pathology. fluid, abundantmature neuraltissueand resembling choroid plexus. hair-like material, skinwithadnexalstructures, bone,cartilage,serous are consistentwithamature teratoma containingfocalcalcification, with mass containsamulti-loculated cystwithsolidandcysticareas. Findings Figure 2. Histologyslide.Rightovary specimenweight427g.Theovarian upon removal of thetumour. altered levelsof consciousness,with improvement psychiatric symptoms,anovarianteratoma and in 1997twoyoungwomenwho presented with Anti-NMDA-R encephalitiswasinitiallydescribed Discussion on day 25. plasmapheresis andrituximabwasextubated cystic teratoma. Postoperatively, she received IVIG, admission (Figure 3). Histologyconfirmed mature left salpingo-oophrectomy onday15of her seen onimaging.Sheunderwentalaparoscopic serology, toan18mm leftovariandermoid secondary with anti-NMDA-R encephalitisonserumand CSF presentation. On thisadmission,shewasdiagnosed her thirdpresentation, eightdaysafter theinitial diagnosis of epilepsy. Shewasadmittedafter was initiallydischargedwithapresumed new activity, confusion andbehaviouralchanges.She A 37-year-old presented with syncope,seizure Case three immunotherapy todate. intubated foreightmonthsandisreceiving dysfunction andremains hospitalised.Shewas still haspersistingneurological andautonomic Twelve monthsafter herfirstsurgery, thispatient was negative forateratoma. to remove as well. Thefinalpathology theleftovary consultation,multidisciplinary thedecisionwas made not beconfirmed onimagingand after extensive exchange. Thepresence of aleftteratoma could therapy, rituximab,plasmapheresis andplasma epilepticus. Sheproceeded tohaveIVIG,steroid facial andlimbmovements,catatonia andstatus improve andshecontinuedtohave involuntary teratoma. Unfortunately, herclinicalconditiondidn’t on day11of admission,confirming mature cystic she hadalaparoscopic rightsalpingo-oophrectomy 4 WOMEN’S HEALTH

4 Vol. 20 No. 3 Spring 2018 | 71 Vol. 1 There have also There 4 and early tumour 1 toma (dermoid cyst) and 2 2011;10(1):63-74. Available Available Lancet Neurol. 2011;10(1):63-74. 4 en L, Gabilondo I, et al. Treatment and et al. Treatment en L, Gabilondo I, . 2015;14: 1-3. Available Available 1-3. Gynacol Oncol Rep. 2015;14: Orphanet J Rare Dis. 2017; June 19;9(157). , Marcus C, Garg R. Anti-NMDA-receptor C, Garg R. Anti-NMDA-receptor , Marcus while others have presented with while others have presented 1,3 , Lancaster E, Martinez-Hernandez E, et al. Clinical , Lancaster E, Martinez-Hernandez , Acien M, Ruiz-Macia E, et al. Ovarian teratoma- , Acien M, Ruiz-Macia A high index of suspicion for this serious A high index of 4 Tibulaer M, McCrack Braverman J Dalmau J with anti- in patients investigations experience and laboratory encephalitis. NMDAR from:www.ncbi.nlm.nih.gov/pubmed/21163445. Acien P of review encephalitis: a systematic anti-NMDAR associated cases. reported from:www.ncbi.nlm.nih.gov/pmc/articles/ Available 10.1186/s13023-014-0157-x. PMC4203903/DOI: Barbieri R, Clark R. Ovarian tera OBG Manag. on your radar. encephalitis: a link to keep from:www.mdedge.com/.../ Available 2014;26(1):12,15,16. article/.../ovarian-teratoma-dermoid-cyst-and-encephalitis-link. with factors for long-term outcome in patients prognostic cohort study. encephalitis: an observational receptor anti-NMDA from:www.ncbi.nlm. Available Lancet Neurol. 2013;12(2):157-65. nih.gov/pubmed/23290630. with associated syndrome encephalitis: a neuropsychiatric ovarian teratoma. from:www.ncbi.nlm.nih.gov/pmc/articles/PMC4688824/.

While the majority of ovarian teratomas won’t trigger ovarian teratomas While the majority of encephalitis, the anti-NMDA-R the development of and their family should be alerted to report patient or behavioural any new onset neuropsychiatric and expectant is diagnosed changes if a teratoma management is pursued. encephalitis months to years following removal of of encephalitis months to years following removal is around The mean time to recovery the teratoma. but permanent sequelae is seen in months, 3.6 and seven per cent die from patients, 10 per cent of complications. encephalitis-related and potentially fatal condition, and potentially fatal Contraceptive use is essential while on long-term Contraceptive use is essential while on long-term reversible long-acting especially immunotherapy, have residual often contraceptives, as patients makes cognitive and memory impairment that compliance difficult. Conclusion to play The gynaecologist has an important role team caring for these within the multidisciplinary patients. References 1. 2. 3. 4. 5. been reports of recurrent teratomas with recurrent with recurrent teratomas recurrent of been reports encephalitis, detection and removal result in improved prognosis. in improved result detection and removal for a minimum of 12 months and be screened with 12 months and be screened for a minimum of imaging every six months for four years for the an ovarian teratoma. of presence 4 In 4 This 1 1,4,5 Anticonvulsive As anti-NMDA-R As anti-NMDA-R 3,5 Definitive diagnosis Definitive 4 4 as delayed surgery This is followed 2,4 4 There is substantial is substantial There 4 1 First-line treatment First-line treatment Left ovarian dermoid seen on laparoscopy. Figure 3. 4 and the syndrome starts with and the syndrome 1 4 hypoventilation, autonomic instability hypoventilation, 1,5 There have been a few cases of ovarian a few cases of have been There 1 neurological improvement in 80 per cent of patients patients per cent of in 80 improvement neurological and immunotherapy. who undergo tumour excision is made by the confirmation of anti-NMDA-R of anti-NMDA-R is made by the confirmation antibodies in the blood or CSF. encephalitis is uncommon, diagnosis is often delayed, delayed, often is diagnosis uncommon, is encephalitis common conditions such as neuro- while more encephalitis are psychotic conditions and infective being considered. therapy is often employed. therapy is often includes immunotherapy with IV steroids, IVIG includes immunotherapy with IV steroids, is and second line treatment or plasmapheresis rituximab and cyclophosphamide. teratomas being detected years after a diagnosis being detected years after teratomas without encephalitis. Patients anti-NMDA-R of detectable tumours should continue immunotherapy a viral-like illness, including headache, nausea, a viral-like to a vomiting, fever and lethargy and then progresses symptoms. neuropsychiatric spectrum of can result in autonomic instability, catatonia, status status catatonia, in autonomic instability, can result epilepticus, coma and death. Occasionally, the syndrome may be caused by the syndrome Occasionally, tumours undetectable by imaging. microscopic In two of our cases, the symptoms improved our cases, the symptoms improved In two of surgery and immunosuppressive within a month of can continue although recovery treatment, months. for up to 24 In patients with acute neurologic findings, initial with acute neurologic In patients for encephalitis should be initiated, investigations CSF studies. and serum including Early stage symptoms include confusion, personality Early stage symptoms include confusion, changes, memory deficits, psychosis, mood disturbances, self-harming behaviours, seizures and facial and limb movement disorders. The mean age is 24 these scenarios, treatment should be medical with these scenarios, treatment Surgery as is not recommended, immunotherapy. histologically normal of in removal it may result ovaries. by imaging to confirm ovarian teratoma. Timely ovarian teratoma. by imaging to confirm risk of essential to reduce diagnosis and surgery are injury, permanent neurological including hypotension or hypertension, bradycardia including hypotension or hypertension, bradycardia or tachycardia and hyperthermia. can progress to decreased GCS requiring ventilator ventilator GCS requiring to decreased can progress support, WOMEN’S HEALTH of casesof tubo-ovarianabscess. Rupture canoccurinapproximately 15percent third trimester Acute abdomen in the Case report despite beingarare occurrence inpregnancy. ruptured tubo-ovarianabscessshouldbeconsidered An acuteabdomeninpregnancy israre, buta Honiara, SolomonIslands National Referral Hospital O&G registrar Dr BrileyPinau Honiara, SolomonIslands Director ofO&G,NationalReferral Hospital Dr LeeannePanisi GP Obstetrician Dr SarahLuthy Figure 1 history. Duringhercurrent pregnancy, shehad uncomplicated andshehadnosignificantmedical normal vaginalbirths.Herprevious pregnancies were A 24-year-old woman(G3P2)hadahistory of two Case report in pregnancy. case reports of ruptured tubo-ovarianabscess . Righttubo-ovarianabscess. 2-5 1 There are afew 1

