Surgical instrument wrap: a pilot recycling initiative.

BACKGROUND: Seven per cent of general waste and 20% of healthcare risk waste produced in acute hospitals in Ireland comes from operating theatres. Surgical wrap comprises 11% of operating theatre waste. AIMS: The primary aim of this study was to pilot the implementation of a recycling initiative for surgical instrument set wrap in an operating theatre in Ireland. Secondary aims included quantification of the surgical wrap diverted from general waste to recycling streams over a 5-week period and estimation of the annual carbon emissions associated with gynaecology surgical wrap use in Cork. METHODS: The amount of polypropylene surgical wrap generated by a single gynaecology theatre at Cork University Maternity Hospital was prospectively quantified from 24/1/22 to 1/3/22. At the end of the study period, individual sheets of polypropylene wrap were counted and dimensions were measured to calculate the total surface area of surgical wrap saved for recycling. RESULTS: A total of 66 surgeries were performed over the 5-week study period. Two hundred twenty-one individual sheets of surgical wrap were collected, equating to 282.1 m2 of polypropylene wrap. An estimated 11,564 m2 of surgical wrap could be recycled annually from the gynaecology theatre service in Cork with an associated annual carbon emissions equivalent of at least 2.2 tonnes of CO2. CONCLUSION: Diversion of surgical wrap from general waste and clinical waste streams to the recycling stream is achievable in every operating theatre. Small changes to operating theatre waste disposal practices have the potential to yield significant reductions to theatre waste outputs and to hospital carbon emissions.

Recurrent miscarriage and infertility: a national service evaluation.

The appropriate clinical care of women/couples with infertility experiencing recurrent miscarriage (RM) is overlooked in international guidelines. We sought to evaluate care provision for women/couples with RM and infertility across public (19 clinics providing RM care, five fertility clinics) and private sectors (nine fertility clinics) using adapted guideline-based key performance indicators (KPIs) for RM. An online survey comprised of multiple-choice/open questions was administered via Qualtrics from November 2021 to February 2022, encompassing: (i) structure of care, (ii) investigations, (iii) treatments, (iv)counselling/supportive care and (v) outcomes. Clinical leads for pregnancy loss and fertility and clinical nurse/midwife specialists within each unit/clinic were invited to participate.The response rate 73% (24/33), varied by provider: Public RM care (18/19; 95%), 2/5 public fertility (40%); private fertility (3/9; 33%). Access to fertility expertise was limited in public RM clinics (39%). While investigations and treatments provided mostly adhered to guidelines, there was uncertainty regarding immunotherapies. Educational needs identified included fertility counselling, informative and supportive care resources. Clinical outcomes were seldom audited (2/22; 9%). Greater engagement with the private sector is required to unify care across sectors and to ensure standardised evidence-based care. Audit and outcomes reporting should be mandated. Lived experience of current care structures should inform service improvements.Impact StatementWhat is already known on this subject? There is a paucity of research into the appropriate clinical care of women/couples with infertility experiencing recurrent miscarriage, with a resulting deficit within international RM guidelines. It is known that RM care is variable and often not in line with guidance.What do the results of this study add? This study demonstrates that while care is largely in line with clinical practice guidelines, there is variation in counselling, imaging and surgical treatments offered. Areas for education identified included fertility counselling and resources for information provision and supportive care. Clinical outcomes were seldom audited.What are the implications of these findings for clinical practice and/or further research? Fertility care must expand to ensure access for women with RM and infertility. Further research exploring barriers and facilitators to the delivery of evidence-based care for women/couples with infertility and RM is required. The lived experiences of service users must inform service improvements.

An examination of care received by women with recurrent miscarriage and infertility against guideline-based key performance indicators.

OBJECTIVES: International guidelines for the management of recurrent miscarriage (RM) do not provide detailed guidance for the care of women/couples with concurrent infertility. Research studies concerning the investigation and treatment of RM frequently omit this cohort. The aim of this study was to assess the care of women/couples with infertility attending a RM clinic in a large tertiary unit in the Republic of Ireland. STUDY DESIGN: We conducted an audit of women with RM and infertility attending our RM clinic from 2008 to 2020 against 110 established guideline-based key performance indicators (KPIs) for RM care, encompassing five categories: structure of care, counselling/supportive care, investigation, treatment and outcomes. Information was gathered from documentation from the RM clinic, hospital laboratory and electronic health records. RESULTS: We identified 128 women with infertility and RM. Information provision in RM clinics regarding modifiable risk factors (71 %; 91/128) and unexplained RM (53 %; 69/128) could be improved. Most women were investigated in line with KPIs, except for pelvic ultrasound (40 %; 51/128), cytogenetic analysis (27 %; 34/128) and 3D ultrasound (2 %; 2/128). Immunotherapies were seldom prescribed (<1%); however, 98 % (125/128) of women received aspirin, 48 % LMWH (62/128) and 16 % corticosteroids (21/128). Surgical interventions were uncommon (5 %; 6/128)). The subsequent pregnancy rate was 70 % (89/128), with 36 % undergoing artificial reproductive technology (32/89). The livebirth rate was 63 % (56/89); 37 % had a further pregnancy loss (33/89), of which two were second-trimester miscarriages. CONCLUSIONS: Women with RM and infertility received care largely in line with RM guideline-based KPIs. However, we identified areas for improvement, including the quality of information provision, and access to certain investigations. While guideline-based KPIs allow for internationally applicable and reproducible audit that can direct service improvements, the experiences and needs of service-users are not captured, meriting further qualitative research.

