Maria Farren

A review of European guidelines on periconceptional folic acid supplementation.

Strong evidence that folic acid (FA) prevents the majority of cases of neural tube defects (NTDs) has led to national organisations developing guidelines for women concerning periconceptional supplementation. In Europe, there is evidence of national variations in the incidence of NTDs, with a recent Irish study reporting an increase in the rate. This review compares the periconceptional FA supplementation guidelines between the different countries in Europe. An online search of country-specific guidelines produced before 2015 concerning periconceptional FA supplementation was conducted. If an English version was not available directly, the EUROCAT register was searched for the English version of the recommendations. We identified national guidelines from 20 European countries. Over half recommended that FA supplements be taken by women planning a pregnancy, but three recommended that they should be taken by all women of child-bearing age. Four guidelines recommended starting FA at least 4 weeks preconceptionally, but no country recommended starting FA at least 12 weeks preconceptionally as suggested by recently published studies. There is a need for further consideration of the duration of preconceptional FA supplementation specifically. The latest scientific evidence in this area should inform the development of European guidelines on FA, as there is wide variation in current recommendations. Overall, the wide variation in national guidelines concerning periconceptional FA supplementation may in part explain the differences in national rates of NTDs reported by EUROCAT. National guidelines on FA supplementation should be standardised across European countries.

The interplay between maternal obesity and gestational diabetes mellitus

Abstract There is a strong epidemiological association between maternal obesity and gestational diabetes mellitus (GDM). Since the publication of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study on women with mild hyperglycemia in 2008, new criteria have been introduced in maternity services internationally for the diagnosis of GDM. As a result, the diagnosis of GDM may be made in one-third of obese women (n=68). The aim of this review was to examine the interplay between maternal obesity and GDM in light of the HAPO study and the subsequent revised diagnostic criteria. Obesity and GDM are important obstetric risk factors because they both are potentially modifiable. However, the new international criteria for the diagnosis of GDM have serious resource implications for maternity services provided to the large number of women attending for care in developed countries. Further consideration needs to be given as to whether obese women with mild hyperglycemia need to be referred to a multidisciplinary team antenatally if they do not require insulin treatment.

Maternal folic acid supplementation trends 2009–2013

We analyzed trends in folic acid supplementation among women booking for antenatal care between 2009 and 2013.

An analysis of folic acid supplementation in women presenting for antenatal care.

BACKGROUND Neural tube defects (NTDs) are major congenital malformations that are potentially preventable if the woman takes periconceptional folic acid (FA) supplements. A recent report found that NTD incidence had increased in Ireland. This study examined the usage of FA supplementation in women presenting for antenatal care in a maternity hospital. METHODS Women were recruited at their convenience in the first trimester. Their clinical and sociodemographic details were computerized. Maternal weight and height were measured before calculating body mass index. Detailed FA questionnaires were completed under supervision of a trained researcher. RESULTS While 96.1% (n = 564) out of 587 reported that they took FA after they became pregnant, only 24.7% (n = 145) took it for >12 weeks preconceptionally as recommended. Only 5.7% (n = 6) of obese women took high-dose FA as recommended. On univariate analysis, the strongest predictors of preconceptional FA usage were higher maternal age, higher education and income, being married, being nulliparous, not smoking, infertility treatment and planned pregnancy. On multivariate analysis, both planned pregnancy and nulliparity were the most important predictors of preconceptional FA use. CONCLUSIONS Our study shows that current recommendations to prevent NTDs by FA supplementation pre-pregnancy are not being fully implemented in Ireland. We recommend a review of current public health policies on FA supplementation.

Trends in maternal obesity in a large university hospital 2009–2013

Maternal obesity has been identified as an important clinical priority in contemporary obstetrics. This study aimed to determine the incidence of maternal obesity in early pregnancy and track recent trends in body mass index (BMI) categories over 5 years 2009–2013.

A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night

Objective To evaluate maternal and neonatal outcomes associated with operative vaginal deliveries (OVDs) performed by day and at night. Design Prospective cohort study. Setting Urban maternity unit in Ireland with off-site consultant staff at night. Population All nulliparous women requiring an OVD with a term singleton fetus in a cephalic presentation from February to November 2013. Methods Delivery outcomes were compared for women who delivered by day (08:00–19:59) or at night (20:00–07:59). Main outcome measures The main outcomes included postpartum haemorrhage (PPH), anal sphincter tear and neonatal unit admission. Procedural factors included operator grade, sequential use of instruments and caesarean section. Results Of the 597 women who required an OVD, 296 (50%) delivered at night. Choice of instrument, place of delivery, sequential use of instruments and caesarean section did not differ significantly in relation to time of birth. Mid-grade operators performed less OVDs by day than at night, OR 0.60 (95% CI 0.43 to 0.83), and a consultant supervisor was more frequently present by day, OR 2.26 (95% CI 1.05 to 4.83). Shoulder dystocia occurred more commonly by day, OR 2.57 (95% CI 1.05 to 6.28). The incidence of PPH, anal sphincter tears, neonatal unit admission, fetal acidosis and neonatal trauma was similar by day and at night. The mean decision to delivery intervals were 12.0 and 12.6 min, respectively. Conclusions There was no evidence of an association between time of OVD and adverse perinatal outcomes despite off-site consultant obstetric support at night.

