Liverpool Womens Hospital

Liverpool, United Kingdom

Liverpool Womens Hospital

Liverpool, United Kingdom

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Mallaiah S.,Liverpool Womens Hospital | Barclay P.,Liverpool Womens Hospital | Harrod I.,Liverpool Womens Hospital | Chevannes C.,Liverpool Womens Hospital | Bhalla A.,Liverpool Womens Hospital
Anaesthesia | Year: 2015

Summary We compared blood component requirements during major obstetric haemorrhage, following the introduction of fibrinogen concentrate. A prospective study of transfusion requirements and patient outcomes was performed for 12 months to evaluate the major obstetric haemorrhage pathway using shock packs (Shock Pack phase). The study was repeated after the pathway was amended to include fibrinogen concentrate (Fibrinogen phase). The median (IQR [range]) number of blood components given was 8.0 (3.0-14.5 [0-32]) during the Shock Pack phase, and 3.0 (2.0-5.0 [0-26]) during the Fibrinogen phase (p = 0.0004). The median (IQR [range]) quantity of fibrinogen administered was significantly greater in the Shock Pack phase, 3.2 (0-7.1 [0-20.4]) g, than in the Fibrinogen phase, 0 (0-3.0 [0-12.4]) g, p = 0.0005. Four (9.5%) of 42 patients in the Shock Pack phase developed transfusion associated circulatory overload compared with none of 51 patients in the Fibrinogen phase (p = 0.038). Fibrinogen concentrate allows prompt correction of coagulation deficits associated with major obstetric haemorrhage, reducing the requirement for blood component therapy and the attendant risks of complications. © 2014 The Association of Anaesthetists of Great Britain and Ireland.


Tacutu R.,University of Liverpool | Craig T.,University of Liverpool | Budovsky A.,Ben - Gurion University of the Negev | Budovsky A.,Regional Development Centre | And 6 more authors.
Nucleic Acids Research | Year: 2013

The Human Ageing Genomic Resources (HAGR, http://genomics.senescence.info) is a freely available online collection of research databases and tools for the biology and genetics of ageing. HAGR features now several databases with high-quality manually curated data: (i) GenAge, a database of genes associated with ageing in humans and model organisms; (ii) AnAge, an extensive collection of longevity records and complementary traits for >4000 vertebrate species; and (iii) GenDR, a newly incorporated database, containing both gene mutations that interfere with dietary restriction-mediated lifespan extension and consistent gene expression changes induced by dietary restriction. Since its creation about 10 years ago, major efforts have been undertaken to maintain the quality of data in HAGR, while further continuing to develop, improve and extend it. This article briefly describes the content of HAGR and details the major updates since its previous publications, in terms of both structure and content. The completely redesigned interface, more intuitive and more integrative of HAGR resources, is also presented. Altogether, we hope that through its improvements, the current version of HAGR will continue to provide users with the most comprehensive and accessible resources available today in the field of biogerontology. © The Author(s) 2012.


Morgan C.,Liverpool Womens Hospital | McGowan P.,Liverpool Womens Hospital | Herwitker S.,University of Liverpool | Hart A.E.,Lancaster University | And 2 more authors.
Pediatrics | Year: 2014

BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (ΔHC) and HC SD score (ΔSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen. METHODS: Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight <1200 g; gestation <29 weeks) were randomly assigned to either start SCAMP (12% glucose, 3.8 g/kg per day protein/lipid) or remain on the control regimen. HC was measured weekly. Actual daily nutritional intake data were collected for days 1 to 28. RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater ΔHC at 28 days (P < .001). The difference between the means (95% confidence interval) for ΔHC was 5 mm (2 to 8), and ΔSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks' corrected gestational age. CONCLUSIONS: Early postnatal head growth failure in VPIs can be ameliorated by optimizing PN. Copyright © 2014 by the American Academy of Pediatrics.


Tempest N.,Liverpool Womens Hospital | Hart A.,Lancaster University | Walkinshaw S.,Liverpool Womens Hospital | Hapangama D.K.,Liverpool Womens Hospital
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2013

Objective: To compare the outcomes of operative cephalic births by Kielland forceps (KF), rotational ventouse (RV), or primary emergency caesarean section (pEMCS) for malposition in the second stage of labour in modern practise. Design: Retrospective observational study. Population: Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS. Methods: Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS). Main outcome measures: Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage - blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded. Results: Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54-14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition. Conclusions: Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour. © 2013 RCOG.


