Caesarean Section at Full Dilatation and Risk of Major Obstetric Haemorrhage.

The purpose of the study was to examine the risk factors for caesarean section (CS) at full dilatation and to assess the risk and management of haemorrhage. The study took place in a tertiary referral maternity hospital. Women who had a CS at full dilatation were included. Clinical and demographic details were recorded. There were 199 cases. The average age was 30.3 years and average BMI was 25.8kg/m2. There were 79.9 % (159) primigravidas and 20.1% (40) multigravidas. The average gestation at delivery was 39.4 weeks. Labour was induced in 46.9 % (92) and spontaneous in 53.8% (107). Oxytocin was used in 67.8 % (135). An instrumental delivery was attempted in 46.7 % (93). The rate of malposition was 46.5 % (92). The average birthweight was 3,629g and 9 babies weighed ?4.5kg. The average estimated blood loss (EBL) was 665mls and 34 had EBL>1L. Most had an oxytocin infusion (141). Other uterotonic agents were used in 70 women. Seven women had blood transfusions. The highest rate of CS at full dilatation was in primigravidas due to malposition. There was a low rate of major obstetric haemorrhage.

Epidemiology of chromosomal trisomies in the East of Ireland.

Background: Chromosomal trisomies are associated with advancing maternal age. In Ireland, information on the total prevalence and outcome of trisomy affected pregnancies is unavailable. This study aimed to ascertain more precise data on Trisomies 21, 18 and 13 in a large Irish region during the period 2011-2013. Methods: Multiple information sources were used in case finding, including a regional congenital anomaly register, all maternity and paediatric hospitals in the region and the regional Department of Clinical Genetics. Results: There were 394 trisomy cases from 80 894 total births, of which 289 were Trisomy 21, 75 were Trisomy 18 and 30 were Trisomy 13. The total prevalence rate was 48.9/10 000 births, 35.7, 9.3 and 3.7 for Trisomies 21, 18 and 13, respectively. Over 90% of Trisomies 18/13 and 47% of Trisomy 21 were diagnosed prenatally; 61% of Trisomy 21 cases and nearly 30% of Trisomies 18/13 were live births; 38% all trisomy affected pregnancies ended in a termination. Conclusions: This study provides precise data on the total prevalence and outcome of trisomy affected pregnancies in the East of Ireland. Total prevalence rates were higher than previously reported. Prenatal diagnosis had a significant impact on outcome. These data provide a better basis for planning of services for live-born children affected by trisomy.

Coagulation indices in very preterm infants from cord blood and postnatal samples.

BACKGROUND: Very premature infants are at high risk of bleeding complications; however, few data exist on ranges for standard coagulation tests. OBJECTIVES: The primary objective of this study was to measure standard plasma coagulation tests and thrombin generation in very premature infants compared with term infants. The secondary objective was to evaluate whether an association existed between coagulation indices and intraventricular hemorrhage (IVH). PATIENTS/METHODS: Cord and peripheral blood of neonates < 30 weeks gestational age (GA) was drawn at birth, on days 1 and 3 and fortnightly until 30 weeks corrected gestational age. Prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen and coagulation factor levels were measured and tissue factor-stimulated thrombin generation was characterized. Control plasma was obtained from cord blood of term neonates. RESULTS: One hundred and sixteen infants were recruited. Median (range) GA was 27.7 (23.7-29.9) weeks and mean (SD) birth weight was 1020 (255) g. Median (5th-95th percentile) day 1 PT, APTT and fibrinogen were 17.5 (12.7-26.6) s, 78.7 (48.7-134.3) s and 1.4 (0.72-3.8) g L(-1) , respectively. No difference in endogenous thrombin potential between preterm and term plasma was observed, where samples were available. Levels of coagulation factors II, VII, IX and X, protein C, protein S and antithrombin were reduced in preterm compared with term plasma. Day 1 APTT and PT were not associated with IVH. CONCLUSION: In the largest cross-sectional study to date of very preterm infants, typical ranges for standard coagulation tests were determined. Despite long clotting times, thrombin generation was observed to be similar in very preterm and term infants.

