Tertiary Referral Maternity Hospital Research Articles

Estimating fetal weight in gastroschisis: A 10 year audit of outcomes at the National Maternity Hospital.

To identify whether conventional methods of estimating fetal growth (Hadlock's formula), which relies heavily on abdominal circumference measurements, are accurate in fetuses with gastroschisis. A retrospective cohort study was performed between the period January 1, 2011 and December 31, 2021 in a tertiary referral maternity hospital identifying all pregnancies with a diagnosis of gastroschisis. Projected fetal weight was obtained using the formula (EFW [Hadlock's formula] + 185 g × [X/7]) where X was the number of days to delivery. During the study period 41 cases were identified. The median maternal age was 25. The median BMI was 25 and 63% were primiparous women (n = 26). Median gestation at diagnosis was 21 weeks. Median gestation at delivery was 36 weeks. A total of 4.8% of mothers had a history of drug use (n = 2). The rate of maternal tobacco use was 21.9% (n = 9). A total of 4.8% of fetuses had additional congenital anomalies including amniotic band syndrome and myelomeningocele (n = 2). Estimated fetal weight (EFW) and birth weight data were available for 34 cases. A Wilcoxon signed-rank test showed projected EFW using Hadlock's formula did not result in a statistically significant different birth weight (Z = -1.3, P = 0.169). Median projected weight and actual birth weight were 2241.35 and 2415 g respectively. Median difference was 0.64 g (95% CI: -148 to -28.5). Our data showed accuracy using standard formulae for EFW in fetuses with gastroschisis.

Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes

Aims Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement – the anterior abdominal wall measurement (AAW) – to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated. Methods This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks’ gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks’ gestation were reported for this study. Results Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida’s. The mean birthweight was 3548 g (+/− 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 383 weeks (314 − 402 weeks). There were 37 (9%) babies born preterm at <37 weeks’ gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks’ gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks’ gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth. Conclusions Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.

Exploring the effect of the \u2018Growing Together\u2019 parenting education kit on early parenting - study protocol for a cluster randomised controlled trial

BackgroundSignificant gaps exist in education for prospective and new parents, especially for some of the most vulnerable families. Prospective parents would like more information during pregnancy to prepare them for parenting, and need access to trusted and quality information.The Royal Women’s Hospital (the Women’s) in Melbourne, Australia, a large tertiary referral maternity hospital, developed a parenting education kit known as ‘Growing Together’. The kit, designed to guide prospective and new parents from conception until 1 year after birth, includes three components: an A4 sized book, a specifically designed ‘App’ and a children’s story book. We aim to evaluate the impact of the kit on a range of outcomes.MethodsA two-arm cluster randomised controlled trial will be used. Antenatal clinic days will be randomised to either the intervention or standard care arms. Women in the intervention arm receive the kit at their antenatal booking visit. Women in the standard care arm receive the standard information resources at the Women’s. Analyses will be by intention to treat. Inclusion criteria: primiparous women with adequate English-speaking ability and ≤ 30 weeks’ gestation at first pregnancy booking appointment.The primary outcome of the study is the ‘experience of motherhood questionnaire’ (EMQ), a 20 item validated self-report measure, ranging from 0 to 80, with lower scores indicating better maternal health and wellbeing. To detect a 10% difference in new mothers scoring ≤40 between women who have received the kit (60%) and those who have not (50%), would require 408 per group (total of 816 women) with 95% confidence and 80% power. Allowing for loss to follow up, we aim to recruit 1000 mothers. Secondary outcomes include parents’ views and experiences of their care and of the kit during pregnancy and after the birth, parental attachment, knowledge, confidence, wellbeing and health-seeking behaviour; and emotional, developmental and physical health of the infant. Survey data will be collected from mothers at 2, 6 and 12 months postpartum and partners at 6 months.DiscussionThis study will provide much needed high-level evidence on the impact of a comprehensive education resource for new parents.Trial registrationANZCTRN12615000270516 - Retrospectively registered (23/03/2015); trial started on 16 March 2015.

