The prediction of morbidity related to vaginal delivery in nulliparous women - A secondary analysis from the genesis multicenter trial.

OBJECTIVE: In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery. STUDY DESIGN: The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated. RESULTS: A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%. CONCLUSION: In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

Analgesia, anaesthesia and obstetric outcome in women with inherited bleeding disorders.

OBJECTIVE: Vertebral canal haematoma (VCH) complicates 1 in 168,000 obstetric epidurals (Ruppen et al., 2006). This risk is increased in women with inherited bleeding disorders (IBD). The impact of a contraindication to regional anaesthesia on pain management and obstetric outcome in these women is unknown. The purpose of this study was to determine anaesthetic use and obstetric outcomes in a cohort of women with IBD. STUDY DESIGN: 97 women with IBD that delivered 130 babies at the CWIUH from Jan 2011 to Dec 2016 were identified from a maternal medicine database. Multidisciplinary planning of peripartum care was communicated to labour ward staff using a simple checklist. The primary bleeding disorders were: Von Willebrands disease (VWD) Type 1 27 (27.8%); VWD Type 2A 3 (3.8%); Low VWF 3 (3.8%); Bleeding disorder of unknown aetiology (BDUA) 19 (19.6%); deficiency of Factors VII, VIII, IX, X, and XI 13 (13.4%); Carriers of Factor VIII, IX, X, XIII deficiency 17 (17.5%); 5 had combined deficiencies (5.2%) and there was one platelet function defect. 9 had a family history of a bleeding disorder (9.3%). Haemostatic support, analgesia, mode of delivery and maternal and fetal outcomes were compared between pregnancies where regional anaesthesia was permitted and those that were not using the Chi-squared test. RESULTS: When pregnancies where regional anaesthesia was not recommended (49) were compared with pregnancies where regional anaesthesia was considered safe (81), the women were more likely to see an anaesthetist before labour 46 (94%) vs 46 (61%): p < 0.001; to require prophylactic haemostatic support for delivery 30 (61%) vs 1 (1%): p < 0.001; to use a remifentanil infusion 15 (31%) vs 0: p < 0.001, and have general anaesthesia for Caesarean Section (CS) 10 (20%) vs 1(1%): p < 0.001. Vaginal birth 35 (71%) vs 53(65%): p = 0.4 and CS rates 14 (29%) vs 26 (32%) p = 0.28 were similar. Postpartum haemorrhage (PPH) was more common 11 (24%) vs 9(12%) vs p = 0.07 but not statistically so. There were no cases of neonatal bleeding or VCH. CONCLUSION: Contraindication to neuraxial blockade in labouring women with IBD does not influence mode of delivery. This information is reassuring to these women who may be anxious about delivery without regional anaesthesia.

Defining the upper limit of the second stage of labor in nulliparous patients.

BACKGROUND: Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity. OBJECTIVE: In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome. STUDY DESIGN: The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture. RESULTS: Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration. CONCLUSION: In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

First trimester serum biomarkers to predict gestational diabetes in a high-risk cohort: Striving for clinically useful thresholds.

OBJECTIVES: Screening and diagnosis of gestational diabetes (GDM) has been a source of controversy. The prevalence has increased in line with an obesity epidemic and a trend towards delayed child-bearing. Treatment of even modest glycaemic impairment in pregnancy has been shown to be beneficial in preventing its clinical sequalae. However the cumbersome nature and timing of the oral glucose tolerance test coupled with debate around universal versus risk factor based screening have been problematic. This group aimed to investigate a panel of biomarkers which have shown promise in the literature to predict GDM from the first trimester in a group of high risk women. METHODS: Serum samples were drawn on 248 women deemed at risk of GDM before 15 weeks' gestation to measure C-reactive protein, sex hormone binding globulin, adiponectin and 1,5 anhydroglucitol. Patients underwent an oral glucose tolerance test as per IADPSG criteria at 28 weeks' gestation. Multiple logistic regression was used to examine the link between incidence of GDM and early pregnancy serum biomarkers. RESULTS: Adiponectin levels in the first trimester are independently linked to the risk of GDM. Serum adiponectin <8.9 µg/ml gives an odds ratio of 3.3 for GDM.Mean 1,5 AG levels are significantly lower in those that go on to develop GDM. SHBG levels measured in the first trimester were linked to the risk of GDM. However, this was no longer statistically significant once BMI, ethnicity and family history were taken into consideration. First trimester measurement of CRP is not a useful indicator of GDM risk. CONCLUSIONS: First trimester measurement of Adiponectin and 1,5 Anhydroglucitol are potential early biomarkers for the later onset of GDM. Risk stratification using these biomarkers may facilitate early diagnosis and management of GDM to mitigate against its complications.

Prediction of cesarean delivery in the term nulliparous woman: results from the prospective, multicenter Genesis study.

