• 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
    • Screening For Gestational Diabetes Mellitus Selectively in a University Maternity Hospital

      O’Malley, EG; O’Duill, M; McArdle, C; Kennedy, RAK; Reynolds, CM; Turner, MJ (Irish Medical Journal, 2018-06)
      Gestational diabetes mellitus (GDM) is one of the commonest complications of pregnancy. The prevalence varies depending, for example, on the diagnostic criteria, the screening test used, laboratory standards and the population studied. However, the prevalence is increasing globally due to the increasing levels of maternal obesity. The detection of GDM is important because there are clinical consequences. The woman has an increased risk of pre-eclampsia and of developing Type 2 diabetes mellitus (T2DM) in later life. Up to 70% of those women with GDM develop T2DM by 28 years after the affected pregnancy2. In a pregnancy complicated by GDM there is an increased risk of fetal macrosomia and polyhydramnios due to fetal hyperglycaemia3. This is associated with an increased risk of shoulder dystocia and caesarean delivery4. Neonatal hypoglycaemia may develop due to increased insulin production secondary to intrauterine hyperglycaemia. The offspring also have an increased risk in their childhood and adult life for the development of diabetes, obesity and metabolic syndrome5.
    • Serum cortisol values, superior vena cava flow and illness severity scores in very low birth weight infants.

      Miletin, J; Pichova, K; Doyle, S; Dempsey, E M; Department of Paediatrics and Newborn Medicine, Coombe Women and Infants, University Hospital, Dublin, Ireland. miletinj@yahoo.com (2012-02-01)
      OBJECTIVE: Recent evidence suggests that high cortisol concentrations are associated with increased morbidity and mortality in very low birth weight (VLBW) infants. Neonatal illness severity and mortality risk scores are reliable in predicting morbidity and mortality. The objectives were (i) to assess the correlation between serum cortisol levels and clinical assessment of multi-organ dysfunction/illness severity scores (CRIB II, SNAPPE-II and neonatal multiple organ dysfunction score (NEOMOD)) in first 24 h in VLBW infants and (ii) to assess the relationship between surrogates of end organ blood flow and serum cortisol levels. STUDY DESIGN: A prospective observational cohort study. Neonates with birth weight <1500 g were eligible for enrollment. Echocardiography evaluation of superior vena cava (SVC) flow was carried out in the first 24 h life. Cortisol levels were measured simultaneously and appropriate clinical scores were calculated. RESULT: A total of 54 VLBW neonates were enrolled following parental consent. Two patients were excluded because of congenital malformations. In 14 babies the cortisol value was not simultaneously obtained. The mean birth weight was 1.08 kg, mean gestational age was 27.8 weeks. There was a significant correlation between cortisol and NEOMOD score (P=0.006). There was no correlation between cortisol and CRIB II score (P=0.34), SVC flow (P=0.49) and mean arterial blood pressure respectively (P=0.35). CONCLUSION: There was no correlation between SVC flow and cortisol values or between cortisol and mean blood pressure values. There was a significant correlation between cortisol levels and neonatal organ dysfunction score evaluated suggesting that stressed VLBW infants do mount a cortisol response.
    • Strategies to enhance assessment of the fetal head position before instrumental delivery: a survey of obstetric practice in the United Kingdom and Ireland.

      Ramphul, Meenakshi; O'Brien, Yvonne; Murphy, Deirdre J; Academic Department of Obstetrics & Gynaecology, Trinity College Dublin & Coombe Women & Infant's University Hospital, Dublin 8, Ireland. ramphulm@tcd.ie (2012-12)
      To establish the current practice of obstetricians with regard to assessment of women in labour before instrumental delivery.
    • Study protocol. ECSSIT - Elective Caesarean Section Syntocinon Infusion Trial. A multi-centre randomised controlled trial of oxytocin (Syntocinon) 5 IU bolus and placebo infusion versus oxytocin 5 IU bolus and 40 IU infusion for the control of blood loss at elective caesarean section.

