Bridgette Byrne

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study

Please cite this paper as: Lutomski J, Byrne B, Devane D, Greene R. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03198.x

Obstetric and neonatal outcome of babies weighing more than 4.5 kg: an analysis by parity.

OBJECTIVES To analyse by parity the obstetric and neonatal outcome of babies delivered weighing more than 4.5 kg. METHODS All deliveries resulting in a baby weighing more than 4.5 kg, in the 5 years from 1991 to 1995, were identified using a computerised database. The following variables confined to singleton, cephalic pregnancies were recorded: mode of delivery, duration of labour, incidence of shoulder dystocia and admission to the neonatal centre. Outcome measures in primigravidae and multigravidae were compared using the Epi Info package (WHO, Version 6.0b January 1997). RESULTS There were 32,834 deliveries over the study period and 828 (2.5%) weighed more than 4.5 kg. Birthweight more than 4.5 kg occurred in 1.6% (n=198) of primigravidae and 3.1% (n=630) of multigravidae (P<0.05). Primigravidae had a higher risk of prolonged labour (27.7% vs. 4.9%), operative vaginal delivery (32% vs.9%) and emergency caesarean section (24.2% vs. 5.7%) compared to multigravidae. When delivering a macrosomic baby, primigravidae had a higher incidence of prolonged labour (27% vs. 7.9%), operative vaginal delivery (32% vs.25%) and emergency caesarean section (24.2% vs. 5.7%) compared to normal weight babies. The incidence of shoulder dystocia and elective caesarean section were similar in both primigravidae and multigravidae. CONCLUSIONS Macrosomic infants have an increased incidence of prolonged labour, operative vaginal delivery and emergency caesarean section compared with normal weight babies and these complications are more pronounced in primigravidae compared to multigravidae. Shoulder dystocia occurs with equal frequency in primigravidae and multigravidae. The poor antenatal predictability of macrosomia, the high rate of vaginal delivery and the low incidence of shoulder dystocia would not support the use of elective caesarean section for delivery of the macrosomic infant either in primigravidae or multigravidae.

Severe maternal morbidity for 2004-2005 in the three Dublin maternity hospitals.

OBJECTIVE To assess the prevalence and causes of severe maternal morbidity in Dublin over a two year period from 2004 to 2005. STUDY DESIGN A prospective cohort study from January 2004 to December 2005 was undertaken in the three large maternity hospitals in Dublin, which serve a population of 1.5 million people. All are tertiary referral centres for obstetrics and neonatology and have an annual combined delivery rate of circa 23,000 births. Cases of severe maternal morbidity were identified. A systems based classification was used. The primary cause of maternal morbidity and the number of events experienced per patient was recorded. RESULTS We identified 158 women who fulfilled the definition for severe maternal morbidity, giving a rate of 3.2 per 1000 maternities. There were two maternal deaths during the time period giving mortality to morbidity ratio of 1:79. The commonest cause of severe morbidity was vascular dysfunction related to obstetric haemorrhage. Eclampsia comprised 15.4% of cases. Intensive care or coronary care admission occurred in 12% of cases. CONCLUSION The prevalence of severe maternal morbidity in this population is 3.2/1000 maternities. Obstetric haemorrhage was the main cause of severe maternal morbidity.

Fetal DNA Quantitation in Peripheral Blood Is Not Useful as a Marker of Disease Severity in Women with Preeclampsia