The emergency room at the Rotunda Hospital: evidence of an improving service over the past 3 years.

INTRODUCTION: This is a retrospective review of the Rotunda Hospital Emergency Room (ER) documentation with respect to attendances for a 4-month period (August-November) in both 2009 and 2012. The aim was to quantify the workload and assess the quality of care offered to patients attending the ER over the two time periods and to highlight any improvements in care after changes were implemented following the initial 2009 review. MATERIALS AND METHODS: This study was done comparing the ER patient attendances over two time periods (1st August 2009 to 30th November 2009 and same period in 2012). SPSS version 20 was used to make statistical analysis along with simple percentage calculation. Comparing the two time frames, a decrease in the number of antenatal patients attending ER was seen (p < 0.001) [7,128 (91.0 %) in 2009 and 6,890 (89.4 %) in 2012], waiting times fell (p < 0.001) [4,351 (55.5 %) in 2009 seen within 2 h and 5,855 (76.2 %) in 2012], less women left ER without being seen (p < 0.001) [151 (1.9 %) in 2009 and 119 (1.5 %) in 2012] and record keeping regarding outcome of attendances improved (p < 0.001) [465 cases (5.9 %) in 2009 not recorded and 259 (3.3 %) in 2012]. CONCLUSION: The improvements noted may be due to establishment of an early pregnancy assessment unit facility and changes in ER staffing. Two registrars being on-call rather than one registrar. Increased numbers of gynaecology patients (p < 0.001) [334 (4.3 %) in 2009 and 463 (6 %) in 2012] were seen, most likely due to changes in benign gynaecology services in north Dublin. All the comparisons were statistically significant.

Therapeutic drug monitoring of atazanavir/ritonavir in pregnancy.

OBJECTIVES: Pregnant women experience physiological changes during pregnancy that can have a significant impact on antiretroviral pharmacokinetics. Ensuring optimal plasma concentrations of antiretrovirals is essential for maternal health and to minimize the risk of vertical transmission. Here we describe atazanavir/ritonavir (ATV/r) plasma concentrations in a cohort of pregnant women undergoing routine therapeutic drug monitoring (TDM). METHODS: Pregnant HIV-positive women received ATV/r as part of their routine pre-natal care. Demographic and clinical data were collected. ATV plasma concentrations ([ATV]) were determined in the first (T1), second (T2) and third (T3) trimesters and at postpartum (PP) using liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS: From January 2007, 44 women (37 black African) were enrolled in the study. All received ATV/r at a dose of 300/100 mg once a day. Twenty-four had received antiretroviral therapy (ART) prior to pregnancy, and 20 initiated ATV/r in pregnancy. At the time nearest to delivery, 36 patients had undetectable plasma viral loads. [ATV] values were determined in 11 (T1), 25 (T2), 34 (T3) and 28 (PP) patients. [ATV] at 24 hours post-dose (C24) values significantly lower at T2/T3 relative to PP. CONCLUSIONS: This study was carried out in one of the larger cohorts of women undergoing TDM for ATV in pregnancy. Lower [ATV] values were seen in T2/T3 compared with T1/PP. However, [ATV] were not associated with a lack of virologic suppression at delivery. Nonetheless, careful monitoring of women in pregnancy is required, and dose adjustment of ATV to 400 mg may be an option.

Changing trends in diabetes mellitus in pregnancy.

The purpose of this study was to identify any changing trends in the incidence and caesarean section (CS) rate of pre-gestational diabetes mellitus (DM) and gestational diabetes mellitus (GDM) over a 10- year period, between 1999 and 2008. Although the incidence of pre-gestational DM has not significantly changed over the course of the last 10 years, there is an obvious rising trend in the incidence of GDM. Despite an increase in the overall CS rate during this time period, a parallel increase in the CS rate has not been observed among women whose pregnancies are complicated either by gestational or by pre-gestational diabetes (PGD).

Pre-pregnancy care and pregnancy outcomes in type 1 diabetes mellitus: a comparison of continuous subcutaneous insulin infusion and multiple daily injection therapy.

