The importance of collaboration in maternal medicine: A retrospective descriptive study of a maternal multidisciplinary team meeting.

OBJECTIVE: In the present study we aimed to review the evolution and function of the maternal medicine multidisciplinary team (MMMDT) meeting of a maternal medicine service of a tertiary level stand-alone maternity hospital. METHODS: We conducted a retrospective descriptive study of all minutes of MMMDT meetings from 2014 to 2020, with the aim of evaluating meeting characteristics and patient demographics. RESULTS: There were 575 multidisciplinary team (MDT) discussions of 486 women during 43 meetings in the 7 year period. On average, 13 (range 3-23; SD = 5.28) women were discussed at each meeting, attended by 17 (range: 11-27; SD = 4.26) attendees. There were 18 women discussed during successive pregnancies. When analyzing the 2017-2020 data, preconceptual discussions made up 7.3% (n = 42) of patients discussed, with 5.7% (n = 33) being postnatal. The mean maternal age was 32.5 years (range 15-48 years) and women were most likely to be discussed in the mid-trimester period (21-24 weeks gestation). The top five primary specialities involved were hematology, neurology, rheumatology, neurosurgery and gastroenterology; however, 22 specialities were represented overall when classified by the primary medical condition. When examining the MDT input, hematology input was required in 144 patients (25.0%), radiology in 161 (28.0%) patients, and 117 in anesthesiology (20.3%). When examining the number of teams required to manage the patient, 80 women required the input of three specialities, with 16 women requiring the input of four specialities. CONCLUSION: We demonstrate the value and role of the MDT in the management of complex patients, providing a forum to discuss care in all phases of the obstetric journey.

Factors influencing medical students' decision to pursue a career in obstetrics and gynaecology.

INTRODUCTION: The career intentions of medical students can exert influence on service provision and medical staffing in the health services. It is vital for a specialty's development and sustainability that it has a constant stream of trainees into it annually. An appreciation of how a specialty is viewed by medical students can be used as an opportunity for early intervention in order to improve perception of the specialty and reduce future workforce problems, such as retention and attrition within obstetrics and gynaecology (O&G). We aimed to analyse positive and negative factors of the specialty of O&G as perceived by medical students in order to gain insight into changes that need to be made to improve recruitment and retention into the specialty. METHODS: A 70-item structured questionnaire consisting of demographic information and 5-point Likert scale questions relating to O&G was administered to final year medical students in the Republic of Ireland. Data were analysed with descriptive statistics, logistic regression, and odds ratios as appropriate. RESULTS: Of 195 medical students approached, 134 completed the questionnaire, a response rate of 68.7%. The majority were female (55.2%, n = 74) and 76.1% of respondents (n = 102) were Direct Entry Medicine students, with the remainder Graduate Entry Medicine students. 30.8% (n = 41) of students who responded scored 6 or more on a 10-point Likert scale when asked about their likelihood of considering a career in O&G. Students' clerkship experience factored heavily into their perception of the specialty and was more likely to be positive if they experienced direct consultant engagement and the opportunity for hands-on experience. Lifestyle factors, litigation and media were found to be deterrents to considering the specialty after graduation. CONCLUSIONS: This study demonstrates the importance of good clerkship experience in fostering an interest amongst undergraduates in O&G. Educators and those working within the specialty should showcase the strengths of the specialty during undergraduate education, and work on ameliorating deterrents to ultimately provide a structured approach to improving recruitment into O&G.

Follow-up and outcomes of patients with a pregnancy of unknown location: A comparison of two prediction models.

BACKGROUND: The time period while delineating the final diagnosis following presentation with a pregnancy of unknown location (PUL) can be an anxious time, as well as being time and resource intensive. Prediction models have been utilised in order to tailor counselling, frame expectations and plan care. OBJECTIVES: We aimed to review diagnoses of PUL in our population and assess the value of two prediction models. STUDY DESIGN: We reviewed all 394 PUL diagnoses over a three year period in a tertiary level maternity hospital. We then retrospectively applied the M1 and M6NP models to assess their accuracy when compared to the final diagnosis. RESULTS: PUL comprises of 2.9% (394/13401) of attendances in our unit, requiring 752 scans and 1613 separate blood tests. Just under one in ten women (9.9%, n = 39) presenting with a PUL had a viable pregnancy at discharge, however of the remainder, only 18.0% (n = 83) required medical or surgical treatment for a PUL. The M1 model was more successful at predicting an ectopic pregnancy than the M6NP, with the latter over-predicting viable pregnancies (33.4%, n = 77). CONCLUSIONS: We demonstrate that the management of women with a PUL could be stratified through the application of outcome prediction models, having positive results for framing expectations and potentially reducing this resource-intensive diagnosis.

