Metabolomic approach to diagnosis of labour

Perinatal/Maternal-Fetal Medicine

FC1.01

Prospective risk of late stillbirth in twins of knownchorionicity: the stork multiple pregnancy cohortdata and systematic review

Dias, T; Patel, D; Bhide, A; Thilaganathan, B

On behalf of The Southwest Thames Obstetric Research Collaborative

(STORK) St George’s University of London, Cranmer Terrace,

London, United Kingdom

Objective: Monochorionic (MC) pregnancies are routinely

delivered electively at various late preterm gestations with the

intention of avoiding stillbirth. The aim of this study was to

evaluate the prospective risk of late stillbirth in a large regional

cohort and undertake a systematic review of the literature on

routinely managed twin pregnancies of known chorionicity.

Methods: A retrospective study of all twin births of known

chorionicity from a large regional cohort of nine hospitals

(STORK collaborative) taken over a 10 year period matched to a

mandatory national register of stillbirth (CMACE). The data of

the current study was included in a systematic review of selected

studies of stillbirth in routinely managed twin pregnancies of

known chorionicity.

Results: A total of 3005 twin pregnancies delivered after 26 weeks of

gestation in the STORK collaborative, and this was combined with

data from eight studies selected from the systematic review of the

literature. The total risk of stillbirth after 26 weeks in MC twins (21.7/

1000 fetuses) was significantly higher (OR 3.26, 95% CI 2.36–4.5)

than in DC twins (6.7/1000 fetuses). The prospective risk of stillbirth

in MC twins did not change significantly between 26+ weeks (3.6/

1000 fetuses) and 36+ weeks (5.2/1000 fetuses, OR 1.85, 95%

0.3–13.2). The equivalent figures for DC twins were 0.8/1000 fetuses

and 1.7/1000 fetuses, respectively (OR 3.4, 95% 0.9–13.2).

Conclusion: The risk of stillbirth in MC twins does not appear to

increase significantly near term. This observation may be due to a

policy of routine surveillance and elective delivery from 36 weeks.

The data does not support a policy of elective birth before

36 weeks of gestation in MC pregnancies.

FC1.02

Dignity in maternity care: literature review andaudit of complaints

Parry-Smith, W; Morad, S; Shrewsbury, R;

McSherry, W

Centre for Practice and Service Improvement, Staffordshire University,

United Kingdom

In the UK the concept of dignity and respect in health care

commands much public and media interest, predominantly in

elderly care. However, there is a paucity of work regarding dignity

and respect in obstetrics and gynaecology despite its important

and topical nature. In order to begin exploring how the concept

might be studied in our specialty we undertook a literature review

on dignity and respect in obstetrics and gynaecology from 2001 to

2011 and identified key themes. Formal complaints to the

department over a 2 year period were then mapped to the themes

identified in the literature review.

The following threats to dignity were identified: discrimination

against women, fear, pain, intimate examinations, power of care-

giver over the woman, over-medicalisation, excessive form-filling

and staff shift changes. Dignity was maintained by the woman

herself through control of the private sphere, setting appropriate

boundaries and retaining ownership of pregnancy, childbirth and

post-natal care. It was also maintained by healthcare teams that

treated women as individuals, ensured the patient was not

exposed either physically or emotionally, and allowed women

their desired level of control. Maintenance of dignity required

women to have a relationship based on trust in the knowledge

and skills of their health care provider and was strongly associated

with honouring requests for pain relief.

The analysis of departmental complaints revealed clustering

around domains addressing pain management, communication

and attitude, not around areas such as autonomy, personal

hygiene, privacy or safety. When compared with the literature

review we had fewer complaints than expected regarding

autonomy, but the complaints revealed no additional themes that

had not been identified in the literature.

Combining the results of the complaint analysis exercise and the

literature review enabled us to plan future service user based

feedback, allowing active quality assurance based on sound

evidence rather than solely relying on a complaint driven system

to effect change. Finally we regard this as a chance to highlight

areas within our specialty that we can reflect on to bring the best

to women’s health care.

FC1.03

Informed Consent – What is the evidence?

Robertson, C1; Verco, C2

1 Flinders Medical School; 2 Flinders Medical Centre, Australia

Background: Informed consent, a fundamental ethical and legal

aspect of medical care, is part of a continuum which is the clinical

encounter. The documentation of ‘informed consent’ may not

always accurately reflect what has been discussed due to time

constraints and other variables common to hospital medicine.

Correct documentation of consent is important because it

accurately records what has been discussed, when the discussion

DOI: 10.1111/j.1471-0528.2012.03375.x

www.bjog.org Abstracts

Oral Presentations

2 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

took place and particular issues raised in relation to the proposed

intervention or procedure.

Objective: To determine how effectively the documentation of

informed consent is carried out at a busy Australian teaching

hospital.

Aims: To identify areas where documentation is lacking and

propose how shortcomings, if any, may be addressed.

Methods: Caesarean section is a common operation at Flinders

Medical Centre (FMC) (approximately 75–100 operations

monthly). Through an audit of 101 case files of women who

underwent caesarean sections at FMC in August and September of

2011 (50 emergency, 51 elective) we examined how informed

consent was documented.

Results: Two of the 101 files did not contain any written evidence

of consent. An average of 4.2 (range 2–6) maternal risks out of a

possible seven were recorded for each elective case and average of

3.3 (range 0–5) maternal risks were recorded for each emergency

case. Risks to future pregnancies in the elective group were

recorded on average 0.3 of 3 (range 0–2) and 0.2 (range 0.1) risks

were recorded in the emergency group. Over the two groups 75%

(76) of the cases didn’t have a single risk to future pregnancies

recorded. A record of written information being given was

recorded in 16% (8) of elective cases and in only 2% (1)

emergency cases. Procedures that were not to be done were

recorded in three of the emergency cases and in none of the

elective cases.

Conclusion: The documentation of informed consent is

universally poor across all of the examined categories. A

structured consent proforma may facilitate the recording of

informed consent.

FC1.04

Pre-pregnancy blood pressure among women withand without preterm birth from the CARDIA cohort

Ness, RB1; Lewis, CE2; Catov, J3; Jacobs, D4;

Tolan, K5; Gunderson, EP6

1 The University of Texas School of Public Health; 2 University of

Alabama School of Medicine Division of Preventive Medicine;3 University of Pittsburgh School of Medicine; 4 University of

Minnesota School of Public Health; 5 Kaiser Permanente Medical Care

Program; 6 Division of Research, Kaiser Permanente

Objective: Prematurity is largely a condition of unknown cause,

although a handful of studies have related it to pre-pregnancy

cardiovascular risk factors including hyperlipidemia, diabetes, and

self-reported hypertension. No studies to date have assessed pre-

pregnancy blood pressure measurements in connection with

prematurity and thus it was our objective to do so.

Methods: CARDIA is a multi-center, prospective observational

study of risk factors for coronary heart disease in young black and

white men and women. Of the 2787 female participants enrolled

in 1985–1986 aged 18–30, 1301 were evaluated who had a birth of

known, self-reported gestational age after the baseline visit and

had blood pressure measurements prior to that subsequent birth.

One hundred sixteen had early preterm births (<34 weeks of

gestation) and 304 had late preterm births (34–37 weeks of

gestation). Logistic regression models adjusted for covariates

including race, recruitment center, and education measured at

baseline; as well as parity, time between blood pressure measure

and conception, and BMI measured at the visit prior to the index

pregnancy; and finally age at delivery.

Results: The highest quartile (range 111–165 mmHg) as

compared to the lowest quartile (range 84–98) of the systolic

blood pressure closest to conception was significantly associated

with early preterm birth (adj OR 1.86, 95% CI 1.01, 3.44) and late

preterm birth (adj OR 1.56, 95% CI 1.03, 2.34). Additional

adjustment for a self-reported pre-pregnancy diagnosis of

hypertension and for self-reported gestational hypertension only

modestly attenuated the relationship with both early preterm (adj

OR 1.81, 95% CI 0.97, 3.36) and late preterm births (adj OR 1.46,

95% CI 0.96, 2.20). Neither diastolic blood pressure nor mean

arterial blood pressure were consistently elevated among women

bearing early and late preterm births. Whereas neither race nor

parity interacted with blood pressure to elevate preterm birth risk,

obesity exaggerated the link (adj OR 14.32, 95% CI 1.55, 135.10)

and the association was unapparent in non-obese women.

Conclusions: These results suggest that pre-pregnancy systolic

blood pressure in the presence of obesity elevates the risk for both

early and late preterm birth.

FC1.05

Transabdominal cervical suture for the preventionof pregnancy loss: the next 42 cases

Gibb, D

The Birth Company, London, United Kingdom

Objective: To assess the performance of Trans Abdominal

Cervical Suture by a single surgeon in the management of high

risk pregnancy over a 16 year period between 1996 and 2012. A

previous series of 50 cases were published in BJOG in 1995 by the

same surgeon.

Methods: Cases were recruited in a referral practice. Almost all of

them had suffered one or more mid trimester pregnancy losses or

premature births between 18 weeks and 32 weeks of gestation.

Some cases had previous failed trans vaginal suture but the

majority had losses following previous surgery for pre-malignant

cervical disease. Open surgery by laparotomy was undertaken as

soon as possible after 11 weeks of gestation except one which was

a pre pregnancy procedure. General anaesthesia was used and the

operative technique was that described by Gibb and Salaria

(1995). Mersilene tape was used. A short video clip will be shown.

The patients stayed in hospital for about 72 h after the procedure.

No antibiotics or tocolytics were used. The women then had high

risk pregnancy surveillance but this did not involve trans vaginal

ultrasound scans or adjunctive therapy. When the fetus reached

maturity delivery was undertaken by caesarean section. The suture

was left in place and some patients proceeded to future

pregnancies.

Results: Forty-two operations were perfomed: 28 operations were

performed in London, eight in the UK outside London and six

Oral Presentations

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 3

abroad. There were three twin pregnancies. Thirty-nine

pregnancies have been delivered after 36 weeks with a successful

outcome including the three sets of twins. In one case the

anomaly scan revealed a fetal malformation and the patient opted

to terminate the pregnancy. In a second case the patient had

experienced previous uterine scar dehiscence and suffered

abdominal pain and anxiety during the rest of the pregnancy after

the suture insertion. On account of the symptoms she had to be

delivered at 32 weeks: the child survived intact and is healthy.

One case is ongoing at 28 weeks of gestation. There was a 100%

success rate of intact survival for normally formed babies.

Conclusion: The role of Trans Abdominal Cervical Suture has

been further clarified. Almost all these women who had very poor

reproductive histories went on to have at least one healthy child.

Study is now required on the place of pre pregnancy

transabdominal cervical suture and cervical suture by a

laparoscopic technique.

FC1.06

The decision delivery interval in emergencycaesarean sections and its correlation withperinatal outcome: evidence from 204 deliveries

Singh, R; Deo, S; Pradeep, Y

Professor Department of Obstetrics and Gynaecology, Chhatrapati

Shahuji Maharaj Medical University (erstwhile KGMU), Lucknow,

India

Objective: To determine the decision to delivery intervals in

emergency caesarean sections and its correlation with the perinatal

outcome.

Methods: It was a prospective observational study over 6 month

period in a tertiary care teaching hospital. Consecutive cases with

live singleton pregnancy undergoing emergency caesarean sections

were included. The primary outcome measure was decision to

delivery intervals and perinatal outcome in terms of 5 min Apgar

score, neonates requiring admission to neonatal intensive care

unit and perinatal deaths. Maternal demographic profiles,

indication for caesarean section, type of anaesthesia were the

secondary outcome measures. Data was analysed using SPSS

version 13.0. Chi square test was used to compare difference in

proportion between the two groups. One way ANOVA was used

to compare the difference in Apgar score and decision to delivery

intervals. For analysis we divided the groups into 30 min decision

delivery intervals(£30, 31–60,>60 min). P value of < 0.05 was

significant.

Results: Over the period, 204 women underwent emergency

caesarean sections. The mean age of women was 26.8 ± 4.6 years.

The mean gestational age at delivery was 38.0 ± 3.0 weeks. The

mean decision delivery interval in the cohort was 42.5 ± 19.4 min.

The decision delivery interval of £30 min was achieved in 19% of

the deliveries; another 60% deliveries were achieved within

60 min, while the remaining 21% delivered after 60 min. There

was no significant difference in the perinatal outcome between

babies delivered within 30 min and 31–60 min of decision

delivery intervals. However, there was a significantly higher risk

for poor perinatal outcome for babies with decision delivery

intervals of > 60 min [OR-6.9, 95% CI: 2.37–20.18].

Conclusion: The perinatal outcome between decision delivery

interval of £30 and 31–60 min was statistically not different,

however the £30 min decision delivery interval should remain as

the gold standard.

FC1.07

Quality of detection of pregnancy inducedhypertension to reduce maternal mortality to onedigit in Sri Lanka

Prathapan, R1; Prathapan, S2; Lindmark, G3;

Fonseka, P4; Lokubalasooriya, A5

1 Base Hospital Kanthale, Sri Lanka; 2 Department of Community

Medicine, Faculty of Medical Sciences, University of Sri

Jayewardenepura, Nugegoda, Sri Lanka; 3 Department of International

Maternal and Child Health, University Hospital, Uppsala, Sweden;4 Department of Community Medicine, Faculty of Medical Sciences,

University of Sri Jayewardenepura, Nugegoda, Sri Lanka; 5 Family

Health Bureau, Ministry of Health, Sri Lanka

Introduction: One of the leading causes of maternal mortality in

Sri Lanka for the last two decades has been pregnancy induced

hypertension (PIH). Disparities between high attendance rates at

field clinics and high maternal deaths from PIH raise questions

about the quality of detection of PIH in field antenatal clinics.

Improving the detection rate of PIH could help Sri Lanka in

reducing maternal mortality to a single digit.

Objective: To describe the quality of detection of PIH in pregnant

women in the field antenatal clinics of Sri Lanka.

Methods: A cross-sectional study design was used. In the

Colombo district, of the 11 MOH areas, according to the Lot

Quality Assurance Sampling method, five field antenatal clinics

were randomly selected (n = 55 clinics). In each of these clinics,

five women in their booking visit (n = 275 women) were sampled.

A checklist was used to observe and the following indicators were

used to assess the quality of services. History and clinical

examination, measuring the BP, explaining the findings,

investigation for urine albumin, explaining the results of the

investigation.

Results: Due to the unavailability of the doctor in 12% of clinics,

a history, a clinical examination and the BP measurement could

not be performed in 60 (21.8%) women. A history was obtained

in only 8 (2.9%) women and a clinical examination with regards

to diagnosis of PIH/PET was performed in 48 (17.5%) women.

Among the women whom were seen by the doctor at the clinic,

the BP was measured in 185 women (86%). Only 1/3 of these

measurements were according to standards. The blood pressure

readings recorded on the pregnancy card was compared with

results of the principal researcher. The sensitivity for systolic BP

and Diastolic BP was 57.1% (95% CI: 47.4% -66.8%) and 16.7%

(95% CI: 9.4% -24%) respectively. The urine albumin was

investigated according to standards in 7% of the women. The

quality of services was unacceptable in all the MOH areas for four

of the six indicators.

Oral Presentations


Conclusions: The need for quality improvement is evident and

urgent steps should be taken to pave the way to reduce the

maternal mortality rate.

