• Maternal body mass index and the prevalence of spontaneous and elective preterm deliveries in an Irish obstetric population: a retrospective cohort study.

      Vinturache, Angela; McKeating, Aoife; Daly, Niamh; Sheehan, Sharon; Turner, Michael; Centre for Human Reproduction, University College Dublin, Coombe Women and Infants University Hospital, Dublin, Ireland (BMJ, 2017-10-15)
      To estimate the association between maternal body mass index (BMI) and risk of spontaneous preterm delivery (sPTD) and elective preterm delivery (ePTD) in singleton and multiple pregnancies. Retrospective cohort study. Electronic records of all deliveries from 2009 through 2013 in a tertiary university hospital were abstracted for demographic and obstetrical information. A total of 38 528 deliveries were included. Participants with missing data were excluded from the study. BMI was calculated from the measurement of height and weight at the first prenatal visit and categorised. Sonographic confirmation of gestational age was standard.
    • Maternal leptin and body composition in the first trimester of pregnancy.

      Fattah, Chro; Barry, Sinead; O'connor, Norah; Farah, Nadine; Stuart, Bernard; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. (2012-02-01)
      BACKGROUND: Leptin is produced mainly by adipocytes. Levels are increased in women with obesity and during pregnancy. Increased levels are also associated with pregnancy complications such as, pre-eclampsia and gestational diabetes mellitus. OBJECTIVE: We studied what component of body composition correlated best with maternal leptin in the first trimester of pregnancy and, whether maternal leptin correlated better with visceral fat rather than fat distributed elsewhere. SUBJECTS AND METHODS: Women were recruited in the first trimester. Maternal adiposity was measured using body mass index and advanced bioelectrical impedance analysis. Maternal leptin was measured using an enzyme-linked immunosorbent assay technique. RESULTS: Of the 100 subjects studied, the mean leptin concentration was 37.7 ng/ml (range: 2.1-132.8). Leptin levels did not correlate with gestational age in the first trimester, maternal age, parity or birth weight. Serum leptin correlated positively with maternal weight and body mass index, and with the different parameters of body composition. On multiple regression analysis, serum leptin correlated with visceral fat but not fat distributed elsewhere. CONCLUSIONS: Visceral fat is the main determinant of circulating maternal leptin in the first trimester of pregnancy. This raises the possibility that maternal leptin in early pregnancy may be a marker for the development of metabolic syndrome, including diabetes mellitus.
    • Maternal morbid obesity and obstetric outcomes.

      Farah, Nadine; Maher, Niamh; Barry, Sinead; Kennelly, Mairead; Stuart, Bernard; Turner, Michael J; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. nadine.farah@ucd.ie (2012-02-01)
      OBJECTIVE: The purpose of this retrospective cohort study was to review pregnancy outcomes in morbidly obese women who delivered a baby weighing 500 g or more in a large tertiary referral university hospital in Europe. METHODS: Morbid obesity was defined as a BMI > or =40.0 kg/m2 (WHO). Only women whose BMI was calculated at their first antenatal visit were included. The obstetric out-comes were obtained from the hospital's computerised database. RESULTS: The incidence of morbid obesity was 0.6% in 5,824 women. Morbidly obese women were older and were more likely to be multigravidas than women with a normal BMI. The pregnancy was complicated by hypertension in 35.8% and diabetes mellitus in 20.0% of women. Obstetric interventions were high, with an induction rate of 42.1% and a caesarean section rate of 45.3%. CONCLUSIONS: Our findings show that maternal morbid obesity is associated with an alarmingly high incidence of medical complications and an increased level of obstetric interventions. Consideration should be given to developing specialised antenatal services for morbidly obese women. The results also highlight the need to evaluate the effectiveness of prepregnancy interventions in morbidly obese women.
    • Maternal mortality and the rising cesarean rate.

