Position statement

Paediatric empyema thoracis occurs in 0.7% of pneumonias in Australia and general paediatricians may only see a few cases in their career. A recent survey demonstrated a lack of consensus in management across Australia, highlighting the need for a local guideline. Empyema is an accumulation of infected fluid in the pleural space caused by a disruption in the equilibrium of pleural fluid secretion and absorption by the pleural lymphatic drainage system. Children with empyema typically present with symptoms and signs of pneumonia. A persistent fever despite 48 hours of appropriate antibiotic treatment may indicate development of empyema. Children with empyema should be managed in a hospital with paediatric expertise — preferably by or in consultation with respiratory paediatricians, and in conjunction with paediatric surgeons (recommendation [R], strong; evidence [E], low quality). If feasible, children should be transferred to a tertiary paediatric centre; treatment of paediatric empyema is very different to that of adult disease. A chest x-ray should be carried out for children in whom empyema is suspected (R, strong; E, high quality); a routine lateral film is not needed. A lateral decubitus or erect film may be used to differentiate a simple parapneumonic effusion from an empyema if ultrasound is not available (R, strong; E, none). Daily x-rays are not necessary to monitor progress as changes on chest x-ray lag behind clinical status (R, strong; E, none). Ultrasound is the central investigation in the management of paediatric empyema; it should be used for all children with empyema as it is the best technique for differentiating pleural fluid and consolidation, estimating effusion size and grading complexity, demonstrating the presence of fibrinous septations and guiding chest drain placement (R, strong; E, high quality). A preoperative chest computed tomography (CT) scan should not be routinely performed (R, strong; E, moderate quality) but should be reserved for complicated cases in which the condition has not responded to treatment or there is concern that another pathological condition, such as a tumour, is involved. Blood tests such as blood culture (R, strong; E, high quality), full blood count and measurement of C-reactive protein level (R, strong; E, none) may help in supporting the diagnosis and monitoring the progress of the disease, but there is no role for routine blood tests. Children with empyema should receive high-dose, intravenous antibiotic therapy to ensure pleural penetration (R, strong; E, high quality). The majority of causative organisms in Australia are Streptococcus pneumoniae (in particular, serotypes 1, 3 and 19A), Streptococcus pyogenes, methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus (MRSA). In the absence of a positive culture result, the initial choice depends on the local hospital infection control policy for managing community-acquired pneumonia. Appropriate antibiotics should cover at least S. pneumoniae and S. aureus (R, strong; E, high quality). Consideration should be given to coverage of MRSA for children from communities with a high prevalence of MRSA (R, strong; E, high quality). Anaerobic infection should be considered in children who are at risk of aspiration. Macrolides should be used when Mycoplasma pneumoniae is thought to be the causative organism but should not be used routinely (R, weak; E, moderate quality). Moderate to large effusions require drainage. There is no role for diagnostic thoracocentesis. If there is a need to access the pleural cavity, the placement of a drain should be considered, thus ensuring that the child undergoes only one invasive intervention (R, strong; E, high quality). Pleural fluid should be sent for cytological testing, microscopic examination and culture, including culture for Mycobacterium tuberculosis (R, strong; E, high quality). Ideally, pleural fluid should be tested using enhanced molecular techniques such as polymerase chain reaction (R, strong; E, high quality). There is currently no role for pleural biochemical markers to guide therapy in children (R, weak; E, low quality). Chest drainage with a large bore drain alone is not recommended (R, strong; E, moderate quality). Instead, percutaneous small bore drainage with a fibrinolytic agent (preferably urokinase) or video-assisted thoracoscopic surgery (VATS) is recommended (R, strong; E, moderate quality). Open thoracotomy is not recommended as it has largely been superseded by the use of VATS. Children with an oxygen saturation level below 93% on room air should be given supplemental oxygen (R, strong; E, high quality). Other standard therapy includes fluid replacement (R, strong; E, none), use of antipyretic agents (R, strong; E, none specific to empyema) and analgesia (R, strong; E, none). There is no role for chest physiotherapy — apart from early mobilisation and encouragement of deep breathing and coughing, particularly after surgical intervention or tube drainage (R, strong; E, low quality) — and no indication for routine bronchoscopy in children with empyema (R, strong; E, weak). If a child has been afebrile for 24 hours, a change from intravenous to oral antibiotic therapy can be considered (R, weak; E, none). The choice of oral antibiotic depends on the organism identified (if any) or the class of antibiotic that was successfully used by intravenous therapy. There is no consensus on duration of oral antibiotic therapy, which varies from 1 week to 6 weeks (R, weak; E, none). A follow-up chest x-ray should be carried out 4–6 weeks after discharge from hospital to confirm that changes are resolving (R, weak; E, none). Further imaging is not required unless there are persistent clinical symptoms or complications (R, weak; E, none). There is no need for routine investigations to identify a possible underlying cause in previously healthy children without a history of recurrent infections (R, weak; E, very low quality). The full position statement is available at http://www.thoracic.org.au/ professional-information/position-papers-guidelines.