Objective: Trophoblast migration into the maternal circulation is increased in preeclampsia and can trigger the endothelial dysfunction that characterizes the clinical disease. We hypothesised that ‘fetal trafficking’ is increased in women with severe preeclampsia and that the quantity of trafficking is greater in women with more severe disease. Study Design: To test the hypothesis, we used a technique that quantifies a genetic marker specific for the fetomaternal unit, that is, the SRY gene in a pregnant woman carrying a male fetus. Thirty two women with pre‐eclampsia and 32 control women (women without preeclampsia) were recruited. Preeclampsia was defined according to the International Society for the Study of Hypertension in Pregnancy (ISSHP). All subjects with preeclampsia had evidence of the multisystemic nature of the disease. DNA was extracted from maternal peripheral blood and RTQ PCR analysis was performed to quantify the fetal DNA (SRY) and the total DNA (β‐actin) in each sample. The ratio of fetal to total DNA was calculated and compared between women with preeclampsia and controls. Results: The women with preeclampsia and the control women did not differ in parity, blood pressure at booking, and gestational age at sampling. The groups differed significantly in age (29 ± 5.7 vs 25 ± 5.1 years; P = .007), diastolic blood pressure (DBP) at sampling (101 ± 9.5 vs 70 ± 5.5 mm Hg; P < .0001), gestational age at delivery (33 ± 4.3 vs 39 ± 1.8 weeks; P < .001), and fetal weight (1.98 ± 1 vs 3.35 ± 0.5 kgs; P < .0001). SRY was detected in 31 out of 32 women with preeclampsia and in 24 out of 32 control women (P < .001). The median SRY copy number per µL was greater in women with preeclampsia (10.6, interquartile range 12.89) than in the control women (8.6, interquartile range 20.1) but these differences were not statistically significant at P = .75. The median ratio of fetal to total DNA was almost identical in both groups (0.06, interquartile range 0.13) in PET compared to (0.06, interquartile range 0.17) the control women. No correlation was found between the quantity of fetal DNA and disease severity. Conclusion: Fetal trafficking is more likely to be detected in women with preeclampsia compared to control women but the quantity does not appear to correlate with disease severity.

Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage

OBJECTIVES The aims of this study are to determine the incidence and aetiology of major obstetric haemorrhage (MOH) in our population, to examine the success rates of medical and surgical interventions and to identify risk factors for peripartum hysterectomy and end organ dysfunction (EOD). STUDY DESIGN This prospective study from 2004 to 2007 was carried out in three Dublin maternity hospitals. Women were identified as having MOH if they received ≥5 units of red cell concentrate (RCC) acutely. Risk factors for hysterectomy or end organ dysfunction were calculated using logistic regression. RESULTS One hundred and seventeen cases of MOH in 93,291 deliveries were identified (1.25/1000). The predominant cause was uterine atony. Haemostasis was achieved with medical therapy alone in 15% of cases. The hydrostatic balloon and the B-Lynch suture arrested bleeding in 75% and 40% of cases utilised respectively. Hysterectomy was required to arrest bleeding in 24% of women and 16% of women developed end organ dysfunction (11 had both). There was one maternal death. Independent risk factors for hysterectomy included the number of previous caesarean sections (OR 3.28, 95% CI 1.95-5.5), placenta praevia (OR 13.5, 95% CI 7.7-184), placenta accreta (OR 37.7, 95% CI 7.7-184), uterine rupture (OR 7.25, 95% CI 1.25-42) and the number of units of RCC transfused (OR 1.31, 95% CI 1.13-1.5). Independent risk factors for end organ dysfunction (EOD) were placenta accreta (OR 5, 95% CI 1.5-16.5), uterine rupture (OR 13.86, 95% CI 2.32-82), the number of RCC transfused (OR 1.31, 95% CI 1.13-1.5) and the minimum haematocrit recorded (OR 5.53, 95% CI 1.7-18). CONCLUSIONS MOH is complicated by hysterectomy in 24% and end organ dysfunction in 16% of cases. The risk of peripartum hysterectomy is increased with the number of previous caesarean sections, the aetiology of the bleed, namely placenta praevia/accreta or uterine rupture and the volume of blood transfused. Critically, failure to maintain optimal haematocrit during the acute event was associated with end organ dysfunction.

