A Prospective Evaluation of Point-of-Care Measurements of Maternal Glucose for the Diagnosis of Gestational Diabetes Mellitus.

BACKGROUND: Point-of-care (POC) measurement of glucose is currently recommended only for the monitoring of gestational diabetes mellitus (GDM). This prospective observational study evaluated the use of POC measurements of maternal glucose to diagnose GDM in women being screened selectively with a 1-step 75 g oral glucose tolerance test (OGTT). METHODS: The strictest preanalytic and analytic international laboratory standards were applied to measure maternal plasma glucose at fasting and at 1 and 2 h post glucose load. The recent International Association of Diabetes and Pregnancy Study Groups diagnostic criteria were used. At the same time, maternal capillary glucose was measured. Because of differences in plasma and capillary glucose measurements, regression analysis of POC capillary glucose results vs laboratory plasma glucose results was conducted. The regression equations for plasma glucose were derived in a derivation cohort (n = 102). These equations were applied in the validation cohort (n = 100). Predicted and actual plasma glucose values were compared. RESULTS: Of the 202 women screened, 36.6% were nulliparous, 56.4% were obese, and 81.2% were Irish-born. Two thirds had a single risk factor for GDM, and a third had multiple risk factors. Based on the plasma measurements, 53.5% had GDM. As a predictor of GDM, the diagnostic accuracy of POC measurement was 83.0% (95% confidence interval, 74.2-89.8). CONCLUSIONS: In high-resource settings where measures to inhibit glycolysis are implemented, the use of POC measurements for the diagnosis of GDM is not justified based on this study. In low- and medium-resource settings, where measures to inhibit glycolysis are not achievable, regression analysis using POC measurements may be acceptable compared with plasma samples subject to glycolysis.

Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study.

BACKGROUND: Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately. METHODS: This study analysed data collected as part of the clinical records by midwives at the woman's first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally. RESULTS: Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit. CONCLUSIONS: This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.

The interaction between maternal smoking, illicit drug use and alcohol consumption associated with neonatal outcomes.

BACKGROUND: The adverse effects of smoking on neonatal outcomes, such as small-for-gestational-age (SGA), has been extensively studied however, the consequences of smoking combined with alcohol and/or drug use is less clear. METHODS: This retrospective observational study analyzed clinical and sociodemographic details of 40156 women who delivered a singleton baby between the years 2011 and 2015. RESULTS: Compared with women who had never smoked, smokers who did not engage in alcohol or drug use had an odds ratio (OR) of delivering a baby who was SGA of 3.2 (95% CI: 3.1-3.5). Smokers who used illicit drugs in isolation or in combination with alcohol during pregnancy had higher ORs for SGA (1.4, 95% CI: 1.1-1.7, P = 0.006 and 1.8, 95% CI: 1.2-2.7, P = 0.007) compared to women who smoked but did not engage in alcohol or drug use in pregnancy. These women also delivered babies with lower mean birthweights (125 g, P < 0.001 and 181.4 g, P = 0.003) and head circumferences (0.4 cm, P < 0.001 and 0.3 cm, P = 0.048). Women who smoked and used alcohol, but not illicit drugs were not associated adverse outcomes above that of smoking in isolation. CONCLUSION: Illicit drug use combined with maternal smoking during pregnancy increases the risk of adverse neonatal outcomes above that of smoking in isolation.

A cross-sectional study of maternal-fetal attachment and perceived stress at the first antenatal visit.