infection/pyelonephritis andtortedovariancyst. appendicitis, placentalabruption,urinary tract At thisstage,thedifferential diagnosiswas the rightfornix.Thefetalheartrate wasnormal. the cervixwasclosed,withsometendernessnotedin contractions were palpated. Onvaginalexamination the fetusincephalicpresentation, notengaged.No renal angletenderness. Fundal heightwas32cmwith was markedly tenderontherightsidewithbilateral pulse 98andtemperature 38degrees. Herabdomen On examination, herbloodpressure was90/59, (PV) bleeding. of rupturedno history membranesorpervaginal vomiting. Shedeniedanytraumaorfalls.There was no dysuriaorbowelsymptomsandnausea iliac fossa.Shealsocomplainedof fever. There was was worseintherightupperquadrantand period) at 6pmwithsevere abdominalpain.Thepain approximately 32weeks(basedonherlastmenstrual the National ReferralHospital,SolomonIslands,at She presented totheemergencydepartmentin been given. 1:4. The first dose of benzathine penicillin had already the firstvisitandshowntobepositivewithatitre of testhadbeencollectedatresearch (VDRL) laboratory was consistentwithherdates. Avenereal disease attended twoantenatal visitswhere herfundalheight Figure 2 . Drainageof abscess. WOMEN’S HEALTH 2017 Gynekol Ceska Vol. 20 No. 3 Spring 2018 | 73 Vol. tions of tubo-ovarian tions of ed tubo-ovarian abscess late in pregnancy. in pregnancy. ed tubo-ovarian abscess late o fertilization complicated by rupture of tubo- of by rupture complicated o fertilization S Afr Med J. 1987 Jan 24;71(2):120-1. . Ruptured tubo-ovarian abscess in pregnancy. Sex tubo-ovarian abscess in pregnancy. . Ruptured ová A, Unzeitig V, Ceska Gynekol. Tubo-ovarian abscess in Tubo-ovarian Ceska Gynekol. V, ová A, Unzeitig Piegz Han C, et al. In vitr Davey M, et al. Ruptur A case report. Derby B Dis. 1986 Jul-Sep;13(3):177. Transm Beigi R. Management and complica July 2016. to date. abscess. Up (case report). pregnancy the 39th week of . J Obstet Gynecol Taiwan ovarian abscess during pregnancy. doi:10.1016/j.tjog.2015.08.017. 2015 Oct;54(5):612-6. Fall;82(4):322-326.

12pm for urgent caesarean section. A general A general section. caesarean for urgent 12pm suxamethonium, was performed using anaesthetic and vecuronium. thiopentone was a large entryUpon peritoneum, there into the the incision site, through pus oozing amount of appendix. Triple a ruptured be from thought to commenced (metronidazole, IV antibiotics were surgeons were and gentamicin). The cephazolin interestingly, the appendix which, called to remove with was irrigated normal. The abdomen appeared was then section caesarean saline. A lower segment clear and the baby appeared performed. The liquor The uterus was closed was born in fair condition. the tubes and ovaries. and exteriorised to examine on the right ovary/tube, A large mass was seen The pfannenstiel least 10cmx6cm. measuring at into a midline laparotomy incision was converted the bowel was examined of incision. The remainder by the surgeons. and shown The tubo-ovarian mass was aspirated to contain thick purulent discharge. The mass up. It was broken was incised and the loculations upon marsupialised, washed out and a drain inserted closing the abdomen. well. mother and baby recovered Post-operation, wound swab subsequently grew The intra-operative Mother and baby staphylococci. coagulase-negative discharged one week later. were 5. References 1. 2. 4. 3. You’ve got mail You’ve news from RANZCOG Collegiate is the College's fortnightlyCollegiate is the e-newsletter, featuring helpful information on a variety of topic and articles latest initiatives on the . RANZCOG by developed information, email: [email protected] more For Post-incision and drainage. Figure 3. A surgical consult was requested and dexamethasone A surgical consult was requested The immaturity. for fetal lung was administered MPS (malaria LFT, FBC, UEC, surgeons requested ultrasound. and renal/obstetric parasite screen) the 1:30am by surgeons was that at review Further pyelonephritis and IV antibiotics woman had likely commenced. were The following morning, she had generalised She was abdominal tenderness and a tense uterus. pregnancy. diagnosed as having an acute abdomen in no variability 5–7, 155, baseline of showed a The CTG variable decelerations and complicated accelerations down to 50bpm (unprovoked). a large An urgent abdominal ultrasound confirmed placental abruption with a live fetus (measurements approximately at to theatre not done). She was taken WOMEN’S HEALTH the practiceofobstetricsandgynaecology informed oncurrentmedicolegalissuesin Your regularlegalupdatetokeep you Melbourne MothersandMonashUniversity Royal Women’s, SunshineandNorthernHospitals FRANZCOG, FACOG A/Prof VinayRane Women’s Ultrasound Melbourne(WUMe) Royal Women’s Hospital,Melbourne COGU, MBioeth MBBS, MRCOG, FRANZCOG, DDU, Dr NicoleWoodrow The leg-up doctors. Thesmear of the allegation couldoutweigh groups that thestancewasunfair andpunitiveto Medical Association (AMA)andmedicaldefence However, concernswere raisedbytheAustralian decision-making of patients seekingmedicalcare. practitioners wasthoughttostrengthen theinformed of transparency and‘information’ abouthealth with ‘noadversefinding’ recorded. Theprinciple was unfounded, thelinkwouldbepublished The MedicalBoardnotedthat where aclaim offences proven againstadoctor.’ if there havebeenseriousdisciplinary orcriminal if there are conditionson adoctor’sregistration or Dr Joanna Flynn:‘...thepublichasarighttoknow quotes theChairof theMedical Board of Australia, of theuseof chaperones toprotect patients’, that 2016 recommendation of the‘independentreview no adversefindingswere made.Thisfollowedthe practitioner registration details,evenincaseswhere andcourtdecisionstomedical linking disciplinary Agency (AHPRA)recently commencedpublicly The AustralianHealthPractitionerRegulation patient complaints AHPRA publicationofunfounded

negatively impactingthequalityof lifeof women.’ to decidefreely abouttheirbodiesandsexuality, bringing withitlossof autonomyandtheability the natural processes intopathological ones, treatment, anabuseof medication, andtoconvert health personnel,whichisexpressed asdehumanised the bodyandreproductive processes of womenby in 2010andisdefinedas‘…theappropriation of The term‘obstetric violence’wascoinedin Venezula 'obstetric violence'. attention tobirthingrightsandcalloutepisodesof have formed,mostnotablyacross Europe, tobring rights violations. Subsequently, severalorganisations or unconsentedmedicalprocedures, ashuman of analgesicmedication orprocedures, andforced and labour, suchasphysicalandverbalabuse,denial labeled ‘disrespectful andabusivecare’ inpregnancy in isolation. In2014, theWorld HealthOrganization The Minister’scomments,however, were notmade and alarmist. as theybelievedthequotedfigures tobeinaccurate and Obstetricians,whocalledforherresignation, rebuke from theFrench Union of Gynaecologists without theirconsent.Theremarks drew strong French womenwere undergoing episiotomies,often gender equality, reported that upto75percentof Last year, MarlèneSchiappa,French ministerfor relevant stakeholders.’ decision, withoutadequately consultingwiththe in policy-making,rather than…aknee-jerk well. We expectthesamelevelof duediligence proclaimed, ‘Doctors are peopleandpatients as of non-adverse findingtribunal results. Steel Scott reversal of theirdecisionregarding thepublication released amediastatement announcingaradical On 28July2018, theMedicalBoardandAHPRA choose theirdoctorwisely. patient protection and‘knowledge’,tohelppatients ‘information’ forthepublic,inlinewithprinciplesof Further concernsrelated towhat constitutes disorder anddestroy theirreputational capital. would increase therate of post-traumatic stress hearings, sayingthat the‘noadversefinding’link doctors whohadbeenvindicated indisciplinary was widelyshared, withemotionalcommentsfrom unfounded complaintsonitsregister. Thewebpage 17,000 signatures, inanefforttostopAHPRAlinking a petitionthrough change.org,withmore than Dr Steel Scott,adoctorinGeelong,Victoria,created career of thedoctor. adverse finding’were to remain linked fortheentire action beingtaken. Thosecomplaintsresulting in‘no 2016–2017, 76.3 percentresulted innofurther Of the 3557notifications totheMedicalBoardin It involvednosmallnumberof healthpractitioners. the exoneration, withaseriouslossof reputation. caesarean section,followingonfrom a ‘cascade LCand moralintegrity’. allegesthat shehadaforced Court of Human Rightsforviolation of her‘physical the caseof LC, whoistakingSpaintotheEuropean enforce women’srightsduringbirth.Thisbringsusto Mexico havenowintroduced formallegislation to Among othernations, Argentina, Venezuela and violations onthelabourward? Are youcommittinghumanrights 1 WOMEN’S HEALTH 6/08/2018 11:52:31 AM SOCIAL MEDIA @RANZCOG facebook.com/RANZCOG Vol. 20 No. 3 Spring 2018 | 75 Vol. [email protected] [email protected] +61 3 9417 1699 Ph: +61 3 9419 0672 Fax: Email: www.ranzcog.com.au Katrina Calvert Katrina A recent Australian Department of Health publication Health publication of Australian Department A recent the of Principles Review ‘First (benignly titled), radically Insurance Fund’, Medical Indemnity capped fee for the 120 scrapping the recommends Who are by this arrangement. doctors covered such emphasis in receive these 120 doctors who of history These doctors have a long the report? rules, introduced the current complaints and under crisis, an insurer the indemnity of in the aftermath medical to offer was beholden last resort of the doctors, including those at insurance cover to all highest risk. the make potentially will cap surcharge the Removing for these doctors, abolishing unaffordable premium sector. in the private their legal right to practise will be Their ability to work as a health practitioner they where to the public health industry, restricted allowing will need to competitively obtain a position insurance. them to obtain employer-indemnified protection’ this may have the ‘patient Potentially, high-risk doctors to practise in advantage by forcing workplaces with better governance and oversight. for privately few recommendations are There as to a consideration practising midwives, except is an ongoing need to cap premiums ‘whether there and to subsidise practising midwives paid by privately advice is given No concrete high claims’. the cost of for intrapartum the indemnity exemption regarding midwives for homebirths. practising by privately care Is there a right of all doctors to a right of all Is there cover? indemnity universal AUSTRALIA College House, 254-260 Albert Street East Melbourne, Victoria 3002, Australia. International Journal of Journal of International Lenore Ellett Lenore Bec Szabo 2 .law.ox.ac.uk/research-and-subject-groups/ https://www international-womens-day/blog/2017/03/reflections-obstetric- violence-and. For R. Obstetric violence: a new D’Gregorio human rights. Perez in Venezuela. legal term introduced Gynaecology and Obstetrics 2010;111(3):201-202. doi:10.1016/j. ijgo.2010.09.002.

