Noirin Russell | University College Cork (original) (raw)

Papers by Noirin Russell

Diabetes Care, Aug 18, 2009

OBJECTIVE -Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mec... more OBJECTIVE -Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mechanisms are unknown. The aim of this study was to determine whether fetal serum markers of cardiac function differ between normal and type 1 diabetic pregnancies and to examine the relationship between these markers and fetal cardiac structure and function. RESEARCH DESIGN AND METHODS -This was a prospective observational study of 45 type 1 diabetic pregnancies and 39 normal pregnancies. All participants had concentrations of fetal pro-B-type natriuretic peptide (proBNP) and troponin-T (TnT) measured at the time of delivery. All patients with type 1 diabetes had Doppler evaluation of the umbilical artery, middle cerebral artery, and ductus venosus in the third trimester, and a subset (n ϭ 21) had detailed fetal echocardiograms performed in each trimester. -Fetal proBNP and TnT concentrations were higher in the diabetic cohort than in the normal cohort (P Ͻ 0.05). ProBNP correlated positively with interventricular septum thickness (P Ͻ 0.05) but not with cardiac function indexes in the third trimester. In patients with poor glycemic control, there was a significant positive correlation (P Ͻ 0.05) between fetal TnT and the third trimester umbilical artery pulsatility index. There were also increased levels of fetal TnT in infants with poor perinatal outcome (P Ͻ 0.05). CONCLUSIONS -Biochemical markers of cardiac dysfunction are elevated in infants of diabetic mothers, especially those with cardiomyopathy or poor perinatal outcome. Hyperglycemia in early pregnancy may affect myocardial and placental development, thus contributing to the susceptibility to hypoxia seen in these infants.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

Placenta, Jun 1, 2019

Background: A rounded intraplacental hematoma (RIH) is a recently delineated placental lesion. Fo... more Background: A rounded intraplacental hematoma (RIH) is a recently delineated placental lesion. Following the observation of two cases of RIH in placentas associated with stillbirth in 2012, we postulated that RIHs were associated with a higher risk obstetric phenotype when compared to other lesions characteristic of maternal vascular malperfusion (MVM). We aimed to investigate this further by reviewing the associated maternal and fetal characteristics in a series of prospectively identified cases. Methods: Pregnancies where a RIH was identified on placental examination were prospectively collected from February 2014 -July 2016. Comparison was made with pregnancies with placental evidence of MVM but without RIH. Results: 26 placentas with a RIH were identified and 26 placentas with MVM were selected for comparison. There was a statistically significantly increased incidence of stillbirth in the RIH group as compared with the MVM-only group (p=0.022). Also, pregnancies with RIHs had a lower maternal age (p=0.041), decreased incidence of antenatally diagnosed growth restriction (p=0.023), a trend to increased incidence of clinical abruption (p=0.051) and heavier mean infant birthweight (p=0.034). Both groups had a high incidence of pre-eclampsia, Caesarean section and preterm delivery when compared with the general population. Discussion: This is the first study to prospectively identify and collect RIHs using standardised pathological criteria and more than doubles the number of reported cases to date. We present 2 comparable, high-risk cohorts but with a significantly increased incidence of stillbirth in those in which RIHs were seen.

American Journal of Obstetrics and Gynecology, Dec 1, 2005

OBJECTIVE: The role of cardiomegaly in the risk of sudden unexplained death in-utero is unclear. ... more OBJECTIVE: The role of cardiomegaly in the risk of sudden unexplained death in-utero is unclear. The study hypothesis is that cardiomegaly in the fetus contributes to the risk of sudden death in -utero. The aim of the study is to report the incidence of cardiomegaly in stillborn normally formed infants of diabetic mothers and to compare this with the incidence of cardiomegaly in stillborn normally formed macrosomic infants (O90th centile) and stillborn normally formed appropriately grown infants (10-90th centile) without abruption and for whom no cause of stillbirth was identified. STUDY DESIGN: This is a retrospective study of hospital annual reports from 1985 to 2002 with institutional ethics approval. Cardiomegaly was defined as greater than 2 standard deviations above the mean weight for that gestational age (Wigglesworth et al). Additionally blinded to the clinical details, the pathologists (PH and PK) reviewed the histology slides to record the presence or absence of myocardial fibre disarray, a known feature of cardiomyopathy in adults. RESULTS: Over this 17 year period there were 28 stillborn infants in mothers with either insulin dependant diabetes or gestational diabetes, 26 of these had post-mortem examination. Of these 26, 7 had evidence of cardiomegaly (27%). There were 19 stillborn infants that were macrosomic without maternal diabetes and 5 of these had cardiomegaly on post-mortem (26%). None of the stillborn infants that were appropriately grown had evidence of cardiomegaly (0/103). Stillborn macrosomic and stillborn infants of diabetic mothers were more likely to show cardiomegaly on post-mortem (p!0.01). Myocardial disarray was evident in only 1 case of diabetic cardiomegaly, suggesting that this histological parameter is not a feature of diabetic cardiomyopathy. CONCLUSION: Cardiomegaly may contribute to the risk of fetal death in macrosomic infants and infants of diabetic mothers. Myocardial disarray does not appear to be a constant histological characteristic of diabetic related fetal cardiomegaly.

