Implementing Medical Student Teaching on Gynaecological Healthcare of Transgender Patients.

Introduction Transgender people have specific healthcare needs and experience difficulty in accessing health services. Medical students should receive teaching on general and gynaecological healthcare issues in this population. Our aim was to assess medical students' knowledge of healthcare needs of transgender people before and after a newly implemented teaching session on transgender healthcare. Method A mixed-method study was carried out over a three month period in a university obstetric and gynaecology hospital in Dublin. A one-hour teaching session was developed and delivered to final year medical students. Students completed a survey before and after receiving the lecture. Results Seventy-one students completed the pre-lecture survey and forty-three completed the post-lecture survey. Pre-lecture, 64 students (90%) reported some-to-no understanding of healthcare issues of transgender people, and only 13 (18%) reported understanding gynaecological issues faced by transgender people. Post-lecture, 41 (95%) had a better understanding of health issues faced by this population and 40 (93%) had a better understanding of gynaecological health issues faced. Most students (81%) wanted further teaching on the topic. Conclusion A one-hour teaching session was effective at improving student knowledge of care of transgender people. This teaching could be expanded to all Irish medical schools. Going forward, the teaching could be adapted for post-graduate obstetric and gynaecology teaching.

Air Pollution Levels Outside the Capital's Maternity Hospitals.

Introduction The World Health Organisation has identified air pollution as the single biggest environmental threat to human health. There is growing evidence in the literature that air pollution is associated with negative outcomes in pregnancy. The purpose of this study was to measure pollution levels in the immediate surroundings of the three Dublin maternity hospitals by measuring fine particulate matter <2.5 micrometres (PM2.5). Methods Data pertaining to levels of PM2.5 at the three Dublin maternity hospitals were obtained from Pollutrack's records for the time period 25/6/2021-2/12/2021. Results were compared to the 2021 WHO Air Quality Guidelines. Results Average PM2.5 levels were 9µg/m³ around the National Maternity Hospital, 10µg/m³ around the Coombe Hospital and 13µg/m³ around the Rotunda Hospital. Levels were higher during the day, weekdays and in December. No matter when the PM2.5 levels were measured, results were higher than those recommended by the World Health Organisation's Air Quality Guideline. Discussion Air pollution levels across Ireland's capital city are higher than recommended by the WHO. This is concerning for the public and in particular for the pregnant population. Going forward, further research is required on the relationship between levels of air pollutants and adverse pregnancy outcomes in Dublin.

Epidemiology of chromosomal trisomies in the East of Ireland.

Background: Chromosomal trisomies are associated with advancing maternal age. In Ireland, information on the total prevalence and outcome of trisomy affected pregnancies is unavailable. This study aimed to ascertain more precise data on Trisomies 21, 18 and 13 in a large Irish region during the period 2011-2013. Methods: Multiple information sources were used in case finding, including a regional congenital anomaly register, all maternity and paediatric hospitals in the region and the regional Department of Clinical Genetics. Results: There were 394 trisomy cases from 80 894 total births, of which 289 were Trisomy 21, 75 were Trisomy 18 and 30 were Trisomy 13. The total prevalence rate was 48.9/10 000 births, 35.7, 9.3 and 3.7 for Trisomies 21, 18 and 13, respectively. Over 90% of Trisomies 18/13 and 47% of Trisomy 21 were diagnosed prenatally; 61% of Trisomy 21 cases and nearly 30% of Trisomies 18/13 were live births; 38% all trisomy affected pregnancies ended in a termination. Conclusions: This study provides precise data on the total prevalence and outcome of trisomy affected pregnancies in the East of Ireland. Total prevalence rates were higher than previously reported. Prenatal diagnosis had a significant impact on outcome. These data provide a better basis for planning of services for live-born children affected by trisomy.

The natural history of neural tube defects in the setting of an Irish tertiary referral foetal medicine unit.