References 1. courtof totheeuropean nowtaken inspain ced cesarean 2. It is alleged that there is no justification documented justification is no there that It is alleged and, for the above interventions in the partogram consent was not documented for each moreover, management decision. Furthermore, or procedure a pre-existing as a consequence of that, states LC position hernia, labouring in the lithotomy hiatus causing reflux, her gastrointestinal exacerbated instructions It is alleged that the throat. stinging of supervisor to the trainee given by the anaesthetic to her which added by the patient, overheard were trainee, by the failed attempts After repeated distress. the epidural successfully. the supervisor then placed section was then a caesarean that states LC LC 8cm dilatation. consent at performed without her pain, anxiety and insomnia and now suffers ongoing seeks damages. violence cases gender-based institutional Claims of globally. in number and prominence increasing are this phenomenon. of should be aware Our readership of unnecessaryof These interventions’. medical use of amniotomy and ranged from interventions an intravenous the placement of to infusion, oxytocin in case’. cannula ‘just

Sarah Janssens (Chair) Doug Barclay Who is on the STAG? training curricula. (Access to simulation and simulation can help with advice on equipment STAG Members of site accreditation.) for training equipment is now a requirement to contact us via: [email protected] Feel free Learn more about sim way to be Twitter is a great via social media. and information resources practice to find Join a community of #SimObGyn #FOAMSim practice. Follow topics: #FOAMObGyn community of involved with a simulation #ObGyn #Simulation The STAG advises the College about how simulation can best be advises the College about how simulation The STAG training program. into the RANZCOG incorporated Training Advisory Group (STAG)? Advisory (STAG)? Group Training Do you know about the Simulation about the Simulation Do you know RAN003 FILLER ADVERT TEMPLATES HALF PAGE HORIZONTAL 5 WOMEN’S HEALTH • • Relative contraindications forpipellebiopsy: • • Absolute contraindica • • • • Indications forpipellebiopsy: Indications andcontraindications usually well-tolerated bypatients. the disposablepipelle.Itiscost-effective,safe and was removed. Today, themostwidelyuseddeviceis and syringeattached forsuctionastheinstrument metal cannulawithasideopening,serrated edges 1930s, endometrialsamplingoriginallyusedanarrow hormone levelsorinfection. Firstintroduced in the cell changesduetoabnormaltissue,variations in undergoes ahistologicalevaluation that canshow , theliningof theuterus.Thissample (AUB). Itinvolvestakingatissuesample from the in womenwithabnormaluterinebleeding biopsy, isacommonmedicalprocedure performed Endometrial sampling,alsoknownasendometrial What isendometrialsampling? can beclassifiedintwomajorcategories. occurs outsideof normalcyclicmenstruation. AUB AUB refers touterinebleeding that isexcessive or Aetiology ofAUB • sampling ingeneralpractice? What istheroleofendometrialpipelle Pr disease. Pr Synthetic heartvalvesormurmurs/valve Coagula disease (PID). Endometritis oracutepelvicin Pr abnormal symptoms. Endometrial cellsoncervicalsmears,with months ina12-monthperiod Inter older than35yearso Significant riskfactorssuchasBMIover30and three months F insertion difficult. can stenosethecervicalcanalandmake transformation zone) orconebiopsy. These antibiotics twohoursbeforehand ailed medicaltreatment of menorrhagiaafter egnancy evious LLETZ(largeloopexcision of the -menstrual bleedingformore thanthree tion disordersoranti-coagulanttherapy ocedure ispreceded byadoseof tions forpipellebiopsy: f age 1 flammatory and gynaecology. questions inobstetrics to thosecurly-yet-common readership, balancedanswers For thebroader • • • classified underthree definableheadings: The FIGOMDCadvisedthat thediagnosesshouldbe and ‘nototherwiseclassified’. dysfunction; endometrialIatrogenic; malignancy andhyperplasia;coagulopathy; ovulatory PALM-COEIN: polyp;adenomyosis; leiomyoma; categories arrangedaccordingtotheacronym The classification systemisstratified intoninebasic (FIGO MDC). and ObstetricsMenstrualDisordersCommittee by theInternational Federation of Gynaecology for underlying aetiologies of AUB has been developed A comprehensive, butflexible,classification system AUB innon-pregnant reproductive-age women • ultrasound results: of postmenopausal bleeding(PMB)willdependon anticoagulant therapy, or infection. Themanagement endometrial hyperplasia,disease inadjacentorgans, fallopian tubeorovarian,vaginal),polyps, Causes include:atrophy, cancer(endometrial, the variouscausesof anovulation are notrelevant. abnormal bleedinginpremenopausal women,since postmenopausal womenislessbroad thanfor The differ the causeof bleedingin10 percentof cases. carcinoma sincethispotentiallylethaldiseasewillbe bleeding shouldbeevaluated forendometrial All postmenopausalwomenwithunexpecteduterine Postmenopausal bleeding should beincludedhere. disorders, suchaschlamydialendometritis, menstruation. Otherinfectious endometrial for regulation of thevolumeof bloodlostat molecular andcellularmechanismsresponsible Disturbancesprincipallycausedbythe – coagulopathies) (AUB-C) Primar uterine bleeding manifest withsymptomsof theirregular onsetof hypothalamic-pituitary-ovarian axisthat typically reflecting dysfunctional relationships inthe Ovula S vaginitis) andfollow upiswithintwomonths tr If theendometriumislessthan 5mm, nofurther ystemic disordersof hemostasis(the eatment isrequired (except totreat atrophic ential diagnosisof bleedingin tory disorders(AUB-O)tory –Generally y disordersof endometrialorigin(AUB-E) Counties ManukauDistrictHealth Board General PractitionerLiaison MBChB, FRNZCGP Dr SueTutty District Health Board Senior HouseOfficer, DeptO&GAuckland MBBS, RNZCGP trainee Dr NatashaTrpkovska Ilievska 2 O&G Magazine WOMEN’S HEALTH 6,7 om a Mirena, om a Mirena, Vol. 20 No. 3 Spring 2018 | 77 Vol. µ/l (within the last y Care Partners. y Care 8 . Available from: from: . Available f heavy menstrual bleeding ena. Available from:www.pharmac.govt. ena. Available eport 2018. Abnormal uterine bleeding. eport 2018. . Endometrial sampling. Available from:https://patient. . Endometrial sampling. Available opriate pharmaceutical therapies as per the pharmaceutical therapies opriate ptodate. Approach to abnormal uterine bleeding in non- Approach ptodate. from: Postmenopausal uterine bleeding. Available ptodate. UT. The endometrial sampling procedure. Available from: from: Available The endometrial sampling procedure. UT. A Counties Manukau Health and Primar for Menorrhagia. August/2015. Care of Pathway Management of Access at:https://poac.rocketspark.co.nz/site_files/359/upload_ files/INFORMATIONPACKAGEMENORRHAGIAPATHWAYMAY2015. pdf?dl=1. Pharmac subsidy for Mir MQSG Annual r Payne J info/doctor/endometrial-sampling). U from:www. women. Available reproductive-age pregnant uptodate.com/contents/approach-to-abnormal-uterine- bleeding-in-nonpregnant-reproductive-age-women. U www.uptodate.com/contents/postmenopausal-uterine- bleeding. Wikipedia. Endometrial biopsy https://en.wikipedia.org/wiki/Endometrial_biopsy. www.fmhs.auckland.ac.nz/en/som/about/our-departments/ obstetrics-and-gynaecology/our-research/pip-studies/ about.html. nz/news/notification-2013-11-15-levonorgestrel-ius/. 12 months) or haemoglobin levels below 120g/L. 12 months) or haemoglobin A clinical diagnosis o to, or intolerance to, other A failed response appr 16 Serum ferritin levels below Heavy Menstrual Bleeding Guidelines Heavy Menstrual Bleeding