American Journal of Obstetrics and Gynecology, 2011

The Ph value was never Ͻ7. It was Ͻ 7.15 in 13 (33%) cases. Using DFHRM or RCOG classifications n... more The Ph value was never Ͻ7. It was Ͻ 7.15 in 13 (33%) cases. Using DFHRM or RCOG classifications no traces resulted normal. In contrast normal traces were found using SOCG (6 cases: 14%), Parer (11 cases: 26%) and NICHHD (4 cases: 9%) classification. When considering ph Ͻ7.15cut off, we observed the following sensitivity and specificity values: 1 and 0 (DFHRM); 1 and 0 (RCOG); 0,5 and 0 (SOGC); 0 and 0.8 (Parer & Ikeda); 0 and 1 (NICHHD). In almost one half of the cases CTG resulted non reassuring or suspicious (DFHRM), suspicious (RCOG), atypical (SOGC) or yellow (Parer & Ikeda). The percentage rices to 91% when adopting NICHHD (indeterminate). Proportion of agreements index ranged from 2.8 (RCOG-Parer & Ikeda) to 8.8 (RCOG-DFHRM). CONCLUSIONS: There is fair agreement in the interpretation of EFM classification systems. Parer & Ikeda and NICHHD classifications have a better specificity in detecting umbilical cord phϽ7.15, but Parer & Ikeda is the one that showed the best predictor value of low levels of umbilical cord ph.

American Journal of Obstetrics and Gynecology, Sep 1, 2008

Fetuses of diabetic pregnancy experience cardiomyopathy, the intracardiac cause of which is under... more Fetuses of diabetic pregnancy experience cardiomyopathy, the intracardiac cause of which is understood poorly. The aim of this study was to assess the interrelation between cardiac functional and structural changes in fetuses of mothers with pregestational diabetes mellitus. Twenty-six mothers with pregestational diabetes mellitus were recruited prospectively to have a fetal echocardiogram at 13, 20, and 36 weeks of gestation to assess cardiac function and structure. For comparison, 30 healthy control subjects were recruited at each gestational age. In the first trimester, there was evidence of poorer fetal cardiac diastolic function among the diabetic cohort (lower left early/atrial ratio, longer isovolumetric relaxation time and higher left myocardial performance index; P < .05). In the third trimester, the fetal interventricular septum and the right ventricular free wall were thicker in the diabetic cohort (P < .05). In fetuses of pregestational diabetic pregnancy, sonographic evidence of altered cardiac function is evident before ultrasound evidence of cardiac structural changes. This suggests that altered cardiac function may precede cardiac structural changes in fetuses of pregestational diabetic pregnancy.

American Journal of Obstetrics and Gynecology, Dec 1, 2007

American Journal of Obstetrics and Gynecology, Dec 1, 2008

BMJ sexual & reproductive health, Apr 15, 2021

Acknowledgements The authors are grateful to Karyn Walsh for her role in data collection for the ... more Acknowledgements The authors are grateful to Karyn Walsh for her role in data collection for the study. Contributors KOD and SL were responsible for the study conceptualisation. EOS and NR completed data collection. EOS and SL analysed the data. EOS, KOD and SL wrote the letter.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

OBJECTIVE: Ultrasound prediction of birthweight is an inaccurate science especially at the extrem... more OBJECTIVE: Ultrasound prediction of birthweight is an inaccurate science especially at the extremes of growth. In utero measurements of fetal anthropometric measurements have been used in an attempt to increase accuracy. The aim of the study is to determine if there is an association between third trimester anterior abdominal wall thickness and birth weight and also whether booking HbA1C in type 1 diabetic pregnancy is associated with an increased fetal anterior abdominal wall thickness. STUDY DESIGN: This is a prospective study with institutional ethics approval and written maternal consent. A measurement of the fetal anterior abdominal wall (AAW) was taken at the traditional abdominal circumference view, 2-3 cm lateral to the cord insertion, and included fetal skin and subcutaneous tissue. Measurements were recorded at 33-37 week's gestation in 167 patients. Birth weight and birth weight centile was recorded. RESULTS: Of 167 measurements taken, 90 were in fetuses of type 1 diabetic mothers, 54 in fetuses of gestational diabetic mothers, 15 in fetuses of nondiabetic mothers and 8 in fetuses of type 2 diabetic mothers. Booking HbA1c in the pregestational diabetic population correlated positively with third trimester AAW measurements (p!0.05). Third trimester anterior abdominal wall thickness correlated positively with birth weight (p!0.01) and with birth weight centile at delivery (p!0.001). Third trimester AAW measurements are significantly higher in babies with a birth weight O/=90th centile compared to those with a birth weight less than the 90th centile (5.4C/À1.1mm vs. 4.9C/ À1.2 p!0.05). CONCLUSION: Poorer periconceptual glycaemic control results in thickened fetal anterior abdominal wall thickness in the third trimester in type 1 diabetes. An AAW measurement of greater than 5mm in the third trimester may help to identify fetuses at risk of macrosomia.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

European Journal of Obstetrics & Gynecology and Reproductive Biology, Dec 1, 2013

There has been considerable evolution in the management of red cell alloimmunisation in recent de... more There has been considerable evolution in the management of red cell alloimmunisation in recent decades . The widespread availability of Rh immune globulin has dramatically reduced the rate of Rh(D) sensitization, with a reported incidence of 6.8 per 1000 live births in the US in 2003 . Rates in developing nations, however, remain far higher . Non-invasive fetal monitoring using middle cerebral artery peak systolic velocity (MCA-PSV), first proposed in 2000 , has become the cornerstone of antenatal surveillance, such that amniocentesis for bilirubin levels is now of historical interest only . Furthermore, assessment of cell-free fetal DNA in maternal blood has made possible the non-invasive determination of fetal Rh genotype, allowing surveillance to be targeted at the highest risk groups . Despite these advances, intrauterine fetal transfusion (IUT) remains the treatment of choice for those fetuses that do develop anaemia. The falling number of intrauterine transfusions and the technical challenges inherent in invasive fetal therapies make it imperative that these procedures are centralized to a small number of specialized centres with the necessary expertise to undertake IUT . Despite the high rate of multiple antibody formation among alloimmunised women , the relationship between antibody type and the effect of multiple antibody formation on outcomes following IUT have not been well reported. We present a retrospective analysis of a cohort of intrauterine transfusions for red cell alloimmunisation over a 16-year period at our national, quaternary-referral fetal medicine centre. We wished to determine the antenatal course of pregnancies requiring IUT for alloimmunisation secondary to Rh(D) vs. non-Rh(D) antibodies, as well as the effect of multiple antibodies in women sensitized to Rh(D) who require IUT.

