• Preconceptual care

      Cowman, Triona; Barry, Paula (Nursing in General Practice, 2015-11)
      Preconceptual health is the health of a woman before she gets pregnant and between subsequent pregnancies. Preconceptual care is a set of interventions that aim to identify and modify biomedical, behavioural, and social risks to a woman’s health or pregnancy outcome through prevention and management.1 It is well documented that modifiable lifestyle factors such as obesity, diet and exercise, alcohol, smoking and use of recreational drugs can have potentially detrimental effects on pregnancy outcomes. A growing body of evidence is showing that recognising and amending risks in women before conception can have a positive impact on reducing maternal and perinatal morbidity and mortality.
    • Prevalence and predictors of periconceptional folic acid uptake--prospective cohort study in an Irish urban obstetric population.

      McGuire, M; Cleary, B; Sahm, L; Murphy, D J; Coombe Women and Infants University Hospital, Dolphins Barn, Dublin 8, Ireland. (2012-02-01)
      BACKGROUND: Neural tube defects (NTDs) are severe abnormalities of the central nervous system that occur as a result of abnormal development in the third and fourth weeks of gestation. Studies have shown that periconceptional folic acid (FA) can reduce both the incidence and recurrence of NTDs. METHODS: A cohort study was carried out using the electronic hospital booking records of women delivering in a large Dublin maternity hospital between 2000 and 2007. Logistic regression analyses were performed to measure the associations between maternal factors and optimal FA use. RESULTS: Of the 61,252 women in the cohort, 85% reported taking FA at some point during the periconceptional period; however, only 28% took FA as recommended. Factors associated with taking the recommended amount of FA included nulliparity [adjusted OR: 1.35 (95% CI: 1.28-1.43)], early booking (<12 weeks) [OR: 1.24 (95% CI: 1.17-1.31)], increasing maternal age (e.g. 30-34 years) [OR: 1.39 (95% CI: 1.30-1.48)], private health care [OR: 4.32 (95% CI: 4.1-4.6)] and fertility treatment [OR: 2.88 (95% CI: 2.44-3.40)]. Factors associated with taking less than recommended or no FA included unplanned pregnancy [OR: 0.08 (0.07-0.08)], lower socio-economic status (e.g. unemployed) [OR: 0.63 (95% CI: 0.55-0.71)], non-Irish nationality [OR: 0.82 (0.74-0.90)] and smokers [OR: 0.51 (95% CI: 0.47-0.55)]. CONCLUSIONS: Social, demographic and economic factors have an important influence on the FA uptake. Vulnerable groups who report limited uptake of FA need to be specifically targeted in future Public Health campaigns and further consideration needs to be given to the debate on food fortification in countries where this is currently not available.
    • Prevalence of problem alcohol use among patients attending primary care for methadone treatment.

      Ryder, Niamh; Cullen, Walter; Barry, Joseph; Bury, Gerard; Keenan, Eamon; Smyth, Bobby P; UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dublin,, Ireland. niamh.ryder@ucd.ie (2012-02-01)
      BACKGROUND: Problem alcohol use is associated with adverse health outcomes among current or former heroin users and primary care is providing methadone treatment for increasing numbers of this population. This study aimed to determine the prevalence of problem alcohol use among current or former heroin users attending primary care for methadone treatment and to describe the socio-demographic characteristics and health service utilisation characteristics associated with problem alcohol uses. METHODS: We conducted a cross sectional survey of patients sampled from a national database of patients attending general practice for methadone treatment. Participants were recruited by their general practitioner and data was collected using an interviewer-administered questionnaire, which included the Alcohol Use Disorders Identification Test ('AUDIT'), with a score of >7 considered abnormal (ie 'AUDIT positive cases') and socio-demographic, medical and substance use characteristics. RESULTS: We interviewed 196 patients (71% of those invited, 31% of those sampled, 11% of the national database). The median age was 32 years, 55% were hepatitis C positive, 79% had used illicit drugs in the previous month and 68% were male. Sixty-eight 'AUDIT positive' cases were identified (prevalence of 35%, 95% CI = 28-41%) and these were more likely to have attended a local Emergency Department in the previous year (p < 0.05) and less likely to have attended a hospital clinic in the previous year (p < 0.05). Twenty-seven (14%) scored 20 or higher indicating possible alcohol dependence. CONCLUSION: Problem alcohol use has a high prevalence among current or former heroin users attending primary care for methadone treatment and interventions that address this issue should be explored as a priority. Interventions that address problem alcohol use in this population should be considered as a priority, although the complex medical and psychological needs of this population may make this challenging.
    • Prevalence, predictors and perinatal outcomes of peri-conceptional alcohol exposure--retrospective cohort study in an urban obstetric population in Ireland.

