Siobhan Corcoran

How safe is preterm operative vaginal delivery and which is the instrument of choice

Abstract Objective: The objective of this study was to determine neonatal outcomes in preterm operative vaginal delivery given the current paucity of data available to guide clinicians. Study design: A retrospective review of 64 cases was conducted, and neonatal outcomes were compared to spontaneous vaginal deliveries in similar gestations. The primary outcomes studied were death and occurrence of intraventricular haemorrhage. Secondary outcomes included admission to NICU, Apgar <3 at 5 min, ventilation requirement, jaundice requiring treatment, culture-proven sepsis and necrotising enterocolitis. The study was conducted in a stand-alone maternity unit of approximately 9000 deliveries per year. Results and conclusions: We concluded that although vacuum delivery is avoided in preterm infants, outcomes were similar to forceps deliveries of similar gestations.

Clinical risk management of obstetric anal sphincter injury

Perineal injury sustained during childbirth, and more particularly third and fourth degree tears, can have substantial effects on future continence, sexual function and the choice of method of childbirth in the future. The aim of our audit was to see if the use of clinical risk management methods could help improve documentation and clincial outcomes for women who sustained an obstetric anal sphincter injury. A proforma for the management of obstetric anal sphincter injury was introduced to the labour ward. We found that after the introduction of the proforma documentation improved significantly for classification of the type of injury (P < .01), counts of swabs, instuments and sharps (P < .01) and future pregnancy information (P < .05). This audit demonstrates how simple clinical risk managment strategies can help ensure the best standards of care are implemented.

The early bird catches the worm - predicting the onset of gestational diabetes in the first trimester.

The ballooning incidence of gestational diabetes is extremely costly both in terms of maternal and neonatal morbidity but also in terms of immediate and long-term cost to the healthcare system. In the short-term, untreated gestational diabetes has been shown to confer a significantly increased risk of stillbirth, macrosomia, neonatal hypoglycemia, erythrocytosis, and hyperbilirubinemia [1]. In the longerterm, the children of diabetic mothers have a 21% risk of developing diabetes in later life compared to a 4% risk in the offspring of non-diabetic mothers. The fetal macrosomia characteristic of GDM is responsible for an increase in maternal morbidity, as evidenced by increased rates of caesarean and operative vaginal delivery, obstetric anal sphincter injury and prolonged parturition. Increased rates of obstetric intervention such as induction of labor and elective caesarean section are observed in the setting of gestational diabetes. The incidence of type II diabetes in mothers diagnosed with GDM is as high as 50% in the decade after the index pregnancy [2]. The development of GDM therefore should be seen as an important window into the future health of the woman and offers a real and timely opportunity to initiate education and lifestyle modifications. There is undoubtedly a high and increasing prevalence of gestational diabetes among the obstetric population globally and current estimates put it 12.4% in the Irish population [3]. Thankfully it has definitively been shown that intervention and appropriate treatment of gestational diabetes significantly improve peri-natal outcomes [4]. Interventions targeted at preventing the onset of GDM have also been shown to result in significant healthcare cost savings. The standard screening modality for gestational diabetes is an oral glucose tolerance test (GTT); usually performed at 24 to 28 weeks. The nature and timing of this test has been the subject of controversy but all regimens are somewhat cumbersome and do not allow for timely intervention for abnormal carbohydrate metabolism in pregnancy. It is an unpleasant test for the pregnant patient to endure and costly for the hospital to perform. We postulate that the ability to accurately predict gestational diabetes in the first trimester of pregnancy would allow for more timely intervention aimed at reducing GDM-related short-term and long-term morbidity. Reserving the formal glucose-tolerance test only for those women deemed to be at high risk on the basis of first trimester biomarkers would have significant resource-saving implications. Altered secretion of glycoproteins has been described in gestational diabetes [4]. It is postulated that proteins modified by intracellular glycosylation may serve as indicators of a maternal response to metabolic changes in pregnancy. Potential GDM biomarkers that have been evaluated to date include the glycoprotein adiponectin, sex-hormone binding globulin, high-sensitivity CRP (also a glycoprotein), placental lactogen and glycosylated fibronectin [5]. The vast majority of studies to date have been conducted on small case-control cohorts and not in a prospective manner. Such studies have demonstrated the above markers as being significantly associated with GDM status. Bearing this data in mind we have commenced a large prospective cohort study which aims to examine a panel of biomarkers (high-sensitivity CRP, sex hormone binding globulin, adiponectin and 1,5 Anhydroglucitol) measured in the first trimester in patients deemed to be at risk of developing gestational diabetes to determine their value in predicting a screen positive OGTT late in the second trimester of pregnancy. Should these biomarkers serve as accurate predictive markers for gestational diabetes, major health benefits would be anticipated from early intervention and treatment along with significant savings in healthcare resources in the short-term due to selective screening with GTT and in the longer term by facilitating early intervention and reducing the burden of disease.

Managing the emerging clinical risk of cutaneous bullae and decubitus ulcers in obstetric patients

[1] Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: Surgical anatomy, embryology, and technique of repair. Am Surg 2006;72(1):42-54. [2] Tsalis K, Zacharakis E, Lambrou I, Betsis D. Incarcerated small bowel in a spigelian hernia. Hernia 2004;8(4):384-6. [3] Rettenbacher T, Hollerweger A, Macheiner P, Gritzmann N, Gotwald T, Frass R, et al. Abdominal wall hernias: cross-sectional imaging signs of incarceration determined with sonography. AJR Am J Roentgenol 2001;177(5):1061-6. [4] Zalel Y, Shalev E, Romano S, Ben-Ami M, Dan U, Weiner E. Incarcerated Spigelian hernia in pregnancy: An ultrasonic diagnosis. J Clin Ultrasound 1992;20(2):146-8.

Shoulder dystocia: analysis from a risk management perspective

We sought to audit the documentation of shoulder dystocia in our institution and re-audit following the introduction of a structured proforma. All cases of shoulder dystocia were identified and studied retrospectively from January 1st 2005 to December 31st 2006. A standardized proforma was introduced and cases of shoulder dystocia were prospectively identified over a 6 month period in 2008. The incidence of shouder dystocia was 0.79% in the initial study and 1.36% in the subsequent audit. Documentation improved with the introduction of the proforma. There was also a significant improvement in neonatal APGARs in the re-audit (35% vs 11.5% APGARs <7 at 1 minute), suggesting improved management of cases of shoulder dystocia. The introduction of a proforma significantly improved the documentation of cases of shoulder dystocia. We would encourage other units to introduce a similar proforma to improve documentation of shoulder dystocia.