on behalf of the Australian Research Network in Empyema (ARNiE)

Haemoglobin A1c (HbA1c — a term that is sometimes used interchangeably with “glycated haemoglobin”) measurements are an indicator of time-averaged blood glucose levels (previous 2–3 months), and are used as the best marker of long-term diabetes control. A recent consensus statement on the worldwide standardisation of HbA1c measurement1 has updated previous international recommendations on the standardisation of HbA1c measurement and reporting.2 Here, we provide the rationale and guidance for implementation of HbA1c reporting in the new Système International (SI) units in Australia. This article represents the views of the Australasian Association of Clinical Biochemists, the Australian Diabetes Educators Association, the Australian Diabetes Society and the Royal College of Pathologists of Australasia, and was prepared by a working party of representatives of these organisations. The International HbA1c Consensus Committee recommends that all HbA1c levels be reported in SI units (mmol/mol, no decimal places) — with results directly traceable to the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) reference method — and in the currently used, National Glycohemoglobin Standardization Program (NGSP) units (percentage, one decimal place). We recommend that dual reporting in Australia begins in July 2011, and that reporting of percentages ceases 2 years later. In New Zealand, dual reporting commenced in August 2009. The key reasons for implementing this recommendation in Australia are that: the SI units relate to a scientifically valid measure of HbA1c; the SI units remove potential confusion between HbA1c values as a percentage and blood glucose values in mmol/L; the change is in keeping with the international consensus statement;1 and the change has already been initiated in New Zealand and a number of countries in the European Union. Until now, all HbA1c measurements performed in Australia have been reported as percentages (HbA1c as a percentage of total haemoglobin) that are aligned with those produced in the Diabetes Control and Complications Trial.3 These units and this standardisation have been promoted by the NGSP in the United States, and the activities of this organisation have produced marked improvement in the accuracy of HbA1c results worldwide. More recently, the IFCC has developed a reference method that is more specific for HbA1c and more analytically robust.4 The IFCC method is now used as the reference system by the NGSP and for all routine methods for measurement of HbA1c, although a numerical conversion is required during the calibration process. The changes recommended here will provide results that are directly aligned with the IFCC method. As the IFCC method is more specific for HbA1c, not measuring several other haemoglobin–sugar complexes, the results are 10% to 40% lower than those from the NGSP system, depending on HbA1c concentration. Because reporting these results as percentages may lead to confusion (eg, producing a result of 5.3% rather than 7.0%), the units are changed to mmol/mol (millimoles HbA1c per mole of total haemoglobin [53 mmol/mol in the previous example]), which is consistent with the SI units recommended for use in Australia. There is a linear relationship between results from the two methods, and the “master equation” is used to convert results between the two methods: HbA1c SI unit (mmol/mol) = 10.93 × HbA1c NGSP unit (%) − 23.50.5 To make the conversion easier for clinicians, it is important to translate current treatment advice to the new units. A general conversion table for clinical use is provided in Box 1. The general HbA1c target of ≤ 7.0% for patients with type 1 and type 2 diabetes mellitus equates to ≤ 53 mmol/mol, although these values need to be individualised for patients. The recently updated diabetes treatment guidelines are shown with SI units in Box 2 and Box 3,6 and recommendations for reporting HbA1c levels in Australia are summarised in Box 4. In addition, supporting material for doctors and patients