BACKGROUND: Maternal-fetal attachment (MFA) psychologically is well described. Suboptimal attachment may have negative consequences particularly if it is associated with unhealthy maternal behaviour that may potentially increase the risk of adverse pregnancy outcomes. The perception of stress or anxiety is also associated with potential adverse outcomes including preterm birth. OBJECTIVE: This cross-sectional study examined MFA and perceived stress at the time of the first ultrasound examination in early pregnancy. METHODS: Convenience sampling was used to recruit women after they presented to the Ultrasound Department for a routine dating ultrasound at their first antenatal visit. Informed consent was obtained and clinical and sociodemographic details were recorded. Women were invited to complete validated Cranley MFA and Perceived Stress Scale (PSS) questionnaires. RESULTS: Of the 90 women recruited, 80 completed the questionnaires successfully. No association was found between the MFA score and maternal age, parity, education, marital status, previous pregnancy loss or smoking behaviour. An unplanned pregnancy was associated with a lower mean MFA score (p < 0.01) and a higher mean PSS score (p < 0.005). These relationships persisted in a multiple regression analysis controlling for maternal age and parity. CONCLUSION: In early pregnancy, an unplanned pregnancy is associated with a lower MFA and higher PSS score. Additional research is required to assess if this persists as pregnancy advances. ABBREVIATIONS: Maternal-Fetal Attachment (MFA), Maternal-Fetal Attachment Scale (MFAS), Perceived stress scale (PSS), Maternal Antenatal Attachment Scale (MAAS), Standard Deviation (SD), Central Statistics Office (CSO), Body Mass Index (BMI), Relative Risk (RR).

Feasibility of recruitment to a behavioural smoking cessation intervention combined with ongoing online support.

The aim of this randomized controlled trial was to determine whether a behavioural intervention in pregnancy supported by online information would improve smoking cessation rates. However, due to a number of challenges, recruitment to this trial was reluctantly halted. We aimed to recruit 220 maternal smokers within 2 years and after screening 1995 women, just 22 enrolled over a 8-month period. Only three women accessed the online element of the intervention and, at follow up, no women reported quitting. We report our findings as they may inform the design and powering of future smoking cessation interventions in pregnancy.

The relationship between unplanned pregnancy and maternal body mass index 2009-2012.

OBJECTIVE: To analyse the relationship between unplanned pregnancy and maternal Body Mass Index (BMI). METHODS: A prospective case-control study of planned vs. unplanned pregnancies among women who delivered an infant weighing ≥ 500 g during the four years 2009-2012 in a large maternity hospital in Ireland. Maternal weight and height were measured at the first antenatal visit before calculation of BMI. Clinical and sociodemographic details were computerised. BMI was categorised according to the World Health Organization. The epidemiological associations were examined using logistic regression, adjusted for confounding variables. RESULTS: Between 2009 and 2012, 34,377 women were included, 31.7% (n = 10,894) reported an unplanned pregnancy and 16.6% (n = 5647) were obese. The odds ratios of unplanned pregnancy were greater among obese women compared with those of normal BMI (unadjusted Odds Ratio (OR) 1.3; 95% Confidence Interval (CI) 1.3-1.4 p < 0.001). These ratios increased with increasing BMI (mild unadjusted OR 1.3; CI 1.2-1.4 p < 0.001; moderate unadjusted OR 1.4; CI 1.2-1.6 p < 0.001; severe obesity unadjusted OR 1.7; CI 1.4-2.0 p < 0.001). The higher rate of unplanned pregnancy among obese women was associated with a lower rate of contraception usage and a higher rate of contraceptive failure. Only 37.6% (n = 2112) of obese women took preconceptional folic acid to prevent neural tube defects compared with 46.1% (n = 8176) of women with a normal BMI (p < 0.001). CONCLUSION: Higher rates of unplanned pregnancy among obese women compared with women with a normal BMI is associated with compromised prepregnancy care in this high-risk population.

Comparison of ultrasound with biomarkers to identify large-for-gestational age in women screened for gestational diabetes mellitus.

OBJECTIVE: Large-for-gestational-age (LGA) is associated with both fetal and maternal complications. One of the few modifiable risk factors for LGA is Gestational Diabetes Mellitus (GDM); for this reason, fetal growth is usually monitored by ultrasound in the third trimester. This prospective study compared a panel of ten established biomarkers measured at the time of selective screening for GDM at 26-28 weeks gestation with the ultrasound prediction of LGA. METHOD: Women were recruited using convenience sampling and consented at the first antenatal visit. Women with maternal risk factors for GDM attended for the one-step 75 g oral glucose tolerance test. An additional blood sample was taken for biomarker measurement. GDM was diagnosed according to the 2013 World Health Organization (WHO) criteria. Fetal biometry, including the abdominal circumference (AC) and the fetal abdominal subcutaneous tissue (FAST) thickness, were measured at 37 weeks gestation. RESULTS: Of the 195 women included, 105 (53.8%) had GDM. Of the 195 babies, 36 (18.5%) were LGA. Whether the woman had GDM or not, fetal biometry was strongly predictive of LGA but none of the following biomarkers measured at 26-28 weeks gestation alone or in combination were predictive: c-peptide, ghrelin, gastric inhibitory polypeptide, glucagon-like peptide-1 (GLP-1), glucagon, insulin, leptin, plasminogen activator inhibitor-1, resistin and visfatin. CONCLUSIONS: In women diagnosed with GDM, surveillance of fetal growth to identify LGA by ultrasound should continue in the third trimester. None of the ten established maternal biomarkers measured at the time of the OGTT was as strongly predictive of LGA as ultrasound.

