Sharon R. Sheehan

Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial.

Objectives To determine the effects of adding an oxytocin infusion to bolus oxytocin on blood loss at elective caesarean section. Design Double blind, placebo controlled, randomised trial, conducted from February 2008 to June 2010. Setting Five maternity hospitals in the Republic of Ireland. Participants 2069 women booked for elective caesarean section at term with a singleton pregnancy. We excluded women with placenta praevia, thrombocytopenia, coagulopathies, previous major obstetric haemorrhage (>1000 mL), or known fibroids; women receiving anticoagulant treatment; those who did not understand English; and those who were younger than 18 years. Intervention Intervention group: intravenous slow 5 IU oxytocin bolus over 1 minute and additional 40 IU oxytocin infusion in 500 mL of 0.9% saline solution over 4 hours (bolus and infusion). Placebo group: 5 IU oxytocin bolus over 1 minute and 500 mL of 0.9% saline solution over 4 hours (placebo infusion) (bolus only). Main outcomes Major obstetric haemorrhage (blood loss >1000 mL) and need for an additional uterotonic agent. Results We found no difference in the occurrence of major obstetric haemorrhage between the groups (bolus and infusion 15.7% (158/1007) v bolus only 16.0% (159/994), adjusted odds ratio 0.98, 95% confidence intervals 0.77 to 1.25, P=0.86). The need for an additional uterotonic agent in the bolus and infusion group was lower than that in the bolus only group (12.2% (126/1033) v 18.4% (189/1025), 0.61, 0.48 to 0.78, P<0.001). Women were less likely to have a major obstetric haemorrhage in the bolus and infusion group than in the bolus only group if the obstetrician was junior rather than senior (0.57, 0.35 to 0.92, P=0.02). Conclusion The addition of an oxytocin infusion after caesarean delivery reduces the need for additional uterotonic agents but does not affect the overall occurrence of major obstetric haemorrhage. Trial Registration Current Controlled Trials ISRCTN17813715.

A clinical review of maternal bacteremia.

To carry out a 4‐year review of cases of bacteremia among obstetric patients.

Evaluation of the systemic inflammatory response syndrome criteria for the diagnosis of sepsis due to maternal bacteremia.

To examine, in the setting of maternal bacteremia, the implications for the diagnosis of maternal sepsis of customizing the systemic inflammatory response syndrome (SIRS) criteria for physiologic changes of pregnancy.

A pregnant Jehovah’s witness

A 39 year old woman booked at 14 weeks’ gestation in her second pregnancy. Her first baby was delivered by vacuum without any complications. At the booking visit she reported that she was a Jehovah’s witness and made it clear that she would not accept blood products. Her antenatal course was complicated by polyhydramnios, fetal macrosomia, and abdominal discomfort. She presented at 40 weeks’ gestation with regular pains and was admitted to the labour ward. The cord prolapsed shortly after rupture of the membranes and she was transferred to the operating theatre for an emergency caesarean section. She gave birth to a healthy boy and the surgery was uneventful. She started to haemorrhage four hours after delivery on the postnatal ward. She was resuscitated by the on-call team without use of blood products. Mother and baby were discharged in good health on day five. 1. How would you counsel this woman? 2. What measures would you take to optimise her haematological status in the antenatal period? 3. How would you manage a postpartum haemorrhage in a woman who refuses blood products? ### Short answers 1. Women who refuse blood products should see a consultant obstetrician early in the antenatal period and have a frank discussion about the issues that may arise. This should be followed up by completing a documented detailed advance directive after a period of reflection. 2. Oral iron supplements should be prescribed throughout …

Maternal body mass index and the prevalence of spontaneous and elective preterm deliveries in an Irish obstetric population: a retrospective cohort study