      O'Dwyer, Vicky; Hogan, Jennifer L; Farah, Nadine; Kennelly, Mairead M; Fitzpatrick, Christopher; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland. vicky.odwyer@ucd.ie (2012-02)
      To review maternal mortality in a large stand-alone maternity hospital in a European city and to determine whether the increased cesarean rate was associated with an increase in maternal deaths.
    • Maternal Obesity and Neck Circumference

      Anglim, B; O’Higgins, A; Daly, N; Farren, M; Turner, MJ (Irish Medical Journal, 2015-06)
      Obese women are more likely to require general anaesthesia for an obstetric intervention than non-obese. Difficult tracheal intubation and oxygen desaturation is more common in pregnancy. Failed tracheal intubation has been associated with an increase in neck circumference (NC). We studied the relationship between maternal obesity and NC as pregnancy advanced in women attending a standard antenatal clinic. Of the 96 women recruited, 13.5% were obese. The mean NC was 36.8cm (SD 1.9) in the obese women compared with 31.5cm (SD 1.6) in women with a normal BMI (p<0.001) at 18-22 weeks gestation. In the obese women it increased on average by 1.5cm by 36-40 weeks compared with an increase of 1.6 cm in women with a normal BMI. The antenatal measurement of NC is a simple, inexpensive tool that is potentially useful for screening obese women who may benefit from an antenatal anaesthetic assessment.
    • Maternal sepsis is an evolving challenge

      Turner, Michael J.; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland. (Wiley, 2019-04-26)
      Despite major advances in the last century, particularly in high resource settings, maternal sepsis remains a common and potentially preventable cause of direct maternal death globally. A barrier to further progress has been the lack of consensus on the definition of maternal sepsis. Publications from two recent multidisciplinary consensus conferences, one on sepsis in the non-pregnant adult and the other on sepsis in the pregnant woman, concluded that the criteria for diagnosing sepsis should be clinically-based, applicable at the bedside, and should not be laboratory-based. Informed by reviews of the evidence, in 2017 WHO published a new definition of maternal sepsis based on the presence of suspected or confirmed infection. It also announced a Global Maternal and Neonatal Sepsis Initiative to identify the diagnostic criteria for the early identificati on, epidemiology, and disease classification of maternal sepsis. Standardizing the criteria for maternal sepsis optimizes clinical audit and research. It may facilitate the evaluation of the role of different clinical parameters and biomarkers in the diagnosis, earlier recognition and management of maternal infection and sepsis. Further work is required to develop an international consensus on the criteria for diagnosing maternal sepsis and any associated organ dysfunction.
    • Maternal weight and body composition in the first trimester of pregnancy.

      Fattah, Chro; Farah, Nadine; Barry, Sinead C; O'Connor, Norah; Stuart, Bernard; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. (2012-02-01)
      OBJECTIVE: Previous studies on weight gain in pregnancy suggested that maternal weight on average increased by 0.5-2.0 kg in the first trimester of pregnancy. This study examined whether mean maternal weight or body composition changes in the first trimester of pregnancy. DESIGN: Prospective observational study. POPULATION: We studied 1,000 Caucasian women booking for antenatal care in the first trimester of pregnancy. SETTING: Large university teaching hospital. METHODS: Maternal height and weight were measured digitally in a standardized way and Body Mass Index (BMI) was calculated. Maternal body composition was measured using segmental multifrequency Bioelectrical Impedance Analysis (BIA). Sonographic examination confirmed the gestational age and a normal ongoing singleton pregnancy in all subjects. MAIN OUTCOME MEASURES: Maternal weight, maternal body composition. RESULTS: The mean BMI was 25.7 kg/m(2) and 19.0% of the women were in the obese category (> or =30.0 kg/m(2)). Cross-sectional analysis by gestational age showed that there was no change in mean maternal weight, BMI, total body water, fat mass, fat-free mass or bone mass before 14 weeks gestation. CONCLUSIONS: Contrary to previous reports, mean maternal weight and mean body composition values remain unchanged in the first trimester of pregnancy. This has implications for guidelines on maternal weight gain during pregnancy. We also recommend that calculation of BMI in pregnancy and gestational weight gain should be based on accurate early pregnancy measurements, and not on self-reported or prepregnancy measurements.
    • 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.
    • Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women.