7. The increased use of Ferinject within primary care Ferinject within primary care use of The increased completes the with AUB anaemia associated to treat women with menorrhagia. for care package of Why should GPs do pipelle biopsies? of advantages. a number Endometrial sampling offers Endometrial cancers can be diagnosed in a more can be triaged more Patients timely manner. The burden if they do need a referral. appropriately on hospitals by avoiding a referral is reduced cases, to secondary (in over 50 per cent of care avoiding a care, women can be managed in primary secondary referral). care References 1. 2. 3. 4. 5. 6. 8. Statistical outcomes January to November from the program An audit of under care had received 78 patients 2017 found that by 21 was administered care This this pathway. managed completely GPs. The women were different has cases. There in primary per cent of in 52 care in primary care, inserted in Mirenas been an increase with seven inserted in the 11-month time period. the pipelle of results The audit showed that biopsies and ultrasounds had been managed who patients with 100 per cent of appropriately, having been to secondary care needed referral needed still patients of cent 48 per Although referred. triaged more they were to secondary care, referral had been as their initial investigations appropriately, completed. Despite the numbers being relatively some impact on the does have small, this project work load in secondary care. If the woman would clinically benefit fr If the woman would clinically but does not fulfil the above criteria, a Mirena can be above criteria, a Mirena but does not fulfil the by referral. the DHB on application from sourced On receipt of the results, the GP will explain the will explain the GP the results, of On receipt appropriate, where and, the patient diagnosis to under protocol. non-surgical treatment provide of for non-surgical treatment option The preferred a Mirena, of is the insertion this pathway under AUB The intrauterine system. a levonorgestrel-releasing Pharmac the is a subsidised item through Mirena met. if certain criteria are Pharmaceutical Schedule The initial criteria are: • • • 3 eater 6 eate a eate te, insufficient or limited equired to hold the cervix equired egardless of thickness, a thickness, egardless of 4,5 fort) ocedure takes one minute. takes ocedure etroverted, and whether it is enlarged etroverted, The pipelle pr steady for the biopsy The central piston is withdrawn to cr with The sample obtained is placed in a container formalin, which is labeled and sent to histology than 8mm: then a gynaecology assessment needs than 8mm: then a gynaecology such as a polyp. to look for other pathology, A A speculum is inserted to expose the cervix. tenaculum may be r the external The pipelle is inserted through cervical os until the fundus is reached (touching the fundus is best avoided, as it causes discom while moving vacuum, then the device is rotated three back and forth/up and down the cavity, the to five times. The sample should be seen in the device chamber of The sample is normal but the thickness is gr The sample is normal A vaginal exam is performed to assess cervix or position, whether the uterus is anteverted r The sample is inadequa Histology is abnormal If the endometrium is more than 5mm thick, than 5mm is more endometrium If the within or cystic spaces fluid reports or the scan r the endometrium is performed. pipelle biopsy Funding regulation Funding GP will potentially perform an The credentialed for the patient endometrial pipelle biopsy and refer a local radiology a transvaginal ultrasound through The DHB patient. the for the convenience of provider pays for the ultrasound and the pipelle biopsy. Pathway of care incorporated by GPs of care incorporated Pathway Counties Manukau District Health Board (DHB) has a funded pathway in Auckland, New Zealand, care The model of AUB. for the management of module for GPs to a credentialing incorporates non-surgical treatment diagnose and provide age reproductive and management for women of AUB. with symptoms of in primary care presenting this from Postmenopausal bleeding is excluded as many GPs as funding package. The intent is that can be so a patient possible will be credentialed, GP without and managed by her ‘regular’ treated to secondary care. referral requiring care of and oversight to maintain quality Training clinical lead for by the secondary care is provided in partnership with primary care. gynaecology, encouraged to manage women completely, GPs are available for further assistance is readily however, a from results of management or interpretation by writing an gynaecology senior medical officer, to a virtual or actual clinic. referral electronic There are a small number of risks: spotting or a small number of are There (for less than one hour); the procedure bleeding after (which is usually discomfort crampy period-like infection small risk of short-lived); and an extremely or uterine perforation. • • • • • Using a pipelle a pipelle biopsy follows this process: Generally, • • • • in the community, biopsy is done When the pipelle on the histology will depend further management thickness into taking the endometrial report, as well. consideration if: will be required Gynaecology assessment • WOMEN’S HEALTH experiment’ inAucklandthemid-20thcentury. contentious historicalmaterial from the‘unfortunate 1A (microinvasive) cancerof thecervix’,dealwith women withoutconventionaltreatment forstage an articlebyPauletalentitled‘Outcomes for In theJuneissue,bothaneditorialbySaville,and this issueof O&GMagazine. in thehandsof readers bythetimeof publication of ANZJOG issuesforJuneandAugust2018shouldbe birth, dilatation increases theriskof subsequentpreterm Cong etalfindthat previous caesarean section at full not arobot, and itdoesn’tmake anythingbetter’. gynaecological surgery, includingapieceentitled‘It’s argue forandagainstthecaserobotically assisted In theCurrent Controversies series,ChanandMunro morbidity. of shoulderdystociaonneonatal andmaternal ANZJOG by theEditoror, occasionally, by thePublications to date. About40percentare direct rejections submissions inthefirsthalf of 2018, around 230 We continued toreceive alarge numberof Editor, including theCurrent Controversies. to theincreased volumeof opinionandLetters tothe Guidelines onhypertensionandotherguidelines, Factor is probably duetopublication of theSOMANZ and Gynaecologycategory. TheriseintheImpact This result placesthejournal53/82inObstetrics ANZJOG hasrisento1.766 (from 1.607 in2016). to letyouknowthat the2017ImpactFactor for our publishersWileyon26June2018. Iamhappy The 2017JournalCitation Reportwasreleased by aneuploidy inthecell-free DNAera, topic of non-invasiveprenatal testingforfetal The Augustissuecontainsseveralarticlesonthe of womenwithdecreased fetalmovements. to AustralianandNewZealand guidelines onthecare from Chan and Munro. surgery, includingtheCurrent Controversy replies on thetopicof robotically assistedgynaecological service fortheprovision of earlymedicalabortion. using anAustraliandirect-to-patient telemedicine Hyland andassociates onthefirst1000patients et al. Perspective Frequently Asked Questionsfrom Rieder editorial from Maxwell andO’Leary, desk editor’s From the 10 3 andMichelottietaldescribetheimpact There are three furtherstimulating pieces 4 There isalsoaninteresting report from 11,12 Also of interest is an update 9 8 andaClinical includingan 13 6,7 1,2 5

issue possible. Committee. Iamgrateful toWileyformaking this Clarke, Chairof theIndigenousWomen’s Health reproductive health.ThiswillbeeditedbyDr Marilyn the journal,concernedwithIndigenouswomen’s a specialfree-access ’virtual’onlineeditionof September inAdelaide, To coincidewiththeRANZCOG 2018ASMin Current Controversies. welcome furthersuggestionsfortopicsthe including shortcommunications. Asalways,Iwould and Methodssectionof alloriginalresearch articles, of de-identifieddata collection)withintheMaterials ethics approval insomecasesof retrospective use approval (orintheabsenceof, needforformal UK spellingandtheinclusionof detailsof ethics the readership. We willbeemphasisingtheuseof Society Guidelines,astheseare inhighdemandby We willalsohaveanothercategory of Specialist and limitations ontablesandfigures adhered to. to addgreater stringencyinregard towordcount by theAssociate andAssistantEditors.Iamexpecting The authorguidelinesare currently beingreviewed the readership. Current Controversies series,andiswellreceived by quality evidence-basedopinion),particularlyinthe section continuestobewellsubscribed(high- ultimately acceptedforpublication. TheOpinion sent forfullpeerreview andaround halfof theseare outside theauthorguidelines.Theremainder are Coordinator, ifthemanuscriptdemonstrablylies 7. 6. 4. 3. 2. 1. References 5.

