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O230 EMERGENCY OBSTETRIC CARE IN NORWAY
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
O230 EMERGENCY OBSTETRIC CARE IN NORWAY H.M. Engjom1 , K. Klungsøyr3 , N.-H. Morken2 , B. Thorsdalen3 , O. Norheim1 . 1 University of Bergen, Department of Public Health and Primary Care, Bergen, Norway; 2 Haukeland University Hospital, Department of Obstetrics and Gynecology, Bergen, Norway; 3 The National Institute of Public Health, Medical Birth Registry of Norway, Bergen, Norway
Two maternal deaths from direct causes were registered in 2009. The regional differences in intrapartum and neonatal mortality are not statistically significant. Maternal morbidity registered in MBRN; intensive care, puerperal sepsis and sepsis during delivery, thromboembolic complications, hemorrhage >1500 ml or transfusion, eclampsia. All women who experience complications will receive appropriate care with a possible delay due to transport.
2.7* 2.2 2.1 2.8 3.1 2.7 2.14 2.70 1.84 1.62 2.78 2.14 17 16.3 17 13.2 18 18.8 2.1 10.4 0.9 1.8 0.8 1.2 1290 575 78 256 85 300 62991 5525 8390 14081 10872 24088 10 6 0 2 0 2 41 (0.8) 9 (1.4) 8 (1.1) 7 (0.7) 8 (0.8) 9 (0.5) 49 5 7 10 10 18 4.852.197 465.619 673.364 1.006.202 936.066 1.770.946 Norway North Region Mid Region West Region South Region East Region
Objectives: To examine short term neonatal outcome of the second twin delivered by cesarean section after vaginal delivery of the first-born twin (combined delivery) and to identify predictors of poor outcome for combined deliveries. Materials: Three year population-based retrospective cohort study of 1254 twin births in Denmark. Methods: The study subjects were divided into 3 groups: Vaginal deliveries, Planned Cesarean deliveries, and Combined deliveries. Data were extracted from medical records, a fetal software program (Astraia) and the National Birth Registry. Short term poor neonatal outcome was measured as 5 min Apgar score ≤7, umbilical cord pH ≤7.10 and admission to neonatal intensive care unit >3 days. Results: Vertex-nonvertex fetal presentations were more prevalent in Combined deliveries than Vaginal deliveries, OR 4.4 (2.5–7.8). Nonvertex second twins born by Combined delivery had a higher risk of Apgar score ≤7 and umbilical cord pH ≤7.10 compared to Vaginal delivery, OR 6.2 (2.1–18) and OR 3.9 (1.6–9.5). Prenatal ultrasound scans were evaluated in Combined deliveries. 48% were vertex-vertex at the latest ultrasound scan (mean GA 34+0), 37% were vertex-vertex at delivery. A higher rate of nonvertex second twins with umbilical cord pH ≤7.10 and admission to NICU >3 days was seen in Vaginal deliveries compared to Planned Cesarean deliveries, OR 4.9 (1.7–13.9) and 0.5 (0.2–0.9). Conclusions: Vertex-nonvertex twins have increased risk of combined delivery. Prenatal ultrasound at 34+0 can predict fetal presentation at delivery. Planned cesarean section gives a better short term neonatal outcome for second nonvertex twins.
Table: WHO EmOC indicators
O229 CESAREAN SECTION FOR THE SECOND TWIN: A POPULATION BASED STUDY OF OCCURRENCE AND OUTCOME L. Engelbrechtsen1 , E. Hoffmann1 , T. Perrin1 , A. Oldenburg2 , A. Tabor2 , L. Skibsted3 . 1 Department of Obstetrics and Gynecology, University hospital Roskilde, Roskilde, Denmark; 2 Department of Fetal Medicine,University hospital Copenhagen, Copenhagen, Denmark; 3 Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
Estimated EmOC institutions Basic OC Deliveries Without Without EmO, Cesarean section Maternal Intrapartum/neonatal need (coverage) institutions 209 EmOC % rate, % morbidity, death rate pr 1000 %
Objectives: We assess the risk of unplanned delivery outside obstetric institutions and describe availability and access to obstetric care in a national setting where the number of institutions declined from 93 in 1980 to 51 in 2009.
