- Email: [email protected]
I242 MILD OVARIAN STIMULATION
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
(quality of certification, adequacy of coding). The effectiveness of vital registration and surveillance at identifying maternal deaths are compared. Findings: Of 51 maternal deaths, 29% (10) were not registered/ registered late. Of the 41 registered deaths, 15% (6) of doctors did not note the fact of pregnancy, however the greatest source of data loss was that 68% (28) of adequately certified deaths were not coded to a maternal cause. While surveillance had identified 84% of maternal deaths, vital registration only effectively identified 20% of events (n = 10). Conclusion: Vital registration missed 80% of maternal deaths. Coders need to be trained to manually code maternal deaths and need opportunities to gain experience coding these rare events. Strategies are needed to improve the timely registration of sudden deaths occurring outside facilities. Surveillance needs to improve the identification of deaths in non-obstetric areas of hospitals (ICU, A&E etc). The new WHO guidelines (ICD-MM) will help address the sources of misclassification of maternal deaths identified. I239 MODERN SURGICAL MANAGEMENT I. Meinhold-Heerlein Epithelial ovarian cancer confers the leading cause of death among all gynaecological malignancies, mainly for two reasons: the failure of an early detection method and the frequency of chemotherapy resistance. Since the patient’s prognosis depends on the complete tumour debulking, the adequate surgical management is mandatory. The involvement of a gynaecologic oncologist – preferably embedded in an interdisciplinary team – enhances the portion of optimal debulked cases. The Gynaecologic Oncology group (GOG) currently defines ‘optimal debulking’ when a residual tumour size of 1 cm or less is achieved, whereby the complete cytoreduction without macroscopic residues includes the best prognosis and should be classified as an optimal debulking. Ovarian cancer tends to spread throughout the abdominal cavity. Even in putative early stage cases abdominal metastases may occur. Therefore, the open surgery via midline incision enabling the surgeon to carefully investigate the whole abdominal cavity remains the standard for invasive cancers of all stages. The role of minimally invasive approaches is controversially discussed. Before neoadjuvant chemotherapy, a biopsy is taken laparoscopically. It is technically feasible to perform a complete staging operation for early stage invasive tumours minimally invasive, although the prognostic similarity has not been shown so far. Early stage borderline tumours can be treated laparoscopically with results comparable to open surgery. Laparoscopy is used to remove suspicious ovarian tumours or to further diagnose a CUP syndrome. If the same oncological principles are considered than in open surgery, laparoscopy or even robotic surgery is safe and adds a fundamental benefit to the patient. I240 MANAGEMENT OF PTL/PPROM B.M. Mercer Acute preterm labor (PTL) and premature rupture of the membranes (pPROM) are pregnancy complications that result in considerable perinatal morbidity and mortality, and carry the potential for life-long sequelae. While in many cases, delivery is inevitable or required once the patient arrives with these complications, specific treatments including antenatal corticosteroid therapy and transfer to a teriary care institution can improve newborn outcomes in some cases of PTL and PROM. Antibiotic administration can prolong pregnancy and reduce newborn complications in selected cases of pPROM. When delivery is inevitable, additional interventions, such as magnesium sulfate for neuroprotection and intrapartum GBS prophylaxis, can be helpful. It is important that the diagnosis of
S221
PTL and PROM be made accurately, and that fetal/maternal status and gestational age be considered when interventions to prolong pregnancy or pursue early delivery are considered for these women. In this session, we discuss current issues in the diagnosis and management of preterm labor and preterm premature rupture of the membranes. I241 WHY MISOROSTOL IS THE RIGHT ANSWER RIGHT NOW FOR PREVENTION OF PPH IN SOUTH SUDAN A.M. Mergani South Sudan (SS), the world’s newest country has recently celebrated its second independence day. 5 decades of war rendered the health care system grossly non-functional and the Government of the Republic of SS has begun efforts to strengthen the system and provide a minimum package of health care services to the predominantly rural and diverse population through support of donors and international partners. With the world’s highest Maternal Mortality Ratio (2054/100,000 live births) largely due to Postpartum Hemorrhage (PPH) and 80% of births occurring at home, the Ministry of Health (MOH) has committed to a program for PPH prevention, regardless of where women deliver.’ The MOH, in partnership with MCHIP, SHTP-II, SIAPs, and VSI (funded by USAID) is implementing the learning phase of a community-based misoprostol distribution programme by Home Health Promoters (HHPs) in two counties in Western Equatoria State. Building on misoprostol’s demonstrated effectiveness in reducing PPH cases, the combined facility and community-focused programme for prevention of PPH includes training of skilled birth attendants (SBA) to strengthen the provision of active management of third stage of labour at health facility level; and distribution of misoprostol to pregnant women during ANC visits at 32nd weeks of gestation by providers and at home by HHPs. Women will selfadminister the drug if they are unable to deliver at the health facility or with a SBA. In all 1660 pregnant women will be reached during the six months of the first phase and the lessons learned will inform ongoing scale up and expansion. I242 MILD OVARIAN STIMULATION I.E. Messinis. Department of Obstetrics and Gynaecology, University of Thessalia, Medical School, Larissa, Greece Ovarian stimulation is frequently used in IVF programmes. The aim is to retrieve more than one fertilizable oocyte, so that a certain number of embryos would be available for transfer, increasing thus the chance of a pregnancy. Nevertheless, induction of multiple follicular development disturbs the endocrinology of the menstrual cycle and may increase the risk of the ovarian hyper-stimulation syndrome (OHSS) and multiple pregnancies. To reduce the possibility of these two complications, milder ovarian stimulation protocols were introduced in clinical practice during the last decade. These protocols aim to obtain fewer than eight oocytes, decreasing thus patients’ discomfort. Lower dosages of FSH are used than in conventional protocols starting usually in the midfollicular phase of the cycle in conjunction with a GnRH antagonist. Preliminary evidence has shown that with such protocols the treatment outcome even after single embryo transfer is comparable to that achieved with conventional protocols involving long GnRH agonist regimens. A patient’s friendly approach is also the use of clomiphene citrate followed by low-dose gonadotrophins and a GnRH antagonist. With mild ovarian stimulation protocols, high and low responders may benefit possibly via the reduction of the cost and the rate of complications. So far, only a few studies have investigated the role of minimal-mild ovarian stimulation in IVF. Well designed randomized controlled trials are required to clarify further the advantages of this approach in decreasing the cost and increasing the tolerability of IVF treatment.
(quality of certification, adequacy of coding). The effectiveness of vital registration and surveillance at identifying maternal deaths are compared. Findings: Of 51 maternal deaths, 29% (10) were not registered/ registered late. Of the 41 registered deaths, 15% (6) of doctors did not note the fact of pregnancy, however the greatest source of data loss was that 68% (28) of adequately certified deaths were not coded to a maternal cause. While surveillance had identified 84% of maternal deaths, vital registration only effectively identified 20% of events (n = 10). Conclusion: Vital registration missed 80% of maternal deaths. Coders need to be trained to manually code maternal deaths and need opportunities to gain experience coding these rare events. Strategies are needed to improve the timely registration of sudden deaths occurring outside facilities. Surveillance needs to improve the identification of deaths in non-obstetric areas of hospitals (ICU, A&E etc). The new WHO guidelines (ICD-MM) will help address the sources of misclassification of maternal deaths identified. I239 MODERN SURGICAL MANAGEMENT I. Meinhold-Heerlein Epithelial ovarian cancer confers the leading cause of death among all gynaecological malignancies, mainly for two reasons: the failure of an early detection method and the frequency of chemotherapy resistance. Since the patient’s prognosis depends on the complete tumour debulking, the adequate surgical management is mandatory. The involvement of a gynaecologic oncologist – preferably embedded in an interdisciplinary team – enhances the portion of optimal debulked cases. The Gynaecologic Oncology group (GOG) currently defines ‘optimal debulking’ when a residual tumour size of 1 cm or less is achieved, whereby the complete cytoreduction without macroscopic residues includes the best prognosis and should be classified as an optimal debulking. Ovarian cancer tends to spread throughout the abdominal cavity. Even in putative early stage cases abdominal metastases may occur. Therefore, the open surgery via midline incision enabling the surgeon to carefully investigate the whole abdominal cavity remains the standard for invasive cancers of all stages. The role of minimally invasive approaches is controversially discussed. Before neoadjuvant chemotherapy, a biopsy is taken laparoscopically. It is technically feasible to perform a complete staging operation for early stage invasive tumours minimally invasive, although