Richard A. Greene

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

The effect of moderate gestational alcohol consumption during pregnancy on speech and language outcomes in children: a systematic review

BackgroundConsensus has not been reached on safe alcohol consumption recommendations during pregnancy. The National Institutes for Care and Health Excellence (NICE) in the UK suggest that one to two drinks not more than twice per week is safe. However, the speech and language effects of even low levels of alcohol use among offspring are unknown. The aim of this study was to review systematically the evidence on studies of the effect of low to moderate levels of alcohol consumption during pregnancy (up to 70 grams of alcohol per week) compared to abstinence on speech and language outcomes in children.MethodsUsing medical subject headings, PubMed, Web of knowledge, Scopus, Embase, Cinahl and the Cochrane Library were searched from their inception up to March 2012. Case control and cohort studies were included. Two assessors independently reviewed titles, abstracts and full articles, extracted data and assessed quality.ResultsA total of 1,397 titles and abstracts were reviewed of which 51 full texts were retrieved. Three cohort studies totaling 10,642 women met the inclusion criteria. All three studies, (United States (2) and Australia (1)) indicated that language was not impaired as a result of low to moderate alcohol consumption during pregnancy. Two studies were judged to be of low quality based on a six-item bias classification tool. Due to heterogeneity, results could not be meta-analyzed.ConclusionStudies included in this review do not provide sufficient evidence to confirm or refute an association between low to moderate alcohol use during pregnancy and speech and language outcomes in children. High quality, population based studies are required to establish the safety of low to moderate levels of alcohol use such as those set out by the NICE guidelines in the UK.

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.

Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies

Objectives To compare the prevalence and predictors of alcohol use in multiple cohorts. Design Cross-cohort comparison of retrospective and prospective studies. Setting Population-based studies in Ireland, the UK, Australia and New Zealand. Participants 17 244 women of predominantly Caucasian origin from two Irish retrospective studies (Growing up in Ireland (GUI) and Pregnancy Risk Assessment Monitoring System Ireland (PRAMS Ireland)), and one multicentre prospective international cohort, Screening for Pregnancy Endpoints (SCOPE) study. Primary and secondary outcome measures Prevalence of alcohol use pre-pregnancy and during pregnancy across cohorts. Sociodemographic factors associated with alcohol consumption in each cohort. Results Alcohol consumption during pregnancy in Ireland ranged from 20% in GUI to 80% in SCOPE, and from 40% to 80% in Australia, New Zealand and the UK. Levels of exposure also varied substantially among drinkers in each cohort ranging from 70% consuming more than 1–2 units/week in the first trimester in SCOPE Ireland, to 46% and 15% in the retrospective studies. Smoking during pregnancy was the most consistent predictor of gestational alcohol use in all three cohorts, and smokers were 17% more likely to drink during pregnancy in SCOPE, relative risk (RR)=1.17 (95% CI 1.12 to 1.22), 50% more likely to drink during pregnancy in GUI, RR=1.50 (95% CI 1.36 to 1.65), and 42% more likely to drink in PRAMS, RR=1.42 (95% CI 1.18 to 1.70). Conclusions Our data suggest that alcohol use during pregnancy is prevalent and socially pervasive in the UK, Ireland, New Zealand and Australia. New policy and interventions are required to reduce alcohol prevalence both prior to and during pregnancy. Further research on biological markers and conventions for measuring alcohol use in pregnancy is required to improve the validity and reliability of prevalence estimates.

Caesarean Delivery and Subsequent Stillbirth or Miscarriage: Systematic Review and Meta-Analysis

