Evaluating the effects of hypoxic storage on platelet function and health using a novel storage system.

BACKGROUND: Thousands of units of whole blood (WB) and blood components are transfused daily to treat trauma patients. Improved methods for blood storage are critical to support trauma-related care. The Hemanext ONE® system offers a unique method for hypoxic storage of WB, with successfully demonstrated storage of clinically viable RBCs. This work evaluated the system for the storage of WB, focusing on platelet health and function. STUDY DESIGN AND METHODS: WB was collected from healthy donors and processed through the Hemanext ONE® system. Hemoglobin oxygen saturation (HbSO2) levels of WB were depleted to 10%, 20%, or 30% of total HbSO2 and then stored in PVC bags sealed in oxygen-impermeable bags (except for normoxic control) with samples collected on days 1, 7, and 14 post-processing. Flow cytometry assessed the activation and apoptosis of platelets. Clot dynamics were assessed based on aggregometry and thromboelastography assays, as well as thrombin generation using a calibrated-automated thrombogram method. RESULTS: Hypoxic storage conditions were maintained throughout the storage period. Hypoxia triggered increased lactate production, but pH changes were negligible compared to normoxic control. Storage at 10% HbSO2 had a significant impact on platelet function, resulting in increased activation and reduced clot formation and aggregation. These effects were less significant at 20% and 30% HbSO2. DISCUSSION: This study indicates that platelets are sensitive to hypoxic storage and suffer significant metabolic and functional deterioration when stored at or below 10% HbSO2.

Resigning oneself to a life of wound-related odour - A thematic analysis of patient experiences.

AIMS: To determine how patients with chronic wounds describe wound odour, identify what strategies they use to manage it and how effective these are. MATERIALS AND METHODS: Using a qualitative descriptive approach, semi-structured interviews were conducted between July and August 2021 with seven patients living with an odorous chronic wound at home. Data were analysed using Braun and Clarke's thematic analysis framework. RESULTS: The results were organised into two main themes: 1) becoming resigned to living with wound-related odour 2) strategies used to manage wound-related odour. Participants were sad, embarrassed and felt isolated but became resigned to living with this odour and accepting of it as a consequence of having a wound. Frequent dressing changes, household cleaning along with the use of sprays were the most frequently used tactics to manage odour none of which were deemed to be very effective. CONCLUSION: This study highlights the problem of odour management in clinical practice and how individuals develop strategies to overcome odour. Sadly, patients were resigned to living with wound odour and were accepting of it as part of daily life. This highlights the importance for healthcare professionals to recognise, assess for and ensure a better understanding of how people experience wound odour, the impact it can have on them personally. Frequent dressing changes can help manage wound odour from the patient's perspective.

Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds.

Chronic wounds adversely affect the quality of life of individuals and odour is a well-recognised associated factor. Odour can affect sleep, well-being, social interactions, diet and potentially wound healing. This systematic review aims to examine the effectiveness of topical interventions in the management of odour associated with chronic and malignant fungating wounds. A systematic review guided by PRISMA recommendations of randomised controlled trials where odour intensity/odour is the primary outcome was undertaken. Inclusion criteria were adults (18 years and over) with chronic venous, arterial, diabetic or pressure ulcers or with malignant fungating wounds where odour has been managed through topical application of pharmacological/non-pharmacological agents. Searches were conducted in CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, and Web of Science. Eligibility screening, risk of bias assessment and data extraction was completed by authors working independently. Searches retrieved 171 titles and abstracts (157 post de-duplication). Thirteen studies were retained for full text review of which five (n = 137 individuals) examining the following treatments remained: metronidazole (n = 4), silver (n = 1). Meta-analysis was not possible but individual studies suggest improved outcomes (i.e., reduced odour) using metronidazole. Treatment options to manage wound odour are limited and hampered by lack of clinical trials, small sample sizes, and absence of standardised outcomes and consistent measurement. Whereas metronidazole and silver may have a role in controlling wound odour, robust and well-designed interventions with rigorous procedures and standardised odour outcomes are necessary to evaluate their contribution.

