First Trimester Prediction of Uteroplacental Disease- Results of the Prospective Handle Study

To assess the ability of non-invasive cardiac output monitoring (NICOM), a novel method of non-invasive maternal hemodynamic assessment using bioreactance, in combination with first trimester biomarkers to predict the evolution of gestational hypertension (GH), pre-eclampsia (PE) and normotensive fetal growth restriction (FGR)

Placental Pathology in Twin Pregnancies

Twin pregnancies remain a challenge in perinatal medicine, with significantly higher rates of complications and increased perinatal morbidity and mortality when compared to singletons. Abnormal growth in twins is a significant independent contributory factor to this increased morbidity, and knowledge of the underlying pathological processes governing growth disorders in twins is vital to improving our antenatal surveillance and clinical management of these pregnancies. We performed a comprehensive study of the placental factors governing growth and development of twin pregnancies in a large, prospectively collected cohort of twins. Placental pathology was evaluated in terms of gross placental abnormalities and histopathological variants with further stereological studies then performed on a selected cohort of placentas. The findings of this study emphasised the differing pathologies underlying disordered growth in monochorionic and dichorionic twin pregnancies. Placentas of monochorionic twins with discordant growth and intrauterine growth restriction showed increased rates of gross abnormalities such as abnormalities of umbilical cord insertion. This likely reflects the unequal placental sharing that may lead to growth discordance among these twins. In contrast, placentas from dichorionic twins with abnormal growth displayed histopathological features consistent with uteroplacental insufficiency. The stereological studies of dichorionic twins further confirmed this with placentas from growth restricted dichorionic twins displaying a reduction in surface area and volume of terminal villi and capillaries. In addition the stereological studies contrasting normal twins and normal singletons gave an interesting insight into the adaptive mechanisms at play to maintain growth in multiple pregnancies. The findings of this study reinforce the importance of accurate assessment of chorionicity in twins, targeted ultrasound assessment including evaluation of placental cord insertion and selected use of multi-vessel Doppler studies to evaluate fetal well-being as part of antenatal ultrasound surveillance.</p

Do obstetrics trainees working hours affect caesarean section rates in normal risk women?

Objectives: The rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates. Study design: This was a population-based study in a tertiary referral centre from 2008-2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p Results: There were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90-1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01-1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07-1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) CONCLUSION: This study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.</p

The RECIPE study: reducing emergency caesareans and improving the primiparous experience: a blinded, prospective, observational study

Background: The RECIPE study aims to validate a risk prediction model for intrapartum caesarean delivery which has been developed by our group. The Genesis study was a prospective observational study carried out by the Perinatal Ireland Research Consortium across 7 clinical centres in Ireland between October 2012 and June 2015. Genesis investigated a range of maternal and fetal parameters in a prospective blinded study of 2336 singleton pregnancies between 39 + 0-41 + 0 weeks' gestational age. This resulted in the development of a risk prediction model for Caesarean Delivery in nulliparous women at term. The RECIPE study now proposes to provide external validation of this risk prediction tool. Methods: In order to externally validate the model, we aim to include a centre which was not involved in the original study. We propose a trial of risk-assignment for intrapartum caesarean amongst nulliparous women with a singleton pregnancy between 38 + 0 and 40 + 6 weeks' gestational age who are planning a vaginal birth. Results of the risk prediction tool will be concealed from participants and from midwives and doctors providing labour care.. Participants will be invited for an ultrasound scan and delivery details will be collated postnatally. The principal aim of this study is to externally validate the risk prediction model. This prediction model holds the potential to accurately identify nulliparous women who are likely to achieve an uncomplicated vaginal birth and those at high prospect of requiring an unplanned caesarean delivery. Discussion: Validation of the Genesis prediction model would enable more accurate counselling for women in the antenatal setting regarding their own likelihood of requiring an intrapartum Caesarean section. It would also provide valuable personalised information to women about the anticipated course of their own labour. We believe that this is an issue of national relevance that will impact positively on obstetric practice, and will positively empower women to make considered, personalised choices surrounding labour and delivery.</p