Rotunda Hospital

This study investigates the impact of patent ductus arteriosus (PDA) status and treatment response on myocardial adaptation in preterm infants by comparing serial echocardiographic trajectories across three groups: high-risk infants with treatment success, high-risk infants with treatment failure, and low-risk infants not requiring treatment. In this prospective cohort study, preterm infants born < 29 weeks' gestation were stratified using the EL-Khuffash PDA Severity Score and subsequent response to medical therapy. Echocardiographic assessments were performed at three timepoints: day 2, 2 weeks, and 36 weeks corrected gestational age. A range of structural and functional parameters was analysed. Of 184 included infants, 58 were high risk with treatment success, 52 were high risk with treatment failure, and 74 were low risk. High-risk infants with treatment failure had persistent myocardial and haemodynamic alterations, including higher left ventricular wall thickness and lower coeliac artery velocities at follow-up. Treatment success was associated with improvements in strain metrics, systemic perfusion, and structural indices. Low-risk infants demonstrated spontaneous PDA closure and overall stable haemodynamics. Distinct differences in the evolution of myocardial trajectories between groups were apparent between day 2 and week 2 echocardiograms. Serial echocardiographic assessments highlight the dynamic impact of PDA treatment response on myocardial adaptation. Persistent ductal patency despite treatment is associated with sustained structural and functional changes. Early definitive ductal closure may promote haemodynamic stability and mitigate maladaptive remodelling in a subgroup of high-risk infants.

SummaryActivating mutations in the ABCC8 gene are extremely rare and cause ABCC8-MODY. The phenotype is variable with onset of diabetes in childhood/early adulthood. Retinopathy is the most common reported complication. We describe a 31-year-old primigravida woman referred to and seen at our antenatal ambulatory diabetes clinic at 6 weeks plus 5 days gestation. She had a strong family history of diabetes and was diagnosed at the age of 11 years. Genetic testing revealed an activating pathogenic c.4139G>A variant in the ABCC8 gene. She was managed with glibenclamide, sitagliptin, and dapagliflozin. Her complications included mild bilateral non-proliferative retinopathy and necrobiosis lipoidica. Her BMI was 19 kg/m2, and HbA1c was 68 mmol/mol. Oral agents were discontinued, and insulin therapy was commenced. At 22 weeks gestation, routine retinal screening identified progression to bilateral active proliferative diabetic retinopathy (time in range for pregnancy (TIRp) 68%, HbA1c 39 mmol/mol). She received four sessions of panretinal photocoagulation (PRP) bilaterally between 22 and 33 weeks gestation. There was no associated loss of vision or nephropathy. TIRp was ≥70% for the remainder of the pregnancy. She delivered a 3.9 kg unaffected female infant at 38 weeks via elective caesarean section without maternal or neonatal complications. Bilateral active proliferative retinopathy persisted up to 61 weeks postnatally and required additional PRP. Forty-six weeks post-partum, after ceasing breastfeeding, insulin was switched to glibenclamide and dapagliflozin. This is the first case report of rapid progression of clinically significant diabetic retinopathy during pregnancy in a woman with ABCC8-MODY. This is an unusual finding as there is a relatively low risk of significant progression of diabetic retinopathy in women with type 2 diabetes during pregnancy.Learning pointsRapid progression of diabetic retinopathy during pregnancy is an uncommon complication in women with type 2 diabetes.This woman with ABCC8-MODY developed rapidly progressive clinically significant diabetic retinopathy without nephropathy during pregnancy.There is a paucity of literature regarding pregnancy-related complications of ABCC8-MODY.This case highlights the risks of end organ disease in a rare form of diabetes.

The authors declare that no conflict of interest could be perceived as prejudicing the impartiality of the research reported. Data sharing does not apply to this article as no new data were created or analyzed in this study.

