• Continuous Glucose Monitoring in the Management of Neonatal Hypoglycaemia

      McGlacken-Byrne, S.M; O’Neill, R.; Jenkinson, A.; Murphy, J.F.A. (Irish Medical Journal, 2019-03)
      A quality improvement project was carried out in a Level 3 Neonatal Intensive Care Unit (NICU) which aimed to successfully implement the use of continuous glucose monitoring systems (CGMS) in hypoglycaemic infants. Piloting of the device revealed several potential practical barriers to its reliably successful implementation. Five Plan-Do-Study-Act (PDSA) cycles followed, tackling these problems and other issues inductively identified throughout the project. Parents and multi-professional stakeholders were involved and consulted throughout. Change was measured on a runchart using qualitative and quantitative feedback. Problem rate per patient was reduced to zero by the end of a one-month study period. This study used basic quality improvement methodologies to implement a change intervention in a structured manner and elucidated aspects of its use that need to be adapted for its successful incorporation into real-life clinical practice.
    • A Low Glycaemic Index Diet in Pregnancy Induces DNA Methylation Variation in Blood of Newborns: Results from the ROLO Randomised Controlled Trial.

      Geraghty, Aisling A; Sexton-Oates, Alexandra; O'Brien, Eileen C; Alberdi, Goiuri; Fransquet, Peter; Saffery, Richard; McAuliffe, Fionnuala M; National Maternity Hospital Holles Street Dublin, University College Dublin, Cancer and Disease Epigenetics, Murdoch Children's Research Institute, Melbourne, Victoria, Aus, Department of Paediatrics, University of Melbourne, Victoria, Aus (MDPI, 2018-04-06)
      The epigenetic profile of the developing fetus is sensitive to environmental influence. Maternal diet has been shown to influence DNA methylation patterns in offspring, but research in humans is limited. We investigated the impact of a low glycaemic index dietary intervention during pregnancy on offspring DNA methylation patterns using a genome-wide methylation approach. Sixty neonates were selected from the ROLO (Randomised cOntrol trial of LOw glycaemic index diet to prevent macrosomia) study: 30 neonates from the low glycaemic index intervention arm and 30 from the control, whose mothers received no specific dietary advice. DNA methylation was investigated in 771,484 CpG sites in free DNA from cord blood serum. Principal component analysis and linear regression were carried out comparing the intervention and control groups. Gene clustering and pathway analysis were also explored. Widespread variation was identified in the newborns exposed to the dietary intervention, accounting for 11% of the total level of DNA methylation variation within the dataset. No association was found with maternal early-pregnancy body mass index (BMI), infant sex, or birthweight. Pathway analysis identified common influences of the intervention on gene clusters plausibly linked to pathways targeted by the intervention, including cardiac and immune functioning. Analysis in 60 additional samples from the ROLO study failed to replicate the original findings. Using a modest-sized discovery sample, we identified preliminary evidence of differential methylation in progeny of mothers exposed to a dietary intervention during pregnancy.
    • CA125 Measured During Menstruation Can Be Misleading

      Crosby, DA; Glover, LE; Martyn, F; Wingfield, M (Irish Medical Journal, 2018-04)
      Abstract The aim of these case reports and literature review is to report the importance of cyclical variation of serum CA-125 levels in two patients with endometriosis. Two case reports and a literature review of cyclical variation in serum CA-125 levels are discussed. There was significant variation in serum CA-125 levels taken during menses and mid-cycle in these two cases. Serum CA-125 levels increase dramatically during menstruation in women with endometriosis. This is important when assessing disease status.
    • Placenta Accreta Spectrum: A Review of Pathology, Molecular Biology, and Biomarkers.

