Forceps delivery rates are increasing significantly, with a significant decrease in vacuum-assisted delivery, with no change in neonatal morbidity or mortality.

Introduction: Unsuccessful operative vaginal delivery (OVD) is associated with high rates of materno-fetal morbidity. We aimed to examine institutional rates of unsuccessful OVDs (uOVD) and compare them with successful OVD (sOVD) in order to identify factors to aid patient selection and education. Methods: A 6-month retrospective cohort study was performed on all unsuccessful and successful OVDs in a tertiary level maternity hospital in the Republic of Ireland. Maternal demographics and obstetric factors were assessed to evaluate potential underlying risk factors for unsuccessful operative vaginal delivery versus successful vaginal delivery. Results: There were 4,191 births during the study period with an OVD rate of 14.2% (n = 595) with 28 (4.7% of OVDs) being unsuccessful. Unsuccessful OVD were predominately nulliparous (25; 89.2%) with a mean maternal age of 30.1 years (range 20-42), with more than half (n = 15, 53.5%) being induced. The most common indication for induction was prolonged rupture of membranes (PROM) (n = 7, 25%) which was significantly different from the successful OVD group. A senior obstetrician was significantly more likely to be the primary operator in uOVD when compared to sOVD. (82.1 % V 54.1% p < 0.01). The majority of unsuccessful OVD were vacuum deliveries (n = 17; 60.7%), with a significantly higher mean birthweight when compared to successful OVD (3.695 kg V 3.483 kg; p < 0.01). Following an unsuccessful OVD, women were more likely to have a postpartum haemorrhage (64.2 % V 31.5% p < 0.01) and their infant was more likely to require admission to the neonatal intensive care unit (NICU) (32.1 % V 5.8% p < 0.01) when compared with successful OVD. Conclusion: Risk factors for unsuccessful OVD were higher birth weight and induction of labour. There was a higher incidence of postpartum haemorrhage and NICU admission when compared with successful OVD.

Objective Twin to twin transfusion syndrome (TTTS) complicates 5-15% of monochorionic twin pregnancies and untreated is associated with a 90% mortality rate. The aim was to present the perinatal survival of patients with TTTS treated with laser ablation, by a national fetal medicine team. Methods This was a review of all cases of TTTS treated with fetoscopic laser ablation performed from March 2006 through to December 2020. All patients treated with fetoscopic laser were identified from the hospital database. The perinatal outcomes for the overall cohort and the individual Quintero stages were determined. Results A total of 155 cases of TTTS underwent fetoscopic laser ablation during the study period. The median gestational age at diagnosis was 19+1 weeks, with a mean growth discordance of 23.6%. The Quintero stage at diagnosis was: Stage 1 6.5% (10/155), Stage 2 49% (76/155), Stage 3 38.7% (60/155), Stage 4 5.8% (9/155). There was at least one survivor in 83.2% (129/155) of pregnancies, with dual survival in 52.9% (82/155). An increase in the rate of any survivor was observed from 75% (2006-2014) to 94% (2014-2020) (p<0.05). Dual survival decreased with increasing Quintero Stage (p<0.05). 80.6% (125/155) of pregnancies delivered prior to 34+6 weeks gestation. Conclusion Fetoscopic laser ablation is the recommended first line treatment for severe TTTS. We observed a survival rate of at least one twin in 83.2% pregnancies which is comparable to internationally published data on single-centre outcomes.