      Murphy, Deirdre J; Carey, Michael; Montgomery, Alan A; Sheehan, Sharon R; Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Trinity, College Dublin, Dublin 8, Ireland. deirdre.j.murphy@tcd.ie (2012-02-01)
      BACKGROUND: Caesarean section is one of the most commonly performed major operations in women throughout the world. Rates are escalating, with studies from the United States of America, the United Kingdom, China and the Republic of Ireland reporting rates between 20% and 25%. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. The value of routine oxytocics in the third stage of vaginal birth has been well established and it has been assumed that these benefits apply to caesarean delivery as well. A slow bolus dose of oxytocin is recommended following delivery of the baby at caesarean section. Some clinicians use an additional infusion of oxytocin for a further period following the procedure. Intravenous oxytocin has a very short half-life (4-10 minutes) therefore the potential advantage of an oxytocin infusion is that it maintains uterine contractility throughout the surgical procedure and immediate postpartum period, when most primary haemorrhages occur. The few trials to date addressing the optimal approach to preventing haemorrhage at caesarean section have been under-powered to evaluate clinically important outcomes. There has been no trial to date comparing the use of an intravenous slow bolus of oxytocin versus an oxytocin bolus and infusion. METHODS AND DESIGN: A multi-centre randomised controlled trial is proposed. The study will take place in five large maternity units in Ireland with collaboration between academics and clinicians in the disciplines of obstetrics and anaesthetics. It will involve 2000 women undergoing elective caesarean section after 36 weeks gestation. The main outcome measure will be major haemorrhage (blood loss >1000 ml). A study involving 2000 women will have 80% power to detect a 36% relative change in the risk of major haemorrhage with two-sided 5% alpha. DISCUSSION: It is both important and timely that we evaluate the optimal approach to the management of the third stage at elective caesarean section. Safe operative delivery is now a priority and a reality for many pregnant women. Obstetricians, obstetric anaesthetists, midwives and pregnant women need high quality evidence on which to base management approaches. The overall aim is to reduce maternal haemorrhagic morbidity and its attendant risks at elective caesarean section. TRIAL REGISTRATION: number: ISRCTN17813715.
    • Study protocol. IDUS - Instrumental delivery & ultrasound: a multi-centre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery.

      Murphy, Deirdre J; Burke, Gerard; Montgomery, Alan A; Ramphul, Meenakshi; Academic Department of Obstetrics & Gynaecology, Trinity College Dublin & Coombe Women & Infant's University Hospital, Dublin, Ireland. (2012)
      Instrumental deliveries are commonly performed in the United Kingdom and Ireland, with rates of 12 - 17% in most centres. Knowing the exact position of the fetal head is a pre-requisite for safe instrumental delivery. Traditionally, diagnosis of the fetal head position is made on transvaginal digital examination by delineating the suture lines of the fetal skull and the fontanelles. However, the accuracy of transvaginal digital examination can be unreliable and varies between 20% and 75%. Failure to identify the correct fetal head position increases the likelihood of failed instrumental delivery with the additional morbidity of sequential use of instruments or second stage caesarean section. The use of ultrasound in determining the position of the fetal head has been explored but is not part of routine clinical practice.
    • Sweeten, soother and swaddle for retinopathy of prematurity screening: a randomised placebo controlled trial.

      O'Sullivan, A; O'Connor, M; Brosnahan, D; McCreery, K; Dempsey, E M; Department of Paediatrics and Newborn Medicine, Coombe Women and Infants, University Hospital, Dublin, Ireland. (2012-02-01)
      OBJECTIVE: To assess the efficacy of oral sucrose combined with swaddling and non-nutritive suck (NNS) as a method for reducing pain associated with retinopathy of prematurity (ROP) screening. DESIGN: Randomised placebo controlled study. SETTING: Tertiary level neonatal intensive care unit. SAMPLE: 40 infants undergoing primary eye examination for ROP screening. INTERVENTION: The control group were swaddled, and received 0.2 ml of sterile water given by mouth using a syringe and a soother. The intervention group were swaddled, and received 0.2 ml of sucrose 24% given by mouth using a syringe and a soother. RESULTS: 40 infants were included in the study. There was no difference in mean gestational age at birth, mean birth weight or corrected gestational age at first examination between both groups. The sucrose group had a significantly lower median Neonatal Pain, Agitation and Sedation Scale (N-PASS) score during ROP screening, initially following insertion of the speculum (6.5 vs 5, p=0.02) and subsequently during scleral indentation (9.5 vs 7.5, p=0.03). Fewer infants experienced episodes of desaturations or bradycardia in the intervention group (1 vs 4, p=0.18). CONCLUSION: ROP screening is a necessary but recognised painful procedure. Sucrose combined with NNS and swaddling reduced the behavioural and physiological pain responses. However, pain scores remained consistently high and appropriate pain relief for ROP screening remains a challenge.
    • Team Objective Structured Bedside Assessment (TOSBA) as formative assessment in undergraduate Obstetrics and Gynaecology: a cohort study.

