• Impact of diabetes, obesity and hypertension on preterm birth: Population-based study.

      Berger, Howard; Melamed, Nir; Davis, Beth Murray; Hasan, Haroon; Mawjee, Karizma; Barrett, Jon; McDonald, Sarah D; Geary, Michael; Ray, Joel G (2020-03-25)
      Objective: To determine the impact of pre-pregnancy diabetes mellitus (D), obesity (O) and chronic hypertension (H) on preterm birth (PTB). Methods: Retrospective population-based cohort study in Ontario, Canada between 2012-2016. Women who had a singleton livebirth or stillbirth at > 20 weeks gestation were included in the cohort. Exposures of interest were D, O and H, individually, and in various combinations. The primary outcome was PTB at 241/7 to 366/7 weeks. PTB was further analyzed by spontaneous or provider-initiated, early (< 34 weeks) or late (34-37 weeks), and the co-presence of preeclampsia, large for gestational age (LGA), and small for gestational age (SGA). Multivariable Poisson regression models with robust error variance were used to generate relative risks (RR), further adjusted for maternal age and parity (aRR). Population attributable fractions (PAF) were calculated for each of the outcomes by exposure state. Results: 506,483 women were eligible for analysis. 30,139 pregnancies (6.0%) were complicated by PTB < 37 weeks, of which 7375 (24.5%) had D or O or H. Relative to women without D or O or H, the aRR for PTB < 37 weeks was higher for D (3.51; 95% CI 3.26-3.78) and H (3.81; 95% CI 3.55-4.10) than O (1.14; 95% CI 1.10-1.17). The combined state of DH was associated with a significantly higher aRR of PTB < 37 weeks (6.34; 95% CI 5.14-7.80) and < 34 weeks (aRR 10.33, 95% CI 6.96-15.33) than D alone. The risk of provider initiated PTB was generally higher than that for spontaneous PTB. Pre-pregnancy hypertension was associated with the highest risk for PTB with preeclampsia (aRR 45.42, 95% CI 39.69-51.99) and PTB with SGA (aRR 9.78, 95% CI 7.81-12.26) while pre-pregnancy diabetes was associated with increased risk for PTB with LGA (aRR 28.85, 95% CI 24.65-33.76). Conclusion: Combinations of DOH significantly magnify the risk of PTB, especially provider initiated PTB, and PTB with altered fetal growth or preeclampsia.
    • ART in Europe, 2015: results generated from European registries by ESHRE.

