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The latest in maternity medicine

The fourth Irish Congress of Obstetrics, Gynaecology and Perinatal Medicine took place in the Kilkenny Convention Centre at the Lyrath Estate Hotel on 31 November and 1 December. The biennial meeting brings together experts in the overlapping fields of women’s health, pregnancy and ne­onatology, with contributions from the clinical societies that make up the specialities.

Abortion

To practice obstetrics in Ireland today is to work in a field under­going rapid changes, shaped by changing pressures and expecta­tions in society as a whole. The cur­rent abortion debate and potential for significant change in Ireland, should the Eighth Amendment be repealed in this year’s referendum, was reflected in the first session of the conference. Prof Leslie Regan, President of the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK, has been an ad­vocate for women’s healthcare and better public understanding of ob­stetrics and gynaecology for over 30 years. She was elected as Pres­ident on a promise of vision and advocacy for reproductive rights — to the disdain of some elements of the British press. Having been criticised on the front page of The Daily Mail twice in eight days, she remarked that she “must be do­ing something right”. Prof Regan spoke of the current British de­bate on decriminalisation of abor­tion and the push back against the 1967 Abortion Act, which stands in contrast to the Irish constitution­al ban on abortion in all circum­stances, except threat to the moth­er’s life. Prof Regan discussed the need for timely access to reproduc­tive healthcare and suggested that the reason that women sometimes present late for termination of pregnancy is because they have en­countered a range of barriers out­side of their control.

Prof Sir Sabaratnam Arulku­maran, Head of Obstetrics and Gy­naecology at St George’s, Universi­ty of London, and former President of the RCOG, International Feder­ation of Obstetrics and Gynaecol­ogy, and the British Medical Asso­ciation, is perhaps best known in Ireland as the author of the Savi­ta Halappanavar report published in 2013.

Prof Arulkumaran spoke on the safety of abortion. The mor­tality rate of a first trimester sur­gical abortion is 100 times low­er than having a baby at term. Ire­land, with its low maternal mortali­ty rate, is one of the safest countries in the world to have a baby. How­ever, Prof Arulkumaran speculat­ed that if abortion in the UK was not so readily available to Irish women, this mortality rate could potential­ly be higher: “If one does not sup­port legal abortion, then in effect one supports illegal abortion. It’s time for Ireland to join the rest of the world in human rights,” he said.

Dr Catriona Henchion of the Irish Family Planning Association (IFPA) called for free contracep­tion to prevent unplanned preg­nancies, which account for an esti­mated 40 per cent of pregnancies in Ireland. The lack of sex educa­tion in schools, barriers to obtain­ing contraception, and the use of alcohol and drugs all play a role in unplanned pregnancies. There are approximately 25 abortions per year in Ireland under the Protec­tion of Life in Pregnancy Act, how­ever Dr Henchion says the system is unwieldy and causes delays for women. Understandably, many women who have the means to travel to the UK will preferentially take that option, even if they qual­ify under the Irish Act, as obtain­ing an abortion in the UK does not require an overly-onerous process for the woman. This makes abor­tion a class issue, as women from lower socioeconomic groups are often unable to travel, she main­tained. Research suggests that thousands of women are order­ing abortion pills online, meaning that for illegal abortion, “the genie is well out of the bottle”.

The way women have abortions is also affected by the Irish consti­tutional ban. According to UK sta­tistics, Irish women undergoing termination in the UK are more likely to have a surgical procedure rather than a medical abortion with tablets, as a surgical proce­dure is a day case. This is despite the fact that a medical abortion with tablets is safer than a surgi­cal abortion. Dr Henchion said that women face barriers to trav­el, such as money, visa status, lan­guage difficulties and the need for secrecy. The practical side of planning an abortion means that a woman has to think of things like childcare or carers instead of her own situation. The stig­ma encountered by these women persists into the post-treatment phase, with many women afraid to seek post-abortion care with their doctor at home in Ireland.

Panel discussion

The first three speakers were followed by a panel discussion and audience questions about in­frastructural and workforce is­sues at the packed first session.

The five participant societies of the Congress — Continence Foun­dation Ireland, the Irish Gynaeco­logical Endoscopy Society, Irish Fertility Society, Irish Society of Gynaecological Oncology, and Irish Perinatal Society, along with the Institute of Obstetricians and Gynaecologists and the Junior Obstetrics and Gynaecology So­ciety (JOGS), each had break-out sessions over the two days.