Objective To estimate the association between maternal body mass index (BMI) and risk of spontaneous preterm delivery (sPTD) and elective preterm delivery (ePTD) in singleton and multiple pregnancies. Design Retrospective cohort study. Setting Electronic records of all deliveries from 2009 through 2013 in a tertiary university hospital were abstracted for demographic and obstetrical information. Participants A total of 38 528 deliveries were included. Participants with missing data were excluded from the study. BMI was calculated from the measurement of height and weight at the first prenatal visit and categorised. Sonographic confirmation of gestational age was standard. Outcome measures Primary outcomes, sPTD and ePTD in singleton and multiple pregnancies, were evaluated by multinomial logistic regression analyses, stratified by parity, controlling for confounding variables. Results Overall rate of PTD was 5.9%, from which 2.7% were sPTD and 3.2% ePTD. The rate of PTD was 50.4% in multiple pregnancies and 5.0% in singleton pregnancies. The risk of sPTD was increased in obese nulliparas (adjusted OR (aOR) 2.8, 95% CI 1.7 to 4.4) and underweight multiparas (aOR 2.2, 95% CI 1.3 to 3.8). The risk of ePTD was increased in underweight nulliparas (aOR 1.8; 95% CI 1.04 to 3.4) and severely obese multiparas (aOR 1.4, 95% CI 1.02 to 3.8). Severe obesity increased the risk of both sPTD (aOR 1.4; 95% CI 1.01 to 2.1) and ePTD (aOR 1.4; 95% CI 1.1 to 1.8) in singleton pregnancies. Obesity did not influence the rate of either sPTD or ePTD in multiple pregnancies. Conclusion Maternal obesity is an independent risk factor for PTD in singleton pregnancies but not in multiple pregnancies. Obesity and nulliparity increase the risk of sPTD, whereas obesity and multiparity increase the risk of ePTD.

P278 A cohort study of 500 patients recruited to ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial

Aims: Major obstetric haemorrhage is a leading cause of maternal mortality worldwide. The aim of ECSSIT is to compare blood loss at elective lower segment caesarean section with administration of oxytocin 5IU bolus versus oxytocin 5IU bolus and oxytocin 40 IU infusion. The aim of this initial cohort study was to analyse the clinical risk factors and contributors to major obstetric haemorrhage (MOH) at elective caesarean section. The analyses remained blinded to infusion allocation. Methods: Women booked for elective caesarean section were recruited to the randomised controlled trial and received either oxytocin bolus and placebo infusion or oxytocin bolus and oxytocin 40 IU infusion. The primary outcome measures were major obstetric haemorrhage (blood loss >1000mls) and the need for an additional uterotonic agent. A detailed dataset was completed recording clinical and peri-operative information. Results: The overall rate of MOH was 15%. Of the 500 women, 63% had at least one previous caesarean section. The rate of MOH was similar in women undergoing their first caesarean section compared to those having a repeat procedure, 16% and 15% respectively (p = 0.7). Pre-operative anaemia (Hb < 10.5 g/dl) was present in 79 women (16%), with rates of MOH in this group no higher than among those with normal pre-operative haemoglobin, 13% vs. 16% (p =0.7). A senior grade of operator (year 4/5 specialist registrar or higher) performed 57% of the caesarean sections, and the rate of MOH in this group was 14%, compared to 17% when the operator was more junior (p = 0.4). An additional uterotonic agent was required in 48 (10%) women. The rate of post-operative anaemia was 51% (247 women) with severe anaemia (≥20% fall in Hb) in 8%. Conclusions: The rate of major obstetric haemorrhage at elective caesarean section is high and is associated with significant morbidity. A first elective caesarean section appears to be as risky as subsequent procedures. Neither the grade of operator nor the presence of pre-operative anaemia affected the rates of major haemorrhage. There was a high rate of pre-operative anaemia in this study population that should be targeted antenatally with appropriate iron therapy. The randomised controlled trial aims to recruit 2000 women with a target end date of August 2010. It remains to be seen whether an additional oxytocin infusion has a role to play in reducing major obstetric haemorrhage at elective caesarean section.