Endometriosis affects 1 in 10 women globally. We aimed to determine health provider involvement and preferred methods of obtaining an endometriosis diagnosis across international jurisdictions. A global cross‐sectional survey, distributed through formal and informal FIGO Reproductive Medicine, Endocrinology, and Infertility (REI) committee networks from September through October 2024. A total of 445 respondents from 76 countries began the survey, with 360 completions. Of the respondents, 63.9% were female, with most being gynecologists. Academics and/or researchers comprised 6.7%, with 39.2% involved in research in some capacity. Endometriosis was largely diagnosed by gynecologists (95.0%), with most respondents overall describing ultrasound as the most common method of diagnosis (77.8%). Of those surveyed, 93.6% stated clinicians in their country used non‐invasive imaging (predominantly ultrasound) to diagnose endometriosis before surgery. One third of respondents did not feel confident distinguishing between routine gynecological scans and specialist endometriosis imaging. Significant barriers for uptake of imaging diagnostics included access to training, cost, and geographical accessibility. Regarding adoption of non‐invasive imaging in clinical care, “game‐changing” effects were described, including improvements in surgical preoperative mapping, and patient‐centered care, with concerns that it could increase clinical workloads. Significantly, shifts in endometriosis diagnosis, from visualization of lesions at laparoscopy to non‐invasive imaging diagnostics, were observed internationally. Policies should aim to overcome barriers to uptake of imaging‐based diagnostics by supporting training initiatives, reducing associated costs, and improving geographical accessibility. Respondents predicted transformative changes in endometriosis care once non‐invasive endometriosis diagnostics are effectively adopted.

IntroductionPulmonary aspiration under general anaesthesia is a rare but serious risk in obstetric populations, leading to conservative fasting protocols prior to elective caesarean delivery (CD). However, prolonged fasting may negatively impact maternal comfort and metabolic status. ‘Sip til Send’ (STS), a liberal fasting protocol permitting clear fluids until theatre admission, has been shown to improve the perioperative patient experience. Pre-operative carbohydrate loading (CHO), as part of Enhanced Recovery After Surgery (ERAS) pathways, may offer additional benefits, yet its role in obstetrics is underexplored. This study aimed to compare CHO with STS in women undergoing elective CD, focusing on patient-reported comfort measures.MethodsIn this single-blinded, randomised controlled trial, 100 eligible women scheduled for elective CD under spinal anaesthesia were randomised to either STS or CHO groups. Women in the CHO group consumed two 200 ml carbohydrate drinks (Nutricia preOp™) pre-operatively. Primary outcomes included self-reported pre-operative thirst, hunger, nausea, dizziness, anxiety, and comfort using a 0–10 visual analogue scale (VAS). Secondary outcomes included ketonuria, blood glucose, lactate levels, intra-operative nausea, post-operative temperature, and recovery scores at 24 h.ResultsMean [SD] anxiety scores were significantly lower in the CHO group compared with STS (CHO 4.1 [2.9] vs STS 5.5 [2.6], p = 0.01. No other primary patient-reported outcomes differed significantly. Ketonuria was less prevalent in the CHO group (CHO 2/50 [4%] vs. STS 10/50 [20%], p = 0.002), and mean [SD] blood glucose was higher (CHO 5.0 [1.5] mmol.L-1 vs. STS 4.5 [0.6] mmol.L-1, p = 0.046). Intra-operative nausea was more common in the CHO group (CHO 22/50 [44%] vs. STS 8/50 [16%], p = 0.002). No differences were observed in lactate, post-operative temperature, or quality of recovery scores (OBS QOR-11, global health score) at 24 h.ConclusionsPre-operative carbohydrate loading before elective CD significantly reduces maternal anxiety and ketonuria compared to a liberal clear fluid protocol. However, it was associated with increased intra-operative nausea and no improvement in other patient-centred outcomes or recovery quality. These findings suggest limited additional benefit of CHO over STS in this population. Further multicentre trials are warranted to refine carbohydrate loading protocols and assess their role in obstetric ERAS pathways.Trial registrationClinicaltrials.gov NCT06505915, 30th June 2024. Retrospectively registered.

