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
4 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 5
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
6 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 7
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
8 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 9
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
10 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 11
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
12 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 13
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
14 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 15
(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
16 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 17
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
18 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 19
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
20 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 21
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
22 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 23
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
24 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
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
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 25