PLOS ONE, Feb 17, 2012

Aim: Placental growth hormone (PGH) is a major growth hormone in pregnancy and acts with Insulin ... more Aim: Placental growth hormone (PGH) is a major growth hormone in pregnancy and acts with Insulin Like Growth Factor I (IGF-I) and Insulin Like Growth Hormone Binding Protein 3 (IGFBP3). The aim of this study was to investigate PGH, IGF-I and IGFBP3 in non-diabetic (ND) compared to Type 1 Diabetic (T1DM) pregnancies. Methods: This is a prospective study. Maternal samples were obtained from 25 ND and 25 T1DM mothers at 36 weeks gestation. Cord blood was obtained after delivery. PGH, IGF-I and IGFBP3 were measured using ELISA. Results: There was no difference in delivery type, gender of infants or birth weight between groups. In T1DM, maternal PGH significantly correlated with ultrasound estimated fetal weight (r = 0.4, p = 0.02), birth weight (r = 0.51, p,0.05) and birth weight centile (r = 0.41, p = 0.03) PGH did not correlate with HbA1c. Maternal IGF-I was lower in T1DM (p = 0.03). Maternal and fetal serum IGFBP3 was higher in T1DM. Maternal third trimester T1DM serum had a significant band at 16 kD on western blot, which was not present in ND. Maternal T1DM PGH correlated with both antenatal fetal weight and birth weight, suggesting a significant role for PGH in growth in diabetic pregnancy. IGFBP3 is significantly increased in maternal and fetal serum in T1DM pregnancies compared to ND controls, which was explained by increased proteolysis in maternal but not fetal serum. These results suggest that the normal PGH-IGF-I-IGFBP3 axis in pregnancy is abnormal in T1DM pregnancies, which are at higher risk of macrosomia.

Pediatric and Developmental Pathology, 2008

To report the incidence of cardiomegaly in stillborn normally formed infants of mothers with diab... more To report the incidence of cardiomegaly in stillborn normally formed infants of mothers with diabetes mellitus. This is a retrospective study with institutional ethics approval. The presence of cardiomegaly was recorded in stillborn infants of diabetic mothers ( N = 27) and compared with that recorded in stillborn large-for–gestational age (LGA > 90th percentile, n = 18) and stillborn appropriately grown (10th to 90th percentiles, n = 107) nondiabetic infants. Blinded to the clinical details, the histology slides were reviewed to measure cardiac wall thickness and to record the presence or absence of myocardial fiber disarray. Stillborn infants of mothers with diabetes mellitus, when compared with appropriately grown stillborn nondiabetic infants and when adjusted for birth weight, had heavier hearts, thicker ventricular free wall measurements, and lighter brains. While cardiomegaly was reported in 22% of stillborn LGA infants, comparison with stillborn appropriately grown infants revealed no difference in heart weights corrected for birth weight. Comparison of LGA nondiabetic infants with stillborn diabetes mellitus infants revealed greater actual heart weight/expected for birth weight ( P < 0.05) and lighter brains (actual brain weight/expected for birth weight, P < 0.05) in the diabetes mellitus group. Cardiomegaly is a common finding in stillborn infants of mothers with diabetes mellitus and may contribute to the risk of fetal death in these pregnancies.

European Journal of Obstetrics & Gynecology and Reproductive Biology, Sep 1, 2008

The purpose of this study was to investigate whether third trimester fetal anterior abdominal wal... more The purpose of this study was to investigate whether third trimester fetal anterior abdominal wall (AAW) thickness in diabetic pregnancy reflects glycaemic control and predicts macrosomia. Prospective cohort study in a tertiary level maternity unit. One hundred and twenty-five diabetic mothers (71 pre-gestational and 54 gestational diabetics on insulin) underwent routine serial third trimester ultrasound examination with the additional measurement of AAW thickness. Pregnancy outcome was obtained. 335 fetal AAW measurements were recorded in diabetic pregnancy from 30 to 38 weeks gestation. Third trimester AAW was significantly higher in macrosomic babies (5.4+/-1.4 mm vs. 4.7+/-1.4 mm, p<0.05). ROC derived cut off for AAW in the prediction of macrosomia was 3.5 mm at 30 weeks, 4.5 mm at 33 weeks and 5.5 mm at 36 weeks gestation. Using either a raised AAW measurement or an AC>90th centile, the prediction of birth weight greater than the 90th centile was better (88%) than with AC alone (70%). This improvement in sensitivity held even at earlier gestations in the third trimester. Measurement of AAW in diabetic pregnancy may have a role in the prediction of macrosomia.