      Deane, Richard P; Joyce, Pauline; Murphy, Deirdre J (BioMed Central, 2015-10-09)
      Team Objective Structured Bedside Assessment (TOSBA) is a learning approach in which a team of medical students undertake a set of structured clinical tasks with real patients in order to reach a diagnosis and formulate a management plan and receive immediate feedback on their performance from a facilitator. TOSBA was introduced as formative assessment to an 8-week undergraduate teaching programme in Obstetrics and Gynaecology (O&G) in 2013/14. Each student completed 5 TOSBA sessions during the rotation. The aim of the study was to evaluate TOSBA as a teaching method to provide formative assessment for medical students during their clinical rotation. The research questions were: Does TOSBA improve clinical, communication and/or reasoning skills? Does TOSBA provide quality feedback?
    • The thickness and volume of LLETZ specimens can predict the relative risk of pregnancy-related morbidity.

      Khalid, S; Dimitriou, E; Conroy, R; Paraskevaidis, E; Kyrgiou, M; Harrity, C; Arbyn, M; Prendiville, W; RCSI Department of Gynaecology, Coombe Women & Infants University Hospital, Dublin, Ireland. (2012-05)
      The aim of this study was to determine if the individual physical characteristics of the extirpated transformation zone after large loop excision of the transformation zone (LLETZ) might predict the relative risk of adverse obstetric outcome, specifically preterm labour (PTL).
    • 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.
    • Timing of screening for gestational diabetes mellitus in women with moderate and severe obesity.

      O'Dwyer, Vicky; Farah, Nadine; Hogan, Jennifer; O'Connor, Norah; Kennelly, Mairead M; Turner, Michael J; University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital, Ireland. vicky.odwyer@ucd.ie (2012-04)
      We evaluated screening with a diagnostic oral glucose tolerance test earlier than 20 weeks gestation in women with moderate to severe obesity.
    • To screen or not to screen for subclinical hypothyroidism in pregnancy?

      Freyne, A; Byrne, B (Irish Medical Journal, 2013-06)
      Not unlike screening for gestational diabetes, controversy prevails over the value of screening for thyroid disease in pregnancy. Fortunately, overt hypothyroidism is rare in pregnancy (0.3-0.5%) because it is associated with infertility and increased rates of first trimester miscarriage. Studies suggest that obstetric complications such as hypertension, placental abruption, preterm delivery, perinatal morbidity and mortality are increased in women with hypothyroidism in pregnancy1 and there is evidence that the offspring of untreated mothers have neuropsychological and cognitive impairment. Subclinical hypothyroidism (Elevated TSH and normal Free T4) is estimated to be present in 2 â 2.5% of pregnant women. It is not as clearly associated with adverse obstetric and neonatal outcome but there is some evidence that maternal subclinical hypothyroidism is associated with impaired psychomotor development in the offspring 2.
    • The treatment of CIN: what are the risks?

      Prendiville, W; Royal College of Surgeons in Ireland, Department of Gynaecology, Coombe and, Tallagh Hospital, Dublin, Ireland. walter.prendiville@gmail.com (2012-02-01)
      The treatment of CIN: what are the risks?The treatment of squamous cervical intraepithelial neoplasia is to remove or destroy the transformation zone (TZ). It is likely that no method of treatment is superior to another if it is performed properly and the limited available evidence supports this view. The significant advantages of excision (simplicity, cost, outpatient procedure, histological examination of the entire TZ) mean that treatment thresholds may have lowered over the last decade. Long-term pregnancy-related morbidity associated with excision has been reported recently. The evidence would suggest that this increase equates to a genuine increase in serious adverse outcome for cone biopsy but not large loop excision of the transformation zone (LLETZ). The available data also point to an increase in both incomplete excision and premature labour associated with the excision of large endocervical TZs. The clinical implications arising from this are firstly that women with large type 2 and 3 TZs need appropriate counselling before treatment and that the threshold for treating young women with mild abnormalities needs review.