Development of a novel bedside index for the early identification of severe maternal infection

ObjectivesInternational consensus reports have recently recommended that the Systemic Inflammatory Response Syndrome (SIRS) criteria for the diagnosis of sepsis should cease and that new bedside criteria need to be developed to improve prevention, early diagnosis and treatment.The aim of this retrospective audit was to evaluate a suite of four bedside clinical criteria, called the Early Maternal Infection Prompts (EMIP), in helping to identify women with a suspected severe infection who were admitted to a High Dependency Unit (HDU) in a large tertiary referral stand-alone maternity hospital. Study designThe four EMIP criteria were decided based on existing national obstetric guidelines and a review of the recent literature on maternal critical illnesses. Cases were identified from the HDU registry for the three years 2015-2017. Individual charts were retrieved, and the four EMIP parameters were measured at the time of the clinical assessment that led to the HDU admission. Clinical and sociodemographic details were computerised for analysis. ResultsOf 73 women admitted with suspected severe maternal infection, the handwritten records were available in 69. The mean age was 31.3 years, 71% were multiparous and 26.1% were obese. Three quarters of cases were antenatal admissions. Infection was confirmed microbiologically in 56 (81.1%) of cases. There were no maternal deaths. There was no case of organ dysfunction diagnosed but two women required vasopressors to maintain blood pressure. Recordings of the maternal vital signs were not always fully completed before admission. In 69.1% (n = 47) of cases the temperature was elevated ≥ 37.5 C, in 81.2% (n = 56) of cases the heart rate was increased ≥ 100 bpm, in 51.9% (n = 27) cases the respiratory rate was increased ≥ 20 bpm, and in 25.4% (n = 17) cases the systolic blood pressure was ≤100 mmHg. At least one of the four EMIP criteria was abnormal in 91.3% (n = 63) of cases of suspected severe infection. ConclusionsThe audit confirmed that this bedside index has potential in helping to identify maternal infection early before sepsis develops. Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infection.

Examining the infectious aetiology and diagnostic criteria of maternal pyrexia in labour to improve antibiotic stewardship

ObjectivesTo determine the infectious aetiology of peripartum maternal pyrexia and to assess the diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria and cardiotocography as predictors of peripartum infection, in order to guide appropriate antibiotic management of mother and neonate.Study DesignThis study was carried out in a tertiary referral maternity hospital in Dublin, Ireland. A prospective cohort analysis was performed of 175 mother-newborn pairs with maternal pyrexia (≥38 °C) that developed after labour onset or within four hours postnatal. Infection was confirmed microbiologically in the case of sterile site infection, urinary tract infection (UTI) or growth of a significant perinatal pathogen from a placental swab. Infection was confirmed histologically by gross and microscopic examination of placentas in cases where there was growth of potentially pathogenic micro-organisms at a non-sterile site. Systemic inflammatory response syndrome criteria and cardiotocography in patients with confirmed infection versus those without evidence of infection were compared using independent samples t-test for continuous data and pearson chi-square test for nominal data. Diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria (elevated maternal heart rate, elevated respiratory rate, decreased systolic blood pressure and elevated white cell count) for the identification of infection among women with peripartum pyrexia was determined using receiver operating characteristic curves.ResultsThe infection rate was 17.1% (30/175). The rate was 22% (22/100) for pyrexia that occurred during labour and 10.7% (8/75) if it occurred within four hours after delivery. Obstetric systemic inflammatory response syndrome criteria and cardiotocography were not predictive of infection in women with peripartum pyrexia. No significant differences were observed in mean temperature, heart rate, respiratory rate, systolic blood pressure or white cell count between those with infections and those with no evidence of infection.ConclusionsPeripartum pyrexia is predominantly of non-infectious origin. Improved diagnostic criteria are needed to identify infection for this indication. Early discontinuation of antibiotic treatment is appropriate in the majority of patients who develop term peripartum pyrexia after onset of labour.

Influenza vaccination in pregnancy: vaccine uptake, maternal and healthcare providers' knowledge and attitudes. A quantitative study.