      Mullally, Aoife; Cleary, Brian J; Barry, Joe; Fahey, Tom P; Murphy, Deirdre J; Academic Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital & Trinity College Dublin, Dublin 8, Republic of Ireland. (2011-04)
      Evidence-based advice on alcohol consumption is required for pregnant women and women planning a pregnancy. Our aim was to investigate the prevalence, predictors and perinatal outcomes associated with peri-conceptional alcohol consumption.
    • The prevention of neural tube defects in Ireland

      McKeating, A; Turner, M.J (Irish Medical Journal, 2017-06)
    • Prevention of thrombosis in pregnancy: how practical are consensus derived clinical practice guidelines?

      Hayes-Ryan, D; Byrne, B M; RCSI Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital (CWIUH), Dublin, Ireland. (2012-11)
      Thromboembolic disease (TED) has, for many years, consistently been identified as one of the leading causes of direct maternal mortality. In November 2009, the RCOG published a guideline on the prevention of TED that has been rapidly adopted by hospital trusts in the UK. The aim of our study was to determine the number and profile of women in our population that would require treatment with low molecular weight heparin (LMWH) and the cost implications of such treatment if these guidelines were implemented. A retrospective review of the first 100 women who delivered at the Coombe Women & Infants University Hospital (CWIUH) in 2010 was conducted and risk stratification applied at the relevant time points. A total of 51% were deemed to be at intermediate or high risk of TED at some point during pregnancy. In 35 of the 51 women (70%), this risk was attributable to factors such as age>35 years, parity≥3, BMI>30 kg/m2 or cigarette smoking. In our obstetric population, the percentage of women with these risk factors was: 25.5%, 8.5%, 19% and 16.7%, respectively. Implementation of this guideline would increase the hospital annual expenditure on LMWH by a factor of 17. The strategy of attributing risk by accumulating factors that individually have a low risk of TED and are prevalent in the population needs to be re-visited. The cost of implementation of these guidelines is not inconsiderable in the absence of data to indicate that clinical outcome is improved with their implementation.
    • A primary care-based health needs assessment in inner city Dublin.

      O'Kelly, C M; Cullen, W; O'Kelly, S M; O'Kelly, F D; Bury, G; School of Medicine and Medical Science, The Coombe Healthcare Centre, Dublin 8,, Ireland. conor.okelly@ucdconnect.ie (2012-02-01)
      BACKGROUND: In 2001, a primary care-based health needs assessment (HNA) in South Inner City of Dublin identified high levels of morbidity and widespread and frequent use of primary care and specialist hospital services as particular concerns. AIMS: This study aims to determine the primary care health needs of a local community, from the perspective of service users and service providers. METHODS: A similar methodology to our 2001 HNA was adopted, involving semi-structured interviews with a convenience sample of patients attending two general practices and key informants regarding local health issues and health service utilisation. RESULTS: High levels of morbidity and chronic illness were found. A correlation between the local environment and ill-health was identified, as well as high utilisation of primary care services in the area. CONCLUSION: The establishment of a Primary Care Team would begin to address the health needs of the community.
    • Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment.

      Field, Catherine Anne; Klimas, Jan; Barry, Joseph; Bury, Gerard; Keenan, Eamon; Smyth, Bobby P; Cullen, Walter; UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dolphins Barn, Dublin 8, Ireland. (2013)
      Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients' experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care.
    • A prospective cohort study of alcohol exposure in early and late pregnancy within an urban population in Ireland.