A complication after a previous caesarean section

A 38 year old woman booked for antenatal care in her second pregnancy. Her first baby had been delivered by emergency caesarean section after failed induction of labour. She had an uncomplicated antenatal course and hoped to achieve a vaginal delivery. At 39 weeks’ gestation she presented in spontaneous labour with regular uterine contractions. The fetus was of average size and in a cephalic presentation, with two fifths of the head palpable abdominally. On vaginal examination, the cervix was 5 cm dilated and clear liquor was draining. She was reassessed after two hours and had progressed to 9 cm dilation with the vertex 2 cm above the ischial spines. The cardiotocograph at that time was reassurring. The obstetric registrar was called to review the patient 20 minutes later because of deep late decelerations on the cardiotocograph and fresh vaginal bleeding. On abdominal examination, four fifths of the head was palpable but no scar tenderness was noted. Vaginal examination showed a high presenting part and findings otherwise unchanged from the previous examination. A liveborn female infant weighing 4.1 kg was delivered by emergency caesarean section. Apgar scores were 5 at one minute and 8 at five minutes. The cord blood results were abnormal (pH artery 6.9, base excess −14.6; pH vein 7.0, base excess −12.4). The mother was transferred to the high dependency unit after delivery for 24 hours and made a good recovery. She was discharged on day 6. The baby was discharged on day 12 with arrangements for neurodevelopmental follow-up. ### Short answers

Feasibility of recruitment to a behavioural smoking cessation intervention combined with ongoing online support

The aim of this randomized controlled trial was to determine whether a behavioural intervention in pregnancy supported by online information would improve smoking cessation rates. However, due to a number of challenges, recruitment to this trial was reluctantly halted. We aimed to recruit 220 maternal smokers within 2 years and after screening 1995 women, just 22 enrolled over a 8-month period. Only three women accessed the online element of the intervention and, at follow up, no women reported quitting. We report our findings as they may inform the design and powering of future smoking cessation interventions in pregnancy.

A prospective, observational study investigating the use of carbon monoxide screening to identify maternal smoking in a large university hospital in Ireland.

Objectives This study evaluated breath carbon monoxide (BCO) testing in identifying maternal smokers as well as the difference between disclosers and non-disclosers of smoking status. We also investigated if other extrinsic factors affected the women’s BCO levels in pregnancy. Design A prospective observational study. Setting A university obstetric hospital in an urban setting in Ireland. Participants Women (n=250) and their partners (n=54) were recruited at their first antenatal visit. Women <18 years and those who did not understand English were excluded. A booking history, including recording of smoking status, was collected by midwives. Following this, women were recruited and completed a detailed research questionnaire on smoking and extrinsic/environmental BCO sources. A BCO test was performed on both the woman and her partner. Primary and secondary outcome measures The number of self-reported smokers and those that were positive on the BCO test. The characteristics of women who disclosed and did not disclose smoking status. The effect of extrinsic factors on the BCO test results. Results Based on the receiver-operating characteristic curve, a BCO cut-off point of ≥3 ppm was the optimal level to identify ongoing smoking. At booking history, 15% of women reported as current smokers. Based on BCO levels ≥3 ppm combined with self-reported smoking in the research questionnaire, the rate increased to 25%. Non-disclosers had similar characteristics to non-smokers. No extrinsic factors affected maternal BCO levels. Conclusions Based on self-report and BCO levels, a quarter of women presenting for antenatal care continued to smoke, but only 60% reported their smoking to midwives. BCO measurement is an inexpensive, practical method of improving identification of maternal smoking, and it was not effected by extrinsic sources of BCO. Improved identification means more smokers can be supported to stop smoking in early pregnancy potentially improving the short-term and long-term health of both mother and child.

The clinical outcomes of unplanned pregnancy in severely obese women

Abstract Objective: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies. Methods: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥40.0 kg/m2) who delivered a baby weighing ≥500 g over 5 years 2009–2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit. Results: Of the 650 women, the mean BMI was 43.8 kg/m2, mean age was 31.6 years, and 30.0% (n = 195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n = 368). Compared with planned pregnancies (58.2%, n = 378), those that were unplanned (41.8%, n = 272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p = 0.03) and depression (6.6% versus 3.2%, p = 0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight > 4.5 kg) compared with planned pregnancies (p = 0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes. Conclusion: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.