Population 1.1.2010
Methods: In the first group of patients we anchored the uterus with a posterior polypropylene mesh, and we suspended this complex to the sacrospinal ligaments bilaterally using a special technique. For repairing of the recto-vaginal fascia we performed “posterior bridge” technique usually associated with perineal body reconstruction. In the second group, we used vaginal hysterectomy with McCall culdoplasty, and if necessary posterior colpoperineoraphy. Results: We evaluated the immediate and three months postoperative results in these two groups. All patients completed questionnaires before and three months after surgery in order to asses the functional improvement. We found that in the first group the anatomical results were better (vaginal posterior fornix completely restored), while in the second one the vaginal vault was descended and mobile (23 out of 29). In both groups we found similar improvements in faecal emptying problems (82% vs 80%), pelvic tension (92% vs 96%) or pelvic pain (80% vs 60%). We discovered in the first group significant improvements in symptoms that are not classically linked to enterocel and posterior compartment defects: nocturia, urgency and frequency (p-value <0.04). Conclusions: This study demonstrates that enterocel repair using alloplastic material provides a better anatomical result than the classic technique. Interestingly we proved that enterocel repair correlates unexpectedly with urinary symptom improvement. Acknowledgement: This paper is supported by the Sectoral Operational Programme Human Resources Development (SOP HRD) 2007–2013, financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/107/1.5/S/82839
S341
S342
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
Methods: Retrospective cohort study of birthplace in or outside obstetric institutions 1979–2009 and of all births in 2009. For 2009 we used the World Health Organisation (WHO) emergency obstetric care (EmOC) indicators with the following classification of institutions; comprehensive emergency obstetric care (CEmOC), basic emergency obstetric care (BEmOC) and basic obstetric care for normal deliveries (Basic OC). Demographic data on estimated travel time to the nearest institution or to EmOC institution was obtained in a cross-sectional study. Calculations were performed with geographic information systems (GIS) software and based on registered address and the national road database. Statistical analyses were performed with Pearson Chi-square test for groups and logistic regression for individual data. Results: The risk of unplanned delivery outside institution in Norway doubled from 1979 to 2009 (OR 1.96; 1.82–2.10). All emergency institutions provide comprehensive care, national and regional indicators are listed in the table. Maternal morbidity was 2.14% nationally. Regional comparisons with the West region and adjusted for age, parity and education show increased risk in the North (OR 1.72; 1.45–2.12) and South (OR 1.75; 1.45–2.12). In five of the 19 counties 10.4–16.6% of the women travel more than one hour to reach an EmOC institution. In six counties 14.4–44.5% of the women travel more than one hour to any obstetric institution, 20–70% travel more than one hour to reach EmOC and 8.7–69% travel more than two hours to reach EmOC. Conclusions: The risk of unplanned delivery outside institutions doubled in the last 30 years. Norway does not meet the estimated need of EmOC coverage nationally and on regional levels. The demographic distribution support a decentralized care model. We found regional variations in maternal outcome and the impact of the present care structure on maternal risk of complications need to be explored further to provide guidance for policy decisions. Materials: National registry based data from the Medical Birth Registry of Norway (MBRN) on 62291 births in 2009 and 1.774.093 births in 1979–2009. National population registry data from Statistics Norway on age and address for women 15–49 years, 1.127.665 women by 1.1.2010. O231 INCURABLE OBSTETRIC FISTULAE: THE SOCIO-CLINICOPATHOLOGY OF 182 CASES G. Esegbona1 . 1 Nomado, London, United Kingdom Objectives: To explore the clinico-pathology of women with an incurable obstetric fistula and explore client perspectives about their incurability. Methods: Women with an incurable fistula under Fistula Foundation Nigeria in Kano. Results: 127 of 182 clinical records revealed varied clinicopathology. 76% (97) of women had sole involvement of the urethra in the form of urethral damage or an urethral vesicovaginal fistula (UVVF). Of these 40% (39) had had at least one repair at centres elsewhere before presenting for help to the specialist fistula unit. 30% (38) of women with clinical records had developed after a successful repair(s) an incurable fistula after further attempts at childbearing. Women had several attempts at repair with 45 not disclosing to providers how many repairs they had before for various s reasons: such as not feeling cured because they were not like they were before (15). Of these 10 had mild leakage but a minimum of 3 repairs with different providers. Women classified themselves as incurable because of their incontinence but also their inability to have intercourse and bear children. During interviews 98 said they had Bahanya (vaginal stenosis). A review of available clinical notes (71) revealed that this was pre-existing in 87% (61) prior to repair. Most of the women (81) felt that if they would prefer a vagina to being continent. As subfertility was cited as a major concern with most women childless (167 women), the index pregnancy having caused the fistula resulting in a stillbirth.
