Epilepsy is a common serious neurological disorder, affecting approximately 28 per 10,000 pregnancies internationally each year. There are limited data on the use of newer anti-seizure medicines (ASMs) in pregnancy, despite increasing use. We aimed to describe the use of newer ASMs in women with epilepsy (WWE) attending the Rotunda Hospital, Dublin, in pregnancy, between 2018 and 2023. We conducted a retrospective case series using electronic health record data. All WWE with a medication order for a newer ASM and a completed pregnancy were included. We identified 34 pregnancies exposed to newer ASMs, namely zonisamide (35.2 %), brivaracetam (23.5 %), eslicarbazepine (23.5 %), lacosamide (17.6 %), and perampanel (2.9 %). Newer ASMs were used as monotherapy in 58.8 % cases. Levetiracetam was the most commonly prescribed concomitant ASM in polytherapy regimens (32.4 %). Seizures occurred during pregnancy or the postpartum period in 50.0 % and 14.7 % of pregnancies, respectively. Twenty-eight pregnancies (80 %) resulted in a livebirth, with median gestation and birth weight of 39 weeks’ [IQR 2] and 3100 g [IQR 790]. One neonate exposed to polytherapy including eslicarbazepine was observed to have a minor anomaly at birth, not requiring follow-up. Findings show that in WWE, most pregnancies exposed to newer ASMs resulted in healthy livebirths at term without negative outcomes. A high proportion of polytherapy exposures and high rate of seizures during pregnancy suggests that this may be a cohort at greater risk for caesarean section or other complications. Findings should be interpreted with caution, with additional data needed to examine the impact of individual ASMs on outcomes.

Pregnant patients with epilepsy are at particularly high risk of maternal and fetal morbidity and mortality, likely in large part due to suboptimal medication prescribing. In our health system a recent tragic case of a double maternal / neonatal death in a woman with epilepsy triggered a quality improvement analysis of our practice in this regard. We analysed the care received by this patient cohort in a large obstetric hospital with over 10,000 pregnancies per annum. A prospectively-maintained database of patients with epilepsy in pregnancy at a single large obstetric hospital was interrogated for the 6-month time period of July to December 2021 for metrics of good clinical practice in the obstetric management of epilepsy. This included patient engagement with specialist services, adequacy of pre-conceptional care and anti-epileptic drug (AED) prescribing patterns. During the 6-month study period, a total of 50 women reported at initial antenatal visit as having a seizure disorder, 26 (52%) of whom had a confirmed diagnosis of epilepsy. 46 of 50 (96%) had complete care provided through a specialist epilepsy in pregnancy service, but only 2/50 (4%) had completed formal pre-conceptional consultation with a neurologist or primary care provider. Amongst the 17 patients using AED, a total of 17/24 (70%) had adequate AED prescription completed and in place to cover the peripartum period. However, appropriate recording of self-administered AEDs during the peripartum period was confirmed in the hospital electronic healthcare record system in only 13/24 (54%) of cases. While it is reassuring to confirm specialist engagement with services for the majority of patients with epilepsy, our study demonstrates significant room for improvement. Given the significant risk of undermedication for these patients in the peripartum period, inadequacy of documentation of AED medication poses a serious risk to the health and safety of these patients. Our study calls for significant additional investment in pre-conceptional and antenatal care systems to minimise this risk.

CONTEXT.—:A severe third wave of COVID-19 disease affected Ireland in the first 3 months of 2021. In this wave, 1 second-trimester miscarriage and 6 stillbirths were observed in the Irish population because of placental insufficiency as a result of SARS-CoV-2 placentitis. This observation was at odds with the country's previous experience with COVID-19 disease in pregnant mothers.OBJECTIVE.—:To describe the clinical and pathologic features of these pregnancy losses.DESIGN.—:Retrospective review of clinical and pathologic data of cases of second-trimester miscarriage, stillbirth, or neonatal death identified by perinatal pathologists as being due to SARS-CoV-2 placentitis during the third wave of COVID-19 in Ireland.RESULTS.—:Clinical and pathologic data were available for review in 6 pregnancies. Sequencing or genotyping of the virus identified SARS-CoV-2 alpha (B.1.1.7) in all cases. Three of the 6 cases had maternal thrombocytopenia, and fetal growth restriction was not prominent, suggesting a rapidly progressive placental disease.CONCLUSIONS.—:The identification of SARS-CoV-2 alpha in all these cases suggests that the emergence of the variant was associated with an increased risk of fetal death due to SARS-CoV-2 placentitis when compared with the original virus. Maternal thrombocytopenia may have potential as a clinical marker of placentitis, but other inflammatory markers need investigation. Three of the 6 women had been assessed for reduced fetal movements in hospital some days before the fetal deaths actually occurred; this could suggest that there may be a window for intervention in some cases.