      Bartels, Helena C; Postle, James D; Downey, Paul; Brennan, Donal J; 1 National Maternity Hospital, Holles Street, Dublin 2, Ireland. 2 UCD School of Medicine, National Maternity Hospital, Holles Street, Dublin 2, Ireland (Hindawi, 2018-01-01)
      Placenta accreta spectrum (PAS) is a condition of abnormal placental invasion encompassing placenta accreta, increta, and percreta and is a major cause of severe maternal morbidity and mortality. The diagnosis of a PAS is made on the basis of histopathologic examination and characterised by an absence of decidua and chorionic villi are seen to directly adjacent to myometrial fibres. The underlying molecular biology of PAS is a complex process that requires further research; for ease, we have divided these processes into angiogenesis, proliferation, and inflammation/invasion. A number of diagnostic serum biomarkers have been investigated in PAS, including human chorionic gonadotropin (HCG), pregnancy-associated plasma protein-A (PAPP-A), and alpha-fetoprotein (AFP). They have shown variable reliability and variability of measurement depending on gestational age at sampling. At present, a sensitive serum biomarker for invasive placentation remains elusive. In summary, there are a limited number of studies that have contributed to our understanding of the molecular biology of PAS, and additional biomarkers are needed to aid diagnosis and disease stratification.
    • Maternal and fetal blood lipid concentrations during pregnancy differ by maternal body mass index: findings from the ROLO study.

      Geraghty, Aisling A; Alberdi, Goiuri; O'Sullivan, Elizabeth J; O'Brien, Eileen C; Crosbie, Brenda; Twomey, Patrick J; McAuliffe, Fionnuala M; 1 UCD Perinatal Research Centre, Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland. 2 Clinical Chemistry, St. Vincent's University Hospital, Dublin 4, Ireland. 3 UCD School of Medicine, University College Dublin, Dublin, Ireland. 4 UCD Perinatal Research Centre, Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland. (Biomed Central, 2017-10-16)
      Pregnancy is a time of altered metabolic functioning and maternal blood lipid profiles change to accommodate the developing fetus. While these changes are physiologically necessary, blood lipids concentrations have been associated with adverse pregnancy outcomes such as gestational diabetes, pregnancy-induced hypertension and high birth weight. As blood lipids are not routinely measured during pregnancy, there is limited information on what is considered normal during pregnancy and in fetal blood. Data from 327 mother-child pairs from the ROLO longitudinal birth cohort study were analysed. Fasting total cholesterol and triglycerides were measured in early and late pregnancy and fetal cord blood. Intervals were calculated using the 2.5th, 50th and 97.5th centile. Data was stratified based on maternal body mass index (BMI) measured during early pregnancy. Differences in blood lipids between BMI categories were explored using ANOVA and infant outcomes of macrosomia and large-for-gestational-age (LGA) were explored using independent student T-tests and binary logistic regression. All maternal blood lipid concentrations increased significantly from early to late pregnancy. In early pregnancy, women with a BMI < 25 kg/m Blood lipid concentrations increase during pregnancy and differ by maternal BMI. These intervals could help to inform the development of references for blood lipid concentrations during pregnancy.
    • Preventing Excessive Gestational Weight Gain and Postpartum Weight Retention.

      O’Dwyer, V; McAuliffe, F (Irish Medical Journal, 2017-10)
      regnancy and the postpartum period are unique opportunities to promote healthy lifestyle choices including a healthy diet and regular exercise. This is especially important for those who are overweight or obese. Women are weighed at their first antenatal visit and body mass index (BMI) calculated, but not all hospitals routinely weigh women throughout pregnancy. A qualitative Dublin study examined experiences of routine weighing during antenatal care. This study found that women expected to be weighed during pregnancy and postpartum. The benefits of this included providing reassurance and minimising postpartum weight retention. Furthermore, women were eager to receive more information about healthy lifestyle interventions and gestational weight gain (GWG) from healthcare professionals
    • Interpregnancy weight changes and impact on pregnancy outcome in a cohort of women with a macrosomic first delivery: a prospective longitudinal study.