Some women (19) requested needing assistance to get dilators and lubricant ky jelly in order to have intercourse daily. The degree of urinary leakage varied from a little (26) to having to change every 2 hours (127). All women used self- made pads from rags. Pad changes ranged from 4 times (23) to 10–12 times (112) per day. The worst problem was the smell of the pads (156) with 90% having to spend 40% of their daily income and 1–2 hours a day on washing the pads. Substances like bleach used were cited to cause rashes and infections in the genital area(155). Not drinking was also used to cope (132). Conclusions: Incurable women constitute a complex challenge as their clinical and social course is not straightforward. They need extensive counseling outlining the nature of their injuries to reduce morbidity and help them cope with their incontinence. O232 PREVALENCE AND OUTCOME OF ASYMPTOMATIC PERIPHERAL MALARIA PARASITAEMIA IN PREGNANCY ON MATERNAL HAEMOGLOBIN C.O.U. Esike1 , U.O. Ugochukwu J1 , O. Ezeonu1 , V.E. Egwuatu1 . 1 Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria Objectives: Eleven percent of maternal deaths in Nigeria are attributable to malaria which clearly show the enormous challenge of the disease to the Country. Most cases of malaria in pregnancy are asymptomatic. The prevalence of asymptomatic malaria in pregnancy and its effect on the mother, though acclaimed to be adverse, has never been studied in our area of practice. This work sets out to evaluate this. Patients: Pregnant women in labour. Methods: This was a prospective cross-sectional study that was carried out in the labour ward of Ebonyi State University Teaching Hospital, Abakaliki, Nigeria over an eight month period from January 2008 to September 2008. This study entailed collecting 2ml of blood from a vein in the forearm of asymptomatic, HIVnegative parturients with genotype of AA who had never bled in the index pregnancy or taken antimalaria drugs 2 months prior to presentation who came in labour. Thick and thin blood films were made with the blood which were stained and read in the laboratory by two laboratory scientists dedicated to the research. The haemoglobin concentration was also determined. Ethical clearance was obtained for the project. Results: Forty (21.2%) of the women were primigravidas, 112 (58.8%) were in the para 1–4 group. Ninety six samples out of the 186 samples analysed had malaria parasites; a prevalence rate of 51.6% of malaria parasitaemia in asymptomatic women. Seventy (72.9%) had one plus of malaria parasite, 24 (25%) had two pluses and only 2(2.1%) had 3 pluses. The study population was infested with all the 4 species of plasmodium malaria parasite with eighty three (86.5%) being plasmodium falciparum. Generally, there was no significant difference in the maternal haemoglobin of parturients without peripheral malaria parasitaemia, However parity had effect on maternal haemoglobin of the subjects as the average haemoglobin of parasitized primigravida was 8.8mg/dl against that of non parasitized primigravidas of 10.89mg/dl, a difference of 1.92mg/dl which was statistically significant. There was no significant difference in parasitized and non parasitized multiparas. Conclusions: The prevalence of asymptomatic peripheral blood malaria parasitaemia of 51.6% is high and had a signficiant effect on the haemoglobin of primigravidas. There is need for Obstetricians to intensity all the malaria preventive measures being taken to protect pregnant women whether they are symptomatic or not. This is very compelling especially as it concerns primigravidas.