Development and validation of the Safe Sleep Calculator to assess risk of sudden unexpected death in infancy.

We describe the development and validation of a Sudden Unexpected Death in Infancy (SUDI) risk assessment clinical tool. An initial SUDI risk assessment algorithm was developed from an individual participant data meta-analysis of five international SIDS/SUDI case-control studies. The algorithm was translated into a clinical web tool called the Safe Sleep Calculator, which was tested at the routine infant 6-week check-up in primary care clinics in New Zealand. Evidence was gathered through mixed-methods research to inform the revision of the algorithm and the clinical tool. The revised algorithm performance was validated on a new contemporary New Zealand SUDI case-control study dataset and the pilot population data set. The area under the Receiver Operator Characteristic (ROC) curve is 0.89, with a sensitivity of 83.0% and a specificity of 80.9% in the NZ infant population when 0.3 per 1000 live births or more risk is used to define 'at higher risk'. The Safe Sleep Calculator SUDI risk assessment tool provides individualized evidence-based specific SUDI prevention advice for every infant and enables the concentration of additional SUDI prevention efforts and resource for infants at higher risk.

The profile of patients with venous leg ulcers: A systematic review and global perspective.

BACKGROUND: A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes. OBJECTIVES: To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area. METHODS: A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting. RESULTS: twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm2; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together. CONCLUSION: a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

The jungle book of neuropsychology: Disentangling the influence of feral childhood from adult brain injury in order to provide effective rehabilitation.

BACKGROUND AND AIMS: This article considers the complexities of neuropsychological assessment and rehabilitation in brain injury when the client is illiterate, is from a foreign culture with English as a second language, and reports highly atypical childhood feral experiences prior to injury. METHOD: MC was a 63-year-old woman referred for neuropsychological rehabilitation with a diagnosis of suspected St Louis encephalitis and global cognitive impairment. In formulating her clinical presentation, consideration was given to a reported history of feral childhood living with monkeys in the Colombian jungle and subsequent physical and emotional abuse. MC participated in comprehensive neuropsychological assessment and then targeted rehabilitation. RESULTS: Neuroimaging documented relatively focal damage in the right temporal lobe. MC's family described her as "the same but worse"; assessment and formulation indicated an exacerbation of attentional, pragmatic, arousal and executive weaknesses but with new memory and emotion recognition impairments. Rehabilitation techniques for communication and executive difficulties were successful despite the complexities of the case. CONCLUSIONS: The importance of carefully considered assessment and formulation in understanding MC's presentation is discussed. To the authors' knowledge, this is the only case of neuropsychological assessment and rehabilitation in brain injury involving a history of feral childhood.

Characterization of patients with diabetic foot disease presenting to an Irish Podiatry Centre: profiling suitability for entry to a clinical trial of advanced wound therapeutics.

BACKGROUND: Diabetes mellitus, coined the 'Black Death of the Twenty-First Century', is associated with complications, including foot ulceration with potential loss of limb. There is a need for development of new wound therapies through completion of robust clinical trials. AIMS: To profile demographics and wound characteristics of an Irish cohort with diabetes, forecast eligibility for entry to a clinical trial of advanced wound therapeutics, and adjust criteria to optimize eligibility for enrolment. METHODS: A cross-sectional study of out-patients attending a Podiatry centre over 12 weeks was conducted. Information was collected through clinical assessment, including Neuropathy Disability Score and Ankle-Brachial Pressure Index. Ulcers were characterised as 'healing' or 'non-healing'; a 'healing' wound decreased by 30 % over the previous month, accomplished by retrospective analysis of files. Statistics, including binomial logistic regression and column analysis for eligibility assessment, were conducted. RESULTS: Seventy-four participants were identified with a mean age of 67 (± 8.79) years. Non-healing DFU status correlated significantly with larger wound area (P = 0.013), infection (P = 0.009), and greater degrees of ischaemia (P = 0.015). The eligibility criteria were modelled after those proposed by the EU consortium project REDDSTAR. In this Irish population, these criteria limit eligibility to 1.4 %. CONCLUSIONS: This research found an eligibility criterion of wound area 2-10 cm2 for enrolment in a clinical trial of mesenchymal stromal cell therapy too restrictive. Extension of wound area to 1-10 cm2 and the inclusion of neuro-ischaemic ulcers increased eligibility for enrolment from 1.4 to 20 %.