We read with interest the article by Godet et al. [1] and commend the authors for presenting a well-structured and timely investigation into tracheal extubation practices. Their study contributes meaningful evidence to the ongoing discussion on how tracheal extubation location may influence peri-operative efficiency. The primary outcome of the study, a quantifiable gain in operating theatre efficiency when tracheal extubation occurs in the post-anaesthesia care unit (PACU), is notable. However, the associated finding of a 30-min increase in PACU stay offsets any efficiency gained intra-operatively. This challenges the assumption that tracheal extubation in the PACU translates automatically to improved system-wide throughput. We agree that any practice change must be viewed in the context of both safety and overall workflow implications. Crucially, it also raises the issue of whether the infrastructure and staffing of PACUs are adequately prepared to absorb this role shift. We commend the authors for highlighting the important topic of complications following tracheal extubation in the PACU. However, we urge caution in interpreting some of the reported findings, particularly regarding the definition of desaturation used. Defining desaturation as any drop in oxygen saturation below 96% may be overly sensitive and could overestimate clinically significant events. In otherwise healthy adults, brief, self-resolving desaturations or those rapidly corrected with simple interventions often carry limited clinical consequences. This conservative threshold may, therefore, skew complication rates unfavourably. A more pragmatic cutoff, such as SpO2 < 92%, coupled with enhanced PACU staff training and standardised tracheal extubation protocols, might provide a clearer and more balanced assessment of risks and benefits. Supporting this approach, a large retrospective study at Massachusetts General Hospital used a stricter definition of desaturation (SpO2 < 90% for > 10 s) to better correlate hypoxaemia with adverse outcomes, including escalation of care [2]. Previous research similarly favours lower thresholds as they better reflect clinically meaningful hypoxaemia, avoid overdiagnosis and help reduce unnecessary oxygen administration and its associated risks [3]. We suggest future investigations adopt these more evidence-based parameters to gauge more accurately the safety and efficiency of tracheal extubation in the PACU. There are also encouraging real-world examples of PACU-based tracheal extubation protocols being implemented successfully with nurse-led models. A hospital in Ireland describes a Lean approach to nurse-led tracheal extubation in adult PACU, reporting good outcomes and safety under defined protocols [4]. Similarly, Chillingworth et al. reported on safe tracheal extubation in the PACU, highlighting the potential for such models to be both effective and safe when supported appropriately [5]. These examples suggest that, rather than dismissing tracheal extubation in the PACU based solely on complication rates, we should explore the conditions under which it can succeed, particularly with enhanced training, adequate staffing and refined protocols. In summary, Godet et al. have contributed valuable insight into the potential trade-offs between operating theatre efficiency and PACU resource demands. We propose that a nuanced interpretation of their findings is warranted and advocate for further prospective work that builds on these results, incorporating adjustments to complication definitions and structured implementation strategies. This would allow us to better understand whether the benefits of tracheal extubation in the PACU can be realised safely and sustainably.