Neural tube defects (NTDs) carry a heavy burden for affected individuals and their family. Physical and neurological outcome measures may help in counselling couples. The aim of this audit was to review all cases of NTDs seen at a tertiary referral foetal medicine unit. Cases were identified from obstetric, neonatal and neurosurgical records. Thirty-six cases of NTDs were identified. Of the 36, 25% (n = 9, one trisomy 18) opted for termination of pregnancy abroad. Of the remaining 27, 19% (n = 5) died in the antepartum period. 81% (n = 22) were liveborn with four neonatal deaths (one trisomy 18). Of 15 cases, 14 had neurosurgical repair within a median time of 3 days and 9 of these also had a ventriculoperitoneal shunt inserted. Antenatal ultrasound accurately diagnosed lesion level in the majority of cases. The survival rate for babies diagnosed with non-lethal neural tubes defects is high when multidisciplinary care is initiated early.

Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496.

OBJECTIVES: To identify risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery. DESIGN: Observational study, nested within a randomised controlled trial. SETTING: Two university-affiliated maternity hospitals. SAMPLE: A cohort of 478 nulliparous women at term (≥37 weeks of gestation) undergoing instrumental delivery. METHODS: Univariable and multivariable logistic regression analyses were performed. MAIN OUTCOME MEASURES: Risk factors for suboptimal application of vacuum or forceps, maternal and neonatal morbidity, and the sequential use of instruments, second operator, and caesarean section following failed instrumental delivery. RESULTS: Instrument placement was suboptimal in 138 of 478 (28.8%) deliveries. Factors associated with suboptimal instrument placement included fetal malposition (OR 2.44, 95% CI 1.62-3.66), mid-cavity station (OR 1.68, 95% CI 1.02-2.78), and forceps as the primary instrument (OR 2.01, 95% CI 1.33-3.04). Compared with optimal instrument placement, suboptimal placement was associated with prolonged hospital stay (adjusted OR 2.28, 95% CI 1.30-4.02) and neonatal trauma (adjusted OR 4.25, 95% CI 1.85-9.72). Suboptimal placement was associated with a greater use of sequential instruments (adjusted OR 3.99, 95% CI 1.94-8.23) and caesarean section for failed instrumental delivery (adjusted OR 3.81, 95% CI 1.10-13.16). The mean decision to delivery interval (DDI) was 4 minutes longer in the suboptimal group (95% CI 2.1-5.9 minutes). CONCLUSIONS: Suboptimal instrument placement is associated with increased maternal and neonatal morbidity and procedural complications. Greater attention should be focused on instrument placement when training obstetricians for instrumental delivery.

Instrumental delivery and ultrasound : a multicentre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery.

OBJECTIVE: To determine whether the use of ultrasound can reduce the incidence of incorrect diagnosis of the fetal head position at instrumental delivery and subsequent morbidity. DESIGN: Two-arm, parallel, randomised trial, conducted from June 2011 to December 2012. SETTING: Two maternity hospitals in the Republic of Ireland. SAMPLE: A cohort of 514 nulliparous women at term (≥37 weeks of gestation) with singleton cephalic pregnancies, aiming to deliver vaginally, were recruited prior to an induction of labour or in early labour. METHODS: If instrumental delivery was required, women who had provided written consent were randomised to receive clinical assessment (standard care) or ultrasound scan and clinical assessment (ultrasound). [Correction added on 17 April 2014, after first online publication: Sentence was amended.] MAIN OUTCOME MEASURE: Incorrect diagnosis of the fetal head position. RESULTS: The incidence of incorrect diagnosis was significantly lower in the ultrasound group than the standard care group (4/257, 1.6%, versus 52/257, 20.2%; odds ratio 0.06; 95% confidence interval 0.02-0.19; P < 0.001). The decision to delivery interval was similar in both groups (ultrasound mean 13.8 minutes, SD 8.7 minutes, versus standard care mean 14.6 minutes, SD 10.1 minutes, P = 0.35). The incidence of maternal and neonatal complications, failed instrumental delivery, and caesarean section was not significantly different between the two groups. CONCLUSIONS: An ultrasound assessment prior to instrumental delivery reduced the incidence of incorrect diagnosis of the fetal head position without delaying delivery, but did not prevent morbidity. A more integrated clinical skills-based approach is likely to be required to prevent adverse outcomes at instrumental delivery.

A retrospective cohort study evaluating pregnancy outcomes in women with MIDD.