The clinical management of hyperglycemia in pregnancy complicated by maturity-onset diabetes of the young

OBJECTIVE Women with maturity-onset diabetes of the young (MODY) are often first identified and diagnosed with diabetes during pregnancy. Genetics and hyperglycemia play an important role in determining fetal size in MODY pregnancies. The principal objective of the current study is to determine the outcomes and clinical management of hyperglycemia in pregnancies complicated by glucokinase gene (GCK) and hepatocyte nuclear factor (HNF)-1α MODY mutations. STUDY DESIGN A retrospective chart review of 37 women with a GCK/HNF-1α mutation was conducted. Data on variables such as birthweight, mode of delivery, and the treatment of hyperglycemia were available on 89 pregnancies. RESULTS The birthweight in unaffected GCK offspring was significantly higher than in the affected GCK offspring (4.8 [4.1-5.2] kg vs 3.2 [3.1-3.7] kg; P = .01). Seven-point home blood glucose monitoring over a 7-day period in each trimester demonstrated higher fasting and postprandial glycemic excursions in the first trimester of GCK pregnancies when compared to HNF-1α pregnancies (fasting 104 [90-115] mg/dL vs 84 [77-88] mg/dL; P = .01 and postprandial 154 [135-196] mg/dL vs 111 [100-131] mg/dL; P = .04) despite insulin treatment. There was a higher percentage of miscarriages in the GCK group when compared to the HNF-1α MODY group (33.3% vs 14%; P = .07), which was similar to the background population. Insulin initiated at an early gestation appeared to lower the incidence of macrosomia in GCK unaffected offspring. CONCLUSION Hyperglycemia in HNF-1α pregnancies is easily managed with current insulin protocols; in contrast, glycemic excursions are difficult to manage in GCK pregnancies. There was an increased percentage of miscarriages in GCK pregnancies highlighting the importance of a diagnosis of GCK-MODY in women prior to conception and the necessity for preconception care.

Severe maternal morbidity during childbirth hospitalisation: a comparative analysis between the Republic of Ireland and Australia

OBJECTIVE To determine the population-based rates of severe maternal morbidity during childbirth hospitalisation and associated characteristics in the Republic of Ireland and to directly compare incidence rates with Australia. STUDY DESIGN Retrospective cohort study of 330,955 childbirth hospitalisations between 2005 and 2009. Using validated diagnostic criteria from Australia, we examined hospital discharge records (ICD-10-AM) to identify likely cases of severe maternal morbidity. We derived overall and category-specific morbidity incidence rates and examined five-year trends. Unadjusted relative risks were computed to assess sociodemographic and obstetric factors associated with morbidity status. RESULTS The severe maternal morbidity five-year incidence rate was 1.34 per 100 deliveries. Between 2005 and 2009, the overall rate of severe morbidity significantly increased from 1.31 to 1.55 cases per 100 deliveries (test for trend p-value <0.001). Similar to Australia, the most frequently diagnosed severe morbidity indicators in Ireland were blood transfusion (112.6 per 10,000 deliveries), evacuation of haematoma (7.2 per 10,000 deliveries) and dilation and curettage with general anaesthesia (3.9 per 10,000 deliveries). In the Irish cohort, the risk of severe morbidity was more than three-fold (RR 3.48; 95% CI: 3.06-3.95) among women carrying multiple gestations and more than four-fold (RR 4.37; 95% CI: 3.66-5.22) among women with a stillbirth. Further, severe morbidity risk was 2.62 times higher among women with a pre-existing medical condition (RR 2.62; CI 2.03-3.37). CONCLUSION Our use of low-cost administrative data to identify severe maternal morbidity contributes to a growing body of international initiatives to inform preventive efforts. The ability to directly compare morbidity rates is advantageous, underscoring the need for a uniform definition of severe morbidity to promote accurate and reliable international comparisons.

Retrievable Inferior vena cava filters in pregnancy: Risk versus benefit?