will be presented in SI units in the future. The routine reporting of an estimated average glucose (eAG) value may be useful for consultations with individual patients. However, the working party strongly agrees with the revised consensus statement that routine reporting of eAG with all requests for HbA1c analysis is not appropriate.1 The reasons for this include variability in the methods used to measure eAG, the risk of confusing a measure of long-term glycaemia (eAG) with a measure of short-term blood glucose control (actual blood glucose level), and its lack of applicability in the majority of patients with type 2 diabetes (in whom blood glucose levels are not measured at frequent intervals).7 Nonetheless, eAG values will be used as an educational tool at the discretion of individual clinicians, who can assist patients to understand the significance and limitations of the result. 1 Conversion table for haemoglobin A1c (HbA1c) values HbA1c as percentage (old units) HbA1c in mmol/mol (new units) 5.0 31 6.0 42 6.5 48 7.0 53 8.0 64 9.0 75 10.0 86 11.0 97 12.0 108 2 Recommended haemoglobin A1c (HbA1c) target ranges for patients with type 1 diabetes6 HbA1c target General target ≤ 53 mmol/mol, ≤ 7.0%* Specific clinical situations Pregnancy or planning pregnancy ≤ 53 mmol/mol, ≤ 7.0%*† Children and adolescents ≤ 58 mmol/mol, ≤ 7.5%* Recurrent severe hypoglycaemia or hypoglycaemia unawareness ≤ 64 mmol/mol, ≤ 8.0% Patients with major comorbidities likely to limit life expectancy Symptomatic therapy of hyperglycaemia‡ and avoidance of ketosis * Achievement of HbA1c targets must be balanced against risk of severe hypoglycaemia. † An HbA1c level of ≤ 42 mmol/mol (≤ 6.0%) is desirable if it can be achieved safely. ‡ Where practical, suggest blood glucose target level < 15 mmol/L to help minimise risk of infection. 3 Recommended haemoglobin A1c (HbA1c) target ranges for patients with type 2 diabetes6 HbA1c target General target ≤ 53 mmol/mol, ≤ 7.0%* Specific clinical situations Diabetes of short duration† and no clinical cardiovascular disease Requiring lifestyle modification ± metformin ≤ 42 mmol/mol, ≤ 6.0%* Requiring any antidiabetic agents other than metformin or insulin ≤ 48 mmol/mol, ≤ 6.5%* Requiring insulin ≤ 53 mmol/mol, ≤ 7.0%* Pregnancy or planning pregnancy ≤ 42 mmol/mol, ≤ 6.0%* Children and adolescents ≤ 53 mmol/mol, ≤ 7.0%* Diabetes of longer duration† or clinical cardiovascular disease (any therapy) ≤ 53 mmol/mol, ≤ 7.0%* Recurrent severe hypoglycaemia or hypoglycaemia unawareness (any therapy) ≤ 64 mmol/mol, ≤ 8.0% Patients with major comorbidities likely to limit life expectancy‡ (any therapy) Symptomatic therapy of hyperglycaemia§ * Achievement of HbA1c targets must be balanced against risk of severe hypoglycaemia, especially among older people. † In an older adult, long duration might be considered to be > 10–20 years, but for a person who develops type 2 diabetes at a young age, it might be considerably longer. ‡ Examples of major comorbidities include chronic medical conditions, such as chronic kidney disease stages 4 or 5; heart failure stages III or IV (New York Heart Association grading); incurable malignancy; and moderate to severe dementia. § Where practical, suggest blood glucose target level < 15 mmol/L to help minimise risk of infection. 4 Recommendations for reporting haemoglobin A1c (HbA1c) levels in Australia From July 2011, HbA1c levels should be reported in both National Glycohemoglobin Standardization Program units (percentage) and the Système International (SI) units (mmol/mol) by all pathology laboratories and, where possible, from point-of-care devices. The period of dual reporting will be 2 years, after which only the SI units will be used. These recommendations are consistent with international recommendations and are already in place in New Zealand.

Graham R D Jones MB BS, DPhil, FRCPA, Chemical Pathologist · George Barker BHSc, CDE-RN, NP · Ian Goodall BSc, FAACB, FFRCPA · Hans-Gerhard Schneider MD, FRACP, FRCPA · Mark D S Shephard MAACB, FFRCPA, PhD · Stephen M Twigg MB BS, PhD, FRACP