BackgroundInfluenza during pregnancy is a potentially life threatening illness. There are limited data on influenza vaccination uptake and determinants of uptake in Irish obstetric populations.AimTo determine the uptake of influenza vaccination during pregnancy; determinants of vaccination uptake; knowledge, attitudes, and concerns of postnatal women; and knowledge and attitudes of healthcare professionals (HCPs) surrounding vaccination.Design & settingA quantitative study of postnatal women attending the Rotunda Hospital, a tertiary referral maternity hospital in Dublin, Ireland. A separate quantitative study conducted by the North Dublin City GP Training Programme surveyed GPs, pharmacists, and Rotunda Hospital clinical staff.MethodA paper-based survey was distributed to postnatal women. HCPs completed the survey via the online tool Survey Monkey.Results330 patient surveys were disseminated, with a 60.0% response rate. Of 198 responders, 109 (55.1%) were vaccinated against influenza. Non-professionals were less likely to be vaccinated (adjusted odds ratio [aOR] 0.29, 95% confidence interval [CI] = 0.09 to 0.89). Vaccination in previous pregnancy (aOR 5.2, 95% CI = 1.69 to 15.62) and information from an HCP were strongly associated with vaccination (aOR 12.8, 95% CI = 2.65 to 62.5). There was a 20.2% (n = 1180) response rate among HCPs. More GPs felt that it was their role to discuss vaccination (92.9%; n = 676), and offer to vaccinate women (91.7%; n = 666) than any other HCP.ConclusionProvision of information about the importance of vaccination against influenza and pertussis during pregnancy by HCPs and their consistent recommendations in support of vaccination were key determinants of vaccine uptake during pregnancy. The sociodemographic determinants of a woman’s vaccination status should be addressed in health promotion campaigns. Education of HCPs may address knowledge gaps surrounding vaccination.

P249 Audit of adherence to referral pathway for pregnant women with history of genital herpes booked at a tertiary referral maternity hospital, aug 2015 – aug 2016

IntroductionGenital Herpes Simplex Virus (HSV) can be transmitted in the perinatal period with the potential for serious and devastating consequences for the fetus/infant. Transmission from mother to infant most commonly occurs due to exposure during delivery (85 – 90%). Early 2014, the team caring for women with Infectious Diseases in pregnancy identified that women, with a history of genital HSV or an outbreak in pregnancy, were an at-risk group without a specific care pathway, often with differing clinical decisions regarding their care.MethodsA retrospective audit was undertaken to ascertain adherence to a newly introduced referral pathway for pregnant women who gave a history of genital herpes booking into a tertiary referral Maternity Hospital, August 2015 – August 2016.ResultsOur initial audit over a 9 month period demonstrated that there was an overall deficit in knowledge regarding the new referral pathway. The 9 month audit showed that only 13 of 49 (26%) of women were referred to specialist services at any time during their pregnancy. Our subsequent audit showed 54% of women were referred for specialist consult in the period following re-education; a large improvement in awareness of our referral pathway.DiscussionAudit of practice and in particular following an introduction of a new care pathway, is an essential tool for demonstrating compliance as well as highlighting gaps which require addressing. Education targeting the team of midwives who ascertain women’s history on booking into the maternity services, has improved referrals as per our 4 month follow-up audit.

Pelvic floor assessment after delivery: how should women be selected?

ObjectivePelvic floor dysfunction after delivery is quite common. New mothers deserve to receive targeted care for pelvic floor dysfunction, but how should women who are at risk be identified and selected for treatment? This study investigated risk factors and puerperal health-seeking behaviours to develop a restrictive patient selection model for postpartum pelvic floor dysfunction assessment. Study designThis prospective observational study involved women who were at ≥32 weeks gestational age when they delivered in a tertiary referral maternity hospital in Milan, Italy, between July and December 2014. Eligible women were scheduled for a 3-month postnatal pelvic floor clinic. The adherence rate to the pelvic floor clinic and the prevalence of pelvic floor dysfunctions at 3 months postpartum were recorded. Univariable and logistic multivariable analyses were performed to select risk factors for pelvic floor dysfunctions. Risk factors were then tested for sensitivity and specificity for 3-month postpartum pelvic floor dysfunctions. ResultsOf 1606 eligible women, 1293 (80.5%) were included in the analysis; 685 puerperal women (53.0%) adhered to the 3-month postnatal pelvic floor clinic; pelvic floor dysfunctions were detected in 238 women (34.7%). Four elements emerged as risk factors: symptoms before pregnancy (OR 1.72, 95% CI 1.15–2.56; p=0.008), symptoms during pregnancy (OR 2.13, 95% CI 1.49–3.06; p<0.0001), vacuum extractor use (OR 1.62, 95% CI 1.04–2.54; p=0.034), and severe perineal tears (OR 19.45, 95% CI 2.42–156.15; p=0.005). The combined sensitivity and specificity for the 4 risk factors were 82% and 39%, respectively. ConclusionInternal risk factors analysis offers the potential to efficiently restrict patient selection for follow-up.