Trends in private maternity care in Ireland's capital during and after the Great Economic Recession 2009-2017.

BACKGROUND: Maternity care in hospitals in the Republic of Ireland is funded by a hybrid of public finance and private health insurance. AIMS: The aim of this longitudinal observational study was to investigate the annual trends in maternity care from 2009 to 2017 during and after the Great Economic Recession. METHODS: All women who delivered a singleton baby weighing ≥ 500 g during the 9 years (2009-2017) were included. Detailed clinical and sociodemographic details were computerised at the first antenatal visit by a trained midwife. Women who delivered their first baby during the study were analysed longitudinally if they delivered again during the 9 years. RESULTS: The mean age of the 73,266 women was 31.3 ± 5.6 years, 40.1% were nulliparas, and 70.3% were Irish-born. Overall, 75.2% opted for the public, 10.8% for the semi-private, and 14.0% for the private package of maternity care. Over the 9 years, the number of women choosing private and semi-private care decreased by 21.6% and 35.3%, respectively, whereas the number of women using public care increased by 12.3%. Most women opted for the same package of care in subsequent pregnancies. CONCLUSIONS: Ireland's recent economic recession was accompanied by an overall decrease in the number of women choosing private maternity care after 2009. Furthermore, economic recovery with increasing female employment after 2012 was not associated with a recovery in demand for private care. These findings have important implications for healthcare policies and for the future organisation and funding of our maternity services.

Reducing Caesarean Section Surgical Site Infection (SSI) by 50%: A Collaborative Approach.

OBJECTIVE: Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center. METHODS: Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change. RESULTS: Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity. CONCLUSIONS: The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

Does maternal obesity explain trends in caesarean section rates? Evidence from a large Irish maternity hospital.

BACKGROUND: A feature of contemporary obstetrics in wealthy countries has been both the continuing increase in caesarean section (CS) rates and the emergence of high levels of maternal obesity. AIMS: The purpose of this study was to examine whether the increasing CS rate in a large university maternity hospital was attributable in part to maternal obesity. METHODS: We studied all women who delivered a baby weighing ≥ 500 g from 2009 to 2014 in one of the largest maternity hospitals in Europe. Logistic regression techniques were employed to examine the contribution of trends in maternal BMI on the prevalence of CS. RESULTS: Obese women were more likely to be delivered by CS in 2014 than in 2009. Multivariate analysis shows that the increase in CS rates could not be explained by changes in obesity levels in either nulliparas or multiparas. The increase in CS rates during the 6 years was strongly associated with advancing maternal age, particularly for nulliparas. CONCLUSIONS: The study found that although the prevalence of being overweight or obese changed little over the period, the odds of having a CS if a woman is obese have increased for multiparas. For nulliparas, increasing CS rates were found to be strongly associated with an increase in maternal age over the period which is important because of the evidence that Irish women are choosing to defer having their first baby until later in life.

Childbirth in Ireland's capital city over sixty years.