OBJECTIVE Venous thromboembolism remains one of the leading causes of maternal mortality in the developed world. Retrievable inferior vena cava (IVC) filters have a role in the prevention of lethal pulmonary emboli when anticoagulation is contraindicated or has failed [1]. It is unclear whether or not the physiological changes in pregnancy influence efficacy and complications of these devices. The decision to place an IVC filter in pregnancy is complex and there is limited information in terms of benefit and risk to the mother. The objective of this study was to determine the efficacy and safety of these devices in pregnancy and to compare these with rates reported in the general population. STUDY DESIGN The aim of this study was report three recent cases of retrievable IVC filter use in pregnant women in our department and to perform a systematic review of the literature to identify published cases of filters in pregnancy. The efficacy and complication rates of these devices in pregnancy were estimated and compared to rates reported in the general population in a recent review [2]. Fishers exact test was used for statistical analysis. RESULTS In addition to our three cases, 16 publications were identified with retrievable IVC filter use in 40 pregnant women resulting in a total of 43 cases. There was no pulmonary embolus in the pregnant group (0/43) compared to 57/6291 (0.9%) in the general population. Thrombosis of the filter (2.3% vs. 0.9%, p = 0.33) and perforation of the IVC (7.0% vs 4.4%, p = 0.44) were more common in pregnancy compared to the general population but the difference was not statistically significant. Failure to retrieve the filter is more likely to occur in pregnancy (26% vs. 11%, p = 0.006) but this did not correlate with the type of device (p = 0.61), duration of insertion (p = 0.58) or mode of delivery (p = 0.37). CONCLUSION Data for retrievable IVC filters in pregnancy is limited and there may be a publication bias towards complicated cases. This study shows that the filter appears to protect against PE in pregnancy but the numbers are small. Complications such as filter thrombosis and IVC penetration appear to be higher in pregnancy but this difference is not statistically significant. It is not possible to retrieve the device in one out of every four pregnant women. This has implications in terms of long term risk of lower limb thrombosis and post thrombotic syndrome. The decision to use an IVC filter in pregnancy needs careful consideration by a multidisciplinary team. The benefit and risk assessment should be individualised and clearly outlined to the patient.

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study: Correspondence

that the last of these will have had time to make any impact on case ascertainment because it was published at the very end of their 11-year review. Although the authors state that active third-stage management is widely practiced in Ireland and the prophylactic use of syntocinon is common we would be very interested to hear if the authors have any additional data about the pharmacological agents used for the management of the third stage? Recommendations from the National Institute for Health and Clinical Excellence for the active management of the third stage and from the Centre for Maternal and Child Enquiries convey that ‘it is now sensible to reach the conclusion that Syntometrine should be avoided as a routine drug completely’ and oxytocin 10 IU be recommended management. This follows three maternal deaths from hypertensive complications and has led to the virtual replacement of syntometrine with syntocinon over the last 5 years. The Cochrane review Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour clearly showed that ergometrine–oxytocinon is more effective than oxytocinon in reducing blood loss during the delivery of the placenta for blood loss between 500 and 1000 ml but has more side effects, although this difference in efficacy was not noted for more clinically significant PPH >1000 ml. We would like to suggest that this may be making a contribution to the increasing rates of PPH being noted and would be interested to hear if our view is shared by the authors? j

MOde of delivery in women with inherited bleeding disorders

Women with inherited bleeding disorders (IBD) and their infants are at risk of bleeding complications at the time of childbirth. The aim of this study was to report mode of delivery and rates of postpartum haemorrhage (PPH) and intracranial haemorrhage (ICH) in a cohort of women with IBD. Methods 35 women with IBD who attended a specialised obstetric haematology clinic and delivered between January 2009 and June 2011 were identified. Charts were reviewed and patient demographics, mode of onset of labour and delivery, anaesthesia, PPH and ICH in neonates were recorded. Results The following bleeding disorders were identified, 16 Von Willebrands disease, 3 Haemophilia A, 2 Christmas disease, 7 Haemophilia carriers, 1 Factor V, 1 Factor XII deficiency, 2 combined deficiency disorder and 3 had bleeding disorders of unknown aetiology with a positive family history. The mean age was 30.3 years (+/- 7 SD) and the mean gestational age at delivery was 39 weeks (+/- 1 SD). 54 % were primparous. Labour began spontaneously in 16 women, 13 were induced and 6 had an elective caesarean section (CS) for obstetric indications. 13 women had an epidural, six spinal and three received general anaesthesia. 21 women had a spontaneous vaginal delivery, 5 required assisted delivery and 3 and 6 women had emergency and elective CS respectively. The third stage was actively managed and there was no PPH. There was no case of ICH in the neonate. Conclusion Vaginal delivery was achieved safely in 90% of women with IBD in the absence of obstetric indications for elective CS and remains a feasible option in this group of women.