Treating Problem Gambling Samples with Cognitive Behavioural Therapy and Mindfulness-Based Interventions: A Clinical Trial.

The problem gambling (PG) intervention literature is characterised by a variety of psychological treatments and approaches, with varying levels of evidence (PGRTC in Guideline for screening, assessment and treatment in problem and pathological gambling. Monash University, Melbourne, 2011). A recent PG systematic review (Maynard et al. in Res Soc Work Pract, 2015. doi: 10.1177/1049731515606977 ) and the success of mindfulness-based interventions to effectively treat disorders commonly comorbid with PG suggested mindfulness-based interventions may be effective for treating PG. The current study tested the effectiveness of three interventions to treat PGs: 1. case formulation driven Cognitive Behaviour Therapy (CBT); 2. manualised CBT; and 3. mindfulness-based treatment. All three interventions tested returned large effect size improvements in PG behaviour after seven sessions (Cohen's d range 1.46-2.01), at post-treatment and at 3 and 6-month follow-up. All of the interventions were rated as acceptable by participants at post-treatment. This study suggests that the mindfulness-based and TAU interventions used in the current study appear to be effective at reducing PG behavior and associated distress and they also appear to generalise to improvements in other measures such as quality of life-mental functioning and certain mindfulness facets more effectively than the manualised form of CBT utilised used here. Secondly, a brief mindfulness intervention delivered after psycho-education and a brief CBT intervention may be a useful supplement to traditional CBT treatments by addressing transdiagnostic processes such as rumination and thought suppression. Thirdly, CBT interventions continue to report effectiveness in reducing PG behaviour and associated distress consistent with the prevailing literature and clinical direction.

The effect of two cognitive aid designs on team functioning during intra-operative anaphylaxis emergencies: a multi-centre simulation study.

This multi-centre repeated measures study was undertaken to determine how contrasting designs of cognitive aids affect team performance during simulated intra-operative anaphylaxis crises. A total of 24 teams consisting of a consultant anaesthetist, an anaesthetic trainee and anaesthetic assistant managed three simulated intra-operative anaphylaxis emergencies. Each team was assigned at random to a counterbalanced order of: no cognitive aid; a linear cognitive aid; and a branched cognitive aid, and scored for team functioning. Scores were significantly higher with a linear compared with either a branched version of the cognitive aid or no cognitive aid for 'Team Overall Behavioural Performance', difference between study groups (F-value) 5.8, p = 0.01. Aggregate scores were higher with the linear compared with the branched aid design (p = 0.03). Cognitive aids improve co-ordination of the team's activities and support team members to verbalise their actions. A linear design of cognitive aid improves team functioning more than a branched design.

Oocyte expression, secretion and somatic cell interaction of mouse bone morphogenetic protein 15 during the peri-ovulatory period.

