Mode of conception of triplets and high order multiple pregnancies

A retrospective audit was performed of all high order multiple pregnancies (HOMPs) delivered in three maternity hospitals in Dublin between 1999 and 2008. The mode of conception for each pregnancy was established with a view to determining means of reducing their incidence. A total of 101 HOMPs occurred, 93 triplet, 7 quadruplet and 1 quintuplet. Information regarding the mode of conception was available for 78 (81%) pregnancies. Twenty eight (27.7%) were spontaneous, 34 (33.7%) followedlVF/ICSI/FET treatment (in-vitro fertilisation, intracytoplasmic sperm injection, frozen embryo transfer), 16 (15.8%) resulted from Clomiphene Citrate treatment and 6 (6%) followed ovulation induction with gonadotrophins. Triplet and HOMPs are a major cause of maternal, feta land neonatal morbidity. Many are iatrogenic, arising from fertility treatments including Clomiphene. Reducing the numbers of embryos transferred will address IVF/ICSI/FET-related multiple pregnancy rates and this is currently happening in Ireland. Clomiphene and gonadotrophins should only be prescribed when appropriate resources are available to monitor patients adequately.

Unprecedented C-2 arylation of indole with diazonium salts: Syntheses of 2,3-disubstituted indoles and their antimicrobial activity

A novel reaction of indole with aryldiazonium salts leading to the formation of 2-aryl-3-(arylazo)indoles was discovered. The products were found to possess potent anti-MRSA and anti-LLVRE activities. The SAR studies indicate that the potentially metabolically labile azo functionality can be replaced with ether oxygen and thioether sulfur atoms without any loss of activity.

Low birthweight and preterm birth rates 1 year before and after the Irish workplace smoking ban

OBJECTIVE

It is well-established that maternal smoking has adverse birth outcomes (low birthweight, LBW, and preterm births). The comprehensive Irish workplace smoking ban was successfully introduced in March 2004. We examined LBW and preterm birth rates 1 year before and after the workplace smoking ban in Dublin.

DESIGN

A cross-sectional observational study analysing routinely collected data using the Euroking K2 maternity system.

SETTING

Coombe University Maternal Hospital.

POPULATION

Only singleton live births were included for analyses (7593 and 7648, in 2003 and 2005, respectively).

METHODS

Detailed gestational and clinical characteristics were collected and analysed using multivariable logistic regression analyses and subgroup analyses.

MAIN OUTCOME MEASURES

Maternal smoking rates, mean birthweights, and adjusted odds ratios (ORs) of LBW and preterm births in 2005 versus 2003.

RESULTS

There was a 25% decreased risk of preterm births (OR, 0.75; 95% CI, 0.59-0.96), a 43% increased risk of LBW (OR, 1.43; 95% CI, 1.10-1.85), and a 12% fall in maternal smoking rates (from 23.4 to 20.6%) in 2005 relative to 2003. Such patterns were significantly maintained when specific subgroups were also analysed. Mean birthweights decreased in 2005, but were not significant (P=0.99). There was a marginal increase in smoking cessation before pregnancy in 2005 (P=0.047).

CONCLUSIONS

Significant declines in preterm births and in maternal smoking rates after the smoking ban are welcome signs. However, the increased LBW birth risks might reflect a secular trend, as observed in many industrialised nations, and merits further investigations.

Oral misoprostol is rapidly absorbed in postpartum women at term

OBJECTIVE

To determine the rate of bioavailability of oral misoprostol in the tablet and a new capsule form in women with term pregnancies in the postpartum period.

METHODS

Twenty-seven women received 400 microg of misoprostol orally after delivery of the fetal vertex in either the standard tablet form or crushed in methylcellulose capsules prepared in our pharmacy. Serum levels of misoprostol free acid, the principal metabolite, were measured at 5-, 15- and 30-min intervals after administration of the medication. The pharmacokinetics of the tablet and capsule groups were then compared.

RESULTS

Twenty patients were included in the analysis. At 5 min, there was a trend towards a statistically significant difference in the concentration of misoprostol acid in the tablet group (89 pg/ml) versus the capsule group (20 pg/ml) (p = 0.007). No significant difference in plasma concentration was noted in the two groups at 15 min (tablet group, 256 pg/ml; capsule group, 245 pg/ml; p = 0.85) or 30 min (tablet group, 381 pg/ml; capsule group, 455 pg/ml; p = 0.45).

CONCLUSION

Oral misoprostol is rapidly absorbed and bioavailable in the postpartum period. Misoprostol may prove useful in postpartum management. The novel packaging of misoprostol in capsule form allows for double-blinded studies with similar pharmacokinetics to the standard tablet.