      Crosby, David A; Walsh, Jennifer M; Segurado, Ricardo; McAuliffe, Fionnuala M; Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland. UCD Perinatal Research Centre, School of Medicine, University College Dublin, Dublin, Ireland. CSTAR, School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, Ireland. (BMJ Publishing Group Ltd, 2017-06-06)
      To determine the median interpregnancy maternal weight change between first and second pregnancies, and second and third pregnancies and to assess the impact of this weight change on pregnancy outcome in a cohort of women with a macrosomic first delivery.
    • Managing Epilepsy in Pregnancy

      O Dwyer, V (Irish Medical Journal (IMJ), 2017-02)
      Epilepsy is one of the commonest medical conditions affecting women of childbearing age1. In the most recent triennial report into maternal deaths in Ireland and the UK, two thirds of women who died had a medical condition. In this report, 14 maternal deaths during pregnancy and up to 42 days postpartum were attributable to epilepsy or seizures; a rate of 0.4 per 100,000 maternities. In 12 of these women’ the cause was sudden unexplained death in epilepsy. Thus, epilepsy remains a high-risk condition in pregnancy. The gold standard of care is a multidisciplinary approach involving obstetricians, a neurologist and an epilepsy nurse specialist2. Like other units in Ireland this multidisciplinary service is currently provided in the National Maternity Hospital’s maternal medicine clinic, in conjunction with neurology services in Beaumont Hospital.
    • A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study.

      Rossen, Janne; Lucovnik, Miha; Eggebø, Torbjørn Moe; Tul, Natasa; Murphy, Martina; Vistad, Ingvild; Robson, Michael (BMJ Publishing Group Ltd, 2017)
      Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information.
    • Uptake of the Influenza Vaccination in Pregnancy

      Crosby, DA; Deleau, D; Brophy, C; Mcauliffe, FM; Mahony, R (Irish Medical Journal, 2016-09)
      Influenza is caused by a highly infectious RNA virus, which usually occurs in a seasonal pattern with epidemics in the winter months. The objective of this study was to determine the uptake of the influenza vaccine in a pregnant population and ascertain the reasons why some women did not receive it. A prospective cohort study was conducted over a two-week period in January 2016 in the National Maternity Hospital Dublin, a tertiary referral maternity hospital delivering over 9000 infants per year. There were 504 women studied over the 2-week period. Overall, 197(39.1%) women received the vaccine at a mean gestational age 20.9 weeks (SD 7.0). Given the increased rates of influenza in the community and the associated implications for mother and infant, it is important that pregnant women are educated regarding the risks of influenza in pregnancy and encourage this cohort to be vaccinated.
    • Standardised versus Individualised Parenteral Nutrition. Further Food for Thought

      McCarthy, R; Segurado, R; Crealey, M; Twomey, A (Irish Medical Journal, 2016-04)
      Parenteral Nutrition may be prescribed as a standard PN (SPN) formulation or as an individualised PN (IPN) formulation. SPN may have advantages in terms of rapid availability, less prescription errors, decreased risk of infection and cost savings but IPN, specifically tailored to an infant’s needs, may achieve better outcomes in terms of nutrient intake and weight gain. The aim of our study was to determine if VLBW infants in our NICU benefited from receiving IPN over currently available SPN solutions. Our findings were that VLBW infants prescribed IPN received significantly more amino acid (28%), glucose (6%), energy (11%) and calcium (8%) from the aqueous phase of PN than had they received a similar volume of SPN. The benefits were seen over all the days for which PN was administered. In conclusion, IPN was found to offer significant benefits to our VLBW infants. Modifications to currently available SPN would result in better SPN formulations. Our study also supported the recent recommendation to reduce the calcium:phosphate ratio in PN solutions to avoid early hypophosphataemia
    • Early pregnancy ultrasound and management – effect of a multifaceted training on physician knowledge