Bone morphogenetic protein 15 (BMP15) is a key intraovarian growth factor regulating mammalian fertility, yet expression and localisation of different BMP15 protein forms within ovarian follicles around the time of the preovulatory LH surge remains unclear. Using immunoblotting and immunocytochemistry, the present study identified that post-translationally processed BMP15 proregion and mature proteins are increasingly expressed and localised with cumulus and granulosa cells from mice treated with pregnant mare's serum gonadotropin (PMSG) + human chorionic gonadotrophin (hCG). However, this increased expression was absent in cumulus-oocyte complexes matured in vitro. Pull-down assays further revealed that the recombinant BMP15 proregion is capable of specific interaction with isolated granulosa cells. To verify an oocyte, and not somatic cell, origin of Bmp15 mRNA and coregulated growth differentiation factor 9 (Gdf9), in situ hybridisation and quantitative polymerase chain reaction results confirmed the exclusive oocyte localisation of Bmp15 and Gdf9, regardless of treatment or assay method. Relative oocyte expression levels of Bmp15 and Gdf9 decreased significantly after PMSG + hCG treatment; nevertheless, throughout all treatments, the Bmp15:Gdf9 mRNA expression ratio remained unchanged. Together, these data provide evidence that the preovulatory LH surge leads to upregulation of several forms of BMP15 protein secreted by the oocyte for putative sequestration and/or interaction with ovarian follicular somatic cells.

Does tongue size contribute to risk of airway narrowing in preterm infants sitting in a car safety seat?

BACKGROUND: Preterm infants are at risk of narrowing of the upper airway while restrained in infant car seats, leading to secondary apnea. However, some infants are able to maintain a normal airway. We hypothesized that this might reflect relatively smaller tongue size. METHODS: We retrospectively analyzed previously reported respiration-timed lateral radiographs of the upper airways of 17 preterm infants ready for discharge (32.6 ± 1.0 weeks gestation at birth, and 37.8 ± 9.7 days old at study) taken during sleep, first in a car safety seat with an insert that allowed the head to remain upright, and then without the insert, when the head slumped forward. The presence of air above the tongue was used as an index of relative tongue size. RESULTS: A smaller airspace around the tongue (relatively larger tongue) was associated with greater narrowing of the upper airway when the head was flexed forward in sleep (p < 0.002). In contrast, there was no significant correlation between baseline airway size and change in airway size (r (2) = 0.16, p = 0.11). CONCLUSION: The present study supports the hypothesis that the vulnerability of preterm infants to airways compromise while restrained in a car safety seat may be in part related to relative tongue size.

A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study.

BACKGROUND: This is the first study to examine risk factors for diabetic foot ulceration in Irish general practice. AIM: To determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor. DESIGN: A prospective observational study. METHODS: Patients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later. RESULTS: Of 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11%, respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10 g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; P = 0.64]. CONCLUSION: Our data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.

Regulation of the delta and alpha epithelial sodium channel (ENaC) by ubiquitination and Nedd8.

The δ epithelial sodium channel (δENaC) is a proton-activated, sodium-selective, amiloride-sensitive ion channel in the ENaC/degenerin family of ion channels involved in blood pressure regulation and mechanosensation. Other ENaC family members are subject to ubiquitin modification leading to internalization from the cell surface, and degradation of the channel. Here, we show that δENaC is also modified by ubiquitin on three intracellular lysine residues. Absence of these lysines abolished ubiquitin modification of δENaC and increased cell surface levels of δENaC. Although the HECT-domain ubiquitin ligase Nedd4-2 reduced amiloride-sensitive current generated by δßγENaC-containing channels, δENaC does not contain a binding site for Nedd4-2; therefore, this effect is probably mediated by the ßγENaC subunits. Nedd8, a ubiquitin-like protein that regulates RING-domain E3 ubiquitin ligases, promoted δENaC ubiquitination, decreased both the intracellular and cell surface δENaC populations, and decreased δßγENaC amiloride-sensitive short circuit current (Isc -amiloride) in a mammalian epithelium. Nedd8 also promoted α- and γENaC ubiquitination, decreased the cell surface pools, and decreased αßγENaC Isc -amiloride. Conversely, XIAP, a single subunit RING E3 ligase, decreased ubiquitinated δENaC, increased the δENaC cell surface pool and increased δßγENaC Isc -amiloride. Therefore δ- and α - ßγENaC channel function may be influenced by RING-domain E3 ubiquitin ligases.

