Admission ultrasonography as a means of identifying unrecognized fetal compromise in term singleton pregnancies at the onset of labor - a feasibility study.

OBJECTIVES: Apparently uncomplicated low-risk pregnancies, especially first time births, account for a significant proportion of adverse birth outcomes. Improved risk stratification with a simple bedside scan on admission in early labor could potentially reduce adverse intrapartum outcomes. The aim of this feasibility study was to assess a cohort of low-risk subjects with admission ultrasonography at the onset of labor with a view to conducting a future randomized controlled trial (RCT). The objectives were three-fold; i) to determine the logistics of performing a labor admission ultrasound scan ii) to establish whether abnormal ultrasound features can be identified and iii) whether they are associated with emergency delivery and/or poor condition of the neonate at birth. METHODS: We performed a prospective cohort study of 295 participants with term singleton cephalic pregnancies admitted in early labor or for labor induction with non-fetal indications. The setting was a university teaching hospital in Ireland with almost 8000 births annually. A bedside ultrasound scan was performed to assess fetal biometry, amniotic fluid volume and placental maturity. Patients and their babies were followed up until hospital discharge. The outcomes of interest included image quality, time to perform a scan, oligohydramnios (Single Deepest Pool ≤ 2 cm), small for gestational age (SGA; abdominal circumference <10th centile), mature placenta (Grannum 2 or 3), pathological CTG, emergency cesarean section (CS), fetal acidosis (cord arterial pH <7.10 or base excess <-12.0), low Apgar score <7 at 5 min and neonatal unit admission. RESULTS: Image quality was optimal in 274 of the 295 scans (93%) and 271 (92%) were completed in less than 10 min. Of this low-risk population, 67 of 294 (23%) had oligohydramnios, 11 (4%) were small for gestational age and 87 (30%) had a mature placenta (Grannum grade 2). The incidence of pathological CTG and emergency CS was higher among patients with oligohydramnios than those with a normal scan but did not reach statistical significance; Odds Ratio 3.40 (95% Confidence Intervals 0.55 to 20.92) and OR 1.43 (95% CI 0.66 to 3.08) respectively. The mean birthweight was significantly lower in those with oligohydramnios -139 g (95% CI -248 to -30) and admission scan detected SGA -357 g (95% CI -557 to -137). Adverse perinatal outcomes were uncommon with a higher incidence of fetal acidosis (pH < 7.10) in the oligohydramnios group. The incidence of neonatal unit admission >24 h was higher in the oligohydramnios group but not statistically significant; OR 3.75 (95% CI 0.61 to 22.97). Results for SGA alone were non-significant and results for oligohydramnios and SGA combined were similar to those for oligohydramnios alone. CONCLUSIONS: Admission ultrasonography is feasible in a routine clinical setting, but evidence of benefit is weak and does not currently justify a randomized controlled trial.

Fetal anomaly diagnosis and termination of pregnancy in Ireland: a service evaluation following implementation of abortion services in 2019.

BACKGROUND: Approximately 3% of pregnancies are diagnosed with a fetal anomaly, of which a proportion is fatal or life-limiting. The introduction of legislation for termination of pregnancy in Ireland in 2019 for conditions "likely to lead to the death of the fetus" made termination of pregnancy for "fatal fetal anomaly" an option for pregnant women in Ireland. OBJECTIVE: This study examined all cases of termination of pregnancy performed for major fetal anomaly over the first 3 years of service implementation, including cases that did not meet the legal criteria, resulting in women traveling outside Ireland for abortion care. STUDY DESIGN: A retrospective service evaluation of tertiary fetal medicine clinics in 2 tertiary maternity hospitals between 2019 and 2021 was undertaken. We compared pregnancies of patients diagnosed with fatal fetal anomaly who underwent termination of pregnancy in Ireland with those of patients who did not meet the legal criteria and hence traveled outside Ireland for termination of pregnancy. RESULTS: Overall, 139 pregnancies met the inclusion criteria; 83 (59.7%) patients had termination of pregnancy in the tertiary maternity hospital (local), and 56 (40.3%) traveled abroad, mainly to the United Kingdom. Demographic characteristics were similar between the 2 groups, as was gestation at diagnosis and delivery. All cases where termination of pregnancy was local were discussed at fetal medicine multidisciplinary meetings, as opposed to 34% of cases of patients who ultimately traveled outside Ireland for termination of pregnancy. The most common indication (25/83; 30.1%) for local termination of pregnancy was trisomy 18, followed by anencephaly. Traveling to obtain abortion care was mainly due to diagnosis of trisomy 21 (30/56; 53.6%), followed by other multiple structural anomalies/syndromes deemed locally as not meeting the legal criteria. CONCLUSION: Legislation for termination of pregnancy for fetal anomaly, restricted to fatal diagnoses, is difficult to implement, requires significant multidisciplinary input, and can lead to limited services for pregnancies diagnosed with major fetal anomalies. Our findings emphasize the impact of legislative barriers to abortion care for fetal anomaly and the need for policies and services that support women's access to termination of pregnancy for fetal anomaly.

Ovulation induction: comparing success rates between anovulatory and ovulatory cycles using different treatment protocols.

The management of patients with sub-fertility, particularly unexplained sub-fertility, is a sensitive and complex matter. This was a prospective observational study conducted from October 2016 to March 2017 in Galway, Ireland, the aim of which was to identify the clinical pregnancy rates (CPR) in women undergoing ovulation induction (OI) with timed sexual intercourse (TSI) or intrauterine insemination (IUI) and to compare them across two groups: (1) Anovulatory women and (2) ovulatory women with unexplained subfertility. Patients undergoing OI were recruited consecutively and OI regimens were prescribed as per local clinical protocol. The main observation was a higher CPR in the anovulatory group (18%) compared with the ovulatory group (CPR = 10%) (p < 0.05). No difference was observed in the CPR between the TSI and IUI groups. There are many studies to support the use of OI in the treatment of women with anovulatory subfertility, though the use of OI in ovulatory women is a more controversial issue. The treatment options offered to these patients need to be individualized to each couple and should consider their length of infertility, age, and financial means. Due to the lower cost and the less invasive nature of OI-treatment we conclude that a short treatment course could be offered as an acceptable alternative prior to IVF.

Comparison of costs associated with substituting culture medium with saline solution for follicular flushing during oocyte retrieval.

OBJECTIVES: To compare culture medium and saline solution for follicular flushing during oocyte retrieval with assisted reproductive technologies. METHODS: The present retrospective study analyzed data collected at Galway Fertility Clinic, Galway, Ireland, between January 1, 2015 and August 31, 2016; all patients attending the clinic for in vitro fertilization/intracytoplasmic sperm injection during this period were included. Data were stratified by whether follicular flushing was performed with culture medium or saline, and the oocyte yield rate, fertilization rate, embryo utilization rate, and biochemical and clinical pregnancy rates were compared between the groups. RESULTS: In total, 422 oocyte retrieval procedures with culture medium and 277 with normal saline were analyzed. The fertilization (P=0.676) and clinical pregnancy rates (P=0.593) did not differ between the groups. Using normal saline resulted in an approximately 41-fold per-patient cost saving compared with culture medium. CONCLUSION: Switching from culture medium to normal saline for follicular flushing significantly reduced oocyte-retrieval costs without adversely affecting reproductive outcomes.