AIMS: The most common pathogenic mitochondrial mutation associated with mitochondrial disease is m.3243A>G. Increased obstetric complications, such as spontaneous abortion, gestational diabetes (GDM), preterm delivery, and preeclampsia, have been reported in women carrying this mutation. We aimed to determine the fetal and maternal outcomes in pregnant women with mitochondrial disease. METHODS: We retrospectively studied the obstetric and perinatal outcomes in 88 pregnancies of 26 women with genetically confirmed mitochondrial disease (m.3243A>G in the MTTL1 gene (n = 25); m.12258C>A in the MT-TS2 gene (n = 1)). Outcomes included pregnancy related complications, mode of delivery, gestational age at delivery and birthweight. RESULTS: Mean heteroplasmy rate was 18%. The miscarriage rate was higher than background at 25%. 21 pregnancies (24%) were complicated by GDM; 9 pregnancies (13.6%) had a preterm delivery and 2 of them (3%) an extreme premature delivery < 32 weeks. One woman had preeclampsia and one had a postpartum hemorrhage. The caesarean section (CS) rate was 20%. For every unit increase in maternal heteroplasmy levels there was a 26% increased risk of undergoing an assisted operative vaginal delivery (OR 1.26, 95% CI 1.04-1.53, P = 0.002, Bonferroni corrected P = 0.005) and an 18% increased risk of undergoing a CS (OR 1.18, 95% CI 1.01-1.39, P = 0.01, Bonferroni corrected P = 0.03) compared to a spontaneous vaginal delivery. There was a statistical significant correlation between maternal and offspring heteroplasmy levels. Spearman correlation rho = 0.96, 95% CI 0.78-0.99, P = 0.0002. CONCLUSION: Women with mitochondrial disease appear to have more frequent obstetric complications including miscarriage and GDM. Pre-pregnancy diagnosis of m.3243A>G will enable the counseling of women and increase awareness of possible obstetric complications.

International Spinal Cord Injury Urinary Tract Infection Basic Data Set.

OBJECTIVES: To develop an International Spinal Cord Injury (SCI) Urinary Tract Infection (UTI) Basic Data Set presenting a standardized format for the collection and reporting of a minimal amount of information on UTIs in daily practice or research. SETTING: International working group. METHODS: The draft of the Data Set developed by a working group was reviewed by the Executive Committee of the International SCI Standards and Data Sets, and later by the International Spinal Cord Society (ISCoS) Scientific Committee and the American Spinal Injury Association (ASIA) Board. Relevant and interested scientific and professional (international) organizations and societies (∼40) were also invited to review the data set, and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, Executive Committee and ASIA Board received the data set for final review and approval. RESULTS: The International SCI UTI Basic Data Set includes the following variables: date of data collection, length of time of sign(s)/symptom(s), results of urine dipstick test for nitrite and leukocyte esterase, urine culture results and resistance pattern. The complete instructions for data collection and the data form itself are freely available on the website of ISCoS (http://www.iscos.org.uk).

A review of contemporary modalities for identifying abnormal fetal growth.

Detecting aberrant fetal growth has long been an important goal of modern obstetrics. Failure to diagnose abnormal fetal growth results in perinatal morbidity or mortality. However, the erroneous diagnosis of abnormal growth may lead to increased maternal anxiety and unnecessary obstetric interventions. We review the aetiology of deviant fetal growth and its implications both for the neonatal period and later in adult life. We examine maternal factors that may influence fetal growth such as obesity, glycaemic control and body composition. We discuss novel ways to improve our detection of abnormal fetal growth with a view to optimising antenatal care and clinical outcomes. These include using customised centiles or individualised growth assessment methods to improve accuracy. The role of fetal subcutaneous measurements as a surrogate marker of the nutritional status of the baby is also discussed. Finally, we investigate the role of Doppler measurements in identifying growth-restricted babies.

International variation in caesarean section rates and maternal obesity.