Effects of species differences on oocyte regulation of granulosa cell function.

The aims were to investigate whether oocyte-secreted growth factors from a high (i.e. rat) and low (i.e. sheep) ovulation rate species could stimulate (3)H-thymidine incorporation in granulosa cells (GC) from antral follicles from the same or across species. Denuded oocytes (DO) were co-incubated with GC with or without specific antibodies to growth differentiating factor 9 (GDF9) or bone morphogenetic protein 15 (BMP15). Co-incubations of DO-GC from the same or across species significantly increased thymidine incorporation in GC with increasing numbers of DO. GDF9 immuno-neutralisation reduced thymidine incorporation in rat GC co-incubated with either rat or ovine DO and in ovine GC co-incubated with ovine or rat DO. BMP15 immuno-neutralisation only reduced thymidine incorporation when ovine DO were co-incubated with either ovine or rat GC. Western blotting of oocytes co-incubated with GC identified GDF9 and BMP15 proteins for sheep and GDF9 protein for rats in oocyte lysates and incubation media. With respect to rat BMP15, a promature protein was identified in the oocyte lysate but not in media. Expression levels of GDF9 relative to BMP15 mRNA in DO co-incubated with GC were highly correlated (R (2)=0.99) within both species. However, the expression ratios were markedly different for the rat and sheep (4.3 vs 1.0 respectively). We conclude that during follicular development, rat oocytes secrete little, if any, BMP15 and that GDF9 without BMP15 can stimulate proliferation of rat and ovine GC. In contrast, ovine oocytes secrete both BMP15 and GDF9, and both were found to stimulate proliferation in ovine and rat GC.

The feasibility of Dementia Care Mapping (DCM) on a neurorehabilitation ward.

Person-centred care (PCC) is recommended when working with patients with neurological difficulties. Despite this, to date there has been no appropriate methodology for assessing or developing PCC in neurorehabilitation settings. Dementia Care Mapping (DCM) is a well-established tool for assessing and developing PCC in dementia settings and the current study investigated the feasibility of applying DCM on an acute neurorehabilitation ward. DCM procedure and coding required minor adaptations for use in this setting and further recommended adaptations were subsequently identified. It was found that the DCM coding system was generally suitable and could identify strengths, weaknesses and areas for development in ward care. Q-methodology identified that staff views endorsed the feasibility of using DCM in neurorehabilitation, with staff reporting that they found DCM useful and relevant to their work. DCM could be further developed for this setting by amendments to the behaviour coding system, concept and coding of person-centred care, and a population-specific manual. DCM is a promising methodology to develop and promote PCC in neurorehabilitation.

Active immunization against the proregions of GDF9 or BMP15 alters ovulation rate and litter size in mice.

The transforming growth factor ß (TGFB) superfamily proteins bone morphogenetic protein 15 (BMP15) and growth differentiation factor 9 (GDF9), are essential for mammalian fertility. Recent in vitro evidence suggests that the proregions of mouse BMP15 and GDF9 interact with their mature proteins after secretion. In this study, we have actively immunized mice against these proregions to test the potential in vivo roles on fertility. Mice were immunized with either N- or C-terminus proregion peptides of BMP15 or GDF9, or a full-length GDF9 proregion protein, each conjugated to keyhole limpet hemocyanin (KLH). For each immunization group, ovaries were collected from ten mice for histology after immunization, while a further 20 mice were allowed to breed and litter sizes were counted. To link the ovulation and fertility data of these two experimental end points, mice were joined during the time period identified by histology as being the ovulatory period resulting in to the corpora lutea (CL) counted. Antibody titers in sera increased throughout the study period, with no cross-reactivity observed between BMP15 and GDF9 sera and antigens. Compared with KLH controls, mice immunized with the N-terminus BMP15 proregion peptide had ovaries with fewer CL (P<0.05) and produced smaller litters (P<0.05). In contrast, mice immunized with the full-length GDF9 proregion not only had more CL (P<0.01) but also had significantly smaller litter sizes (P<0.01). None of the treatments affected the number of antral follicles per ovary. These findings are consistent with the hypothesis that the proregions of BMP15 and GDF9, after secretion by the oocyte, have physiologically important roles in regulating ovulation rate and litter size in mice.

