• Antenatal rubella immunity in Ireland

      O Dwyer, V; Bonham, S; Mulligan, A; O’Connor, C; Farah, N; Kennelly, MM; Turner, MJ (Irish Medical Journal, 2013-09)
      The objective of the study was to identify those women attending for antenatal care who would have benefited from prepregnancy rubella vaccination. It was a population-based observational study of women who delivered a baby weighing e500 g in 2009 in the Republic of Ireland. The womanâ s age, parity, nationality and rubella immunity status were analysed using data collected by the National Perinatal Reporting System. Of the 74,810 women delivered, the rubella status was known in 96.7% (n=72,333). Of these, 6.4%(n=4,665) women were not immune. Rubella seronegativity was 8.0%(n=2425) in primiparous women compared with 5.2%(n=2239) in multiparous women (p<0.001), 14.7%(n=10653) in women <25 years old compared with 5.0%(n=3083) in women e25 years old (p<0.001), and 11.4%(n=780) in women born outside the 27 European Union (EU27) countries compared with 5.9%(n=3886) in women born inside the EU27 countries (p<0.001). Based on our findings we recommend that to prevent Congenital Rubella Syndrome, the health services in Ireland should focus on women who are young, nulliparous and born outside the EU.
    • Aortic isthmus Doppler velocimetry: role in assessment of preterm fetal growth restriction.

      Kennelly, M M; Farah, N; Turner, M J; Stuart, B; Ultrasound and Fetal Medicine Centre, Coombe Women & Infants University Hospital,, Dublin, Ireland. mkennelly@doctors.org.uk (2012-02-01)
      Intrauterine fetal growth restriction (IUGR) is an important pregnancy complication associated with significant adverse clinical outcome, stillbirth, perinatal morbidity and cerebral palsy. To date, no uniformly accepted management protocol of Doppler surveillance that reduces mortality and cognitive morbidity has emerged. Aortic isthmus (AoI) evaluation has been proposed as a potential monitoring tool for IUGR fetuses. In this review, the current knowledge of the relationship between AoI Doppler velocimetry and preterm fetal growth restriction is reviewed. Relevant technical aspects and reproducibility data are reviewed as we discuss AoI Doppler and its place within the existing repertoire of Doppler assessments in placental insufficiency. The AoI is a link between the right and left ventricles which perfuse the lower and upper body, respectively. The clinical use of AoI waveforms for monitoring fetal deterioration in IUGR has been limited, but preliminary work suggests that abnormal AoI impedance indices are an intermediate step between placental insufficiency-hypoxemia and cardiac decompensation. Further prospective studies correlating AoI indices with arterial and venous Doppler indices and perinatal outcome are required before encorporating this index into clinical practice.
    • An audit of caesarean sections for very low birth weight babies.

      Khalifeh, A; Farah, N; Turner, M; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. (2012-02-01)
      This study reviewed caesarean sections for very low birth weight babies in a tertiary referral maternity hospital. Maternal and neonatal complications were recorded and classified according to uterine incision type. We reviewed medical records of 89 women over a period of 2 years. The indication for the caesarean section influenced the type of uterine incision made (p = 0.004). Women who had antepartum haemorrhage were more likely to need a vertical incision. There was also a higher incidence of vertical incisions for gestations <28 weeks (p = 0.029). Surprisingly, when the computerised discharge summaries were reviewed retrospectively, all the vertical uterine incisions were recorded as lower segment caesarean sections. This would have a clinical impact on those women in future pregnancies, especially in a highly mobile population.
    • Comparison in maternal body composition between Caucasian Irish and Indian women.

      Farah, N; Murphy, M; Ramphul, M; O'Connor, N; Kennelly, M M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. nadine.farah@ucd.ie (2012-02-01)
      The use of body mass index (BMI) for the diagnosis of obesity has limitations, especially when comparing ethnic groups with different body proportions. The aim of this prospective study was to compare maternal body composition in early pregnancy between Caucasian Irish and Indian women. A total of 81 Indian women and 81 Irish Caucasian women were matched for age, parity and BMI. Maternal weight and height were measured, and body composition analysed using bioelectrical impedance. The Irish women were taller and weighed more than the Indian women (p<0.001). At any given BMI, the Indian women had a higher total body fat percentage, visceral fat level and high fat percentage than the Irish women (p=0.024, 0.001 and 0.001, respectively). Our findings suggest that lower BMI cut-offs should be used for screening for gestational diabetes mellitus in Indian women attending our antenatal services.
    • The impact of new national guidelines on screening for gestational Diabetes Mellitus