Neonatal and maternal outcomes following midtrimester preterm premature rupture of the membranes: a retrospective cohort study.

BackgroundPreterm premature rupture of membranes (PPROM) complicates 1 % of all pregnancies and occurs in one third of all preterm deliveries. Midtrimester PPROM is often followed by spontaneous miscarriage and elective termination of ongoing pregnancies is offered in many countries. The aim of this retrospective descriptive cohort study was to investigate the natural history of midtrimester PPROM in a jurisdiction where termination of pregnancy in the absence of maternal compromise is unavailable.MethodsCases of midtrimester PPROM diagnosed between 14 and 23 + 6 weeks’ gestation during April 2007 to June 2012 were identified following a manual search of all birth registers, pregnancy loss registers, annual reports, ultrasound reports, emergency room registers and neonatal death certificates at Cork University Maternity Hospital - a large (circa 8500 births per annum) tertiary referral maternity hospital in southwest Ireland. Cases where delivery occurred within 24 h of PPROM were excluded.ResultsThe prevalence of midtrimester PPROM was 0.1 % (42 cases/44,667 births). The mean gestation at PPROM was 18 weeks. The mean gestation at delivery was 20 + 5 weeks, with an average latency period of 13 days.Ten infants were born alive (23 %; 10/42). The remainder (77 %; 32/42) died in utero or intrapartum. Nine infants were resuscitated. Two infants survived to discharge. The overall mortality rate was 95 % (40/42).Five women had clinical chorioamnionitis (12 %; 5/42) but 69 % demonstrated histological chorioamnionitis. One woman developed sepsis (2.4 %; 1/42). Other maternal complications included requirement of intravenous antibiotic treatment (38 %; 17/42), retained placenta (21 %, 9/42) and post-partum haemorrhage (12 %; 5/42).ConclusionsThis study provides useful and contemporary data on midtrimester PPROM. Whilst fetal and neonatal mortality is high, long-term survival is not impossible. The increased risk of maternal morbidity necessitates close surveillance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0813-3) contains supplementary material, which is available to authorized users.

Day care versus inpatient management of nausea and vomiting of pregnancy: cost utility analysis of a randomised controlled trial

ObjectiveTo assess the comparative cost effectiveness of day care over inpatient management of nausea and vomiting of pregnancy (NVP). Study designA cost utility analysis was performed using a decision analytical model in which a Markov model was constructed. The Markov model was primarily populated with data from a recently published randomised controlled trial. Which included pregnant women presenting to Cork University Maternity Hospital, a tertiary referral maternity hospital, seeking treatment for NVP. Costs and outcomes were estimated from the perspective of the Irish health service (HSE) and patients. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was also performed. A Bayesian Value of Information analysis was used to estimate the value of collecting additional information. ResultsWhen both the healthcare provider and patient's perspective was considered, day care management of NVP remained less costly (mean €985; 95% C.I. 705–1456 vs. €3837 (2124–8466)) and more effective (9.42; 4.19–12.25 vs. 9.49; 4.32–12.39 quality adjusted life years) compared with inpatient management. The Cost Effectiveness Acceptability Curve indicates the probability that day care management is 70% more cost effective compared to inpatient management at a ceiling ratio of €45,000 per QALY, indicating little decision uncertainty. The Bayesian Value of Information analysis indicates there is value in collecting further information; the Expected Value of Perfect Information (EVPI) is estimated to be €5.4 million. ConclusionDay care management of NVP is cost effective compared to inpatient management.

Prevalence of gonococcal conjunctivitis in adults and neonates.

