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O399 Differential diagnostic performance of MR in the detection of lymph node metastases in early-stage cervical cancer patients
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
Objectives: To study: demographics of ALSO instructors; commitment to ALSO; perceived changes in confidence, ability and motivation; and before and after change in knowledge, skills and attitude. Methods: This is an observational cross-sectional study conducted in Sudan, targeting ALSO instructors trained between Feb 04-Feb 09. A structured questionnaire was used for data collection from all 45 instructors currently residing in Sudan. Data were analyzed using STATA Statistical software. Results: Male to female ratio is 1:1, 42% over 40 and 55% less than 40 years. Majority are consultants 27%, 67% from Khartoum, and the rest from other states. 96% would commit to continue as instructors. 76% are a lot more confident in managing post partum haemorrhage, 71% for shoulder dystocia and 69% for breech delivery. 95% feel more able to manage obstetric emergencies. 64% are motivated to teach what was learnt to their colleagues/students, 47% would always use course manual as a reference and 76% would always/frequently utilize the pneumonics in clinical practice. In respect to ‘before and after’ change, 49% felt that their knowledge changed a lot, in contrast to 73% for skills and 78% for attitude. Conclusion: Instructors perceived themselves as much more confident in managing obstetric emergencies. An enhanced capability in teaching, acquired knowledge and skills were stated. There was a widespread use of the ALSO pneumonics in practical settings. More than 50% of instructors anticipate high impact on maternal and neonatal mortality and morbidity. O396 “ECV” – Today’s place in breech presentation T. Hymakr. Narayana Medical College Hospital Objectives: Breech presentation complicates 3–4% of all term deliveries and a higher proportion of preterm deliveries. The incidence of Caesarean section for breech presentation has increased markedly in the last two decades and further1 with the publication of the term breech trial which.concluded that, elective Caesarean section was safer for the fetus and of similar safety to the mother when compared with vaginal delivery. The objective of this presentation is to insist that External cephalic version (ECV) has still a place in reducing breech associated morbidity, mortality & overall Caeserean section rate ECV at term reduces the incidence of non cephalic presentation at delivery Attempting ECV lowers the chances of Caesarean section. An overall success rate of 40% for nulliparous, and 60% for multiparous women can usually be achieved. There are few absolute and relative contraindications to ECV. Tocolytics may be indicated in some cases as it has been shown to increase the success rate. Materials and Methods: Present study (Jan 2005-Dec2007) was done in our hospital a tertiary care centre. ECV was done in all breech cases taking the various factors into like gestational age, parity and type of breech etc. Results: The success rate of ECV in our study was found to be quite satisfactory (85%). The Caeserean section rate in these cases was reduced thereby. Conclusions: Local policies should be implemented to actively increase the number of women offered and undergoing ECV to bring down the breech associated morbidity and mortality ECV has a very low complication rate. women should be alerted to potential complications. ECV should be performed where facilities for monitoring and immediate delivery are available. O397 “Cerebral palsy” – Who is responsible? T. Hymakrm, H. Kaliki. 1 NMC Hospitals Objective: Cerebral palsy (CP) is defined as a group of non progressive disorders of movements or posture due to a defect or lesion of the developing brain. Events during labour and delivary
S205
notably trauma and asphyxia have long been thought to be possible causes of CP.. This paper discusses what is known and what is not known about the asphyxia-CP relationship and also to what extent directly or indirectly an obstetrician is responsible? The extent to which obstetric care can be claimed as responsible for abnormal fetal outcome has been markedly over estimated and has resulted in the justification of possibly unnecessary obstetric interventions and a most detrimental rise in litigation Research has shown that birth prevalence has not fallen as anticipated with the widespread introduction of new technologies aimed at reducing birth asphyxia. It has also been shown that there are many causes and causal sequences which result in CP and Wheather obstetric care could prevent such cases is still unknown. It is very difficult to prove the specific cause of CP in any one case. Conclusions: There may be many routes to spastic CP, each contributing only a small proportion and many routes