      Ali, FM; Farah, N; O’Dwyer, V; O’Connor, C; Kennelly, MM; Turner, MJ (Irish Medical Journal, 2013-02)
      Gestational diabetes mellitus (GDM) has important maternal and fetal implications. In 2010, the Health Service Executive published guidelines on GDM. We examined the impact of the new guidelines in a large maternity unit. In January 2011, the hospital replaced the 100g Oral Glucose Tolerance Test (OGTT) with the new 75g OGTT. We compared the first 6 months of 2011 with the first 6 months of 2010. The new guidelines were associated with a 22% increase in women screened from 1375 in 2010 to 1679 in 2011 (p<0.001). Of the women screened, the number diagnosed with GDM increased from 10.1% (n=139) to 13.2% (n=221) (p<0.001).The combination of increased screening and a more sensitive OGTT resulted in the number of women diagnosed with GDM increasing 59% from 139 to 221 (p=0.02).This large increase has important resource implications but, if clinical outcomes are improved, there should be a decrease in long-term costs.
    • The impact of new national guidelines on screening for gestational diabetes mellitus.

      Ali, F M; Farah, N; O'Dwyer, V; O'Connor, C; Kennelly, M M; Turner, M J (2013-02)
      Gestational diabetes mellitus (GDM) has important maternal and fetal implications. In 2010, the Health Service Executive published guidelines on GDM. We examined the impact of the new guidelines in a large maternity unit. In January 2011, the hospital replaced the 100 g Oral Glucose Tolerance Test (OGTT) with the new 75 g OGTT. We compared the first 6 months of 2011 with the first 6 months of 2010. The new guidelines were associated with a 22% increase in women screened from 1375 in 2010 to 1679 in 2011 (p < 0.001). Of the women screened, the number diagnosed with GDM increased from 10.1% (n=139) to 13.2% (n=221) (p<0.001).The combination of increased screening and a more sensitive OGTT resulted in the number of women diagnosed with GDM increasing 59% from 139 to 221 (p = 0.02).This large increase has important resource implications but, if clinical outcomes are improved, there should be a decrease in long-term costs.
    • Longitudinal study of aortic isthmus Doppler in appropriately grown and small-for-gestational-age fetuses with normal and abnormal umbilical artery Doppler.

      Kennelly, M M; Farah, N; Hogan, J; Reilly, A; Turner, M J; Stuart, B; Ultrasound and Fetal Medicine Centre, Coombe Women and Infants University Hospital, Dublin, Ireland. mkennelly@doctors.org.uk (2012-04)
      To establish reference ranges using longitudinal data for aortic isthmus (AoI) Doppler indices in appropriate-for-gestational-age (AGA) fetuses and to document the longitudinal trends in a cohort of small-for-gestational-age (SGA) fetuses with normal umbilical artery Doppler and in fetuses with intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler.
    • The measurement of maternal adiposity.

      Fattah, C; Farah, N; Barry, S; O'Connor, N; Stuart, B; Turner, M J; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. (2012-02-01)
      The issue of maternal obesity has become a major public health problem. Internationally, the diagnosis of obesity is based on body mass index (BMI) that is, weight in kg/height in m2. While epidemiological associations have been shown between different BMI categories and adverse clinical outcomes, there is also a growing realisation that BMI has significant limitations. In this review, we assess current methods to measure body fat and, in particular, their application in pregnant women.
    • Peripartum hysterectomy in the first decade of the 21st century.

      Tadesse, W; Farah, N; Hogan, J; D'Arcy, T; Kennelly, M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. (2012-02-01)
      We reviewed the role of peripartum hysterectomy (PH) in the first decade of the 21st century. The study was confined to women who delivered a baby weighing 500 g or more between 2000 and 2009, and who required a hysterectomy within 72 h of delivery for obstetric reasons. Individual case records were reviewed. There were 19 cases of PH in 78,961 deliveries giving an incidence of 1 in 4,156 (0.02%). Of the 19 cases, 95% were delivered by caesarean section and 89% had one or more prior sections. The indications were placental bed pathology (79%), uterine atony (16%) and uterine trauma (5%). Of the 19 hysterectomies, 16 (84%) were total and a gynaecological oncologist was involved in nine (56%) of these cases. There were no maternal or fetal deaths, but a mother required an average blood transfusion of 10 units. The overall rate of PH was remarkably low compared with other studies but it is likely to increase in the future because of the strong association between increasing caesarean section rates and placental bed pathology. The potential involvement of the cervix and other pelvic structures by placental pathology means that PH in the future will be more challenging, and the hysterectomy will need to be total rather than subtotal.
    • Polycystic ovary syndrome and the peripheral blood white cell count.