      Murphy, Deirdre J; Dunney, Clare; Mullally, Aoife; Adnan, Nita; Fahey, Tom; Barry, Joe (2014-02)
      Most studies of alcohol consumption in pregnancy have looked at one time point only, often relying on recall. The aim of this longitudinal study was to determine whether alcohol consumption changes in early and late pregnancy and whether this affects perinatal outcomes. We performed a prospective cohort study, conducted from November 2010 to December 2011 at a teaching hospital in the Republic of Ireland. Of the 907 women with a singleton pregnancy who booked for antenatal care and delivered at the hospital, 185 (20%) abstained from alcohol in the first trimester but drank in the third trimester, 105 (12%) consumed alcohol in the first and third trimesters, and the remaining 617 (68%) consumed no alcohol in pregnancy. Factors associated with continuing to drink in pregnancy included older maternal age (30-39 years), Irish nationality, private healthcare, smoking, and a history of illicit drug use. Compared to pre-pregnancy, alcohol consumption in pregnancy was markedly reduced, with the majority of drinkers consuming ≤ 5 units per week (92% in first trimester, 72-75% in third trimester). Perhaps because of this, perinatal outcomes were similar for non-drinkers, women who abstained from alcohol in the first trimester, and women who drank in the first and third trimester of pregnancy. Most women moderate their alcohol consumption in pregnancy, especially in the first trimester, and have perinatal outcomes similar to those who abstain.
    • A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night.

      Butler, Katherine; Ramphul, Meenakshi; Dunney, Clare; Farren, Maria; McSweeney, Aoife; McNamara, Karen; Murphy, Deirdre J (2014)
      To evaluate maternal and neonatal outcomes associated with operative vaginal deliveries (OVDs) performed by day and at night.
    • Prospective risk of fetal death in uncomplicated monochorionic twins.

      Farah, Nadine; Hogan, Jennifer; Johnson, Sucheta; Stuart, Bernard; Daly, Sean; Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin. nadine.farah@ucd.ie (2012-03)
      A retrospective cohort study was carried out in a university teaching hospital to determine the prospective risk of unexpected fetal death in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies after viability. All MCDA twins delivered at or after 24 weeks' gestation from July 1999 to July 2007 were included. Pregnancies with twin-twin transfusion syndrome, growth restriction, structural abnormalities, or twin reversed arterial perfusion sequence were excluded. Of the 144 MCDA twin pregnancies included in our analysis, the risk of intrauterine death was 4.9%. The prospective risk of unexpected intrauterine death was 1 in 43 after 32 weeks' gestation and 1 in 37 after 34 weeks' gestation. Our results demonstrate that despite close surveillance, the unexpected intrauterine death rate in uncomplicated MCDA twin pregnancies is high. This rate seems to increase after 34 weeks' gestation, suggesting that a policy of elective preterm delivery warrants evaluation.
    • Quality of care in the management of major obstetric haemorrhage.

      Johnson, S N; Khalid, S; Varadkar, S; Fleming, J; Fanning, R; Flynn, C M; Byrne, B; Coombe Women and Infant's University Hospital, Dolphin's Barn, Dublin 8. (2012-02-01)
      Substandard care is reported to occur in a large number of cases of major obstetric haemorrhage (MOH). A prospective audit was carried out by a multidisciplinary team at our hospital over a one year period to assess the quality of care (QOC) delivered to women experiencing MOH. MOH was defined according to criteria outlined in the Scottish Audit of Maternal Morbidity (SAMM). 31 cases were identified yielding an incidence of 3.5/1000 deliveries. The predominant causes were uterine atony 11 (35.4%), retained products of conception 6 (19.3%) and placenta praevia/accreta 6 (19.3%). Excellent initial resuscitation and monitoring was noted with a high level of senior staff input. Indicators of QOC compared favourably with the SAMM. Areas for improvement were identified. This pilot study demonstrates the feasibility of detailed prospective data collection in MOH in a busy Dublin obstetric unit with a view to developing a national audit. Standardization of definitions allows for international comparisons.
    • A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section--pilot study. ISRCTN 40302163.