FC1.08

Fetal fibronectin rapid test versus phosphorylatedinsulin-like growth factor-1 (phIGFBP-1) as bedsidetest kits for prediction of preterm delivery in theclinical setting

Thandayathany, V; Yassin, MAJM; Omar, MH;

Ismail, NAM; Tamil, AM; Kampan, NC

Hospital Universiti Kebangsaan, Malaysia

Objective: The objective of this study is to compare

Phosphorylated insulin-like growth factor-1 (phIGFBP-1) test and

fetal fibronectin (fFN) test in the prediction of preterm delivery.

Methods: All patients between the gestations of 24–34 weeks

with documented contraction on the cardiotocography were

recruited. phIGFBP-1 test and fetal fibronectin test were done

on all patients. The fetal fibronectin test results were blinded

and the patient was managed as per standard protocol for

preterm delivery. The administration of tocolysis, steroids and

antibiotics were based on clinical judgement of the attending

obstetrician. The outcome of pregnancy and delivery were

analysed.

Results: One hundred and seventy four patients were recruited.

The negative predictive value for phIGFBP-1 test was 97.3, 94.0,

89.3, and 92.0 for 48 h, 7 days, 14 days and £34 weeks

respectively. The NPV for fFN test was 96.7, 92.7, 88.0, and 90.6

for 48 h, 7 days, 14 days and £34 weeks respectively. The mean

gestational age at delivery was 35.8 ± 3.81 weeks for women with

positive phIGFBP-1 test and 36.5 ± 3.54 weeks for women with a

positive fFN test. For women with both tests positive, the mean

delivery was 35.8 ± 3.62 weeks. The delivery interval from initial

presentation was 2.16 weeks shorter in women with phIGFBP-1

test positive as compared to women with negative phIGFBP-1 test

(3.67 vs. 5.83 weeks). It was 1.8 weeks shorter in women with fFN

test positive than those with negative FfN test (3.96 vs.

5.77 weeks). Both phIGFBP-1 and fFN test have high negative

predictive value in predicting risk of preterm delivery. Both the

test had a fair kappa agreement i.e 0.21–0.40. The area under the

curve for phIGFBP-1 test and fFN test is 0.766 and 0.720

respectively.

Conclusion: Both phIGFBP-1 and fFN test are good diagnostic

tools in prediction of preterm delivery. A negative phIGFBP-1 test

or fFN test will confer that the patient has a 92.7% to a 94%

changes of not delivering in the next 7 days. phIGFBP-1 test may

be a better diagnostic tool with higher negative predictive value,

longer delivery interval and a higher kappa agreement.

FC1.09

Psychological issues in reproduction – why itmatters

Chung, T

The Chinese University of Hong Kong, Hong Kong, China

In many countries, suicide has become the post common cause of

maternal death. This is especially so in countries where historical

causes of maternal mortality such as haemorrhage, infection and

severe hypertensive disease have been mitigated to a large extent.

However, where there is reasonable investment by governments in

maternal health, there is a accelerating trend in reduction in

maternal mortality even in relatively resource poor countries. It is

reasonable to anticipate that mental health causes of maternal

mortality will become more prominent and will need preparation

and planning in order to address this. A 15 year experience

describing initial research and implementation of a service

programme using local research will be presented. Potential future

developments will be discussed.

FC1.10

Fetal gender determination in early pregnancyusing PCR analysis of maternal serum

El Razik, AA1; El Missiry, AG2

1 Ain Shams University, Faculty of Medicine, Obstetrics &

Gynaecology Department, Cairo, Egypt; 2 Medical Research Centre,

Ain Shams University, Faculty of Medicine, Obstetrics & Gynaecology

Department, Cairo, Egypt

Objective: Fetal DNA has been found in maternal serum.

Diagnosis of fetal gender using maternal serum has been

attempted in an effort to develop a new non-invasive method of

prenatal diagnosis.

Methods: Peripheral blood samples were obtained from 25

Egyptian pregnant women at 9–12 weeks of gestation. DNA was

extracted from 800 lL of each serum sample. To detect Y-

chromosome-specific sequences DYS14 in the maternal serum, 40

cycles of PCR were carried for each DNA extract. The PCR

products were analysed by 2.5%agarose gel electrophoresis and

ethidium bromide staining, and the results were compared with

the results of ultrasound scan which done at 21 weeks of gestation

for all the 25 pregnant women for determination of fetal gender.

Results: Ultrasound scan at 12 weeks of gestation revealed that 13

pregnant women had a male fetus and the remaining 12 women

had a female fetus. DYS14 was not detected in serum samples

obtained from any of the 12 women carrying a female fetus. Fetal

gender was determined successfully in all the 25 Egyptian

pregnant women. So our method had the highest sensitivity

(100%) reported to date.

Conclusion: PCR analysis of maternal serum can be used to

diagnose fetal gender in first trimester.

Oral Presentations


FC1.11

Incidence of cardiac events amongst pregnantwomen with cardiac disease – HUSM experience

Lee, SJ1; Nik Mohamed Zaki, NM1; Ng, SL2;

Zurkurnai, Y2

1 Department of Obstetrics & Gynaecology, Hospital Universiti Sains

Malaysia; 2 Department of Internal Medicine, Hospital Universiti Sains

Malaysia

Introduction: It has long been recognized that certain cardiac

predicting factors including pre-pregnancy NYHA class, poor left

ventricular function, presence of pulmonary hypertension or

cyanosis, outflow tract obstruction and prosthetic valves adversely

influences pregnancy outcome.

Objective: The primary objective of this study was to determine

the incidence of cardiac events amongst pregnant women with

cardiac disease in HUSM. The secondary objectives were to

specifically indentify incidence of primary and secondary cardiac

events in the studied population, to identify presence of

CARPREG predictors amongst pregnant women with cardiac

disease, to formulate a risk stratification index for the prediction

of cardiac events during pregnancy and to look into neonatal and

obstetric outcomes in studied group.

Methods: A total of 200 patients aged 18 years old and above

with underlying or newly diagnosed cardiac disease were recruited

into this prospective cohort study. At entry, any presence of

cardiac event predictors was identified from history, physical

examination, ECG and echocardiography findings. Follow up data

were obtained during clinical visits. Data analysis using Chi-

square test followed by univariate analysis using Simple Logistic

Regression analysis. Following this, a Multivariate Logistic

Regression analysis was performed.

Result: The incidence of cardiac events among 200 studied

patients in HUSM was 14%. The incidences of primary and

secondary cardiac events were 9.5% and 7.0% respectively. Out of

total studied patients, there were 150 patients with no cardiac

event predictor, 41 patients with 1 cardiac event predictor and

nine patients with more than one cardiac event predictors.

Correlation between occurrence of cardiac event and number of

cardiac event predictor which were analyzed using Chi-square test,

simple logistic regression and multiple logistic regressions, had all

consistently shown presence of cardiac event predictor would

strongly predict occurrence of cardiac event (all with P < 0.001).

The risk of cardiac event in pregnancies with 0, 1 and >1

predictors were estimated to be 2%, 43.9% and 77.8%

respectively.

Conclusion: This study had shown that the incidence of cardiac

events was almost similar as estimated during the beginning of

study when the sample size was calculated (14% vs. 13%). The

number of cardiac event predictor(s) identified at entry were

highly predictive of occurrence of cardiac events. This can be put

up as risk stratification index to identify those patients who are at

high risk of developing cardiac events during the prepartum,

peripartum and postpartum period.

FC1.12

Metabolomic approach to diagnosis of labour

Meloni, A1; Caboni, P2; Manconi, F2; Atzori, L3;

Lussu, M3; Murgia, F3; Barberini, L4; Noto, A5;

Fanos, V5; Paoletti, A1; Ragusa, A6

1 Department.of Obstetrics and Gynaecology San Giovanni di Dio

Hospital; 2 Department.of Life Science and Environment;3 Department.of Toxicology; 4 Department.of Cardiovascular and

Neurological Sciences; 5 Department.of Neonatal Intensive Care Unit,

Puericulture Institute and Neonatal section, University of Cagliari,

Italy; 6 UOC di Ostetricia e Ginecologia, Ospedale Sesto S, Giovanni

Milano, Italy

Objective: Currently there are few studies that may clearly

establish scientific criteria for diagnosis of labour. We conducted a

prospective cohort study to evaluate if metabolomic analysis of

urine samples collected from term pregnant women could

represent a new tool for diagnosis of labour.

Methods: Urine samples were collected from 45 women with

physiological singleton pregnancy at 37–42 weeks of gestation

referred to our delivery settings for term pregnancy monitoring or

admitted for labour. Written informed consent was obtained from

each woman. After aliquoting samples were stored at )80 �C.

Urines were chemically analysed by means of GC/MS and 1H-

NMR techniques as described before.1 Data matrix generated by

these procedures were analysed by means of PLS-DA models

(Partial least squares discriminant analysis; SIMCA-P+ version

12.0, Umetrics, Sweden) to test the hypothesis of the

discriminating power of urinary metabolites concentrations as

labour starts. The analysis on the variables of primary importance

in this separation was applied to evaluate the set of discriminating

metabolites.

Results: PLS-DA models from both 1H-NMR and GC/MS

analysis were able to discriminate between the pregnant women in

labour state (n = 20) from the ones far from the delivery (n = 25)

[PLS-DA_NMR (R2X = 0.46; R2Y = 0.753 Q2 = 0.573; P-

value = 0.002); PLS-DA_GC_MS (R2X = 0.3; R2Y = 0.8; Q2 = 0.4;

P-value = 0.005)]. A metabolic fingerprint based mainly on:

succinate, hyppurate, creatinine, alanine, X267, hydroxybutanoic

acid, X175, hetanedioic acid, ribonic acid, glicine, galactose,

xilitol, was identified as metabolic pattern responsible of this

separation.

Conclusions: Wrong diagnosis of labour can lead to inadequate

management of labour with possible adverse maternal outcome

and fetal distress. Correct diagnosis of labour can reduce

caesarean sections and instrumental delivery rate and improve

perinatal outcomes. Our experimental data confirm the hypothesis

that urine is a biological fluid adequate to identify pregnant

women in labour. Collecting urine is a simple and non invasive

technique, and it is extremely relevant from a clinical point of

view because it makes possible for the first time to diagnose

labour prospectively. Moreover by the identification of the

discriminating metabolites we may better understand the

molecular pathways of labour.

Oral Presentations


Reference:

1. Fabiano A,et al. Metabolomic analysis of bronchoalveolar

lavage fluid in preterm infants complicated by respiratory distress

syndrome: preliminary results. Matern Fetal Neonatal Med,

2011;24(S2):55–8.

FC1.13

A novel regimen for HBV PMTCT – based on theinternational cooperative clinical study (ICCS)

Inaba, N; Hayashida, S; Shu-Kang, X; Oshima, K;

Inaba, M; Inaba, F; Fukasawa, I

Dokkyo Medical University, Japan

The ICCS was done to establish the new regimen for HBV

PMTCT (prevention of mother-to-child transmission), which

should be most economic and realize the smallest patients’ load

and fewest dropouts by comparing the three regimens, i.e. the

regimen recommended by the Japan Ministry of Health and

Welfare (JMHW-R) in 1985, Inaba Regimen (Inaba-R) established

in 1984 by me, and a new Inaba-R (n-Inaba-R) established

recently. Three hundred and seventy two infants received JMHW-

R (G0,2/V2,3,5; G represents HBIG, V stands for HB vaccine.

Zero means the period within 7 days after birth and the other

numbers mean infants’ age by months), 135 did Inaba-R (G0/V0,

1, 3–5; V0 means the period within 24 h after birth) and 50

received n-Inaba-R (G0/V0,1). All these infants underwent

HBsAg-screening and tests for serum levels of HBsAb, AST and

ALT, and Hb, at least for 12 months after birth. Among these

three groups, no differences were found statistically regarding

infants’ development of carrier-state, their serum levels of HBsAb,

sAST and sALT, and their Hb concentration. These results

demonstrate that n-Inaba-R is equal to the other two regimens

(JMHW-R and Inaba-R) with HBV PMTCT. Besides, n-Inaba-R is

completed within 1 month after birth, which dramatically saves

the dropouts, medical bills and works of both puerperas and

obstetricians.

FC1.14

Induction of labour in outpatient setting in DistrictGeneral Hospital

Anita Rao, C; Joshi, M

Broomfield Hospital, Essex, United Kingdom

Objective: The primary aim of the study was to determine

whether the procedure was feasible, effective and safe for mother,

foetus, and baby. The secondary aim was to examine the

outcomes of various aspects of labour and mode of delivery.

Methods: A prospective study involving 210 low risk women

which includes well controlled hypertension and Diabetes in

pregnancy was undertaken in the year 2011. Outpatient setting of

induction of labour (IOL) was defined as initial treatment and

monitoring in hospital and discharged home. We chose Propess

slow release prostaglandin E2 preparation 10 mg (releasing

300 mg/h). Propess was inserted high into the vagina to sit behind

the posterior lip of cervix. Women were sent home 6 h after

insertion of Propess. Patients were advised to return when in

labour or 24 h after insertion.

Results: Of the 210 women in this study 131 were Primigravida

and 79 were Multigravida. Pre induction cervical Bishop’s score

was 4 or less in 88% (186) women. The mean insertion Propess

delivery interval was 30 h. Onset of labour (reaching to 4 cm

dilatation) in the first 24 h was noted in 63% (132) women.

Spontaneous rupture of membranes in the first 24 h occurred in

38% (80) women. Artificial rupture of membranes and

Syntocinon was required in 76.6% (160) women. 71% (49) of

women had vaginal births and 29% (61) had caesarean sections.

The higher caesarean section was observed among Primigravidas.

60% (120) of women delivered before midnight and 40% (90) of

women delivered after midnight. Neonatal outcome, the mean

birthweight, was 3651 g. In one baby, Apgar score was less than 7

at 5 min. Neonatal admission was reported in four babies. Hyper

stimulation of the uterus occurred in 1% (2) women.

Conclusion: Outpatient setting of IOL in low risk women is

feasible, effective and safe. The secondary outcomes were similar

to that of inpatient induction of labour. This procedure had the

advantage of less usage of medical professional time and NHS

resources.

FC1.15

Fetal pillow: a novel device to reduce morbidity ina second stage caesarean section. a case controlledstudy

Seal, SL1; Dey, A2; Barman, SC3; Kamilya, G4;

Mukherji, J5; Mahsud-Dornan, S6

1 R G Kar Medical College, Kolkata; 2 R G Kar Medical College,

Kolkata; 3 Bankura Sammilani Medical College, Bankura; 4 Bankura

Sammilani Medical College, Bankura; 5 R G Kar Medical College,

Kolkata; 6 The Royal Jubilee Maternity Hospital, Belfast

There is some evidence that the rates of caesarean section at full

dilation (CSFD) have increased disproportionately to the overall

rise in caesarean section rates. The reasons for this are unclear but

reduction in instrumental delivery rates, use of epidural analgesia,

fear of litigation and changes in training have been cited.

There is evidence that CSFD carries much higher morbidity for

both the mother and the baby. There is a higher incidence of

uterine incision extensions into the broad ligament, postpartum

haemorrhage, increased operating time, blood transfusion, ITU

admission and increased length of hospital stay for the mother.

For the baby, there is an increased risk of admission to NICU and

birth injury. Intraoperative complications account for most of

morbidity related to a CSFD. These often occur as result of

increased manipulation required for delivery of the head due to

reduced liquor, thin overstretched and edematous lower segment,

excessive caput and moulding, and often a deeply engaged head.