may be multi factorial with most commencing before delivary. It is felt thrrerefore unlikely that any single preventive activity will significantly reduce CP rates. Many agree that most full term CP children without obvious intrapartum or postpartum events (the majority) probably experienced their brain damaging effect ante-natally. O398 “Total hysterectomy” – An avoidable epidemic R. Hymavathi. Narayana Medical College Hospital Objective: Hysterectomy remains the commonest major operation in gynaecological surgery. There has been an increasing awareness of and research into the sequelae of total hysterectomy (TH). While arguments continue about the most advantageous type of operation, the real question is whether the cervix should be removed or preserved when hysterectomy is performed for benign indications. Attention has been focused on the possibility of anatomical and neurophysiological disruptions induced by TH. Teleologically it is reasonable to suppose that the more conservative procedures might have advantages. It is clear that subtotal hysterectomy (STH) is not a popular option, but there are number of reasons why views may have to change. The increased risks associated with TH but minimized by STH might persuade some to consider whether the former operation is always necessary especially in the present climate of medical litigation. Finally there is growing interest in this issue and it may be only a matter of time before women start demanding one or other operation. Minimal access surgery with all it’s advantages is gaining increasing interest. Should STH turnout to be advantageous over TH then the optimal procedure may well turnout to be laparoscopic assisted subtotal hysterectomy (LASTH). Conclusions: Any changes in surgical practice should be based on scientific evidence rather than fashion. It is clear that the paucity of data on which rational discussions can be made and the much wanted goal of evidence based medicine will remain a dream until the issues in question are resolved by prospective randomized and appropriately blinded studies of sufficient power. O399 Differential diagnostic performance of MR in the detection of lymph node metastases in early-stage cervical cancer patients C. Hyuck Jae1 , H. Kil-Sun. 1 Department of radiology, Asan medical center Purpose: The objective of this study is to evaluate the diagnostic performance in managing early-stage cervical cancer according to the FIGO stage or tumor size. Patients and Methods: We performed a retrospective review of patients with FIGO stage IB1-IIA cervical carcinoma who underwent magnetic resonance imaging (MRI) before lymphadenectomy. Lymphadenectomy involved all visible lymph nodes in the surgical
S206
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
fields. We compared the accuracy of MRI for detecting metastatic lymph nodes in the FIGO IB group and the FIGO IIA group and in the non-bulky (≤4 cm) and bulky (>4) tumor groups. Chi-square analysis was used to compare the accuracy of MRI for detecting metastatic lymph nodes. A p value ≤0.05 was considered statistically significant. Results: Three hundred and five patients were included. Lymph node metastases were present in 49 (16.1%) of these patients. The sensitivity, specificity, and positive and negative predictive values were 7%, 99.3%, 31.3%, and 95.8% in the non-bulky tumor group and 43.8%, 97.1%, 70%, and 91.8% in the bulky tumor group (p values were 0.001, 0.0097, 0.0479, and 0.0142, respectively). Conclusion: For predicting lymph node metastasis with MRI in early-stage cervical cancer patients, MRI showed a higher diagnostic performance in the bulky tumor group compared with that in the non-bulky tumor group and had low value in non-bulky tumor group, even when accounting for FIGO stage. O400 Management of changing fetal activity pattern at Stafford General Hospital, United Kingdom A. Ibrahim, F. Saeed Abdul Hakim, K. Powell. Stafford General Hospital, United Kingdom Objectives: To audit the management of changing fetal activity pattern and to evaluate the current Maternity Unit guidelines at a District General Hospital in the United Kingdom. Materials and Methods: Patients with changes in fetal activity pattern were identified using the Maternity Delivery Statistic forms from June to September 2008. This retrospective study included 50 patients. Data was collected from case notes using a predesigned proforma and analysed using SPSS. Results: Of the total 50 patients with changes in fetal activity pattern, 45 had reduced fetal movements and 5 had absent fetal movements. 