      O’Leary, B; Khalid, A; Higgins, M (2016-02)
      Vaginal bleeding is a common event in early pregnancy, with 20-40% of pregnancies affected. Prompt diagnosis and management of bleeding is important, both to reduce morbidity and to avoid excessive emotional distress. This was a prospective study of an educational programme aimed at Obstetrics and Gynaecology BST trainees in the National Maternity Hospital, Dublin. The educational programme consisted of didactic lectures, and simulation and practical sessions. A questionnaire reviewing early pregnancy complications was used to assess participant knowledge. Six trainees participated in the programme, with five (83%) answering the questionnaire. The pre-education questionnaire showed a generally poor level of knowledge of early pregnancy complications with 8/50 (16%) questions answered correctly. Following the educational intervention there was a statistically significant increase in participant knowledge with 45/50 (90%) questions answered correctly. A significant increase in participant knowledge of early pregnancy complications followed our multifaceted educational programme. Study limitations exist, however we have shown the potential value of our educational programme.
    • Maternal Nutrition and Glycaemic Index during Pregnancy Impacts on Offspring Adiposity at 6 Months of Age--Analysis from the ROLO Randomised Controlled Trial.

      Horan, Mary K; McGowan, Ciara A; Gibney, Eileen R; Byrne, Jacinta; Donnelly, Jean M; McAuliffe, Fionnuala M (MDPI AG, 2016-01-04)
      Childhood obesity is associated with increased risk of adult obesity and metabolic disease. Diet and lifestyle in pregnancy influence fetal programming; however the influence of specific dietary components, including low glycaemic index (GI), remains complex. We examined the effect of a maternal low GI dietary intervention on offspring adiposity at 6 months and explored the association between diet and lifestyle factors in pregnancy and infant body composition at 6 months. 280 6-month old infant and mother pairs from the control (n = 142) and intervention group (n = 138), who received low GI dietary advice in pregnancy, in the ROLO study were analysed. Questionnaires (food diaries and lifestyle) were completed during pregnancy, followed by maternal lifestyle and infant feeding questionnaires at 6 months postpartum. Maternal anthropometry was measured throughout pregnancy and at 6 months post-delivery, along with infant anthropometry. No difference was found in 6 months infant adiposity between control and intervention groups. Maternal trimester three GI, trimester two saturated fats and trimester one and three sodium intake were positively associated with offspring adiposity, while trimester two and three vitamin C intake was negatively associated. In conclusion associations were observed between maternal dietary intake and GI during pregnancy and offspring adiposity at 6 months of age.
    • Gentamicin dosing in therapeutic hypothermia; a quality improvement initiative

      Whitla, L; Fitzgerald, D; Twomey, A; Knowles, S; Murphy, JFA (Irish Medical Journal, 2016-01)
      We read with interest a number of articles on gentamicin dosing in neonates treated with therapeutic hypothermia 1-3 . Therapeutic hypothermia has now become the standard of care for newborn infants with hypoxic-ischaemic encephalopathy. Many of these infants concurrently receive gentamicin. Gentamicin is nephrotoxic and ototoxic at high serum concentrations. We therefore carried out a study in The National Maternity Hospital Holles St to analyse trough and peak gentamicin levels in infants who were cooled and compared them to a control group of non-cooled infants.
    • Gestational Age at Birth and 'Body-Mind' Health at 5 Years of Age: A Population Based Cohort Study.