BACKGROUND: Ireland has changed over the past sixty years, and the dynamic practice of obstetrics and gynaecology has changed with it. STUDY DESIGN AND METHODS: To describe these changes, a review was performed of clinical reports of a tertiary referral teaching hospital over six decades. RESULTS: Since the 1960s, the hospital's total births per annum has risen (3050 to 8362 births). Teenage pregnancy is less common (4.7 to 2.0%, p < 0.001), with more women over age 40 at booking (2.6 to 6.4%, p < 0.001). There are more multiple pregnancies now (1.8 to 4.1%, p < 0.001) and less grand-multiparous woman (10.1 to 1.3%, p < 0.001). Eclampsia is less common (0.18 to 0.02%, p = 0.003), with a slight decrease in rate of preeclampsia (3.8 to 3.0%, p = 0.03). Induction of labour increased considerably (8.8 to 32.1%, p < 0.001). While the instrumental delivery rate remained stable, the instrument of choice has changed from forceps (11.3 to 5.4%, p = 0.001) to ventouse delivery (0.6 to 9.1%, p = 0.001). The caesarean section rate rose (5.9 to 29.7%, p < 0.001). Vaginal birth after caesarean section rate dropped (90.4 to 28.2%, p < 0.001) without significant change in rate of uterine rupture (0.4 to 0.7%, p = 0.1). The perinatal mortality rate improved (48.5 to 5.4 per 1000 births, p < 0.001). Preterm birth rate rose (4.9 to 6.6%, p = 0.001). Foetal macrosomia decreased in this time (2.5 to 1.7%, p = 0.007), despite a rise in the incidence of gestational diabetes mellitus. CONCLUSION: This study provides an intriguing glimpse into the changes in the practice of obstetrics and demonstrates how it adapts to the population it serves.

Maternal employment and pregnancy outcomes in a large European maternity hospital.

OBJECTIVE: Epidemiological studies have previously reported that maternal socioeconomic disadvantage is associated with adverse feto-maternal outcomes. However, little attention has been paid to the question of the woman's employment status. The aim of this observational study was to examine the relationship between maternal employment status at the first antenatal visit and pregnancy outcomes. STUDY DESIGN: The study was confined to women with a singleton pregnancy who attended for maternity care between the years 2010 and 2017 and delivered a baby weighing ≥500 g. Self-reported sociodemographic and clinical details were recorded at the first antenatal visit by a trained midwife and updated before hospital discharge. The hospital is one of the largest in Europe and accepts women from all socioeconomic groups, including women in the public system and those with private health insurance, across the rural-urban spectrum. RESULTS: Of the 62,395 women, the mean age was 31.5 years (SD 5.4), 39.3% were nulliparas and 70.7% were Irish born. Compared with the 45,028 (72.2%) women who reported as being in paid employment, the 4984 (8.0%) women who were unemployed had a higher rate of stillbirth (8/4984 vs. 27/45,028, p = 0.005) and homemakers had a higher incidence of neonatal death (31/12,383 vs. 73/45,028, p = 0.02). On multivariable analysis, women who were unemployed or homemakers had increased adjusted odds ratios for neonatal unit (NNU) admissions, preterm birth, low birth weight, and small-for-gestational-age. Compared to women in paid employment, women who were unemployed or homemakers were associated with younger age (<30 years) in pregnancy, multiparity, unplanned pregnancy, no or postconceptional only folic acid supplementation, anxiolytic/antidepressant use, as well as persistent smoking and illicit drug use during pregnancy. CONCLUSIONS: In a high-income European country, women who reported as unemployed or homemakers were associated with higher rates of adverse pregnancy outcomes. Furthermore, these women were associated with suboptimal lifestyle behaviours such as smoking and illicit drug use in early pregnancy. This highlights the need for long term public policies on female unemployment and retaining women with children in employment.

The use of biomarkers at the end of the second trimester to predict Gestational Diabetes Mellitus.