66% of patients had been investigated using Sonicaid, 90% had Cardiotocography (CTG) and 80% had Ultrasound scan (USS). Of the 80% (40/50) of patients who had USS, 33 patients had normal USS, whilst 7 patients had abnormal USS. All patients with abnormal USS had risk factors except two. None of the patients who had a normal CTG had an abnormal USS. The nulliparous and primigravids most frequently presented with reduced fetal movements. Conclusions: Current Unit guidlines assesses patients with changes in fetal activity pattern by using both CTG and USS. In this study patients with reduced fetal movements and abnormal USS had risk factors like advanced age, smoking, diabetes, hypertension/eclampsia and high BMI. We recommend that patients admitted with changes in fetal activity pattern without risk factors should be assessed by CTG. If the CTG is normal and fetal movements are felt then plan for discharge. If patients present with recurrent episodes of reduced fetal movements or have risk factors then they should be assessed by CTG and USS. O392 Knowledge, attitude and practice of family planning amongst women attending antenatal clinic in Aminu Kano Teaching Hospital, Kano S. Ibrahim, Z. Muhammad, I. Abubakar. Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria Objective: This study is designed to determine the knowledge, attitude and practice of family planning amongst pregnant women attending antenatal clinic in Aminu Kano Teaching Hospital, Kano. Methodology: A standardized structured questionnaire was administered by trained interviewers on the women attending antenatal clinic in the facility over a period of 3 days from January to June 2006. the designed questionnaire contains biosocial
characteristics of the respondents, reproductive health knowledge, and knowledge, use and attitude towards family planning. Result: The mean age of the respondents was 27.85 years (±5.47sd). Hausa/Fulani constituted 53.3% of the respondents. Sixty six percent were Muslins, Christians constituted 34%. Fifty seven Pont one percent of the women have a degree of diploma. Fifty eight percent believe family planning is the best way of prevent unwanted pregnancy band 55.3% knows what the fertile period is. Knowledge of modern family planning method is high (93.7%) but the practice is low (35.0) mostly because of fears for health concern (48.7). The commonest method practiced was oral pills (25.1%) while abstinence was the least (1.5%). Conclusion: Majority of the women attending antenatal clinic in the facility were literate and their knowledge of family planning was high but the practice is low. O401 Laparoscopic evaluation of infertile women in Teaching Hospital, Kano, Nigeria: An update S.A. Ibrahim, I.A. Yakasai, I.S. Abubakar. Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria Objectives: To determine the type of infertility, laparoscopic findings and complications in women that had laparoscopy and dye test for evaluation of infertility in Aminu Kano Teaching Hospital, Kano. Methodology: The case files of women that had laparoscopy and dye test in AKTH Kano between January 2002 and June, 2007 were retrieved and analysed. Results: In this study, we report the laparoscopic findings of 190 consecutive infertile women in the Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospitalk, Kano. Secondary infertility constituted 56%, while primary infertility was 44%. Tubal disease was found in 37% of cases with bilateral tubal occlusion in 26%. Two patients were found to have typical violin string perihepatic adhesions and one had endometriosis. Uterine fibroids were found in 18% of cases; ovarian cysts 3% and streak gonads 7%. The complication rate was 2% and there was no mortality. Conclusion: Laparoscopy is the gold standard for the evaluation of tubo-peritoneal factors in female infertility and complication rate is low in experienced hands. O402 Acute splenic sequestration in pregnant woman with homozygous sickle cell disease A. Igai1 , R. Nomura1 , C. Maia1 , G. Fonseca2 , S. Gualandro2 , M. Zugaib1 . 1 Department of Obstetrics and Gynecology, Faculty of Medicine, University of S˜ ao Paulo, 2 Department of Hematology, Faculty of Medicine, University of S˜ ao Paulo Acute splenic sequestration is a life threatening event that is characteristic for sickle cell disease (SCD) and generally occurs in children up to 6 years old. It is rarely reported in adults, and whether it occurs, the underlying disease is almost always a mixed heterozygous SCD (SC or S-Beta thalassemia). We believe that the present case is very important because acute splenic sequestration crisis was not reported before during pregnancy. Case report: A 25 year old woman, gesta 2, para 1 (1 previous cesarean), with homozygous SCD (HbS 82.2%, HbF 15.1%, HbA 22.7%), was admitted at 32 weeks’ gestation with weakness, fever and worsening anemia. Her temperature was 38ºC, pulse 115 bpm, blood pressure 120/80 mmHg, and fetal heart rate 144 bpm. The spleen was easily palpable 4 cm below the left costal margin. The hemoglobin (Hb) count was 2.4 g/dL, hematocrit (Ht) 7.8%, white blood cell (WBC) count 17.8×103 /mm3, platelet fells to 84,000/mm3, total bilirrubin 3.63 mg/dL, and lactic dehydrogenase (DHL) 1,661 U/L. Five units of packed red cells were transfused. The pregnancy progressed well, ultrasound revealed normal fetal
