A retrospective cohort study of the characteristics of unsuccessful operative vaginal deliveries.

INTRODUCTION: Unsuccessful operative vaginal delivery (OVD) is associated with high rates of materno-fetal morbidity. We aimed to examine institutional rates of unsuccessful OVDs (uOVD) and compare them with successful OVD (sOVD) in order to identify factors to aid patient selection and education. METHODS: A 6-month retrospective cohort study was performed on all unsuccessful and successful OVDs in a tertiary level maternity hospital in the Republic of Ireland. Maternal demographics and obstetric factors were assessed to evaluate potential underlying risk factors for unsuccessful operative vaginal delivery versus successful vaginal delivery. RESULTS: There were 4,191 births during the study period with an OVD rate of 14.2% (n = 595) with 28 (4.7% of OVDs) being unsuccessful. Unsuccessful OVD were predominately nulliparous (25; 89.2%) with a mean maternal age of 30.1 years (range 20-42), with more than half (n = 15, 53.5%) being induced. The most common indication for induction was prolonged rupture of membranes (PROM) (n = 7, 25%) which was significantly different from the successful OVD group. A senior obstetrician was significantly more likely to be the primary operator in uOVD when compared to sOVD. (82.1 % V 54.1% p < 0.01). The majority of unsuccessful OVD were vacuum deliveries (n = 17; 60.7%), with a significantly higher mean birthweight when compared to successful OVD (3.695 kg V 3.483 kg; p < 0.01). Following an unsuccessful OVD, women were more likely to have a postpartum haemorrhage (64.2 % V 31.5% p < 0.01) and their infant was more likely to require admission to the neonatal intensive care unit (NICU) (32.1 % V 5.8% p < 0.01) when compared with successful OVD. CONCLUSION: Risk factors for unsuccessful OVD were higher birth weight and induction of labour. There was a higher incidence of postpartum haemorrhage and NICU admission when compared with successful OVD.

Multi-institutional and multi-disciplinary care: A successfully managed aortic dissection in the third trimester of pregnancy.

Multi-disciplinary collaborative care for pregnant women with complex and emergent conditions is essential. Logistical planning, clear communication and human factor awareness are all non-clinical skills which need to be utilised in order to maximise outcomes. We describe the case of a proximal aortic dissection in the late third trimester of pregnancy diagnosed in a peripheral hospital that was transferred to a cardiothoracic centre for successful operative management 160 km away. This required the time-sensitive mobilisation and liaison of a receiving cardiothoracic, anaesthesiology and perfusionist team in conjunction with obstetric and midwifery support from an affiliated maternity hospital, as well as the national neonatal transport team. We emphasise the importance of multidisciplinary team management in complex cases and how imperative good inter-disciplinary communication is to ensure safe inter-hospital transfer.

Medicine, media and the law: The effect on training in obstetrics and gynaecology.

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

The general populations' understanding of first trimester miscarriage: a cross sectional survey.

OBJECTIVES: Miscarriage is a common, yet for many, devastating adverse pregnancy outcome. However, despite this the level of public knowledge on the topic is sub-optimal. We aimed to examine the general public's knowledge of miscarriage as well as their health information seeking behaviours associated with this topic. STUDY DESIGN: We commissioned a national cross-sectional telephone survey of adults in the Republic of Ireland. 967 members of the general public consented to participate to this anonymised telephone survey. Sampling procedures ensured proportionality as per national standards. We examined respondents' definitions of miscarriage, its incidence and clinical findings, as well as the information seeking behaviours of the general population surrounding miscarriage. RESULTS: 699 (72%) of respondents provided an estimate of miscarriage frequency, with 28% of respondents correctly estimating that miscarriage occurs in 21-30% of pregnancies, with 61% under-estimating the incidence. Men were three times more likely than women to under-estimate (aOR3.5; 95% CI 2.4-4.9), as were those without children (aOR 1.7; 95% CI 1.2-2.6), or those living in urban areas (aOR 1.6; 95%CI 1.0-2.4. One third of respondents (33%) believed that the risk of miscarriage was higher following only one miscarriage. While 83% of respondents knew someone who had experienced a miscarriage, just over one third had discussed the topic of miscarriage with a family member/friend. CONCLUSIONS: The general populations' knowledge of miscarriage, its incidence and associated factors is concerning, as are their health information seeking behaviours. Improving the level of knowledge of the general public could be achieved by adopting the topic into existing public health and education strategies. This will allow those experiencing miscarriage to frame their experience and expectations.

Recurrent hepatocellular carcinoma in pregnancy: A case report and literature review.