Knowledge about folic acid supplementation in women presenting for antenatal care

Background/Objectives:The incidence of neural tube defects (NTDs) in Ireland has increased in recent years. This study examines knowledge about folic acid (FA) supplementation for the prevention of NTDs among women presenting for antenatal care.Subjects/Methods:Women were recruited at their convenience in the first trimester after sonographic confirmation of an ongoing singleton pregnancy. A detailed questionnaire was completed under the supervision of a research dietitian. Clinical and socio-demographic details were collected.Results:Of the 587 women studied, 96% took FA during early pregnancy. Of these, 56.4% cited brain/spinal development or the prevention of brain/spinal defects, spina bifida or NTDs as the reason for taking FA. Multivariate analysis showed that women who were experiencing material deprivation or who were living in Ireland <5 years were least likely to be knowledgeable about the benefits of FA supplementation (P<0.05 for both). Over half (57.1%) of the women did not take FA preconceptionally. The main reason reported for not supplementing preconceptionally was that the woman did not expect to get pregnant (76.4%). Over one-third of women (35%), however, reported that they did not know they needed to take FA before becoming pregnant.Conclusions:These results highlight the need for a renewed public health campaign in Ireland about the importance of FA. As well as focusing on women who have recently come to live in Ireland, this campaign needs focus on women living in deprivation, as these are the women most at risk of having inadequate knowledge about the importance of FA in improving pregnancy outcomes.

Duration of periconceptional folic acid supplementation in women booking for antenatal care

OBJECTIVE To provide accurate estimates of the commencement time, duration and dosage of folic acid (FA) supplementation taken by Irish women in the periconceptional period. The study also aimed to establish the factors associated with optimal FA supplementation practices. DESIGN Cross-sectional observational study. Womens clinical and sociodemographic details were computerised. Maternal weight and height were measured before calculating BMI. Detailed FA supplementation questionnaires were completed under the supervision of a trained researcher. SETTING A large university maternity hospital, Republic of Ireland, January 2014-April 2016. SUBJECTS Women (n 856) recruited at their convenience in the first trimester. RESULTS While almost all of the women (97 %) were taking FA at enrolment, only one in four women took FA for at least 12 weeks preconceptionally (n 208). Among the 44 % of women who were supplementing with FA preconceptionally, 44 % (162/370) reported taking FA for less than the 12 weeks required to achieve optimal red-blood-cell folate levels for prevention of neural tube defects. On multivariate analysis, only planned pregnancy and nulliparity were associated with taking FA for at least 12 weeks preconceptionally. Among women who only took FA postconceptionally, almost two-thirds commenced it after day 28 of their pregnancy when the neural tube had already closed. CONCLUSIONS As the timing of FA was suboptimal both before and after conception, we recommend that current national FA guidelines need to be reviewed.

A national survey of preanalytical handling of oral glucose tolerance tests in pregnancy.

Title A national survey of preanalytical handling of oral glucose tolerance tests in pregnancy Authors(s) Daly, Niamh; Flynn, Iseult; Carroll, Ciara; Farren, Maria; McKeating, Aoife; Turner, Michael Publication date 2016-08 Publication information Clinical Chemistry and Laboratory Medicine, 54 (8): 221-223 Publisher De Gruyter Item record/more information http://hdl.handle.net/10197/9259 Publishers version (DOI) 10.1515/cclm-2015-1083

Response to Comment on Farren et al. The Prevention of Gestational Diabetes Mellitus With Antenatal Oral Inositol Supplementation: A Randomized Controlled Trial. Diabetes Care 2017;40:759–763

We thank Drs. Pintaudi and Di Vieste for their comments (1) on our article (2). They highlight diversity among our study cohort. However, we believe this does not explain the ineffectiveness of inositol in preventing gestational diabetes mellitus (GDM). First, of the 240 women, 151 had a family history of diabetes as their only risk factor, with 74 in the intervention group and 77 in the control group. The incidence of GDM was 17.6% in the intervention group compared with 10.4% in the control group ( P = 0.2). The authors highlight that most women in the study were Irish-born. The Irish population is increasingly diverse, and 39 women …