      De Geyter, C; Calhaz-Jorge, C; Kupka, M S; Wyns, C; Mocanu, E; Motrenko, T; Scaravelli, G; Smeenk, J; Vidakovic, S; Goossens, V (2020-02-24)
      Study question: What are the European trends and developments in ART and IUI in 2015 as compared to previous years? Summary answer: The 19th ESHRE report on ART shows a continuing expansion of treatment numbers in Europe, and this increase, the variability in treatment modalities and the rising contribution to the birth rates in most participating countries all point towards the increasing impact of ART on European society. What is known already: Since 1997, the ART data generated by national registries have been collected, analysed and reported in 18 manuscripts published in Human Reproduction. Study design size duration: Collection of European data by the European IVF-Monitoring Consortium (EIM) for ESHRE. The data for treatments performed between 1 January and 31 December 2015 in 38 European countries were provided by national registries or on a voluntary basis by clinics or professional societies. Participants/materials settings methods: From 1343 institutions in 38 countries offering ART services a total of 849 811 treatment cycles, involving 155 960 with IVF, 385676 with ICSI, 218098 with frozen embryo replacement (FER), 21 041 with preimplantation genetic testing (PGT), 64 477 with egg donation (ED), 265 with IVM and 4294 with FOR were recorded. European data on IUI using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 1352 institutions offering IUI in 25 countries and 21 countries, respectively. A total of 139 050 treatments with IUI-H and 49 001 treatments with IUI-D were included. Main results and the role of chance: In 18 countries (14 in 2014) with a population of approximately 286 million inhabitants, in which all institutions contributed to their respective national registers, a total of 409 771 treatment cycles were performed, corresponding to 1432 cycles per million inhabitants (range: 727-3068 per million). After IVF the clinical pregnancy rates (PRs) per aspiration and per transfer were slightly lower in 2015 as compared to 2014, at 28.5 and 34.6% versus 29.9 and 35.8%, respectively. After ICSI, the corresponding PR achieved per aspiration and per transfer in 2015 were also slightly lower than those achieved in 2014 (26.2 and 33.2% versus 28.4 and 35.0%, respectively). On the other hand, after FER with own embryos the PR per thawing continued to rise from 27.6% in 2014 to 29.2% in 2015. After ED a slightly lower PR per embryo transfer was achieved: 49.6% per fresh transfer (50.3% in 2014) and 43.4% for FOR (48.7% in 2014). The delivery rates (DRs) after IUI remained stable at 7.8% after IUI-H (8.5% in 2014) and at 12.0% after IUI-D (11.6% in 2014). In IVF and ICSI together, 1, 2, 3 and ≥4 embryos were transferred in 37.7, 53.9, 7.9 and in 0.5% of all treatments, respectively (corresponding to 34.9, 54.5, 9.9 and in 0.7% in 2014). This evolution towards the transfer of fewer embryos in both IVF and ICSI resulted in a proportion of singleton, twin and triplet DR of 83.1, 16.5 and 0.4%, respectively (compared to 82.5, 17.0 and 0.5%, respectively, in 2014). Treatments with FER in 2015 resulted in twin and triplet DR of 12.3 and 0.3%, respectively (versus 12.4 and 0.3% in 2014). Twin and triplet delivery rates after IUI-H were 8.9 and 0.5%, respectively (in 2014: 9.5 and 0.3%), and 7.3 and 0.6% after IUI-D (in 2014: 7.7 and 0.3%). Limitations reasons for caution: The methods of data collection and reporting vary among European countries. The EIM receives aggregated data from various countries with variable levels of completeness. Registries from a number of countries have failed to provide adequate data about the number of initiated cycles and deliveries. As long as incomplete data are provided, the results should be interpreted with caution. Wider implications of the findings: The 19th EIM report on ART shows a continuing expansion of treatment numbers in Europe. The number of treatments reported, the variability in treatment modalities and the rising contribution to the birth rates in most participating countries point towards the increasing impact of ART on reproduction in Europe. Being the largest data collection on ART worldwide, detailed information about ongoing developments in the field is provided. Study funding/competing interests: The study has no external funding and all costs are covered by ESHRE. There are no competing interests.
    • Gestational weight gain counselling practices among different antenatal health care providers: a qualitative grounded theory study.

      Murray-Davis, Beth; Berger, Howard; Melamed, Nir; Mawjee, Karizma; Syed, Maisah; Barrett, Jon; Ray, Joel G; Geary, Michael; McDonald, Sarah D (2020-02-12)
      Background: Inappropriate gestational weight gain in pregnancy may negatively impact health outcomes for mothers and babies. While optimal gestational weight gain is often not acheived, effective counselling by antenatal health care providers is recommended. It is not known if gestational weight gain counselling practices differ by type of antenatal health care provider, namely, family physicians, midwives and obstetricians, and what barriers impede the delivery of such counselling. The objective of this study was to understand the counselling of family physicians, midwives and obstetricians in Ontario and what factors act as barriers and enablers to the provision of counselling about GWG. Methods: Semi-structured interviews were conducted with seven family physicians, six midwives and five obstetricians in Ontario, Canada, where pregnancy care is universally covered. Convenience and purposive sampling techniques were employed. A grounded theory approach was used for data analysis. Codes, categories and themes were generated using NVIVO software. Results: Providers reported that they offered gestational weight gain counselling to all patients early in pregnancy. Counselling topics included gestational weight gain targets, nutrition & exercise, gestational diabetes prevention, while dispelling misconceptions about gestational weight gain. Most do not routinely address the adverse outcomes linked to gestational weight gain, or daily caloric intake goals for pregnancy. The health care providers all faced similar barriers to counselling including patient attitudes, social and cultural issues, and accessibility of resources. Patient enthusiasm and access to a dietician motivated health care providers to provide more in-depth gestational weight gain counselling. Conclusion: Reported gestational weight gain counselling practices were similar between midwives, obstetricians and family physicians. Antenatal knowledge translation tools for patients and health care providers are needed, and would seem to be suitable for use across all three types of health care provider specialties.
    • Factors Contributing to Non-Exclusive Breastfeeding in Primigravid Mothers

      Panaviene, J.; Zakharchenko, L.; Olteanu, D.; Cullen, M.; EL-Khuffash, E.L (Irish Medical Journal, 2019-10)
      We aimed to examine the factors contributing to non-exclusive breastfeeding in primigravid mothers in a large Irish tertiary maternity hospital.
    • Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