To report the prevalence of gonococcal conjunctivitis (GC) presenting to a tertiary referral maternity hospital (NMH) and a tertiary referral ophthalmic hospital (RVEEH) from 2011 to 2013 and describe the demographics, clinical presentation, and antibiotic susceptibility of Neisseria gonorrhoeae ocular infections. Demographic, clinical, and microbiological data were collected from patients with laboratory confirmed GC. There were 27 556 live births at NMH during the study period, and no case of neonatal GC was identified. Fourteen cases of GC were identified at RVEEH in this period, representing a prevalence of 0.19 cases per 1000 eye emergency attendees. Antibiotic susceptibility data were available on nine cases, of which, all were ceftriaxone- and ciprofloxacin sensitive. 64.3% of patients were male, with a mean age of 18 years. The mean duration of symptoms was 3 days. All patients presented with unilateral conjunctival injection and purulent discharge. Eight cases had visual impairment at presentation and their mean visual acuity was 6/15. Corneal involvement was present in 25% of patients. Uveitis was not detected. On receipt of positive culture and/or PCR results, treatment was altered in two thirds of patients. All patients were referred for full STI screening and all patients showed a full clinical recovery 1 week posttreatment. We observed that GC presented in young adults with a male predominance and was rare in neonates. In cases of unilateral purulent conjunctivitis, there should be a high clinical suspicion of GC, early swab for PCR and culture, and knowledge of current CDC-recommended antibiotic guidelines.

Pregnancy Outcomes of Mothers with Detectable CMV-Specific IgM Antibodies: A Three-Year Review in a Large Irish Tertiary Referral Maternity Hospital.

A retrospective audit was performed for all obstetric patients who had positive CMV IgM results between January 2012 and December 2014 in the Rotunda Hospital, Ireland. In total, 622 CMV IgM positive tests were performed on samples from 572 patients. Thirty-seven patients had a positive CMV IgM result (5.9%) on the Architect system as part of the initial screening. Three patients were excluded as they were not obstetric patients. Of the 34 pregnant women with CMV IgM positive results on initial screening, 16 (47%) had CMV IgM positivity confirmed on the second platform (VIDAS) and 18 (53%) did not. In the 16 patients with confirmed positive CMV IgM results, four (25%) had acute infection, two (12.5%) had infection of uncertain timing, and ten (62.5%) had infection more than three months prior to sampling as determined by the CMV IgG avidity index. Two of the four neonates of women with low avidity IgG had CMV DNA detected in urine. Both these cases had severe neurological damage and the indication for testing their mothers was because the biparietal diameter (BPD) was less than the 5th centile at the routine 20-week gestation anomaly scan.

Establishing trimester-specific maternal thyroid function reference intervals

Thyroid disorders are common in women of childbearing age and are associated with adverse pregnancy outcomes. Physiological changes in pregnancy and the lack of pregnancy-specific reference ranges make managing thyroid disorders in pregnancy challenging. Our aim was to establish trimester-specific thyroid function reference intervals throughout pregnancy, and to examine the prevalence of thyroid autoimmunity in otherwise euthyroid women. This was a prospective, cross-sectional study of thyroid function tests (TFTs) in pregnant women attending a large, tertiary referral maternity hospital. Patients with known thyroid disorders, autoimmune disease, recurrent miscarriage, hyperemesis gravidarum and pre-eclampsia were excluded. TFTs were analysed in the CUH biochemistry laboratory using Roche Modular E170 electrochemiluminescent immunoassay. Trimester-specific reference ranges (2.5th, 50th and 97.5th centiles) were calculated. Three-hundred-and-fifty-one women were included into the analysis. Median maternal age was 30. Thyroid-stimulating hormone concentrations showed slightly increasing median centile throughout gestation. Free thyroxine (T4) and T3 decreased throughout gestation. Table 1 demonstrates the calculated percentiles according to gestational weeks. We established pregnancy-specific thyroid function reference intervals for our pregnant population, for use in clinical practice.

Pregnancy in dark winters: implications for fetal bone growth?

To prospectively examine the prevalence of hypovitaminosis D in pregnancy and to correlate maternal and fetal vitamin D to fetal anthropometry. A prospective cohort study. Tertiary referral maternity hospital. Sixty pregnant women. Serum 25-hydroxyvitamin D (25OHD) was measured in early pregnancy, at 28 weeks, and in cord blood at delivery. The prevalence of hypovitaminosis D and the relationship between fetal growth and serum 25OHD concentrations. Two subgroups were analyzed to examine results in the context of seasonal variation in 25OHD: a winter and a summer cohort. Fetal anthropometry was assessed at 20 and 34 weeks, and at delivery the neonatal anthropometry was recorded. There was a high prevalence of hypovitaminosis D ranging from 33% to 97%, with a marked seasonal variation. Fetal 25OHD concentrations correlated with all biometry at 20 weeks. In the winter cohort, a correlation was found between early pregnancy 25OHD and femur length at 20 weeks, and between 28-week 25OHD and femur length at 34 weeks. Infant length was shorter in those with early pregnancy 25OHD less than the median (52.1 vs. 53.6 cm). The high prevalence of maternal hypovitaminosis D during winter months in northern latitudes may have detrimental effects on fetal skeletal growth.