Occupational predictors of pregnancy outcomes in Irish working women in the Lifeways cohort

OBJECTIVE

The objective of this study was to explore the association between occupational factors and pregnancy outcomes in a prospective cohort of Irish pregnant women.

DESIGN

This study has a prospective design.

POPULATION

The Lifeways cohort included 1124 pregnant women, 676 of whom delivered a single baby and were working at their first prenatal care visit when they filled in a self-administered questionnaire.

METHODS

Occupational factors were measured using this questionnaire and included eight factors describing job and working conditions. Data including pregnancy outcomes were also obtained from clinical hospital records. Logistic regression analysis was used to adjust for well-known risk factors.

MAIN OUTCOME MEASURES

Birthweight (< or =3000 g and < or =2500 g), preterm delivery (<37 gestation weeks) and small-for-gestational-age.

RESULTS

Significant associations were found between physical work demands and low birthweight (< or =2500 g) and working with between a temporary contract and preterm delivery. Trends were also observed between working 40 hours or more a week and shift work, and birthweight of 3000 g or less. The study of a cumulative index showed that being exposed to at least two of these occupational factors significantly predicted birthweight of < or =3000 g (OR = 2.44, 95% CI: 1.17-5.08) and of < or =2500 g (OR = 4.65, 95% CI: 1.08-20.07) and preterm delivery (OR = 5.18, 95% CI: 1.00-27.01).

CONCLUSIONS

Our findings suggest that occupational factors may predict birthweight through their predictive effects on preterm delivery. This is one of the few prospective studies on pregnancy outcomes that include working conditions. As they may be modifiable, occupational factors deserve more attention in relation to birth outcomes.

National survey of the management of eye emergencies in the accident and emergency departments by senior house officers: 10 years on--has anything changed?

OBJECTIVE

To assess changes in basic ophthalmic training of accident and emergency (A&E) senior house officers (SHOs) in the last 10 years, their own perceived level of confidence and the availability of appropriate equipment in their departments.

METHODS

A standardised structured questionnaire from a telephone survey carried out in 1993 was used. One SHO from each A&E department listed in the British Association of Emergency Medicine directory of 2003 was chosen at random and interviewed.

RESULTS

168 A&E departments were contacted and 133 SHOs were successfully interviewed (response rate 79.2%). The number of A&E departments with a slit lamp increased by 25.7% from 1993, and slit lamp training increased by 21%. There was no significant change in the prevalence of training in the management of eye emergencies (74.0% in 1993 vs 77.4% in 2003) and the proportion of SHOs who felt confident in dealing with these cases was unchanged.

CONCLUSIONS

A&E departments are better equipped with slit lamps 10 years on, and staff are being trained to use them. This has unfortunately not improved the confidence levels in dealing with eye emergencies, reflecting the lack of adequate basic ophthalmic training for A&E SHOs. Recent changes in postgraduate medical training could provide a platform to bring about the changes required.

Near miss maternal morbidity

Audit of severe maternal morbidity is a potent tool in determining standards of maternity care. This study determines the incidence of severe acute maternal morbidity in our population, identifies the underlying organ dysfunction and associated obstetric risk factors, and compares them to published international reports. Over a 5 year period, 1999-2003, data were collected prospectively from patients with severe acute maternal morbidity. There were 36,802 women who delivered infants weighing more than 500 g over the 5 years with 53 cases of severe maternal morbidity. There were two indirect maternal deaths yielding an incidence of 1.4/1000 for severe maternal morbidity and 5.4/100,000 for maternal mortality. The severe maternal morbidity to mortality ratio was 26.5:1. Massive obstetric haemorrhage requiring acute blood transfusion of > or = 5 units of packed red cells occurred in 77% of cases. This study identifies the feasibility of audit of severe maternal morbidity using simple defined clinical criteria. The incidence and underlying aetiology of severe maternal morbidity in our unit is comparable to other developed countries. It is essential that data on severe maternal morbidity are reviewed and analysed continuously at local hospital and national level to assess, maintain and improve clinical standards.