BACKGROUND: Pre-pregnancy care improves pregnancy outcomes in type 1 diabetes mellitus (T1DM). Continuous subcutaneous insulin infusion (CSII) therapy and multiple daily injection (MDI) therapy can both be used to achieve glycaemic targets, but few data are available to compare their efficacy in pre-pregnancy care. AIM: To compare MDI and CSII in pre-pregnancy care in T1DM. METHODS: Retrospective database review of women with T1DM attending the Dublin Diabetes in Pregnancy Centre. RESULTS: 464 women with T1DM (40 treated with CSII) were included. Women attending for pre-pregnancy care had lower HbA1c levels at booking to antenatal services [52 ± 10 mmol/mol (6.9 ± 0.9 %) vs. 62 ± 16 mmol/mol (7.8 ± 1.5 %), p < 0.001], and booked at an earlier gestation (6 ± 2 vs. 8 ± 6 weeks, p < 0.001). In those who attended for pre-pregnancy care, the CSII group had lower HbA1c levels at booking than those using MDI [48 ± 8 mmol/mol (6.5 ± 0.7 %) vs. 53 ± 10 mmol/mol (7.0 ± 0.9 %), p = 0.03]. Gestational age at delivery and birth weight did not differ between groups. Caesarean section rates were associated with CSII use (p < 0.001), duration of diabetes (p = 0.002), and parity (p = 0.006). Nulliparous women using CSII with a longer history of diabetes were more likely to deliver by Caesarean section. There was no perinatal mortality. CONCLUSIONS: Pre-pregnancy care delivered by a specialist multi-disciplinary team effectively reduces HbA1c levels peri-conception. CSII use results in lower HbA1c levels in pre-pregnancy care in selected individuals and should be considered in women with T1DM planning pregnancy.

Universal antenatal screening for hepatitis C.

The aims of this study were to pilot universal antenatal HCV screening and to determine the true seroprevalence of HCV infection in an unselected antenatal population. A risk assessment questionnaire for HCV infection was applied to all women booking for antenatal care over a 1-year period. In addition the prevalence of anti-HCV antibody positive serology in this population was determined. Over the course of the year, 9121 women booked for antenatal care at the Rotunda and 8976 women agreed to take part in the study, representing an uptake of 98.4%. 78 (0.9%) women were diagnosed as anti-HCV positive, the majority of whom were Irish (60.3%) or from Eastern Europe (24.4%). 73% of anti-HCV positive women reported one or more known risk factor with tattooing and a history of drug abuse the most commonly reported. 27% (n = 21) of anti-HCV positive women had no identifiable risk factors. Due to selective screening, seroprevalence of HCV is impossible to accurately calculate. However the universal screening applied here and the high uptake of testing has allowed the prevalence of anti-HCV among our antenatal population to be calculated at 0.9%. A significant proportion (27%) of anti-HCV positive women in this study reported no epidemiological risk factors at the time

Therapeutic drug monitoring of lopinavir/ritonavir in pregnancy.

OBJECTIVES: The aim of the study was to determine total and unbound lopinavir (LPV) plasma concentrations in HIV-infected pregnant women receiving lopinavir/ritonavir (LPV/r tablet) undergoing therapeutic drug monitoring (TDM) during pregnancy and postpartum. METHODS: Women were enrolled in the study who were receiving the LPV/r tablet as part of their routine prenatal care. Demographic and clinical data were collected and LPV plasma (total) and ultrafiltrate (unbound) concentrations were determined in the first, second and third trimesters using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Postpartum sampling was performed where applicable. Antepartum and postpartum trough concentrations (C(trough) ) were compared independently [using analysis of variance (anova)] and on a longitudinal basis (using a paired t-test). RESULTS: Forty-six women were enrolled in the study (38 Black African). Forty women initiated LPV/r treatment in pregnancy. Median (range) gestation at initiation was 25 (15-36) weeks and median (range) baseline CD4 count and viral load were 346 (14-836) cells/µL and 8724 (<50-267408) HIV-1 RNA copies/mL, respectively. Forty women (87%) had LPV concentrations above the accepted minimum effective concentration for wild-type virus (MEC; 1000 ng/mL). Geometric mean (95% confidence interval [CI]) total LPV concentrations in the first/second [3525 (2823-4227) ng/mL; n=16] and third [3346 (2813-3880) ng/mL; n=43] trimesters were significantly lower relative to postpartum [5136 (3693-6579) ng/mL; n=12] (P=0.006). In a paired analysis (n=12), LPV concentrations were reduced in the third trimester [3657 (2851-4463) ng/mL] vs. postpartum (P=0.021). No significant differences were observed in the LPV fraction unbound (fu%). Conclusions The above target concentrations achieved in the majority of women and similarities in the fu% suggest standard dosing of the LPV/r tablet is appropriate during pregnancy. However, reduced LPV concentrations in the second/third trimesters and potentially compromised adherence highlight the need for TDM-guided dose adjustment in certain cases.

