Introduction:Interstitial ectopic pregnancy (IEP), although a rare clinical entity representing 2%-6% of all ectopic pregnancies, is associated with higher morbidity and mortality than other types of ectopic pregnancy, compounded by distinct challenges in diagnosis and management. Case Presentation:A 40-year-old multiparous female (G7P3M2E1) presented for routine early pregnancy ultrasound due to a previous history of pregnancy of unknown location (presumed tubal ectopic pregnancy). Transvaginal ultrasound scan did not identify any intrauterine gestational sac, despite β-hCG levels elevated at 19,009 iU/L. Imaging was noted to be technically challenging due to the presence of a large fundal fibroid. Serial measurement noted a drop in β-hCG levels and the patient was initially managed conservatively as a pregnancy of unknown location. After becoming acutely unwell, ruptured ectopic pregnancy was the primary differential diagnosis. The patient underwent emergency laparoscopy, where a right IEP was diagnosed with associated large haemoperitoneum. Right superficial cornuostomy and right salpingectomy were performed, and the patient had an excellent recovery. Conclusion:Challenges in diagnosis and management of IEP are recognised; however, these are further complicated in situations where there is coexistence of other uterine pathology such as large uterine fibroids. This case highlights that with appropriate expertise, safe and successful surgical management of ruptured IEP is possible using a laparoscopic approach, with cornuostomy and ipsilateral salpingectomy.

OBJECTIVES:To evaluate the use of the Abbott i-STAT®1 point-of-care-test (POCT) device for measurement of human chorionic gonadotropin (hCG) to support the management of early pregnancy complications in a remote early pregnancy unit (EPU). METHODS:Women attending the EPU who required an hCG blood test were invited to take part in the study. Participants provided an additional blood sample for whole blood hCG measurement using the Abbott i-STAT®1 analyzer. The remaining sample was sent to the hospital laboratory for hCG analysis using the Abbott Architect, the designated comparator method. Statistical analysis was performed using Analyze-IT software. RESULTS:A total of 61 women were recruited, including cases of pregnancy of unknown location, ectopic pregnancy, and molar pregnancy. Fourteen hCG results that were outside the i-STAT®1 assay's quantitative range, although still broadly concordant with laboratory hCG results, were excluded from statistical analysis. Analysis of the remaining 47 paired hCG results demonstrated strong agreement across the concentration range (4-2072 IU/L), with excellent Spearman correlation (r = 0.99, P < 0.001). Passing-Bablok linear regression indicated good agreement (y = 1.18 + 0.96x) and Bland-Altman analysis showed a mean difference of -23.7 IU/L (-3.5%). CONCLUSIONS:All hCG results from the i-STAT®1 analyzer were clinically concordant with the central laboratory method, supporting its application in an EPU setting using established clinical decision thresholds. However, further verification through larger-scale studies is necessary before the i-STAT®1 analyzer can be integrated into clinical practice.

A crisis in early pregnancy can be due to an unplanned pregnancy or a suspected abnormality. Pregnant people have the right to unbiased and comprehensive advice of all options from healthcare providers. Using story completion models (SCM), the aim of this qualitative study was to explore the attitudes of medical students and doctors in training towards crisis pregnancy, specifically two scenarios: early unplanned pregnancy and fatal fetal abnormality (anencephaly). Participants were invited from medical students attending University College Dublin (UCD) and trainees in Obstetrics and Gynaecology at the Royal College of Physicians of Ireland (RCPI) from July to December 2022. SCM involves giving the consenting participant an introduction to a hypothetical situation that acts as the beginning of a story and asking them to complete it. Stories were compiled and analysed using thematic analysis. Research Ethics Committee approval was given by both UCD and the RCPI. The standards for reporting qualitative research guidelines were followed. Eight doctors in training and six medical students consented to participate in the study; all but two medical students completed both stories to the required word count, giving 25 stories for analysis. For both situations, stories described a variety of approaches, all of which were based on the person's, or couple's, wishes, from continuing in pregnancy to deciding to end the pregnancy. SCM allowed detailed analysis of potentially sensitive subjects such as pregnancy options. This study showed that participating medical students and doctors in training recognise that pregnant people have the right to all choices in crisis pregnancy.