the prognostic similarity has not been shown so far. Early stage borderline tumours can be treated laparoscopically with results comparable to open surgery. Laparoscopy is used to remove suspicious ovarian tumours or to further diagnose a CUP syndrome. If the same oncological principles are considered than in open surgery, laparoscopy or even robotic surgery is safe and adds a fundamental benefit to the patient. I240 MANAGEMENT OF PTL/PPROM B.M. Mercer Acute preterm labor (PTL) and premature rupture of the membranes (pPROM) are pregnancy complications that result in considerable perinatal morbidity and mortality, and carry the potential for life-long sequelae. While in many cases, delivery is inevitable or required once the patient arrives with these complications, specific treatments including antenatal corticosteroid therapy and transfer to a teriary care institution can improve newborn outcomes in some cases of PTL and PROM. Antibiotic administration can prolong pregnancy and reduce newborn complications in selected cases of pPROM. When delivery is inevitable, additional interventions, such as magnesium sulfate for neuroprotection and intrapartum GBS prophylaxis, can be helpful. It is important that the diagnosis of
S221
PTL and PROM be made accurately, and that fetal/maternal status and gestational age be considered when interventions to prolong pregnancy or pursue early delivery are considered for these women. In this session, we discuss current issues in the diagnosis and management of preterm labor and preterm premature rupture of the membranes. I241 WHY MISOROSTOL IS THE RIGHT ANSWER RIGHT NOW FOR PREVENTION OF PPH IN SOUTH SUDAN A.M. Mergani South Sudan (SS), the world’s newest country has recently celebrated its second independence day. 5 decades of war rendered the health care system grossly non-functional and the Government of the Republic of SS has begun efforts to strengthen the system and provide a minimum package of health care services to the predominantly rural and diverse population through support of donors and international partners. With the world’s highest Maternal Mortality Ratio (2054/100,000 live births) largely due to Postpartum Hemorrhage (PPH) and 80% of births occurring at home, the Ministry of Health (MOH) has committed to a program for PPH prevention, regardless of where women deliver.’ The MOH, in partnership with MCHIP, SHTP-II, SIAPs, and VSI (funded by USAID) is implementing the learning phase of a community-based misoprostol distribution programme by Home Health Promoters (HHPs) in two counties in Western Equatoria State. Building on misoprostol’s demonstrated effectiveness in reducing PPH cases, the combined facility and community-focused programme for prevention of PPH includes training of skilled birth attendants (SBA) to strengthen the provision of active management of third stage of labour at health facility level; and distribution of misoprostol to pregnant women during ANC visits at 32nd weeks of gestation by providers and at home by HHPs. Women will selfadminister the drug if they are unable to deliver at the health facility or with a SBA. In all 1660 pregnant women will be reached during the six months of the first phase and the lessons learned will inform ongoing scale up and expansion. I242 MILD OVARIAN STIMULATION I.E. Messinis. Department of Obstetrics and Gynaecology, University of Thessalia, Medical School, Larissa, Greece Ovarian stimulation is frequently used in IVF programmes. The aim is to retrieve more than one fertilizable oocyte, so that a certain number of embryos would be available for transfer, increasing thus the chance of a pregnancy. Nevertheless, induction of multiple follicular development disturbs the endocrinology of the menstrual cycle and may increase the risk of the ovarian hyper-stimulation syndrome (OHSS) and multiple pregnancies. To reduce the possibility of these two complications, milder ovarian stimulation protocols were introduced in clinical practice during the last decade. These protocols aim to obtain fewer than eight oocytes, decreasing thus patients’ discomfort. Lower dosages of FSH are used than in conventional protocols starting usually in the midfollicular phase of the cycle in conjunction with a GnRH antagonist. Preliminary evidence has shown that with such protocols the treatment outcome even after single embryo transfer is comparable to that achieved with conventional protocols involving long GnRH agonist regimens. A patient’s friendly approach is also the use of clomiphene citrate followed by low-dose gonadotrophins and a GnRH antagonist. With mild ovarian stimulation protocols, high and low responders may benefit possibly via the reduction of the cost and the rate of complications. So far, only a few studies have investigated the role of minimal-mild ovarian stimulation in IVF. Well designed randomized controlled trials are required to clarify further the advantages of this approach in decreasing the cost and increasing the tolerability of IVF treatment.