The Cancer Council Australia (CCA) Alcohol Working Group has prepared a position statement on alcohol use and cancer. The statement has been reviewed by external experts and endorsed by the CCA Board. Alcohol use is a cause of cancer. Any level of alcohol consumption increases the risk of developing an alcohol-related cancer; the level of risk increases in line with the level of consumption. It is estimated that 5070 cases of cancer (or 5% of all cancers) are attributable to long-term chronic use of alcohol each year in Australia. Together, smoking and alcohol have a synergistic effect on cancer risk, meaning the combined effects of use are significantly greater than the sum of individual risks. Alcohol use may contribute to weight (fat) gain, and greater body fatness is a convincing cause of cancers of the oesophagus, pancreas, bowel, endometrium, kidney and breast (in postmenopausal women). The existing evidence does not justify the promotion of alcohol use to prevent coronary heart disease, as the previously reported role of alcohol in reducing heart disease risk in light-to-moderate drinkers appears to have been overestimated. CCA recommends that to reduce their risk of cancer, people limit their consumption of alcohol, or better still avoid alcohol altogether. For individuals who choose to drink alcohol, CCA recommends that they drink only within the National Health and Medical Research Council guidelines for alcohol consumption.

Margaret H Winstanley BA · Iain S Pratt GradDip(Diet), APD, AEP · Kathryn Chapman BSc, MNutrDiet · Hayley J Griffin BMedSc, MNutrDiet, PhD · Emma J Croager PhD, MBA · Ian N Olver MD, PhD, FRACP · Craig Sinclair MPubPolMgt, GradDipOrgBehav, BEd(Sec) · Terry J Slevin MPH, FPHAA

The medical and psychosocial needs of children and adolescents differ from those of adults, and this should be reflected in the care they receive in all areas of a health service. Children and adolescents must be accommodated separately to adults to ensure that their unique needs are met and risks of harm are minimised. The Standards for the care of children and adolescents in health services have been developed by a working group of clinicians, health service providers and consumer advocates based on a combination of available research evidence, published best practice guidelines and multidisciplinary expert consensus. Stakeholder input was obtained through invitations to comment, and pilot testing of the Standards was conducted in six metropolitan, regional and rural hospitals. The Standards provide detailed recommendations in the areas of recognising rights; the provision of child-, adolescent- and family-friendly health service facilities; the availability of child- and adolescent-specific equipment; and the importance of appropriately trained staff. To facilitate implementation and allow ongoing performance monitoring, the Standards have been developed for use alongside the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program. The Standards provide a vehicle to ensure patient safety and to facilitate the provision of high-quality care for children and adolescents in Australian health services.

Melissa K Hill BSc(Hons), PhD · Marjorie Pawsey MB BS, DPH · Anne Cutler MEd(Health) · Joanna L Holt BSc, MHP · Sharon R Goldfeld FRACP, FAFPHM, PhD

Pancreatic exocrine insufficiency (PEI) occurs when the amounts of enzymes secreted into the duodenum in response to a meal are insufficient to maintain normal digestive processes. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function is commonly assessed by conducting a 3-day faecal fat test and by measuring levels of faecal elastase-1 and serum trypsinogen. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. In adults, the initial recommended dose of pancreatic enzymes is 25 000 units of lipase per meal, titrating up to a maximum of 80 000 units of lipase per meal. In infants and children, the initial recommended dose of pancreatic enzymes is 500 units of lipase per gram of dietary fat; the maximum daily dose should not exceed 10 000 units of lipase per kilogram of bodyweight. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid-suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high-dose enzyme therapy. A dietitian experienced in treating PEI should be involved in patient management. Dietary fat restriction is not recommended for patients with PEI. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Medium-chain triglycerides do not provide any clear nutritional advantage over long-chain triglycerides, but can be trialled in patients who fail to gain or to maintain adequate bodyweight in order to increase energy intake.

James Toouli MB BS, FRACS, PhD · Andrew V Biankin MB BS, PhD, FRACS · Mark R Oliver MB BS, MD, FRACP · Callum B Pearce MB ChB, MD, FRACP · Jeremy S Wilson MD, FRACP, FRCP · Nicholas H Wray MND, BAppSc(ExSportSc), APD