Sharp A.N.,Liverpool Womens Hospital | Alfirevic Z.,Liverpool Womens Hospital
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2014

Objective: To identify the current status of specialist preterm labour (PTL) clinic provision and management within the UK. Design: Postal survey of clinical practice. Setting: UK Population: All consultant-led obstetric units within the UK. Methods: A questionnaire was sent by post to all 210 NHS consultant-led obstetric units within the UK. Units that had a specialist PTL clinic were asked to complete a further 20 questions defining their protocol for risk stratification and management. Main outcome measures: Current practice in specialist preterm labour clinics. Results: We have identified 23 specialist clinics; the most common indications for attendance were previous PTL (100%), preterm prelabour rupture of membranes (95%), two large loop excisions of the transformation zone (95%) or cone biopsy (95%). There was significant heterogeneity in the indications for and method of primary treatment for short cervix, with cervical cerclage used in 45% of units, progesterone in 18% of units and Arabin cervical pessary in 5%. A further 23% used multiple treatment modalities in combination. Conclusions: A significant heterogeneity in all topics surveyed suggests an urgent need for networking, more evidence-based guidelines and prospective comparative audits to ascertain the real impact of specialist PTL clinics on the reduction in preterm birth and its sequelae. © 2013 Royal College of Obstetricians and Gynaecologists.


McNamara H.,Liverpool Womens Hospital | Barclay P.,Liverpool Womens Hospital | Sharma V.,University of Liverpool
British journal of anaesthesia | Year: 2014

Cardiac output (CO) monitoring is helpful in the assessment of critically ill pregnant women, but invasive monitors are often unsuitable for use. We aimed to measure agreement between the non-invasive ultrasound cardiac output monitor (USCOM) and three-dimensional transthoracic echocardiography (3D-TTE) in pregnant women. Healthy pregnant women from 25 weeks gestation onwards participated. In the left lateral position at rest, CO was measured with the USCOM and 3D-TTE. A single operator performed all USCOM measurements, with a different operator performing all echocardiography. Both were blinded to results from the other device. Each USCOM trace was analysed using two modes: flowtrace (FT) and touchpoint (TP). A second, blinded USCOM reading was taken to assess reproducibility. USCOM readings were obtained in 92, and 3D-TTE images in 85 participants. The mean CO was 5.7, 7.7, and 6.2 litre min(-1) measured by 3D-TTE, USCOM FT, and USCOM TP, respectively. USCOM bias was +2.0 litre min(-1) (FT) and +0.4 litre min(-1) (TP). Limits of agreement were -0.2 to +4.2 litre min(-1) (FT) and -1.4 to +2.3 litre min(-1) (TP). The mean percentage difference was 32.6% (FT) and 31.4% (TP) for CO and 27.0% (FT) and 27.5% (TP) for stroke volume. Intraclass correlation between repeated USCOM readings was 0.9 (FT) and 0.86 (TP). USCOM has acceptable agreement with 3D-TTE for the measurement of CO in pregnancy. The positive bias of the USCOM, particularly in the FT mode, may be due to the hyperdynamic cardiovascular state in pregnancy. We suggest using the TP mode in this patient population. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.


Ibrahim H.,Liverpool Womens Hospital
Cochrane database of systematic reviews (Online) | Year: 2011

Systemic hypotension is a relatively common complication of preterm birth and is associated with periventricular haemorrhage, periventricular white matter injury and adverse neurodevelopmental outcome. Corticosteroid treatment has been used as an alternative or an adjunct to conventional treatment with volume expansion and vasopressor/inotropic therapy. To determine the effectiveness and safety of corticosteroids used either as primary treatment of hypotension or for the treatment of refractory hypotension in preterm infants. Randomized or quasi-randomised controlled trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE (1996 to Jan 2011), EMBASE (1974 to Jan 2011), CINAHL (1981 to 2011), reference lists of published papers and abstracts from the Pediatric Academic Societies and the European Society for Pediatric Research meetings published in Pediatric Research (1995 to 2011). We included all randomised or quasi-randomised controlled trials investigating the effect of corticosteroid therapy in the treatment of hypotension in preterm infants (< 37 weeks gestation) less than 28 days old. Studies using corticosteroids as primary treatment were included as well as studies using corticosteroids in babies with hypotension resistant to inotropes/pressors and volume therapy. We included studies comparing oral/intravenous corticosteroids with placebo, other drugs used for providing cardiovascular support or no therapy in this review. Methodological quality of eligible studies was assessed according to the methods used for minimising selection bias, performance bias, attrition bias and detection bias. Studies that evaluated corticosteroids (1) as primary treatment for hypotension or (2) for refractory hypotension unresponsive to prior use of inotropes/pressors and volume therapy, were analysed using separate comparisons. Data were analysed using the standard methods of the Neonatal Review Group using Rev Man 5.1.2. Treatment effect was analysed using relative risk, risk reduction, number needed to treat for categorical outcomes and weighted mean difference for outcomes measured on a continuous scale, with 95% confidence intervals. Four studies were included in this review enrolling a total of 123 babies. In one study, persistent hypotension was more common in hydrocortisone treated infants as compared to those who received dopamine as primary treatment for hypotension (RR 8.2, 95% CI 0.47 to 142.6; RD 0.19, 95% CI 0.01 to 0.37). In two studies comparing steroid versus placebo, persistent hypotension (defined as a continuing need for inotrope infusion) was less common in steroid treated infants as compared to controls who received placebo for refractory hypotension (RR 0.35, 95% CI 0.19 to 0.65; RD -0.47, 95% CI - 0.68 to - 0.26; NNT = 2.1, 95% CI 1.47, 3.8). There were no statistically significant effects on any other short or long-term outcome. A further two studies that have only been published in abstract form to date, may be eligible for inclusion in a future update of this review. Hydrocortisone may be as effective as dopamine when used as a primary treatment for hypotension. But the long term safety data on the use of hydrocortisone in this manner is unknown.Steroids are effective in treatment of refractory hypotension in preterm infants without an increase in short term adverse consequences. However, long term safety or benefit data is lacking. With long term benefit or safety data lacking steroids cannot be recommended routinely for the treatment of hypotension in preterm infants.