Objectives: To study: demographics of ALSO instructors; commitment to ALSO; perceived changes in confidence, ability and motivation; and before and after change in knowledge, skills and attitude. Methods: This is an observational cross-sectional study conducted in Sudan, targeting ALSO instructors trained between Feb 04-Feb 09. A structured questionnaire was used for data collection from all 45 instructors currently residing in Sudan. Data were analyzed using STATA Statistical software. Results: Male to female ratio is 1:1, 42% over 40 and 55% less than 40 years. Majority are consultants 27%, 67% from Khartoum, and the rest from other states. 96% would commit to continue as instructors. 76% are a lot more confident in managing post partum haemorrhage, 71% for shoulder dystocia and 69% for breech delivery. 95% feel more able to manage obstetric emergencies. 64% are motivated to teach what was learnt to their colleagues/students, 47% would always use course manual as a reference and 76% would always/frequently utilize the pneumonics in clinical practice. In respect to ‘before and after’ change, 49% felt that their knowledge changed a lot, in contrast to 73% for skills and 78% for attitude. Conclusion: Instructors perceived themselves as much more confident in managing obstetric emergencies. An enhanced capability in teaching, acquired knowledge and skills were stated. There was a widespread use of the ALSO pneumonics in practical settings. More than 50% of instructors anticipate high impact on maternal and neonatal mortality and morbidity. O396 “ECV” – Today’s place in breech presentation T. Hymakr. Narayana Medical College Hospital Objectives: Breech presentation complicates 3–4% of all term deliveries and a higher proportion of preterm deliveries. The incidence of Caesarean section for breech presentation has increased markedly in the last two decades and further1 with the publication of the term breech trial which.concluded that, elective Caesarean section was safer for the fetus and of similar safety to the mother when compared with vaginal delivery. The objective of this presentation is to insist that External cephalic version (ECV) has still a place in reducing breech associated morbidity, mortality & overall Caeserean section rate ECV at term reduces the incidence of non cephalic presentation at delivery Attempting ECV lowers the chances of Caesarean section. An overall success rate of 40% for nulliparous, and 60% for multiparous women can usually be achieved. There are few absolute and relative contraindications to ECV. Tocolytics may be indicated in some cases as it has been shown to increase the success rate. Materials and Methods: Present study (Jan 2005-Dec2007) was done in our hospital a tertiary care centre. ECV was done in all breech cases taking the various factors into like gestational age, parity and type of breech etc. Results: The success rate of ECV in our study was found to be quite satisfactory (85%). The Caeserean section rate in these cases was reduced thereby. Conclusions: Local policies should be implemented to actively increase the number of women offered and undergoing ECV to bring down the breech associated morbidity and mortality ECV has a very low complication rate. women should be alerted to potential complications. ECV should be performed where facilities for monitoring and immediate delivery are available. O397 “Cerebral palsy” – Who is responsible? T. Hymakrm, H. Kaliki. 1 NMC Hospitals Objective: Cerebral palsy (CP) is defined as a group of non progressive disorders of movements or posture due to a defect or lesion of the developing brain. Events during labour and delivary
S205
notably trauma and asphyxia have long been thought to be possible causes of CP.. This paper discusses what is known and what is not known about the asphyxia-CP relationship and also to what extent directly or indirectly an obstetrician is responsible? The extent to which obstetric care can be claimed as responsible for abnormal fetal outcome has been markedly over estimated and has resulted in the justification of possibly unnecessary obstetric interventions and a most detrimental rise in litigation Research has shown that birth prevalence has not fallen as anticipated with the widespread introduction of new technologies aimed at reducing birth asphyxia. It has also been shown that there are many causes and causal sequences which result in CP and Wheather obstetric care could prevent such cases is still unknown. It is very difficult to prove the specific cause of CP in any one case. Conclusions: There may be many routes to spastic CP, each contributing only a small proportion and many routes may be multi factorial with most commencing before delivary. It is felt thrrerefore unlikely that any single preventive