O230 EMERGENCY OBSTETRIC CARE IN NORWAY H.M. Engjom1 , K. Klungsøyr3 , N.-H. Morken2 , B. Thorsdalen3 , O. Norheim1 . 1 University of Bergen, Department of Public Health and Primary Care, Bergen, Norway; 2 Haukeland University Hospital, Department of Obstetrics and Gynecology, Bergen, Norway; 3 The National Institute of Public Health, Medical Birth Registry of Norway, Bergen, Norway
Two maternal deaths from direct causes were registered in 2009. The regional differences in intrapartum and neonatal mortality are not statistically significant. Maternal morbidity registered in MBRN; intensive care, puerperal sepsis and sepsis during delivery, thromboembolic complications, hemorrhage >1500 ml or transfusion, eclampsia. All women who experience complications will receive appropriate care with a possible delay due to transport.
2.7* 2.2 2.1 2.8 3.1 2.7 2.14 2.70 1.84 1.62 2.78 2.14 17 16.3 17 13.2 18 18.8 2.1 10.4 0.9 1.8 0.8 1.2 1290 575 78 256 85 300 62991 5525 8390 14081 10872 24088 10 6 0 2 0 2 41 (0.8) 9 (1.4) 8 (1.1) 7 (0.7) 8 (0.8) 9 (0.5) 49 5 7 10 10 18 4.852.197 465.619 673.364 1.006.202 936.066 1.770.946 Norway North Region Mid Region West Region South Region East Region
Objectives: To examine short term neonatal outcome of the second twin delivered by cesarean section after vaginal delivery of the first-born twin (combined delivery) and to identify predictors of poor outcome for combined deliveries. Materials: Three year population-based retrospective cohort study of 1254 twin births in Denmark. Methods: The study subjects were divided into 3 groups: Vaginal deliveries, Planned Cesarean deliveries, and Combined deliveries. Data were extracted from medical records, a fetal software program (Astraia) and the National Birth Registry. Short term poor neonatal outcome was measured as 5 min Apgar score ≤7, umbilical cord pH ≤7.10 and admission to neonatal intensive care unit >3 days. Results: Vertex-nonvertex fetal presentations were more prevalent in Combined deliveries than Vaginal deliveries, OR 4.4 (2.5–7.8). Nonvertex second twins born by Combined delivery had a higher risk of Apgar score ≤7 and umbilical cord pH ≤7.10 compared to Vaginal delivery, OR 6.2 (2.1–18) and OR 3.9 (1.6–9.5). Prenatal ultrasound scans were evaluated in Combined deliveries. 48% were vertex-vertex at the latest ultrasound scan (mean GA 34+0), 37% were vertex-vertex at delivery. A higher rate of nonvertex second twins with umbilical cord pH ≤7.10 and admission to NICU >3 days was seen in Vaginal deliveries compared to Planned Cesarean deliveries, OR 4.9 (1.7–13.9) and 0.5 (0.2–0.9). Conclusions: Vertex-nonvertex twins have increased risk of combined delivery. Prenatal ultrasound at 34+0 can predict fetal presentation at delivery. Planned cesarean section gives a better short term neonatal outcome for second nonvertex twins.
Table: WHO EmOC indicators
O229 CESAREAN SECTION FOR THE SECOND TWIN: A POPULATION BASED STUDY OF OCCURRENCE AND OUTCOME L. Engelbrechtsen1 , E. Hoffmann1 , T. Perrin1 , A. Oldenburg2 , A. Tabor2 , L. Skibsted3 . 1 Department of Obstetrics and Gynecology, University hospital Roskilde, Roskilde, Denmark; 2 Department of Fetal Medicine,University hospital Copenhagen, Copenhagen, Denmark; 3 Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
Estimated EmOC institutions Basic OC Deliveries Without Without EmO, Cesarean section Maternal Intrapartum/neonatal need (coverage) institutions 209 EmOC % rate, % morbidity, death rate pr 1000 %
Objectives: We assess the risk of unplanned delivery outside obstetric institutions and describe availability and access to obstetric care in a national setting where the number of institutions declined from 93 in 1980 to 51 in 2009.