HIV testing and treatment in the antenatal care setting.

Routine linked HIV antenatal screening, with "opt-out", was introduced at the Rotunda in January 1998. This paper reviews the screening and subsequent pregnancy management and outcome in HIV positive women from 1998 to 2006. During this time 225 women (280 pregnancies) were HIV positive and 194 women subsequently delivered at the Rotunda, representing 233 liveborn infants. Overall anti-HIV prevalence was 0.42%, increasing from 0.06% in 1998 to 0.57% in 2006. Of 233 livebirths, 111 (48%) were delivered by spontaneous vaginal delivery (SVD). HIV treatment was started pre-pregnancy in 14 (6%) pregnancies and antenatally in 208 (90%). The vertical transmission rate in mothers receiving >4 weeks of treatment was 0%. We conclude that routine antenatal HIV screening is effective and significantly benefits the health of mother and child.

National guidelines for the management of HIV-1 in pregnancy.

Management of HIV-1 in pregnancy has reduced the mother-to-child-transmission (MTCT) rate from 25-30% to <2% in the developed world, including Ireland. In Ireland most HIV positive pregnant women are diagnosed through antenatal screening many of whom arrive here late in pregnancy. Geographic dispersal and subsequent involvement of obstetric units throughout the country has resulted in a need for clear, accessible management guidelines. The Irish Infection Society first published guidelines for the management of HIV-1 in pregnancy in 2001 (1). The updated guidelines became operational in January 2002 with some amendments in March 2003 and July 2004. These guidelines offer a broad management outline for HIV positive pregnant women. Ultimately, each woman is assessed individually by a multidisciplinary team and a careful plan is determined.

An audit of the use of magnesium sulphate in severe pre-eclampsia and eclampsia.

Over the last decade there has been an increase in the use of MgSO4 for the prevention of seizures in women with severe pre-eclampsia or eclampsia. At the Rotunda Hospital it is regularly used for this purpose. The aim of this study was to audit the use of MgSO4 at the hospital, to determine whether the drug was being used according to the hospital's protocol and to observe its effectiveness in the prevention of eclampsia in our population. A retrospective chart review over the two years from 1/1/2000 to 31/12/2001 was undertaken. Outcome measures assessed were; Patient selection, Administration of the drug - whether recommended protocols were adhered, Effectiveness of therapy for seizure prophylaxis, Maternal and neonatal outcomes. There were 12,910 deliveries at the Rotunda hospital over this period of time. Fifty of these women were treated with MgSO4 (0.4%). Patient selection was appropriate in all cases. The correct loading dose of MgSO4 was administered in all cases, however MgSO4 levels were recorded in only 30 (60%) of women. There were no seizures in the treated group. Two women presented with seizures (one was antenatal the other post-natal period), both were treated with MgSO4. There were no maternal or neonatal mortality. Seventy two percent (36) of these women were delivered by lower segment caesarean section. The mean gestation at delivery was 36 weeks (range 28-41 weeks). Thirty eight percent (13) of babies required admission to the neonatal intensive care unit. The mean birth weight at delivery was 2.54 kg (range 1.11-3.68 kg). MgSO4 use in the Rotunda hospital appears to be safe and effective for the prevention of seizures in women with severe pre-eclampsia or eclampsia. Serum MgSO4 levels were only recorded in 60% of patients and the hospital's protocol was not adhered to regarding monitoring of patients on treatment. This needs to be addressed.