58(3):375. at allanditdoesn’tmake anythingbetter. ANZJOG2018Jun; Munr gynaecology inAustralasia. Chan F of thefirst18 months. telemedicine abortionserviceinAustralia: Retrospective analysis Hyland P Michelotti F preterm birth? full dilatation increase thelikelihood of subsequentspontaneous Cong A,deV carcinoma of thecervix. without conventionaltreatment forstage1A(microinvasive) Paul C,SharplesKJ cervical screening. Saville M,McNallyO and maternal morbidity. ANZJOG2018Jun;58(3):298. stratified bytype of manoeuvre, onsevere neonatal outcome o MG.Thesurgical‘Robot’ ingynaecology:Itisn’tarobot . Robotic-assisted surgical procedures are thefuture of ANZJOG Editor-in-Chief FRANZCOG Prof Caroline deCosta , RaymondEG, ChongE.Adirect-to-patient , Flatley C,Kumar S. Impactof shoulderdystocia, ries B, LudlowJ. Doesprevious caesarean sectionat ANZJOG 2018Jun;58(3):267. , BaranyaiJ, etal.Outcomesforwomen ANZJOG 2018Jun;58(3):265. . ‘Lest weforget’ aswemoveforwardwith ANZJOG 2018Jun;58(3):335. ANZJOG 2018Jun;58(3):321. ANZJOG willbepublishing ANZJOG 2018Jun;58(3):371. WOMEN’S HEALTH ANZJOG 2018 Aug; Vol. 20 No. 3 Spring 2018 | 79 Vol. , et al. Care of pregnant women pregnant of , et al. Care . Right of reply to: The surgical ‘Robot’ in gynaecology: It in gynaecology: surgical ‘Robot’ to: The reply . Right of o MG. Right of reply to: Robotic-assisted surgical to: Robotic-assisted reply o MG. Right of isn’t a robot at all and it doesn’t make anything better. ANZJOG anything better. make all and it doesn’t at isn’t a robot 2018 Aug;58(4):478. a clinical practice of movements: update fetal with decreased and New Zealand. guideline for Australia 58(4):463. Munr G, Bowring V Daly LM, Gardener Chan F in Australasia. gynaecology of the future are procedures ANZJOG 2018 Aug;58(4):480. 12. 11. 13. ranzcogasm.com.au ANZJOG 2018 Aug; ANZJOG 2018 Aug;58(4):397. Join the conversation. Keep up to date and follow and follow up to date Keep Join the conversation. #RANZCOG18 news in real-time all the breaking at updates Follow ASM developments and program www.ranzcogasm.com.au on Facebook Connect with RANZCOG Can’t make it to Adelaide? Can’t make , O’Leary P. Public funding for non-invasive prenatal for non-invasive prenatal Public funding , O’Leary P. clay J, Poulton A, et al. Prenatal diagnosis and diagnosis and et al. Prenatal Poulton A, clay J, , White S, McGillivray G, Hui L. Contemporary prenatal prenatal G, Hui L. Contemporary McGillivray , White S, Rieder W Hui L, Bar Maxwell S aneuploidy – it’s time. testing for fetal asked In Australia: Frequently practice? aneuploidy screening DNA era. cell-free questions in the socioeconomic status in the non-invasive era: prenatal in the non-invasive status socioeconomic ANZJOG 2018 Aug;58(4):404. study. a population-based 58(4):385. 8. 9. 10. WOMEN’S HEALTH Club Journal WOMEN’S HEALTH study reported onthechangeintrends of route of hysterectomy andremoval of adnexaefrom 2001–2015. or preserved. hysterectomy. However, there wasnodifference inthechange,comparingwomenwhohadtheirtubes removed preservation of theirfallopiantubes.Inbothgroups, there wasasignificantdecrease inAMHthree months after anti-Müllerian hormone(AMH)levelspre andpost-hysterectomy inwomenwhowere randomisedtoremoval or is decrease of ovarianreserve, despitepreservation of theovaries.Arecent smallstudycompared thedecrease in a significant reduction intheoccurrence of ovariancancer(OR=0.51, 95%CI 0.35-0.75). that removal of thefallopiantubesat hysterectomy orsterilisation inthegeneralnon-high-riskpopulation had A significantproportion of ovariancanceroriginates inthefallopiantubes.A2016meta-analysis concluded Salpingectomy athysterectomy 3. oon S, KimS, ShimS, etal.Bilateral salpingectomycanreduce theriskof ovariancancerinthegeneralpopulation: Ameta-analysis. 2. 1. References removal from 2001–2011ineithertheyoungerorolderagegroups. This increase hasoccurred almostentirely after 2011.There wasnosignificantincrease intherate of adnexal 65 percent(p<0.005), andintheolderagegroup (over55yearsold)from 44percentto58(p<0.005). hysterectomy forbenignreasons increased inboththeyoungeragegroup (35–54yearsold)from 31percentto the rate of laparoscopic hysterectomy rose by153 percentoverthestudyperiod.Therate of adnexalremoval at There wasadecrease inthenumberof hysterectomies performedbytheabdominalandvaginalroutes, while overall rate of hysterectomy fellsignificantlyacross theseyearsfrom 54.7 to40.7 per10,000 peryear(p<0.005). included treatment observation, excision orablative treatments. A 2017 LLETZ) treatment forCIN1between1997and2009, andtheir31,021 subsequentdeliveries. pregnancy outcomesof more than4500womenwhoreceived loopelectrosurgical excision procedure (LEEP, adverse obstetricoutcomes,includingpreterm birth.Alargeregister-based Scandinavianstudyexaminedthe women willgoontopregnancies after treatment forCINandthere isconcernabouttreatment methodsand Cervical intraepithelialneoplasia(CIN)isaprecancerous lesioncommoninreproductive-aged women.Many 2. 1. References dysplasia for cervical Pregnancy following treatment may beconsidered asanalternative insomewomen. increases therisk of preterm labourin subsequent pregnancies. Appropriate observation orablative procedures risk of preterm labour(oddsratios 1.45, 95%CI1.02–1.92). (odds ratios 0.95, 95% con received adiagnosisof CIN1,butdidnothaveaLEEPprocedure, didnothaveanincreased riskof preterm labour 0.71–1.13). Incomparisonwithotherwomendeliveringinthesamecatchment inthestudyperiod,thosewho women received adiagnosisof CIN1,but didnothaveaLEEPprocedure (oddsratios 0.90, 95%con post-LEEP treatment (oddsratios 1.47, 95%con women, there wasincrease intherate of preterm birth(before 37weeksgestation) whencomparingpre- and of excision forrepeat treatment. rate of withexcisional preterm delivery rather thanablative techniques,andincreased rates withincreased depth RR 1.75, 95%CI1.57to1.96). Theyalsohadhigherrates before of 34and28weeks. There delivery wasahigher risk of preterm birthat lessthan37weeks,compared towomenwhohadnotreceived treatment (10.7% vs5.4%, pregnancies, with65,000 womenhavingreceived treatment. Women who hadtreatment were at increased overall

methods of withandwithoutprophylactic bilateral salpingectomy:arandomized controlled trial. Asgari Z,T study. 2018;2018:5828071. MinimallyInvasiveSurgery Cur 2016 Mar;55:38-46. Y disease. K cohort study. ActaObstetGynecolScand 2018;97:135-141. Heinon enA,GisslerM,PaavonenJ yrgiou M,Athanasiou A,Kalliala IEJ, etal.Obstetricoutcomes after conservative treatment for cervicalintraepitheliallesionsandearly invasive Cochrane reviewanalysedtreatment of anygrade of CINandearly gradeIA1cervicalcancer. Studies e N, RobsonS. Changesinhysterectomy route andadnexalremoval forbenigndiseaseinAustralia2001–2015:anational population-based Cochrane Database Syst Rev.2017Nov2;11:CD012847. ehranian A,RouholaminS, etal.Comparingsurgicaloutcomeandovarianreserve after laparoscopic hysterectomy betweentwo 3 fi dence interval 0.76–1.21), while those who had a LEEP procedure did have an increased , etal.Riskof preterm birthinwomenwithcervicalintraepithelialneoplasiagradeone:apopulation-based 2 Thesestudiesreinforce theknowledge that excision treatment of cervical disease fi dence interval1.05–2.06). There wasnosignificantincrease if 1 2 The analysis includeddata from oversixmillion 2 Onepossibleconsequenceof hysterectomy mini-reviews byDrBrett Daniels. recent research byreading these journals? Catch uponsome Had timetoread thelatest J CanResTher2018;14:543-8. 1 Arecent Australian 1 Within thisgroup of fi dence interval Eur J Cancer 2 The THE COLLEGE Vol. 20 No. 3 Spring 2018 | 81 Vol. -Gyn 27) -Obs 57) tion 3 June 2018 tion of intermenstrual and postcoital tion of intermenstrual pdated references pdated tural Competence (WPI 20) tural Competence (WPI  U tionale: The Women’s Health Committee tionale: The Women’s 1. references Updated 2. elearning resources Link to CLIMATE 1. references Updated 1. has highlighted that the Australasian Society has highlighted that for Ultrasound in Medicine (ASUM) provides is accessible via guidance on this topic that their website. It was their recommendation in this statement only one paragraph (4.3) that and added to the College should be retained fetal structural assessment of Prenatal statement 60) as a recommendation. conditions (C-Obs COGU from Additional feedback was requested The correspondence this statement. regarding was in line with the discussions and received made by the committee. recommendations  Ra Endometrial Abla Investiga 6) bleeding (C-Gyn (C Fibroids in Infertility Cul Fetal Morphology (C Notice of Deceased Fellow the death The College was saddened to learn of Fellow: the following RANZCOG of Dr Ralph Hickling, • College Statement Retired • on can be viewed College Statements A full list of at: Guidance app or on the website the RANZCOG www.ranzcog.edu.au/Statements-Guidelines. Patient Information RANZCOG Information Patient 33 RANZCOG are There and Pamphlets, including the new Pregnancy 18 pamphlets, now available. All Childbirth pack of at: can be viewed and ordered these products of www.ranzcog.edu.au/Womens-Health/Patient- Information-Guides/Patient-Information-Pamphlets. for publication The following new title was approved and is now available: • • • Prof Yee Leung Prof Yee Chair Committee Health Women’s RANZCOG t term -Obs 55) tal Period (2017) tional Guideline July 2018: f consultation and f consultation