Our aim was to assess if the aberrant changes measured by non-invasive cardiac output monitoring (NICOM) in women with pregnancies complicated by Gestational Hypertension (GH), Preeclampsia (PE), or Fetal growth restriction (FGR) persist postpartum. Low risk nulliparous women were enrolled in a single center prospective study assessing the ability of NICOM to predict the evolution of GH, PE and FGR, as part of the HANDLE study. NICOM was performed at >6 weeks postpartum. Hemodynamic variables assessed included cardiac output (CO), indexed cardiac output (CO), total peripheral resistance (TPR), indexed total peripheral resistance (TPRI), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), stroke volume (SV) and indexed stroke volume (SVI). Comparison was made to 30 matched non-pregnant controls. Statistical analysis was performed by independent t-test using SPSS Version 23. Of 318 recruits, 291 (79.5%) of women attended the postpartum review. Four pregnancies were affected by PE, 17 by GH, 18 by FGR and 252 uncomplicated pregnancies. In comparison to non-pregnant values, uncomplicated pregnancies postnatally exhibited an increase in TPRI (p=0.04) and a decrease in COI (p<0.001), SV (p=0.003) and SVI (p<0.001) while HR, CO, TPR and BP were unchanged. FGR pregnancies exhibited a similar trend but did not achieve significance. Pregnancies complicated by hypertensive disease in the postpartum period maintained a lower SVI (p=0.04) but higher SBP (p=0.03), DBP (p=0.01), HR (p<0.05) and TPRI (p=0.009) when compared to non-pregnant values (Table 1). Pregnancy is associated with hemodynamic changes, which persist in the postpartum period. Women with pregnancies complicated by GH/PE were characterised by persistently higher intravascular resistance, coupled with persistently elevated blood pressures. This altered postnatal adaption may explain why women with a pregnancy complicated by PE have a life-long increased risk of cardiovascular disease.

Background: Assessment of myocardial performance in neonates using advanced techniques such as deformation imaging and rotational mechanics has gained considerable interest. The applicability of these techniques for elucidating abnormal myocardial performance in various clinical scenarios is becoming established. We hypothesise that term infants born to mothers with gestational hypertension (GH) may experience impaired performance of the left and right ventricles during the early neonatal period. Objectives: We aimed to assess left and right ventricular (LV and RV) function using echocardiography in infants born to mothers with GH and compare them to a control group. Methods: Term infants (>36+6 weeks) born to mothers with GH underwent assessment to measure biventricular function using ejection fraction (EF), deformation imaging, left-ventricle rotational mechanics (apical rotation, basal rotation, twist, twist rate, and untwist rate), and right ventricle-specific functional parameters (tricuspid annular plane systolic excursion and fractional area change) in the first 48 h after birth. A control group comprising infants born to healthy mothers was used for comparison. Results: Fifteen infants with maternal GH and 30 age-matched controls were enrolled. The GH infants exhibited no differences in birthweight or LV or RV length, but they had lower EF (54 vs. 61%; p < 0.01), LV global longitudinal strain (-20 vs. -25%; p < 0.01), and LV twist (11 vs. 16°; p = 0.04). There were no differences in any of the RV functional parameters. Conclusion: Infants born to mothers with GH exhibited lower LV function than healthy controls, while RV function appeared to be preserved. This relationship warrants further exploration in a larger cohort.

Background. Non-invasive cardiac output monitoring (NICOM) using bioreactance (BRT) in pregnancy is gaining interest but lacks validation. We compared simultaneous cardiac output (CO) measurements obtained using the NICOM ® (BRT-CO) and echocardiography (echo-CO), and assessed the relationship between maternal characteristics and myocardial performance. Methods. Paired stroke volume (SV) and CO readings were obtained using NICOM ® and echocardiography, in a group of healthy nulliparous women throughout a 15 min period. Agreement between NICOM ® and echocardiography was assessed using Bland-Altman analysis and the intraclass correlation coefficient (ICC). Left ventricular (LV) function was assessed using systolic strain and tissue Doppler velocities (S', E', and A' waves). Results. Thirty-five women with a median [interquartile range] age, weight, and gestation of 29 [26-34] yr, 71 [64-79] kg, and 28 [21-29] weeks, respectively, were enrolled. There was good agreement between NICOM ® -measured and echocardiographically measured SV [mean bias 6 ml (limits of agreement -18 to 29); ICC 0.8 (95% confidence interval 0.6-0.9), P <0.001] and CO [mean bias 0.2 litres (limits of agreement -1.3-1.7); ICC 0.8 (95% confidence interval 0.7-0.9), P <0.001; mean percentage error ±26%; coefficient of error (precision)=3.4%]. The mean ( sd ) LV S' was 9.7 (2.3) cm s -1 . The mean ( sd ) LV strain was -18.6 (2.6)%. There was a negative relationship between BMI and LV diastolic function measured using the E':A' ratio ( r  = -0.51, P <0.01). Conclusions. Stroke volume and CO measurements obtained using NICOM ® were comparable to those obtained using echocardiography, with acceptable limits of agreement. Increased maternal BMI negatively impacts LV diastolic function measured using tissue Doppler imaging.