Pregnancy in dark winters: Implications for fetal bone growth?

Objective To prospectively examine the prevalence of hypovitaminosis D in pregnancy and to correlate maternal and fetal vitamin D to fetal anthropometry. Design A prospective cohort study. Setting Tertiary referral maternity hospital. Patient(s) Sixty pregnant women. Intervention(s) Serum 25-hydroxyvitamin D (25OHD) was measured in early pregnancy, at 28 weeks, and in cord blood at delivery. Main Outcome Measure(s) The prevalence of hypovitaminosis D and the relationship between fetal growth and serum 25OHD concentrations. Result(s) Two subgroups were analyzed to examine results in the context of seasonal variation in 25OHD: a winter and a summer cohort. Fetal anthropometry was assessed at 20 and 34 weeks, and at delivery the neonatal anthropometry was recorded. There was a high prevalence of hypovitaminosis D ranging from 33% to 97%, with a marked seasonal variation. Fetal 25OHD concentrations correlated with all biometry at 20 weeks. In the winter cohort, a correlation was found between early pregnancy 25OHD and femur length at 20 weeks, and between 28-week 25OHD and femur length at 34 weeks. Infant length was shorter in those with early pregnancy 25OHD less than the median (52.1 vs. 53.6 cm). Conclusion(s) The high prevalence of maternal hypovitaminosis D during winter months in northern latitudes may have detrimental effects on fetal skeletal growth.

Overweight and obesity in Australian mothers: epidemic or endemic?

To document temporal trends in maternal overweight and obesity in Australian women and to examine associations with pregnancy outcomes. Retrospective 12-year cohort study of 75432women with singleton pregnancies who had pre-pregnancy height and weight data available and who gave birth in a tertiary referral maternity hospital in Brisbane between January 1998and December 2009. Maternal body mass index (BMI); prevalence of overweight and obesity, and pregnancy complications including hypertension, gestational diabetes, caesarean delivery, and perinatal morbidity and mortality. From 1998to 2009, class III and class II obesity increased significantly (from 1.2% to 2.0%, and 2.5% to 3.2%, respectively), while the proportions of underweight women and those with class I obesity fell slightly (from 7.9% to 7.4%, and 7.7% to 7.5%, respectively). Increasing maternal BMI was associated with many adverse pregnancy outcomes, including hypertension in pregnancy, gestational diabetes, caesarean delivery, perinatal mortality (stillbirth and neonatal death), babies who were large for gestational age, and neonatal morbidities including hypoglycaemia, jaundice, respiratory distress and the need for neonatal intensive care (P<0.001for all). Most associations remained significant after adjusting for maternal age, parity, insurance status, smoking status, ethnicity and year of the birth. The frequency of congenital anomalies was not associated with maternal BMI (P=0.71). Maternal overweight and obesity are endemic challenges for Australian obstetric care and are associated with serious maternal and neonatal complications, including perinatal mortality.