Prof Richard Anderson of the University of Edinburgh, Dr Lucy- Ann Behan, Consultant Endocri­nologist at Tallaght Hospital, and Dr Stephen Dobbs, Consultant Gynaecology Oncologist in Bel­fast, discussed fertility preserva­tion in patients undergoing treat­ment for cancer, something which affects one-in-49 women aged un­der 40 years old. These include medical treatments to protect the ovaries and fertility-preserving treatments in the setting of cer­vical cancer. Dr Yvonne O’Brien presented qualitative research on attitudes towards fertility preser­vation in transgender patients at­tending Prof Donal O’Shea’s clinic in Loughlinstown Hospital, win­ning the Irish Fertility Society’s medal for Best Oral Presentation.

Gynae issues

Mr Dudley Robinson of King’s Hospital London led a timely dis­cussion on the use of mesh for re­pair of pelvic organ prolapse and incontinence. Recent media re­ports and legal cases have cast a cloud over the use of mesh, but evidence suggests there is still a strong case for its use, particularly in urinary incontinence. Following on from this, Prof Annette Kuhn of Universitätsklinik für Frauen­heilkunde, Bern, Switzerland, dis­cussed what to do if the bladder hurts in a wide-ranging talk on the management of bladder pain.

Day one of the Congress was closed by Mr James English, Con­sultant Gynaecologist at Bright­on and Sussex University Hospi­tals, UK, discussing the manage­ment of deep endometriosis and Prof Linda Cardozo of King’s Col­lege Hospital, London, speaking on the rise of cosmetic gynaecol­ogy internationally. “In a socie­ty that has increased access to fe­male body images, it seems wom­en’s perception of what is ‘nor­mal’ and desirable is becoming skewed,” said Prof Cardozo. Any woman seeking cosmetic geni­tal surgery should be referred for counselling in the first instance as there may be body image prob­lems at play, rather than a genu­ine issue with genital appearance.

Day two of the Congress began with the JOGS trainee research session of 24 oral presentations competing for prizes, including Best Case Report and the Clinch Medal for Best Oral Presentation by an SHO. The latter was won by Academic Intern Dr Adrianne Wyse for her research with Dr Paul Byrne in the Rotunda Hos­pital, Dublin, on HPV testing in women after treatment of cervical intraepithelial neoplasia (CIN). Prof Mary Horgan, President of the RCPI, spoke on the regulatory changes happening in the College since her election, with a focus on a renewed relationship with the Institute of Obstetricians and Gy­naecologists through better repre­sentation in the RCPI.

Neonatology

Dr Namasivayam Ambalavanan, a neonatologist from Birmingham, Alabama, US — who is affiliated with multiple hospitals in the ar­ea, including Children’s Hospi­tal of Alabama at UAB — spoke on the top advances in neonatology that have improved outcomes for babies, including the use of corti­costeroids for foetal lung matura­tion, genomic studies, therapeu­tic cooling to prevent brain inju­ry and advances in surgery for ne­onates. He also discussed the top disappointments of recent years, including therapies which prom­ised better outcomes for neonates but did not deliver, such as inhaled steroids or nitric oxide for preven­tion of bronchopulmonary dyspla­sia in preterm infants and electron­ic healthcare records, which have been touted as a panacea for all the ills of modern healthcare.

A final keynote address by Prof John Lantos of Children’s Mercy Hospital Bioethics Centre in Kan­sas City, US, debated ‘Should we resuscitate babies at 22 weeks?’ and was followed by an audience discussion on the limits of viabil­ity and the ethics of resuscitation of peri-viable babies.

The Congress closed with the Annual Hospital Reports Meet­ing, where the Masters of the three Dublin maternity hospitals, along with the Clinical Directors of the next three largest maternity units in Ireland — South Southwest, University of Limerick and Saol­ta Hospital Groups — presented their figures for 2016. These pres­entations focused on survival and outcomes of very low-birthweight infants and was chaired by Prof Neil Marlow of University Col­lege London and current Chair of the NHS England Neonatal Criti­cal Care Clinical Reference Group. Dr Rhona Mahony of the National Maternity Hospital discussed the lack of anomaly scans for many women in Ireland and said that Holles Street gave over 1,000 foe­tal medicine opinions in 2016 to women from all over Ireland. She also criticised the medical negli­gence system, which sees more money being paid out annually in claims than the total amount giv­en to fund maternity services in Ireland.

The Congress closed with prize-giving for best presentations and posters and a well-deserved thanks to the organising commit­tee, headed by Dr Aoife Mullal­ly, Consultant Obstetrician at the Coombe and Midlands Regional Hospital, Portlaoise.

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