While there are several studies detailing the altered hemodynamic profile of pregnancy in the presence of co-existing uteroplacental disease, we sought to establish the role of NICOM using bioreactance as a novel method of cardiac output assessment in this high risk setting. In this study, we aimed to establish the different hemodynamic profiles amongst nulliparous women who develop either gestational hypertension or pre-eclampsia (GH/PET) versus nulliparous women who develop intrauterine growth restriction (IUGR) using NICOM. Patients were enrolled in a large single centre prospective observational study assessing the ability of NICOM to predict the evolution of GH/PET or IUGR in the low risk nulliparous patient (HANDLE study). NICOM was performed during the first, second and third trimester and at least 6 weeks postpartum. Cardiac output (CO), systemic vascular resistance (SVR), stroke volume (SV), heart rate (HR) and systolic blood pressure (SBP) of women developing GH/PET were then compared to the hemodynamic profile of those developing IUGR. A total of 42 women had a pregnancy affected by uteroplacental disease. Women developing GH/PET (n=24) had a greater weight [70 (16) vs. 59 (9) Kg, p=0.006] and a higher BMI [26 (5) vs. 22 (4), p=0.03] than those developing IUGR (n=18). There was no difference in age [30 (6) vs. 29 (6) years, p=0.6]. Women affected by GH/PET had a higher SBP throughout the study period. They also had a higher SVR at baseline (Figure 1). Women with GH/PET tended to have a lower SV and a higher SVR. At baseline (14 weeks), there was a positive correlation between BMI and SBP/SVR, and a negative correlation between BMI and CO/SV. Women with evolving GH/PET develop a different hemodynamic profile to those developing IUGR, which is characterised by a higher SVR, and HR and a lower SV and is apparent from as early as 14 weeks' gestation. This presents us with a potential novel screening tool for hypertensive disease in pregnancy and at a gestational age where preventative measures may be possible.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Intrauterine growth restriction (IUGR) is the largest contributing factor to perinatal mortality in non-anomalous fetuses. The aim of the study was to evaluate changes in rates of stillbirth and neonatal death secondary to IUGR over a 10 year period. A retrospective cohort study was performed from 2003 to 2012 in a large tertiary referral hospital. Rates of stillbirth and neonatal death with IUGR as a causative factor were calculated. Comparison was made between the first 5 years and the second 5 years of the study period. A total of 253,061 births occurred in the period 2003–2012, 117,667 in the first 5 year period and 135,394 in the second 5 years. The overall rate of stillbirths decreased between the two time periods (0.47% vs 0.39%; p = 0.005), as did the rate of NND (0.28% vs 0.23%; 0 = 0.01). The proportion of stillbirths attributed to IUGR decreased from 7.4% to 4.1% (p = 0.002). However, the proportion of NND with IUGR as a factor increased (1.2% to 0.62%; p < 0.001). This resulted in no significant overall change in perinatal mortality rates attributable to IUGR (5.1% vs. 4.0%; p = 0.3). We have identified that the proportion of stillbirths and NND due to IUGR has not significantly changed over the study period. The proportion of stillbirths attributed to IUGR has decreased, reflecting the increased use of ultrasound surveillance, with both improved access to such imaging techniques and more personnel with expertise in performing antenatal ultrasound. However, the proportion of NND with IUGR as a factor has increased. This would suggest that we are identifying growth restricted babies and opting for timely delivery, but this is not necessarily translating into better outcomes overall for IUGR babies.