Dietary habits of pregnant women in Ireland

This analysis of the Lifeways Cohort study mothers during pregnancy (n = 1124), utilises information from a standard food frequency questionnaire completed at baseline recruitment during early pregnancy. We demonstrate that 76% of women achieved recommended intakes of 5 plus portions of fruit and vegetables daily, though this is strongly socially patterned, inversely associated with age and positively associated with level of education. Achievement of the other recommended shelf intakes of the Food Pyramid is much lower, ranging from 12% achieving the recommended sparing intake of foods high in fat, salt or sugar, to 45% consuming the recommended 3 portions per day of meat and poultry. General medical services eligible respondents are generally less likely to achieve recommended intakes. While 61% of women under 25 years old stopped drinking during pregnancy, this dropped to 38% of expectant mothers over 35 years. Less than half (45%) of those (n = 860) who responded specifically to the question reported peri-conceptual folate supplement intake, again strongly socially patterned. These findings both provide important prevalence data and highlight the need for more concerted and supportive health promotion interventions during pregnancy.

Self-reported pre-pregnancy maternal body mass index and infant birth-weight

This analysis examines the association between maternal characteristics, particularly body mass index (BMI) and infant birth weight in 1048 live infants. Mean reported pre pregnancy BMI of mothers was 23.74 kg/m2 (SD 4.21). The educational level of the mother's parents was independently associated with maternal BMI, those with higher educated parents having a lower reported BMI (F = 2.787, p = 0.029). Mean infant birth weight was 3493 g (SD 18.1) and there was a strong graduated relationship to estimated gestational age. In a sub-group of participating maternal grandmothers (n = 171), reported BMI was 26.7Kg/m2. The BMI of expectant mothers was significantly associated with their own mother's BMI. (r = 0.179, p = 0.005) in this sub-group. These preliminary findings, which will be investigated further with recorded height and weight information, suggest that familial factors are influential, perhaps through genetic predisposition or shared socio-cultural factors such as diet.

Socio-demographic, lifestyle and cross-generation predictors of self-rated health in mothers during pregnancy

The Lifeways Cross-generation study was established to assess the influence of socio-economic and familial characteristics on the health status and early development of children. Between October 2001 and June 2002, 1124 women were recruited to the Lifeways study at booking or first visit to maternity hospital. Lifeways mothers were 29.4 (SD 5.9) years old at recruitment, two-thirds from greater Dublin area, 17.9% held a General Medical Services (GMS) card, 64.3% were married and 40.8% were third level educated. At uni-variate level, GMS eligibility, own and parents' education and marital status all predicted mother's self rated health during pregnancy, whilst in the final multivariate logistic regression model, GMS status, household-adjusted income, marital status and grand-maternal education were each independently predictors. The Lifeways cohort confirms the importance of social position in predicting health in pregnant Irish women.

Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre

OBJECTIVE

To establish the clinical characteristics, aetiology, neuro-physiological characteristics, imaging findings and other investigations in a cohort of patients with non-traumatic brachial plexopathy (BP).

METHODS

A 3-year retrospective study of patients with non-traumatic BP identified by electromyography (EMG) and nerve conduction studies (NCS). Clinical information was retrieved from patients' medical charts.

RESULTS

Twenty-five patients were identified. Causes of BP included neuralgic amyotrophy (NA) (48%), neoplastic (16%), radiation (8%), post infectious (12%), obstetric (4%), rucksack injury (4%), thoracic outlet syndrome (4%) and iatrogenic (4%). Patients with NA presented acutely in 50%. The onset was subacute in all others. Outcome was better for patients with NA. All patients with neoplastic disease had a previous history of cancer. MRI was abnormal in 3/16 patients (18.8%). PET scanning diagnosed metastatic plexopathy in two cases.

CONCLUSIONS

NA was the most common cause of BP in our cohort and was associated with a more favourable outcome. The authors note potentially discriminating clinical characteristics in our population that aid in the assessment of patients with brachial plexopathies. We advise NCS and EMG be performed in all patients with suspected plexopathy. Imaging studies are useful in selected patients.

A study examining inter- and intrarater reliability of three scales for measuring severity of psoriasis: Psoriasis Area and Severity Index, Physician's Global Assessment and Lattice System Physician's Global Assessment

BACKGROUND

There is a lack of consensus as to the best way of monitoring psoriasis severity in clinical trials. The Psoriasis Area and Severity Index (PASI) is the most frequently used system and the Physician's Global Assessment (PGA) is also often used. However, both instruments have some drawbacks and neither has been fully evaluated in terms of 'validity' and 'reliability' as a psoriasis rating scale. The Lattice System Physician's Global Assessment (LS-PGA) scale has recently been developed to address some disadvantages of the PASI and PGA.

OBJECTIVES

To evaluate the inter-rater and intrarater reliability of the PASI, PGA and LS-PGA.