Fetal Pillow (FP) is a silicone balloon that is inserted vaginally

prior to carrying out a CSFD. The inflation of the balloon

produces a bubble of fluid in the pelvic cavity and results in a 3–

4 cm upward displacement of fetal head.

Oral Presentations


We report a prospective study of the FP use in 50 patients

undergoing a CS at full dilation. The study was carried during a

5-month period in one of the teaching institution of West Bengal

(India). The data was compared to a group of 124 patients who

underwent CSFD without the use of FP.

Maternal and fetal data recorded were maternal age, weight at

delivery, gestational age at delivery, duration of first and second

stage of labour, the position and station of fetal head, birthweight

and operating time. Maternal morbidity outcomes studied were

intra-operative trauma, need for blood transfusion, postpartum

haemorrhage (blood loss > 1000 mL), admission to intensive care

unit, febrile morbidity and length of hospital stay. Neonatal

morbidity characteristics recorded were a low 5-min Apgar score

need for intubation, septicemia, neonatal trauma, admission to

NICU for more than 24 h and neonatal death.

In the FP group there was reduction in incision delivery interval,

time taken for the procedure, length of hospital stay, need for

transfusion and extension of uterine incisions. The results are very

encouraging and a RCT is in progress to assess the routine use of

fetal pillow in CSFD.

FC1.16

Escaped maternal deaths in a remote district of SriLanka

Fernando, TRN

Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka

Objective: (i)To find out the escaped maternal deaths in

Anuradhapura district. (ii) Find out the causes of maternal deaths

and compare it with Sri Lankan country statistics.

Methods: Data collection and analytic study. Data collected from

maternal death review reports from the regional health office in

Anurdhapura district, of Sri Lanka, during the years 2007–2009.

Results: Total number of maternal deaths is 40, in Anuradhapura

district (AD), during the years 2007–2009. The leading cause of

death in pregnant mothers in AD 2007–2009 is suicide. That is

nine deaths out of total 40 deaths. Three of them were unmarried

pregnant mothers. Seven out of nine suicides were among primi

para. Six of these women had committed suicide by ingesting

poison. The time of suicide had been before the 28 weeks of

gestation in six of these women. Second leading cause of maternal

death in AD is postpartum haemorrhage (PPH), with six deaths.

Heart disease is the third leading cause, with five maternal deaths.

The leading cause of maternal death in Sri Lanka for the past

decade had been PPH. When comparing to the national statistics

of 2006 the 2nd leading cause of maternal death had been septic

termination of pregnancy (TOP). However septic TOP were very

low in AD, only one documented death in 2007–2009. Only 2

(5%) deaths were due to hypertensive diseases during 2007–2009.

This is a significant improvement compared to national statistics

in 2004 where hypertensive disease caused 17% of maternal

deaths. 52% of maternal deaths in Anuradhapura district in 2007–

2009 have occurred during antenatal period, compared to Sri

Lankan country statistics in 2006, majority of maternal deaths

occurring during the postpartum period.

Conclusions: According to the WHO definition of maternal

deaths suicides are categorized as ‘‘accidental or incidental cause’’.

FC1.17

Human chorionic gonadotrophin hormone forpreventing recurrent miscarriage

Morley, LC1; Tang, T2; Simpson, N1

1 Department of Obstetrics and Gynaecology, The General Infirmary of

Leeds, Leeds, United Kingdom; 2 Obstetrics and Gynaecology,

Bradford Teaching Hospitals NHS Trust, Bradford, United Kingdom

Objective: Recurrent miscarriage (RM) is the loss of three or

more consecutive pregnancies, which can have a significant

physical and psychological impact on a couple. The aetiologies

underlying RM remain poorly understood, with up to half of

cases remaining of unknown cause. As such, further research is

needed to explore the mechanisms involved in successful

pregnancies. Human chorionic gonadotrophin (hCG) is vital for

maintaining the corpus luteum, but may have additional roles

during implantation which support its use as a therapeutic agent

for RM. The aim of this systematic review and meta-analysis is to

determine the efficacy of hCG in preventing further miscarriage in

women with a history of unexplained RM.

Methods: The review was conducted following publication of our

protocol by the Cochrane Collaboration (2010). The primary

outcome was the efficacy and safety of prophylactic hCG.

Selection criteria included all randomised controlled trials (RCTs)

investigating hCG versus placebo or no treatment in preventing

RM. The search was conducted by the Cochrane Pregnancy and

Childbirth Group’s Trial Register (to week 4, September 2011).

Results: Five studies met the inclusion criteria, totalling 302

participants. The meta-analysis suggested a statistically significant

reduction in miscarriage rate in the hCG groups (RR 0.51; 95%

CI 0.32–0.81 (I2 = 39%)). The number needed to treat was 7.14.

A sensitivity analysis combined only the results from the larger-

powered, more recent studies. Combining this data no longer

suggested a statistically significant benefit (RR 0.74; 95% CI 0.44–

1.23). These results showed less heterogeneity when combined

(I2 = 0%). However, removing these studies reduces the data from

which conclusions can be drawn, thus limiting the power of this

meta-analysis to exclude any possible treatment effect. As such,

the role of hCG in preventing RM remains uncertain. There were

no reported adverse effects of using hCG.

Conclusion: Each study indicated that hCG was safe, with no

adverse events reported as a direct result of hCG. However, the

evidence to support hCG supplementation in preventing RM

remains equivocal. A well designed RCT of adequate power and

methodology is required to establish whether hCG may have an

evidence-based role in preventing further miscarriages. The

efficacy of hCG in preventing RM should be compared to other

interventions, such as progesterone.

Oral Presentations


FC1.18

Postpartum posterior reversible encephalopathysyndrome without hypertension

Kuntal, S; Raheem, T; Parveen, S

Royal Gwent Hospital, Newport South Wales, United Kingdom

We report a case of a patient who developed posterior reversible

encephalopathy syndrome (PRES) in puerperium without Pre-

eclampsia, eclampsia or chronic hypertension. The woman a P3,

presented on day 4 after an uneventful spontaneous normal

vaginal delivery. She complained of severe occipital headache,

neckpain, seizure and loss of consciousness. There was no relevant

past medical history, no proteinurea and her BP was 140/86. She

was treated with magnesium sulphate anticipating imminent

eclampsia the CT scan Brain, Lumbar puncture Carotid Doppler

and Venogram was normal. Her full blood count, calcium, TFT,

CRP were in the normal range. The normal investigations posed a

challenge to the diagnosis. The MRI showed presence of oedema

involving the white matter of parieto-occipital regions in keeping

with changes consistent with posterior reversible encephalopathy

syndrome. The patient was treated symptomatically and made a

full recovery. The posterior reversible encephalopathy syndrome is

a clinicoradiological diagnosis. The other causes could be

autoimmune diseases, immunosuppresants, thrombotic

thrombocytopenic purpura, sepsis etc. The pathogenesis is

thought to be a disturbed cerebral auto regulation with

endothelial injury or dysfunction which results in increased

vascular permeability in posterior circulation. The MRI head

including the T1 weighted image, fluid attenuation inversion

recovery, diffusion weighted imaging; apparent diffusion

coefficient and Magnet resonance arteriography are the imaging

options available. Early diagnosis followed by appropriate

treatment is associated with good outcome and reversal of the

clinicoradiological changes. The case is presented here due to

puzzling constellation of signs and symptoms for both the

Obstetricians and Neurologists. It also reflects on the fact that

postpartum women may be at risk of posterior reversible

encephalopathy syndrome without pre-eclampsia, eclampsia and

high degree of suspicion and multidisciplinary approach is key to

timely diagnosis and treatment.

FC1.19

Role of abdominal packing in management ofpostpartum haemorrhage

Yahaya, AS; Shaffie, Z

Department of Obstetrics & Gynaecology, Tuanku Fauziah Hospital,

Perlis, Malaysia

Introduction: Postpartum haemorrhage (PPH) is an important

cause of maternal morbidity & mortality. Standard measures to

control PPH include medical therapy, surgical intervention such

as repair of genital tract trauma, evacuation of retained product of

conception, uterine balloon tamponade, exploratory laparotomy

and uterine compression sutures, uterine arteries & internal iliac

arteries ligation, systemic vascular devascularization and

abdominal hysterectomy. Abdominal packing had been used as a

useful alternative to control pelvic bleeding when standard

measures fail.

Objective: To study the effectiveness of abdominal packing in

management of massive postpartum haemorrhage.

Methods: Retrospective study of 10 cases of uncontrollable

haemorrhage following emergency peripartum hysterectomies

where abdominal packing were used as a last resort over a period

from March 2007 to September 2011 in Tuanku Fauziah Hospital,

Perlis, Malaysia.

Results: Total deliveries during the period studied were 19 666, in

which 30 emergency peripartum hysterectomies were done (1.525/

1000 deliveries) following massive PPH. Out of these, 10 cases

were followed with abdominal packing as a last intervention for

management of massive blood loss. Packing were done using 2–5

abdominal packs (abdominal gauze pack size 29 · 29 cm) left

intra-abdominally. Relaparotomy for removal of packing were

done 33–60 h after packing surgery. Abdomen were closed in

layers after removal of abdominal packs and no active bleeding

noted in all of the cases. No relaparotomy indicated after removal

of pack in all cases. No documented sepsis or peritonitis

attributed to abdominal packing in the case series. No bowel

obstruction or organ injury noted and no maternal mortality

reported from these cases.

Conclusions: In the event of massive postpartum haemorrhage,

bleeding that is uncontrolled by surgical intervention may be

controlled with abdominal packing. The packing technique we

described was able to achieved complete haemostasis which we

believe may have been impossible using alternative measures.

FC1.20

Multiple pregnancy in assisted reproductivetechnology (ART): is there heritable factor?

Gupta, M; Vaidya, A; Al Saffar, N

Department of Obstetrics and Gynaecology, Farwaniya Hospital,

Kuwait

Objective: Multiple pregnancy is a major complication of assisted

reproductive technology (ART) because of associated Obstetric,

Neonatal complications, and financial, psychological impact. The

aim of our study was to determine whether women with a family

history of multiple pregnancies are more prone to have multiple

pregnancies through ART.

Methods: A comparative prospective case controlled study carried

in Farwaniya Hospital. Four groups of pregnant women with 100

women each were studied. (i) Multiple pregnancies following ART

(ii) Singleton pregnancy following ART (iii) Spontaneous multiple

pregnancy (iv) Spontaneous singleton pregnancy ART included

In-vitro fertilization (IVF), intracytoplasmic sperm injection

(ICSI) and induction of ovulation with gonadotropins.

Background history of multiple pregnancies in mothers, sisters,

grandmothers, aunts or any other close relative was documented.

The pregnancies were followed up till delivery and obstetric

complications, mode of delivery and neonatal outcome were

documented.

Oral Presentations


Results: Women with Multiple pregnancies from ART have

significant family history of multiple pregnancies than their ART

counterparts with singleton pregnancies (46% vs. 18%; P < 0.01).

Spontaneous multiple pregnancy was significantly associated with

family history of multiple pregnancy compared to spontaneous

singleton pregnancy (48% vs. 16%; P < 0.01). There was no

significant difference in the family history of multiple pregnancy

between women with spontaneous multiple pregnancies and those

through ART (46% vs. 48%; P = 0.8%). More multiple

pregnancies through ART ended in preterm delivery compared

with spontaneous multiple pregnancies (84–44%; P < 0.04%).

Conclusion: (i)Those with a genetic predisposition to multiple

pregnancy appear to have a higher risk of multiple pregnancy

even with ART. (ii) There is need for prenatal education for

women referred for ART and tailor treatment to the background

of the patient. (iii) Probably a risk scoring system for patients

undergoing ART involving family history of multiple pregnancies

should be adopted. In these patients treatment should be

individually tailored in terms of controlled use of inducing agent,

limiting the number of embryos transferred and delaying embryo

transfer.

FC1.21

The value of prenatal diagnosis for lethal fetalabnormalities in the United Arab Emirates (UAE)

Ramanathan, G1; Lo, W2; Mustafa, A3; Jahangir,

FB3; Lee, J4

1 Consultant ObGyn, Director of Fetal Medicine; 2 Senior Charge

Midwife, Fetal Medicine; 3 Specialist ObGyn & Fetal Medicine; 4 Chief

Medical Officer Corniche Hospital, UAE

Objective: The management of serious fetal abnormalities

includes the option of continuing the pregnancy with surveillance,

or termination of pregnancy (TOP). The UAE Abortion Law

states TOP is only permissible if a mother’s life is at risk, or there

is a lethal fetal abnormality, in both the pregnancy must be

<120 days post-conception. In countries with similar laws,

offering prenatal diagnosis may seem futile. This study examined

the value of prenatal diagnosis for lethal fetal abnormalities in the

UAE.

Methods: Pregnancies with fetal abnormalities that are

incompatible with life seen at the Fetal Medicine Unit (FMU)

Corniche Hospital between 1st January and 31st December 2011

were identified. These were categorized into two groups: those

diagnosed <120 days, and those diagnosed ‡120 days post-

conception. Management and outcomes of these pregnancies were

reviewed.

Result: During the 1-year period, 16 lethal abnormalities

diagnosed before 120 days post-conception requested TOP. Fifteen

women continued with the decision, one opted to continue her

pregnancy. Eighteen pregnancies were diagnosed ‡120 days of

conception. Detailed counseling on the options of obstetric and

neonatal management was given by an Obstetrician and

Neonatologist. Management decisions were aimed at reducing

potential maternal morbidity and immediate neonatal morbidity.

All opted to avoid a caesarean section (CS) unless for maternal

reasons, and opted for non-invasive/comfort care for their baby.

Two were lost to follow-up. 81% (13/16) achieved vaginal

deliveries, three women had CS at our facility (one for obstructed

labour, one opted for CS; the third with anhydramnios underwent

an elective CS in another hospital).

Conclusion: Prenatal diagnosis for lethal fetal abnormalities not

only offers the option of TOP, it provides women the opportunity

to reduce the risks posed to her and her newborn child in the

immediate postnatal period. In the UAE where women have large

families, avoiding a caesarean delivery has huge implications on

future reproductive health. With consanguinity rates up to 50%,

the incidences of recurrent lethal genetic disorders are also higher.

This study highlights the importance of prenatal diagnosis and

counseling even in countries where the Laws on TOP are

restricted.

FC1.22

A case study of severe pre-eclampsia and eclampsiareferral pattern at Dr Soetomo Hospital, EasternJava, Indonesia

Uning Marlina, M; Ardian, CL

Obstetrics and Gynecology Department, Airlangga University, Dr

Soetomo Hospital, Surabaya, Indonesia

Objective: In 2011, nearly half of patients at delivery ward in Dr

Soetomo Hospital were referral patients. Nearly quarter of them

were referred due to severe pre-eclampsia or eclampsia. This study

aimed to investigate and to evaluate the referral pattern of severe

pre-eclampsia and eclampsia at obstetric ward of the Dr Soetomo

Hospital in Eastern Java, Indonesia between January until

December 2011.

Methods: This study was conducted at Dr Soetomo Hospital in

Surabaya, the capital city of East Java Province. Information of

the obstetric referral history was retrieved using data from delivery

ward register book, referral register book, and patient report from

January to December 2011.

