Colm O’Herlihy

Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury.

OBJECTIVE To determine the influence of parity and method of primary anal sphincter repair on outcome following obstetrical third degree perineal tear. STUDY DESIGN Prospective study of 154 women after primary repair following third degree tear conducted over 2 years. Postpartum evaluation included a continence questionnaire, anal manometry and endoanal ultrasound. RESULTS Third degree tears occurred in 1.6% primiparae and 0.6% multiparae during the study period; in 42/112 (38%) primiparae and 10/42 (24%) multiparae, these tears occurred at instrumental deliveries. Mean birthweight (3.8+/-0. 43 kg) was similar in both groups, but prolonged latent second stage of labour (P=0.003), use of epidural analgesia (P<0.0001) and episiotomy extension (P1 quadrant) anal sphincter defect. CONCLUSION Outcome of anal sphincter repair was not influenced by parity or mode of repair. Despite good symptomatic outcomes, ultrasound evidence of significant anal sphincter injury was found in one-third of patients.

The transcription factor Sox11 is a prognostic factor for improved recurrence-free survival in epithelial ovarian cancer

BACKGROUND Current prognostic molecular markers for epithelial ovarian cancer (EOC) are insufficient. The aim of the current study was to investigate the role of Sox11 in EOC. METHODS Using an in silico transcriptomic screen, Sox11 was identified as a potential EOC biomarker. Sox11 protein expression was evaluated using immunohistochemistry (IHC) in 76 EOC cases, which were analysed using automated algorithms to develop a quantitative scoring model. RESULTS Sox11 mRNA expression was upregulated in EOC compared to normal tissues. Automated analysis of Sox11 in the EOC cohort revealed high expression of Sox11, in 40% of tumours, who had an improved recurrence-free survival (RFS) (p=0.002). Multivariate analysis confirmed that Sox11 was an independent predictor of improved RFS after controlling for stage and grade. CONCLUSIONS These data suggest that Sox11 is a new prognostic marker in EOC. Loss of Sox11 is associated with a decreased RFS and a more aggressive phenotype.

Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear.

PURPOSE: Third-degree tears are generally managed by primary anal sphincter repair. Postoperatively, some physicians recommend laxative use, whereas others favor bowel confinement after anorectal reconstructive surgery. This randomized trial was designed to compare a laxative regimen with a constipating regimen in early postoperative management after primary obstetric anal sphincter repair. METHODS: A total of 105 females were randomized after primary repair of a third-degree tear to receive lactulose (laxative group) or codeine phosphate (constipated group) for three days postoperatively. Patients were reviewed at three days and at three months postpartum. Recorded outcome measures were symptomatic and functional outcome and early postoperative morbidity. RESULTS: Forty-nine patients were randomly assigned to the constipated group and 56 patients to the laxative group. The first postoperative bowel motion occurred at a median of four (mean, 4.5 (range, 1–9)) days in the constipated group and at two (mean, 2.5 (range, 1–7)) days in the laxative group (P < 0.001). Patients in the constipated group had a significantly more painful first evacuation compared with the laxative group (P < 0.001). The mean duration of hospital stay was 3.7 (range, 2–6) days in the constipated group and 3.05 days in the laxative group (range, 2–5; P = 0.001). Nine patients in the constipated group complained of troublesome postoperative constipation compared with three in the laxative group (P = 0.033). Continence scores, anal manometry, and endoanal ultrasound findings were similar in the two groups at three months postpartum. CONCLUSIONS: Patients in the laxative group had a significantly earlier and less painful bowel motion and earlier postnatal discharge. There was no difference in the symptomatic or functional outcome of repair between the two regimens.

Iodine intake in pregnancy in Ireland — A cause for concern?

BackgroundAdequate dietary iodine intake is necessary to maintain maternal thyroid function at a level permitting normal neuropsychological development of the foetus.Aims and MethodsTo determine dietary iodine status by measuring urinary iodine excretion (UIE), proportional to dietary intake, in Irish mothers during the first trimester of pregnancy.ResultsMedian UIE showed seasonal variations, being lower in summer than in winter. The median values in pregnant women were, summer 45μg/l, winter 68μg/l. Equivalent values for controls were 43 and 91μg/l respectively UIE required to achieve WHO recommended daily iodine intakes would be 120–180μg/l. In the Irish subjects UIE values suggestive of iodine deficiency (<50μg/l) were observed in 55% of pregnant women tested in summer and 23% in winter. Dairy milk iodine, a major dietary iodine source, showed similar variation.ConclusionsWhile there is as yet no available evidence of widespread thyroid hypofunction in the Irish obstetric population, the findings are a cause of concern, which if confirmed by a more comprehensive investigation, may indicate the need for iodine prophylaxis.

