Walsh C.A.,National Maternity Hospital |
McAuliffe F.M.,University College Dublin
Ultrasound in Obstetrics and Gynecology | Year: 2012
ABSTRACT Objectives Selective fetoscopic laser photocoagulation (SFLP) is now the treatment of choice for twin-twin transfusion syndrome (TTTS). The incidence of recurrent TTTS following SFLP has been inconsistently reported across different studies.We performed a systematic review of TTTS recurrence following SFLP. Methods PubMed and MEDLINE online databases were searched for articles published between 2000 and August 2011, using combinations of the terms .twin-twin transfusion', .TTTS', .laser', .recur' and .outcome'. Citations identified in the primary search were screened for eligibility. Studies reporting outcomes from selective SFLP for TTTS in twin pregnancies, which addressed specifically the issue of TTTS recurrence, were included. The primary outcome was rate of TTTS recurrence. Secondary outcomes were therapeutic preference and fetal outcomes in cases of recurrent TTTS. Results The primary search identified 22 eligible studies that are included in this review (n=2447 twin pregnancies). Two studies included a minority of non-selective procedures. The published incidence of recurrent TTTS ranged from 0 to 16%. Clinical management was reported in 65.7% (71/108) cases, with repeat SFLP the most commonly performed secondary intervention. Only three studies provided comprehensive outcome data for cases of recurrent TTTS. The overall rate of neurologically-intact survival was 44% (23/52). The data were inadequate to determine the effects of secondary therapeutic approach, placental location or gestational age on perinatal outcome in cases of recurrent TTTS. Conclusions The published rate of TTTS recurrence following SFLP in monochorionic twin pregnancies ranges from 0 to 16%. Although limited follow-up data suggest that recurrence is associated with significant perinatalmortality and morbidity, further study is needed. Currently, there are insufficient data available to guide recommendations for clinical management of TTTS recurrence. Future studies on SFLP for TTTS must include details on recurrence rates and provide outcome data specific to the recurrent subset. Copyright ©2012 ISUOG. Published by John Wiley & Sons, Ltd.
Higgins M.,University College Dublin |
McAuliffe F.M.,University College Dublin |
Mooney E.E.,National Maternity Hospital
Pediatric and Developmental Pathology | Year: 2011
Delayed villous maturation (DVM) is a spectrum of placental disease characterized by decreased tertiary villus formation, reduced vasculosyncytial membrane formation, and, in its more severe forms, increased large bullous villi. In some series it has been associated with an increased risk of stillbirth in the late third trimester, but overall there are few data on its significance. The aim of this study was to assess perinatal factors associated with, and the clinical significance of, the finding of DVM on placental histology. This was a retrospective study investigating all pregnancies with DVM diagnosed on placental histology in a tertiary level unit between December 2001 and August 2006. Over a 6-year period, 2915 placentas were triaged for histopathological assessment, representing 6.1% of all 48 054 deliveries in this time period. One hundred ninety (6.3%) of these selected cases showed DVM. Fifteen placentas from infants with less than 34 completed weeks of gestation were excluded, leaving 175 for further analysis. When compared with controls matched for gestation and delivering within the same time period (n = 175), DVM was significantly associated with pregestational diabetes (8% vs 2.8%, P < .05; relative risk 2.8 [95% confidence interval 1.03-7.6]), gestational diabetes (8.6% vs 3.4%, P < 0.05; relative risk 2.5 [95% confidence interval 0.99-6.3]), and prenatal or intrapartum intrauterine death (8.6% vs 0%, P < 0.05). Delayed villous maturation is associated with both gestational and pregestational diabetes mellitus and with perinatal death. © 2011 Society for Pediatric Pathology.
Power R.F.,National Maternity Hospital |
Murphy J.F.,National Maternity Hospital
Archives of Disease in Childhood | Year: 2015
Aims: Currently there is debate on how best to manage young infants with tongue-tie who have breastfeeding problems. One of the challenges is the subjectivity of the outcome variables used to assess efficacy of tongue-tie division. This structured review documents how the argument has evolved. It proposes how best to assess, inform and manage mothers and their babies who present with tongue-tie related breastfeeding problems. Methods: Databases were searched for relevant papers including Pubmed, Medline, and the Cochrane Library. Professionals in the field were personally contacted regarding the provision of additional data. Inclusion criteria were: infants less than 3 months old with tongue-tie and/or feeding problems. The exclusion criteria were infants with oral anomalies and neuromuscular disorders. Results: There is wide variation in prevalence rates reported in different series, from 0.02 to 10.7%. The most comprehensive clinical assessment is the Hazelbaker Assessment Tool for lingual frenulum function. The most recently published systematic review of the effect of tongue-tie release on breastfeeding concludes that there were a limited number of studies with quality evidence. There have been 316 infants enrolled in frenotomy RCTs across five studies. No major complications from surgical division were reported. The complications of frenotomy may be minimised with a check list before embarking on the procedure. Conclusions: Good assessment and selection are important because 50% of breastfeeding babies with ankyloglossia will not encounter any problems. We recommend 2 to 3 weeks as reasonable timing for intervention. Frenotomy appears to improve breastfeeding in infants with tongue-tie, but the placebo effect is difficult to quantify. Complications are rare, but it is important that it is carried out by a trained professional. © 2015, BMJ Publishing Group. All rights reserved.