-Obs 29a) -Obs 46) COG/HGSA statement rewritten by rewritten statement COG/HGSA tion of paragraph (4.3) from the from paragraph (4.3) tion of f title: formerly Prenatal screening f title: formerly Prenatal f title: formerly Testing for f title: formerly Testing ecommendations and definitions ecommendations eview and update to align with the new eview and update f the recommendations relevant to relevant f the recommendations tal anxiety and depression (C-Obs 48) tal anxiety and depression (C-Obs tal assessment of fetal structural tal screening and diagnostic testing for pdated references pdated pdated references and recommendations references pdated pdated references pdated ternal suitability for models of care and   Aligned with Australian Na Appendices consisting o referral guidelines changed to a link rather referral than full document  All o (with permission) taken were care maternity and placed in this Guideline the National from statement Clear r regarding the treatment of overt of the treatment regarding and subclinical hypothyroidism hypothyroidism  Mental Health in the Perina working group Joint RANZ        and diagnosis of chromosomal and genetic chromosomal and diagnosis of conditions in the fetus in pregnancy Amalgama Change o Early r Fetal Morphology (C-Obs College statement 57 can be retired 57), so C-Obs U Program Cervical Screening National hypothyroidism during pregnancy during hypothyroidism U Change o U -Obs 56) 1. 1. 1. 1. 2. Updated references 2. references Updated 3. 3. 1. 2. 1. references Updated 2. 1. 1. 1. references Updated Prena 60) conditions (C-Obs Diethylstilboestrol (DES) exposure in utero (C Prena fetal chromosomal and genetic conditions 59) (C-Obs Substance use in pregnancy (C Perina Subclinical hypothyroidism and hypothyroidism Subclinical hypothyroidism and hypothyroidism in pregnancy (C Ma for referral within and between indications 30) models of care (C-Obs Timing of elective caesarean section a Timing of elective caesarean of the and in Progesterone support the first trimester (C (C-Obs 23) (C-Obs • • • • • The following revised statements were approved by approved were statements The following revised Council and Board in RANZCOG • • • • July 2018 July College Statements Revised College Statements update Statements College THE COLLEGE Dr Winston Almeida. Dr Sarah Rylancewithherhusband Andrew; andFellow, FRANZCOG Trainee, Dr Stephanie Green; FRANZCOG Trainee, Deputy ChairProvincial FellowsCommittee,DrJared Watts; knowing you Knowing me, to followsoon. Coast, Queensland,inJune2019, withfurtherdetails Regional ScientificMeetingwillbeheldontheGold The RANZCOG 2019Provincial Fellows/QLD/NSW who helpedmake themeetingsuchasuccess. ABBA-themed gala dinner. Thankyoutoeveryone theme alsoservedasinspiration forthesold-out creating healthyandsupportiveworkplaces.The on lookingafter ourselvesandourcolleagues, The theme,‘Knowing Me,KnowingYou’, focused Diplomates DayforGPs. pre-conference workshops,includingadedicated and GPs.Attendees alsoparticipated inseven day scientificprogram designedforbothspecialists trainees andmedicalstudentstookpartinthetwo- More than170Fellows,Diplomates, midwives, Bunker Bay, Western Australia,26–29April2018 Regional ScientificMeeting RANZCOG 2018ProvincialFellows/WA/SA/NT College Councillor, DrKristyMilward. Radiologist/sonologist, DrEmmelineLee,andWA masterclass creations. Fellow, Dr Patty Edge,showoff theirpastry FRANZCOG Trainee, DrJenniPontre, and spirit of theABBA-themed galadinner. President-elect, DrVijayRoach,get intothe Board member, Prof Yee Leung,and THE COLLEGE Vol. 20 No. 3 Spring 2018 | 83 Vol. Generalist Gynaecology ATM Gynaecology Generalist 26 weeks FTE Level 6 Level 6 Compulsory ATMs the who elect to take For advanced trainees satisfactory of completion generalist pathway, and Generalist ATM both the Generalist Obstetric these This means that is required. Gynaecology ATM the level across to consultant trainees will progress practice. of generalist O&G scope pursuing the academic pathway An advanced trainee pathway, met the criteria for that have will already are which includes a PhD (or equivalent). They in to complete the Essential O&G Skills ATM required the common consultant level across order to reach practice. scope of trainee electing to take the subspecialty Similarly, will need to complete the the subspecialist pathway in order to formalise the Essential O&G Skills ATM the consultant-level practice across of attainment practice. common scope of for Why mandate the Essential O&G Skills ATM trainees? subspecialty aspect This has perhaps been the most controversial Why not let the changes to advanced training. of The subspecialty trainees do only their subspecialty? following is the rationale. on What is the scope of practice of a new Fellow is awarded? the day that FRANZCOG credentialing for It is perfectly reasonable it define College that the committees to demand of Currently, FRANZCOG. it means to be awarded what question. In the the College is unable to answer that Subspecialty training Year 2 Subspecialty training Year Subspecialty training Year 1 Subspecialty training Year Generalist Obstetrics ATM 26 weeks FTE Elective training 46 weeks FTE Generalist Obstetrics ATM 46 weeks (ca 0.5 FTE) 46 weeks (ca 0.5 Generalist Obstetrics ATM FTE Elective training 46 weeks ca 0.5 Example 1 Example 5 Example 3 Example 2 Example 4 FRANZCOG Advanced Training (104 weeks) Advanced Training FRANZCOG Level 5 Level 5 FRANZCOG Advanced Training/Subspecialty Training (104 weeks) Training Advanced Training/Subspecialty FRANZCOG Subspecialist pathway. . Generalist pathway. Subspecialty training Year 1 Subspecialty training Year for example, Essential O&G Skills ATM, (incorporating the hospital) a fortnightly shift on-call for O&G at Elective training 46 weeks FTE Elective training 46 weeks Essential O&G Skills ATM) (incorporating Generalist Obstetrics ATM and Generalist Gynaecology Generalist Obstetrics ATM 46 weeks ATM Generalist Gynaecology ATM 46 weeks (ca 0.5 FTE) 46 weeks (ca 0.5 Generalist Gynaecology ATM FTE Elective training 46 weeks ca 0.5 The College has developed the Advanced Training the Advanced Training The College has developed to structure more to provide Modules (ATMs) training FRANZCOG Advanced Training. FRANZCOG the College’s governing body, by was last reviewed the of One Council, in 2013. the Australian Medical report the accreditation of recommendations key to Advanced structure was to implement greater Complete flexibility is no longer tenable. All Training. on or advanced trainees who commenced training to complete a required are 1 December 2014 after prior to being awarded FRANZCOG. compulsory ATM the past over has been disseminated Information e-newsletter and the Collegiate years through three Bulletins. the Training to FRANZCOG Pathways training. the same basic (core) All trainees undertake the trainee This can be viewed as progressing scope of a broad level across to senior registrar basic training, the practice. On completion of to begin a trainee should be equipped FRANZCOG position as an O&G senior registrar. distinct pathways three The College now recognises consultant level reach All pathways to FRANZCOG. practice’, but each has scope of the ‘common across practice: academic, generalist an additional scope of map to ATMs or subspecialist. The new compulsory these scopes of practice. Michael Permezel Education Strategy Committee Chair, Table 2. Table Training Modules Training FRANZCOG Advanced Advanced FRANZCOG Table 1 Table THE COLLEGE Queen’s BirthdayHonoursAwards circumstances that applythrough variouslocations 'on-call' forthehospital.However, there are myriad uncommon (outsideof MFM)forasubspecialisttobe hospitalsinlargecities,wherefocus tertiary itis of practisingtheirsubspecialty. easyto Itisvery simple office O&G atconsultantlevelinthecourse A subspecialistmayalsobeexpectedtoperform the O&Gon-callroster A subspecialistmayberequiredtoparticipatein consultant practiceforthelatter year(s)of training. subspecialty trainingpathways are dependenton subspecialty training?Thisisnotpossibleasmany Could FRANZCOG bedelayeduntilcompletionof O&G at seniorregistrar level. a generalist,neverhavingperformednon-complex new Fellow. Thetraineeisneitherasubspecialistnor in apositionwhere theylackascopeof practiceasa practice at seniorregistrar level,thetraineemaybe In theabsenceof performingthecommonscopeof non-completion are relatively highinsomeareas. These differ across thesubspecialties,butrates of subspecialty trainingforavarietyof reasons. trainees (approximately 30percent)donot complete It isanunfortunate reality that manysubspecialty subspecialty training A subspecialty traineemightnotcomplete of practice. level across thisrelatively restricted commonscope new FRANZCOGs are abletopractiseat consultant the EssentialO&GSkillsATM shouldensure that all senior registrar levelat theendof basictraining, outside of theirsubspecialty. Havingonlyreached practice non-complexobstetricsandgynaecology subspecialties, manysubspecialistswillelectto Although thisvariessignificantlybetweenthevarious common scopeofpractice A subspecialistmaycontinuetopractiseacrossthe common scopeof practice. Fellows havereached consultantlevelacross the future, theCollegewillbeabletosaythat allnew than 70papersin peer-reviewed journals. over 100scientificmeetingsand haspublishedmore Editor of ANZJOG.Hehasbeenaninvitedspeaker at International MenopauseSocietyandAssociate at theUniversity of Sydney, President of the Prof Baber isProfessor of obstetricsand gynaecology Prof Rodney Baber of Australia: Member (AM)intheGeneralDivisionofOrder for pre-eclampsia andprevention of stillbirth. management of fetal growth disorders,treatments interests focusonimproving thedetectionand and anacademicclinicalresearcher. Herresearch Prof Walker isamaternal-fetal medicinesubspecialist Prof SusanWalker of Australia: Officer (AO) intheGeneralDivisionofOrder and gynaecology. for theircrucialworkinthefield of obstetrics for beingawardedhonoursonAustraliaDay2018 RANZCOG wouldlike tocongratulate ourFellows Advanced-Training-Modules. Training/Specialist-Training/Training-Requirements/ For more information goto:www.ranzcog.edu.au/ • ATMscompulsory andinclude: interest. Theycanbedoneinconjunctionwiththe wanting tofurtherdevelopanarea of particular Optional SpecialInterest ATMs are availableforthose Special InterestATMs a yearthat ismore geared towardsgynaecology. commenced subspecialitytrainingorare undertaking in Years 5and6, includingthosetraineeswhohave three-month block.We believethat thisisachievable through weekends on-callforanO&Gunitorina of the EssentialO&GSkillsATM maybeachievable time orfull-time.Theprocedural requirements anytime during Advanced Training, either part- ATMsThe compulsory can beundertaken ATMsWhen mustthecompulsory beundertaken? was awarded. practice waspresent onthe daythat FRANZCOG committees are entitledtoknowwhat scopeof and CPDbeyondFRANZCOG. However, credentialing role of credentialing committeestoassesscurrency Fellows onthedaytheyacquire FRANZCOG. Itisthe the commonscopeof practiceappliesonlytonew them. Theabilitytopractiseat consultantlevelacross subspecialists andthosethat wouldhavetotrain has causedneedlessalarmamongboththe The prospect of retraining establishedsubspecialists the commonscopeofpractice? Do allsubspecialistsnowneedtoretrainacross subspecialists participate ontheon-call roster. in AustraliaandNewZealand. There are sites where • • • specialist endometriosis managementteams. involved intheirowncare andstrongly advocates for conception techniques,heencourages patients tobe requiring advancedsurgicaland/orassisted Specialising inthetreatment of endometriosis training centres forgynaecologistsinAustralia. A/Prof Cooperinitiated oneof the earlyendoscopic A/Prof MichaelCooper Medal (CAM)oftheOrderAustralia: of theCentre AgainstSexualAssault(CASAHouse). Health at LaTrobe University. Heisalsoco-founder Women's HospitalandAdjunctA/Prof of Public Services andClinicalGovernanceat theRoyal A/Prof RetiisDirector of Gynaecology, Cancer Adjunct A/ProfLeslieReti of Australia: Member (AM)intheGeneralDivisionofOrder education andtothecommunity. has beenawardedforsignificantservicetomedical Dr Taylor isaurologist andurogynaecologist, who Dr JohnTaylor (HL-ATM) Colposcopy (C (SRH Contraception, AbortionandSexualHealth Hyster Pelvic FloorDisorders(PFD -ATM) oscopic andLaparoscopic Surgery -ATM). -ATM) THE COLLEGE Vol. 20 No. 3 Spring 2018 | 85 Vol. 10/08/2018 10:17:13 AM Dr Lisa Rasmussen General Practitioner Planning Austin Family Australia Heidelberg, Victoria, Vol. 20 Winter O&G Magazine of Since publication to have the No. 2 on abortion, I was fortunate Professional the 2018 opportunity to attend Group the Abortion Providers at Development Forum The forum, held (APGANZ). New Zealand Aotearoa of a program presented over two days in Dunedin, women having early for care talks on all aspects of program A thought-provoking abortions. and late by local practitioners, including was presented doctors, midwives, nurses, and two international British of Medical Director Lohr, guests, Dr Patricia Advisory from Pregnancy Service, and Dr Ea Mulligan Flinders University. O&G at the Department of committed of It was a privilege to meet such a group not for and caring practitioners. I was struck, and and the first time, by how important it is to listen on our practices each other; to reflect learn from social and the wide-ranging cultural, political and we do. How we practise shape what that forces the forum, conclusion of the is not immutable. At invited to think about what all participants were to change over the next 12 months. we would like Supported by the warm collegiality I experienced, work my place of to work with others at I would like protocol prophylaxis anti-D our current to review to prophylaxis and to consider not giving anti-D less than