In 2019, a termination of pregnancy (TOP) service was established in Ireland following a landmark change to the constitution. Under Section 12 of the Health Act, TOP is permitted without restriction until 12 + 0 weeks’ gestation. Retrospective review of inpatient medical TOP under Section 12 between 1 January 2019 to 31 December 2022 in a single tertiary maternity hospital in Ireland. Anonymised data from eligible cases was obtained from electronic healthcare records. The final cohort included 149 individuals. Gestational age (>9 + 0 weeks’) was the primary indication for hospital TOP (81.2%) with over 44% of the cohort at >11 + 0 weeks’ gestation. Misoprostol was administered within the recommended 24–48 h from mifepristone in 75.2% of cases. After one course of the medication regime, 9.4% of individuals required additional doses of misoprostol to complete the termination. Haemorrhage with blood loss >500 ml occurred in 4.2% of cases, with no other major/significant complications reported. This is the first reported review of the efficacy and complications of the newly established Irish TOP service. Findings highlight the importance of timely access to care given the strict legal gestational cut-off. Variations in practice, specifically in timing of medication administration, were also shown.

BackgroundMethotrexate (MTX) is used in clinical practice as a medical treatment option in patients with early pregnancy complications like ectopic pregnancy.AimsTo review systemic MTX therapy use in the first trimester of pregnancy in our hospital and to examine subsequent clinical outcomes.MethodsRetrospective review of all women treated with systemic MTX in early pregnancy identified from electronic prescription records from 1 January 2018 to 31 December 2020 at Cork University Maternity Hospital, Ireland. Relevant data was transcribed from electronic health records.ResultsIndications for treatment were tubal ectopic pregnancy (70%, n = 51), persistent pregnancy of unknown location (22%, n = 16) and caesarean scar pregnancy (7%, n = 5). Treatment was successful in 88% (n = 44) of tubal ectopic pregnancies with 73% (n = 37) and 14% (n = 7) of women receiving a single dose and repeated doses, respectively. Only 8% (n = 4) of tubal ectopic pregnancies required emergency surgery for subsequent tubal rupture. In 93% (n = 15) of cases of persistent pregnancy of unknown location, treatment was successful with one patient requiring uterine evacuation. Women with caesarean scar pregnancy were treated with combined MTX and uterine evacuation without complication.ConclusionsThe efficacy of medical treatment with systemic MTX for confirmed tubal ectopic pregnancy in our hospital is in line with national and international standards. Careful consideration should be given to treating caesarean scar pregnancy and persistent pregnancy of unknown location with systemic MTX. Systemic MTX use guided by clinicians specialised in early pregnancy complications and safe medication practices may improve treatment success and reduce adverse events.

A G5P2+2 woman in her 30s presented to hospital with per vaginum (PV) bleeding, approximately 2 weeks post electric vacuum aspiration (EVA) for retained products of conception. Ultrasound and MRI demonstrated a large vascular myometrial lesion, suggestive of a uterine arteriovenous malformation (UAVM). She underwent digital subtraction angiography (DSA) with interventional radiology and simultaneous uterine artery embolisation (UAE). She represented 2 weeks later with recurrent PV bleeding and anaemia. She underwent repeat DSA, demonstrating persistent UAVM, and a repeat embolisation was performed. Symptoms resolved following the second embolisation, and a repeat MRI performed 12 weeks later demonstrated complete resolution of the UAVM.Although UAVMs are rare lesions, they can cause significant haemorrhage and morbidity. The presence of UAVM should particularly be considered after uterine intervention such as EVA or caesarean section.UAE is a safe and effective therapy, which preserves fertility.

INTRODUCTION:Capillary blood collection, a technique traditionally used in diabetes care, shows promise for many applications including pregnancy monitoring. Serial measurement of serum human Chorionic Gonadotrophin (hCG) is frequently necessary for managing early pregnancy, including molar pregnancy, requiring multiple visits to a maternity hospital for blood collection by venepuncture. This proof-of-concept study aimed to assess the clinical performance and user acceptability of capillary blood samples collected remotely, as an alternative to venous blood for hCG measurement. METHODS:Women attending the early pregnancy unit who required serum hCG measurement, were invited to participate. Following informed written consent, participants were shown how to collect capillary blood samples using the Mini-Collect® collection device. Matched venous and capillary blood samples were collected in clinic for hCG comparison purposes. Participants were also supplied with a home collection kit in a prepaid return envelope. They were asked to perform a finger-prick blood collection at home using the instructions provided and to return the capillary blood sample by post within 24 h of collection, along with a completed user-satisfaction questionnaire. Statistical analysis was performed using Analyse-it® software. RESULTS:The study enrolled 71 participants and over a third of these women collected a capillary blood sample at home. The median age of participants was 33 years (range 29-36). Passing-Bablok linear regression (y = -0.037 + 1.04x) and Spearman correlation (r = 0.999, p < 0.0001), demonstrated good agreement and strong correlation between venous and capillary samples, over a broad range of hCG values (1.2 to 224,0000 IU/L). The majority of capillary samples collected remotely (39%, 27/69) had sufficient blood volume for analysis (74%, 20/27). Respondents (77%, 18/25) found the collection device easy to use and expressed willingness to use a future service if available (80%, 20/25) CONCLUSION: The study demonstrated excellent agreement between the hCG results obtained from both collection methods, suggesting that capillary blood can serve as a reliable alternative for venous hCG measurement, particularly in clinical settings requiring frequent hCG monitoring. Feedback from the study questionnaire indicates a preference for this type of follow-up among women, indicating potential improvements in compliance for blood based diagnostic tests.