Robson M.,National Maternity Hospital |
Hartigan L.,National Maternity Hospital |
Murphy M.,National Maternity Hospital
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2013
Caesarean section rates continue to increase worldwide. The appropriate caesarean section rate remains a topic of debate among women and professionals. Evidence-based medicine has not provided an answer and depends on interpretation of the literature. Overall caesarean section rates are unhelpful, and caesarean section rates should not be judged in isolation from other outcomes and epidemiological characteristics. Better understanding of caesarean section rates, their consequences and their benefits will improve care, and enable learning between delivery units nationally and internationally. To achieve and maintain an appropriate caesarean section rate requires a Multidisciplinary Quality Assurance Programme in each delivery unit, recognising caesarean section rates as one of many factors that determine quality. Women will always choose the type of delivery that seems safest to them and their babies. Professionals need to monitor the quality of their practice continuously in a standardised way to ensure that women can make the right choice. © 2012 Elsevier Ltd. All rights reserved.
Flannelly G.,National Maternity Hospital
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2010
The management of women with abnormal cytology in pregnancy represents both a diagnostic and a therapeutic challenge for colposcopists. The emphasis should be on diagnosis and confirmation of cervical precancer (Cervical intraepithelial neoplasia (CIN) or Adenocarcinoma in situ (AIS), thus excluding invasive cancer). Following an initial assessment, careful follow-up is essential. This must include colposcopy and take into account the physiological changes of the cervix during pregnancy and the puerperium. The management of women with invasive cancer diagnosed during pregnancy depends on the gestation at diagnosis and requires careful assessment and multidisciplinary planning. © 2009 Elsevier Ltd. All rights reserved.
Robson M.S.,National Maternity Hospital
Obstetrics and Gynecology | Year: 2011
Objective: To examine the contribution of singleton, cephalic, term (37 weeks or later) nulliparous cesarean rates to overall cesarean incidence in a single institution during a 35-year period. Methods: Cesarean rates were examined for 1974, 1984, 1994, 1999, 2005, and 2008, applying a 10-group classification system. Groups 1 (spontaneously laboring, term nulliparous women) and 2 (prelabor cesarean and induced term nulliparous women) were combined as a composite variable-the term, singleton, cephalic nulliparous woman. Results: Overall and term, singleton, cephalic nulliparous cesarean rates correlated throughout the 35-year period (r=0.93, P<.001). Between 1974 and 2008, overall cesarean rates increased from 5% to 19.1% and from 4.4% to 15.8% among term, singleton, cephalic nulliparous women. Term, singleton, cephalic nulliparous inductions increased from 19.7% to 32.7% (P<.001) and the intrapartum cesarean rate in term, singleton, cephalic nulliparous inductions rose from 4.1% to 27.3%. The cesarean rate in group 1 increased from 2.3% to 7.2%. Conclusion: The increase in term, singleton, cephalic nulliparous cesarean rates correlated with the increase in overall cesarean rates throughout 35 years in an institution with standard management of labor. This relationship was due to an increase in both the incidence and rate of cesarean delivery within term, singleton, cephalic nulliparous inductions. Examination of the different term, singleton, cephalic nullipara components (spontaneous labor, induction, or prelabor cesarean) can help to identify major variations in practice between institutions. © 2011 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.
Lindsay K.L.,University College Dublin |
Kennelly M.,University College Dublin |
Culliton M.,National Maternity Hospital |
Smith T.,Park University |
And 4 more authors.