American Journal of Obstetrics and Gynecology, Dec 1, 2008

While insulin resistance (IR) of pregnancy is commonly believed to be a necessity to support offs... more While insulin resistance (IR) of pregnancy is commonly believed to be a necessity to support offspring, no in vivo evidence has supported this theory. Using a tool to modulate IR in pregnant rats, we tested the impact of improved insulin sensitivity on placenta and pups in vivo. STUDY DESIGN: We studied 3 groups of age-matched SD rats: 1)Pregnant (Day 19) non-obese, glucose tolerant (P; nϭ6), 2)Pregnant rats(Day 19) which had visceral fat surgically removed 1 month prior to mating(PVF-; nϭ6) and 3)Non-Pregnant (NP; nϭ6). We used a model of pre-conception surgical removal of visceral fat (previously shown to improve insulin sensitivity based on glucose infusion rate during hyperinsulinemic clamp) as a tool to improve insulin action in pregnancy. A bolus of 2-[U-14C]deoxyglucose (20 Ci) was administered over 30 minutes before the end of hyperinsulinemic-euglycemic clamp to determine tissue glucose uptake. During this clamp all rats were exposed to similar insulin levels, plasma samples for 2-[U-14C]deoxyglucose-specific activity were obtained at 10min intervals and tissue samples of hid-limb muscle, visceral fat, placenta and pups were collected after the clamp. RESULTS: Glucose uptake in muscle was greater in NP compared to P (27.6Ϯ4 v 13.5Ϯ3.4 ug/g/min, pϽ0.05) and intermediate in VF-(23.8Ϯ6.3 ug/g/min, pϭNS compared to other groups) demonstrating variation in insulin action. Placental uptake was similar in P and VF-(70.2Ϯ10.3 v 67.6Ϯ12.3 ug/g/min, pϭNS), but fetal uptake was almost doubled in P compared VF-(69.9Ϯ7.3 v 39.5Ϯ9.8 ug/g/min, pϽ0.05). The percentage of total body glucose uptake into the fetal/ placental unit is much larger than that into muscle (P 63.0 v 6.1% and VF-48.6 v 9.3%, respectively). CONCLUSION: IR in pregnancy is a determining factor in glucose uptake to the fetus, but not placenta. Yet, the degree of IR required for adequate, but not excessive fetal growth has yet to be determined as well as if maternal IR increases fetal risk for development of diabetes later in life.

Archives of Disease in Childhood-fetal and Neonatal Edition, Apr 1, 2012

Objective To examine perinatal outcomes following intrauterine fetal transfusion (IUT), in a sing... more Objective To examine perinatal outcomes following intrauterine fetal transfusion (IUT), in a single tertiary fetal medicine unit over a 15-year period. Study design A retrospective analysis of women undergoing IUT in the National Maternity Hospital, Dublin from 1996-2010. Eligible cases were identified from a prospectively collated transfusion register. Cases of alloimmune thrombocytopenia, non-immune hydrops or parvovirus infection were excluded. The cord insertion was the preferred site, with the intra-hepatic vein and free cord reserved for inaccessible cases. All procedures were performed by 2 specialists in fetal medicine. Post-transfusion, women were admitted overnight, with biophysical profile and Doppler indices performed prior to discharge. Results Between 1996 and 2010, 262 IUTs were performed in our unit, of which 244 (93%) were undertaken for red cell alloimmunisation, involving 97 pregnancies. The majority of women (84%) had anti-D antibodies, with a smaller incidence of anti-Kell (12%), anti-c (3%) and anti-E (1%) antibodies. Affected women underwent a median of 3 (IQR 2-4) procedures. In total, there were 3 intrauterine fetal deaths and 4 early neonatal deaths, for a perinatal mortality rate of 7%. The procedure-related loss rate was 1.2% (3/244). Two women had in utero fetal demise within 48 hours of the IUT, at 25 weeks and 29 weeks respectively. The third loss was from a cord haematoma at 32 weeks, with early neonatal demise. Conclusion Intrauterine fetal transfusion is a safe procedure, associated with a low (1%) rate of procedure-related fetal loss, when performed by experienced practitioners in a national referral centre.

In 2016 the Health Service Executive (HSE) launched the National Standards for Bereavement Care f... more In 2016 the Health Service Executive (HSE) launched the National Standards for Bereavement Care for Pregnancy Loss and Perinatal Death (Health Service Executive 2016). Dr. Keelin O Donoghue was appointed as Lead Clinician for standards implementation. A multidisciplinary National Implementation Group was formed to roll out the standards, subdividing into four workstreams. Each work stream had specific aims and objectives. The Education and Staff Support Work-stream was asked to explore the current landscape of perinatal bereavement education programmes for all personnel involved in caring for women and their families (Appendix 1).

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

BMC Pregnancy and Childbirth, Jan 29, 2016

Diabetes Care, Aug 18, 2009

OBJECTIVE -Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mec... more OBJECTIVE -Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mechanisms are unknown. The aim of this study was to determine whether fetal serum markers of cardiac function differ between normal and type 1 diabetic pregnancies and to examine the relationship between these markers and fetal cardiac structure and function. RESEARCH DESIGN AND METHODS -This was a prospective observational study of 45 type 1 diabetic pregnancies and 39 normal pregnancies. All participants had concentrations of fetal pro-B-type natriuretic peptide (proBNP) and troponin-T (TnT) measured at the time of delivery. All patients with type 1 diabetes had Doppler evaluation of the umbilical artery, middle cerebral artery, and ductus venosus in the third trimester, and a subset (n ϭ 21) had detailed fetal echocardiograms performed in each trimester. -Fetal proBNP and TnT concentrations were higher in the diabetic cohort than in the normal cohort (P Ͻ 0.05). ProBNP correlated positively with interventricular septum thickness (P Ͻ 0.05) but not with cardiac function indexes in the third trimester. In patients with poor glycemic control, there was a significant positive correlation (P Ͻ 0.05) between fetal TnT and the third trimester umbilical artery pulsatility index. There were also increased levels of fetal TnT in infants with poor perinatal outcome (P Ͻ 0.05). CONCLUSIONS -Biochemical markers of cardiac dysfunction are elevated in infants of diabetic mothers, especially those with cardiomyopathy or poor perinatal outcome. Hyperglycemia in early pregnancy may affect myocardial and placental development, thus contributing to the susceptibility to hypoxia seen in these infants.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