Objective: To compare the risk profiles, anatomical, and functional outcomes between obese and non-obese women who experienced obstetric anal sphincter injury (OASI). Methods: A retrospective electronic database study was conducted at Cork University Maternity Hospital (CUMH). Women with missing data/repairs conducted outside CUMH were excluded. Participants were categorized into obese (BMI >= 30 kg/m(2)) and non-obese (BMI <30 kg/m(2)) groups. Primary measure was a composite adverse outcome assessed 6 months post-delivery, including one or more of the following: resting pressure <40 mmHg, squeezing pressure <100 mmHg, defects in the internal and/or external anal sphincter. Statistical analyses were performed using SPSS version 28. Results: Among the 349 women included in the study, 285 (81.7%) had a BMI <30 kg/m(2 )and 64 (18.3%) had a BMI >= 30 kg/m(2). Gestational diabetes was significantly higher in obese women. No significant differences were observed in newborn weight or mode of delivery. The majority of tears were classified as grade 3B in both groups. Attendance rates at the OASI clinic did not differ between the groups. Among those attending, no statistical differences were noted in manometry results, which were reduced in both groups. Rates of internal anal sphincter defects were lower in the obese group (7.0% vs 15.6%, P = 0.15) and external anal sphincter defects were significantly lower in obese women (0% vs 9.1%, P = 0.04). No difference was found in the rates of composite adverse outcomes between the groups. Conclusion: Functional outcomes and manometry results did not differ, but non-obese women had higher rates of anatomical defects in OASI, requiring further study.

Introduction Medical management of first trimester pregnancy loss is a safe option that is well tolerated and affords women more autonomy in relation to their care. Recent trials provide robust evidence that mifepristone pretreatment is the optimal approach for women with missed miscarriage who desire medical management. Methods Following a change in medical management of first trimester miscarriage in our unit, we conducted a retrospective audit over a 3-month period of all women who had elected medical management as their primary treatment option. We compared the results with a previous audit that had been undertaken prior to the change in practice. Results The implementation of mifepristone resulted in an increased effectiveness of primary medical treatment for first trimester miscarriage from 53.8% to 85.2% (p=<0.001). Discussion The results of our study support the introduction of mifepristone into routine clinical practice for medical management of first trimester pregnancy loss across all maternity units.

Proficiency in early pregnancy assessment and management is a core component of Basic Speciality Training (BST) in Obstetrics & Gynaecology. Performance and interpretation of early pregnancy ultrasound is not formalised in Ireland, resulting in variation in exposure and experience amongst trainees. We aimed to improve trainee's knowledge and confidence in early pregnancy ultrasound. This was though a multimodel teaching program of didactic lectures, tutorials, and case-based discussions. Additionally, we organised structed assessment tests over a six-week period with a repeat revision of teaching to allow all participants attendance. All teaching was provided with facilities already available in our institution. We assessed knowledge and confidence by an anonymised survey comprising both quantitative and qualitative components pre and post training completion. We showed an improvement in knowledge, a non-significant increase was noted in mean test score in multiple choice questions relating to early pregnancy from 78.8% to 83.5% post study completion. Trainees were noted to report an increase in training during the duration of the study with 70% reporting have received little training prior to the study dropping to 13% at the end. Increased exposure to both witnessed and performed transabdominal and transvaginal ultrasound and training on the interpretation of early pregnancy ultrasound was noted. Among trainees 62% reported no formalised training in interpreting early pregnancy ultrasound at commencement reducing to 13% post study (p = 0.04). Improved confidence although non-significant was also reported among trainees. Our study demonstrates that a low-cost multimodel teaching program over a short time frame can improve knowledge, confidence and interpretation in early pregnancy ultrasound. This simple model can be easily reproduced in other institutions. As this was a pilot study, we would envision expanding it across further sites to assess its effectiveness.

