Martin Lupton

Effect of pregnancy on clinical status and ventricular function in women with heart disease

BACKGROUND Pregnant women with heart disease (HD) are at an increased risk for maternal and neonatal adverse events. However, the effect of pregnancy on clinical status and ventricular function in women with HD has not been examined in a controlled study. METHODS AND RESULTS Ninety-three women with HD were studied longitudinally. Of these, fifty-three underwent clinical and echocardiographic evaluation before and 1.5+/-1.1 years after pregnancy (pregnancy group), whereas forty served as controls matched for age (28.6+/-4.6 versus 28.5+/-6.6, p=0.88), diagnosis, and length of follow-up (2.9+/-1.4 versus 2.6+/-1.1, p=0.23). NYHA functional class remained unchanged in both groups during follow-up. End diastolic and end systolic dimensions and shortening fraction of the morphologic left ventricle also remained unchanged. Furthermore, systemic and subpulmonary ventricular function remained unchanged in the pregnancy and control groups on semiquantitative analysis. Pregnancy, however, was associated with a persisting increase in subpulmonary ventricular size in patients with tetralogy of Fallot (ToF) which was not present in tetralogy controls. Furthermore, diagnosis of ToF was the only predictor of an increase in subpulmonary ventricular size after pregnancy on univariate logistic regression analysis (OR 8.8[95% CI 1.9-41.1], p=0.006). CONCLUSIONS In this longitudinal controlled study amongst women with HD no deleterious midterm effects of pregnancy on clinical status and right and left ventricular function were found. However, pregnancy was associated with a persisting increase in subpulmonary ventricular size, attributable to patients with repaired ToF. This may have prognostic implications and merits further investigation.

Effect of maternal heart disease on fetal growth.

OBJECTIVE: To estimate the effect of maternal heart disease on fetal growth and neonatal outcomes. METHODS: A retrospective cohort study of all women with congenital and acquired heart disease admitted at Chelsea and Westminster Hospital between 1994 and 2010 was performed. The women who delivered immediately before and immediately after each index pregnancy were used as controls. Data were obtained from medical and obstetric notes. Birth weight percentiles were calculated using a customized birth weight percentile program, and neonatal complications (preterm birth, perinatal mortality, and recurrence of congenital heart disease) were noted. RESULTS: Median birth weight percentile was significantly lower in the heart disease group (n=31) compared with the control group (n=49; P<.001 Mann-Whitney U test). The rate of neonatal complications was significantly higher in the heart disease group (34% compared with 15%). Preterm birth occurred in 42 (13%) pregnancies, of which 67% were iatrogenic. Eighty-one (25%) newborns in the heart disease group were small for gestational age, and there were four stillbirths and four neonatal deaths (perinatal mortality rate 20 per 1,000). CONCLUSION: This cohort study suggests a significant reduction in fetal growth rates associated with maternal heart disease, which is also associated with preterm delivery and reduced birth weight. The presence of maternal cyanosis and a reduced cardiac output are the most significant predictors. LEVEL OF EVIDENCE: II

Pregnancy in women with a systemic right ventricle after surgically and congenitally corrected transposition of the great arteries

OBJECTIVE To determine maternal and neonatal outcomes in women with a systemic right ventricle (RV). STUDY DESIGN A retrospective (historical) cohort study of maternal and neonatal outcomes at a tertiary referral academic obstetric unit (Chelsea and Westminster Hospital, London). RESULTS Nineteen pregnancies in 14 women with a systemic RV were compared with 76 controls. There were no maternal deaths. In the study group cardiac complications occurred in six (32%) pregnancies. Obstetric complications occurred in four (21%) case pregnancies, not significantly higher than in the control group. The rate of neonatal complication was significantly higher in the study population with neonatal complications in 12 (63%) case pregnancies compared with 13 (17%) control pregnancies. The median birthweight centile was 9 in the study population, significantly lower than the control population. CONCLUSIONS Our cohort study demonstrates high maternal and neonatal morbidity and low birthweight in the presence of a systemic RV. Cardiac complications were more common in women with RV dysfunction and arrhythmias prior to pregnancy. Preconception counselling and tertiary care during pregnancy for these patients is highly advisable.

Teaching and learning gynaecology examination with hybrid simulation

U nderstanding how to perform a bimanual gynaecological examination, pass a speculum and visualise the cervix to do a cervical smear are key skills. Medical students typically have limited opportunities for such practical experience. In addition, male medical students have fewer opportunities than their female peers. These difficulties have long been recognised and hence there is an increasing use of bench-top pelvic simulators to assist learning. Despite this, when students are required to examine patients, they remain apprehensive. The technical aspects of a procedure can be covered by using a bench-top simulator, but appropriate communication and professionalism are harder to replicate. Students lack confidence in their ability to integrate the complex skills (technical, communication and professional) required for success.