Placenta, Jun 1, 2019

Background: A rounded intraplacental hematoma (RIH) is a recently delineated placental lesion. Fo... more Background: A rounded intraplacental hematoma (RIH) is a recently delineated placental lesion. Following the observation of two cases of RIH in placentas associated with stillbirth in 2012, we postulated that RIHs were associated with a higher risk obstetric phenotype when compared to other lesions characteristic of maternal vascular malperfusion (MVM). We aimed to investigate this further by reviewing the associated maternal and fetal characteristics in a series of prospectively identified cases. Methods: Pregnancies where a RIH was identified on placental examination were prospectively collected from February 2014 -July 2016. Comparison was made with pregnancies with placental evidence of MVM but without RIH. Results: 26 placentas with a RIH were identified and 26 placentas with MVM were selected for comparison. There was a statistically significantly increased incidence of stillbirth in the RIH group as compared with the MVM-only group (p=0.022). Also, pregnancies with RIHs had a lower maternal age (p=0.041), decreased incidence of antenatally diagnosed growth restriction (p=0.023), a trend to increased incidence of clinical abruption (p=0.051) and heavier mean infant birthweight (p=0.034). Both groups had a high incidence of pre-eclampsia, Caesarean section and preterm delivery when compared with the general population. Discussion: This is the first study to prospectively identify and collect RIHs using standardised pathological criteria and more than doubles the number of reported cases to date. We present 2 comparable, high-risk cohorts but with a significantly increased incidence of stillbirth in those in which RIHs were seen.

American Journal of Obstetrics and Gynecology, Dec 1, 2005

OBJECTIVE: The role of cardiomegaly in the risk of sudden unexplained death in-utero is unclear. ... more OBJECTIVE: The role of cardiomegaly in the risk of sudden unexplained death in-utero is unclear. The study hypothesis is that cardiomegaly in the fetus contributes to the risk of sudden death in -utero. The aim of the study is to report the incidence of cardiomegaly in stillborn normally formed infants of diabetic mothers and to compare this with the incidence of cardiomegaly in stillborn normally formed macrosomic infants (O90th centile) and stillborn normally formed appropriately grown infants (10-90th centile) without abruption and for whom no cause of stillbirth was identified. STUDY DESIGN: This is a retrospective study of hospital annual reports from 1985 to 2002 with institutional ethics approval. Cardiomegaly was defined as greater than 2 standard deviations above the mean weight for that gestational age (Wigglesworth et al). Additionally blinded to the clinical details, the pathologists (PH and PK) reviewed the histology slides to record the presence or absence of myocardial fibre disarray, a known feature of cardiomyopathy in adults. RESULTS: Over this 17 year period there were 28 stillborn infants in mothers with either insulin dependant diabetes or gestational diabetes, 26 of these had post-mortem examination. Of these 26, 7 had evidence of cardiomegaly (27%). There were 19 stillborn infants that were macrosomic without maternal diabetes and 5 of these had cardiomegaly on post-mortem (26%). None of the stillborn infants that were appropriately grown had evidence of cardiomegaly (0/103). Stillborn macrosomic and stillborn infants of diabetic mothers were more likely to show cardiomegaly on post-mortem (p!0.01). Myocardial disarray was evident in only 1 case of diabetic cardiomegaly, suggesting that this histological parameter is not a feature of diabetic cardiomyopathy. CONCLUSION: Cardiomegaly may contribute to the risk of fetal death in macrosomic infants and infants of diabetic mothers. Myocardial disarray does not appear to be a constant histological characteristic of diabetic related fetal cardiomegaly.

American Journal of Obstetrics and Gynecology, 2011

The Ph value was never Ͻ7. It was Ͻ 7.15 in 13 (33%) cases. Using DFHRM or RCOG classifications n... more The Ph value was never Ͻ7. It was Ͻ 7.15 in 13 (33%) cases. Using DFHRM or RCOG classifications no traces resulted normal. In contrast normal traces were found using SOCG (6 cases: 14%), Parer (11 cases: 26%) and NICHHD (4 cases: 9%) classification. When considering ph Ͻ7.15cut off, we observed the following sensitivity and specificity values: 1 and 0 (DFHRM); 1 and 0 (RCOG); 0,5 and 0 (SOGC); 0 and 0.8 (Parer & Ikeda); 0 and 1 (NICHHD). In almost one half of the cases CTG resulted non reassuring or suspicious (DFHRM), suspicious (RCOG), atypical (SOGC) or yellow (Parer & Ikeda). The percentage rices to 91% when adopting NICHHD (indeterminate). Proportion of agreements index ranged from 2.8 (RCOG-Parer & Ikeda) to 8.8 (RCOG-DFHRM). CONCLUSIONS: There is fair agreement in the interpretation of EFM classification systems. Parer & Ikeda and NICHHD classifications have a better specificity in detecting umbilical cord phϽ7.15, but Parer & Ikeda is the one that showed the best predictor value of low levels of umbilical cord ph.