Reference standard for serum bile acids in pregnancy

Please cite this paper as: Egan N, Bartels Ä, Khashan A, Broadhurst D, Joyce C, O’Mullane J, O’Donoghue K. Reference standard for serum bile acids in pregnancy. BJOG 2012;119:493–498.Objective Obstetric cholestasis (OC) is a liver disorder characterised by pruritus and elevated serum bile acids (SBA) that affects one in 200 pregnant women. It is associated with adverse perinatal outcomes such as premature delivery and stillbirth. Mild OC is defined as SBA levels of 10–39 μmol/l, and severe OC is defined by levels &gt;40 μmol/l. SBA levels in normal pregnancy have not been investigated. We aimed to establish reference values for SBA in healthy pregnant women across different trimesters of pregnancy.Design Cross‐sectional analysis of SBA levels.Setting A large tertiary referral university teaching maternity hospital.Population Healthy pregnant women with a singleton pregnancy and a body mass index (BMI) &lt; 40, excluding women with significant alcohol intake, history of liver disease, prior cholecystectomy and OC.Methods Cross‐sectional analysis of SBA levels at 12, 20, 28 and 36 weeks of gestation, and on days 1–3 postpartum.Main outcome measures SBA levels in μmol/l.Results A total of 219 women attending for antenatal care were recruited, and SBA levels were assayed at 12, 20, 28 and 36 weeks of gestation, and up to 72 hours postpartum (n = 44–49 cases at each stage). The majority were white European women, with a median age of 30 years (range 17–46 years) and median BMI of 25 (range 18–38). Values of SBA ranged from 0.3 to 9.8 μmol/l in 216 women, with only three measurements outside this range. There were no significant changes throughout pregnancy.Conclusions SBA values in uncomplicated pregnancies are consistent, regardless of gestation, and are not elevated in pregnancy. The current reference values for the diagnosis of OC appear to be appropriate.

Australian maternity reform through clinical redesign

The current Australian national maternity reform agenda focuses on improving access to maternity care for women and their families while preserving safety and quality. The caseload midwifery model of care offers the level of access to continuity of care proposed in the reforms however the introduction of these models in Australia continues to meet with strong resistance. In many places access to caseload midwifery care is offered as a token, usually restricted to well women, within limited metropolitan and regional facilities and where available, places for women are very small as a proportion of the total service provided. This case study outlines a major clinical redesign of midwifery care at a metropolitan tertiary referral maternity hospital in Sydney. Caseload midwifery care was introduced under randomised trial conditions to provide midwifery care to 1500 women of all risk resulting in half of the publicly insured women receiving midwifery group practice care. The paper describes the organisational quality and safety tools that were utilised to facilitate the process while discussing the factors that facilitated the process and the barriers that were encountered within the workforce, operational and political context.

1339 Risk Factors for Meconium Aspirationem

The objective of this study was to identify linkbetween fetal distress and respiratory distress (RD)in association with meconium stained liquor. In ourhospital -a tertiary referral maternity hospital wasborn 6783 live newborns for one year during ourprospective study. All infants born after meconimstained liquor who developed RD has: 1. fetal distress, proven with CTG, first pHafter admission, Apgar score, asphyxia relatedcomplications (also were analysed mode of thedelivery, sex, gestational age and birth bodywaight) 2. maternal risk factors: fetal infection 3. meconium aspirationem syndrome (MAS), PPHNand infection.12% of newborns born alive for oneyear had meconium stained liquor, 74 term infantsand 27 preterm developted RD. There were 58term infants who had evidence of fetal distress and67% had chorioamnionitis, 29% MAS, 54% developPPHN. In preterm infants 87% had suspectedinfection. We conclude that asphyxia and infectionare common in newborns who develop RD aftermeconim stained liquor.

Obstetric epidural catheter-related infections at a major teaching hospital: a retrospective case series

Background Clinically overt infections of the epidural catheter skin entry site occur in approximately 1-5% of patients after a few days of catheterization but serious complications such as deep tissue infection or epidural abscess appear rare in the obstetric population. In recent years, sporadic reports and small series suggest that the incidence may be higher than previously estimated. Methods A retrospective chart review was conducted to identify epidural catheter-related infections occurring between January 2002 and December 2005 in a tertiary referral maternity hospital delivering between 4000 and 6000 women per annum. Cases were identified using International Statistical Classification of Diseases coding. Results In total 9482 women (52.8%) who delivered had an epidural catheter inserted. There were 258 cases with the relevant code identified and 49 (0.52%, 95% CI 0.37-0.66%) had epidural catheter-related infection. Four women had deep tissue infection (incidence 0.04%, 95% CI 0.01-0.11%; rate 1 in 4741), represented by paraspinous and epidural abscess formation (incidence of both 0.02%, 95% CI 0-0.08%; rate 1 in 2371). Three of the cases are described. Conclusions Serious epidural catheter-related infection in obstetric patients is rare, but our incidence of serious deep tissue infection was at the upper extreme of figures quoted in other studies.