Objective Medication use is a common therapeutic intervention during pregnancy, in the postpartum period and during lactation. Women routinely consult a variety of medical practitioners to request advice and prescription of medication. However, it is noted internationally that healthcare providers have insufficient knowledge to support women through their therapeutic journeys, and continual education is not provided as routine during postgraduate training and practice. Study Design There are five colleges in Ireland responsible for postgraduate medical training in Ireland for medicine, surgery, general practice, anaesthesiology and psychiatry. These are responsible for the curriculum design and implementation of 45 training programs, with the Royal College of Physicians responsible for 26 training programs and the Royal College of Surgeons of Ireland responsible for 15 training programs. We reviewed the national postgraduate training curricula of all speciality in the Republic of Ireland, excluding care of the elderly and pathology (given these practitioners would not be actively prescribing and treating pregnant or lactating women). Results We demonstrate that less than 50 % of the 43 post-graduate training programs mention medications in pregnancy and lactation. Pregnancy is not mentioned by 12 programs in any degree, and 18 programs do not mention lactation or breastfeeding in any form. Conclusion It is imperative that consistent knowledge is provided and accessible to healthcare providers in order to support women and their families through healthy pregnancies, and support breastfeeding for as long as possible. Therefore, we call on postgraduate training bodies to include comprehensive education on medications in pregnancy and lactation in their syllabi going forward.

Concurrent with the global COVID-19 pandemic, studies have identified an increased prevalence of sexual and intimate partner violence.1 In the Republic of Ireland, six Sexual Assault Treatment Units (SATUs) provide around-the-clock forensic, physical, preventative and supportive care for people over the age of 14 years who disclose sexual violence. All six SATUs have remained operational without limitation throughout the period of the pandemic. We here summarise the Irish SATU experience for a 10-month period during the pandemic, starting when the first case of COVID-19 was diagnosed in Ireland and comparing our findings with the same time period in 2019. Comparing attendances between 1 March and 31 December 2019 (pre-COVID) and 1 March and 31 December 2020, we found several notable features of attendances at the SATU network (table 1). View this table: Table 1 Comparison of attendances at national Sexual Assault Treatment Units during the periods March–December …

BACKGROUND:Sexual Assault Treatment Units (SATUs) provide holistic care, frequently including forensic examination, for people who disclose sexual violence. Storage of forensic evidence without reporting to An Garda Síochána (AGS), the Irish national police service (Option 3), was introduced in August 2016. This allowed attendees time to decide whether they wanted to report to AGS, without the loss of all forensic evidence. AIMS:This paper presents a retrospective analysis of all "Option 3" cases including their subsequent disclosures to AGS, at the Dublin SATU, between 1 Aug. 2016 and 30 Jul 2020. METHODS:The contemporaneous medical charts of Option 3 cases were reviewed and anonymised data extracted from them. RESULTS:During the study period, there were 1258 attendances to the Dublin SATU. Of these, 10% (n = 127/1258) were Option 3. Ninety-three percent (n = 118/127) were female and 7% (n = 9/127) were male. The mean age was 26. Seventy percent (89/127) indicated a sexual assault occurred and 30% (38/127) were unsure. Twenty percent (n = 25/127) subsequently reported the incident to AGS, 60% (n = 15/25) within 7 days, and 80% (n = 20/25) within 1 month. Eighty percent (n = 20/25) of these reported cases had their evidence retrieved by AGS for analysis. Three percent (n = 4/127) requested that their evidence kits be kept for an additional year. None of these patients reported over that following year, and their evidence was subsequently destroyed. CONCLUSION:In conclusion, the availability of Option 3 has afforded people the opportunity to access responsive SATU care including storage of forensic evidence which may have significant evidential value. This potentially provides further opportunities for comprehensive detection of a crime, even if reporting to AGS is delayed.

Allergic Rhinitis (AR) is a highly burdened chronic respiratory disease1-4, which affects about 40% of the world's population5. Research shows that only 15% of people with AR, in the community pharmacy setting are using optimal AR medication6. There is a clear need to better implement AR management guidelines so that more effective medication selection and an evidence-based approach to the management of AR is implemented.This paper describes the methods that will be used to develop, implement, evaluate and refine an evidence-based, guideline informed allergic rhinitis clinical management pathway, Allergic Rhinitis Clinical Management Pathway (AR-CMaP) for community pharmacy.AR-CMaP was developed based on the latest AR management guidelines for pharmacy7 and empirical evidence associated with patient self-management behaviours in community pharmacy15, utilising the Promoting Action on Research Implementation in Health Services implementation framework (Phase 1). AR-CMaP was then implemented in six pharmacies in the Australian Capital Territory (ACT), Australia (Phase 2). The impact of AR-CMaP on AR management in the pharmacy (AR medication management and pharmacy practice) will be evaluated in a pre-post intervention study design (Phase 3). Phase 4 will involve the refinement of AR-CMaP to ensure its generalisability and scalability; readiness for large-scale dissemination across different pharmacy locations (e.g. rural, remote, metropolitan) and different pharmacy business models.There is an urgent need to develop a translational AR clinical pathway, to address the wide-spread challenge of suboptimal AR management and burden of AR on individuals and society. This protocol paper describes the methods underpinning the development, implementation, evaluation and refinement of an evidence-based AR clinical pathway for community pharmacy setting, which is in line with current clinical evidence and feasible for effective implementation into the community pharmacy setting.