Result: During January–December 2011, there were 330 cases

from 1213 referral due to hypertension in pregnancy, in which

204 patient due to severe pre-eclampsia and 63 referral cases due

to eclampsia. Most severe pre-eclampsia patients admitted to

hospital due to raising blood pressure detected during antenatal

care (55.9%) or during intrapartum (22.5%). Meanwhile,

eclampsia patients came mostly due to danger sign (66.7%). Both

severe pre-eclampsia and eclampsia patients had meet the WHO

requirement for minimum antenatal care at average 5.5 and five

antenatal visit respectively. Majority patients had gone through a

referral journey visited more than one health provider. Seventy

percent (70%) referral for severe pre-eclampsia or eclampsia came

from secondary provider or hospital, and only small proportion

came directly from primary provider. Most mentioned reason for

referral was due to operation room not available for severe pre-

eclampsia patient and no intensive care unit for eclampsia cases.

Majority eclampsia patients had received sulfas magnesium (86%)

Oral Presentations


before being referred, while only half (52.1%)of severe pre-

eclampsia patients had sulfas magnesium.

Conclusion: Referred patients are becoming an important part of

obstetric services at Dr Soetomo Hospital due to its high referral

rate. Attention should be emphasized on the managing

collaboration between the referral agencies especially on the

management before referral. Delay in receiving appropiate care

might be reduced if only there were standart what to do and

where to go for referring pre-eclampsia and eclampsia patient.

FC1.23

Recurrent pregnancy failure: seven or more losseshas a different prognosis compared to motherswith 3 to 6 losses

Nuzhat, A; Surapaneni, T; Fernandez, E

Fernandez Hospital, Hyderabad, India

Introduction: Recurrent miscarriage, affecting 1% of pregnancies,

is defined as three or more consecutive spontaneous fetal losses.

Many mothers who have recurrent miscarriages have a higher

incidence of perinatal loss. The prognosis for a live birth for

mothers with more than three pregnancy failures (miscarriages

and perinatal deaths) has not been categorized based on the

number of previous losses. We hypothesized that the live birth

rate decreases as the number of pregnancy losses increased.

Objective: To compare the live birth rates in different categories

of recurrent pregnancy losses.

Methods: A retrospective observational study from 2000 to 2011,

including women with three or more pregnancy losses, identified

through database of Fernandez Hospital, Hyderabad, India. This

hospital is a tertiary referral centre with 6000 deliveries annually,

and has a dedicated recurrent pregnancy loss clinic. The primary

outcome was the live birth rates at 28 days of life, with secondary

outcomes including preterm births, mean birthweight, incidence

of small for gestational age babies, caesarean section rate, stillbirth

and neonatal deaths.

Results: A recurrent pregnancy losses criterion was found in 1844

mothers. Three pregnancy losses were present in 1121 (60.7%),

four losses in 432 (23.4%), five losses in 166 (9%) and six losses

in 73 (3.9%). Eighteen mothers had seven pregnancy losses, 15

had eight, 11 had nine and 14 mothers had >10 losses in their

past history. The live birth rates were 89.65%, 77.54%, 77.10%

and 80.82% for mothers with three, four, five and six pregnancy

losses respectively and was 33.3% for those with seven prior

losses. Women with seven or more prior losses had a live

pregnancy rate of only 36.53%.

Conclusion: Mothers who had seven or more pregnancy losses

have significantly different outcomes from women with 3–6 prior

losses. The live birth rate for women with seven or more losses is

significantly lower than for women with 3–6 prior losses.

FC1.24

Outcome of delivery in unbooked mothers at AlQasimi Hospital

Perveen, K

Al Qasimi Hospital, Sharjah, UAE

Unbooked mothers who don’t receive antenatal care make a

substantial contribution to the perinatal morbidity and mortality

in terms of higher incidence of operative and caesarean deliveries

as well increased in perinatal deaths. The aim of the study was to

determine the pregnancy outcome of unbooked mothers who

delivered in Al Qasimi hospital in 22 months from 1st January

2010 to 30th October 2011.Controls were the booked mothers

who received optimum antenatal care with our maternal & child

health centre and our antenatal clinics at Al Qasimi & Kuwaiti

hospital. This was a retrospective study and the data included

socieodemographics, intrapartum complications, mode of delivery,

postpartum blood loss, fetal birthweight, Apgar score, admission

to NICU, perinatal morbidity and mortality, puerperal morbidity

and hospital stay. There were 864 unbooked mothers in the study,

during this time there were 9111 deliveries giving an incidence of

unbooked pregnancies of 9.48%. The majority of women had a

spontaneous vertex delivery (74.5%). The ‘unbooked’ women had

a higher rate of caesarean section (25%) as compared to booked

mothers (17.5%).The unbooked mothers had higher rate of

preterm delivery of 9.5% compared to 5.5%. There was higher

rate of low birthweight infants 8.7% compared to 6.4%. The

number of admissions to the NICU was higher for infants of

unbooked mothers (6.7%) of their babies were admitted to the

NICU as compared to 3.5% of ‘booked’. The perinatal mortality

rate for the ‘unbooked’ was higher at 9.1/1000 compared to 7.7/

1000 in the ‘booked’ group. Since perinatal outcome is

significantly worse in unbooked patients compared to those who

were attending antenatal clinics regularly. The pregnancy should

be regarded as high risk due to lack of evaluation of the maternal

history, gestational age and health of the pregnancy. The

introduction of peripheral clinics and free antenatal care along

with more staff in government hospital could play a major role in

improving fetal outcome.

FC1.25

Breech presentation of singletons at term delivery:10 years of ECV clinic experience

Hemelaar, J; Lim, L; Impey, L

Nuffield Department of Obstetrics and Gynaecology, University of

Oxford, Women’s Centre, John Radcliffe Hospital, Oxford, United

Kingdom

Background: External cephalic version (ECV) reduces the chance

of breech presentation at delivery. Attempting ECV lowers the

chance of a caesarean section. ECV should be offered from

36 weeks in nulliparous women and 37 weeks in multiparous

women. A dedicated weekly ECV clinic has been available at the

John Radcliffe Hospital, Oxford, since March 1998.

Oral Presentations


Objective: To evaluate the management of singleton pregnancies

which resulted in a breech presentation at term delivery, with

particular focus on diagnosis of breech presentation, referral for

ECV, and mode of delivery.

Methods: Retrospective review of case notes of 200 consecutive

singleton breech deliveries at the John Radcliffe Hospital, Oxford,

between September 2008 and December 2009. Results were

compared to an identical study of 200 notes completed at the

same hospital in 1998–1999.

Results: Over the 10-year period the proportion of patients

referred for ECV increased from 36% to 48% and the proportion

who underwent an ECV attempt increased from 29% to 39%. A

reduction in the failure of clinicians to offer ECV from 22% to

2.5% was seen, as was a reduction in the proportion of patients

declining ECV from 19% to 9%. On the other hand, a rise in the

proportion of breech presentations that were ‘missed’ (i.e. not

diagnosed until labour or at caesarean section (CS) increased

from 23% to 32.5%. The proportion diagnosed in labour

increased from 21% to 25.5%. A reduction in the rate of vaginal

delivery from 12% to 7.5% was seen and the majority of vaginal

deliveries were due to late diagnosis in labour. A rise in the

proportion of emergency CS from 28% to 40% was found, 81%

of which were performed in labour. Maternal and neonatal

outcomes were generally good, but the Apgar score at 1 min was

notably lower for those infants delivered vaginally (mean 5.9)

compared to either elective or emergency CS (mean 8.7).

Conclusion: While ECV referral and attempt rates have increased

and fewer patients decline ECV, a larger proportion of breech

presentations at term delivery were due to late diagnosis in

labour, resulting in an increase in the proportion of deliveries by

emergency caesarean section. Efforts should be made to improve

the detection of breech presentation before labour.

FC1.26

How long is the latent phase of labour?

Loi, G1; Meloni, A1; Melis, GB1; Deiana, S1; Diaz,

G2; Ferrazzi, E3; Ragusa, A4

1 Clinica Ostetrica Ginecologica Ospedale San Giovanni di Dio,

Cagliari; 2 Dipartimento di Scienze e Tecnologie Biomediche, Cagliari;3 Clinica Ostetrica Ginecologica Ospedale dei bambini V. Buzzi,

Milano; 4 Reparto di Ostetricia e Ginecologia Ospedale di Niguarda,

Milano

Objective: Modern delivery-room practices owe much to the

studies of Doctor Friedman. However, the patients he considered

had different features if compared to modern ones, as his studies

were held in the last century. Doctor Friedman claimed that the

latent phase of labour had to be considered prolonged if it was

over 14 h for nulliparous women and over 20 h for multiparous

women. In order to update these data, we have conducted a

prospective cohort study to analyse the duration of latent phase of

labour in our population.

Methods: In our research we have taken into consideration

women who were between the 37th and the 42nd week of

gestation, with singleton physiological pregnancy and fetus in

cephalic presentation, who presented to Niguarda Hospital in

Milan between June 2009 and June 2010 for one of these

conditions: contractile activity, premature rupture of membrane,

blood loss. On the whole, we have collected 537 cases; among

these, we have selected the ones whose first labour diagnosis

proved to be right. The data have been accurately collected by two

researchers. Overall, these patients have resulted being 308, of

which 155 nulliparous and 153 multiparous.

Results: Statistical analysis shows that in nulliparous women the

average length of the latent phase is of 155 min (2.58 h) and the

95� centile takes 415 min (6.9 h), while for multiparous women

the average length of the same phase is of 81 min (1.35 h) and

the 95�centile takes 315 min (5.25 ore). As a consequence, a

nulliparous woman can be considered in a prolonged latent phase

of labour if, after 7 h since contractions have begun, active labour

has not started yet; a multiparous woman can be considered in a

prolonged latent phase of labour if, after five and a half hours

since contractions have begun, active labour has not started yet.

Conclusion: Prolonged latent phase of labour is a condition that

can lead to negative maternal-fetal outcomes. At present times,

two types of intervention are proposed to solve the prolonged

latent phase: it is possible to accelerate the labour, or, inversely, to

sedate the patient, either pharmacologically or non-

pharmacologically. Beyond personal beliefs, the most important

thing is to ascertain whether the patient has entered the prolonged

latent phase of labour, in order to intervene promptly and thus

improve maternal.

FC1.27

Comparison of intracervical foley catheter plus oralmisoprostol with oral misoprostol alone forcervical ripening in primigravidas at term

Nasir, S; Chaudhry, R

Holy Family Hospital, Rawalpindi, Pakistan

Objective: To compare efficacy of combination of intracervical

foley and oral Misoprostol with oral Misoprostol alone for

cervical ripening is primigravidas at term.

Study design: Quasi-experimental study conducted in the

Department of Obstetrics and Gynaecology unit I, Holy Family

Hospital, Rawalpindi, from July 1st, 2008 to July 31, 2009.

Subjects: Sixty primigravidas at term.

Methods: Two Groups were formed: Group A and Group B

having 30 patients in each group. In group A, induction of labour

was done at 12:00 MN with intracervical foley catheter followed

by 100 lg oral misoprostol after 6 h at 6:00 am. Oral misoprostol

was repeated 4 hourly to maximum four doses till bishop score

was ‡6. In group B induction of labour was done with 100 lg

oral misoprostol at 6:00am alone repeated 4 hourly to maximum

four doses till bishop score was ‡6. Data was collected on a

special proforma. All variables were defined and qualitative

variables were tested by descriptive statistics as mean and standard

deviation also applying t-test and categorical data was analyzed by

chi-square test on SPSS version 10.

Oral Presentations


Results: Mean induction to delivery interval was 12.3 ± 3 h

(ranging from 9 to 15 h) in Group A, while 13.47 ± 4 (ranging

from 10 to 17 h in Group B. There is a significant relationship

between Group A and Group B on the basis of induction delivery

interval when two tail t-test was applied at the level of 5%. In

Group A 74 patients were delivered after first dose of oral

misoprostol and only 26% patients required second dose of oral

misoprostol. In Group B 80% patients delivered at least three

doses of oral misoprostol and 20% delivered after four doses of

oral misoprostol. Thirty per cent patients in Group A and 56%

patients in Group B required Augmentation with syntocinon

injection. In Group A 90% patients had normal vaginal delivery

and 10% patients underwent caesarean section. In Group B 60%

patients had normal vaginal delivery and 40% patients underwent

caesarean section. P value was 0.007 which was highly significant,

chi square was 7.2.

Conclusion: Combination of intracervical foley and oral

misoprostol is better than oral misoprostol alone for cervical

ripening and induction of labour is primigravidas at term.

FC1.28

Bakri Balloon: an effective treatment in themanagement of severe postpartum haemorrhage –an Australian experience

Epitawela, DN; Polyakov, A; Cole, S

The Royal Women’s Hospital, Melbourne, Australia

Background: Primary postpartum haemorrhage (PPH) is

considered as an obstetric emergency. In Australia, obstetric

haemorrhage is one of the four leading causes of direct maternal

deaths. In the events of severe bleeding not responding to the

uterotonics, uterine tamponade can be attempted as the next step.

It can potentially avoid more radical surgical procedures such as

laparotomy for B- Lynch suture, uterine/internal iliac artery

ligation or hysterectomy. Tamponade effect can be achieved by

various methods. In this audit we used the Bakri ‘SOS’ balloon to

achieve this effect.

Objective: To evaluate the experience of intrauterine Bakri ‘SOS’

(Surgical Obstetric Silicone) balloon in the management of severe

PPH in a tertiary Australian institution.

Methods: A retrospective review of consecutive patients receiving

the Bakri Balloon for management of primary PPH from 2005 to

2010. All insertions took place in the theatre, following caesarean

section or after transfer from delivery suite following a vaginal

delivery. All cases were preceded by examination under

anaesthesia to exclude /remove retained products. Patients

received parenteral antibiotics. Balloons were attached to a free

drainage system, suction was not used.

Results: Sixty patients with PPH who were non responsive to

uterotonics had the Bakri Balloon inserted. Mean blood loss prior

to insertion was 2100 mL. (range 700 to 6000 mL). In 6/60

patients (10%), bleeding continued post insertion and these

patients went on to hysterectomy. In the remaining 54 patients

(90%) bleeding settled post insertion. Mean blood loss post

insertion was 290 mL (20–800 mL). 8/60 (13%) developed a fever

post insertion but there were no confirmed cases of sepsis. There

was no other serious maternal morbidity.

Conclusion: The study is one of the largest series of patients

treated with Bakri Balloon, and demonstrates that Bakri Balloon

tamponade can be used as a highly effective technique for

controlling PPH to avoid hysterectomy. It is simple to use and is

not associated with morbidity. Given the success of Bakri Balloon

technique, it could be considered earlier in the course of PPH

rather than leaving it to the ‘last resort’. Comment: There is no

conflict of interest to declare relating to this audit.

FC1.29

Observational Study to determine the relationshipbetween inter-twin delivery time interval andperinatal outcome

Quek, YS2; Ravichandran, N1; Woon, SY2;

Kaliammah, MK2; Shantala, V3; Ravichandran, J2

1 Singapore General Hospital, Singapore; 2 Hospital Sultanah Aminah,

Malaysia; 3 Kokilaben Dhuribhai Ambani Hospital, India

Objective: To determine the relationship between inter-twin

delivery time interval and perinatal outcome in vaginal delivery.

Methods: Prospective observational study on twin births delivered

at ‡34 weeks in the largest maternity unit in Malaysia from

January to December 2009. Relationship between inter-twin

delivery time interval and the umbilical arterial blood parameters

of the 2nd twin in relation to inter-twin delivery time interval

were measured.

Results: Sixty three sets of twins were included in the study with

38 sets being Monochorionic Diamniotic (MCDA) and 25 sets

Dichorionic Diamniotic (DCDA). Mean inter-twin delivery time

interval in the vaginally delivered group was 9.33 min and six

instrumental deliveries of 2nd twin with mean time interval of

18.5 min. All instrumental deliveries were performed due to fetal

distress had a mean pH of 7.28 and Base Excess (BE) of )5.3.