METHODS

On the day before the study, 14 dermatologists (raters), with varied experience of assessing psoriasis, received detailed training (2.5 h) on use of the scales. On the study day, each rater evaluated 16 adults with chronic plaque psoriasis in the morning and again in the afternoon. Raters were randomly assigned to assess subjects using the scales in a specific sequence, either PGA, LS-PGA, PASI or PGA, PASI, LS-PGA. Each rater used one sequence in the morning and the other in the afternoon. The primary endpoint was the inter-rater and intrarater reliability as determined by intraclass correlation coefficients (ICCs).

RESULTS

All three scales demonstrated 'substantial' (a priori defined as ICC > 80%) intrarater reliability. The inter-rater reliability for each of the PASI and LS-PGA was also 'substantial' and for the PGA was 'moderate' (ICC 75%).

CONCLUSIONS

Each one of the three scales provided reproducible psoriasis severity assessments. In terms of both intrarater and inter-rater reliability values, the three scales can be ranked from highest to lowest as follows: PASI, LS-PGA and PGA.

Significant reduction of endemic MRSA acquisition and infection in cardiothoracic patients by means of an enhanced targeted infection control programme

Due to increasing methicillin-resistant Staphylococcus aureus (MRSA) infection in cardiothoracic patients at St Thomas' Hospital, an enhanced infection control programme was introduced in September 2000. It was based on UK national guidelines on the control of MRSA and targeted additional identified risk factors for surgical site infection (SSI). It included recognition of the problem by senior staff and their taking responsibility for it; intensive support, education and advice from the infection control team; improved ward and theatre hygiene; pre-admission, admission and weekly MRSA screening; isolation and clearance treatment; nursing care pathways for MRSA colonized patients; and teicoplanin plus gentamicin surgical prophylaxis. The effectiveness of the programme was assessed by retrospective analysis of computerized patient data for the 16 months before and after the introduction of the programme. There was no significant change in the number of operations or the proportion of patients admitted with MRSA, although nine patients were cleared of carriage before admission. However, there were significant falls in the proportion of patients acquiring MRSA on the ward [38/1036 to 14/921, P=0.003, RR 2.4 (95%CI 1.32-4.42)] and in the rate of bloodstream MRSA infections [12/1075 to 2/956, P=0.014, RR 5.34 (95%CI 1.20-23.78)]. Sternal and leg wound infections both halved (from 28/1075 to 13/956 and 16/1075 to 7/956, respectively) but this did not reach statistical significance. These results demonstrate that an enhanced, targeted infection control programme based on the UK national guidelines, SSI prevention guidelines and local risk assessment can reduce the incidence of nosocomial MRSA acquisition and invasive infection in cardiothoracic patients in the face of continuing endemic risk.

The international infections in pregnancy study: group B streptococcal colonization in pregnant women

BACKGROUND

Heavy colonization with group B streptococcus (GBS) has been associated with increased risk of preterm birth and neonatal sepsis; the burden of neonatal GBS disease varies geographically. To determine whether variation in heavy colonization and GBS serotypes could contribute to geographic differences in disease burden, we assessed the prevalence of heavy colonization and the distribution of serotypes in asymptomatic pregnant women in multiple countries.

METHODS

Cervical, lower vaginal and urine samples were collected from women attending seven prenatal clinics in six countries. Light colonization was defined as GBS isolation from Lim broth only; heavy colonization was isolation from urine or sheep blood agar plates. Isolates were serotyped using capillary precipitation.

RESULTS

GBS was present in 11.3% of 1308 participants (range 7.1-21.7%); 5.0% were heavily colonized (0.4-18.8%) and 6.4% were lightly colonized (2.9-8.0%). Serotypes III and V were most common (both 17.2%). Serotypes VII and VIII were found in one study center.

CONCLUSIONS

The prevalence of heavy colonization and GBS serotypes varied significantly among our study centers. Whether this variation could in part explain geographic differences in neonatal morbidity and mortality is a hypothesis that needs further study.

Air travel in pregnancy: the 'air-born' study

An increasingly common question posed by patients antenatally is whether air travel can be considered safe in pregnancy. The aim of this study was to assess whether any agreed standards or policies exist between airlines with respect to flying in pregnancy. Sixty-eight international airlines were surveyed, of whom seventeen (25%) replied. Three of seventeen (17.5%) airlines applied no restrictions at all to pregnant passengers; the remainder applied restrictions to air travel with varying gestations (28 to 36 weeks). A full delivery kit was carried by 5/17 airlines (29%), and some form of training in the management of a delivery was provided to the cabin crew in 12/17 airlines (70%). Experience of in-flight obstetric emergencies was reported by 11/17 airlines (65%). This study highlights a lack of consensus regarding restrictions on air travel in pregnancy. The low response rate also suggests an unwillingness on the part of the airline industry to openly declare their policy on this issue.