Sir, As a specialist trainee in Obstetrics and Gynaecology in Ireland, I wish to add some supportive information to reinforce the suggestion that the minimum time spent training in gynaecology be one year. An important issue for all trainees in Obstetrics and Gynaecology in this country, and indeed globally, is the struggle to acquire a good standard of surgical competency in gynaecology. The total number of years spent on the higher specialist training programme equates to approximately 5 years. Rotations between hospitals/regions on the specialist register are typically changed over on a yearly basis, with a few exceptions. This means that theoretically if a trainee is employed in the one institution for a period of 12 months that the system would allow for the trainee to remain operating with the same trainer for that time period. As the scheme encompasses both obstetrics and gynaecology training, at least one year with a designated gynaecology theatre list should not infringe upon obstetrics experience. I am including an anecdotal synopsis of my own exposure to gynaecology in theatre and cases performed while working as a Specialist Registrar in the National Maternity Hospital. While working here I also had a full time clinical involvement in obstetrics, including antenatal clinics and covering labour ward sessions. Favouring the argument for at least one year of operating in one centre, with one trainer for higher specialist trainees, is my experience as a 3rd year higher specialist trainee in obstetrics and gynaecology. Over a consecutive 12 month period at the National Maternity Hospital, 2013-2014, only 50% of theatre sessions were attended by me due to annual leave (consultant and my own) EWTD, having time off pre and post call (which was avoided if at all possible)and also where there was no unscheduled leave of absence. Attending one operating list a week the cases included 7 abdominal major cases, 8 vaginal hysterectomies and 14 vaginal repairs. This is a very basic and probably inadequate number of major procedures for a specialist trainee. In our view (myself and my trainer) the minimum amount of time for attachment to a unit should be one year, not forgetting that the trainer needs to establish a rapport with the trainee. N Maher, M Foley Department of Obstetrics & Gynaecology, National Maternity Hospital, Holles St, Dublin 2 Email: niamhisa@gmail.com Gynaecology Training for Higher Specialist Trainees in Obstetrics and Gynaecology, a Personal View 1

Objective: In this center, women with a history of gestational diabetes (GDM) are treated without rescreening from early pregnancy in any subsequent pregnancies, commencing with a low glycemic diet and insulin if and when indicated. The objective of this study was to see if this practice reduced the incidence of macrosomia compared with the index pregnancy. Method: The analysis was confined to women who required insulin in the subsequent pregnancy. Results: Among 369 women who were prospectively identified with a history of previous GDM, 95 required insulin - the study cohort. Insulin treatment was commenced at an earlier gestation in the subsequent pregnancy. The incidence of macrosomia was significantly less in the subsequent pregnancy in the group of women who required insulin in both pregnancies (p = 0.02). Conclusion: This data suggests early treatment is of benefit to this high-risk group in the reduction of macrosomia.

In this center all women with a previous history of GDM are treated without rescreening from early pregnancy, commencing with a low glycaemic diet and insulin if indicated. The objective was to see if this practice reduced the incidence of macrosomia compared with the previous pregnancy. As only 70% will develop GDM in subsequent pregnancy the analysis was confined to women who then required insulin. In this center screening is selective, based on historical or other risk factors. Data was collated prospectively on all women with GDM with a secondary analysis of data for the years 2003-2010. Amongst 68, 498 women there were 873 gestational diabetics (1.3%) of whom 335(38%) required insulin. Overall 369 (42%) had previous GDM and were treated without rescreening, of whom 25% (92/369) received insulin the study cohort. Sixty three of these women (68%; 63/92) received insulin in both pregnancies. Overall treatment commenced at an earlier gestational age (mean 10 weeks vs. 31 weeks) and insulin treatment was commenced significantly earlier when comparing the current pregnancy with the preceding pregnancy (mean 19 weeks, range 4-34 weeks) vs 29 weeks (range 8-38 weeks) (P 90centile, corrected for gestational age and gender) was 28.3% (26/92) (current) vs 33.7 % (31/92) (preceding) respectively (P=0.5). Comparing only those who required insulin in both pregnancies there was a significant reduction in the incidence of macrosomia (23.8% 15/63) vs 42.85% (27/63) (P=0.03). While the benefit of treating all women with a history of GDM from early pregnancy without rescreening is debatable, the significant reduction of macrosomia in the cohort requiring insulin in both pregnancies would suggest the earlier treatment is of benefit in this high risk cohort.