      Clooney, L; Ronayne, A; Glennon, K; Brennan, M; Hickey, N; Magee, C; Cooley, S; Eogan, M; Drew, R.J (Irish Medical Journal, 2019-06)
      Acute pyelonephritis is one of the most common medical complications of pregnancy. It occurs in 0.5–2% of pregnant women and can result in significant maternal and fetal morbidity1,2. Additionally there is a financial burden on the hospital due to prolonged inpatient stays, increased preterm birth rate and associated neonatal care 3. Although there have been many studies evaluating the benefit of treating asymptomatic bacteriuria to prevent pyelonephritis in pregnancy, there is little recent evidence around how to treat pyelonephritis in pregnancy 4-6. In 1995 a study was published which showed the benefit of ceftriaxone in pregnancy, when compared to cefazolin but did not address issues such as prophylaxis during the remaining pregnancy and need for additional gentamicin
    • Awareness and Preventative Behaviours Regarding Toxoplasma, Listeria and Cytomegalovirus Among Pregnant Women

      Basit, I; Crowley, D; Geary, M; Kirkham, C; Mc Dermott, R; Cafferkey, M; Sayers, G (Irish Medical Journal, 2019-06)
      Serious fetal infections can be transmitted transplacentally or perinatally. Vaccination is a key prevention method as shown by the dramatic reduction of congenital rubella. Reducing the risk of toxoplasmosis, listeriosis and CMV in pregnancy requires knowledge of their epidemiology and appropriate prevention strategies in the absence of vaccines. Primary infection with Toxoplasma gondii occurs following ingestion of active or inactive cysts. Sources of cysts include undercooked or raw meat (e.g. uncooked or dried meats), contaminated unwashed cooking surfaces and utensils, contaminated cat litter, soil and water supplies, unwashed soil-grown fruits and vegetables, unpasteurised milk, and less frequently, transplanted organs and blood products. Primary toxoplasmosis in pregnancy can lead to chorioretinitis, deafness, microcephaly, developmental delay, late onset of ocular defects, and stillbirth.
    • Early Onset Neonatal E.Coli Sepsis

      O’Rahelly, M.; Smith, A.; Drew, R.; McCallion, N. (Irish Medical Journal, 2019-02)
      Neonatal sepsis is a major cause of neonatal morbidity and mortality in term and preterm infants. The timely identification of infants at risk of infection is of particular importance in the vulnerable preterm group1 and is a major focus of microbiological research in the Rotunda Hospital. E.coli accounts for approximately 14.1% of early onset sepsis, i.e. sepsis before 72 hours of age in our centre. E.coli is the second most common pathogen, along with coagulase negative Staphylococcus, after group B Streptococcus (GBS)2.
    • Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice and Education among Obstetricians and Gynaecologists in Ireland

      Abdelrahman, M; Geary, M; Eogan, M (Irish Medical Journal, 2019-01)
      This paper summarises results of a survey of obstetricians in Ireland regarding their technique, management, and education on episiotomy and Obstetric Anal Sphincter Injury (OASIS). An anonymous survey was emailed to all obstetricians and gynaecologists in Ireland, including trainees between January and September 2017. The response rate was 45% (155/343) with 111 out of 144 (77%) reported clinical experience as part of their training and 92 (64%) attended an OASIS workshop or classroom teaching. The majority prescribe antibiotics and laxatives post-op, request physiotherapy review and follow-up patients in outpatient settings. We identified that most specialists and trainees practice within guidelines, but some recognise a need for further teaching and exposure to these types of injuries. These results will direct future curriculum and optimise ongoing training for trainees, unify service provision and contribute to patient safety.
    • Staff Attitudes towards Patient Safety Culture and Working Conditions in an Irish Tertiary Neonatal Unit

      Dwyer, L; Smith, A; McDermott, R; Breatnach, C; El-Khuffash, A; Corcoran, JD; Rotunda Hospital, Dublin (Irish Medical Journal, 2018-07)
      There is little published research evaluating attitudes towards patient safety culture and working conditions in neonatal units. This study aimed to explore this within a Level III Irish neonatal unit setting.
    • A Review of the Parenteral Nutrition Supply Service in an Irish Neonatal Unit

      Smith, A; Glynn, AC; Shankar, A; McDermott, C; McCallion, N (Irish Medical Journal, 2018-06)
      Neonatal Intensive Care (NICU) patients have individual nutritional requirements often requiring Patient Specific Parenteral Nutrition (PSPN). From October 2015, the national PSPN compounding service availability changed from 7 days per week service to 5 days per week (i.e. no weekend and limited bank holiday ordering available). The aim of this study was to examine the introduction of a 5 day only PSPN supply on neonatal patient parenteral nutrition availability in a tertiary NICU.
    • The Triangular Sign, a Useful Diagnostic Marker for Biliary Atresia: A Case Series of Three Irish Infants