BACKGROUND: In contemporary practice many nulliparous women require intervention during childbirth such as operative vaginal delivery or cesarean delivery (CD). Despite the knowledge that the increasing rate of CD is associated with increasing maternal age, obesity and larger infant birthweight, we lack a reliable method to predict the requirement for such potentially hazardous obstetric procedures during labor and delivery. This issue is important, as there are greater rates of morbidity and mortality associated with unplanned CD performed in labor compared with scheduled CDs. A prediction algorithm to identify women at risk of an unplanned CD could help reduced labor associated morbidity. OBJECTIVE: In this primary analysis of the Genesis study, our objective was to prospectively assess the use of prenatally determined, maternal and fetal, anthropomorphic, clinical, and ultrasound features to develop a predictive tool for unplanned CD in the term nulliparous woman, before the onset of labor. MATERIALS AND METHODS: The Genesis study recruited 2336 nulliparous women with a vertex presentation between 39+0 and 40+6 weeks' gestation in a prospective multicenter national study to examine predictors of CD. At recruitment, a detailed clinical evaluation and ultrasound assessment were performed. To reduce bias from knowledge of these data potentially influencing mode of delivery, women, midwives, and obstetricians were blinded to the ultrasound data. All hypothetical prenatal risk factors for unplanned CD were assessed as a composite. Multiple logistic regression analysis and mathematical modeling was used to develop a risk evaluation tool for CD in nulliparous women. Continuous predictors were standardized using z scores. RESULTS: From a total enrolled cohort of 2336 nulliparous participants, 491 (21%) had an unplanned CD. Five parameters were determined to be the best combined predictors of CD. These were advancing maternal age (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09 to 1.34), shorter maternal height (OR, 1.72; 95% CI, 1.52 to 1.93), increasing body mass index (OR, 1.29; 95% CI, 1.17 to 1.43), larger fetal abdominal circumference (OR, 1.23; 95% CI, 1.1 to 1.38), and larger fetal head circumference (OR, 1.27; 95% CI, 1.14 to 1.42). A nomogram was developed to provide an individualized risk assessment to predict CD in clinical practice, with excellent calibration and discriminative ability (Kolmogorov-Smirnov, D statistic, 0.29; 95% CI, 0.28 to 0.30) with a misclassification rate of 0.21 (95% CI, 0.19 to 0.25). CONCLUSION: Five parameters (maternal age, body mass index, height, fetal abdominal circumference, and fetal head circumference) can, in combination, be used to better determine the overall risk of CD in nulliparous women at term. A risk score can be used to inform women of their individualized probability of CD. This risk tool may be useful for reassuring most women regarding their likely success at achieving an uncomplicated vaginal delivery as well as selecting those patients with such a high risk for CD that they should avoid a trial of labor. Such a risk tool has the potential to greatly improve planning hospital service needs and minimizing patient risk.

Passing through - reasons why migrant doctors in Ireland plan to stay, return home or migrate onwards to new destination countries.

BACKGROUND: International recruitment is a common strategy used by high-income countries to meet their medical workforce needs. Ireland, despite training sufficient doctors to meet its internal demand, continues to be heavily dependent on foreign-trained doctors, many of whom may migrate onwards to new destination countries. A cross-sectional study was conducted to measure and analyse the factors associated with the migratory intentions of foreign doctors in Ireland. METHODS: A total of 366 non-European nationals registered as medical doctors in Ireland completed an online survey assessing their reasons for migrating to Ireland, their experiences whilst working and living in Ireland, and their future plans. Factors associated with future plans - whether to remain in Ireland, return home or migrate to a new destination country - were tested by bivariate and multivariate analyses, including discriminant analysis. RESULTS: Of the 345 foreign doctors who responded to the question regarding their future plans, 16 % of whom were Irish-trained, 30 % planned to remain in Ireland, 23 % planned to return home and 47 % to migrate onwards. Country of origin, personal and professional reasons for migrating, experiences of training and supervision, opportunities for career progression, type of employment contract, citizenship status, and satisfaction with life in Ireland were all factors statistically significantly associated with the three migratory outcomes. CONCLUSION: Reported plans may not result in enacted emigration. However, the findings support a growing body of evidence highlighting dissatisfaction with current career opportunities, contributing to the emigration of Irish doctors and onward migration of foreign doctors. Implementation of the WHO Global Code, which requires member states to train and retain their own health workforce, could also help reduce onward migration of foreign doctors to new destination countries. Ireland has initiated the provision of tailored postgraduate training to doctors from Pakistan, enabling these doctors to return home with improved skills of benefit to the source country.

The impact of a surgical boot camp on early acquisition of technical and nontechnical skills by novice surgical trainees.

BACKGROUND: Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program. METHODS: New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills. RESULTS: The scores for knowledge (53.8% vs 68.4%, P < .01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P < .01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later. CONCLUSION: The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.

The controversial association of ABCB1 polymorphisms in refractory epilepsy: an analysis of multiple SNPs in an Irish population.

Controversy has surrounded the reported association of the single nucleotide polymorphism (SNP) C3435T of the ATP-binding cassette subfamily B member 1 (ABCB1, MDR1) gene, with refractory epilepsy. Here we examine this question by: (1) attempting to replicate the original association, (2) assessing the association of other variants in high linkage disequilibrium (LD) with C3435T, and (3) evaluating and comparing our findings with other published studies. We defined drug-responsiveness as seizure freedom or a 50% or more reduction in seizure frequency in the preceding year. Drug resistance was defined as a less than 50% reduction in seizure frequency in the preceding year. We used a combination of map-based (tagging SNPs) and direct sequence-based methods allowing a comprehensive assessment of variation across the associated interval. Genotypic data on 8 SNPs was collected on 440 patients, of whom 242 were drug-responsive and 198 were drug-resistant. We were unable to observe the original association of drug-resistant epilepsy with C3435T, nor any association with other functional variants at SNP or haplotype level in the ABCB1 gene. Evaluation of other attempted replication studies suggest that if the original C3435T association is indeed real, it would appear highly sensitive to the phenotype used. Alternatively, the discrepant results of this and other association attempts may be indicative of the original report of the CC genotype at C3435T in ABCB1 being a false positive finding. Variability in phenotypic descriptions in genetic association studies may partly explain the inconsistency of attempted replications.