      Murphy, Deirdre J; MacGregor, Honor; Munishankar, Bhagya; McLeod, Graeme; Academic Department of Obstetrics & Gynaecology, Coombe Women's Hospital &, Trinity College, University of Dublin, Dublin 8, Ireland. deirdre.j.murphy@tcd.ie (2012-02-01)
      OBJECTIVE: To compare the blood loss at elective lower segment caesarean section with administration of oxytocin 5IU bolus versus oxytocin 5IU bolus and oxytocin 30IU infusion and to establish whether a large multi-centre trial is feasible. STUDY DESIGN: Women booked for an elective caesarean section were recruited to a pilot randomised controlled trial and randomised to either oxytocin 5IU bolus and placebo infusion or oxytocin 5IU bolus and oxytocin 30IU infusion. We wished to establish whether the study design was feasible and acceptable and to establish sample size estimates for a definitive multi-centre trial. The outcome measures were total estimated blood loss at caesarean section and in the immediate postpartum period and the need for an additional uterotonic agent. RESULTS: A total of 115 women were randomised and 110 were suitable for analysis (5 protocol violations). Despite strict exclusion criteria 84% of the target population were considered eligible for study participation and of those approached only 15% declined to participate and 11% delivered prior to the planned date. The total mean estimated blood loss was lower in the oxytocin infusion arm compared to placebo (567 ml versus 624 ml) and fewer women had a major haemorrhage (>1000 ml, 14% versus 17%) or required an additional uterotonic agent (5% versus 11%). A sample size of 1500 in each arm would be required to demonstrate a 3% absolute reduction in major haemorrhage (from baseline 10%) with >80% power. CONCLUSION: An additional oxytocin infusion at elective caesarean section may reduce blood loss and warrants evaluation in a large multi-centre trial.
    • A randomised trial of the analgesic efficacy of ultrasound-guided transversus abdominis plane block after caesarean delivery under general anaesthesia.

      Tan, Terry T; Teoh, Wendy H L; Woo, David C M; Ocampo, Cecilia E; Shah, Mukesh K; Sia, Alex T H; From the Coombe Women and Infants University Hospital, Dublin, Ireland (TT) and Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore (WHLT, DCMW, CEO, MKS, ATHS). (2012-02)
      Previous studies examining the efficacy of transversus abdominis plane block after caesarean section have mostly been in parturients under spinal anaesthesia.
    • A rare case of cryptogenic stroke with an incidental finding of patent foramen ovale.

      Anglim, B; Maher, N; Cunningham, O; Mulcahy, D; Harbison, J; O'Connell, M (Irish Medical Journal, 2015-03)
      Patent foramen ovale (PFO) occurs in 25-30% of the general population. Stroke in the puerperium is a rare phenomenon, 34 per 100,000 women. A 32 year old lady, Para3+2 presented eight days postnatally with symptoms of a transient episode of left sided facial and limb parathesia and dysphasia. She had a CT brain which was normal, however a subsequent MRI brain showed a small right parietal lobe infarct. An echocardiogram was performed which showed a small PFO, with an ejection fraction of 60-65%. A bubble study was performed which was positive with valsalva. She was started on aspirin 300mg once daily for 2 weeks, and shall remain on life-long aspirin 75mg.
    • Reduction of severity of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine: a randomised comparison of prophylactic granisetron and ondansetron.

      Tan, T; Ojo, R; Immani, S; Choroszczak, P; Carey, M; Department of Anaesthesia and Perioperative Medicine, Coombe Women and Infants, University Hospital, Dublin, Ireland. tutan@me.com (2012-02-01)
      BACKGROUND: The incidence of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine may be 60-100%, and is a common cause of maternal dissatisfaction. Ondansetron has been shown to reduce pruritus but the effect is short-lived. The objective of this randomized double-blind trial was to evaluate the anti-pruritic efficacy of granisetron compared with ondansetron. METHODS: Eighty ASA I or II women undergoing elective caesarean section received spinal anaesthesia with 0.5% hyperbaric bupivacaine 10 mg, fentanyl 25 microg and preservative-free morphine 150 microg. After delivery of the baby and clamping of the umbilical cord, they were randomised to receive granisetron 3mg i.v. (group G) or ondansetron 8 mg i.v. (group O). RESULTS: The two groups were similar for age, gestational age, height and weight. According to visual analogue pruritus scores, patients in group G experienced less pruritus at 8h (P=0.003) and 24h (P=0.01). Fewer patients in group G (n=8) than group O (n=18) required rescue anti-pruritic medication (P=0.03). Satisfaction scores were also higher in group G than in group O (P=0.03). There was no difference in overall incidence of pruritus, nausea and vomiting, and visual analogue pain scores between the two groups. CONCLUSIONS: Administration of granisetron 3mg i.v. reduces the severity of pruritus and the use of rescue anti-pruritic medication, and improves satisfaction but does not reduce the overall incidence of pruritus in women who have received subarachnoid morphine 150 microg compared to ondansetron 8 mg i.v.
    • The reliability of foetal blood sampling as a test of foetal acidosis in labour.