      Cleary, Brian J; Butt, Hajeera; Strawbridge, Judith D; Gallagher, Paul J; Fahey, Tom; Murphy, Deirdre J; Coombe Women and Infants University Hospital, Dublin, Republic of Ireland., bcleary@coombe.ie (2012-02-01)
      PURPOSE: To examine the extent, nature and determinants of medication use in early pregnancy. METHODS: We reviewed early pregnancy medication use, as reported to a midwife at the booking interview, in women delivering between 2000 and 2007 in a large maternity hospital in Dublin, Ireland (n = 61 252). RESULTS: Excluding folic acid, at least one medication was reported in 23 989 (39.2%) pregnancies. Over the counter (OTC) medications were reported in 11 970 (19.5%) pregnancies, illicit drugs or methadone in 545 (0.9%) and herbal medicines/supplements in 352 (0.58%). FDA category D and X medications were reported by 1532 (2.5%) and 1987 (3.2%) women. Asthma, depression and hypertension were among the most commonly reported chronic medical disorders. Medications with potential for foetal harm were reported by 86 (15.7%) women treated for depression and 68 (20%) women treated for hypertension. Factors associated with reporting the use of medications with potential for foetal harm included unplanned pregnancy (adjusted odds ratio [aOR] 1.31, 95% confidence interval [CI] 1.12-1.52), booking at less than 12 weeks gestation (aOR 1.83, 95%CI 1.58-2.13), being above 25 years of age, unemployed (aOR 2.58, 95%CI 2.03-3.29), nulliparous (aOR 1.41; 95%CI 1.22-1.63), single (aOR 1.28; 95%CI 1.06-1.54) or smoking during pregnancy (aOR 1.96, 95%CI 1.67-2.28). CONCLUSIONS: Women frequently report medication use in early pregnancy. Women and prescribers need to be aware of the lack of pregnancy safety data for many medications, and the need for pre-pregnancy planning. Prescribers should ensure that optimal medications are used when treating women of childbearing potential with chronic medical disorders.
    • Methadone and perinatal outcomes: a retrospective cohort study.

      Cleary, Brian J; Donnelly, Jean M; Strawbridge, Judith D; Gallagher, Paul J; Fahey, Tom; White, Martin J; Murphy, Deirdre J; Department of Obstetrics and Gynecology, Trinity College Dublin, Royal College of, Surgeons in Ireland, Dublin, Republic of Ireland. bcleary@coombe.ie (2012-02-01)
      OBJECTIVE: The purpose of this study was to examine the relationship among methadone maintenance treatment, perinatal outcomes, and neonatal abstinence syndrome. STUDY DESIGN: This was a retrospective cohort study of 61,030 singleton births at a large maternity hospital from 2000-2007. RESULTS: There were 618 (1%) women on methadone at delivery. Methadone-exposed women were more likely to be younger, to book late for antenatal care, and to be smokers. Methadone exposure was associated with an increased risk of very preterm birth <32 weeks of gestation (adjusted odds ratio [aOR], 2.47; 95% confidence interval [CI], 1.40-4.34), being small for gestational age <10th percentile (aOR, 3.27; 95% CI, 2.49-4.28), admission to the neonatal unit (aOR, 9.14; 95% CI, 7.21-11.57), and diagnosis of a major congenital anomaly (aOR, 1.94; 95% CI, 1.10-3.43). There was a dose-response relationship between methadone and neonatal abstinence syndrome. CONCLUSION: Methadone exposure is associated with an increased risk of adverse perinatal outcomes, even when known adverse sociodemographic factors have been accounted for. Methadone dose at delivery is 1 of the determinants of neonatal abstinence syndrome.
    • Methadone dose and neonatal abstinence syndrome-systematic review and meta-analysis.

      Cleary, Brian J; Donnelly, Jean; Strawbridge, Judith; Gallagher, Paul J; Fahey, Tom; Clarke, Mike; Murphy, Deirdre J; Coombe Women and Infants University Hospital, Dublin 8, Ireland School of, Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland., bcleary@coombe.ie (2012-02-01)
      AIM: To determine if there is a relationship between maternal methadone dose in pregnancy and the diagnosis or medical treatment of neonatal abstinence syndrome (NAS). METHODS: PubMed, EMBASE, the Cochrane Library and PsychINFO were searched for studies reporting on methadone use in pregnancy and NAS (1966-2009). The relative risk (RR) of NAS was compared for methadone doses above versus below a range of cut-off points. Summary RRs and 95% confidence intervals (CI) were estimated using random effects meta-analysis. Sensitivity analyses explored the impact of limiting meta-analyses to prospective studies or studies using an objective scoring system to diagnose NAS. RESULTS: A total of 67 studies met inclusion criteria for the systematic review; 29 were included in the meta-analysis. Any differences in the incidence of NAS in infants of women on higher compared with lower doses were statistically non-significant in analyses restricted to prospective studies or to those using an objective scoring system to diagnose NAS. CONCLUSIONS: Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.
    • Miscarriage after sonographic confirmation of an ongoing pregnancy in women with moderate and severe obesity.