Consensus recommendations for managing chronic suppurative lung disease (CSLD) and bronchiectasis, based on systematic reviews, were developed for Australian and New Zealand children and adults during a multidisciplinary workshop. The diagnosis of bronchiectasis requires a high-resolution computed tomography scan of the chest. People with symptoms of bronchiectasis, but non-diagnostic scans, have CSLD, which may progress to radiological bronchiectasis. CSLD/bronchiectasis is suspected when chronic wet cough persists beyond 8 weeks. Initial assessment requires specialist expertise. Specialist referral is also required for children who have either two or more episodes of chronic (> 4 weeks) wet cough per year that respond to antibiotics, or chest radiographic abnormalities persisting for at least 6 weeks after appropriate therapy. Intensive treatment seeks to improve symptom control, reduce frequency of acute pulmonary exacerbations, preserve lung function, and maintain a good quality of life. Antibiotic selection for acute infective episodes is based on results of lower airway culture, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients whose condition does not respond promptly or adequately to oral antibiotics are hospitalised for more intensive treatments, including intravenous antibiotics. Ongoing treatment requires regular and coordinated primary health care and specialist review, including monitoring for complications and comorbidities. Chest physiotherapy and regular exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and vaccines administered according to national immunisation schedules. Individualised long-term use of oral or nebulised antibiotics, corticosteroids, bronchodilators and mucoactive agents may provide a benefit, but are not recommended routinely.

Anne B Chang MPHTM, PhD, FRACP · Scott C Bell MB BS, MD, FRACP · Cass A Byrnes MB ChB, MD, FRACP · Keith Grimwood MB ChB, MD, FRACP · Peter W Holmes MB BS, FCCP, FRACP · Paul T King MB BS, FRACP, PhD · John Kolbe MB BS, FRACP · Louis I Landau MB BS, MD, FRACP · Graeme P Maguire MB BS, FRACP, PhD · Malcolm I McDonald MB BS, FRCPA, PhD · David W Reid MB ChB, MRCP, FRACP · Francis C Thien MB BS, MD, FRACP · Paul J Torzillo MB BS, FRACP, FJFICM

Older people living in residential aged care facilities (RACFs) are at considerably higher risk of suffering fractures than older people living in the community. When admitted to RACFs, patients should be assessed for fracture risk to ensure early implementation of effective fracture prevention measures. Routine or regular determination of calcium and phosphate serum levels in institutionalised older people is not indicated. Opinion is divided about the value of routine measurements of serum concentrations of 25-hydroxyvitamin D, parathyroid hormone and bone turnover markers. The non-pharmacological approach to fracture prevention includes multifactorial programs of falls prevention and the use of hip protectors. Vitamin D supplementation is recommended for all patients in RACFs. Dietary calcium intake should be optimised (1200–1500 mg per day is recommended) and supplementation offered to those with inadequate intake. The decision to prescribe calcium supplements should be guided by patients’ tolerance, whether or not they have a history of kidney stones, and emerging data about its cardiovascular safety. Bisphosphonates are the first-choice pharmacological agents for fracture prevention in older persons at high risk. Intravenous administration is as efficient as oral and has the significant advantage of better adherence. Use of strontium ranelate has not been tested on people in RACFs, but evidence in the “old-old” (those aged 75 years and older) suggests it could be a therapeutic option for fracture prevention in this setting. In general, teriparatide should not be considered as a first-line treatment for fracture prevention, particularly for people in RACFs.

Gustavo Duque MD, PhD, FRACP · Jacqueline J Close MD, FRCP, FRACP · Julien P de Jager FRACP · Peter R Ebeling MD, FRACP · Charles Inderjeeth MB ChB, MPH, FRACP · Stephen Lord PhD · Andrew J McLachlan PhD · Ian R Reid MD, PhD · Bruce R Troen MD · Philip N Sambrook MD, FRACP

Cough is a common and distressing symptom that results in significant health care costs from medical consultations and medication use. Cough is a reflex activity with elements of voluntary control that forms part of the somatosensory system involving visceral sensation, a reflex motor response and associated behavioural responses. At the initial assessment for chronic cough, the clinician should elicit any alarm symptoms that might indicate a serious underlying disease and identify whether there is a specific disease present that is associated with chronic cough. If the examination, chest x-ray and spirometry are normal, the most common diagnoses in ADULTS are asthma, rhinitis or gastro-oesophageal reflux disease (GORD). The most common diagnoses in CHILDREN are asthma and protracted bronchitis. Management of chronic cough involves addressing the common issues of environmental exposures and patient or parental concerns, then instituting specific therapy. In ADULTS, conditions that are associated with removable causes or respond well to specific treatment include protracted bacterial bronchitis, angiotensin-converting enzyme inhibitor use, asthma, GORD, obstructive sleep apnoea and eosinophilic bronchitis. In CHILDREN, diagnoses that are associated with removable causes or respond well to treatment are exposure to environmental tobacco smoke, protracted bronchitis, asthma, motor tic, habit and psychogenic cough. In ADULTS, refractory cough that persists after therapy is managed by empirical inhaled corticosteroid therapy and speech pathology techniques.