Reviewing the past to inform the future: an 8-year review of severe maternal morbidity.

BACKGROUND: Maternal morbidity is becoming a key indicator used to compare health systems in the developed world and also to inform clinical practice. OBJECTIVE: This study aimed to evaluate a single center experience of severe maternal morbidity over an 8-year period. STUDY DESIGN: We conducted a retrospective review of all cases of severe maternal morbidity from 2012 to 2019 at a tertiary level maternity hospital in the Republic of Ireland with approximately 9000 births per year. We examined maternal demographics, pregnancy characteristics, and care requirements. Descriptive statistics were used throughout. RESULTS: There were 81,504 maternity cases and 67,894 births during the study period. A total of 504 women had a severe maternal morbidity, giving a rate of 6.1 per 1000 maternity cases overall, peaking in 2017 at 8.8 per 1000. When individual severe maternal morbidity events were evaluated, the rate increased from 6 per 1000 to 9 per 1000 over the 8-year period. There were no differences in maternal age, nationality, or body mass index during the years analyzed. Interestingly, 8.9% (n=45) were multiple gestations, and nearly one-fifth (19.4%; n=98) required escalation of care to a general hospital; of these, 14.0% (n=74) required cardiac or intensive care management. The majority of morbidities manifested in the third trimester (58.7%; n=296) or postnatally (42.8%, n=216). The most common severe maternal morbidities were hypertensive disorders of pregnancy, followed by postpartum hemorrhage and sepsis (45.0%, 44.2%, and 12.7%, respectively). CONCLUSION: We provide a longitudinal overview of severe maternal morbidity in a large maternity hospital that replicates other international findings. This information can be used for healthcare comparisons and for resource planning and allocation.

A qualitative review of challenges in recruitment and retention in obstetrics and gynecology in Ireland: The consultants' solution based perspective.

AIM: Recruitment and retention remains a concern in obstetrics and gynecology, with consultants having a unique perspective on the daily challenges. We aimed to examine these and examine their solutions to future-proofing the workforce. METHODS: Primary data were collected from consultant obstetrician-gynecologists in the Republic of Ireland. Using a qualitative methodology, semi-structured interviews were conducted with 17 participants recruited through purposive sampling. Following transcription, deductive content analysis was conducted to identify themes and categories with respect to challenges and solutions in the specialty. RESULTS: Findings revealed four superordinate themes of professional and personal factors, opinions of the specialty and the role of the consultant. Respondents expressed fear about low morale in the specialty, but also threats posed by resource availability and training limitations, in addition to medico-legal and media challenges. Solutions centered around re-evaluating training pathways and implementing improved advocacy and support structures for the specialty and for those working within it. CONCLUSIONS: This study provides a unique standpoint from which to explore an international in obstetrics and gynecology. Its solution-based outlook provides the framework to implement changes to protect and retain the current workforce as well as future-proofing recruitment to secure the specialty.

Management of pregnancy in a patient with long-chain 3-hydroxyacyl CoA dehydrogenase deficiency.

Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is a rare mitochondrial defect of ß-oxidation of long-chain fatty acids. Patients may present with muscle pain, hypotonia, peripheral neuropathy, cardiomyopathy, recurrent rhabdomyolysis and sudden death. Dietary management of LCHADD aims at preventing prolonged fasting and decreasing energy production from long-chain fatty acids compensated by an increase in medium-chain triglyceride fat. Herein, we present medical and dietetic management of a successful pregnancy in a LCHADD female patient and the delivery of a healthy baby boy.

Herpes encephalitis and hepatitis in pregnancy: A case report and literature review.

We present the case of a healthy nulliparous woman who presented with persistent fever, proteinuria and elevated transaminases at 33 weeks' gestation. Following initial treatment for suspected chorioamnionitis and potential pre-eclampsia, she had a caesarean section delivering a healthy male infant. However, on her third post-operative day, she developed neurological symptoms and accompanying severe sepsis, necessitating inotropic support and transfer to a higher level of care. A comprehensive work-up revealed herpes simplex Virus-2 (HSV-2) in serum and cerebrospinal fluid. Abdominal imaging was suggestive of accompanying hepatitis with micro-abscesses. This lady recovered well following intravenous acyclovir for 14 days. Her infant was not affected and was discharged home with his mother. Herpes simplex encephalitis and hepatitis associated with HSV-2 have been described three times previously in pregnancy. We delineate the diagnostic challenges that rare conditions such as this pose and emphasise the importance of multi-disciplinary care in managing complicated medical conditions in pregnancy.

Medication use in pregnancy and lactation: A gap to be filled in postgraduate medical education.