American Journal of Clinical Nutrition | Year: 2014
Background: Recent studies have reported beneficial effects of probiotics on maternal glycemia in healthy pregnant women. Obesity significantly increases risk of impaired glucose tolerance in pregnancy, but glycemic effects of probiotics in this specific obstetric group require additional investigation. Objective: The aim of the Probiotics in Pregnancy Study was to investigate the effect of a probiotic capsule on maternal fasting glucose in obese pregnant women. Design: In this placebo-controlled, double-blind, randomized trial, 175 pregnant women with an early pregnancy body mass index (BMI; in kg/m 2) from 30.0 to 39.9 were recruited from antenatal clinics at the National Maternity Hospital, Dublin, Ireland. Exclusion criteria were BMI <30.0 or >39.9, prepregnancy or gestational diabetes, age ,18 y, multiple pregnancy, and fetal anomaly. Women were randomly assigned to receive either a daily probiotic or a placebo capsule from 24 to 28 wk of gestation in addition to routine antenatal care. The primary outcome was the change in fasting glucose between groups from preintervention to postintervention. Secondary outcomes were the incidence of gestational diabetes and neonatal anthropometric measures. Results: In 138 women who completed the study (63 women in the probiotic group; 75 women in the placebo group), mean (6SD) early pregnancy BMI was 33.6±2.6, which differed significantly between probiotic (32.9±2.4) and placebo (34.1±2.7) groups. With adjustment for BMI, the change in maternal fasting glucose did not differ significantly between treated and control groups [20.09±0.27 compared with 20.07±0.39 mmol/L; P = 0.391; B = 20.05 (95% CI: 20.17, 0.07)]. There were also no differences in the incidence of impaired glycemia (16% in the probiotic group compared with 15% in the placebo group; P = 0.561), birth weight (3.70 kg in the probiotic group compared with 3.68 kg in the placebo group; P = 0.723), or other metabolic variables or pregnancy outcomes. A secondary analysis of 110 women, excluding antibiotic users and poor compliers, also revealed no differences in maternal glucose or other outcomes between groups. Conclusion: Probiotic treatment of 4 wk during pregnancy did not influence maternal fasting glucose, the metabolic profile, or pregnancy outcomes in obese women. This trial was registered at Current Controlled Trials as ISRCTN97241163 (part A). © 2014 American Society for Nutrition.
Wingfield M.,National Maternity Hospital |
Cottell E.,National Maternity Hospital
Human Reproduction | Year: 2010
This paper concerns the requirements of the EU Tissue and Cells Directives with regard to the biological screening of donors of reproductive cells which are to be used for partner donation. Methods We review the evidence regarding the risks of transmission of blood-borne viruses [hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV)] in the assisted reproductive technology (ART) setting. We document the experience in seven Irish ART clinics since the introduction of the legislation. Results Even among those known to be HBV-, HCV- or HIV-positive, when current best practice ART procedures are employed for gamete and embryo processing, cross-contamination in the ART facility or horizontal or vertical transmission to a partner or neonate has never been documented. When samples are processed and high-security straws are used for cryopreservation, transmission of virus and cross-contamination in storage have not been reported. Conclusions While initial screening of those about to embark on ART treatment is good practice, we can find no medical or scientific evidence to support re-screening prior to each treatment cycle for individuals undergoing partner donation in ART. It would seem more appropriate to focus on risk reduction using a combination of initial baseline screening (with a reduced frequency of re-testing), appropriate sample processing and best possible containment systems for cryostorage. © The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
Foley M.E.,National Maternity Hospital
Irish medical journal | Year: 2013
The improved survival for bulky cervical cancers (> 4cm) reported with combination platinum based chemoradiation (1999) prompted a move away from surgery as these cases frequently received adjuvant radiotherapy and were exposed to the morbidity of multimodality treatment. The period pre-1999 (Group 1) was compared with post-1999 (Group 2) when chemoradiation was the preferred treatment for bulky operable cervical cancer. Significantly more cases were treated surgically among Group 1 compared with Group 2 (79% vs. 62%; P < 0.001). Switching from surgery to radiotherapy improved survival in both treatment categories (73% vs. 78% and 37% vs. 44%, respectively) but with no improvement in overall survival (70%/ov.s 70%). Survival (86%) was similar in both groups among surgically treated women with tumors < 4 cm, but significantly more in Group 2 with negative nodes received postoperative adjuvant chemoradiotherapy (Groups 1 vs. 2; 16% vs.37.5%: P < 0.001) and overall the surgically treated patients received more not less multimodality treatment (46.5% vs. 59%; P = 0.7).
Barrett M.J.,National Maternity Hospital
Archives of disease in childhood. Fetal and neonatal edition | Year: 2013
We discuss possible aetiological factors, MRI evolution of injury and neuro-developmental outcomes of neonatal encephalopathy (NE). Thirty-six consecutive infants diagnosed with NE were included. In this cohort, four infants (11%) were identified with injury predominantly in the deep white matter on MRI who were significantly of younger gestation, lower birthweight with higher Apgars at one and five minutes compared to controls. Placental high grade villitis of unknown aetiology (VUA) was identified in all four of these infants. Our hypothesis states VUA may induce white matter injury by causing a local inflammatory response and/or oxidative stress during the perinatal period. We underline the importance of continued close and systematic evaluation of all cases of NE, including examination of the placenta, in order to come to a better understanding of the clinical presentation, the patterns of brain injury and the underlying pathophysiological processes.