American Journal of Obstetrics and Gynecology, Sep 1, 2008

Fetuses of diabetic pregnancy experience cardiomyopathy, the intracardiac cause of which is under... more Fetuses of diabetic pregnancy experience cardiomyopathy, the intracardiac cause of which is understood poorly. The aim of this study was to assess the interrelation between cardiac functional and structural changes in fetuses of mothers with pregestational diabetes mellitus. Twenty-six mothers with pregestational diabetes mellitus were recruited prospectively to have a fetal echocardiogram at 13, 20, and 36 weeks of gestation to assess cardiac function and structure. For comparison, 30 healthy control subjects were recruited at each gestational age. In the first trimester, there was evidence of poorer fetal cardiac diastolic function among the diabetic cohort (lower left early/atrial ratio, longer isovolumetric relaxation time and higher left myocardial performance index; P < .05). In the third trimester, the fetal interventricular septum and the right ventricular free wall were thicker in the diabetic cohort (P < .05). In fetuses of pregestational diabetic pregnancy, sonographic evidence of altered cardiac function is evident before ultrasound evidence of cardiac structural changes. This suggests that altered cardiac function may precede cardiac structural changes in fetuses of pregestational diabetic pregnancy.

American Journal of Obstetrics and Gynecology, Dec 1, 2007

American Journal of Obstetrics and Gynecology, Dec 1, 2008

BMJ sexual & reproductive health, Apr 15, 2021

Acknowledgements The authors are grateful to Karyn Walsh for her role in data collection for the ... more Acknowledgements The authors are grateful to Karyn Walsh for her role in data collection for the study. Contributors KOD and SL were responsible for the study conceptualisation. EOS and NR completed data collection. EOS and SL analysed the data. EOS, KOD and SL wrote the letter.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

OBJECTIVE: Ultrasound prediction of birthweight is an inaccurate science especially at the extrem... more OBJECTIVE: Ultrasound prediction of birthweight is an inaccurate science especially at the extremes of growth. In utero measurements of fetal anthropometric measurements have been used in an attempt to increase accuracy. The aim of the study is to determine if there is an association between third trimester anterior abdominal wall thickness and birth weight and also whether booking HbA1C in type 1 diabetic pregnancy is associated with an increased fetal anterior abdominal wall thickness. STUDY DESIGN: This is a prospective study with institutional ethics approval and written maternal consent. A measurement of the fetal anterior abdominal wall (AAW) was taken at the traditional abdominal circumference view, 2-3 cm lateral to the cord insertion, and included fetal skin and subcutaneous tissue. Measurements were recorded at 33-37 week's gestation in 167 patients. Birth weight and birth weight centile was recorded. RESULTS: Of 167 measurements taken, 90 were in fetuses of type 1 diabetic mothers, 54 in fetuses of gestational diabetic mothers, 15 in fetuses of nondiabetic mothers and 8 in fetuses of type 2 diabetic mothers. Booking HbA1c in the pregestational diabetic population correlated positively with third trimester AAW measurements (p!0.05). Third trimester anterior abdominal wall thickness correlated positively with birth weight (p!0.01) and with birth weight centile at delivery (p!0.001). Third trimester AAW measurements are significantly higher in babies with a birth weight O/=90th centile compared to those with a birth weight less than the 90th centile (5.4C/À1.1mm vs. 4.9C/ À1.2 p!0.05). CONCLUSION: Poorer periconceptual glycaemic control results in thickened fetal anterior abdominal wall thickness in the third trimester in type 1 diabetes. An AAW measurement of greater than 5mm in the third trimester may help to identify fetuses at risk of macrosomia.

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

European Journal of Obstetrics & Gynecology and Reproductive Biology, Dec 1, 2013

There has been considerable evolution in the management of red cell alloimmunisation in recent de... more There has been considerable evolution in the management of red cell alloimmunisation in recent decades . The widespread availability of Rh immune globulin has dramatically reduced the rate of Rh(D) sensitization, with a reported incidence of 6.8 per 1000 live births in the US in 2003 . Rates in developing nations, however, remain far higher . Non-invasive fetal monitoring using middle cerebral artery peak systolic velocity (MCA-PSV), first proposed in 2000 , has become the cornerstone of antenatal surveillance, such that amniocentesis for bilirubin levels is now of historical interest only . Furthermore, assessment of cell-free fetal DNA in maternal blood has made possible the non-invasive determination of fetal Rh genotype, allowing surveillance to be targeted at the highest risk groups . Despite these advances, intrauterine fetal transfusion (IUT) remains the treatment of choice for those fetuses that do develop anaemia. The falling number of intrauterine transfusions and the technical challenges inherent in invasive fetal therapies make it imperative that these procedures are centralized to a small number of specialized centres with the necessary expertise to undertake IUT . Despite the high rate of multiple antibody formation among alloimmunised women , the relationship between antibody type and the effect of multiple antibody formation on outcomes following IUT have not been well reported. We present a retrospective analysis of a cohort of intrauterine transfusions for red cell alloimmunisation over a 16-year period at our national, quaternary-referral fetal medicine centre. We wished to determine the antenatal course of pregnancies requiring IUT for alloimmunisation secondary to Rh(D) vs. non-Rh(D) antibodies, as well as the effect of multiple antibodies in women sensitized to Rh(D) who require IUT.