Morgan C.,Liverpool Womens Hospital
Seminars in Fetal and Neonatal Medicine | Year: 2013

Early postnatal growth failure is well described in very preterm infants. It reflects the nutritional deficits in protein and energy intake that accumulate in the first few weeks after birth. This coincides with the period of maximum parenteral nutrition (PN) dependency, so that protein intake is largely determined by intravenous amino acid (AA) administration. The contribution of PN manufacture, supply, formulation, prescribing and administration to the early postnatal nutritional deficit is discussed, focusing on total AA intake. The implications of postnatal deficits in AA and energy intake for growth are reviewed, with particular emphasis on early head/brain growth and long-term neurodevelopmental outcome. The rationale for maximising AA acid intake as soon as possible after birth is explained. This includes the benefits for very early postnatal nutritional intake and metabolic adaptation after birth. These benefits relate to total AA intake and so have to be interpreted with some caution, given the very limited evidence base surrounding the balance of individual AAs in neonatal PN formulations. This work mostly predates current nutritional recommendations and therefore may not provide a true reflection of individual AA utilisation in current clinical practice. © 2013.


Singaravelu S.,Liverpool Womens Hospital | Barclay P.,Liverpool Womens Hospital
British Journal of Anaesthesia | Year: 2013

BackgroundAutomated control of end-tidal inhalation anaesthetic concentration is now possible. The EtControl™ module of an Aisys Carestation Anaesthetic machine digitally adjusts fresh gas flow and plenum vaporizer output to achieve a target end-tidal concentration.MethodsWe evaluated EtControl in clinical practice by measuring volatile agent consumption and the need for user input. We compared these values with contemporaneous controls using manual control of fresh gas flow rates.ResultsA total of 321 patients were anaesthetized with EtControl and 168 with manual control of fresh gas flow. The mean [95% confidence interval (CI)] sevoflurane usage for cases of 20-40 min duration was 14 (13-16) ml h-1 with EtControl and 30 (26-35) ml h-1 with manual control. For cases of the same duration, the mean (95% CI) desflurane consumption was 27 (21-33) ml h-1 with EtControl and 45 (29-62) ml h-1 with manual control. The average number of keypresses per case was 6.5 with EtControl and 13.6 during manual control of fresh gas flow.ConclusionsAutomatic implementation of low-flow anaesthesia using EtControl allows the user to set and maintain a desired end-tidal volatile concentration while using less volatile agent. © 2013 © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.


Ibrahim C.P.H.,Liverpool Womens Hospital | Yoxall C.W.,Liverpool Womens Hospital
European Journal of Pediatrics | Year: 2010

Introduction: Hypothermia at birth is strongly associated with mortality and morbidity in pre-term infants. Background: A local audit showed limited effectiveness of occlusive wrapping in preventing admission hypothermia in very pre-term infants. Self-heating acetate gel mattresses were introduced as a result to prevent hypothermia at birth in infants born at or below 28 weeks gestation. Methods: A retrospective audit was conducted to evaluate the effectiveness of self-heating acetate gel mattresses at resuscitation of infants born at or below 28 weeks to prevent hypothermia at birth. All infants born at or below 28 weeks gestation during 18 months before and 18 months after self-heating acetate gel mattresses were introduced during resuscitation were included. Results: One hundred five babies were born when acetate gel mattresses were not used, and 124 were born during the period when they were. Four (3.3%) babies were hypothermic (temperature <36°C) at admission when the mattresses were used compared to 21 (22.6%) babies who were hypothermic during the period it was not (p∈<∈0.001). Hyperthermia (temperature >37°C) rose from 30.1% prior to use of gel mattresses to 49.6% when they were used (p∈=∈0.004). Conclusions: Self-heating acetate gel mattresses are highly effective in reducing admission hypothermia in infants born at or below 28 weeks gestation. The use of these mattresses is associated with a significant increase in hyperthermia. © 2009 Springer-Verlag.

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