Experience with an obstetric perineal clinic

OBJECTIVE To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital. METHODS Case-note review of all new referrals over 2 years 1998 and 1999. RESULTS A total of 399 women were referred with mean age of 34 years (range 18-77), parity of 1.7 (range 1-13) and duration of symptoms of 14 (range 1-156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation. CONCLUSIONS The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.

Experimental models of neuropathic fecal incontinence: an animal model of childbirth injury to the pudendal nerve and external anal sphincter.

PurposeChildbirth is the most common cause of fecal incontinence and damage to the pudendal nerve is a major component of childbirth injury. This study was designed to develop an acute animal model of injury to the innervation of the external anal sphincter.MethodsForty-eight female virgin wistar rats were studied. Two models of neuropathic injury were developed. Bilateral inferior rectal nerve crush (Group A) acted as a positive control. Prolonged intrapelvic retrouterine balloon inflation (Group B) simulated the pelvic compressive forces of labor. Quantitative analysis of external anal sphincter muscle function was performed by using electromyography, external anal sphincter specific force production, and stereologic calculation of external anal sphincter mass.ResultsInjury in both groups caused significant atrophy of the external anal sphincter (P = 0.002, ANOVA) and electromyographic evidence of reinnervation at one week. Specific force (mN force per mg mass) was not altered. External anal sphincter muscle mass recovered after four weeks in Group B.ConclusionsBalloon dilation within the boney pelvis results in denervation of the external anal sphincter and offers an experimental model of the effects of childbirth on the continence mechanism in humans.

Real increasing incidence of hysterectomy for placenta accreta following previous caesarean section.

OBJECTIVE Placenta accreta, morbid adherence to the uterus to the myometrium, is commonest in association with placenta previa in women previously delivered by caesarean section (CS). It has become proportionally a greater cause of major maternal morbidity and mortality as the frequency of other serious obstetric complications has declined. The aim of this study was to examine the incidence of placenta accreta in the context of a rising caesarean delivery rate. STUDY DESIGN Retrospective review of the incidence of placenta accreta in parous women during the 36 years 1975-2010. Cases were identified from hospital records and then correlated with pathological reports. The incidence of placenta accreta was analysed in the context of women previously delivered by CS. RESULTS During the 36-year period in our unit, 157,162 multiparous women delivered, of whom 15,151 (9.6%) had a previous CS scar. The institutional incidence of CS rose from 4.1% in 1975 to 20.7% in 2010. Twenty-five parous women, all with a previous CS, had placenta accreta requiring hysterectomy. The overall incidence of placenta accreta was 1.65 per 1000 parous women with a previous CS, but was low (1.06/1000) until 2002. From 2003 to 2010 the incidence rose to 2.37/1000 previous CS deliveries (OR 2.2; 95% CI 1.05-5.1). CONCLUSION The frequency of placenta accreta correlated steadily with the CS rate until 2000. Since then, the incidence has nearly doubled in women with previous CS scars, suggesting an additional causative influence on risk.

Ethnic variation between white European women in labour outcomes in a setting in which the management of labour is standardised—a healthy migrant effect?

Please cite this paper as: Walsh J, Mahony R, Armstrong F, Ryan G, O’Herlihy C, Foley M. Ethnic variation between white European women in labour outcomes in a setting in which the management of labour is standardised—a healthy migrant effect? BJOG 2011;118:713–718.

Does oxytocin augmentation increase perinatal risk in primigravid labor

To assess the influence of high-dose oxytocin augmentation of spontaneous labor, a consecutive series of 30,874 primigravid term deliveries were analyzed for adverse perinatal outcome. In spite of a longer mean duration of labor, the frequencies of asphyxial perinatal death, neonatal seizures, and abnormal neonatal neurologic behavior were not significantly increased in 14,119 (45%) oxytocin-treated patients. There was no case of uterine rupture in any primigravid labor during the study. These results from 13 years of clinical practice provide reassurance about maternal and fetal safety if oxytocin is used as part of a protocol of active management to correct dystocia when spontaneous primigravid labor with vertex presentation fails to progress.

Appropriate antenatal corticosteroid use in women at risk for preterm birth before 34 weeks of gestation

Please cite this paper as: Mahony R, McKeating A, Murphy T, McAuliffe F, O’Herlihy C, Foley M. Appropriate antenatal corticosteroid use in women at risk for preterm birth before 34 weeks of gestation. BJOG 2010;117:963–967.