activity will significantly reduce CP rates. Many agree that most full term CP children without obvious intrapartum or postpartum events (the majority) probably experienced their brain damaging effect ante-natally. O398 “Total hysterectomy” – An avoidable epidemic R. Hymavathi. Narayana Medical College Hospital Objective: Hysterectomy remains the commonest major operation in gynaecological surgery. There has been an increasing awareness of and research into the sequelae of total hysterectomy (TH). While arguments continue about the most advantageous type of operation, the real question is whether the cervix should be removed or preserved when hysterectomy is performed for benign indications. Attention has been focused on the possibility of anatomical and neurophysiological disruptions induced by TH. Teleologically it is reasonable to suppose that the more conservative procedures might have advantages. It is clear that subtotal hysterectomy (STH) is not a popular option, but there are number of reasons why views may have to change. The increased risks associated with TH but minimized by STH might persuade some to consider whether the former operation is always necessary especially in the present climate of medical litigation. Finally there is growing interest in this issue and it may be only a matter of time before women start demanding one or other operation. Minimal access surgery with all it’s advantages is gaining increasing interest. Should STH turnout to be advantageous over TH then the optimal procedure may well turnout to be laparoscopic assisted subtotal hysterectomy (LASTH). Conclusions: Any changes in surgical practice should be based on scientific evidence rather than fashion. It is clear that the paucity of data on which rational discussions can be made and the much wanted goal of evidence based medicine will remain a dream until the issues in question are resolved by prospective randomized and appropriately blinded studies of sufficient power. O399 Differential diagnostic performance of MR in the detection of lymph node metastases in early-stage cervical cancer patients C. Hyuck Jae1 , H. Kil-Sun. 1 Department of radiology, Asan medical center Purpose: The objective of this study is to evaluate the diagnostic performance in managing early-stage cervical cancer according to the FIGO stage or tumor size. Patients and Methods: We performed a retrospective review of patients with FIGO stage IB1-IIA cervical carcinoma who underwent magnetic resonance imaging (MRI) before lymphadenectomy. Lymphadenectomy involved all visible lymph nodes in the surgical
S206
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
fields. We compared the accuracy of MRI for detecting metastatic lymph nodes in the FIGO IB group and the FIGO IIA group and in the non-bulky (≤4 cm) and bulky (>4) tumor groups. Chi-square analysis was used to compare the accuracy of MRI for detecting metastatic lymph nodes. A p value ≤0.05 was considered statistically significant. Results: Three hundred and five patients were included. Lymph node metastases were present in 49 (16.1%) of these patients. The sensitivity, specificity, and positive and negative predictive values were 7%, 99.3%, 31.3%, and 95.8% in the non-bulky tumor group and 43.8%, 97.1%, 70%, and 91.8% in the bulky tumor group (p values were 0.001, 0.0097, 0.0479, and 0.0142, respectively). Conclusion: For predicting lymph node metastasis with MRI in early-stage cervical cancer patients, MRI showed a higher diagnostic performance in the bulky tumor group compared with that in the non-bulky tumor group and had low value in non-bulky tumor group, even when accounting for FIGO stage. O400 Management of changing fetal activity pattern at Stafford General Hospital, United Kingdom A. Ibrahim, F. Saeed Abdul Hakim, K. Powell. Stafford General Hospital, United Kingdom Objectives: To audit the management of changing fetal activity pattern and to evaluate the current Maternity Unit guidelines at a District General Hospital in the United Kingdom. Materials and Methods: Patients with changes in fetal activity pattern were identified using the Maternity Delivery Statistic forms from June to September 2008. This retrospective study included 50 patients. Data was collected from case notes using a predesigned proforma and analysed using SPSS. Results: Of the total 50 patients with changes in fetal activity pattern, 45 had reduced fetal movements and 5 had absent fetal movements. 