Audit of Ireland's first manual vacuum aspiration service

INTRODUCTION

Manual vacuum aspiration (MVA) is a safe and effective alternative option for the management of first-trimester miscarriage, termination of pregnancy, or retained pregnancy tissue. Ireland's first MVA clinic was set up in the Rotunda Hospital in April 2020.

OBJECTIVE

To identify the number of women who have undergone MVA since establishing our service, to assess the efficacy and safety of MVA in that service, and to develop local Irish studies that further support the safety of MVA, adding to the international body of evidence.

METHODS

With the approval and assistance of the Clinical Audit Committee, we obtained a log of all patients who underwent MVA in the first 18 months of the service. We performed a retrospective electronic chart review using Maternal and Newborn Clinical Management System. We collected the data and preformed a descriptive analysis.

RESULTS

In total, 86 women underwent MVA, 85 (98.8%) of which were successfully completed. There were no immediate procedural complications, inter-hospital transfers, or emergency electric vacuum aspiration (EVA) required. We obtained an incomplete evacuation rate of 4.7% (n = 4).

CONCLUSION

We have demonstrated that the MVA service in the Rotunda Hospital is a safe, effective management option with advantages for both the patient and the healthcare system. We recommend consideration for provision of funding and resources to enable expansion of this service nationally in order to give women greater autonomy of choice in the management of early pregnancy complications and termination of pregnancy.

Womens experience of Manual Vacuum Aspiration: An Irish perspective

OBJECTIVE

Manual Vacuum Aspiration (MVA) is a well-established management option for early pregnancy loss or early termination of pregnancy. MVA is performed as out-patient surgical procedure using local anaesthetic whereby aspiration of uterine contents is achieved through use of a hand-held negative pressure syringe. Ireland's first MVA service was established at the Rotunda Hospital Dublin in April 2020,. The purpose of this study was to gather feedback from women who had undergone MVA in the unit.

STUDY DESIGN

Prospective mixed methods study of women attending for uterine aspiration under local anaesthetic from July to October 2020 in the unit. Consenting women were contacted one week following MVA via telephone. The survey conducted consisted of structured closed questions along with open-ended questions, to assess womens satisfaction in relation to all aspects of the MVA service.

RESULTS

Nineteen women took part in the study, a response rate of 86.4%. Participants reported feeling well informed prior to attending for MVA. Prior to the procedure, pain expectation scores were high but actual reported pain scores were much lower. Although some participants did find MVA uncomfortable, the fact the procedure was very quick and the side effects so minimal generally negated this. The location and set up of the clinic scored highly among participants as did the staff of the clinic. Overall satisfaction with the MVA service was high with 84.2% of participants reporting they would opt again for MVA in the future.

CONCLUSIONS

Women living in Ireland are interested and agreeable with having Manual Vacuum Aspiration as an available option for management of early pregnancy complications. Consideration should be given to expansion of MVA services nationally.

Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes

AIMS

Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement - the anterior abdominal wall measurement (AAW) - to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated.

METHODS

This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks' gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks' gestation were reported for this study.

RESULTS

Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida's. The mean birthweight was 3548 g (+/- 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 38³ weeks (31⁴ - 40² weeks). There were 37 (9%) babies born preterm at <37 weeks' gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks' gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks' gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth.

CONCLUSIONS

Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.

Caesarean Section at Full Dilatation and Risk of Major Obstetric Haemorrhage

The purpose of the study was to examine the risk factors for caesarean section (CS) at full dilatation and to assess the risk and management of haemorrhage. The study took place in a tertiary referral maternity hospital. Women who had a CS at full dilatation were included. Clinical and demographic details were recorded. There were 199 cases. The average age was 30.3 years and average BMI was 25.8kg/m2. There were 79.9 % (159) primigravidas and 20.1% (40) multigravidas. The average gestation at delivery was 39.4 weeks. Labour was induced in 46.9 % (92) and spontaneous in 53.8% (107). Oxytocin was used in 67.8 % (135). An instrumental delivery was attempted in 46.7 % (93). The rate of malposition was 46.5 % (92). The average birthweight was 3,629g and 9 babies weighed ?4.5kg. The average estimated blood loss (EBL) was 665mls and 34 had EBL>1L. Most had an oxytocin infusion (141). Other uterotonic agents were used in 70 women. Seven women had blood transfusions. The highest rate of CS at full dilatation was in primigravidas due to malposition. There was a low rate of major obstetric haemorrhage.

Maternal obesity and gestational weight gain

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

Antenatal rubella immunity in Ireland

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

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

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

Thromboprophylaxis for women undergoing caesarean section

Thromboprophylaxis for women undergoing caesarean section (CS) was introduced in the hospital in 1995. This study audited the use of tinzaparin prophylaxis in a nested cohort of women who screened negative for diabetes mellitus at 28 weeks gestation. All the women had their weight measured and BMI calculated at the first antenatal visit. Of the 284 women, 68 (24%) had a CS and all received tinzaparin. Of the 68, however, 94% received a dose lower than recommended. Compliance with prophylaxis was complete but compliance with the recommended dosage was suboptimal, which may result in venous thromboembolism after CS despite thromboprophylaxis.