      O'Brien, Yvonne M; Murphy, Deirdre J; Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin 8, Ireland. (2013-04)
      To establish whether foetal blood sampling for pH is a reliable test of foetal acidosis in labour by comparing paired foetal blood samples taken at a single procedure.
    • Resuscitation at the limits of viability--an Irish perspective.

      Khan, R A; Burgoyne, L; O'Connell, M P; Dempsey, E M; Paediatrics and Newborn Medicine, Coombe Women and Infant University Hospital,, Dublin, Ireland. (2012-02-01)
      BACKGROUND: Advances in neonatal care continue to lower the limit of viability. Decision making in this grey zone remains a challenging process. OBJECTIVE: To explore the opinions of healthcare providers on resuscitation and outcome in the less than 28-week preterm newborn. DESIGN/METHODS: An anonymous postal questionnaire was sent to health care providers working in maternity units in the Republic of Ireland. Questions related to neonatal management of the extreme preterm infant, and estimated survival and long-term outcome. RESULTS: The response rate was 55% (74% obstetricians and 70% neonatologists). Less than 1% would advocate resuscitation at 22 weeks, 10% of health care providers advocate resuscitation at 23 weeks gestation, 80% of all health care providers would resuscitate at 24 weeks gestation. 20% of all health care providers would advocate cessation of resuscitation efforts on 22-25 weeks gestation at 5 min of age. 65% of Neonatologists and 54% trainees in Paediatrics would cease resuscitation at 10 min of age. Obstetricians were more pessimistic about survival and long term outcome in newborns delivered between 23 and 27 weeks when compared with neonatologists. This difference was also observed in trainees in paediatrics and obstetrics. CONCLUSION: Neonatologists, trainees in paediatrics and neonatal nurses are generally more optimistic about outcome than their counterparts in obstetrical care and this is reflected in a greater willingness to provide resuscitation efforts at the limits of viability.
    • The risk of caesarean section in obese women analysed by parity.

      O'Dwyer, Vicky; Farah, Nadine; Fattah, Chro; O'Connor, Norah; Kennelly, Mairead M; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin 8, Ireland. vicky.odwyer@ucd.com (2012-02-01)
      OBJECTIVE: This study looked at the association between caesarean section (CS) and Body Mass Index (BMI) in primigravidas compared with multigravidas. STUDY DESIGN: We enrolled women at their convenience, in the first trimester after an ultrasound examination confirmed an ongoing pregnancy. Weight and height were measured digitally and BMI calculated. After delivery, clinical details were again collected from the Hospital's computerised database. RESULTS: Of the 2000 women enrolled, there were 50.4% (n=1008) primigravidas and 49.6% (n=992) multigravidas. Of the 2000 8.5% were delivered by elective CS and 13.4% were delivered by emergency CS giving an overall rate of 21.9%. The overall CS rate was 30.1% in obese women compared with 19.2% in the normal BMI category (p<0.001). In primigravidas the increase in CS rate in obese women was due to an increase in emergency CS (p<0.005) and in multigravidas the increase was due to an increase in elective CS (p<0.01). In obese primigravidas 20.6% had an emergency section for fetal distress. In obese multigravidas 17.2% had a repeat elective CS. CONCLUSION: The influence of maternal obesity on the increase in CS rates is different in primigravidas compared with multigravidas.
    • The role of thromboxane A(2) in the pathogenesis of intrauterine growth restriction associated with maternal smoking in pregnancy.

      Lynch, Caoimhe M; O'Kelly, Ruth; Stuart, Bernard; Treumann, Achim; Conroy, Ronan; Regan, Carmen L; Coombe Women and Infants University Hospital, Dublin, Ireland., caoimhemlynch@eircom.net (2012-02-01)
      BACKGROUND: To examine the effect of maternal smoking in pregnancy on the production of two eicosanoids, thromboxane A(2) and prostacyclin I2, and their role in the pathogenesis of intrauterine growth restriction. METHODS: Prospective case control study enrolled smoking and non-smoking women at