Objective To compare the risk of stillbirth and miscarriage in a subsequent pregnancy in women with a previous Caesarean or vaginal delivery. Design Systematic review of the published literature including seven databases: CINAHL; the Cochrane library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge from 1945 until November 11th 2011, using a detailed search-strategy and cross-checking of reference lists. Study Selection Cohort, case-control and cross-sectional studies examining the association between previous Caesarean section and subsequent stillbirth or miscarriage risk. Two assessors screened titles to identify eligible studies, using a standardised data abstraction form and assessed study quality. Data synthesis 11 articles were included for stillbirth, totalling 1,961,829 pregnancies and 7,308 events. Eight eligible articles were included for miscarriage, totalling 147,017 pregnancies and 12,682 events. Pooled estimates across the stillbirth studies were obtained using random-effect models. Among women with a previous Caesarean an increase in odds of 1.23 [95% CI 1.08, 1.40] for stillbirth was yielded. Subgroup analyses including unexplained stillbirths yielded an OR of 1.47 [95% CI 1.20, 1.80], an OR of 2.11 [95% CI 1.16, 3.84] for explained stillbirths and an OR of 1.27 [95% CI 0.95, 1.70] for antepartum stillbirths. Only one study reported adjusted estimates in the miscarriage review, therefore results are presented individually. Conclusions Given the recent revision of the National Institute for Health and Clinical Excellence guidelines (NICE), providing women the right to request a Caesarean, it is essential to establish whether mode of delivery has an association with subsequent risk of stillbirth or miscarriage. Overall, compared to vaginal delivery, the pooled estimates suggest that Caesarean delivery may increase the risk of stillbirth by 23%. Results for the miscarriage review were inconsistent and lack of adjustment for confounding was a major limitation. Higher methodological quality research is required to reliably assess the risk of miscarriage in subsequent pregnancies.

Hyperemesis gravidarum: current perspectives.

Hyperemesis gravidarum is a complex condition with a multifactorial etiology characterized by severe intractable nausea and vomiting. Despite a high prevalence, studies exploring underlying etiology and treatments are limited. We performed a literature review, focusing on articles published over the last 10 years, to examine current perspectives and recent developments in hyperemesis gravidarum.

At what price? a cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Background Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland. Methods Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations. Results Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis. Conclusions Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

What are the maternal implications of a classical caesarean section

Sixty-two caesarean sections involving a vertical upper uterine segment incision were performed at the Coombe Womens Hospital between January 1983 and December 1995. A detailed chart review was performed. There were no maternal deaths. The maternal outcome was complicated by infection in 49% of cases, and haemorrhage in 19% requiring hysterectomy in two cases. In 15 subsequent pregnancies scar rupture occurred in one case and scar separation in two cases. The perinatal mortality was 200/ 1000; no perinatal death was directly related to the surgery. The operation is associated with a high incidence of maternal morbidity. It also has implications for subsequent deliveries. We recommend that every effort should be made to evaluate critically the need for a caesarean section in the first place and where possible to use a lower uterine segment transverse incision. The patient should be informed of the additional morbidity and long-term risks associated with a vertical incision.

Private health care coverage and increased risk of obstetric intervention

BackgroundWhen clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria.MethodsDifferences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors.Results403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43).ConclusionsIrrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.

Self-collected versus health professional-collected genital swabs to identify the prevalence of group B streptococcus: a comparison of patient preference and efficacy.

OBJECTIVE This study aims to determine the prevalence of genital tract group B streptococcus (GBS) colonization in a cohort of pregnant Irish women and to compare patient preference and efficacy of self-collected versus health professional-collected swabs. STUDY DESIGN In this prospective cohort study, 600 pregnant women attending public and private antenatal clinics at the Unified Maternity Services, Cork were included. At 35-37 weeks of pregnancy, these women self-collected an ano-vaginal swab and a health professional-collected a second swab on same clinic visit. The women filled a questionnaire to indicate their preferences. Statistical analysis was performed on SPSS Version 13. RESULT The cumulative prevalence of maternal GBS colonization was 11.7% (95% CI, 9.3-14.6). The sensitivity of the self-collected swab was 84.3% (95% CI, 73.2-91.5) and that of health professional-collected swab was 94.3% (95% CI, 85.3-98.2). While good agreement in efficacy was found between health professional and patient-collected swabs (Kappa=0.87, p<0.001, 97.5% measure of concordance), only 28.5% women preferred self-collection, while 43.2% preferred a health professional to collect the swab and 28.3% had no preference. CONCLUSION In our study the concordance between health professional and self-collected swab was excellent. However, pregnant women mainly prefer a health professional to collect their ano-vaginal swabs.