The incidence of hepatocellular carcinoma in pregnancy is rare, and we present the first reported case of a pregnancy complicated by pre-existing advanced hepatocellular carcinoma. We describe the case of a 39-year-old woman in her second pregnancy, with a diagnosis of hepatocellular carcinoma. This was discovered in 2013 incidentally following hepato-splenectomy and pancreatectomy for a presumed hepatic adenoma in the context of multiple arterio-venous malformations. Recurrent hepatocellular carcinoma, in conjunction with co-existing pulmonary hypertension was successfully managed in a multi-disciplinary setting, resulting in a spontaneous vaginal delivery of a live female infant with maternal and neonatal survival six months following delivery.

Metastatic gestational choriocarcinoma: a masquerader in obstetrics.

We describe a case of a 36-year-old woman presenting with vaginal bleeding and suboptimally rising serum human chorionic gonadotropin levels, who was investigated for a pregnancy of unknown location. Ultrasonography, laparoscopy and dilatation and curettage failed to reveal signs of an intra-uterine or intra-abdominal pregnancy. Following computed tomography imaging, a mediastinal mass was histologically determined to be a gestational choriocarcinoma. Following surgical resection and chemotherapy, the patient recovered and proceeded to have a successful intra-uterine pregnancy. We describe this exceptionally rare case and emphasise the importance of follow-up of hCG levels in pregnancy of unknown location.

Menorrhagia Outcomes of Minimally Invasive Treatments (MOMITS): A 2 to 5-year follow-up.

We conducted a retrospective postal questionnaire-based study to assess the effectiveness and patient experience of minimally invasive treatments for menorrhagia by performing a two- to five-year follow up of patient symptoms. Questionnaires were distributed to 111 and 117 women following thermal balloon endometrial ablation (TBEA) and levonorgestrel intrauterine system (LNG-IUS), with response rates of 58.5% and 43.6% respectively. Sanitary pad use during the heaviest day of bleeding reduced by 8.4 and 5.2 pads in the TBEA and LNG-IUS groups respectively (p<0.05). An improvement in patients' quality of life (QOL) score exceeding 10 points was found in 79% and 61% in the TBEA and LNG-IUS groups respectively. Patient satisfaction (PS) improved in all areas, more so regarding participation in social activities in the TBEA group (p<0.05). Women undergoing TBEA would recommend the procedure to other women in 95%, and 93% in the LNG-IUS group. TBEA and LNG-IUS are highly acceptable management options for the treatment of menorrhagia, with improvement in QOL, PS and menstrual blood loss.

The use and success of cold coagulation for the treatment of high grade squamous cervical intra-epithelial neoplasia: a retrospective review.

OBJECTIVE: Cold coagulation is recognised as a viable, cost-effective and successful treatment for cervical intraepithelial neoplasia (CIN), being used less frequently than excisional treatments for high grade lesions. We set out to demonstrate successful long term follow-up of patient with high grade CIN treated with cold coagulation. STUDY DESIGN: We conducted a retrospective review over a one-year period of women with biopsy-proven CIN 2 and 3 who were treated with cold coagulation to the cervix, attending the colposcopy service of a large tertiary referral hospital. We examined follow-up cervical smear data for three years post treatment of low and high grade CIN, evaluated the success of treatment and re-treatment rates. RESULTS: 93 patients were included in our study, with 39 (41.9%) having CIN 1 and 54 (58.1%) diagnosed with CIN 2 or 3. Follow-up smears revealed low levels of recurrent high grade changes in both groups, with 31 (79.5%) of our CIN 1 group having a negative smear one year following treatment with cold coagulation, compared to 44 (81.1%) of patients with CIN 2 and 3. Successful primary treatment (i.e. no requirement for further treatment after 3 year follow-up) occurred in 33 (84.6%) of the CIN 1 group, and 42 (77.7%) of the CIN 2/3 group, demonstrating no statistical significance between re-treatment rates between both groups. CONCLUSIONS: This study demonstrates the effectiveness of cold coagulation for the treatment of high grade cervical intraepithelial neoplasia. High success rates, and low re-treatment rates confirm that this is an acceptable primary treatment for CIN 2 and 3.

Conjoined twins: experience in an Irish tertiary centre.

Conjoined twins are rare, with a reported incidence of 0.19 per 10,000 pregnancies in Europe. We discuss four spontaneous conjoined twin pregnancies presenting to a tertiary referral centre from 2005 to 2011, diagnosed on antenatal dating ultrasound. The cases were monitored closely throughout pregnancy by a multidisciplinary team, with serial surveillance, including ultrasound, fetal echocardiography, magnetic resonance imaging, amniocentesis and further referral to cardiology and paediatric surgery specialists, where indicated. Three female sets were determined antenatally to be not surgically separable; these infants were managed palliatively following a live birth. The male set of conjoined twins was accepted for surgical separation at Great Ormond Street Hospital, London, which was successfully performed electively at 4 months. Of interest, all four parents reside within 20 km of each other, representing a possible cluster of cases. The incidence of conjoined twins in our local population is approximately 0.63 per 10,000 over an 8-year period from 2005 to 2012. This case series highlights a cluster of conjoined twins, managed to viability and delivered in a tertiary referral centre.