seven weeks; to women having abortions at training and access to services; continue improving and to start the discussion about general anaesthetic, standard practice in Victoria, versus the standard in New local anaesthetic and sedation practice of for women having first-trimester surgical Zealand, to acknowledge the I would like abortions. Finally, document for Care of new Standards excellent that an abortion in New Zealand women requesting has been completed this year. Thank you to APGANZ and to Dr Janet Downs and the organising committee. @ranzcog O&G Magazine Winter Vol. 20 Vol. O&G Magazine Winter Follow us on social media; join the conversation RAN003 FILLER ADVERT TEMPLATES HALF PAGE HORIZONTAL.indd 1 Dr Margaret Sparrow DNZM, MBE HonDSc FAChSHM, BSc, MBChB, Dip Ven, FRANZCOG(Hon) NZ Wellington, Istar Ltd, Director, Dr Carol Shand CNZM FAChSHM MBChB, FRNZCGP, NZ Wellington, Istar Ltd, Director, Congratulations. contributes significantly to the discussion on No. 2 contributes significantly best medical changes in abortion laws to reflect detail More practice in Australia and New Zealand. laws in on the current could have been provided place but hopefully changes will take New Zealand, The article on the and this topic can be revisited. distance focuses on a universal access tyranny of even though the distances In New Zealand, problem. outside the main centres residing women smaller, are significantly disadvantaged. are that It would have been instructive to point out 1980 has since collection in New Zealand statistics and useful information providing been creditable, From of abortion procedures. safety the confirming in a total of have been no deaths there 1980–2017, very favourably abortions. This compares 436,043 one or fewer deaths of quoted with the WHO figure per 100,000. minor relatively on two is provided Clarification in the article on early medical abortion, points. Firstly, involvement by Dr Rasmussen argues for greater facilities to become doctors outside dedicated Unfortunately, of mifepristone. certified prescribers for this to happen in pathway no is currently there All abortions must be performed in a New Zealand. licensed facility until the law is changed. The advice doctors should contact the Abortion interested that this will only confirm Aotearoa Group Providers in the article on post-abortion Secondly, restriction. contraception under emergency contraception, the is pill the 30mg ulipristal acetate authors imply that it is not. but, regrettably, available in New Zealand, Letters to the Editor to the Letters THE COLLEGE Obituaries large workload, Richard decidedtoretire. Itook In 1998, aged60, withsomehealthissues andavery was admittedasaFellowof RANZCOG in1998. the AustralianandNewZealand Colleges,Richard Fellowship in1984. Followingtheamalgamation of and Gynaecologistsin1979, receiving hisRCOG of the RoyalAustralianCollegeof Obstetricians Richard wasadmittedasaFoundation Fellow College Hospital. had beenaregistrar withRichardat theUniversity joined byDrVivienneO’Connor(MRCOG) who Hospital andinprivate practice.In1977, theywere O&G practiceinMackay, workingat MackayBase In 1975, DrLukinandRichardstartedthefirst obstetrician andgynaecologist. the PaulHopkinsFamily MedicalCentre asaGP Queensland, Australia,where Richardworked in by DrLukin,thefamilyemigrated toMackayin to anadvertisementinthe and University CollegeHospital.In1972,inresponse On return totheUK,heworked at theWhittington College of Obstetricians andGynaecologists. In 1969, RichardbecameaMemberof theRoyal at theKenyatta hospitalinNairobi, Kenya. country. Hethenworked forayearinfamilyplanning to politicalupheaval,hewasforced toleavethe in Ugandaasaseniorregistrar. Unfortunately, due for ayearbefore movingtotheMulagoHospital Richard worked asaregistrar ontheIsleof Wight Tania (deceased). for 43yearsandhadtwochildren: Angusand Richard marriedJanein1968. Theywere married where hemetJaneKerr, anurse. before movingtoSt HospitalinCheam, Anthony’s who encouragedhimtospecialiseinobstetrics, Hospital inSurrey underDrDoreen Daly(MRCOG), his later emigration. Richardthenworked at St Helier Ferguson from Australia,whowere instrumentalin he metDrGresley Lukin(MRCOG) andDrRussell hometown of Chelmsfordasajuniordoctor, where in1962,RichardreturnedQualifying toworkinhis in 1858. appointed SurgeonExtraordinary toQueenVictoria writing severalbooksonthesubject.Hewasalso Stanley (1793–1862)wasdemonstrator of anatomy, where hisgreat-great-great-grandfather Edward medicine at St Bartholomew’sHospitalinLondon, Richard wasborninHarrogate intheUK.Hestudied passed ontohissonandgrandchildren. and hisinspirational workethicare legacieshehas Richard’s commitmenttothecore valueof medicine of Queensland. and introduced keyhole totheMackayregion surgery founding memberof theFertilitySocietyof Australia patients andhadagreat loveof obstetrics.Hewasa Richard wasapersonwhocared deeplyforhis 1938–2012 Dr RichardBowenStanley British MedicalJournal FRANZCOG Dr LanceHerron sadly missed. of fun.Hehadanabilitytomixat alllevels andis manner, patient disposition,andanimpishsense wonderful personality, characterisedbyaneasygoing patients, faithful staff, colleaguesandfamilyforhis 23 May2012.Hewillberemembered byhismany visiting national parks.RicharddiedinBrisbaneon good momentwascherishedandspentwithfamily cancer, anillnesshebore withgreat dignity. Every In 2011,Richardwasdiagnosedwithpancreatic toured manypartsof Australia. four grandchildren. Theyboughtacamper trailer and Jane retired toBrisbanebeclosertheirsonand golf andtravelwasagreat familyman.Heand Richard hadmanyinterests, includingphotography, September 2004. then memberof Mackay, TimMulherinMP, on 16 Stanley House.Thiswaso in Mackay, hadnewrooms builtandnamed them over thepracticeand,asatributetoRichard’swork and Gynaecology (RCOG) from 1967whenheset Alan wasinvolvedintheRoyalCollege of Obstetrics for motherandbaby. change inmanagement,which improved theoutlook obtained thecooperation of themall.Heachieveda family doctorsdoingobstetrics in thisregion andhe pregnant women. There were more thanahundred association studyin1960toimprove thecare of doctors, nursesandmidwives.Hesetupamedical taught medicalstudents,residents, registrars, family Singleton HospitalandCessnockHospital.He former Western SuburbsHospital,Maitland Newcastle Hospital,Mater HospitalBrisbane, the appointments atpractice. Hehadhonorary Royal rapport withhispatients meanthehadahugeprivate skilfulsurgeonandobstetrician. His Alan wasavery achieved thisandreturned toNewcastle. Edinburgh andstudyforthesurgicalfellowship.He Elliott. Alantookayear’ssabbatical in1965togo productive partnershipwithJack He hadavery In 1958, Alanbeganprivate practiceinNewcastle. examination andworkfortwoyearsat Oxford. there before goingtotheUKdospecialty specialise inO&GHobartandspenttwoyears as resident medicalofficers. Hethendecidedto him, andtheybothcametoRoyalNewcastleHospital Alan marriedPia,whograduated inmedicinewith university vacations. this byworkingintheorangeorchards inthe tuition andasmalllivingallowance.Heaugmented medicine at Sydney University. Thisgavehimfree awarded aCommonwealthscholarshiptostudy out workingat BHPdoingmetallurgybefore being him inLisarow, nearGosford,NSW. Alanstarted Alan wasahomebirth.Thelocalmidwifedelivered 1927–2017 Prof AlanHewsonAM fficially openedbythe THE COLLEGE Vol. 20 No. 3 Spring 2018 | 87 Vol. FRANZCOG FRANZCOG Dr William Hugh Patterson 1928–2018 Hugh lived an industrious life and his contributions medicine, military service felt in the practice of were and medical politics. matriculated and, in 1946, He was born in Sydney he Here Sydney. of the University into medicine at met Pamela Nisbet, another medical undergraduate. in 1952 and They graduated Pamela became a GP. married the following year. the Royal Hugh gained early experience at Launceston General Alexandra Hospital for Children, and Lewisham Hospital in Hospital in Tasmania the he travelled to the UK and sat In 1957, Sydney. Obstetricians for the Royal College of examinations becoming a Member and Gynaecologists (RCOG), several years in and after On his return, in 1958. general practice, he was appointed to Royal North Hospital and the Royal Hospital for Women Shore Honorary or in Paddington. He held the positions of at both hospitals for three Visiting Medical Officer in RCOG decades. Hugh was elected a Fellow of Surgeons the American College of a Fellow of 1974, the Royal Australian College in 1976 and a Fellow of Obstetricians and Gynaecologists in 1979. of the Australian and of Following the amalgamation Colleges, Hugh was admitted as a New Zealand his career, For most of in 1998. RANZCOG Fellow of Sydney of the University at he was a clinical lecturer New South Wales. of and the University was the investigation Hugh’s major clinical interest the cervix. cancer of pre-invasive of and treatment the first gynaecologists to use a He was one of private colposcope for this purpose in a Sydney Frankston, Victoria. He obtained Fellowship of of Fellowship He obtained Victoria. Frankston, Obstetricians College of the Royal Australian following the in 1997 and, and Gynaecologists and New Zealand the Australian of amalgamation in RANZCOG of admitted as a Fellow Colleges, was up private to Perth and took Glenn returned 1998. well as public as O&G in Subiaco, WA, practice in and King Osborne Park Hospital appointments at Edward Memorial Hospital. fondness by his with great Glenn is remembered in his man, generous peers as a kind and gentle those junior all colleagues, but especially support of the many of and encouraged to him. He nurtured who miss Australian O&G workforce, Western current a hand. He was always willing to lend him greatly. work and his patients, to his Glenn was dedicated his work as ‘the best job in the describing often described with fondness his sense of world’. Patients and devotion to their gentleness, dedication humour, Glenn Often described as a true gentleman, care. wonderful was a skilled and ethical practitioner and a role model. kite medicine included outside of Glenn’s interests his the pursuits of boarding, gardening and any of and grandfather. He was a devoted father children. his community, missed by the O&G He is greatly Glenn is with whom he worked. and the staff patients his early passing. with much fondness after of spoken LeakeDr Robyn FRANZCOG Dr Colin Leake Dr Glenn Lewis 1963–2017 to Glenn was born in the UK and emigrated Australia with his family as a child. He Western Australia (UWA) Western of the University attended his Bachelor of and received as an undergraduate Glenn met his wife, Surgery. Medicine, Bachelor of who went on to become a UWA, Julie Hammond, at GP in Perth. Julie and Glenn had two children. his training in Glenn completed the majority of Memorial Hospital in Perth, King Edward O&G at and with time also spent in Hobart, Tasmania, up a local branch of the RCOG called the Northern the Northern called the RCOG of branch up a local Society (NOGS). Alan and Gynaecological Obstetrical College the Royal Australian of obtained Fellowship in December Obstetricians and Gynaecologists of the of the amalgamation 1978 and, following Colleges, was admitted and New Zealand Australian in 1998. RANZCOG of as a Fellow the NSW committee of Alan served on the executive he was elected to the Australian for five years before on this council for 11 Council in 1981. He served education the he chaired years, during which time the obligatory committee and masterminded of program and certification continuing education has been a huge success the College. The program for other medical and has formed the template Medal. the President’s colleges. Alan was awarded the College and was became Secretary of He later College subspecialties of involved in the evolution with family doctors and midwives. and relationships the medical board of Alan was chairman of Locally, with the Royal Newcastle Hospital and coordinated, the submission to the Australian Medical Association, a medical Karmel Committee, which recommended in school for Newcastle. Alan was heavily involved the new medical school curriculum of the integrated he was In 1990, and became Conjoint Professor. of Medicine by the University awarded a Doctor of Continuing Newcastle and was Assistant Dean of 1994 onwards. from Medical Education the Hunter member of Alan was a foundation serving in in 1979, Medical Institute Postgraduate the time at Studies of He was Director the executive. the The membership was almost 2000, his death. of largest in Australia. Alan held many positions in medical administration the Planning of He was Chairman in the region. from Committee for the new John Hunter Hospital years. 1983–1990 and served on the board for four the Order of Alan was awarded the Member of awarded Australia (AM) in 2002. He was recently Obstetrics and of a PhD for his thesis, The History In the last year Gynaecology in Australia 1950–2010. his life, he published a hardcover book based on of this thesis. Alan was married twice. With his first wife, Pia, he had a brain tumour and Alan Pia died of children. three who he was married subsequently married Patricia, and four to for 40 years. He has eight grandchildren great-grandchildren. 90. the age of Alan died on 19 August 2017 at Dr Julian Ward FRANZCOG SUBSPEC HALF PAGEHORIZONTAL.indd 1 Subspecialties Department: [email protected] orphone: +6139417 1699 For furtherinformation abouttheNational Selectionapplication timeline, pleasecontact: www.ranzcog.edu.au/Training/Subspecialist-Training/Apply/National-Selection All applications mustbesubmitted usingtheNational Selection Process 2019application form: subspecialties: the RANZCOG SubspecialtyTraining Programs, whichwillleadtocertification inthefollowing Applications are invited,through theNational SelectionProcess, from prospective traineesforALL Subspeciality National Selection