Facilitators and barriers to seeking and engaging with antenatal care in high-income countries: A meta-synthesis of qualitative research.

Inadequate attendance to antenatal care has been associated with negative maternal and fetal outcomes, including stillbirth. This study aimed to identify facilitators and barriers to antenatal care attendance. A systematic search was conducted in March 2019 and updated in January 2021. Qualitative studies involving pregnant or post-partum women up to 12 months from high-income countries that provided data about facilitators and barriers to antenatal care attendance were sought. Meta-ethnography was used to inform this meta-synthesis. Fifteen studies were included in the analysis. Findings indicate that inadequate antenatal care attendance is influenced at different levels. Aspects like sociodemographic factors, difficulties navigating the health system, administrative delays, lack of flexibility and tailored care, constant change of carer and communication issues also act as barriers. These issues affect women's access to knowledge and the formation of women's beliefs and feelings towards seeking care. On the contrary, having a positive attitude towards the pregnancy, encountering empathetic healthcare professionals and availing of social support acted as facilitators. The reasons why women seek or delay attending antenatal care are multifactorial and can be explained using the Social Determinants of Health Framework. Any response needs to be taken across all levels of influence and not just focused on the individual. A better understanding of the barriers and facilitators to antenatal care might contribute to informing intervention or policy development addressing this issue.

Facilitators and barriers influencing weight management behaviours during pregnancy: a meta-synthesis of qualitative research.

BACKGROUND: Obesity and overweight are considered risk factors for a range of adverse outcomes, including stillbirth. This study aims to identify factors reported by women influencing weight management behaviours during pregnancy. METHODS: A systematic search was conducted in five databases from inception to 2019 and updated in 2021. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of weight management during pregnancy were included. Meta-ethnography was used to facilitate the meta-synthesis of 17 studies. RESULTS: Three themes were identified during the analysis: (1) Awareness and beliefs about weight gain and weight management, which included level of awareness and knowledge about dietary and exercise recommendations, risk perception and decision balance, perceived control over health and weight gain and personal insecurities. (2) Antenatal healthcare, women's experiences of their interactions with healthcare professionals during the antenatal period and the quality of the education received had an effect on women's behaviour. Further, our findings highlight the need for clear and direct information, and improved interactions with healthcare professionals, to better support women's weight management behaviours. (3) Social and environmental influence, the social judgement and stigmatization associated with overweight and obesity also acted as a negative influence in womens' engagement in weight management behaviours. CONCLUSION: Interventions developed to promote and maintain weight management behaviours during pregnancy should consider all levels of influence over women's behaviours, including women's level of awareness and beliefs, experiences in antenatal care, education provision and social influence.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group.

BACKGROUND: Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted. METHODS: Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development. RESULTS: From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process. CONCLUSIONS: It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Women/couples who have recurrent/repeated miscarriages should receive care that meets their needs, through agreed care pathways. This is often not the case. Key performance indicators (KPIs) are measures of specific elements of care (structures, processes and/or outcomes), which can help us to judge the quality of care given. In this paper, we describe how we worked with women and men with lived experience, doctors, nurses, managers, and others, to develop and agree on a list KPIs for recurrent miscarriage care in Ireland. We will use these to check what services are doing across the country and what could be done better. Participants filled out surveys and took part in meetings to vote on and agree on what KPIs were important to include. They also shared their views and experiences of taking part in this work. Together, we developed 110 KPIs for recurrent miscarriage care. These include measures of how care is structured, counselling and supports, investigations and treatments provided, and health-related outcomes. Participants' valued the different views that people brought to discussions and what they learned. They suggested ways that the process could be made more participant-friendly. For example, being up-front about the time it would take, explaining medical terms more, and cutting down on the number of items to be rated in surveys. It is important and possible to develop KPIs with different groups, particularly those with lived experience. Learning from our study may help others who want to do similar projects, such as develop KPIs or guidelines for care.

Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research.

BACKGROUND: Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth. AIM: This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy. METHODS: A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis. FINDINGS: Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals. DISCUSSION: Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use. CONCLUSION: Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review.

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

SARS-CoV-2 placentitis: An uncommon complication of maternal COVID-19.

We present a case of third trimester pregnancy complicated by SARS-CoV-2 infection and subsequent reduced fetal movements, resulting in emergency Caesarean delivery with demonstrable placental SARS-CoV-2 placentitis. We show through illustration of this case and literature review that SARS-Co-V-2 placentitis is an uncommon but readily recognisable complication of maternal SARS-CoV-2 infection that may be a marker of potential vertical transmission and that may have the capacity to cause fetal compromise through a direct injurious effect on the placenta.