OBJECTIVE: Medication use is a common therapeutic intervention during pregnancy, in the postpartum period and during lactation. Women routinely consult a variety of medical practitioners to request advice and prescription of medication. However, it is noted internationally that healthcare providers have insufficient knowledge to support women through their therapeutic journeys, and continual education is not provided as routine during postgraduate training and practice. STUDY DESIGN: There are five colleges in Ireland responsible for postgraduate medical training in Ireland for medicine, surgery, general practice, anaesthesiology and psychiatry. These are responsible for the curriculum design and implementation of 45 training programs, with the Royal College of Physicians responsible for 26 training programs and the Royal College of Surgeons of Ireland responsible for 15 training programs. We reviewed the national postgraduate training curricula of all speciality in the Republic of Ireland, excluding care of the elderly and pathology (given these practitioners would not be actively prescribing and treating pregnant or lactating women). RESULTS: We demonstrate that less than 50 % of the 43 post-graduate training programs mention medications in pregnancy and lactation. Pregnancy is not mentioned by 12 programs in any degree, and 18 programs do not mention lactation or breastfeeding in any form. CONCLUSION: It is imperative that consistent knowledge is provided and accessible to healthcare providers in order to support women and their families through healthy pregnancies, and support breastfeeding for as long as possible. Therefore, we call on postgraduate training bodies to include comprehensive education on medications in pregnancy and lactation in their syllabi going forward.

A Rare Coincidence-a Second Trimester Ectopic Pregnancy Following Early Medical Abortion: a Case Report.

We describe a case of a woman in her mid-30s who presented to a tertiary level maternity hospital 17 days following early medical abortion with a positive pregnancy test. On the ultrasound examination, it was discovered that she had a second trimester ectopic pregnancy which was treated surgically with a unilateral salpingectomy. We discuss in depth factors related to this woman's care, such as appropriate assessment and evaluation of early medical abortion cases, the diagnostic challenges of early pregnancy scanning as well as the implications of the COVID-19 pandemic on the provision of care in these scenarios, and how this affected this woman's care.

A double dilemma: treatment of stage IV fetal twin-twin transfusion syndrome in the setting of maternal recurrent venous thromoembolism: a case report.

BACKGROUND: Fetal conditions can pose significant challenges in the management of pregnancies complicated by pre-existing maternal medical conditions. CASE PRESENTATION: We report a case of a 34-year-old woman with Stage IV Twin Twin Transfusion syndrome in the presence of maternal recurrent complex venous thromboembolic disease. Following a previous pregnancy loss, complicated by a third episode of thromboembolic disease, an inferior vena cava filter was placed. One month later, a pregnancy was confirmed and subsequently identified as a monochorionic twin pregnancy. Twin-Twin Transfusion syndrome was identified at 18 weeks' gestation and progressed rapidly to Quintero Stage IV. In consultation with a multi-disciplinary international team, fetoscopic laser photocoagulation was performed. The pregnancy progressed to delivery of female infants at 33 weeks gestation, who have achieved all developmental milestones at 2 years of age. CONCLUSIONS: We describe the multi-disciplinary effort to optimise the maternal condition to allow fetoscopic laser photocoagulation and continued management of the maternal and fetal conditions to a successful pregnancy outcome.

Does an elective induction policy negatively impact on vaginal delivery rates? A 30-month review of an elective induction policy.

BACKGROUND: The rate of induction of labour varies across Health Service Executive hospital regions in Ireland averaging at 23.3 per 100 deliveries in 2005-2009. The increasing rate of elective induction of labour in Ireland calls for more studies looking into associated maternal and/or neonatal outcomes. STUDY AIM: The aim of this study is to show that an elective induction policy with management by a sole consultant obstetrician can decrease caesarean section rates as well as positively impact maternal and neonatal complications. METHODS: We conducted a retrospective review of women attending a named obstetrician over a 1-year period. In total, 22 variables were collected, including basic patient demographics, mode of onset of labour, method of induction, mode of delivery, length of labour and neonatal outcomes. RESULTS: In total, 583 patients were identified in the study period. One hundred twenty-six (21.6%) patients presented with a spontaneous onset of labour, and 405 (69.4%) of patients had an induction of labour. Relative risk of having an emergency caesarean section, if labour is induced, is 1.42 (95% CI 0.64 to 3.14), and no statistical significance was demonstrated (p = 0.38). There was a statistically significant difference in operative vaginal delivery versus standard vaginal delivery relative risk between women ≥ 35-year-old and < 35-year-old groups, 0.47 (95% CI 0.39-0.57), p < 0.0001. CONCLUSION: Elective induction of labour is not associated with an increased risk of caesarean section or operative vaginal delivery in patients less than 35 years of age. This shows that elective induction is an appropriate intervention in selected scenarios without affecting mode of delivery.

Large loop excision of the transformation zone and preterm delivery over a decade in a major women's hospital.