OBJECTIVE: Previous studies that investigated the relationship between biomarkers and gestational diabetes mellitus (GDM) generally focused on individual biomarkers with significant heterogeneity in terms of the screening methodologies, diagnostic criteria for GDM and sample handling of glucose within these studies. This prospective study used an established panel of ten biomarkers to determine if they could predict the diagnosis of GDM. STUDY DESIGN: Women with risk factors for GDM were recruited at their first antenatal visit. They attended for an oral glucose tolerance test at 26-28 weeks' gestation with strict preanalytical handling of glucose samples to minimise glycolysis. A fasting plasma sample taken simultaneously was stored at -80 °C and analysed in bulk for 10 biomarkers (insulin, c-peptide, glucagon, ghrelin, gastric inhibitory polypeptide (GIP), glucagon like peptide-1 (GLP-1), leptin, visfatin, resistin and plasminogen activator inhibitor-1 (PAI-1)) using the Bio-plex-pro Human Diabetes Assay. RESULTS: Insulin and C-peptide levels in the third tertile were associated with the development of GDM (adjusted odds ratio (aOR) 2.6, 95 % CI 1.3-5.0, p = 0.005 and aOR 3.7, 95 % CI 1.8-7.4, p < 0.001 respectively, adjusted for maternal obesity). Elevated levels of ghrelin were associated with a lower odds of developing GDM, after adjustment for maternal obesity. However, approximately half of the women with GDM who were in the obesity category did not have insulin or c-peptide levels in the third tertile. CONCLUSIONS: While three of the ten biomarkers were statistically associated with an increased risk of GDM, the large overlap in values between those with normal and abnormal glucose tolerance meant that the biomarkers (alone or in combination) were not useful clinically.

Longitudinal Study of Maternal BMI in Successive Pregnancies.

OBJECTIVE: This longitudinal observational study examined BMI changes between successive pregnancies. METHODS: The computerized medical records of women who attended a large maternity hospital between 2009 and 2017 for their first and second singleton deliveries were analyzed. Women who had their weight first measured after 15 weeks of gestation in either pregnancy were excluded. RESULTS: Of the 9,724 women, the incidence of obesity increased from 11.6% in the first pregnancy to 16.0% in the second. The mean interpregnancy interval was 32.5 ± 15.7 months, and median BMI change was +0.6 kg/m2 (interquartile range 2.2; P < 0.001). Overall, 10.3% (1,006/9,724) developed overweight and 5.9% (571/9,724) developed obesity by the second pregnancy. Of the nulliparas in the overweight category, 20.6% (526/2,558) entered the obesity category. The development of obesity by the second pregnancy was independently associated with a longer interpregnancy interval, formula feeding at hospital discharge, taking antidepressants or anxiolytics, and postnatal depression. Professional/managerial employment was associated with a lower odds ratio of developing obesity. CONCLUSIONS: Maternal obesity increased between the first and second pregnancy, with one-fifth of nulliparas in the overweight category developing obesity. Pregnancy-related factors were identified as predictors of developing obesity. Further research is needed to assess whether interventions targeting these related factors could optimize maternal weight management between pregnancies.

Maternal obesity and dyslipidemia associated with gestational diabetes mellitus (GDM).

OBJECTIVE: The association between gestational diabetes mellitus (GDM) and maternal dyslipidemia is well established, however, the role of obesity in this relationship is not well defined. We examined the relationship between maternal obesity at the first prenatal visit and fasting lipids measured at the time of the oral glucose tolerance test (OGTT) in women screened selectively for GDM. STUDY DESIGN: This prospective observational study was conducted in a large university maternity hospital. Women were recruited at the first prenatal visit following measurement of their weight and height. Clinical and sociodemographic details were recorded. Women with maternal risk factors for GDM were screened selectively with a one-step 75 g OGTT at 26-28 weeks gestation. GDM was diagnosed based on the World Health Organization (WHO) 2013 criteria. Fasting lipids were measured simultaneously. Maternal lipid levels and their relationship with GDM and obesity were analysed with linear and logistic models. RESULTS: Of the 275 women recruited at the first antenatal visit 202 attended for their OGTT at 26-28 weeks' and 53.5 % (108) had GDM based on the WHO criteria. The women with GDM were more likely to have obesity (70.4 % vs. 42.6 %, P < 0.001). Compared with women with a normal OGTT (n=94), women with GDM had higher triglycerides (P=0.023) and a lower HDL-Cholesterol (P = 0.013). However, when the cohort with GDM were stratified according to obesity, this trend was only seen in the women who had a BMI >29.9kg/m2. Based on tertiles, women with GDM had a higher odds ratio of increased triglycerides (odds ratio 3.2 (95 % confidence interval; 1.4-6.9), P = 0.004) and lower HDL-Cholesterol (odds ratio 2.2, (95 % confidence interval; 1.1-4.7), P = 0.036) and an increased TG:HDL-cholesterol ratio (odds ratio 2.3, (95 % confidence interval; 1.1-4.9), P = 0.026), only if they had obesity. CONCLUSION: Our findings suggest that the epidemiological association between GDM and dyslipidemia is mediated through maternal obesity. Women with obesity alone or GDM alone did not have an elevated OR for dyslipidemia. Interventions designed to optimise maternal lipids should prioritise women with obesity and it may be preferable for these interventions to start prior to conception.