      O'Dwyer, Vicky; Monaghan, Bernadette; Fattah, Chro; Farah, Nadine; Kennelly, Mairead M; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland. vicky.odwyer@ucd.ie (2012)
      To compare the incidence of spontaneous miscarriage in women with moderate to severe obesity to that in women with a normal BMI after sonographic confirmation of the foetal heart rate in the first trimester.
    • Mode of conception of triplets and high order multiple pregnancies.

      Basit, I; Johnson, S N; Mocanu, E; Geary, M; Daly, S; Wingfield, M; Department of Obstetrics and Gynaecology, Coombe Women and Infant's University Hospital, Cork St., Dublin. irambasit@hotmail.com (2012-03)
      A retrospective audit was performed of all high order multiple pregnancies (HOMPs) delivered in three maternity hospitals in Dublin between 1999 and 2008. The mode of conception for each pregnancy was established with a view to determining means of reducing their incidence. A total of 101 HOMPs occurred, 93 triplet, 7 quadruplet and 1 quintuplet. Information regarding the mode of conception was available for 78 (81%) pregnancies. Twenty eight (27.7%) were spontaneous, 34 (33.7%) followedlVF/ICSI/FET treatment (in-vitro fertilisation, intracytoplasmic sperm injection, frozen embryo transfer), 16 (15.8%) resulted from Clomiphene Citrate treatment and 6 (6%) followed ovulation induction with gonadotrophins. Triplet and HOMPs are a major cause of maternal, feta land neonatal morbidity. Many are iatrogenic, arising from fertility treatments including Clomiphene. Reducing the numbers of embryos transferred will address IVF/ICSI/FET-related multiple pregnancy rates and this is currently happening in Ireland. Clomiphene and gonadotrophins should only be prescribed when appropriate resources are available to monitor patients adequately.
    • Motivators for women to attend cervical screening: the influential role of GPs.

      O'Connor, Mairead; Murphy, Judith; Martin, Cara; O'Leary, John; Sharp, Linda (2014-08)
      Participation in organized cervical cancer screening has declined recently. While research has focussed on barriers to screening participation, less attention has been paid to what motivates women to attend. Moreover, little is known about health care provider/practitioner-level barriers and facilitators to participation. Better understanding of these issues could help inform strategies to improve participation.
    • The MyD88+ phenotype is an adverse prognostic factor in epithelial ovarian cancer.

      d'Adhemar, Charles J; Spillane, Cathy D; Gallagher, Michael F; Bates, Mark; Costello, Katie M; Barry-O'Crowley, Jacqui; Haley, Kathryn; Kernan, Niamh; Murphy, Ciara; Smyth, Paul C; et al. (2014)
      The prognosis of epithelial ovarian cancer is poor in part due to the high frequency of chemoresistance. Recent evidence points to the Toll-like receptor-4 (TLR4), and particularly its adaptor protein MyD88, as one potential mediator of this resistance. This study aims to provide further evidence that MyD88 positive cancer cells are clinically significant, stem-like and reproducibly detectable for the purposes of prognostic stratification. Expression of TLR4 and MyD88 was assessed immunohistochemically in 198 paraffin-embedded ovarian tissues and in an embryonal carcinoma model of cancer stemness. In parallel, expression of TLR4 and MyD88 mRNA and regulatory microRNAs (miR-21 and miR-146a) was assessed, as well as in a series of chemosensitive and resistant cancer cells lines. Functional analysis of the pathway was assessed in chemoresistant SKOV-3 ovarian cancer cells. TLR4 and MyD88 expression can be reproducibly assessed via immunohistochemistry using a semi-quantitative scoring system. TLR4 expression was present in all ovarian epithelium (normal and neoplastic), whereas MyD88 was restricted to neoplastic cells, independent of tumour grade and associated with reduced progression-free and overall survival, in an immunohistological specific subset of serous carcinomas, p<0.05. MiR-21 and miR-146a expression was significantly increased in MyD88 negative cancers (p<0.05), indicating their participation in regulation. Significant alterations in MyD88 mRNA expression were observed between chemosensitive and chemoresistant cells and tissue. Knockdown of TLR4 in SKOV-3 ovarian cells recovered chemosensitivity. Knockdown of MyD88 alone did not. MyD88 expression was down-regulated in differentiated embryonal carcinoma (NTera2) cells, supporting the MyD88+ cancer stem cell hypothesis. Our findings demonstrate that expression of MyD88 is associated with significantly reduced patient survival and altered microRNA levels and suggest an intact/functioning TLR4/MyD88 pathway is required for acquisition of the chemoresistant phenotype. Ex vivo manipulation of ovarian cancer stem cell (CSC) differentiation can decrease MyD88 expression, providing a potentially valuable CSC model for ovarian cancer.
    • A National Audit of Smoking Cessation Services in Irish Maternity Units