PLOS ONE, Feb 17, 2012

Aim: Placental growth hormone (PGH) is a major growth hormone in pregnancy and acts with Insulin ... more Aim: Placental growth hormone (PGH) is a major growth hormone in pregnancy and acts with Insulin Like Growth Factor I (IGF-I) and Insulin Like Growth Hormone Binding Protein 3 (IGFBP3). The aim of this study was to investigate PGH, IGF-I and IGFBP3 in non-diabetic (ND) compared to Type 1 Diabetic (T1DM) pregnancies. Methods: This is a prospective study. Maternal samples were obtained from 25 ND and 25 T1DM mothers at 36 weeks gestation. Cord blood was obtained after delivery. PGH, IGF-I and IGFBP3 were measured using ELISA. Results: There was no difference in delivery type, gender of infants or birth weight between groups. In T1DM, maternal PGH significantly correlated with ultrasound estimated fetal weight (r = 0.4, p = 0.02), birth weight (r = 0.51, p,0.05) and birth weight centile (r = 0.41, p = 0.03) PGH did not correlate with HbA1c. Maternal IGF-I was lower in T1DM (p = 0.03). Maternal and fetal serum IGFBP3 was higher in T1DM. Maternal third trimester T1DM serum had a significant band at 16 kD on western blot, which was not present in ND. Maternal T1DM PGH correlated with both antenatal fetal weight and birth weight, suggesting a significant role for PGH in growth in diabetic pregnancy. IGFBP3 is significantly increased in maternal and fetal serum in T1DM pregnancies compared to ND controls, which was explained by increased proteolysis in maternal but not fetal serum. These results suggest that the normal PGH-IGF-I-IGFBP3 axis in pregnancy is abnormal in T1DM pregnancies, which are at higher risk of macrosomia.

Pediatric and Developmental Pathology, 2008

To report the incidence of cardiomegaly in stillborn normally formed infants of mothers with diab... more To report the incidence of cardiomegaly in stillborn normally formed infants of mothers with diabetes mellitus. This is a retrospective study with institutional ethics approval. The presence of cardiomegaly was recorded in stillborn infants of diabetic mothers ( N = 27) and compared with that recorded in stillborn large-for–gestational age (LGA > 90th percentile, n = 18) and stillborn appropriately grown (10th to 90th percentiles, n = 107) nondiabetic infants. Blinded to the clinical details, the histology slides were reviewed to measure cardiac wall thickness and to record the presence or absence of myocardial fiber disarray. Stillborn infants of mothers with diabetes mellitus, when compared with appropriately grown stillborn nondiabetic infants and when adjusted for birth weight, had heavier hearts, thicker ventricular free wall measurements, and lighter brains. While cardiomegaly was reported in 22% of stillborn LGA infants, comparison with stillborn appropriately grown infants revealed no difference in heart weights corrected for birth weight. Comparison of LGA nondiabetic infants with stillborn diabetes mellitus infants revealed greater actual heart weight/expected for birth weight ( P < 0.05) and lighter brains (actual brain weight/expected for birth weight, P < 0.05) in the diabetes mellitus group. Cardiomegaly is a common finding in stillborn infants of mothers with diabetes mellitus and may contribute to the risk of fetal death in these pregnancies.

European Journal of Obstetrics & Gynecology and Reproductive Biology, Sep 1, 2008

The purpose of this study was to investigate whether third trimester fetal anterior abdominal wal... more The purpose of this study was to investigate whether third trimester fetal anterior abdominal wall (AAW) thickness in diabetic pregnancy reflects glycaemic control and predicts macrosomia. Prospective cohort study in a tertiary level maternity unit. One hundred and twenty-five diabetic mothers (71 pre-gestational and 54 gestational diabetics on insulin) underwent routine serial third trimester ultrasound examination with the additional measurement of AAW thickness. Pregnancy outcome was obtained. 335 fetal AAW measurements were recorded in diabetic pregnancy from 30 to 38 weeks gestation. Third trimester AAW was significantly higher in macrosomic babies (5.4+/-1.4 mm vs. 4.7+/-1.4 mm, p<0.05). ROC derived cut off for AAW in the prediction of macrosomia was 3.5 mm at 30 weeks, 4.5 mm at 33 weeks and 5.5 mm at 36 weeks gestation. Using either a raised AAW measurement or an AC>90th centile, the prediction of birth weight greater than the 90th centile was better (88%) than with AC alone (70%). This improvement in sensitivity held even at earlier gestations in the third trimester. Measurement of AAW in diabetic pregnancy may have a role in the prediction of macrosomia.

American Journal of Obstetrics and Gynecology, Dec 1, 2008

While insulin resistance (IR) of pregnancy is commonly believed to be a necessity to support offs... more While insulin resistance (IR) of pregnancy is commonly believed to be a necessity to support offspring, no in vivo evidence has supported this theory. Using a tool to modulate IR in pregnant rats, we tested the impact of improved insulin sensitivity on placenta and pups in vivo. STUDY DESIGN: We studied 3 groups of age-matched SD rats: 1)Pregnant (Day 19) non-obese, glucose tolerant (P; nϭ6), 2)Pregnant rats(Day 19) which had visceral fat surgically removed 1 month prior to mating(PVF-; nϭ6) and 3)Non-Pregnant (NP; nϭ6). We used a model of pre-conception surgical removal of visceral fat (previously shown to improve insulin sensitivity based on glucose infusion rate during hyperinsulinemic clamp) as a tool to improve insulin action in pregnancy. A bolus of 2-[U-14C]deoxyglucose (20 Ci) was administered over 30 minutes before the end of hyperinsulinemic-euglycemic clamp to determine tissue glucose uptake. During this clamp all rats were exposed to similar insulin levels, plasma samples for 2-[U-14C]deoxyglucose-specific activity were obtained at 10min intervals and tissue samples of hid-limb muscle, visceral fat, placenta and pups were collected after the clamp. RESULTS: Glucose uptake in muscle was greater in NP compared to P (27.6Ϯ4 v 13.5Ϯ3.4 ug/g/min, pϽ0.05) and intermediate in VF-(23.8Ϯ6.3 ug/g/min, pϭNS compared to other groups) demonstrating variation in insulin action. Placental uptake was similar in P and VF-(70.2Ϯ10.3 v 67.6Ϯ12.3 ug/g/min, pϭNS), but fetal uptake was almost doubled in P compared VF-(69.9Ϯ7.3 v 39.5Ϯ9.8 ug/g/min, pϽ0.05). The percentage of total body glucose uptake into the fetal/ placental unit is much larger than that into muscle (P 63.0 v 6.1% and VF-48.6 v 9.3%, respectively). CONCLUSION: IR in pregnancy is a determining factor in glucose uptake to the fetus, but not placenta. Yet, the degree of IR required for adequate, but not excessive fetal growth has yet to be determined as well as if maternal IR increases fetal risk for development of diabetes later in life.