      Cronin, Frances M; Segurado, Ricardo; McAuliffe, Fionnuala M; Kelleher, Cecily C; Tremblay, Richard E (2016)
      Numerous studies have identified the effects of prematurity on the neonate's physical health, however few studies have explored the effects of prematurity on both the physical and mental health of the child as they develop. Secondary analysis of data from the Millennium Cohort Study, a longitudinal study of infants (n = 18 818, born 2000-2002 in the United Kingdom) was performed. Effects of gestational age at birth on health outcomes at 5 years were measured using parental rating of their children's general health and severity of behavior problems. The association between parent's general health ratings and behavior problem ratings was low: 86% of those reporting serious behavior problems (5% of the sample, n = 764) rated their child as being in excellent, very good, or good health. Still, a gradient of increasing risk of poorer outcome with decreasing gestational age was observed for a composite health measure (poor/fair health and/or serious behavior problems), suggesting an association with prematurity for this composite assessment of health status. The greatest contribution to the childhood composite health measure at 5 years was for children born at 32-36 weeks gestation: population attributable fractions for having poor outcomes was 3.4% (Bonferroni-adjusted 95% confidence interval 1.1%-6.2%), compared to 1% (0.2-2.3) for birth at less than 32 weeks. Results suggest that preterm children, by school entry, are not only at high risk of physical health problems, but also of behavioral health problems. The recognition of, and response to comprehensive health and well-being outcomes related to prematurity are important in order to correctly plan and deliver adequate paediatric health services and policies.
    • Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

      Robson, Michael; Murphy, Martina; Byrne, Fionnuala (Elsevier, 2015-10)
      Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10-Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.
    • Gynaecology training for higher specialist trainees in obstetrics and gynaecology: a personal view

      Maher, N; Foley, M (Irish Medical Journal (IMJ), 2015-10)
      As a specialist trainee in Obstetrics and Gynaecology in Ireland, I wish to add some supportive information to reinforce the suggestion that the minimum time spent training in gynaecology be one year.
    • Follow up of infants born to women with Hepatitis B in the National Maternity Hospital

      Travers, CP; Connell, J; Thornton, L; Keane, E; Knowles, S; Murphy, JFA (Irish Medical Journal, 2015-05)
    • Oxytocin is unequally distributed in a bag of normal saline - true or false?

      Chummun, K; O’Hora, H; Gaudel, C; Webster, P; Ogunlewe, O; Boylan, P (Irish Medical Journal, 2015-05)
      Oxytocin infusion used in labour can sometimes be left hung on the stand for many hours. There has been no study to determine if oxytocin is equally distributed throughout the infusion bag and if the distribution stays the same with time. We postulated that there may be settling of the molecules such that oxytocin concentrates at the bottom of the infusion bag. Eight infusion bags were prepared by mixing 10 IU of oxytocin in 1 litre of normal saline. The infusion bags were hung on infusion stands for 8 hours after which 10 samples of 100 mls of the solution from each bag were taken in different containers and the concentration of oxytocin calculated using oxytocin specific Enzyme Immunoassay (EIA) in the different samples. No statistically significant correlation between the oxytocin concentration and the sample number was observed (p-value = 0.738). There was no obvious relationship between oxytocin concentration and the sample number in each bag. There was no evidence to suggest that a linear oxytocin concentration gradient develops in a bag of normal saline over an 8-hour period. In fact the distribution appears to be random and unequal.
    • A randomised controlled trial using the Epidrum for labour epidurals.

      Deighan, M; Briain, D O; Shakeban, H; O'Flaherty, D; Abdulla, H; Al-Jourany, A; Ash, S; Ahmed, S; McMorrow, R (Irish Medical Journal, 2015-03)
      The aim of our study was to determine if using the Epidrum to site epidurals improves success and reduces morbidity. Three hundred parturients requesting epidural analgesia for labour were enrolled. 150 subjects had their epidural sited using Epidrum and 150 using standard technique. We recorded subject demographics, operator experience, number of attempts, Accidental Dural Puncture rate, rate of failure to site epidural catheter, rate of failure of analgesia, Post Dural Puncture Headache and Epidural Blood Patch rates. Failure rate in Epidrum group was 9/150 (6%) vs 0 (0%) in the Control group (P = 0.003). There were four (2.66%) accidental dural punctures in the Epidrum group and none in the Control group (P = 0.060), and 2 epidurals out of 150 (1.33%) in Epidrum group were re-sited, versus 3/150 (2%) in the control group (P = 1.000). The results of our study do not suggest that using Epidrum improves success or reduces morbidity.