• 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.
    • Ultrasound assessment of placental function: the effectiveness of placental biometry in a low-risk population as a predictor of a small for gestational age neonate.

      McGinty, Patricia; Farah, Nadine; Dwyer, Vicky O; Hogan, Jennifer; Reilly, Amanda; Turner, Michael J; Stuart, Bernard; Kennelly, Máireád M; Ultrasound and Fetal Medicine Centre, Coombe Women & Infants University Hospital, Dublin, Ireland. (2012-07)
      The aims of the study were to establish reference ranges for placental length and thickness in a low-risk obstetric population and to assess the likelihood of a small for gestational age (SGA) neonate on the basis of placental length at 18-24 weeks' gestation.
    • Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper.

      O'Brien, S; Cullen, W; UCD General Practice, UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dolphins Barn, Dublin 8, Ireland. sarahob17@gmail.com (2011-12)
      Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.
    • Understanding Women's Differing Experiences of Distress after Colposcopy: A Qualitative Interview Study.

      O'Connor, Mairead; Waller, Jo; Gallagher, Pamela; Martin, Cara M; O'Leary, John J; D'Arcy, Tom; Prendiville, Walter; Flannelly, Grainne; Sharp, Linda (Elsevier, 2015)
      Women who have an abnormal cervical cytology test may be referred for a colposcopy. Accumulating evidence suggests some women may experience distress after colposcopy. This exploratory study examined women's differing experiences of post-colposcopy distress with the aim of identifying factors that are predictive of, or protective against, distress.
    • An unusual reproductive consequence of needle excision of the transformation zone.

      Ramphul, M; Dimitriou, E; Byrne, B; Coombe Women and Infants University Hospital, Dublin, Ireland. ramphulm@tcd.ie (2012-02-01)
    • The use of digital media by women using the maternity services in a developed country.

      O'Higgins, A; Murphy, O C; Egan, A; Mullaney, L; Sheehan, S; Turner, M J (Irish Medical Journal, 2014-11)
      The provision of high quality healthcare information about pregnancy is important to women and to healthcare professionals and it is 1 driven, in part, by a desire to improve clinical outcomes,. The objective of this study was to examine the use of digital media by women' to access pregnancy information. A questionnaire was distributed to women attending a large maternity hospital. Of the 522 respondents, the mean age was 31.8 years, 45% (235/522) were nulliparous, 62% (324/522) lived in the capital city and 29% (150/522) attended the hospital as private patients. Overall 95% (498/522) used the internet for pregnancy information, 76% (399/522) had a smartphone and 59% (235/399) of smartphone owners had used a pregnancy smartapp. The nature of internet usage for pregnancy information included discussion forums (70%), social networks (67%), video media (48%), e-books (15%), blogs (13%), microblogs (9%) and podcasts (4%). Even women who were socially disadvantaged reported high levels of digital media usage. In contemporary maternity care women use digital media extensively for pregnancy information. All maternity services should have a digital media strategy.
    • The use of quality control performance charts to analyze cesarean delivery rates nationally.

      Turner, Michael J; University College Dublin Centre for Human Reproduction, Coombe Women and Infants, University Hospital, Dublin, Ireland. michael.turner@ucd.ie (2012-02-01)
      OBJECTIVE: To examine the use of quality control performance charts to analyze cesarean rates nationally. METHODS: Information on cesarean rates was obtained for all 19 Irish maternity hospitals receiving state funding in 2009. All women who underwent cesarean delivery of a live or stillborn infant weighing 500 g or more between January 1 and December 31 were included. Deliveries were classified as elective or emergency. Individual hospitals were not identified in the analysis. RESULTS: The mean rates per hospital of elective and emergency cesarean were 12.9+/-2.6% (n=9337) and 13.8+/-3.0% (n=9989), respectively-giving an overall mean rate of 26.7+/-4.2% (n=19326) per hospital. Cesarean rates were normally distributed. Using a quality control performance chart with a cutoff 2 standard deviations from the mean, 1 hospital was above the normal range for both total and elective cesareans, indicating that its pre-labor obstetric practices warrant clinical review. Another hospital had a mean emergency cesarean rate above the normal range, indicating that its labor ward practices warrant review. CONCLUSION: Quality control performance charts can be used to analyze cesarean rates nationally and, thus, to identify hospitals at which obstetric practices should be reviewed.
    • Vaginal breech delivery at term: the doctors' dilemma.

      Turner, M J; Maguire, P J (Irish Medical Journal, 2015-03)
      "When an operation is once performed, nobody can ever prove that it was unnecessary". The Craze for Operations from The Doctorâ s Dilemma: Preface on Doctors by George Bernard Shaw, 1909*. Breech presentation complicates 3-4% of deliveries at term and it is associated with an increased risk of perinatal mortality and morbidity 1,2 . The increased fetal risks may be due to the hypoxia or trauma associated with a vaginal delivery, but this can be minimised if cases suitable for vaginal delivery are carefully selected and labour is supervised by experienced clinical staff 2,3 . The increased fetal risk may also be due to other causes, such as congenital malformations, which are independent of the mode of delivery. Before 2000, the elective caesarean section (CS) rate for breech presentation had been rising as obstetricians attempted to avoid the fetal risks associated with vaginal delivery.
    • Vaginal prostaglandin gel to induce labour in women with one previous caesarean section.

      Agnew, G; Turner, M J; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. gerryagnew@gmail.com (2012-02-01)
      This retrospective study reviewed the mode of delivery when vaginal prostaglandins were used to induce labour in women with a single previous lower segment caesarean section. Over a 4-year period, PGE 2 gel was used cautiously in low doses in 54 women. Induction with PGE 2 gel was associated with an overall vaginal birth after caesarean section (VBAC) rate of 74%, which compared favourably with the 74% VBAC rate in women who went into spontaneous labour (n = 1969). There were no adverse outcomes recorded after the prostaglandin inductions but the number reported are too small to draw any conclusions about the risks, such as uterine rupture. We report our results because they may be helpful in assessing the chances of a successful VBAC in the uncommon clinical circumstances where prostaglandin induction is being considered.