Population 1.1.2010
Methods: In the first group of patients we anchored the uterus with a posterior polypropylene mesh, and we suspended this complex to the sacrospinal ligaments bilaterally using a special technique. For repairing of the recto-vaginal fascia we performed “posterior bridge” technique usually associated with perineal body reconstruction. In the second group, we used vaginal hysterectomy with McCall culdoplasty, and if necessary posterior colpoperineoraphy. Results: We evaluated the immediate and three months postoperative results in these two groups. All patients completed questionnaires before and three months after surgery in order to asses the functional improvement. We found that in the first group the anatomical results were better (vaginal posterior fornix completely restored), while in the second one the vaginal vault was descended and mobile (23 out of 29). In both groups we found similar improvements in faecal emptying problems (82% vs 80%), pelvic tension (92% vs 96%) or pelvic pain (80% vs 60%). We discovered in the first group significant improvements in symptoms that are not classically linked to enterocel and posterior compartment defects: nocturia, urgency and frequency (p-value <0.04). Conclusions: This study demonstrates that enterocel repair using alloplastic material provides a better anatomical result than the classic technique. Interestingly we proved that enterocel repair correlates unexpectedly with urinary symptom improvement. Acknowledgement: This paper is supported by the Sectoral Operational Programme Human Resources Development (SOP HRD) 2007–2013, financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/107/1.5/S/82839
S341
S342
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
Methods: Retrospective cohort study of birthplace in or outside obstetric institutions 1979–2009 and of all births in 2009. For 2009 we used the World Health Organisation (WHO) emergency obstetric care (EmOC) indicators with the following classification of institutions; comprehensive emergency obstetric care (CEmOC), basic emergency obstetric care (BEmOC) and basic obstetric care for normal deliveries (Basic OC). Demographic data on estimated travel time to the nearest institution or to EmOC institution was obtained in a cross-sectional study. Calculations were performed with geographic information systems (GIS) software and based on registered address and the national road database. Statistical analyses were performed with Pearson Chi-square test for groups and logistic regression for individual data. Results: The risk of unplanned delivery outside institution in Norway doubled from 1979 to 2009 (OR 1.96; 1.82–2.10). All emergency institutions provide comprehensive care, national and regional indicators are listed in the table. Maternal morbidity was 2.14% nationally. Regional comparisons with the West region and adjusted for age, parity and education show increased risk in the North (OR 1.72; 1.45–2.12) and South (OR 1.75; 1.45–2.12). In five of the 19 counties 10.4–16.6% of the women travel more than one hour to reach an EmOC institution. In six counties 14.4–44.5% of the women travel more than one hour to any obstetric institution, 20–70% travel more than one hour to reach EmOC and 8.7–69% travel more than two hours to reach EmOC. Conclusions: The risk of unplanned delivery outside institutions doubled in the last 30 years. Norway does not meet the estimated need of EmOC coverage nationally and on regional levels. The demographic distribution support a decentralized care model. We found regional variations in maternal outcome and the impact of the present care structure on maternal risk of complications need to be explored further to provide guidance for policy decisions. Materials: National registry based data from the Medical Birth Registry of Norway (MBRN) on 62291 births in 2009 and 1.774.093 births in 1979–2009. National population registry data from Statistics Norway on age and address for women 15–49 years, 1.127.665 women by 1.1.2010. O231 INCURABLE OBSTETRIC FISTULAE: THE SOCIO-CLINICOPATHOLOGY OF 182 CASES G. Esegbona1 . 1 Nomado, London, United Kingdom Objectives: To explore the clinico-pathology of women with an incurable obstetric fistula and explore client perspectives about their incurability. Methods: Women with an incurable fistula under Fistula Foundation Nigeria in Kano. Results: 127 of 182 clinical records revealed varied clinicopathology. 76% (97) of women had sole involvement of the urethra in the form of urethral damage or an urethral vesicovaginal fistula (UVVF). Of these 40% (39) had had at least one repair at centres elsewhere before presenting for help to the specialist fistula unit. 30% (38) of women with clinical records had developed after a successful repair(s) an incurable fistula after further attempts at childbearing. Women had several attempts at repair with 45 not disclosing to providers how many repairs they had before for various s reasons: such as not feeling cured because they were not like they were before (15). Of these 10 had mild leakage but a minimum of 3 repairs with different providers. Women classified themselves as incurable because of their incontinence but also their inability to have intercourse and bear children. During interviews 98 said they had Bahanya (vaginal stenosis). A review of available clinical notes (71) revealed that this was pre-existing in 87% (61) prior to repair. Most of the women (81) felt that if they would prefer a vagina to being continent. As subfertility was cited as a major concern with most women childless (167 women), the index pregnancy having caused the fistula resulting in a stillbirth.