Among the study subjects, there were negative correlation between

inter-twin delivery interval and both the pH (P = 0.04) and BE

(P = 0.13) of the 2nd twin. The longer the duration, the lower the

pH and BE. The rate of reduction of pH and BE, as by linear

regression was 4.59 · 10)3/min and 3.2 · 10)3/min. In twins with

delivery time interval >15 min, there were significant differences

in cord blood pH (P = 0.02) and BE (P = 0.01) between twin

siblings. From the scatted plot graph, we are able to identify that

at 21 min, BE dropped down to )6.8. At 32 min, pH dropped to

7.2. Prediction made from the graph is that at 53 min BE will

drop to )12.

Conclusion: Our study showed that an acceptable time interval

between the 1st and 2nd twin was 21 min after which the BE

begin to deteriorate. The delivery should be competed within

32 min after which pH begin to deteriorate. Hence, all deliveries

of 2nd twin should be within 21 min but not beyond 32 minutes.

Oral Presentations


FC1.30

The effect of reflexology on the pain and out-comes of the labour on the primiparouswomen

Valiani, M; Shiran, E; Kianpour, M;

Hasanpour, M

Isfahan University of Medical Sciences, Iran

Background: Reflexology is one of the non-pharmacological pain

relief methods, and since it is a non-invasive, inexpensive and

applicable technique, it can be used by a skilled and trained

midwife. This study aimed to review the effect of reflexology on

the pain and outcomes of the labour.

Methods: In this quasi-experimental study, 88 primiparous

mothers referred to selected hospitals of Isfahan for vaginal

delivery were selected using simple random sampling method

and then randomised in two groups. Data collection tools were

the demographic data questionnaire, profile and outcomes of

the labour and the short-form of the McGill Questionnaire for

Pain Rating Index (PRI) assessment. The intervention was

general and specific reflexology in the active phase of labour.

PRI was assessed before the intervention and four times after

the intervention (3–5 cm, 6–8 cm and 9–10 cm dilatations and

second stage of labour.

Results: There was no significant difference between groups

before intervention. In the reflexology group, there was a

significant difference between the PRI before and after the four

stages intervention (P < 0.001). PRI was different significantly

between studied groups after intervention (P < 0.001). The length

of active phase of labour was different significantly between the

two groups; but this difference was not significant during the

second (P = 0.29), and the third (P = 0.27) stages. The difference

between the 1st min and the 5th min Apgar score (P < 0.001) and

rate of hemorrhage between the two groups were different

significantly (P = 0.02).

Conclusions: Reflexology can lead to decrease in the labour pain.

Therefore, regarding to the safety of this technique, it can be

replaced as an alternative for pharmacological methods.

FC1.31

Epidemic of obesity in a South East England NHShospital

Hussain, U; Qayam, L; Khan, R

The Princess Alexandra Hospital NHS Trust, Essex, United Kingdom

Background: The UK incidence of pregnant obese women

ranges from 18.5% to 38.35% and is rising. According to

recent CEMACH report, 35% of maternal and 30% of neonatal

deaths were in obese pregnant women. Obesity in pregnancy

was selected as CEMACH‘s principal project with a maternal

health focus for 2008–2011. Increasing body mass index BMI is

associated with increased magnitude of risks for the mother

and fetus.

Objective: To assess the incidence, antenatal and postnatal

complication of raised BMI in pregnant women. To examine the

fetal risks of adverse pregnancy outcome in relation to obesity.

Methods: Retrospective and prospective analysis of 12 000

pregnant women from Pembury Hospital NHS Trust, Kent

between January 2001 and 2007. Data collected from EUROKING

system and statistically analysed. A comparison of pregnancy

outcome was based on the basis of maternal BMI at booking.

Data presented as frequencies and adjusted odds ratios.

Results: Fourty-five per cent of women were found to be pre-

obese or obese. Women of Caucasian origin were more likely to

be obese (P < 0.001) as compared to Black and Asian women.

The caesarean section rate was 32.5% in obese women as

compared to 15.3% in women with normal BMI (statistically

significant). The rate of pre-existing diabetes mellitus was between

3.8% in obese women as compared to 1% in normal population

(P value < 0.0001). Similarly, pre-existing hypertension was found

in 10% of obese women as compared to 2% in women with

normal BMI (P value < 0.0001). 4.1% of babies born to mothers

of normal BMI were admitted as opposed to 6.9% born to obese

mothers. The still birth rate was 1% in obese women as compared

to 0.25% in normal BMI mothers. Up to 20.5% of babies born to

obese mothers weighed >4 kg as compared to 8.6% in normal

BMI (statistically significant).

Conclusion: This study shows that obesity has a negative impact

on pregnancy by increasing antenatal and postnatal complications.

MATERNAL: pregnancy induced hypertension, gestational

diabetes, caesarean delivery, postpartum haemorrhage

NEONATAL: macrosomia and stillbirth.

Recommendation: A multidisciplinary weight management clinic

is suggested to optimise weight control and identify risk

factors.Any woman with a BMI > 35kg/m2 should be identified as

high risk patients and treated with respect, dignity alongside

increased obstetric surveillance.

FC1.32

Comparison between amnisure placental alphamicroglobulin-1 rapid immunoassay and standarddiagnostic methods for detection of rupture ofmembranes

Ng, BK; Lim, PS; Mohamad Nasir, S; Nur Azurah,

AG; Nor Azlin, MI; Mohd Hashim, O; Muhammad

Abdul Jamil, MY

Department of Obstetrics and Gynaecology, UKM Medical Centre,

Malaysia

Background: Management of prelabour rupture of membranes

poses one of the most important therapeutic dilemmas in current

obstetric practice. Conventional clinical methods for diagnosing

rupture of membranes are associated with high false-positive rate.

Absence of an accurate non-invasive diagnostic test for fetal

membrane rupture resulted in the emergence of other tests eg

placental alpha microglobulin-1.

Oral Presentations


Objective: To determine the diagnostic accuracy of placental

alpha microglobulin-1 assay and standard diagnostic methods for

detecting rupture of membrane.

Methods: A prospective diagnostic study was carried out between

June 2011 and November 2011. Patients who presented with

symptoms suggestive of rupture of membranes to Patient

Admission Centre (PAC) PPUKM were recruited. Intial evaluation

included both the standard diagnostic methods for rupture of

membranes (if two of the following three conditions were present:

pooling of fluid at Pouch of douglas, positive nitrazine test, or

ferning) and placental alpha microglobulin-1 immunoassay. The

actual rupture of membranes was diagnosed definitely on review

of the medical records after delivery (absent of membrane or pad

chart positive).

Results: A total of 211 patients were recruited. Review of the

medical records confirmed that 187 of 211 patients (88.6%) had

ruptured membranes at their initial presentation, whereas 24

patients (11.4%) had intact membranes. Placental alpha

microglobulin-1 immunoassay confirmed rupture of membrane at

initial presentation with a sensitivity of 95.7% (179 of 187),

specificity of 100% (24 of 24), positive predictive value of 100%

(179 of 179), and negative predictive value of 75.0% (24 of 32).

By comparison, the conventional standard diagnostic methods

(pooling, nitrazine, and ferning) had a sensitivity of 78.1% (146 of

187), specificity of 100% (24 of 24), positive predictive value of

100% (146 of 146), and negative predictive value of 36.9% (24 of

65) in diagnosing rupture of membrane.

Conclusion: The placental alpha-microglobulin-1 immunoassay is

a rapid and accurate method for confirming the diagnosis of

rupture of membrane. Moreover, it was found to be superior to

conventional standard diagnostic methods (pooling, nitrazine,

ferning), the nitrazine test alone or Fern test alone.

FC1.33

Haemoperitoneum in pregnancy

Karmarkar, R; Mahfous, I; Sohail, A

Basingstoke North Hampshire Foundation Trust, United Kingdom

We report a very rare case of a 33 year old woman who had a

twin pregnancy and presented at 24 weeks gestation with acute

intraperitonial bleeding. An ultrasound scan (USS) and magnatic

resonance imaging (MRI) showed haemoperitoneum. The

haemoglobin level droped from 10.7 g/L on admission to 6.5 g/dL

24 h after admission. The multidisciplinary team decided on

conservative management as she was haemodynamically stable. At

35 weeks, she developed pre-eclampsia and had an emergency

caeserean section (CS). Intraoperative findings showed multiple

intraperitonial adhesion mainly a short, thick fibrovascular band

between the anterior uterine wall and the anterior abdominal wall.

In our opinion, the bleeding was caused by a torn blood vessel(s)

in the the fibrovascular adhesion. The presentation and the

management is discussed.

FC1.34

Preliminary report on retrospective case-controlledstudy on singleton term low birthweight (TLBW)babies, maternal risk factors and neonatal outcome

Eng, YL1; Eugene Leong, WK2; Theam, LC3; Fatt,

QK4

1 Department of Obstetrics and Gynaecology, University Malaya

Medical Centre; Eugene; 2 Department of Obstetrics and Gynaecology,

University Malaya Medical Centre; 3 Department of Paediatric,

University Malaya Medical Centre; 4 Community Health, Sunway

Monash University, Sunway

Background: There is a need to obtain data regarding the

magnitude, determinants of singleton TLBW babies <2.5 kg and

the neonatal outcome in a major hospital in Malaysia.

Objective: To investigate maternal risk factors and neonatal

outcomes in singleton TLBW babies at a tertiary university health

centre in Malaysia.

Methods: A retrospective case-controlled study of singleton

TLBW babies <2.5 kg over 12 months in the year 2010 with

singleton term babies 2.5 kg and above, at University Malaya

Medical Centre (UMMC).

Results: In the study group, significant associated maternal risks

factors were single marital status (P = 0.000), elementary maternal

occupation (P = 0.014), and group B Streptococcus (GBS)

infection (P = 0.017), and placenta marginal insertion

(P = 0.020). In term of neonatal outcomes, there was significant

association with perinatal mortality (P = 0.000).

Conclusion: Several maternal risk factors were identified in

association with term low birthweight babies and its neonatal

outcome. Increased levels of suspicion of mother(s) with the

associated risk factors for low birthweight babies may increase

awareness and prediction of low birthweight so that expedite and

appropriate management or intervention strategies can be put in

place. MEC reference number 866.91.

FC1.35

The consent conundrum

Kerslake, S; Miller, D; Tan, T

Obstetrics and Gynaecology Department, Ealing Hospital NHS Trust,

London, United Kingdom

Objective: Clinicians must describe to patients significant,

unavoidable or frequently occurring risks as part of the consent

process.1. The Royal College of Obstetricians and Gynaecologists

have published consent advice since 2004 including Consent

Advice No. 7 for Caesarean section 2009. Consent taken remains

inadequate and inconsistent. Following an earlier consent audit in

2009, we introduced standardised consent forms in 2010 where

benefits, risks and additional procedures can be individualised and

printed. A re-audit was undertaken to validate these forms.

Method: Consent forms were analysed prospectively over 4 weeks

in 2011. The standard was the RCOG Consent Advice No. 7

Oral Presentations


(2009). Documentation of patient’s demographics, consultant,

intended benefits, risks, consenting doctor’s name, grade,

signature, patient’s name, signature and date of consent were

assessed. Clinicians were blind to the audit, comparison was made

with the previous 1 week 2009 audit.

Results: In 2011, 72 women had caesarean sections. One was

excluded as only verbal consent was taken for the emergency.

Ninety per cent of consents used the printed standardised form

while seven used the previous written consent forms. Mean age

was 31 years and 48% patients of Asian origin. Comparison of the

22 written consents from 2009 demonstrated improvements in all

aspects of consenting, with statistical significance in

documentation of consultant, benefits, risks, consenting doctor’s

name and date. When only standardised consent forms were

analysed, the complete list of risks were documented in 100% of

cases. This is in contrast to only one written consent form

achieving this. The standardised consent form also features a ‘tick

box’ against each risk mentioned. Use of the ‘tick box’ was seen

in only 65% of consent forms.

Conclusions: The adoption of standardised consent forms has

significantly improved recording, standard of care and legibility.

Hand written consent forms consistently omit important RCOG

recommended communication. The new standardised consent

form delivers accurate, up to date, consistent information from

staff to patients. The introduction of ticking the ‘tick box’ against

points discussed is evidence, probity accepted, that it occurred.

This has been tested in the British High Court and accepted as a

valid contemporaneous method documenting information

imparted.2 We advocate the use of printed standardised tick box

consent forms to improve patient care, supporting clinicians to

deliver optimal services

Reference:

1. Department of Health Reference Guide to Consent for

Examination or Treatment 2nd Ed 2009

2. Al Hamwi v Johnston and another [2005] EWHC.

FC1.36

Maternal glycaemic control and perinatal outcomein pregnant diabetic women treated with twicedaily insulin dose regimen

Mohd Azri, MS; Joy, PP; Kunasegaran, K

Obstetrics & Gynaecology Department, Sultan Abdul Halim Hospital,

Sungai Petani, Kedah

Objective: To evaluate the glycaemic control, maternal

complications, and perinatal outcome between twice daily and

four times daily insulin regimen in diabetic pregnant mothers.

Methods: This is a 12 month prospective randomised control

study. Hundred and fifty women with diabetes in pregnancy and

required insulin therapy were recruited. All women were

randomly allocated to twice daily insulin regimen (n = 75) and

four times daily insulin regimen (n = 75). They will have standard

antenatal follow up for diabetes on insulin until delivery and

mode of delivery is base on overall obstetric assessment. Any

intrapartum complications and adverse perinatal outcomes will be

recorded.

Results: There were no significant differences in the case mix

between these two groups. Women with twice daily insulin dose

required lesser total daily insulin to achieve normal Blood Sugar

Profile before delivery (29.8 units/day vs. 34.3 units/day) and

lower incidence of maternal hypoglycaemia when compared to

four times daily group (4% vs. 10.7%; OR 0.35; 95% CI, 0.09–

1.37; P = 0.12). More importantly, data showed that twice daily

group had a better glycaemic control (HbA1c A¢a€� A¤

6.5 mmol/L) although not statistically significant (OR 1.40; 95%

CI, 0.68–2.88; P = 0.36). Women with twice daily insulin had

more successful vaginal delivery (44% vs. 36%; OR 1.39; 95% CI,

0.72–2.69; P = 0.32) and low caesarean section rate (54.7% vs.

64%; OR 0.68; 95% CI, 0.35–1.31; P = 0.25). The incidence of

macrosomic baby is lower in twice daily group (5.3% vs. 6.7%;

OR 0.79; 95% CI, 0.20–3.06; P = 0.72). Both groups have equal

rate of postpartum haemorrhage and incidence of shoulder

dystocia. Twice daily insulin group also found to have lower rate

of neonatal hypoglycaemia and major congenital anomalies, and

have an equal rate of hyperbilirubinaemia and stillbirth as four

times daily group.

Conclusion: This study,performed in a small cohort of women,

lacks of adequate statistical power;nevertheless, it suggests that

twice daily insulin regimen had better maternal glycaemic control,

lower maternal hypoglycemia risk, less caesarean section rate, and

has almost equal intrapartum complications and neonatal

outcomes compared with four times daily insulin regimen. Thus

twice daily regimen could be a better option for insulin therapy to

diabetic pregnant women.