This study examined variations in caesarean section (CS) rates associated with a woman's birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12). Of the 2,811 women enrolled, 2,235 women were born in Ireland, 100 in EU 14 countries and 476 in EU 12 countries. Based on a BMI > 29.9 kg/m(2), maternal obesity was higher in Irish (19.8%; n = 443) and EU 14 women (19.0%; n = 19) compared with EU 12 women (9.5%; n = 45), p < 0.001. BIA of maternal body composition confirmed increased adiposity in both the Irish and EU 14 women. Variations in emergency CS rates in primigravidas based on the woman's birthplace were associated with maternal adiposity and induction of labour, both modifiable risk factors for CS. We recommend, therefore, that induction of labour in obese primigravidas should be undertaken only in carefully considered clinical circumstances. Our findings also suggest economic development in Europe may drive an increase in the CS rates mediated through increased levels of maternal obesity and, therefore, public health interventions should focus on optimising a woman's prepregnancy weight.

Maternal obesity and gestational weight gain.

The aim of the study was to analyse gestational weight gain (GWG) according to body mass index (BMI) category and to explore the relationship between GWG and pregnancy complications. Women were recruited in the 1st trimester. Weight and height were measured and BMI calculated. Weight was measured at 38 weeks' gestation and GWG calculated. Clinical details were obtained prospectively. Of the 604 women recruited, 45.5% were primigravidas and 25.2% were obese. The overall mean GWG was 11.6 kg (SD 6.0). In obese women, the mean GWG was 10.4 kg (SD 7.5) compared with 12.6 kg (SD 5.7) in the normal BMI category (p < 0.001). Maternal obesity but not increased GWG was associated with an increased risk of induction of labour, caesarean section and pre-eclampsia. It was concluded that obese women were more likely to exceed GWG recommendations, despite lower GWG than non-obese women. Maternal obesity and not GWG increased the risk of pregnancy complications.

The impact of new national guidelines on screening for gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) has important maternal and fetal implications. In 2010, the Health Service Executive published guidelines on GDM. We examined the impact of the new guidelines in a large maternity unit. In January 2011, the hospital replaced the 100 g Oral Glucose Tolerance Test (OGTT) with the new 75 g OGTT. We compared the first 6 months of 2011 with the first 6 months of 2010. The new guidelines were associated with a 22% increase in women screened from 1375 in 2010 to 1679 in 2011 (p < 0.001). Of the women screened, the number diagnosed with GDM increased from 10.1% (n=139) to 13.2% (n=221) (p<0.001).The combination of increased screening and a more sensitive OGTT resulted in the number of women diagnosed with GDM increasing 59% from 139 to 221 (p = 0.02).This large increase has important resource implications but, if clinical outcomes are improved, there should be a decrease in long-term costs.

Antenatal rubella immunity in Ireland.

The objective of the study was to identify those women attending for antenatal care who would have benefited from prepregnancy rubella vaccination. It was a population-based observational study of women who delivered a baby weighing < or = 500 g in 2009 in the Republic of Ireland. The woman's age, parity, nationality and rubella immunity status were analysed using data collected by the National Perinatal Reporting System. Of the 74,810 women delivered, the rubella status was known in 96.7% (n = 72,333). Of these, 6.4% (n = 4,665) women were not immune. Rubella seronegativity was 8.0% (n = 2425) in primiparous women compared with 5.2% (n = 2239) in multiparous women (p < 0.001), 14.7% (n = 10653) in women < 25 years old compared with 5.0% (n = 3083) in women < or = 25 years old (p < 0.001), and 11.4% (n = 780) in women born outside the 27 European Union (EU27) countries compared with 5.9% (n = 3886) in women born inside the EU27 countries (p < 0.001). Based on our findings we recommend that to prevent Congenital Rubella Syndrome, the health services in Ireland should focus on women who are young, nulliparous and born outside the EU.

Longitudinal study of aortic isthmus Doppler in appropriately grown and small-for-gestational-age fetuses with normal and abnormal umbilical artery Doppler.