Some women (19) requested needing assistance to get dilators and lubricant ky jelly in order to have intercourse daily. The degree of urinary leakage varied from a little (26) to having to change every 2 hours (127). All women used self- made pads from rags. Pad changes ranged from 4 times (23) to 10–12 times (112) per day. The worst problem was the smell of the pads (156) with 90% having to spend 40% of their daily income and 1–2 hours a day on washing the pads. Substances like bleach used were cited to cause rashes and infections in the genital area(155). Not drinking was also used to cope (132). Conclusions: Incurable women constitute a complex challenge as their clinical and social course is not straightforward. They need extensive counseling outlining the nature of their injuries to reduce morbidity and help them cope with their incontinence. O232 PREVALENCE AND OUTCOME OF ASYMPTOMATIC PERIPHERAL MALARIA PARASITAEMIA IN PREGNANCY ON MATERNAL HAEMOGLOBIN C.O.U. Esike1 , U.O. Ugochukwu J1 , O. Ezeonu1 , V.E. Egwuatu1 . 1 Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria Objectives: Eleven percent of maternal deaths in Nigeria are attributable to malaria which clearly show the enormous challenge of the disease to the Country. Most cases of malaria in pregnancy are asymptomatic. The prevalence of asymptomatic malaria in pregnancy and its effect on the mother, though acclaimed to be adverse, has never been studied in our area of practice. This work sets out to evaluate this. Patients: Pregnant women in labour. Methods: This was a prospective cross-sectional study that was carried out in the labour ward of Ebonyi State University Teaching Hospital, Abakaliki, Nigeria over an eight month period from January 2008 to September 2008. This study entailed collecting 2ml of blood from a vein in the forearm of asymptomatic, HIVnegative parturients with genotype of AA who had never bled in the index pregnancy or taken antimalaria drugs 2 months prior to presentation who came in labour. Thick and thin blood films were made with the blood which were stained and read in the laboratory by two laboratory scientists dedicated to the research. The haemoglobin concentration was also determined. Ethical clearance was obtained for the project. Results: Forty (21.2%) of the women were primigravidas, 112 (58.8%) were in the para 1–4 group. Ninety six samples out of the 186 samples analysed had malaria parasites; a prevalence rate of 51.6% of malaria parasitaemia in asymptomatic women. Seventy (72.9%) had one plus of malaria parasite, 24 (25%) had two pluses and only 2(2.1%) had 3 pluses. The study population was infested with all the 4 species of plasmodium malaria parasite with eighty three (86.5%) being plasmodium falciparum. Generally, there was no significant difference in the maternal haemoglobin of parturients without peripheral malaria parasitaemia, However parity had effect on maternal haemoglobin of the subjects as the average haemoglobin of parasitized primigravida was 8.8mg/dl against that of non parasitized primigravidas of 10.89mg/dl, a difference of 1.92mg/dl which was statistically significant. There was no significant difference in parasitized and non parasitized multiparas. Conclusions: The prevalence of asymptomatic peripheral blood malaria parasitaemia of 51.6% is high and had a signficiant effect on the haemoglobin of primigravidas. There is need for Obstetricians to intensity all the malaria preventive measures being taken to protect pregnant women whether they are symptomatic or not. This is very compelling especially as it concerns primigravidas.