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.

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.

Fetal growth and maternal alcohol consumption during early pregnancy.

OBJECTIVE: The relationship between light maternal alcohol consumption and fetal outcome remains contentious and the professional advice women receive is conflicting. The aim of this large epidemiological study was to examine the relationship between fetal growth and maternal alcohol behaviour before and during early pregnancy. STUDY DESIGN: Clinical and sociodemographic details of women who delivered a baby weighing ≥500 g during the eight years 2010-18 were analysed. Details on lifestyle behaviour before pregnancy and at the time of the first antenatal hospital visit were computerised using a standardised questionnaire. RESULTS: Of 68,925 women, 33.6% abstained from alcohol consumption before pregnancy and 98.4% reported they were abstaining at their first antenatal visit. Only 1.2% reported light consumption (1-2 units/week, median 1.0 IQR 1.0), 0.4% reported moderate/heavy consumption (>3 units/week, median 4.0 IQR 4.0) and 0.3% reported binge drinking (>5 units in one sitting, median 3.0 IQR 4.0). Women who consumed alcohol in binges were more likely to be <30years whereas women who consumed alcohol weekly were more likely to be ≥30years. Women who who consumed any alcohol during early pregnancy were more likely to be multiparous, Irish-born, to have an unplanned pregnancy, to be unemployed, on medications for depression or anxiety, current smokers and abusing illicit drugs. In the absence of persistent smoking or illicit drug abuse, there was no relationship between light alcohol consumption during early pregnancy and the subsequent mean birth weight, preterm delivery (%), small-for-gestational age (%) and mean neonatal head circumference. CONCLUSION(S): Women who consume alcohol should continue to be advised of the fetal and maternal risks of heavy consumption and, if applicable, of the need to quit smoking and avoid illicit drugs. However, women who have consumed alcohol before realising that they were pregnant or who consumed alcohol in light amounts during early pregnancy, may be reassured that their alcohol consumption did not impact adversely on their baby's growth.

Maternal obesity trends in a large Irish university hospital.

OBJECTIVE(S): This study aimed to examine recent trends in maternal obesity. STUDY DESIGN: This retrospective observational study used routinely computerised clinical and sociodemographic data of women who presented for antenatal care in a large maternity hospital in Ireland during the eight years 2010-17. Women with complete body mass index (BMI) data who delivered a baby weighing ≥500 g were included in the study. BMI was based on the measurement of weight and height and was categorised into the World Health Organizations (WHO) classifications. RESULTS: The number of women delivered was 67,949 and 99.1% had complete data. The overall obesity rate increased from 16.0% (95% CI 15.3-16.8%) in 2010 to 18.9% (95% CI 18.0-19.7%) in 2017 (+18.1%, p < 0.001). This increase occurred in the mild, moderate and severe obesity subcategories (all p < 0.01). Overall, obesity was associated with multiparity, maternal age, maternal birth in Ireland or the United Kingdom (UK), depression, unemployment and unplanned pregnancy. The increase in obesity was more pronounced in nulliparas than in multiparas, particularly nulliparas <30 years. The increased obesity levels were accompanied by major sociodemographic changes in the hospital population from 2010 to 2017 with an increase in the average maternal age from 30.5 years to 32.2 years (p < 0.001) and a decrease in the proportion of nulliparas aged <30 years (from 40.6% to 28.8%, p < 0.001). CONCLUSION(S): It is likely that the escalating maternal obesity levels will lead to further increases in obstetric complications and interventions. The escalation was accompanied by major sociodemographic changes which have implications for healthcare planning and public health interventions.

Development of a novel bedside index for the early identification of severe maternal infection.