Obstetrical &GynaecologicalUltrasound • Maternal FetalMedicine • GynaecologicalOncology • THE COLLEGE several timesandin1976achievedtherankof Butterworth inPenang,Malaysia.Hewaspromoted of anobstetricssectionat No.4RAAFHospitalat He assistedinthedevelopmentandsupervision specialist servicestofemalemembersof theRAAF. in theRAAF. Hetransferred in1965andprovided was risingandhesawgreater scopetoapplyhisskills of womenintheRoyalAustralianAirForce (RAAF) Forces in1953.Military Inthemid1960s,number Hugh wascommissionedasaCaptainintheCitizen He treated hundreds of disadvantagedpatients. Callan Park,Broughton Hall andRydalmere hospitals. extended from NorthRydetoGladesvilleHospital, He quicklyestablishedanoutpatient servicethat in what wasthenNorthRydePsychiatric Hospital. Hugh wasoneof thefirstappointedtoasurgicalunit and manysuffered chronic andgross pathologies. of the1960s.Thesepatients hadbeenneglected treatment of patients inthestate psychiatric system some of hismore workhadbeeninthe satisfying In retirement, hewouldoccasionallyremark that needy andvulnerable. sectors devotedmuchof his time totreatment of the Paddington. Hepractisedinbothprivate andpublic of theDepartmentof GynaecologicalOncologyat genital tract.Inlater years,hewasappointedChair treatment of pre-cancerous diseaseof thelower first in Sydney to offer carbondioxide laserinthe studies inAmerica,hispracticewasoneof the of Papanicolousmearscreening; andafter further practice. Hewasanearlyleaderinthedevelopment Applications for2020trainingprogramwillopenon 1 October 2018 and close 1 February 2019.1 October2018andcloseFebruary Urogynaecology • Reproductive EndocrinologyandInfertility • Malcolm HughPatterson by hissonsDavidandMalcolm. Hugh’s wife,Pamela,diedin2010. Hughissurvived died on3May2018. and standardsbodies.Afteralengthyillness,Hugh and various non-clinical responsibilities in disciplinary specialists whowere under-represented inhisfield; midwives; attempts tofurtherthecareers of female population inthefarwestof NSW; theeducation of he treated theAboriginalandTorres Strait Islander stint withSpecialistAerialMedicalServices,inwhich Other valuablecontributionsHughmadeinclude:a visiting practitionersandspecialists. a highlysuccessfularbitration of sessionalrates for Hugh’s leadershipasNSWPresident proved key to following theacrimonious1984Medicare dispute. negotiations with both state and federal governments from 1987–88. In1985, hewasinvolvedindifficult President from 1985–86andaFederalCouncillor on theNSWcommitteefrom 1982–87, state 40 years,duringwhichtimeheservedasaCouncillor a memberof theAustralianMedicalAssociation for Hugh alsofoundtimetoservehisprofession. Hewas National Medal. Reserve Forces Decoration withtwoclaspsandthe three decadesof service,hewasawardedthe a positionhehelduntilretirement in 1985. After the Director-General of AirForce HealthServices, Group Captainandconsultantgynaecologistto 8/08/2018 1:22:54 PM DON’T MISS OUT REGISTER NOW

Subspeciality National Selection

Applications for 2020 training program will open on 1 October 2018 and close 1 February 2019.

Applications are invited, through the National Selection Process, from prospective trainees for ALL the RANZCOG Subspecialty Training Programs, which will lead to certification in the following subspecialties: • Gynaecological Oncology • Reproductive Endocrinology and Infertility • Maternal Fetal Medicine • Urogynaecology • Obstetrical & Gynaecological Ultrasound

All applications must be submitted using the National Selection Process 2019 application form: Sunday 16 September – Wednesday 19 September 2018 www.ranzcog.edu.au/Training/Subspecialist-Training/Apply/National-Selection Adelaide Convention Centre – Adelaide, South Australia

For further information about the National Selection application timeline, please contact: ranzcogasm.com.au Subspecialties Department: [email protected] or phone: +61 3 9417 1699

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