66% of patients had been investigated using Sonicaid, 90% had Cardiotocography (CTG) and 80% had Ultrasound scan (USS). Of the 80% (40/50) of patients who had USS, 33 patients had normal USS, whilst 7 patients had abnormal USS. All patients with abnormal USS had risk factors except two. None of the patients who had a normal CTG had an abnormal USS. The nulliparous and primigravids most frequently presented with reduced fetal movements. Conclusions: Current Unit guidlines assesses patients with changes in fetal activity pattern by using both CTG and USS. In this study patients with reduced fetal movements and abnormal USS had risk factors like advanced age, smoking, diabetes, hypertension/eclampsia and high BMI. We recommend that patients admitted with changes in fetal activity pattern without risk factors should be assessed by CTG. If the CTG is normal and fetal movements are felt then plan for discharge. If patients present with recurrent episodes of reduced fetal movements or have risk factors then they should be assessed by CTG and USS. O392 Knowledge, attitude and practice of family planning amongst women attending antenatal clinic in Aminu Kano Teaching Hospital, Kano S. Ibrahim, Z. Muhammad, I. Abubakar. Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria Objective: This study is designed to determine the knowledge, attitude and practice of family planning amongst pregnant women attending antenatal clinic in Aminu Kano Teaching Hospital, Kano. Methodology: A standardized structured questionnaire was administered by trained interviewers on the women attending antenatal clinic in the facility over a period of 3 days from January to June 2006. the designed questionnaire contains biosocial
characteristics of the respondents, reproductive health knowledge, and knowledge, use and attitude towards family planning. Result: The mean age of the respondents was 27.85 years (±5.47sd). Hausa/Fulani constituted 53.3% of the respondents. Sixty six percent were Muslins, Christians constituted 34%. Fifty seven Pont one percent of the women have a degree of diploma. Fifty eight percent believe family planning is the best way of prevent unwanted pregnancy band 55.3% knows what the fertile period is. Knowledge of modern family planning method is high (93.7%) but the practice is low (35.0) mostly because of fears for health concern (48.7). The commonest method practiced was oral pills (25.1%) while abstinence was the least (1.5%). Conclusion: Majority of the women attending antenatal clinic in the facility were literate and their knowledge of family planning was high but the practice is low. O401 Laparoscopic evaluation of infertile women in Teaching Hospital, Kano, Nigeria: An update S.A. Ibrahim, I.A. Yakasai, I.S. Abubakar. Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria Objectives: To determine the type of infertility, laparoscopic findings and complications in women that had laparoscopy and dye test for evaluation of infertility in Aminu Kano Teaching Hospital, Kano. Methodology: The case files of women that had laparoscopy and dye test in AKTH Kano between January 2002 and June, 2007 were retrieved and analysed. Results: In this study, we report the laparoscopic findings of 190 consecutive infertile women in the Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospitalk, Kano. Secondary infertility constituted 56%, while primary infertility was 44%. Tubal disease was found in 37% of cases with bilateral tubal occlusion in 26%. Two patients were found to have typical violin string perihepatic adhesions and one had endometriosis. Uterine fibroids were found in 18% of cases; ovarian cysts 3% and streak gonads 7%. The complication rate was 2% and there was no mortality. Conclusion: Laparoscopy is the gold standard for the evaluation of tubo-peritoneal factors in female infertility and complication rate is low in experienced hands. O402 Acute splenic sequestration in pregnant woman with homozygous sickle cell disease A. Igai1 , R. Nomura1 , C. Maia1 , G. Fonseca2 , S. Gualandro2 , M. Zugaib1 . 1 Department of Obstetrics and Gynecology, Faculty of Medicine, University of S˜ ao Paulo, 2 Department of Hematology, Faculty of Medicine, University of S˜ ao Paulo Acute splenic sequestration is a life threatening event that is characteristic for sickle cell disease (SCD) and generally occurs in children up to 6 years old. It is rarely reported in adults, and whether it occurs, the underlying disease is almost always a mixed heterozygous SCD (SC or S-Beta thalassemia). We believe that the present case is very important because acute splenic sequestration crisis was not reported before during pregnancy. Case report: A 25 year old woman, gesta 2, para 1 (1 previous cesarean), with homozygous SCD (HbS 82.2%, HbF 15.1%, HbA 22.7%), was admitted at 32 weeks’ gestation with weakness, fever and worsening anemia. Her temperature was 38ºC, pulse 115 bpm, blood pressure 120/80 mmHg, and fetal heart rate 144 bpm. The spleen was easily palpable 4 cm below the left costal margin. The hemoglobin (Hb) count was 2.4 g/dL, hematocrit (Ht) 7.8%, white blood cell (WBC) count 17.8×103 /mm3, platelet fells to 84,000/mm3, total bilirrubin 3.63 mg/dL, and lactic dehydrogenase (DHL) 1,661 U/L. Five units of packed red cells were transfused. The pregnancy progressed well, ultrasound revealed normal fetal