OBJECTIVE: To establish reference ranges using longitudinal data for aortic isthmus (AoI) Doppler indices in appropriate-for-gestational-age (AGA) fetuses and to document the longitudinal trends in a cohort of small-for-gestational-age (SGA) fetuses with normal umbilical artery Doppler and in fetuses with intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler. METHODS: AoI Doppler reference ranges were established from longitudinal data on 72 AGA singleton fetuses. Reliability of AoI Doppler flow measurements at two different sites and reproducibility between two operators was reviewed. A prospective longitudinal study of AoI Doppler indices in 48 SGA fetuses with normal umbilical artery Doppler and 10 IUGR fetuses was performed. RESULTS: The AoI pulsatility index (PI) and peak systolic velocity (PSV) in AGA fetuses showed a significant increase with gestational age. Analysis of intra- and interoperator variability revealed no significant mean difference in measurements of AoI-PI or AoI-PSV. Observations of AoI-PI and AoI-PSV from SGA fetuses did not differ significantly from those of AGA or IUGR fetuses. Retrograde flow in the AoI did not predate changes in the ductus venosus in IUGR fetuses. CONCLUSIONS: Reference ranges for fetal AoI Doppler parameters in AGA fetuses constructed using longitudinal data are consistent with those obtained from cross-sectional data. The AoI Doppler parameters in SGA fetuses did not differ from those in AGA fetuses. Preterm IUGR fetuses did not manifest alterations in AoI-PI or AoI-PSV prior to changes in biophysical profile or ductus venosus Doppler. Further large-scale prospective studies are needed to determine whether AoI Doppler parameters are of any value in timing delivery or reducing adverse neurodevelopmental outcome.

Thromboprophylaxis for women undergoing caesarean section.

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.

Fetal hydronephrosis: optimal renal pelvic measurement to increase detection rate for renal pathology.

We reviewed the outcome of fetal hydronephrosis with a renal pelvic dilatation (RPD) of 4-7 mm to assess whether a RPD > 7 mm had a higher predictive value for renal pathology. 373 fetuses were diagnosed with hydronephrosis giving an incidence of 2.2%. The male: female ratio was 1.8:1. 5(1.34%) fetuses with antenatal hydronephrosis were diagnosed with Down Syndrome. 299 (91.7% fetuses with an RPD of 4-7 mm had resolved by 34 weeks gestation with 10 (3.1%) having moderate to severe hydronephrosis. The resolution rate for RPD > 7 mm was 60.7% (17) with 11 fetuses (39.3%) requiring long term follow up.

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.

Peripartum hysterectomy in the first decade of the 21st century.

We reviewed the role of peripartum hysterectomy (PH) in the first decade of the 21st century. The study was confined to women who delivered a baby weighing 500 g or more between 2000 and 2009, and who required a hysterectomy within 72 h of delivery for obstetric reasons. Individual case records were reviewed. There were 19 cases of PH in 78,961 deliveries giving an incidence of 1 in 4,156 (0.02%). Of the 19 cases, 95% were delivered by caesarean section and 89% had one or more prior sections. The indications were placental bed pathology (79%), uterine atony (16%) and uterine trauma (5%). Of the 19 hysterectomies, 16 (84%) were total and a gynaecological oncologist was involved in nine (56%) of these cases. There were no maternal or fetal deaths, but a mother required an average blood transfusion of 10 units. The overall rate of PH was remarkably low compared with other studies but it is likely to increase in the future because of the strong association between increasing caesarean section rates and placental bed pathology. The potential involvement of the cervix and other pelvic structures by placental pathology means that PH in the future will be more challenging, and the hysterectomy will need to be total rather than subtotal.

Effects of body mass index on sleep patterns during pregnancy.

The purpose of this study was to profile sleep patterns during pregnancy according to body mass index (BMI) and to correlate labour outcomes with both BMI and hours sleep. Data were collected from 200 postpartum women detailing sleep characteristics before and during pregnancy. A validated sleep questionnaire was employed, which comprised of questions about sleep apnoea, snoring, subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction. Descriptive analyses were used. With advancing gestation, the mean (SD) number of hours sleep per night declined: pre-pregnancy 8.1 (SD 1.4); 1st trimester 8.3 (SD 1.8); 2nd trimester 7.7 (SD 1.7) and 3rd trimester 6.7 (SD 2.2). In the 18.5-24.9 BMI group, there was a marked difference in hours sleep per night from pre-pregnancy to 1st (8.6 h, p = 0.007), 2nd (7.9 h, p = 0.023) and 3rd (6.4 h, p = 0.000) trimesters in primiparous women. In the 25-29.9 BMI group, there was a difference from pre-pregnancy to 3rd trimester (p = 0.000). These changes were not reflected in a clinically significant difference in birth weight or mode of delivery.