FC1.37

Incidence of hypothyroidism in Saudi pregnantwomen

Saleem, Z; Sallouhat, B; Mesleh, R; Aisha, MA;

Tasneem, ZH; Saadia,

King Fahad Medical City, Riyadh, Saudi Arabia

Objective: Subclinical and overt hypothyroidism during

pregnancy is associated with various adverse maternal and fetal

outcomes. Worldwide prevalence of overt and subclinical

hypothyroidism is 1% and 2.5% respectively. Prevalence and

incidence of hypothyroidism in Saudi pregnant women was never

studied, but it seems to be higher. Literature is lacking regarding

pregnancy specific ranges of thyroid stimulating hormone (TSH)

and free thyroxin (T4) level for Middle East ethnicity. This study

is aimed to determine the incidence of hypothyroidism in Saudi

pregnant women.

Methods: A prospective study was performed on sixteen hundred

pregnant Saudi females presenting to antenatal clinic in the first

and second trimester in King Fahad Medical City Riyadh from

April 2009 to March 2010. All patients were tested for TSH and

T4. Patients with known hypothyroidism, hyperthyroidism and

with incomplete data were excluded leaving study population of

Oral Presentations


twelve hundred. Results of these investigations were reviewed, and

relevant data was analyzed statistically.

Results: The overall incidences of overt and subclinical

hypothyroidism are 4.4%and 36% respectively and prevalence is

)8.7% in the studied population TSH mean is )2.860 (95% CI

2.75–2.950); T4 mean is )12.6312 (95%CI 12.49–12.70).

Conclusion: The studied incidence of hypothyroidism in Saudi

antenatal population is much higher than that observed

worldwide. These high values might raise the need of establishing

reference ranges of TSH and T4 in Middle East ethnicity, and

suggest implementation of universal antenatal screening. This

accomplishment will improve maternal and fetal outcome. Further

studies on larger scale are needed to re-enforce this initiative.

FC1.38

Neonatal outcomes for pregnancies managed withintrauterine transfusion for haemolytic disease ofthe fetus and newborn

Birchenall, K1; Illanes, S1,2; Overton, T1; Soothill,

P1; Liebling, R1; Lopez, F2; Denbow, M1

1 University Hospitals Bristol (UHB) NHS Trust; 2 Universidad de

Chile

Introduction: This study was conducted within the tertiary Fetal

Medicine Unit (FMU) at St Michael’s Hospital (StMH), Bristol.

The aims of the study were firstly to provide improved

information regarding neonatal outcomes for parents of

pregnancies affected by Haemolytic Disease of the Fetus and

Newborn (HDFN) and managed by intrauterine transfusion

(IUT). The second aim was to determine if a change in IUT

protocol in 2004 had improved safety. The new protocol included

attendance of two FMU Consultants, use of fetal sedation, and use

of the intrahepatic vein as an alternative route to placental cord

insertion if deemed safer.

Methods: Data for pregnancies affected by HDFN as a result of

haemolytic red cell alloimmunisation and managed with IUT at

StMH between 1999 and 2009 were retrospectively collected using

local databases, and review of the medical notes.

Results: 256 relevant IUTs were performed. The median number

of IUTs per pregnancy was two. Ninety-one per cent of live

deliveries had 5 min APGAR scores ‡9. 98% were admitted to

NICU/SCBU; requiring phototherapy (96%), exchange transfusion

(36%) and top-up transfusion (30% immediate, 13% late). An

association was found between increased IUT number and

reduced requirement for both phototherapy duration and hospital

admission: each additional IUT received reduced the duration of

phototherapy by 16% (95% CI: 0.72–0.98), and NICU/SCBU

admission by 44% (95% CI: 0.48–0.66).

Following the change in IUT protocol, there was a significant

reduction in the number of emergency caesarean sections

occurring directly after an IUT procedure (n = 5 vs. P = 0.02).

1% of IUTs resulted in fetal loss within 48 h of IUT, none of

which occurred under the new protocol (n = 3 vs. P = 0.08NS).

Conclusions: Although the majority of neonates required

admission to NICU/SCBU and phototherapy, the median-term

outcomes were positive. Importantly, the safety of the IUT

procedure has significantly improved since the change in protocol.

FC1.39

Prenatal evaluation of the feeding artery in fetuseswith pulmonary sequestration; as the predictivemarkers of the postnatal outcome

Lee, M-Y; Won, H-S; Lee, KA; Kyeong, K-S; Shim,

J-Y; Lee, P-R; Kim, A

Department of Obstetrics and Gynecology, Asan Medical Center

Objective: To evaluate whether the diameter and velocity of the

feeding artery, in addition to the mass size can be the markers for

predicting the postnatal outcome in the fetuses with pulmonary

sequestration (PS).

Methods: We retrospectively analyzed 20 fetuses prenatally

diagnosed with PS between February 2009 and October 2010. The

diameter and peak systolic velocity of feeding arteries originating

from systemic circulation were all evaluated by the prenatal

ultrasound. Postnatal outcomes were evaluated in relation to the

presence of respiratory symptoms, the need for mechanical

ventilator, embolization, or excision of the PS by reviewing the

medical records.

Results: Median gestational age and maximum diameter of the

lesion at diagnosis were 23.6 weeks of gestation (range, 19.5–

35.6 weeks) and 38 mm (range, 21–55 mm) respectively. Among

the 16 patients who underwent at least two serial prenatal

ultrasounds, 7 (44%) cases showed decrease in the lesion, feeding

artery, and velocity. All fetuses were born alive at a median

gestational age of 38.6 weeks (range, 36.6–40.4 weeks). Only one

neonate revealed respiratory symptoms; therefore, required the

mechanical ventilator. Furthermore, in spite of transumbilical

arterial embolization (TUE), surgery was needed because of

persistent tachypnea. Postnatal surgery and TUE were performed

in six cases and three cases respectively. Decrease in the lesions,

feeding artery, and velocity which were evaluated by serial

antenatal ultrasound was significantly outnumbered in the

postnatal expected management group when compared to the

intervention or surgery group (6 cases vs. 1 case).

Conclusions: Our results provide that the diameter and velocity of

the feeding artery might be the additional markers for predicting

postnatal outcome in the fetuses with PS.

Oral Presentations


FC1.40

Pre-eclampsia through the retinal microvasculature

Bakhtiari, A1; Fong, KCS2; Peyman, M2; Zahari,

M2; Omar, SZ1

1 Department Obstetrics and Gynecology, University of Malaya, Kuala

Lumpur, Malaysia; 2 University of Malaya, Eye Research Center, Kuala

Lumpur, Malaysia

Objective: This study aims to find the relationship between

retinal vessels caliber and pre-eclampsia as well as pregnancy-

induced hypertension (PIH).

Methods: A total of 30 patients including healthy normal

pregnant patients, patients with diagnosis of pre-eclampsia and

patients with PIH (each group 10 patients) were recruited in this

study. A clinical history and physical examination was performed.

Blood samples were drawn to measure complete blood count and

uric acid. The proteinuria status of participants was assessed with

24 h urine analysis. Fundus photography was carried out at the

time of diagnosis. Using image analysis software, measurements

summarized as the central retinal artery equivalent (CRAE) and

central retinal vein equivalent (CRVE).

Results: The average age of women was 28.4 ± 6.9 years.

Arteriolar diameter in patients with pre-eclampsia

(138.49 ± 17.20 lm) was significantly less than arteriolar diameter

in patients with PIH (158.65 ± 16.01 lm) [Mann–Whitney test,

P = 0.03]. Compared to healthy pregnant controls

(171.35 ± 18.40 lm), women with pre-eclampsia and PIH had a

lower arteriolar diameter (P < 0.05). No significant difference was

found between venular diameters among three groups (Kruskal–

Wallis test, P > 0.05). No significant difference was found

between mean arterial blood pressure in patients with pre-

eclampsia (109.80 ± 14.79 mmHg) and PIH

(105.59 ± 12.59 mmHg) [Mann–Whitney test P = 0.5]. A

significant reverse correlation was noted between serum levels of

uric acid and retinal arteriolar diameter in patients with high

blood pressure [Spearman’s q = )0.8, P = 0.001].

Conclusions: Significant retinal arteriolar vasoconstriction was

found in patients with pre-eclampsia compared with patients with

PIH. This finding in absence of significant difference in mean

arterial blood pressure between two groups might be due to

endothelial cell dysfunction and subsequent substance alteration

that may induce vasoconstriction in retinal and systemic

arterioles. However the lack of significant difference in mean of

venular diameter is in contrast with the role of the venous system

in the pathogenesis of pre-eclampsia that previously hypothesized.

Presence of significant reverse correlation between uric acid levels

with arteriolar diameter may provide a non-invasive tool to

monitor the disease progress or other organs status and may

predict consequent morbidity and mortality.

FC1.41

Stillbirth – antenatal surveillance and psychologicalsupport in managing subsequent pregnancies

Sibtain, S1; Janga, D2; Sinha, P1

1 Conquest Hospital, United Kingdom; 2 Homerton University

Hospital, London, United Kingdom

Objective: To evaluate identifiable risk factors in women with

pregnancies affected by a stillborn fetus.

Methods: This is a retrospective study of 4 years (2006–2009) in

ESHT. The inclusion criteria were stillbirths after 24 weeks. The

exclusion criteria were twin pregnancy with single fetus demise

under 24 weeks. The demographic details, predisposing risk

factors, body mass index, and baby’s details were collected and

analysed.

Results: Sixty-five women were identified for the study (0.4% of

all deliveries) but only 62 case notes (95.4%) were identified. The

ethnic distribution were- (87%) Caucasian, (8%) Black Africans,

(2%) Asians and 3% unknown. Thirty-seven per cent were

primiparous. In 58% the booking BMI was <30, 11% were obese

and in 31% not recorded. In 61% there was an identifiable risk

factor (17% had antepartum haemorrhage and 14% had

pregnancy induced hypertension). Almost one third of the women

(30%) smoked. In 19% the loss was after 38 weeks. Fifty-seven

per cent of the babies were male. In only 76% of the cases post-

mortem examination was performed out of which 25.8% had no

pathology.

Conclusions: Loss of a baby after 24 weeks can be extremely

distressing to the couple as well as to the health care personnel

involved. As per CEMACH suboptimal intrapartum care was

identified in 40–75% of cases. It is a challenge to care for these

women in subsequent pregnancies. A close antenatal surveillance

with adequate emotional support is the cornerstone in

management of these women.

FC1.42

Why are women dying when they reach hospitalon time? A systematic review of the ‘third delay’

Self, A1,2; Knight, HE3,4; Kennedy, SH3

1 University of Oxford Medical School, John Radcliffe Hospital,

Oxford; 2 Anaesthetics Department, Princess Royal Hospital, Telford;3 Nuffield Department of Obstetrics & Gynaecology and Oxford

Maternal & Perinatal Health Institute, Green Templeton College,

University of Oxford; 4 Office for Research and Clinical Audit, Royal

College of Obstetricians and Gynaecologists, London NW1 4RG

Objective: The ‘three delays model’ attempts to explain delays in

women accessing emergency obstetric care as the result of barriers

to: (i) decision-making, (ii) accessing services and (iii) receipt of

appropriate care once a health facility is reached. The third delay,

although under-researched, is likely to be a source of considerable

inequity in access to emergency obstetric care in low-resource

countries. We aimed to identify facility-level barriers that

contribute to the third delay in low-resource countries.

Oral Presentations


Methods: We searched five electronic databases (PubMed;

CINAHL; CABI Global Health; Global Health Library (Medline)

and WHO Publications) from 1994 to 2010 to identify original

research articles. We used a 4-way strategy combining search

terms related to: (i) maternal health care; (ii) facility-level; (iii)

barriers, and (iv) low-income countries. Two investigators

independently read and abstracted information from papers

eligible to be included in the review, a third investigator resolved

any differences. The frequency with which barriers relating to the

third delay were reported was recorded in order to map trends

found in the literature.

Results: A total of 3389 papers were retrieved and imported

into reference management software. Of these, forty-two studies

were eligible to be included in the review. We identified 32

conceptually unique barriers in operation at the facility-level,

which were categorised into 6 emerging themes (Drugs and

equipment; Policy and guidelines; Human resources; Facility

infrastructure; Patient-related and Referral-related). The five

most commonly cited barriers were inadequate training/skills

mix (90%); drug procurement/logistics problems (67%); staff

shortages (60%); lack of equipment (52%) and low staff

motivation (45%).

Conclusions: This review highlights how a focus on patient-side

delays in the decision to seek care can conceal the fact that many

health facilities in low-resource countries are still chronically

under-resourced and unable to cope effectively with serious

obstetric complications. The findings also stress the importance of

addressing supply-side barriers alongside demand-side factors if

further reductions in maternal mortality are to be achieved. The

development of simple, replicable tools to assess facility-level

barriers should be seen as a priority for future research. The

availability of such tools would assist health managers in

identifying facilities that deliver sub-optimal care, and in making

and monitoring the required improvements.

FC1.43

Barriers to the routine implementation of effectiveobstetric interventions in developing countries:views from the frontline

Knight, HE1,2; Kennedy, S1; Langer, A3; Villar, J1

1 Nuffield Department of Obstetrics and Gynaecology, University of

Oxford; 2 Office for Research and Clinical Audit, RCOG; 3 Women

and Health Initiative, Harvard University, USA

Objective: Over the past few decades, the medical community has

developed interventions which, when implemented successfully,

have resulted in significant reductions in maternal mortality and

morbidity. Unfortunately, these have not been consistently used in

regions with the highest mortality and morbidity rates. The

perspectives of, and pragmatic input from, local healthcare

providers about the barriers to the adoption of evidence-based

practices have rarely been sought on a large scale, or sufficiently

considered in planning global efforts to improve maternal health.

The objective of this study was to seek the views of maternal

healthcare providers in low-income countries about the barriers

they encounter, and the solutions they would like to see

implemented.

Methods: We conducted an online survey and ‘crowdsourcing’

exercise between July 2010 and March 2011, targeting facility-

based, direct maternal healthcare providers working in developing

countries. Participants were randomised to one of five online

surveys on postpartum haemorrhage; sepsis; pre-eclampsia/

eclampsia; obstructed labour, and complications of termination of

pregnancy. We selected seven key, internationally-recommended

interventions per condition based on a review of current practice

guidelines. Participants were asked to rate the availability and use of

these interventions in their facility, and to identify specific barriers

to their implementation. Participants were also invited to contribute

to an online ‘crowdsourcing’ forum where they submitted, discussed

and ranked ideas to overcome the barriers identified.

Results: Thousand four hundred and seventy-nine participants

completed the survey from 963 birthing facilities in Africa, Asia,

Latin America and the Middle East. 60% were obstetrician/

gynaecologists and 40% were nurse-midwives. Of the 35 key

interventions evaluated, only 15 were routinely implemented in at

least 70% of the facilities surveyed. The main barriers to evidence-

based care identified were: (i) the inadequate availability, content

and enforcement of clinical guidelines; (ii) inadequate pre-service

and in-service training; (iii) lack of authorisation for certain

procedures; (iv) lack of specific resources; (v) staff preference for

less effective practices and (vi) the cost of treatment for patients.

A total of 142 potential solutions to these barriers were proposed

via the crowdsourcing forum and the ‘crowd’ voted for eleven

winning ideas.

Conclusions: This study demonstrates that a large-scale online

consultation of frontline health workers is now feasible in

developing country settings. Front-line workers have innovative

ideas about ways to overcome local barriers, and their views must

be routinely included in the development of strategies to

implement best practices in maternal health care.