Archives of Disease in Childhood-fetal and Neonatal Edition, Apr 1, 2012

Objective To examine perinatal outcomes following intrauterine fetal transfusion (IUT), in a sing... more Objective To examine perinatal outcomes following intrauterine fetal transfusion (IUT), in a single tertiary fetal medicine unit over a 15-year period. Study design A retrospective analysis of women undergoing IUT in the National Maternity Hospital, Dublin from 1996-2010. Eligible cases were identified from a prospectively collated transfusion register. Cases of alloimmune thrombocytopenia, non-immune hydrops or parvovirus infection were excluded. The cord insertion was the preferred site, with the intra-hepatic vein and free cord reserved for inaccessible cases. All procedures were performed by 2 specialists in fetal medicine. Post-transfusion, women were admitted overnight, with biophysical profile and Doppler indices performed prior to discharge. Results Between 1996 and 2010, 262 IUTs were performed in our unit, of which 244 (93%) were undertaken for red cell alloimmunisation, involving 97 pregnancies. The majority of women (84%) had anti-D antibodies, with a smaller incidence of anti-Kell (12%), anti-c (3%) and anti-E (1%) antibodies. Affected women underwent a median of 3 (IQR 2-4) procedures. In total, there were 3 intrauterine fetal deaths and 4 early neonatal deaths, for a perinatal mortality rate of 7%. The procedure-related loss rate was 1.2% (3/244). Two women had in utero fetal demise within 48 hours of the IUT, at 25 weeks and 29 weeks respectively. The third loss was from a cord haematoma at 32 weeks, with early neonatal demise. Conclusion Intrauterine fetal transfusion is a safe procedure, associated with a low (1%) rate of procedure-related fetal loss, when performed by experienced practitioners in a national referral centre.

In 2016 the Health Service Executive (HSE) launched the National Standards for Bereavement Care f... more In 2016 the Health Service Executive (HSE) launched the National Standards for Bereavement Care for Pregnancy Loss and Perinatal Death (Health Service Executive 2016). Dr. Keelin O Donoghue was appointed as Lead Clinician for standards implementation. A multidisciplinary National Implementation Group was formed to roll out the standards, subdividing into four workstreams. Each work stream had specific aims and objectives. The Education and Staff Support Work-stream was asked to explore the current landscape of perinatal bereavement education programmes for all personnel involved in caring for women and their families (Appendix 1).

American Journal of Obstetrics and Gynecology, Dec 1, 2006

If the factors contributing to shoulder dystocia could be modified, it could result in decreased ... more If the factors contributing to shoulder dystocia could be modified, it could result in decreased rate and prevention. We sought to investigate the relationship between levels of glycemia, birth percentiles and the occurrence of shoulder dystocia. STUDY DESIGN: Diabetic subjects using memory-based self monitoring blood glucose were treated with diet or insulin. The rate of SHD in each mean blood glucose and birth percentile categories was calculated. Mean blood glucose categories: low-90, 91-100, 101-110, 111-high mg/dl; birth percentiles: low-49, 50-69, 70-89, 90-high. Variables identified in the univariant analysis as being significant or borderline significant were included in multiple variable logistic regression analysis. RESULTS: The overall incidence of SD was 6.7% in the GDM group (82/1215) and PGDM 6.0% (35/545). For GDM subjects: (1.) a continuous increase in the rate of SHD for the first 3 categories of mean blood glucose (1.9, 4.7, 7.8 percent, p=0.05) and similar rate between the third and fourth glucose categories (7.8 vs. 8.7%) (2.) SHD in the low-49 birth percentile was 0.5%; 50-69, 70-89 and 90-high categories was 1.3, 3.9 and 14%, respectively, p=0.0000). In PGDM: (1.) a 4-fold higher rate of SHD was found above the first 2 glucose categories (3.0 vs. 12%). (2.) No SHD in the low-49 birth percentile; in the 50-69, 1.7% and in the 70-89, 8.7%, and in the 90-high, 18.2%, p=0.0000). For GDM and PGDM, logistic regression with adjustment for confounding effects found mean blood glucose, parity, birth percentile and instrumental delivery significant contributors to SHD. Obesity, previous GDM, previous macrosomia, weight at delivery and ethnicity were noncontributing variables. CONCLUSION: When mean blood glucose levels are targeted to !90mg/dl and the estimated birth percentile O70 is included in determining method of delivery, it may be possible to decrease the rate of SHD in diabetic patients.

BMC Pregnancy and Childbirth, Jan 29, 2016