Body mass index and hypertensive disorders of pregnancy

OBJECTIVES

We compared the incidence of the hypertensive disorders of pregnancy in obese women with women of a normal body mass index (BMI).

STUDY DESIGN

Prospective observational study in which BMI was calculated accurately early in pregnancy. Women were enrolled after a sonographic confirmation of an ongoing pregnancy. To reduce confounding variables the study was confined to white European women with a singleton pregnancy.

MAIN OUTCOME MEASURES

Incidence of pre-eclampsia and gestational hypertension.

RESULTS

In 2230 women, 16.8% were obese. Pre-eclampsia was diagnosed in 3.3% (n=74) and gestational hypertension in 3.0% (n=67). Both pre-eclampsia (p=0.01) and gestational hypertension (p<0.01) were common in obese women compared with normal weight women. Overall 13.1% of obese women developed a hypertensive disorder during pregnancy. When analysed by parity pre-eclampsia occurred in 2.1% of primigravidas and 0.3% of multigravidas. Pre-eclampsia was increased in obese multigravidas (p=0.001), but not obese primigravidas, suggesting that parity is more influential than obesity in the development of pre-eclampsia.

CONCLUSIONS

Obese multigravidas are more likely to develop hypertensive disorders in pregnancy and obese primigravidas are more likely to develop gestational hypertension. This is important in clinical practice because maternal weight, unlike parity, is potentially modifiable before or during pregnancy.

Maternal obesity and inpatient medication usage

What is already known about this subject •  Maternal obesity is associated with an increased use of healthcare resources including medication costs in an outpatient setting. What this study adds •  This study shows an increase in inpatient medication usage associated with maternal obesity. This is the case in the antenatal period but not in the peripartum period.

SUMMARY

Maternal obesity is associated with increased medical and obstetric complications. We compared the inpatient antenatal and peripartum medication usage in obese women to that in women in the normal body mass index (BMI) category. White European women with a singleton pregnancy were enrolled after a glucose tolerance test excluded diabetes mellitus at 28 weeks gestation. Weight and height were measured in the first trimester and BMI calculated. Records of medications administered were collated from patient drug charts. Of the 284 women studied, there were 97, 85 and 102 women in the normal, overweight and obese categories, respectively. Delivery details across the weight categories did not vary significantly and Caesarean section rates were 22.7, 22.4 and 26.5%, respectively. The length of hospital stay postpartum for each category was similar. The administration of antenatal medication showed a trend towards increasing usage with increasing BMI category with increases in analgesic and antibiotic use. There was no difference in peripartum medication usage. The study showed that maternal obesity was associated with an increased inpatient usage of medication in the antenatal period. This has implications for healthcare costs particularly if the prevalence of maternal obesity continues to increase.

Maternity services for obese women in Ireland

Nearly one in five women booking for antenatal care in Ireland is obese. The purpose of this survey was to audit the services and facilities for obese pregnant women in the country's maternity units. In June 2010, a detailed questionnaire was sent to all 20 units which included questions on services, equipment and facilities for obese women. All 20 units responded: 17 (85%) were calculating and recording Body Mass Index in pregnancy. Only 15 (75%) were screening obese women for gestational diabetes mellitus and 2 (10%) were omitting thromboprophylaxis for caesarean section in obese women. Only 3 (15%) had clinical guidelines for obesity and pregnancy. The facilities and equipment, particularly for severely obese women, were inadequate in the majority of units. This survey showed variations nationally in obstetric practices and facilities. It highlights the need to develop, disseminate and implement standardised guidelines on maternal obesity.

What models of maternity care do pregnant women in Ireland want?

The introduction of new models of care in the Irish maternity services has been recommended by both advocacy groups and strategic reports. Yet there is a dearth of information about what models of care pregnant women want. We surveyed women in early pregnancy who were attending a large Dublin maternity hospital. Demographic and clinical details were recorded from the hospital chart. Of the 501 women, 351 (70%) (352 (70.3%) of women wanted shared antenatal care between their family doctor and either a hospital doctor or midwife. 228 (45.5%) preferred to have their baby delivered in a doctor-led unit, while 215 (42.9%) preferred a midwifery-led unit. Of those 215 (42.9%), 118 (55%) met criteria for suitability. There was minimal demand (1.6%) for home births. Choice was influenced by whether the woman was attending for private care or not. Safety is the most important factor for women when choosing the type of maternity care they want. Pregnant women want a wide range of choices when it comes to models of maternity care. Their choice is strongly influenced by safety considerations, and will be determined in part by risk assessment.