Subsequent pregnancy outcomes following second trimester miscarriage-A prospective cohort study.

OBJECTIVES: Pregnancy after second-trimester miscarriage represents as clinical challenge. This study sought to determine the rates of recurrence, preterm birth and live births in a cohort of 185 women with previous second-trimester miscarriage. We hypothesized that there would be a higher rate of second-trimester miscarriage and preterm birth in subsequent pregnancy after second trimester miscarriage. The primary objectives of this study were to establish rates of second-trimester miscarriage, preterm birth and live births in this cohort. Secondary objectives were to examine medical and surgical interventions, in addition to other pregnancy outcomes and complications. STUDY DESIGN: This was a prospective cohort study carried out in a tertiary referral center in southern Ireland with over 8000 deliveries per year. 175 women were followed up. Inclusion criteria were an ultrasound confirmed second-trimester miscarriage between June 2009 and June 2013 and subsequently having a pregnancy between July 2009 and January 2016. Fifty-five women did not become pregnant during the study period and were excluded. Ten women were excluded for missing data. RESULTS: Between July 2009 and January 2016, 110 women became pregnant following a previous second-trimester miscarriage. In total, 81 babies were born to 77 mothers. The recurrence rate of second-trimester miscarriage was 6.3% (7/110) and the preterm birth rate was also 6.3% (7/110). The cesarean section rate was 45%. Including those who experienced first or second trimester miscarriage, 47% (78/155) of those who were followed up did not go on to have a live infant. CONCLUSIONS: Women experiencing second-trimester miscarriage are at increased risk in subsequent pregnancies of recurrence. Second-trimester miscarriage needs to be highlighted as a risk factor for adverse pregnancy outcomes. Greater research into its pathophysiology is required to advance preventative measures.

Neonatal and maternal outcomes following midtrimester preterm premature rupture of the membranes: a retrospective cohort study.

BACKGROUND: Preterm premature rupture of membranes (PPROM) complicates 1% of all pregnancies and occurs in one third of all preterm deliveries. Midtrimester PPROM is often followed by spontaneous miscarriage and elective termination of ongoing pregnancies is offered in many countries. The aim of this retrospective descriptive cohort study was to investigate the natural history of midtrimester PPROM in a jurisdiction where termination of pregnancy in the absence of maternal compromise is unavailable. METHODS: Cases of midtrimester PPROM diagnosed between 14 and 23 + 6 weeks' gestation during April 2007 to June 2012 were identified following a manual search of all birth registers, pregnancy loss registers, annual reports, ultrasound reports, emergency room registers and neonatal death certificates at Cork University Maternity Hospital - a large (circa 8500 births per annum) tertiary referral maternity hospital in southwest Ireland. Cases where delivery occurred within 24 h of PPROM were excluded. RESULTS: The prevalence of midtrimester PPROM was 0.1% (42 cases/44,667 births). The mean gestation at PPROM was 18 weeks. The mean gestation at delivery was 20 + 5 weeks, with an average latency period of 13 days. Ten infants were born alive (23%; 10/42). The remainder (77%; 32/42) died in utero or intrapartum. Nine infants were resuscitated. Two infants survived to discharge. The overall mortality rate was 95% (40/42). Five women had clinical chorioamnionitis (12%; 5/42) but 69% demonstrated histological chorioamnionitis. One woman developed sepsis (2.4%; 1/42). Other maternal complications included requirement of intravenous antibiotic treatment (38%; 17/42), retained placenta (21%, 9/42) and post-partum haemorrhage (12%; 5/42). CONCLUSIONS: This study provides useful and contemporary data on midtrimester PPROM. Whilst fetal and neonatal mortality is high, long-term survival is not impossible. The increased risk of maternal morbidity necessitates close surveillance.

Assessing quality of life questionnaires in urogynaecology--tick or type?

It is recognised that urogynaecological symptoms can have a significant impact on patient quality of life (QoL). Many of the QoL questionnaires are long and provide a burden to patients. The aim of this study was to compare patients' responses to utilising equivalent QoL questionnaires in different formats. The electronic personal assessment questionnaire, ePAQ-PF, was compared to the paper-based Queensland questionnaire. ePAQ-PF appeared to be of greater value but not more burdensome. However, women were more likely to complete the sexual function section using the Queensland questionnaire.

Empyema thoracis from an inhaled peanut.

A 77-year-old man with a history of pulmonary sarcoidosis was referred with persistent cough and reduced air entry on auscultation of the right lung base. He was an ex-smoker with a 40-pack-year history and his general practitioner was concerned about the possibility of bronchogenic carcinoma. A chest radiograph showed a right-sided pleural effusion with right mid-zone airspace opacification. Bronchoscopy revealed a peanut covered in mucus lodged in the right lower lobe bronchus. CT of the thorax demonstrated a multiloculated right pleural effusion with associated compressive atelectasis, consistent with chronic empyema. A chest drain was inserted but failed to fully clear the collection and the patient proceeded to a thoracoscopic decortication of a pleural empyema secondary to the right lower lobe obstruction from an inhaled peanut. His postoperative recovery was uncomplicated.