FC1.44

Bacteriological and epidemiological study onneonatal sepsis

Al-Talib, H1; Al-Khalidi, R2

1 Faculty of Medicine, Universiti Teknologi MARA, Shah Alam,

Malaysia; 2 Department of Medical Microbiology and Parasitology,

College of Medicine, Mosul University, Mosul, Iraq

Neonatal septicemia (NNS) is a major cause of death in newborns

despite sophisticated intensive care.

Objective: This study aimed to describe the epidemiology of

NNS, evaluated the impact of risk factors on the NNS cases and

mortality rate, and to determined the bacteriological profile and

antibiotic sensitivity pattern of NNS in neonatal care units.

Methods: This study was conductedin four referral hospitals

located in north Iraq for a period of 2 years. Hospital records of

all neonates with positive blood cultures were reviewed

retrospectively. Neonates were divided into those with onset of

sepsis in the first 7 days of life (early-onset group) and those with

Oral Presentations


onset after 7 days of life (late-onset group). Epidemiology, risk

factors, outcomes, causative pathogens, and antibiotic sensitivity

pattern of early and late-onset NNS were compared.

Results: The estimated incidence rate of NNS was 5.7/1000 live

birth, with both proportional morbidity rate and fatality rate of

9%. In early-onset group, a low Apgar score at 5 min, and

prolong rupture of membrane were significantly higher, while

younger gestational age was significantly higher among late-onset

group. The most frequently isolated bacteria were coagulase-

negative staphylococci and S. aureus. Gram positive organisms

displayed a high degree of resistance to most penicillins and

cephalosporins but vancomycin and imepenem were effective in

them. There was a high resistance rates noted with most third

generation cephalosporins and aminoglycosides amongst most

Gram negative organisms where amikacin and imepenem were

effective in most cases.

Conclusion: The knowledge of the prevailing strains, the

epidemiologic and microbiologic characteristic of NNS remain the

keystones for management of this nosocomial infection, and is

essential to meet the challenge of NNS with equal proficiency and

opposing force.

FC1.45

Risk based screening misses more than one third ofGDM cases

Dahanayaka, NJ; Agampodi, SB; Ranasinghe,

ORJC; Jayaweera, PMED

Department of Medicine and Department of Community Medicine,

Faculty of Medicine, Rajarata University of Sri Lanka

GDM has been increasing globally in recent years, especially

among young mothers and high risk ethnic groups. Objective of

this study was to evaluate the present risk factor based approach

in diagnosis of GDM in Sri Lanka in comparison to new

guidelines proposed by International Association of Diabetes and

Pregnancy Study Groups (IADPSG).

Methods: A community based cross sectional descriptive study.

The study population included pregnant women with gestational

age of 24–28 weeks and residing in Anuradhapura district. All

eligible pregnant women residing in selected MOH areas were

invited to participate. Fasting Plasma glucose and Oral Glucose

Tolerance Test was carried out among all participants.

Results: According to IADPSG criteria, 36 (8.89%) pregnant

women had GDM, compared to 29 (7.16%) according to WHO

criteria. Prevalence of GDM in the study population (positive in

one or both methods) was 10.6% (n = 43) (95% CI 7.9–13.9%).

Of these 43 women, 22 (51.1%) had positive results in both

methods. Seven (16.3%) women were positive only according to

WHO criteria and 14 (32.6%) were positive only according to

IADPSG criteria. A total of 170 (42.0%) participants had at least

one risk factor and of them, WHO criteria for GDM were

satisfied in a single woman on FPG and in 21 women at 2 h. Risk

based approach could have detected only 22 GDM patients

compared to 36 patients that could have been detected using new

criteria. Compared to IADPSG criteria, current risk factor

approach missed 14 cases (38.9%) of GDM whom did not have

any of the risk factors or indicators for GDM.

Interpretation: Risk factor based approach misses more than one

third of GDM cases. Urgent revision of current GDM screening

guidelines is recommended.

FC1.46

Major placenta praevia with or without accreta orincreta

Deb, P1; Muzaffar, S2

1 Obgyn, Al Wasl Hospital, Dubai; 2 Obs/Gynae, Al Wasl Hospital,

Dubai

Objective: The purpose of this study was to identify risk factors,

outcome and complications of placenta praevia with or without

accreta/increta.

Methods: Retrospective analysis of case records of women

diagnosed with placenta previa and delivered at Al Wasl over a

2 year period (June 2009–2011).

Results: Major placenta previa cases comprised 0.37% of total

deliveries at Al Wasl hospital during the study period. Zero per

cent of these were expatriates and 30%women were of local

origin. Majority of cases occurred in the 26–35 years age group

and in multiparous women. Fourty per cent cases were unbooked.

Major risk factors identified was previous history of caesarean

section (30% local women and 41% of expatriate women). Mean

gestational age at diagnosis was 28–36 weeks of pregnancy. Eleven

out of 55 cases were diagnosed preoperatively to be placenta

accrete/increta by ultrasound color Doppler. Seventy per cent of

cases were at 34–37 weeks by caesarean section. Major blood

loss(>2 L) was seen in 22 out of 55 cases. Blood and blood

products transfusion varied from 4 to 100 units. Thirty per cent

cases had hysterectomy, four cases needed relaparotomy and there

was one maternal death.

Conclusion: Previous caesarean, grandmultiparity and

hypertensive disorder were risk factors for accrete in placenta

previa. This condition is associated with high mortality and

morbidity, incurring high cost on health resources.

FC1.47

The role of antepartum transabdominalamnioinfusion in the management ofoligohydramnios in pregnancy

Ahmed, B

Hamad Medical Corporation Women‘s Hospital, Doha, Qatar

Objective: The purpose of this study was to evaluate the role of

transabdominal amnioinfusion in the management of

oligohydramnios with the view to improving pregnancy outcome.

Methods: The study consisted of a prospective analysis of 33

pregnant women presenting with oligohydramnios who were

treated with amnioinfusion during pregnancy in a period from

2003–2011.

Oral Presentations


Results: The mean gestational age at first treatment was 24 weeks.

The mean pre-procedure deepest pool of amniotic fluid was

1.8 cm and post procedure was 3.8 cm. The mean number of

infusions was 1.05. The mean first infusion to delivery interval

was 31 days. Perinatal mortality was 68% and neonatal mortality

was 25%. There were three cases of chorioamnionitis, with one of

these cases presenting with premature rupture of the membranes

(PROM) at the time of amnioinfusion.

Conclusion: Transabdominal amnioinfusion is a useful procedure

to reduce complications that result from oligohydramios.

Although the results show a high perinatal mortality, it must be

borne in mind that most of these pregnancies had multiple fetal

abnormalities with an already predicted poor outcome.

Importantly, as this procedure increases the latency period, it may

be useful in preterm pregnancies where prolonging the duration

of the pregnancy may result in better perinatal outcome by

improving important factors that influence survival including

increased birthweight.

FC1.48

A review of surgical techniques in themanagement of major obstetric haemorrhage

Mak, CH; Ahmed, S; Varadkhar, S; Fergus, A;

Fanning, R; Flynn, C; Byrne, B

Coombe Women’s and Infant’s University Hospital. Ireland

Background: Obstetric haemorrhage continues to be a major

cause of severe maternal morbidity. In addition to the appropriate

use of oxytocic agents for uterine atony, surgical intervention

including uterine balloon tamponade, compression sutures and

hysterectomy maybe required and should not be delayed.

Objective: To determine the incidence of major obstetric

haemorrhage (MOH) in our unit and evaluate the type of surgical

treatment modalities necessitated in these cases.

Methods: Cases of MOH as defined by an estimated blood loss

(EBL) of 2.5 or more litres, transfusion of five or more units of

blood or treatment of a coagulopathy were identified prospectively

at the CWIUH from January 2009 to December 2011 and details

recorded on a database. Patient demographics, aetiology of the

MOH and medical and surgical interventions to arrest bleeding

were recorded.

Results: Sixty-two cases of MOH out of 26 393 deliveries were

identified over a 3 year period yielding an incidence of 2.3/1000.

Mean EBL was 3.7 L (range 0.8–12 L). Mean age and parity was

32.1 years and 1.3 respectively. There were 24 primiparous and 38

multiparous women. Twenty-three of the cases were managed

medically and 39 cases required surgical intervention. Of those

who were managed medically, 20 cases settled with uterotonics

alone with 3 other cases required EUA and removal of retained

placenta tissue (RPOC) in theater. Uterine balloon tamponade

was used in 24 (62%) cases but failed to control bleeding in three

of these cases; one of which required uterine artery embolisation

and two women who had placenta accreta proceeded to

hysterectomy. Laparotomy was required in six (15%) cases all of

which had had caesarean section (CS) delivery. Four of these cases

had repair of a uterine or broad ligament tear, one had inferior

epigastric vessel ligation and one had B-lynch suture insertion.

There were a total of nine (23%) peripartum hysterectomies, all of

which had placenta accreta and were diagnosed antenatally and

counselled for possibility of major haemorrhage and hysterectomy.

Seven cases had a planned elective CS and two cases had

emergency CS following substantial antepartum haemorrhage.

Conclusion: When cases of suspected placenta accreta delivered

electively are excluded, the majority of cases of MOH (80%) can

be managed effectively with medical and simple surgical

techniques such as EUA, removal or RPOC and balloon

tamponade. This emphasises the importance of the acquisition of

these skills in training junior doctors.

FC1.49

Using balloon tamponade technology to minimiseblood loss during transfer of patients in themanagement of postpartum haemorrhage

Georgiou, C1; Suharjono, H2; Ruey, S3; Lim, C4

1 Illawarra Health and Medical Research Institute, Australia; 2 Tun

Ahmad Zaidi, Sarawak, Malaysia; 3 Hospital Likas, Likas, Malaysia;4 Sabah Women’s and Children Hospital, Sabah

Objective: Worldwide, postpartum haemorrhage (PPH) is the

leading cause of direct maternal mortality. In the ‘Report on the

confidential enquires into maternal deaths in Malaysia 2001–2005’,

PPH resulted in 15.8% of direct deaths. Although there are a

number of predisposing factors that contribute to PPH, one

crucial factor in the management of PPH is the time interval from

diagnosis to receiving appropriate treatment. The longer treatment

is delayed, the greater the blood loss. The objective of this study is

to minimize blood loss using balloon tamponade technology

during transfer of patients experiencing a PPH.

Methods: In remote areas of Malaysia, where there is a paucity of

facilities and skilled personnel, the management of PPH for an

atonic uterus is problematic. Acceptable practice is to arrange for

transport to an appropriate facility if first-line uterotonics prove

to be unsuccessful. However, difficult terrain, unpredictable

transport and the great distances involved may result in a

significant amount of blood loss by the time the patient reaches

these facilities. Balloon tamponade technology has recently been

introduced as a method in the management of PPH. Data

suggests that it is easily deployed and may be an effective

treatment. Even if not entirely successful in stopping bleeding, it

will result in a significant decrease in blood volume. The methods

employed for this study involve familiarising medical staff,

including midwives and birthing attendants in the use of balloon

tamponade technology thereby reducing blood loss and

consequently morbidity and mortality.

Results: An inaugural workshop was designed and provided to

accredit staff from a variety of such remote regional hospitals in

using balloon tamponade technology in the management of PPH.

This was in order to commence a regional program of using

balloon technology when a patient is transferred, after first-line

uterotonics have been unsuccessful.

Oral Presentations


Conclusions: This presentation describes the establishment of this

workshop and the results obtained when using balloons in these

remote hospitals for the management of PPH.

FC1.50

Random urine protein to creatinine ratio as adiagnostic tool of significant proteinuria inpre-eclampsia

Basharat, A; Ayub, S; Usmani, AT

Benazir Bhutto Hospital, Rawalpindi, Pakistan

Objective: To determine the frequency of correct results of

random urine protein:creatinine ratio in comparison to 24-h

urine protein estimation in the diagnosis of significant proteinuria

in preeclampsia.

Study design: Cross-sectional study. Setting: The study was

carried out at Department Of Obstetrics & Gynaecology, Benazir

Bhutto Hospital (RGH), Rawalpindi.

Methods: Hundred and fifty pregnant women with preeclampsia

defined as a BP > 140/90 and 1+ proteinuria at a gestational age

>20 weeks were recruited through outpatient and emergency

department by performing a dipstick examination. The first

sample on the first post-admission day provided a spot mid-

stream urine sample for urine P:C ratio. From the next voided

specimen till the first sample on next morning were collected for a

24-h urinary protein determination.

Results: The mean age of the patients was 27.56 ± 4.4 years and

the mean gestational age was 34.9 ± 2.87 weeks. 115 (76.67%)

patients had positive 24-h urine protein test for significant

proteinuria. Out of these 115 (100%) also had a positive spot

urine protein creatinine ratio test and none (0%) had a negative

spot urine protein creatinine ratio test. Thirty-five (23.3%)

patients had negative 24-h urine protein test for significant

proteinuria. Out of these 1 (2.8%) had a positive spot urine

protein creatinine ratio test and 34 (97.2%) had a negative spot

urine protein creatinine ratio test. Spot urine protein creatinine

ratio test had an accuracy of 99.3%. The mean 24-h urine protein

of the patients was 1909.5 ± 1437 mg/day and the mean spot

urine protein creatinine ratio was 1.85 ± 1.5. Both had a positive

linear correlation, which was statistically significant (Pearson

Correlation coefficient 0.896; P = 0.00). The calculated sensitivity

and specificity of the Spot urine protein creatinine ratio test in

comparison to 24-h urine protein test was 100% and 97.14%

respectively and a positive predictive value (PPV) and negative

predictive value (NPV) of 99.1% and 100% respectively.

Conclusion: We conclude that the P:C in spot urine specimens is

an accurate method to estimate the protein excretion in urine and

there is a strong correlation between the protein:creatinine ratio

in a random urine sample and 24-h protein excretion.

FC1.51

Reducing the incidence of third degree tear in O&GDepartment of Bintulu Hospital

Yii, MS; Ahua, M; Dah, L; Bajat, C; Madu, LC;

James, JD; Saging, AB

Bintulu Hospital Sarawak, Malaysia

Background: Bintulu Hospital is the referral centre where

problematic cases were anticipated. From year 2007 to 2009, there

have been more than 2% of total vaginal delivery mothers per

year experiencing third degree tear. The study is to ensure quality

improvement in the service and patient care.

Objective: This study is specifically designed for nurses to identify

contributing factors to third degree tear, implement remedial

action and evaluating the effectiveness of the implemented

measures ensuring reduction in the number of incidences of third

degree tear from above 2% to not more than 1% of total vaginal

deliveries per year.

Methods: Validated questionnaires and interview methods were

used. Mothers admitted from January to June 2010 were

interviewed and supervision on nurses conducting deliveries was

also done. Assessment and evaluation was carried out from July to

December 2010. Remedial measures were evaluated by monitoring

all high risk mothers.

Finding: Total of 1514 vaginal deliveries in January–June 2010

and noted that primigravida, mothers with history of big baby

and non ante-natal mothers were at risk. After analyzing and

interpreting the finding, improvement steps were taken to ensure

reduction in third degree tear among the targeted group.

Remedial action taken: Discussion with health clinic staff was

conducted and an ante-natal class was recommended. Hospital

staff will re-enforce on the education, supervised delivery, protect

perineum, appropriate time for episiotomy and no sweep and

stretch was implemented. Lateral episiotomy training, continuous

nursing education and hands-on practice was implemented for

better knowledge and skills. Shortage of staff is a major issue and

negotiation with higher authority to provide more staff has been

done. Early pushing is one of the contributing factors, therefore

pain relief like pethidine and entonox were given to ensure

relaxation and less pain. Husband friendly is encouraged, good

teamspirit ensure success and target achieved.