Peter G Gibson MB BS, FRACP · Anne B Chang FRACP, MPHTM, PhD · Nicholas J Glasgow FRACGP, MD, FAChPM · Peter W Holmes MB BS, FCCP, FRACP · Peter Katelaris MB BS, MD, FRACP · Andrew S Kemp MB BS, FRACP, PhD · Louis I Landau AO, MD, FRACP · Stuart Mazzone PhD · Peter Newcombe DipT, BEd, PhD · Peter Van Asperen MB BS, MD, FRACP · Anne E Vertigan BAppSc(SpPath), MBA, PhD

The 21st century has the most diabetogenic environment in human history with the number of people with diabetes worldwide increasing to 380 million by 2025. The fastest rate of increase will be in developing countries. Diabetes is now the major cause of end-stage kidney disease globally; 20%–40% of people on dialysis are diabetic. In Australia, the number of people with type 2 diabetes starting dialysis increased fivefold between 1993 and 2007. We must act now at local, national and international levels to prevent type 2 diabetes; screen for early diabetic kidney disease; increase public awareness of kidney disease; treat with medications proven to reduce kidney disease progression; and promote research into and trialling of new therapies. The problem is global yet requires local action. World Kidney Day on 11 March 2010 is a time to intensify action on diabetic kidney disease and to continue to do so until this huge but largely preventable health burden is controlled.

Robert C Atkins MSc, DSc, FRACP · Paul Z Zimmet PhD, MD, FRACP

Standard and Droplet Precautions are considered adequate to control the transmission of influenza in most health care situations. Vaccination of health care staff, carers and vulnerable patients against seasonal and, eventually, pandemic influenza strains is an essential protective strategy. Management principles include: performance of hand hygiene before and after every patient contact or contact with the patient environment, in accord with the national 5 Moments for Hand Hygiene Standard; disinfection of the patient environment; early identification and isolation of patients with suspected or proven influenza; adoption of a greater minimum distance of patient separation (2 metres) than previously recommended; use of a surgical mask and eye protection for personal protection on entry to infectious areas or within 2 metres of an infectious patient; contact tracing for patient and health care staff and restriction of prophylactic antivirals mainly to those at high risk of severe disease; in high aerosol-risk settings, use of particulate mask, eye protection, impervious long-sleeved gown, and gloves donned in that sequence and removed in reverse sequence, avoiding self-contamination; exclusion of symptomatic staff from the workplace until criteria for non-infectious status are met; reserving negative-pressure ventilation rooms (if available) for intensive care patients, especially those receiving non-invasive ventilation; ensuring that infectious postpartum women wear surgical masks when caring for their newborn infants and practise strict hand hygiene; and implementation of special arrangements for potentially infected newborns who require nursery or intensive care.

Rhonda L Stuart FRACP, PhD · Allen C Cheng FRACP, MPH, PhD · Caroline L Marshall FRACP, PhD, GradDipClinEpi · John K Ferguson FRACP, FRCPA, DTMH

Pregnancy and delivery are critical times for women with bleeding disorders, with mothers, and possibly their affected infants, being exposed to a variety of haemostatic challenges. Management of women with bleeding disorders during pregnancy involves a multidisciplinary team including, but not limited to, an obstetrician, an anaesthetist and a haematologist. This consensus document from the Australian Haemophilia Centre Directors’ Organisation (AHCDO) provides practical information for clinicians managing women with bleeding disorders during pregnancy. Included are: the expected physiological response in pregnancy in such women; management of pregnancy, labour and delivery, as well as obstetric anaesthesia issues, postpartum care, and reducing and treating postpartum haemorrhage; and management of infants at risk of a bleeding disorder and of bleeding in neonates. The guidelines were developed after extensive consultation, face-to-face meetings and revisions. The final document represents a consensus opinion of all AHCDO members. Where evidence is lacking, recommendations are based on clinical experience and consensus opinion.

on behalf of the Australian Haemophilia Centre Directors’ Organisation