      Reynolds C.M.E.; Egan B; Cawley S; Kennedy , R; Sheehan S R; Turner M.J (Irish Medical Journal, 2017-06)
      There is international consensus that smoking cessation in the first half of pregnancy improves foetal outcomes. We surveyed all 19 maternity units nationally about their antenatal smoking cessation practices. All units recorded details on maternal smoking at the first antenatal visit. Only one unit validated the self-reported smoking status of pregnant women using a carbon monoxide breath test. Twelve units (63%) recorded timing of smoking cessation. In all units women who reported smoking were given verbal cessation advice. This was supported by written advice in 12 units (63%), but only six units (32%) had all midwives trained to provide this advice. Only five units (26%) reported routinely revisiting smoking status later in pregnancy. Although smoking is an important modifiable risk factor for adverse pregnancy outcomes, smoking cessation services are inadequate in the Irish maternity services and there are variations in practices between hospitals.
    • A national survey of implementation of guidelines for gestational diabetes mellitus

      O’Higgins, A; Dunne, F; Lee, B; Smith, D; Turner, MJ (Irish Medical Journal, 2014-09)
      In 2010, national guidelines for the management of gestational diabetes mellitus (GDM) were published by the Health Service Executive (HSE). In 2012, a questionnaire was distributed to all maternity units to survey implementation of the guidelines. All units screened women for GDM, but used different screening tests with fifteen units (79%) using the recommended 75g OGTT, three units (16%) using a 100g OGTT and one unit (5%) using a 50g glucose challenge test. Optimal outcomes are best achieved through multidisciplinary diabetes-obstetric care and this was available in nine of the units (47%). The prevalence of GDM varied from 2.2 â 7.4%. Insulin usage varied from 15-56%. Six centres (31%) had not implemented the national guidelines in full because of lack of resources. Despite national endorsement of the guideline, significant variations remain in implementation. This may lead to differences in clinical outcomes depending on where a woman attends for obstetric care.
    • National Variation in Caesarean Section Rates: A Cross Sectional Study in Ireland.

      Sinnott, Sarah-Jo; Brick, Aoife; Layte, Richard; Cunningham, Nathan; Turner, Michael J (PLoS One, 2016)
      Internationally, caesarean section (CS) rates are rising. However, mean rates of CS across providers obscure extremes of CS provision. We aimed to quantify variation between all maternity units in Ireland.
    • Neonatal Brachial Plexus Palsy and Causation

      Turner, M J; Farren, M (Irish Medical Journal, 2016-07)
      A vaginal childbirth is the result of the internal (endogenous) expulsive forces of uterine contractions, usually supplemented by active maternal pushing1. Depending on the clinical circumstances, additional external (exogenous) traction forces may be required from the birth attendant. This blend of internal and external forces varies from birth to birth. Women who have had a previous vaginal delivery, for example, may deliver successfully with uterine contractions alone and the role of the birth attendant may be simply to control and slow the delivery so that trauma to the maternal perineum from stretching by the fetal head is minimised. In contrast, additional traction may be required by an obstetrician at the time of an operative vaginal delivery for fetal distress or dystocia. The strength of the traction required may be increased by clinical factors, for example, fetal macrosomia or malposition. The traction should be axial in the direction of the birth canal, which is a vector combining horizontal and vertical traction at 25-45 degrees below the horizontal when the woman is in the lithotomy position.
    • The NOFLO trial: low-flow nasal prongs therapy in weaning nasal continuous positive airway pressure in preterm infants.

      O'Donnell, Sinéad M; Curry, Sarah J; Buggy, Niamh A; Moynihan, Margaret M; Sebkova, Sylva; Janota, Jan; Miletin, Jan; Coombe Women and Infants University Hospital, Dublin, Ireland. (2013-07)
      To determine if low-flow nasal prongs therapy with room air, compared with no treatment, facilitates weaning from nasal continuous positive airway pressure (NCPAP) in very low birth weight (VLBW, birth weight <1500 g) infants.