[Abdominal morbidity following TRAM flap breast reconstruction--patient-reported outcome measures]. / Die subjektive Wahrnehmung abdomineller Symptome nach Brustrekonstruktion mit gestielter und freier TRAM Lappenplastik.

PURPOSE/BACKGROUND: Excellent aesthetic outcomes have been demonstrated with TRAM flap breast reconstruction. However, abdominal wall morbidity after TRAM flap breast reconstruction has not been accurately evaluated in terms of patient symptoms or patient quality of life. To further examine this issue, we performed a cross-sectional survey of TRAM flap breast reconstruction patients utilising questions from a patient-related outcome measure questionnaire. PATIENTS AND METHOD: The questions were posed to post-mastectomy breast reconstruction patients. Items pertaining to abdominal wall symptoms and satisfaction with the outcome were reported on a 5-point Linkert Scale (1=very satisfied/no symptoms to 5=very dissatisfied/frequent symptoms). RESULTS: The study population consisted of 270 patients who underwent pedicled (n=183) or free (n=87) TRAM flap procedures. The frequency of abdominal wall symptoms reported on abdomen-specific questionnaire items was increased in the pedicled TRAM group relative to the free TRAM group. This included "tightness or pulling in abdomen" (2.34 vs. 2.01); "abdominal pain, bloating, or discomfort" (2.11 vs. 1.69); "difficulty doing everyday activities requiring the use of your abdominal muscles" (2.11 vs. 1.67); and "abdominal weakness" (2.36 vs. 1.8). CONCLUSION: We found a relatively low frequency of abdominal symptoms in the TRAM flap patients as a whole. However, there was a tendency towards increased abdominal symptoms in the pedicled TRAM patients compared to the free TRAM patients. As the population sizes in this study are somewhat limited, future studies with increased patient numbers may find greater differences between pedicled and free TRAM patients. In addition, studies evaluating the patients' abdominal wall symptoms pre- and postoperatively may allow for a detailed analysis of abdominal wall morbidity in post-mastectomy TRAM patients.

Breast cancer local recurrence after breast reconstruction.

The primary aim of surgery in breast cancer is to achieve local control of disease. Secondly, improving quality of life and patient satisfaction is of utmost importance. While the positive effect of postmastectomy reconstruction on the psychological well-being of women with breast cancer has been demonstrated, evidence-based data on its oncological safety remain sparse. There is concern that the presence of autologous tissue or an implant may mask locoregional recurrence. Furthermore, there is little agreement on the appropriateness of routine radiological surveillance of these patients as well as on the surgical treatment of locoregional recurrence. We attempt to review the impact of breast reconstruction on the incidence and detection of locoregional recurrence and discuss treatment options.

Low temperature protocol for efficient transformation of Mycobacterium smegmatis spheroplasts.

Spheroplasts of Mycobacterium smegmatis LM15, strain 607, were prepared by a combined treatment with glycine and lysozyme. The spheroplasts were tested for ability to take up and express purified mycobacteriophage DNA. Exposure of 1.0 x 10(8) to 1.0 x 10(9) spheroplasts to saturating DNA (1 microgram) for 15 min at 5 degrees C resulted in a transfection efficiency of approximately 0.009% . The transfer of the beta-lactamase marker with DNA purified from strain LM15 to spheroplasts of a beta-lactamase-negative mutant, strain LM144, was achieved. The DNA-treated cultures, after reversion to the bacillary form, contained 20-fold more penicillin-resistant cells than the nontreated control culture. Approximately 80% of the penicillin-resistant colonies from the DNA-treated cells were positive for beta-lactamase Cell-free extracts of penicillin-resistant transformants contained beta-lactamase activity that ranged from 0.046 to 0.134 micromol of benzylpenicillin hydrolyzed/min per mg protein. This low temperature procedure is recommended for high efficiency transformation of M. smegmatis.

Incorporation of 5-fluorouracil into RNA by Mycobacterium avium complex strain LM1.

The incorporation of 5-fluorouracil (FUra) into RNA of Mycobacterium avium complex strain LM1 was evaluated. Cells were labeled with either [14C]FUra or [3H]uracil and the ribonucleosides were analyzed by high-performance liquid chromatography. The identification of the ribonucleosides was facilitated by the use of an isocratic system that provided unambiguous identification of the RNA pyrimidine components. Uracil was incorporated into RNA as uridine, but an equal amount was converted to cytidine. [14C]FUra was incorporated directly into RNA as 5-fluorouridine and there was no evidence of its conversion to other pyrimidines. The ratio of 5-fluorouridine:uridine was 2.8-fold greater for cells grown in 100 micrograms FUra/mL than for cells grown in 20 micrograms FUra/mL. Analysis of the RNA nucleotides was performed and deoxyribonucleotides were present; DNA contamination was estimated to range from about 2 to 8% of the RNA preparations.