OBJECTIVES: International consensus reports have recently recommended that the Systemic Inflammatory Response Syndrome (SIRS) criteria for the diagnosis of sepsis should cease and that new bedside criteria need to be developed to improve prevention, early diagnosis and treatment. The aim of this retrospective audit was to evaluate a suite of four bedside clinical criteria, called the Early Maternal Infection Prompts (EMIP), in helping to identify women with a suspected severe infection who were admitted to a High Dependency Unit (HDU) in a large tertiary referral stand-alone maternity hospital. STUDY DESIGN: The four EMIP criteria were decided based on existing national obstetric guidelines and a review of the recent literature on maternal critical illnesses. Cases were identified from the HDU registry for the three years 2015-2017. Individual charts were retrieved, and the four EMIP parameters were measured at the time of the clinical assessment that led to the HDU admission. Clinical and sociodemographic details were computerised for analysis. RESULTS: Of 73 women admitted with suspected severe maternal infection, the handwritten records were available in 69. The mean age was 31.3 years, 71% were multiparous and 26.1% were obese. Three quarters of cases were antenatal admissions. Infection was confirmed microbiologically in 56 (81.1%) of cases. There were no maternal deaths. There was no case of organ dysfunction diagnosed but two women required vasopressors to maintain blood pressure. Recordings of the maternal vital signs were not always fully completed before admission. In 69.1% (n = 47) of cases the temperature was elevated ≥ 37.5 C, in 81.2% (n = 56) of cases the heart rate was increased ≥ 100 bpm, in 51.9% (n = 27) cases the respiratory rate was increased ≥ 20 bpm, and in 25.4% (n = 17) cases the systolic blood pressure was ≤100 mmHg. At least one of the four EMIP criteria was abnormal in 91.3% (n = 63) of cases of suspected severe infection. CONCLUSIONS: The audit confirmed that this bedside index has potential in helping to identify maternal infection early before sepsis develops. Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infection.

The implications of high carbon monoxide levels in early pregnancy for neonatal outcomes.

OBJECTIVES: The aim of this study was to examine the implications of increased maternal Breath Carbon Monoxide (BCO) levels at the first antenatal visit for subsequent birthweight (BW) and neonatal outcomes. STUDY DESIGN: Secondary analysis of a prospective, observational study. Pregnant women aged ≥18years who understood English were recruited (n=250). However, only women who delivered a normally formed baby weighing ≥500g were analysed (n=234). At the first antenatal visit, a research questionnaire was completed and a BCO test was performed. Obstetric and neonatal data computerised by midwives at the first antenatal visit and updated after delivery were also analysed. RESULTS: Results from the receiver operating characteristic (ROC) curve indicated the highest combined sensitivity and specificity for smoking was observed at a BCO cut-off level of 3ppm (sensitivity 85%, specificity 90%). Of the 234 women, 53 (22.6%) had a BCO ≥3ppm but only 36 (15.4%) disclosed smoking to the midwife on routine questioning. A further 23 (9.8%) were classified as non-disclosers based on a research questionnaire and/or a BCO measurement ≥3ppm. No relationship was found between the self-reported number of cigarettes daily in early pregnancy and BW (r=0.05, p=0.78). However, an inverse relationship was found between maternal BCO levels and BW (r=-0.31, p<0.001). BCO levels ≥3ppm in early pregnancy were associated with an increased risk of emergency caesarean section, low birth weight, BW <25th centile, fetal distress and having two or more adverse pregnancy events (all p<0.05). Smoking non-disclosers had babies with decreased BWs (-400.1g, 95% CI 141.1-659.0g, p<0.001), and higher rates of BW <25th centile (56.5% versus 25.3%, p<0.001), small-for-gestational-age (21.7% versus 9.1%, p<0.001) and fetal distress (39.1% versus 16.0%, p<0.01) compared to non-smokers Non-disclosers at the first antenatal visit also had a 22% higher rate of having two or more adverse pregnancy events (p<0.05). CONCLUSION: The results showed that an increased BCO level was associated with a lower BW and increased risk of adverse pregnancy and neonatal outcomes. This strengthens the case for universal BCO screening at the first antenatal visit. A high BCO reading should be an indication for referral to stop smoking services referral and close fetal surveillance.