Circulating maternal levels of placental growth factor correlates well with placental function and numerous studies advocate its role to help rule-out preterm pre-eclampsia. A number of automated immunoassay platforms to quantify placental growth factors are currently available. The aim of this study was to highlight the importance of developing and validating appropriate reference ranges and clinical cut-offs for immunoassays, by comparing the results obtained from two different immunoassays of placental growth factor; the Quantikine® ELISA and the automated Triage® test. This was a secondary subgroup analysis of samples collected as part of a prospective cross-sectional study of placental growth factors in twin pregnancy. Consenting pregnant women with a twin pregnancy, across a variety of gestations, had a single blood sample taken at a one-time point only during their pregnancy. The plasma was initially biobanked and then later analysed in batches using both immunoassays. Although the placental growth factor values of the two immunoassays correlated well (r = 0.88, n = 178, p < .001), the actual results obtained were significantly different (mean difference 238.1 pg/ml). Poor concordance between the two immunoassays was also present, with the Triage® test recording 36 cases as <100 pg/ml whereas the Quantikine® ELISA identified only 4 as <100 pg/ml. Biomarker levels may vary significantly between different immunoassay platforms, highlighting the importance of developing validated clinical cut-offs for any automated immunoassay before its clinical application. These differences need to be understood to facilitate clinical utility given that placental growth factor testing is likely to be introduced into widespread clinical practice.

We describe a case of a woman in her mid-30s who presented to a tertiary level maternity hospital 17 days following early medical abortion with a positive pregnancy test. On the ultrasound examination, it was discovered that she had a second trimester ectopic pregnancy which was treated surgically with a unilateral salpingectomy. We discuss in depth factors related to this woman’s care, such as appropriate assessment and evaluation of early medical abortion cases, the diagnostic challenges of early pregnancy scanning as well as the implications of the COVID-19 pandemic on the provision of care in these scenarios, and how this affected this woman’s care.

Hypertensive disorders of pregnancy are common and may result in increased maternal and neonatal morbidity and mortality. Multiple pregnancies confer an increased risk of development of a hypertensive disorder of pregnancy. The purpose of this study was to examine a large cohort of women delivering a multiple pregnancy in a single large tertiary unit, and to evaluate the implications of hypertensive disorders of pregnancy on both maternal and perinatal outcomes. Retrospective study of all twin pregnancies delivered at Cork University Maternity Hospital, Ireland over a 9-year period (2009-2017). The twin pregnancies were divided according to the presence or absence of hypertensive disorder of pregnancy and the two groups were compared. Maternal age >40 years, nulliparity, conception through use of a donor oocyte, and presence of obstetric cholestasis are all risk factors for the development of hypertensive disorders of pregnancy in women with a multiple pregnancy. When a hypertensive disorder complicates a twin pregnancy, it increases the incidence of iatrogenic late prematurity and neonatal hypoglycemia. This study is informative for clinicians caring for women with a multiple pregnancy with its relevant data on perinatal outcomes following a diagnosis of hypertensive disorder in pregnancy.

INTRODUCTION:Hypertensive disorders of pregnancy are common and may result in increased maternal and neonatal morbidity and mortality. Multiple pregnancies confer an increased risk of development of a hypertensive disorder of pregnancy. The purpose of this study was to examine a large cohort of women delivering a multiple pregnancy in a single large tertiary unit, and to evaluate the implications of hypertensive disorders of pregnancy on both maternal and perinatal outcomes. MATERIAL AND METHODS:Retrospective study of all twin pregnancies delivered at Cork University Maternity Hospital, Ireland over a 9-year period (2009-2017). The twin pregnancies were divided according to the presence or absence of hypertensive disorder of pregnancy and the two groups were compared. RESULTS:Maternal age >40 years, nulliparity, conception through use of a donor oocyte, and presence of obstetric cholestasis are all risk factors for the development of hypertensive disorders of pregnancy in women with a multiple pregnancy. When a hypertensive disorder complicates a twin pregnancy, it increases the incidence of iatrogenic late prematurity and neonatal hypoglycemia. CONCLUSIONS:This study is informative for clinicians caring for women with a multiple pregnancy with its relevant data on perinatal outcomes following a diagnosis of hypertensive disorder in pregnancy.