Adapting and implementing PACES as a tool for undergraduate assessment

Assessment of clinical competence for these disciplines has been by a series of Objective Structured Clinical Examinations (OSCEs).

A novel method of defining the core objectives of a specialty undergraduate curriculum

Context and setting In the UK there is no national undergraduate curriculum. Each medical school sets its own curriculum, which must comply with guidance set by the General Medical Council and published in Tomorrow’s Doctors. Medical schools vary in their approaches to defining curricular content. Traditionally, this was determined through a process of negotiation by teaching leads within and between specialties, according to historical power dynamics. Why the idea was necessary Imperial College was formed in 1997 as the result of the merging of three London medical schools. Many of the existing undergraduate subject curricula arose from an unstructured amalgamation of learning objectives. Moreover, students reported differences in educational experience according to the hospital site of their clinical attachments. Teaching leads agreed that there was a need for each specialty to develop a curriculum with clear, structured core objectives. A process for achieving this was initially developed for obstetrics and gynaecology (O&G). What was done Informed by guidance in Tomorrow’s Doctors and by the curriculum for postgraduate O&G training produced by the Royal College of Obstetricians and Gynaecologists (RCOG), we created a list of learning objectives, structured within modules. A panel of local experts was convened. This included O&G doctors, general practitioners, and accident and emergency doctors, all of whom were active in undergraduate education (n = 16). The expert panel did not meet face-to-face, but were surveyed using a modified Delphi technique by one of the study authors (NL-B). Panel members were asked to classify objectives as essential, important or expert. The threshold for consensus was set at 75%. NL-B then facilitated three focus groups of newly qualified doctors (n = 16) in order to explore issues relating to modules lacking consensus. At a meeting of the O&G Curriculum Committee, we presented the anonymised results of the Delphi survey. Those learning objectives classified as important or essential were included as core learning objectives. For areas lacking consensus, the relevant focus group themes were discussed as a means of deciding how to define, and whether to include, particular learning objectives. The final document was accepted by all Curriculum Committee members. Evaluation of results and impact The final curriculum document included 130 core learning objectives, 91 of which were classified as essential. Our results were triangulated with the RCOG national undergraduate O&G curriculum, which was published after our study had been completed. Although it differed in format and presentation, the Imperial College document was similar in content to the RCOG curriculum, emphasising both core generic and subject-specific competencies. Engaging a broad spectrum of local opinion in the development of a specialty undergraduate curriculum produced a document whose content was similar to national specialty guidelines, but whose genesis was inclusive. Local ownership of the process facilitated its implementation. In the absence of a cross-specialty national undergraduate curriculum, a modified Delphi technique supplemented by focus groups of newly qualified doctors appears to be a legitimate tool for developing undergraduate specialty curricula.

Development of a web-based tool for undergraduate engagement in medical research; the ProjectPal experience

BackgroundWe report the development and evaluation of a web-based tool designed to facilitate student extra-curricular engagement in medical research through project matching students with academic supervisors.UK based university students were surveyed to explore their perceptions of undergraduate research, barriers and facilitators to current engagement. Following this, an online web-based intervention (www.ProjectPal.org) was developed to support access of students to research projects and supervisors. A pilot intervention was undertaken across a London-based university in January 2013 to February 2016. In March 2016, anonymised data were extracted from the prospective data log for analysis of website engagement and usage. Supervisors were surveyed to evaluate the website and student outputs.ResultsFifty-one students responded to the electronic survey. Twenty-four (47%) reported frustration at a perceived lack of opportunities to carry out extra-curricular academic projects. Major barriers to engaging in undergraduate research reported were difficulties in identifying suitable supervisors (33/51; 65%) and time pressures (36/51; 71%) associated with this. Students reported being opportunistic in their engagement with undergraduate research. Following implementation of the website, 438 students signed up to ProjectPal and the website was accessed 1357 times. Access increased on a yearly basis. Overall, 70 projects were advertised by 35 supervisors. There were 86 applications made by students for these projects. By February 2016, the 70 projects had generated 5 peer-review publications with a further 7 manuscripts under peer-review, 14 national presentations, and 1 national prize.ConclusionThe use of an online platform to promote undergraduate engagement with extra-curricular research appears to facilitate extra-curricular engagement with research. Further work to understand the impact compared to normal opportunistic practices in enhancing student engagement is now underway.