Ireland continues to experience a high incidence of neural tube defects (NTD). Knowledge about the natural history of this condition is limited as pregnancy termination is practiced in most countries. We aimed to describe perinatal outcomes of pregnancies complicated by fetal NTDs in a setting in which pregnancy termination is not locally available. We conducted a retrospective cohort study over a 6-year period in a tertiary referral center in Dublin (2005–2010). Only singleton gestations with confirmed normal karyotype were included for analysis. During the study period 1742 women attended a specialist clinic to confirm and manage fetal abnormalities. NTDs accounted for 4.5% of consultations. We identified 78 consecutive cases of NTD; these comprised 29 meningomyeloceles (37%), 11 encephaloceles (14%) and 38 cases of anencephaly (49%). The majority of pregnancies affected by anencephaly were terminated (71%). Of the 11 cases of anencephaly in which expectant management was chosen, 7 (64%) infants were liveborn. Of the 39 non-lethal NTDs, 15 patients (38%) terminated their pregnancy. Of the 23 ongoing pregnancies with available outcome data, four fetuses with encephaloceles (19%) had an intrauterine fetal demise at a mean gestational age of 24+2 weeks. Of the 19 liveborn infants, 15 (79%) were delivered by caesarean section. There were 3 neonatal deaths (16%). 16 infants underwent meningomyelocele closure ± ventriculoperitoneal shunting. 14/16 (88%) were alive at follow-up (2 months to 6 years). The above natural history outcome data provides useful information for health professionals charged with prenatal counselling for NTD.

The Republic of Ireland continues to be one of the countries with the highest incidences of neural tube defects (NTD). Knowledge about the natural history of this condition is limited as pregnancy termination is practiced in most countries. We aimed to document the perinatal outcomes with respect to mode of delivery and neonatal survival. Only singleton gestations with confirmed normal karyotype were included for analysis. We retrospectively reviewed antenatally diagnosed cases of non-lethal open neural tube defects (meningomeloceles and encephaloceles) over a 5-year period (2005–2009) in a tertiary-referral hospital in the Republic of Ireland. During the study period 43,228 women attended for antenatal care and 63 consecutive cases of open NTD with normal karyotype were identified resulting in an incidence of 0.15%. In this population there were 24 meningomyeloceles (38.1%) and 10 encephaloceles (15.9%). Of the 34 non-lethal NTD, 14 (41.2%) patients elected to terminate their pregnancy. Twenty patients continued, of whom three delivered in another hospital without available outcome data. 4/17 (23.5%) had an intrauterine fetal demise at a mean gestational age of 24 + 2 weeks (range 16 + 0 to 29 + 2). Of the 13 liveborn infants, 11 were delivered by Caesarean section and two mothers delivered vaginally. Three neonatal deaths occurred within a 12 hour period. The surviving 10 babies were evaluated by the paediatric neurosurgeon after birth. One baby received palliative care and died, and 9 underwent meningomyelocele closure and ventriculoperitoneal shunting. Eight of 9 babies (88.9%) were alive at follow-up (6 months to 5 years). The above natural history outcome data provides useful information for health professionals charged with prenatal counselling. Over 20% of fetuses diagnosed with non-lethal NTD suffered intrauterine fetal demise, 8/13 (61.5%) liveborn infants survived and 8 of 9 babies (88.9%) underwent successful surgery. Antenatal assessment of these fetuses by a paediatric neurosurgeon may also be beneficial.

The Republic of Ireland continues to be one of the countries with the highest incidences of neural tube defects (NTD). Knowledge about the natural history of this condition is limited as pregnancy termination is practiced in most countries. We aimed to investigate the pregnancy outcomes with respect to mode of delivery and neonatal survival. Only singleton gestations with confirmed normal karyotype were included for analysis. We retrospectively reviewed antenatally diagnosed cases of anencephaly over a 5-year period (2005–2009) in a tertiary-referral hospital in the Republic of Ireland. During the study period 43,228 women attended for antenatal care and 63 consecutive cases of open NTD with normal karyotype were identified resulting in an incidence of 0.15%. Twenty-nine (46%) represented cases of anencephaly. Seventeen of 29 mothers (58.6%) terminated their pregnancy and 2 were lost to follow up as they delivered in another hospital. Of the 10 women who continued their antenatal care in our hospital, four (40%) had an intrauterine fetal demise at a mean gestational age of 30 + 4 weeks (range 25 + 0 to 35 + 4 weeks) and subsequently delivered vaginally following induction of labour. Three (30%) patients underwent Caesarean section at term. The remaining three patients delivered vaginally at a mean gestational age of 37 weeks, one of whom required induction of labour at term (range 34 + 5 to 39 + 2 weeks). The median neonatal survival was 33 minutes. Despite the fact that pregnancy termination is not legally available in Ireland, the majority of women, when faced with a diagnosis of anencephaly, were prepared to travel outside the jurisdiction to avail of pregnancy termination. Nevertheless, over 40% of women in our case series chose to continue their pregnancy and in the absence of intrauterine fetal demise, the majority of pregnancies progressed to term. The above natural history outcome data provides useful information for health professionals charged with prenatal counselling.