      Smith, A; Shankar, A; Collins, A; Tarrant, A; Boyle, MA (Irish Medical Journal, 2018-06)
      The triangular cord (TC) sign is the appearance of a triangular shaped echogenic density visualised immediately cranial to the portal vein bifurcation on ultrasonographic examination. Several studies have reported that this ultrasonographic sign is a reliable and helpful marker in identifying Biliary Atresia (BA).
    • The Utility of Routine Echocardiography in Newborn Infants with a Persistent Oxygen Requirement

      Walsh, N; Breathnach, C; El-Khuffash, A; Franklin, O; Corcoran, JD (Irish Medical Journal, 2018-05)
      In the era of antenatal screening for congenital heart disease (CHD), infants presenting with an undiagnosed significant CHD are rare. However, term infants admitted with an initial diagnosis of TTN and a prolonged oxygen requirement often undergo an echocardiogram. We aimed to assess whether this practice yields any additional cases of undiagnosed CHD. We performed a retrospective chart review over a three year period [2013 – 2015] of term (> 36 weeks) infants admitted to the NICU for ≥ 5 days with a diagnosis of TTN and received an echocardiogram. The presence of CHD on the echocardiogram was assessed. Forty-seven infants were enrolled. The median age of echocardiogram was day four [2 – 8]. No infant had a diagnosis of significant CHD on the postnatal echocardiogram. A small muscular VSD was identified in two infants. Routine echocardiography for this cohort of infants to rule out major CHD appears to be unwarranted.
    • Caesarean Section at Full Dilatation and Risk of Major Obstetric Haemorrhage

      O’Dwyer, V; Freyne, A; Joyce, N; Coulter-Smith, S (Irish Medical Journal, 2018-03)
      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.
    • The use of cold coagulation for the treatment of cervical intraepithelial neoplasia

      Wyse, A; Seah, WA; O’Neill, J; Byrne, P (Irish Medical Journal, 2017-05)
      In 2015, Cold Coagulation was introduced as a treatment for cervical intraepithelial neoplasia (CIN) at our colposcopy clinic. We reviewed the 6-month follow up data of the first 200 women who underwent Cold Coagulation using cytology and HPV status as tests of cure (TOC). A random sample of 200 patients treated by Large Loop Excision of the Transformation Zone (LLETZ) during the same period was used to compare treatment outcome. Six months following treatment,173 (86.5%) of the women treated by CC and 167 (83.5%) treated by LLETZ had negative cytology. (x2= P>0.05). 148 (74%) treated by Cold Coagulation and 166 (83%) treated by LLETZ were HPV negative (x2= P<0.05). One hundred and thirty-nine (70%) women treated by Cold Coagulation and 152 (76%) treated with LLETZ had normal cytology and were HPV negative. This audit of our initial experience supports the observation that Cold Coagulation is as effective as LLETZ in the management of CIN when cervical cytology is used as a test of cure.
    • Invasive meningococcal disease in children in Ireland, 2001-2011.

      Ó Maoldomhnaigh, Cilian; Drew, Richard J; Gavin, Patrick; Cafferkey, Mary; Butler, Karina M (2016-12)
      In 1999, invasive meningococcal disease was hyperendemic in Ireland at 14.75/100 000 population, with 60% group B and 30% group C diseases. National sepsis guidelines and meningococcal C vaccines were introduced in 2000. Despite a spontaneous decline in group B infection, invasive meningococcal disease remains a leading cause of sepsis. This study characterises the epidemiology of invasive meningococcal disease in children in Ireland since the introduction of meningococcal C vaccine and reviews its clinical presentation, hospital course and outcome in anticipation of meningococcal B vaccine introduction.
    • Neonatal Bacteraemia Among 112,360 Live Births