Objective To explore pregnant women's views of participation in a clinical research trial while pregnant. Design Prospective nested qualitative cohort study embedded within a national, multi-site randomized controlled trial of a diagnostic test for preeclampsia: Placental Growth Factor. One-to-one in-depth semi-structured interviews were undertaken with 19 women who had recently participated in the trial at a single recruiting site. The interviews were conducted in private, recorded digitally and transcribed verbatim. Setting Single tertiary maternity hospital currently recruiting eligible women onto an on-going randomized controlled trial (NCT 02881073). Participants Women who had participated in the PARROT Ireland randomized controlled trial during their recent pregnancy. Methods Thematic analysis was utilized. Each line of the transcribed interviews was coded into a category by two researchers. The resultant categories were reviewed, and those with similarities were pooled allowing the development of themes. Main Outcome Measures Women's opinions and experience of participation in a randomized controlled trial of an interventional diagnostic test during their pregnancy. Results Four major themes were identified as follows: (a) Understanding of preeclampsia, (b) Motivators for clinical trial participation, (c) Barriers to decision making and (d) Influence of PARROT Ireland on pregnancy experience. Conclusions Women are generally interested and positively inclined to participate in research during pregnancy. The potential of risk is an important consideration for eligible pregnant woman. Information and support by both researchers and clinicians are paramount in aiding women's understanding of a research trial.

Objective To compare cerebral activity and oxygenation in preterm infants (<32 weeks of gestation) randomized to different cord clamping strategies. Study design Preterminfants born at <32 weeks of gestation were randomized to immediate cord clamping, umbilical cord milking (cord stripped 3 times), or delayed cord clamping for 60 seconds with bedside resuscitation. All infants underwent electroencephalogram (EEG) and cerebral near infrared spectroscopy for the first 72 hours after birth. Neonatal primary outcome measures were quantitative measures of the EEG (17 features) and near infrared spectroscopy over 1-hour time frames at 6 and 12 hours of life. Results Forty-five infants were recruited during the study period. Twelve infants (27%) were randomized to immediate cord clamping, 19 (42%) to umbilical cord milking, and 14 (31%) to delayed cord clamping with bedside resuscitation. There were no significant differences between groups for measures of EEG activity or cerebral near infrared spectroscopy. Three of the 45 infants (6.7%) were diagnosed with severe IVH (2 in the immediate cord clamping group, 1 in the umbilical cord milking group; P = .35). Conclusions There were no differences in cerebral EEG activity and cerebral oxygenation values between cord management strategies at 6 and 12 hours.

To compare gestation specific placental growth factor (PlGF) levels in multiple pregnancies complicated by pre- eclampsia (PET) or any hypertensive disorder of pregnancy (HDP) to controls. Prospective study conducted in a single tertiary maternity hospital from July 2015-December 2017. Maternal plasma samples were collected at one time point across a cross section of gestations from consenting women with a multiple pregnancy without signs/symptoms or diagnosis of PET. Samples were analysed for PlGF using the Triage® PlGF Test (Alere). Clinical outcome data were gathered from medical notes following delivery. The cohort was divided into 2 groups based on gestational age at time of enrollment; <24 weeks and ≥ 24 weeks. Non parametric tests were conducted to compare the mean PlGF at each gestational interval using SPSS Version 23. Of the 275 women with a multiple pregnancy recruited, 15.3% (n=42) subsequently developed HDP and of those 11.3% (n=31) developed PET. Median time from sampling to diagnosis of HDP/PET was 97 days when recruited <24 weeks and 25 days when recruited at 24 weeks or beyond. A Mann-Whitney U Test revealed PlGF levels were significantly lower in the women who later developed PET than in the controls (153 pg/ml vs. 247 pg/ml, p = 0.04, 99.8 pg/ml vs. 304 pg/m, p = 0.01). However in those that later developed HDP, PlGF was lower <24 weeks only (150 pg/ml vs 250 pg/ml, p = 0.02). No differences in PlGF levels were noted when BMI >30, parity, assisted reproductive therapy or pregnancy through use of donor oocyte was compared between the two groups. PlGF levels in multiple pregnancy differs significantly between those pregnancies that will be complicated by PET and those that will not. This difference is present many weeks before clinical signs or symptoms of disease are present.View Large Image Figure ViewerDownload Hi-res image Download (PPT)