We read with interest the article by Nitzani et al. [1] exploring women's perceptions of the consent process for epidural analgesia during labour induction. We found the quotes from women particularly interesting as well as the thematic analysis capturing a critical challenge in modern obstetric care: the significant discrepancy between the legal and ethical requirements for informed consent and the practical realities of the labour ward. The themes of compromised understanding due to time constraints, the overwhelming impact of pain and fatigue and the lack of robust checks for patient comprehension are extremely important and challenging for obstetric anaesthetists. While the study concentrates mainly on the legal aspects of consent, we believe it is equally important to consider the ethical aspects. The implications of these findings raise questions about consent across the spectrum of intrapartum interventions as well as how best we can achieve this. Healthcare professionals have an ethical and legal duty to inform patients about procedures beforehand, so that they can exercise their right to autonomy, which is the primary basis for both healthcare ethics and law. Often on a busy labour ward, in the context of epidural analgesia, clinicians are caught between two competing needs: the ethical and legal duty to ensure a patient understands and consents voluntarily; and the clinical urgency to provide safe and effective care. To be able to exercise their authority and consent voluntarily, patients need to have capacity, which is the ability to understand, at the time that a decision is to be made, the nature and consequences of the decision to be made by them in the context of the available choices at that time and retain the information given [2]. There is no consensus on whether women in labour have capacity [3]. This aspect may compromise the legal aspect of consent at the time. However, the clinical urgency to provide safe and effective care can challenge our ethical and moral responsibility to relieve pain and do no harm. Clinicians aim to act in the patient's best interest. Providing pain relief or intervening to ensure a safe delivery is a clear manifestation of beneficence, with evidence showing the benefit of labour epidurals in reducing severe maternal morbidity [4]. However, if achieving this benefit compromises the patient's autonomous decision-making, it may be perceived negatively by the patient. The study also highlights how the physiological and psychological demands of labour can undermine a woman's ability to engage with the consent process for an epidural. This situation may also arise when consent is required for more urgent and invasive procedures. If a woman's capacity to process information about an epidural is diminished, her ability to provide robust informed consent for an instrumental delivery or an emergency caesarean section must be questioned. These procedures involve significantly higher risks and more serious long-term consequences than epidural placement, including major haemorrhage; infection; organ damage; and future obstetric complications. The consent process for these interventions often occurs under heightened stress. It may also be exacerbated by potential fetal distress, escalating pain and extreme time pressure. This highlights a critical vulnerability in safeguarding patient autonomy precisely when it is most crucial. Similar studies are required to explore women's perception of the consent process for these procedures. The General Medical Council guidance on decision-making and consent [2] states that information that might be relevant to the decision-making of a patient should be shared with them at a time when they are most likely to understand and retain the information, which in the case of information about analgesia in labour is probably not when spontaneous labour or induction of labour has already commenced. This study should serve as a catalyst for change, compelling us to move beyond simply acknowledging the problem. The solution potentially lies in fundamentally redesigning the timing and delivery of information. However, the optimal timing for consent for labour epidurals has yet to be determined. Is it feasible to see all women antenatally and consent them for a procedure they may or may not require? Should they have antenatal consent for emergency caesarean sections and discussions around general anaesthesia? Guidelines from the Association of Anaesthetists regarding consent in obstetrics state “every obstetric unit must provide, in early pregnancy, advice about pain relief and anaesthesia during labour and delivery” but do not specify obtaining consent antenatally [5]. We believe the core tenets of consent – namely risks, benefits and alternatives –should ideally be comprehensively discussed antenatally, well before the onset of labour. How best to do this in practice remains to be seen. Perhaps the answer is a combination of antenatal anaesthesia-led clinics, interactive decision aids, and standardised information leaflets provided early in the third trimester.

Social media is often lauded as a tool for effective science communication There is anecdotal evidence that science communication has changed on social media since the movement from "chronological" timelines to "algorithmic" timelines We demonstrate for 2023-24, there was limited evidence for correlation between social media metrics and article accesses/citations.

IntroductionNausea and vomiting of pregnancy (NVP) affects up to 90% of women, while hyperemesis gravidarum (HG), a severe form of NVP, impacts quality of life, and ability to eat and drink normally, with reported recurrence rates up to 89% in subsequent pregnancies. Severe NVP has a profound impact on maternal physical and mental health, impairing daily functioning and quality of life, and is associated with anxiety and depression.AimsTo conduct a scoping review to identify and characterise interventions initiated before and after pregnancy that aim to mitigate the impact and consequences of severe NVP on maternal health.MethodsA comprehensive search was conducted across seven electronic databases and included grey literature without restrictions on language or date. Eligible studies were identified according to a prespecified criteria. All references were screened independently by two reviewers.FindingsThree studies were included; two utilised pre-emptive counselling and antiemetic treatment beginning before pregnancy or in early pregnancy/upon recognition of pregnancy, while one focused on post-pregnancy writing therapy. Both pre-emptive interventions reported a reduction in NVP symptom severity and a lower recurrence rate of HG, while writing therapy was beneficial in aiding recovery from severe NVP and allowed women an opportunity to externalise and process the experience.DiscussionThis study revealed a paucity of interventions initiated before and after pregnancy for women with severe NVP. The included studies showed some benefits of pre-emptive treatment and writing therapy.ConclusionTailored pre-pregnancy and postpartum interventions for women with previous severe NVP are urgently needed to address the physical and mental health burden of the condition.