      Huggard, D; Drew, R; McCallion, N (Irish Medical Journal, 2016-10)
      Our aims were to determine the incidence of bacteraemia in a cohort of neonatal patients over a 14 year period, to describe the organisms involved, and to establish the rates of sepsis with regard to both early onset sepsis (EOS) and late onset sepsis (LOS). Lastly, we investigated the trends of neonatal sepsis, to determine whether changes in clinical practice influenced the rate of blood culture positivity. With regards to EOS, GBS was the predominant pathogen, followed by E.coli, CoNS, and S. aureus . The overall mean EO rate per 1000 live births (LBs) was 1.19. Looking at LOS, S. aureus , CoNS , Enterococcus spp. were the most common bacteria cultured. The mean LOS rate was 1.88 per 1000 live births. The overall rate of EOS remained fairly steady. GBS remains the major pathogen in EOS; however its incidence has remained largely unchanged over time in relation to both EOS and LOS. Conversely the rate of LOS peaked from ’05-’09, mainly due to an increase in Staphylococcus aureus , CoNS and Enterococcus spp. cases, and then improved dramatically in the following years. This was likely due to a change in hospital policies in relation to hand hygiene and intravenous line placement and maintenance.
    • Maternal Mortality in Women with Epilepsy

      Holohan, M (Irish Medical Journal, 2016-10)
      It is estimated that, in Ireland, there are 10,000 women with epilepsy of childbearing potential1. In this paper the maternal mortality rate for women with epilepsy attending the Rotunda Hospital Epilepsy Clinic 2004 - 2013 was determined. There were 3 maternal deaths in women with epilepsy during this time, which represents a mortality rate of 0.8%. In those women who died, there were concerns in relation to risks to the foetus by taking Anti-Epileptic Drugs (AED) and also issues with access to neurology services before pregnancy, acceptance of specialist support and lack of consistency in advice from health care professionals outside of Ireland. Implementing the nationally agreed care plan for women with epilepsy will improve the quality of care given and potentially we will see a reduction in maternal mortality in these women.
    • Postnatal MRI brain in infants treated for Twin–Twin Transfusion Syndrome

      Boyle, M; Lyons, A; Ryan, S; Malone, F; Foran, A; Ryan, S (Irish Medical Journal, 2015-09)
      Untreated twin-twin transfusion syndrome (TTTS) is associated with significant mortality and neurological impairment. Fetoscopic laser surgery (FLS) is the treatment of choice. We sought to assess intracranial abnormalities in TTTS twins following treatment. In this prospective, blinded study MRI scans were performed on 3 groups; (1) monochorionic diamniotic (MCDA) twins with TTTS who had undergone FLS (n=10), (2) MCDA twins without TTTS (n=8) and (3) dichorionic twins (n=8). Scans were scored as either normal or abnormal. The primary outcome was a composite of abnormal MRI brain or intrauterine fetal demise. The primary outcome occurred in 6/10 (60%) of the TTTS group versus 3/8 (37.5%) in the MCDA group. The primary outcome was significantly different across all study groups [p = 0.029; X² = 7.112]. We found that twins treated for TTTS are more likely to have abnormalities on MRI brain at term than other twin groups. This group merits term-corrected MRI as part of their postnatal assessment
    • Advanced maternal age and assisted reproductive technologies in an Irish population

      O’Shea, L; Hughes, C; Mocanu, EV (Irish Medical Journal, 2015-09)
      In recent decades the amount of women over 40 seeking assisted reproductive technology (ART) interventions in order to become pregnant has dramatically increased, both in Ireland and worldwide. This is due to an increase in the average age at which women are choosing to have their first child while additionally, many couples are choosing to have a second family later in life. However, as with natural conception, ART success rates decrease with maternal age. In the present study, we perform a 16 year retrospective analysis on our clinical data of women between 40 and 45 years of age, who have undergone ART at a tertiary referral ART clinic. The percentage of patients in this age group was analysed over time, in order to determine follicle recruitment, % oocyte yield, embryonic quality, positive hCG (pregnancy rate), clinical pregnancy rate and rate of preclinical pregnancy loss. Results from our clinic show that women greater than 43 years of age have a significantly reduced reproductive potential compared to women in the 40 to 42 years age group. Woman in the 43-45 age group showed reduced fertilization rates (53.73% versus 58.82%), reduced positive hCG rates (11.51% versus 19.03%) and clinical pregnancy rates (5.04% versus 12.52%) and increased rates of preclinical pregnancy loss (56.23% versus 34.23%), compared to women in the 40-42 age group. With the age at which couples are choosing to have children constantly increasing, novel ART treatment strategies need to be developed.
    • The accuracy of locating the cricothyroid membrane by palpation - an intergender study

      Campbell, Mark; Shanahan, Hilary; Ash, Simon; Royds, Jonathan; Husarova, Viera; McCaul, Conan; Rotunda Hospital Dublin (2015-07-14)