Primary fetal hydrothorax is an uncommon complication in the fetus which has an unpredictable clinical course. It is due to lymphatic leakage which generates an increased intra-thoracic pressure. It may resolve, remain stable or progress to fetal hydrops. Primary hydrothorax is a diagnosis of exclusion and all structural and chromosomal causes should be outruled. We present a case of a large fetal hydrothorax with cardiac dextroposition. A 31 year old primipara presented for a routine structural sonogram at 24 weeks gestation. An isolated left sided pleural effusion was identified, measuring 8 mm in maximum depth with mediastinal shift resulting in cardiac dextroposition. The heart was structurally and functionally normal with no associated AV valve regurgitation. There were no extrathoracic anomalies, specifically no stigmata of hydrops fetalis. A genetic amniocentesis was performed, which ultimately identified a normal female karyotype. The TORCH screen was negative. Four days following identification of the left-sided pleural effusion and amniocentesis, a follow-up ultrasound demonstrated near-total resolution of this hydrothorax, with resultant restoration of levocardia. Serial fetal sonograms showed no evidence of re-accumulation of the hydrothorax and the remaining weeks of the pregnancy were uncomplicated. She had a vaginal delivery of a live female infant weighing 3570 g at 39 weeks gestation. A comprehensive paediatric review of the baby was carried out which was normal. A six week postnatal review did not detect any re-accumulation of a pleural effusion. This case highlights the unpredictable nature of primary fetal hydrothorax. Spontaneous regression is believed to occur in 22% of cases, this may be underestimated as many cases will go unreported. In this case, the size of the effusion, sufficiently large to cause cardiac dextroposition, prompted consideration for pleuro-amniotic shunt placement. Spontaneous resolution within 4 days was, therefore, an unanticipated but welcome outcome.

Ultrasound evaluation of middle cerebral artery peak systolic velocity (MCA-PSV) is the standard investigation for the diagnosis of fetal anemia. It has replaced serial amniocentesis for surveillance in red cell alloimmunization but has also proved effective in the detection of fetal anemia due to other disease states. MCA-PSV greater than 1.5 multiples of the median (MoM) for gestational age is an indication for diagnostic cordocentesis. Critically, the seminal work on this screening tool reported a sensitivity of 100% for the detection of moderate-to -severe fetal anemia. We present a case of significant fetal anemia associated with normal indices on repeated interrogation of the middle cerebral artery. A 25-year-old woman presented for a routine structural sonogram at 20 weeks’ gestation. Fetal hydrops was identified with severe ascites, scalp edema and a pericardial effusion. Maternal serology confirmed recent parvovirus seroconversion with positive IgG and IgM. MCA-PSV was 31 cm/s, corresponding to between 1.0 MoM and 1.29 MoM for this gestation. Despite the normal MCA-PSV, a diagnostic cordocentesis was performed which confirmed significant fetal anemia with haematocrit of 23%. Intrauterine transfusion (IUT) of 35cc packed red cells was performed. Repeat sonographic evaluation 4 days later showed persistent hydrops and MCA-PSV 23 cm/s (normal). Two weeks following IUT, fetal hydrops had resolved. MCA-PSV remained within normal limits. The remainder of the pregnancy was uncomplicated. This case illustrates the possibility of false negative MCA-PSV in the setting of fetal anemia. In the absence of another cause for fetal hydrops definitive diagnostic testing with fetal cordocentesis should be performed.