Pancreatic ß-cell prosurvival effects of the incretin hormones involve post-translational modification of Kv2.1 delayed rectifier channels.

Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are the major incretin hormones that exert insulinotropic and anti-apoptotic actions on pancreatic ß-cells. Insulinotropic actions of the incretins involve modulation of voltage-gated potassium (Kv) channels. In multiple cell types, Kv channel activity has been implicated in cell volume changes accompanying initiation of the apoptotic program. Focusing on Kv2.1, we examined whether regulation of Kv channels in ß-cells contributes to the prosurvival effects of incretins. Overexpression of Kv2.1 in INS-1 ß-cells potentiated apoptosis in response to mitochondrial and ER stress and, conversely, co-stimulation with GIP/GLP-1 uncoupled this potentiation, suppressing apoptosis. In parallel, incretins promoted phosphorylation and acetylation of Kv2.1 via pathways involving protein kinase A (PKA)/mitogen- and stress-activated kinase-1 (MSK-1) and histone acetyltransferase (HAT)/histone deacetylase (HDAC). Further studies demonstrated that acetylation of Kv2.1 was mediated by incretin actions on nuclear/cytoplasmic shuttling of CREB binding protein (CBP) and its interaction with Kv2.1. Regulation of ß-cell survival by GIP and GLP-1 therefore involves post-translational modifications (PTMs) of Kv channels by PKA/MSK-1 and HAT/HDAC. This appears to be the first demonstration of modulation of delayed rectifier Kv channels contributing to the ß-cell prosurvival effects of incretins and of 7-transmembrane G protein-coupled receptor (GPCR)-stimulated export of a nuclear lysine acetyltransferase that regulates cell surface ion channel function.

Repeat caesarean delivery as a risk factor for abnormal blood loss, blood transfusion and perinatal mortality.

We reviewed 450 cases of caesarean delivery (January-December 2009) at the University of Ilorin Teaching Hospital in Nigeria. We analysed the association between caesarean delivery status (primary or previous) and the following outcomes: abnormal blood-loss, blood transfusion and perinatal mortality. Although significant differences were observed between primary and previous caesarean delivery groups in regards to maternal age, urgency of the caesarean delivery, booking status, and cadre of birth attendant staff, no association was noted between caesarean delivery status and any of the three outcomes. Further analyses identified parity as an important predictor for blood transfusion and abnormal blood loss. In addition, we found a dose?response relationship between parity and abnormal blood loss (< 0.05). Also, mothers with an emergency caesarean delivery of the index pregnancy were more than twice as likely to have a blood transfusion as compared with those with an elective caesarean delivery.

Interpregnancy BMI change and risk of primary caesarean delivery.

We conducted a retrospective study using Missouri maternally linked cohort files (1989-2005). We examined the association between interpregnancy body mass index (BMI) change and risk of primary caesarean delivery. BMI was classified as normal (18.5-24.9 kg/m(2)) or obese (≥30.0 kg/m(2)). Interpregnancy BMI change was defined using the following categories: normal-normal, normal-obese, obese-normal and obese-obese. Logistic regression models were used to generate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the risk of primary caesarean delivery in the second pregnancy. Elevated risks for caesarean delivery in the second pregnancy were noted for normal weight mothers becoming obese (OR = 1.41, 95% CI 1.26-1.57) and obese mothers maintaining their obese status across both pregnancies (OR = 1.75, 95% CI 1.65-1.87). Women with a reduction in BMI (obese-normal) had a risk level for primary caesarean section that was comparable with that of women with normal BMI status in both pregnancies.