Microvessel quantification in benign and malignant ovarian tumors.

Microvessel density (MVD) in 92 paraffin sections of ovarian samples of different histologic subtypes was correlated with microvessel counts from 58 corresponding frozen sections. Anti-human von Willebrand factor antibody was used as an endothelial marker. MVD was performed in neovascular hotspots using a Quantimet 500+ Image Analyzer. The highest vessel density (HVD) and average vessel density (AVD) of three fields at the x 200 and x 400 magnification were recorded. There was a strong correlation between the HVD and AVD at the x 200 and x 400 magnifications when comparing fixed with frozen sections (correlation coefficients at x 200 for the HVD was 0.37, P = 0.005 and AVD was 0.30, P = 0.02; correlation coefficients at x 400 for the HVD was 0.38, P = 0.003 and AVD was 0.37, P = 0.004). In the fixed tissue, the HVD and AVD at both these magnifications were significantly greater in the group containing functional cysts; this was also the case for the frozen sections. These findings are consistent with the development of a microcirculation necessary for the growth and maturation of such cysts, and this appears to be greater than that in tumors. The good correlation between MVD in fixed and frozen sections suggests that such observations represent a true reflection of ovarian angiogenesis in both physiologic and pathologic states.

A national confidential survey of obstetrician's personal preferences regarding mode of delivery.

OBJECTIVE: To survey the personal preferences of obstetricians regarding mode of delivery, and relate these to hospital caesarean section rates. STUDY DESIGN: A confidential, questionnaire based survey to all obstetricians working in the Republic of Ireland (n=234). RESULTS: The response rate was 71% (n=165). Seven percent of Irish obstetricians would choose an elective caesarean section for themselves (or their partners) if they were primigravida with an uncomplicated, singleton cephalic presentation at term in the absence of any clinical indication. Caesarean section was the preferred mode of delivery for 38% of respondents if the estimated foetal weight was 4.5kg. There was a highly significant association between consultant obstetricians' personal preferences of towards caesarean section and their working in a hospital with a caesarean section rate greater than 16% (P<0.005). CONCLUSIONS: Irish obstetricians' personal preferences towards elective caesarean section for an uncomplicated, cephalic pregnancy at term are significantly lower than published data examining London based obstetricians' choices. There is a consistent trend against vaginal delivery if the obstetrician is female or younger. The association between a personal preference of the consultant for abdominal delivery and the caesarean section rate of the hospital that they work in may hamper efforts to decrease the rising numbers of caesarean sections.

A pilot study of the efficacy and tolerability of intralesional recombinant human beta-interferons in cervical intraepithelial neoplasia.

Beta-interferons possess anti-viral, cell proliferation inhibition and immunomodulatory characteristics which may be of use in the treatment of cervical intraepithelial neoplasia (CIN). Intralesional administration may avoid systemic side effects. Twenty-six women with cervical punch biopsy proven CIN I and II were treated by interferon injection into the cervical transformation zone according to three dosage regimens--6 million international units (IU) weekly for six weeks, 9 million IU weekly for six weeks and 12 million IU bi-weekly for three weeks. At the last treatment visit, cervical cytology and biopsy were taken to ensure no disease progression and large loop excision of the transformation zone (LLETZ) was carried out six months after treatment. Therapy was well-tolerated with 93% of the scheduled 156 treatments given. Side effects which caused cessation of treatment included severe myalgia, headaches and prolonged flu-like symptoms. The 2 patients who failed to attend for LLETZ at six months and another 2 patients who received fewer than five scheduled treatments were excluded from analysis. LLETZ histology was negative in 12 patients (54%), showed inflammatory changes or squamous metaplasia in 4 (18%), was unchanged in 4 patients and had progressed in 2 (10%). Whilst intralesional beta-interferon clearly has activity in CIN, the response rate is less than that seen for excisional or ablative procedures. Nevertheless, it may have a role in the management of CIN where, for medical reasons of patient preference, there is a desire to avoid surgical therapy.