Conclusion: The group had achieved the set standard in reducing

the incidence of third degree tear to not more to 1% of total

vaginal delivery. We have identified the contributing factors and

learned that antenatal education and good delivery technique is

critically important. Therefore; preventing third degree tear will

definitely lessen time in post delivery management thus quality

patient care is achieved.

Oral Presentations


FC1.52

Pregnancy outcome following LLETZ; 12 yearsretrospective study

Mohanty, AK; Sibtain, S; Sinha, P; Zaidi, J

Conquest Hospital, United Kingdom

Background: Because of the advent of effective screening

programmes, large loop excision of transformation zone (LLETZ)

has been established as the accepted method of treatment for

cervical intraepithelial neoplasia / microinvasive cervical cancer

especially in young women.1 Published studies, which looked in to

the outcome of pregnancies following LLETZ remain

inconclusive.1,2,3

Method: We conducted a retrospective analysis of pregnancy

outcomes over last 10 years (2000–2009) for those women who

were cared for their pregnancy in our Trust after having LLETZ.

Data were collected retrospectively from the euroking and joe

system and were analysed. During this period there were 409

women who were pregnant beyond 16 weeks gestation following

LLETZ, of whom 45 had their pregnancies ending before 37

completed weeks. This amounts to 11% of this population. Out of

these 45 women fourteen have had term pregnancies prior to

LLETZ. Others had been pregnant for the first time beyond

16 weeks after the LLETZ. Three women from the study had their

pregnancy ended before 28 completed weeks, while eight other

delivered between 28 and 34 weeks of gestation. All women who

delivered before 34 weeks gestation (n = 11) had some evidence of

infection/inflammation as per either the high vaginal swab culture

/ mid specimen urine culture / placental swab culture / placental

histology report. On the contrary those women who delivered

between 34 and 37 completed weeks gestation had no significant

evidence of infection although these group did not have the

placental swab nor the placental histology routinely.

Conclusion: In our study we found LLETZ to be associated with

increased incidence of preterm deliveries, which is in accordance

with other studies. Although preterm birth is defined as being

before 37 completed weeks, most mortality and morbidity is

experienced by babies born before 34 weeks. We found preterm

deliveries before 34 weeks are associated with some evidence of

infection which can be prevented in most if not all of the cases.

References:

1. Kyrgiou M et al. Obstetric outcomes after conservative

treatment for intraepithelial or early invasive cervical lesions:

systematic review and meta-analysis. Lancet. 2006 Feb

11;367(9509):489–98.

2. Arbyn M. et. al. Perinatal mortality and other severe adverse

pregnancy outcomes associated with treatment of cervical

intraepithelial neoplasia: meta-analysis. BMJ 2008 Sep

18;337:a1284.

3. Cruickshank ME et. al. Fertility and pregnancy outcome

following large loop excision of the cervical transformation zone.

BJOG 1995; 102: 467–470.

FC1.53

The impact of body mass index on maternal andneonatal outcomes: a retrospective study of 30 298singleton pregnancies in a tertiary referral hospitalin Northern Ireland, 2004–2011

Scott-Pillai, R1; Spence, D1; Cardwell, C2; Hunter,

A3; Holmes, VA1

1 School of Nursing and Midwifery, Queen’s University Belfast, United

Kingdom; 2 Centre for Public Health, School of Medicine, Dentistry

and Biomedical Sciences, Queen’s University Belfast, United Kingdom;3 Royal Jubilee Maternity Service, Belfast Health and Social Care Trust,

Belfast, United Kingdom

Objective: To assess the prevalence of overweight and obesity in a

UK obstetric population and to explore the impact of body mass

index (BMI) on maternal and neonatal outcomes.

Methods: Retrospective data were obtained from the Northern

Ireland maternity system for 30 298 singleton pregnancies with a

BMI recorded before 16 weeks’ gestation, delivered over an 8 year

period, 2004–2011. Women were categorised according to the

WHO classification into underweight (BMI <18.5 kg/m2), normal

weight (BMI 18.5–24.99; reference group), overweight (BMI 25–

29.99), obese class I (BMI 30–34.99), obese class II (BMI 35–

39.99) and obese class III (BMI ‡40). Antenatal, intranatal,

postnatal and neonatal outcomes were examined and adjusted

odds ratios (OR) with 95% confidence intervals (CI) presented

following logistic regression analysis. Data were adjusted for

maternal age, social deprivation, marital status and parity.

Results: Within the cohort, women were categorized as normal

weight (52.5%), underweight (2.8%), overweight (27.8%), obese

class I (11.0%), obese class II (3.9%) and obese class III (1.9%).

Compared to normal weight women, overweight and obese class I

women were at significantly increased risk of the following

outcomes: hypertensive disorders of pregnancy (OR 1.9 (95%CI

1.7–2.2), 3.5 (3.0–4.0); for overweight and obese class I,

respectively); gestational diabetes [1.8 (1.4–2.2), 3.7 (3.0–4.7)];

induction of labour [1.2 (1.1–1.3), 1.4 (1.2–1.5)]; caesarean

section [1.4 (1.3–1.5), 1.8 (1.7–2.0)]; postpartum haemorrhage

[1.4 (1.3–1.5), 1.8 (1.7–2.0)]; and macrosomia [1.5 (1.4–1.6), 1.9

(1.7–2.1)], with risk for all outcomes increasing for obese class II

and III. Conversely, as BMI increased, there was decreased

likelihood of achieving a vaginal birth or successful breastfeeding.

In addition, women with a BMI of 40 or over had an increased

risk of having a preterm birth [1.6 (1.2–2.3)], stillbirth [3.1 (1.3–

7.2)], a baby with low Apgar scores at 5 min [2.0 (1.3–3.2)], a

baby admitted to the neonatal unit [1.6 (1.2–2.4)], a longer

postnatal stay [2.0 (1.5–2.6)] and a wound problem following

caesarean section [4.9 (2.9–8.0)].

Conclusion: This study highlights that obese women and their

babies are at increased risk of adverse maternal and neonatal

outcomes, with the risk of adverse outcomes increasing across

BMI categories. While those women with the highest BMI are at

greatest risk of having an adverse outcome, it is essential to plan

adequate care for all women with an elevated BMI, from the

overweight through to the highest obese categories.

Oral Presentations


FC1.54

A simple classification system for maternaltraumatic injuries associated with second stagecaesarean section

Angala, P; Raja, M; Ikomi, A; Varma, R

Basildon and Thurrock University Hospital, United Kingdom

Introduction: Incidence of caesarean section (CS) deliveries is

increasing in the developed world. The obsolete status of high

cavity instrumental delivery and concurrent reduction in overall

instrumental rates in UK units suggest a rising rate of CS at full

dilatation. A recent UK study showed 15.3% of emergency CS

were performed in the 2nd stage. CS at full dilatation is a

technically demanding procedure and has an association with

complications of intra-operative trauma (high rates of laceration

injuries to uterus, cervix and vagina). This is reflected in the most

recent Scottish Morbidity data (2009) which shows 25% of

women delivered by emergency CS and experiencing massive

obstetric haemorrhage (MOH) were delivered in the 2nd stage of

labour. 16.3% of all the MOH cases were caused by extensions of

the uterine incisions and/or broad ligament haematomas at the

time of CS. It is surprising that to date a universally accepted

formal classification system for maternal injuries (similar to that

of obstetric anal sphincter injuries) relating to this scenario, has

failed to emerge.

Aim: To design a simple classification system and apply this in a

review of second stage deliveries. Setting A UK district general

hospital

Method: A retrospective analysis of 60 patients from January to

September 2010 (9 months). The data was collected by analysing

the labour and operation notes. All the patient who had CS at full

dilatation were included in the study. The complexity of suturing

of uterine incision was graded with grade 1 being uterine incision

that were easy to suture and did not increase the operating time

Grade 2 being those wich increased operating time and total

blood loss. Involvement of cervix, vagina, bladder in the uterine

incision and need for senior help was graded as Grade 3

Results: Uterine incision extension was noted in 25% of these

patients and of those 53.3% were Grade 1,Grade 2 were 26.6%

and 20% were Grade 3

Conclusions: To the best of our knowledge, this is the first

reported classification system relating to this clinical scenario and

in our hands has proved to be a useful tool for audit. It offers a

grading based not only the extent of the damage but also on the

effort required to treat. With further validity development

(ongoing) potential applications include as a research tool and as

a reproducible method for improving the quality of

contemporaneous documentation for this high risk episode.

FC1.55

UK obstetrician’s response to the NICE and RCOGguidelines on antenatal thrombo-prophylaxis – asurvey and an audit

Dutta, D1; Allen, K1; Thornton, J2

1 Nottingham University Hospitals NHS Trust, City Hospital campus,

Nottingham; 2 Faculty of Medicine & Health Sciences, Nottingham

City Hospital

Objective: The National Institute for Health and Clinical

Excellence (NICE) and Royal College of Obstetricians and

Gynaecologists (RCOG) guidelines do not give any clear advice

for most prenatal venous thromboembolism (VTE) risk scores.

There have been no randomised control trials for administering

Low Molecular Weight Heparin (LMWH) antenatally as

thromboprophylaxis for modest scores. There were no venous

thromboses or pulmonary embolism events in the two trials where

LMWH was administered in the women with recurrent

miscarriages (SPIN, Kaandorp et al. 2010). Therefore there is no

evidence base for administering heparin antenatally. Hence for

pregnant women, without a previous VTE and thrombophilia,

with a score above two risk factors, the guidelines rightly say

‘consider antenatal heparin’. We measured how many pregnant

women in UK had a VTE score above 2, and how many UK

obstetricians responded to this risk score and administered

heparin antenatally.

Method: A web-based survey was done, where a questionnaire

was sent to 600 obstetricians who are members of the British

Maternal and Fetal Medicine Society (BMFMS). This comprised

of ten hypothetical scenarios in which the respondents were asked

whether they would prescribe LMWH for these antenatal patients.

The VTE score of each scenario was three or above, and therefore

LMWH should have been considered. In addition, a retrospective

audit of 265 women, who delivered in January 2012 in a UK

teaching hospital was completed. Case notes were reviewed to

identify those who had three or more risk factors antenatally.

Results: Seventy two obstetricians responded to the survey. The

number of obstetricians, who would prescribe LMWH ranged

from 22 (31%) for a 36 years old lady with a BMI of 35 and who

is in her 4th pregnancy to 68 (94%) for a 37 years old paraplegic

woman with a BMI of 36. For most (seven out of 10) scenarios

half or more of the obstetricians would give LMWH antenatally.

In the audit, 18 of 265 patients (6.8%) were found to have three

or more risk factors for VTE at their booking visit.

Conclusion: Our survey suggests most of these obstetricians

would respond to the NICE/RCOG guidelines by prescribing

heparin antenatally. Assuming our audit sample is representative

of other units in UK, over 49 000 pregnant women are considered

for antenatal LMWH every year. This suggests that a very large

number of pregnant women in UK are likely to receive antenatal

thromboprophylaxis in absence of any trials.

Oral Presentations


FC1.56

Maternal medications and science of breastfeeding

Khan, MI; Sharara, H; AlKilani, H; Al Jusaiman,

M; Sakka, M; AlNoimi, M; Manzoor, S; Badran,

H; Bahnas, F; Foukhri, N; Amara, Z; Laib, R;

Khan, T; Sharara, S; Mubeen, S

Hamad Medical Corporation, Qatar

Introduction: Human milk is one of nature’s most extraordinary

fluids, perfectly balanced to meet all of the nutritional,

developmental, and protective needs of the newborn infant. In the

last 30 years, as our understanding of the importance of

breastmilk and pregnancy and lactation occur within the context

of a woman’s breastfeeding have grown, so has the number of

women who have made the decision to breastfeed As virtually all

pregnant and breastfeeding mothers will at some time require

medication, this means that more mothers and their infants will

be exposed to medications. Questions about the use of certain

medications during breastfeeding concern both women and their

health-care providers. Unfortunately, far too many women

discontinue breastfeeding on the advice of well-meaning but

misinformed physicians, nurses and pharmacists.

Physians, nurses and pharmacists can play an important role in

the promotion of breastfeeding and in supporting mothers who

are breastfeeding. To be effective, pharmacists must overcome

several obstacles: Most pharmacists have received little instruction

on the topic of medications and breastfeeding. There is a tendency

to focus on theoretical drug toxicities rather than the real risks of

not breastfeeding. There is confusion between the risks of

medication use during pregnancy versus medication use during

breastfeeding. Misleading or incorrect information is common.

The Physicians’ Desk Reference (PDR) is the poorest source of

information. Most medications are safe for breastfeeding mothers

and their infants. As not breastfeeding carries significant risks for

both mother and infant, recommending that a mother stop

breastfeeding to take a medication is almost never required and

should only be done as a last resort.

Medication Classification Systems: To assist clinicians to better

assess risk versus benefit for specific drugs and drug groups,

classification systems have been offered. The American Academy

of Pediatrics 23 lists drugs in tables as summarized in Table 3,

with most medications in the extensive ‘compatible with

breastfeeding’.

Conclusion: Overall health, with breastfeeding women

experiencing both acute and chronic conditions needing

treatment. It is critical that the effects of medication use during

lactation be evaluated and the information made readily accessible

to both women and health-care providers, especially Physicians

and pharmacists. This allows all to make informed decisions

about the use of medications during lactation and the

management of maternal and infant conditions. Without

evidence-based counseling, women may undermine their own

health by discontinuing needed medications.

FC1.57

An interdisciplinary analysis of emotions in thecontext of prenatal diagnosis of Down syndromeand choice of medical termination of pregnancy:the perspective of couples and healthcareprofessionals

Broussin Ducos, A

Departement d‘ethique appliquee, Universite de Sherbrooke, Canada

The prenatal diagnosis (PND) is used to identify the fetal

anomalies. In the case of a PND of Down syndrome (DS),

Health professionals (HPs) announces the irreversible nature of

the anomaly. The couples are faced with the options to terminate

the pregnancy or not and confronted with negative emotions. If

couples choose the termination of pregnancy (TOP), they and the

HPs are here confronted with the symbolic violence of feticide

A review on the various aspects of the PND of DS and emotions

felt by the French, Canadian american couples/HPs concerned

allowed me to develop a conceptual grid analysis which served me

to identify the emotions, their role and consequences on the

wellbeing of couples/HPs concerned by these PND/TOP.

Results: From various perspectives: Psychological: These PND of

DS/TOP generate various emotions: guilt, shame, anger, hate,

regret, fear, anguish, remorse, denial and sadness which cause

psychological/physical damages in the context of their over-

expression. Clinical: TOP categorisation grids containing the

emotions and personalities who experience them should help

psychologists to identify those who run a significant risk of

developing depression Sociopolitical: A comparative analysis of

the emotions experienced by couples/HPs from different countries

demonstrates that the emotions,their intensity differ according to

societal values and public health organisation. Ethical: The couples

disinvest emotionally the fetus for decision making. The feticide

causes the emergence of hidden feelings, generates trauma, casts

doubts on the well-founded of the decision of TOP, undermines

the wellbeing. The DPN/TOP allows to grasp how it’s important

to consider the emotions during the decision-processes and the

importance of compassion/empathy.

Oral Presentations


Metabolomic approach to diagnosis of labour

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