      Herlihy, A C; Kelly, R E; Hogan, J L; O'Connor, N; Farah, N; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. (2012-02-01)
      This retrospective cross-sectional study examined if the white cell count (WCC) is increased in women with polycystic ovary syndrome (PCOS) and if so, is it due to PCOS or to the associated obesity? Body mass index (BMI) was calculated and body composition was measured using bioelectrical impedance analysis. Of the 113 women studied, 36 had PCOS and 77 did not. The mean WCC was higher in the PCOS group compared with the non-PCOS group (8.9 x 10(9)/l vs 7.4 x 10(9)/l p = 0.002). This increase was due to a higher neutrophil count (5.6 x 10(9)/l vs 4.3 x 10(9)/l; p = 0.003). There was a leucocytosis (WCC >11 x 10(9)/l) present in 19% of the PCOS group compared with 1% in the non-PCOS group (p < 0.001). The neutrophil count was abnormally high (>7.7 x 10(9)/l) in 14% of the PCOS group compared with 4% in the non-PCOS group (p < 0.001). On regression analysis, however, the only independent variable which explained both the increased WCC and the increased neutrophil count was PCOS. We found that PCOS is associated with an increased WCC due to increased neutrophils, which supports the evidence that PCOS is associated with low-grade inflammation. The increase appears to be due to the underlying PCOS, and not to the increased adiposity associated with PCOS.
    • Thromboprophylaxis for women undergoing caesarean section.

      Kennedy, C; O'Dwyer, V; O'Kelly, S; Farah, N; Kennelly, M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infant's University Hospital, Cork St, Dublin 8. (2012-02)
      Thromboprophylaxis for women undergoing caesarean section (CS) was introduced in the hospital in 1995. This study audited the use of tinzaparin prophylaxis in a nested cohort of women who screened negative for diabetes mellitus at 28 weeks gestation. All the women had their weight measured and BMI calculated at the first antenatal visit. Of the 284 women, 68 (24%) had a CS and all received tinzaparin. Of the 68, however, 94% received a dose lower than recommended. Compliance with prophylaxis was complete but compliance with the recommended dosage was suboptimal, which may result in venous thromboembolism after CS despite thromboprophylaxis.
    • What is the value of ultrasound soft tissue measurements in the prediction of abnormal fetal growth?

      Farah, N; Stuart, B; Donnelly, V; Rafferty, G; Turner, M; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin 8, Ireland. nadine.farah@ucd.ie (2012-02-01)
      Abnormal fetal growth increases the complications of pregnancy not only for the baby but also for the mother. Growth abnormalities also have lifelong consequences. These babies are at increased risk of insulin resistance, diabetes and hypertension later in life. It is important to identify these babies antenatally to optimise their clinical care. Although used extensively antenatally to monitor fetal growth, ultrasound has its limitations. Despite the use of more than 50 different formulae to estimate fetal weight, their performance has been poor at the extremes of fetal weight. Over the past 20 years there has been emerging interest in studying fetal soft tissue measurements to improve detection of growth abnormalities. This review paper outlines the value of soft tissue measurements in identifying fetal growth abnormalities, in estimating fetal weight and in managing diabetes mellitus in pregnancy.
    • What models of maternity care do pregnant women in Ireland want?

      Byrne, C; Kennedy, C; O'Dwyer, V; Farah, N; Kennelly, M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Cork St, Dublin 8 (2012-02-01)
      The introduction of new models of care in the Irish maternity services has been recommended by both advocacy groups and strategic reports. Yet there is a dearth of information about what models of care pregnant women want. We surveyed women in early pregnancy who were attending a large Dublin maternity hospital. Demographic and clinical details were recorded from the hospital chart. Of the 501 women, 351 (70%) (352 (70.3%) of women wanted shared antenatal care between their family doctor and either a hospital doctor or midwife. 228 (45.5%) preferred to have their baby delivered in a doctor-led unit, while 215 (42.9%) preferred a midwifery-led unit. Of those 215 (42.9%), 118 (55%) met criteria for suitability. There was minimal demand (1.6%) for home births. Choice was influenced by whether the woman was attending for private care or not. Safety is the most important factor for women when choosing the type of maternity care they want. Pregnant women want a wide range of choices when it comes to models of maternity care. Their choice is strongly influenced by safety considerations, and will be determined in part by risk assessment.