BACKGROUND: The success of cervical screening relies on assessment and treatment of pre-malignant disease. Large loop excision of the transformation zone (LLETZ) has been the mainstay of treatment for cervical intraepithelial neoplasia (CIN). Preterm delivery (PTD) in subsequent pregnancy is a long-term complication of the intervention. AIMS: To describe the characteristics of women who had LLETZ treatment(s) followed by PTD in the Rotunda Hospital over a 10-year period. METHODS: The pathology and the obstetric databases were searched to identify women who had LLETZ followed by PTD from 1 January 2007-31 December 2016. Details including gestation at delivery, depth of LLETZ and grade of CIN were extracted. Exclusion criteria included multiple pregnancy, and deliveries due to current pregnancy indications. RESULTS: There were 97 women eligible for inclusion. Mean gestation at delivery was 33+2 weeks. CIN 1 was diagnosed in 16, CIN 2 in 24, CIN 3 in 53, and four were negative for CIN. No microinvasive or invasive disease was identified. The average depth of excision was 9.9 mm, 11.4 mm and 8.5 mm for CIN 1, 2 and 3, respectively. The difference in depth between excisions with CIN 2 and 3 was significant (p = 0.019). CONCLUSIONS: Despite having a lower mean depth of excision, women with CIN 3 comprised the majority of those who experienced PTD, suggesting that factors other than mechanical weakness are implicated in PTD for these women. This is in keeping with recent suggestions that the common denominator in high grade CIN and PTD is an altered vaginal microbiome.

The pregnancy experience: a mixed methods analysis of women's understanding of the antenatal journey.

BACKGROUND: Positive contact with antenatal care and its providers improves positive outcomes for women and their babies. This involves the accrual and use of knowledge accumulated through education, experiential learning and other fora and is reliant on a positive experience. AIMS: Women's knowledge of antenatal and postnatal care was examined, in addition to the positive and negative feelings and experiences they associate with it. METHODS: Employing a mixed methodology, a self-administered questionnaire was distributed to women attending antenatal clinics. It consisted of open and closed questions examining women's experiences of antenatal care and knowledge of the intrapartum and postnatal journey. Following this, individual semi-structured interviews were conducted with eight postnatal women gaining further in-depth insight into their peripartum experiences. RESULTS: Respondents to the questionnaire had varied opinions and beliefs about the purpose of antenatal care and prenatal screening policies, with the majority of their knowledge obtained from non-medical sources. The knowledge of labour and its complications was significantly better in multiparous women. However, in some postnatal scenarios, both cohorts lacked knowledge. In the qualitative study, women described positive feelings with their experience of antenatal care, with women expressing variations in the amount of knowledge they wanted to receive. CONCLUSIONS: This research demonstrates the varied experiences of women attending our services, highlighting both the positive and negative aspects of care. Topics of poor knowledge are highlighted, particularly in primiparous women and regarding the postnatal period. Using this information, women can be provided with an optimised, personalised experience in our maternity services.

Perinatal outcomes of reduced fetal movements: a cohort study.

BACKGROUND: The perception of reduced fetal movement (RFM) is an important marker of fetal wellbeing and is associated with poor perinatal outcome (such as intra-uterine death). METHODS: We conducted a prospective study of women presenting with RFM over 28 weeks' gestation to a tertiary-level maternity hospital. We examined pregnancy outcomes and compared them to a retrospectively collected control group delivering contemporaneously. RESULTS: In total, 275 presentations were analysed in the RFM group, with 264 in the control group. Women with RFM were more likely to be nulliparous (p = 0.002) and have an induction of labour (p = 0.0011). 26.5 % (n = 73) of cases were admitted following presentation with RFM, and 79.4 % (n = 58) delivered on primary presentation. Overall, 15.2 % (n = 42) women were induced for RFM specifically. CONCLUSION: This prospective study shows the increased burden of care required by those with RFM, including increased neonatal unit admission rates, increased induction rates and higher surveillance demands, demonstrating the need for increased attention to this area of practice.

Managing novel orally administered anticoagulants in patients undergoing urogynaecological surgery.

The use of novel orally administered anticoagulant agents (NOACs) provides new challenges to clinicians in the perioperative care of patients undergoing urogynaecological surgery. We aimed to assess evidence for managing patients taking NOACs before and after urogynaecological surgery. We conducted a literature search in CINAHL, MEDLINE, CENTRAL, Cochrane Library and PubMed for original research articles in the English language on this topic. However, despite initially identifying 556 articles, no articles pertained to the use of NOACs in urogynaecological surgery. We subsequently reviewed national and international guidance on managing patients prescribed NOACs and created a concise guideline to aid urogynaecologists in the perioperative care of these patients. Consensus is needed on perioperative optimisation of anticoagulation in urogynaecological patients using NOACs.