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I244 Cigarette smoking and perinatal mortality
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I243 Should chemotherapy replace radiotherapy in high risk cases? K. Ochiai Postoperative therapy of endometrial cancer patients should be based on prognostic factors determined by surgical and pathologic staging. Patients can generally be classified into three treatment categories i.e. low risk, intermediate risk and high risk. Patients who have high rate of recurrence and low survival rate without postoperative treatment fall into high risk group. Options for postoperative management in these patients include vaginal vault irradiation, external pelvic irradiation, extended-field irradiation, whole-abdominal irradiation or systemic chemotherapy. Although the GOG 122 trial was the first to suggest an improvement in outcome for advanced endometrial cancer patients for use of adjuvant chemotherapy compared with whole-abdominal irradiation, toxicity was more prevalent with chemotherapy. JGOG 2033 trial compared wholepelvis irradiation versus cyclophosphamide/doxorubicin/cisplatin chemotherapy again demonstrated chemotherapy provides survival benefits for those patients. Controversy, however, still exists regarding how postoperative treatment should be performed. Recent survey we conducted in Japan reveled that among 4090 endometrial cancer patients underwent surgery in 2004, 1675 (41%) patients received postoperative chemotherapy while 273 (7%) received adjuvant radiation therapy. Regarding regimen of chemotherapy, 67% of them received taxanes/platinum chemotherapy regimens, while 24% received anthracycline/platinum regimens. At most Japanese institutions, adjuvant chemotherapy was routinely delivered to high-risk groups. Although the optimal regimen and duration have not been defined, taxanes/platinum combinations are commonly used in the adjuvant setting at many institutions. It remains unclear, however, whether these combinations have a greater efficacy and less toxicity than anthracycline/platinum. Therefore, JGOG is now conducting a RCT to evaluate this question. I244 Cigarette smoking and perinatal mortality H. Odendaal Several meta-analyses have confirmed the association of common complications during pregnancy such as placenta praevia, abruptio placentae, premature rupture of membranes, preterm delivery, low birth weight, intrauterine growth restriction, perinatal complications of pre-eclampsia and intrapartum asphyxia with cigarette smoking during pregnancy. All these conditions carry a higher perinatal mortality. There is also more direct evidence as cigarette smoking during pregnancy is associated with more unexplained intrauterine deaths. Furthermore, it is well known that sudden infant death syndrome (SIDS) is associated with cigarette smoking during and after pregnancy. There are several mechanisms by which smoking could harm the pregnancy such as hypoxia and poor uterine blood flow to the uterus due to vasoconstriction of the uterine arteries. Additionally, cigarette smoking could cause endothelial damage which may lead to a decline in microcirculation. Cigarette smoking also has several effects on nutrition. Generally it causes oxidative stress, thereby reducing circulating anti-oxidants. In addition, cigarette smoking reduces dietary anti-oxidants and micronutrient intake. Zinc transport to the fetus is reduced. In addition, smoking reduces the preferences for vitamin C rich foods and reduces these levels independently of intake. It should be remembered that many smokers consume alcohol and smoke more during binge drinking. The combined effects of alcohol and smoking should therefore be addressed. Little information is available on the combined effect but a recent meta-analysis has shown that it increases the risks of preterm birth, term birth weight and low birth weight to a larger extent than any of the substances on their own.
S61
I245 A critical review of electronic fetal heart rate monitoring in labour H. Odendaal When fetal heart rate (FHR) monitoring during labour was introduced commercially, no randomized trials had been done to assess reduction of stillbirths during labour or birth asphyxia. Much later well conducted randomized controlled trials demonstrated no superiority to regular auscultation of the fetal heart in low risk pregnancies. For high risk pregnancies there is circumstantial evidence that fetal monitoring is beneficial. However, FHR monitoring is associated with increased caesarean section and operative delivery rates. It is essential that FHR monitoring is used where it could make its greatest impact, both in high and low-income countries. Such an example is induction of labour with either prostaglandin or oxytocin or during augmentation of labour with oxytocin. The use of oxytocin for induction or augmentation of labour is extensive. In low-income countries, up to 50% of hospital-based deliveries are associated with the use of oxytocin or misoprostol. As the use of oxytocin during labour is closely associated with adverse neonatal outcome and is one of the main reasons for litigation against labour ward personnel, it is essential to ensure that oxytocin is administered safely. Although augmentation of labour is recommended for the primigravida only, some obstetricians unfortunately also use it for slow progress in the multigravida. If this potential dangerous practice is performed, it is essential that the fetal heart rate and strength of contractions are accurately monitored. For the monitoring of contractions the use of an intrauterine catheter is strongly recommended as overstimulation of the uterus can be detected in time. I246 Current management of platelet alloimmunisation D. Oepkes. Leiden, Netherlands Fetal and Neonatal Alloimmune Thrombocytopenia is the most common cause of severe thrombocytopenia in neonates. The disease is analogous to fetal or neonatal anemia due to red cell (Rhesus) allommunisation in pregnancy. Maternal-paternal incompatibility for antigens on platelets leads to production of antibodies against fetal platelets during pregnancy. The resulting low platelet count in the fetus or neonate can cause bleeding complications, of which the most feared is intracranial hemorrhage (ICH). Many of these children suffer form life-long handicaps, cerebral palsy, cortical blindness and mental retardation. In the last decade, our insights in the pathophysiology, laboratory methods for detection of pregnancies at risk and treatment options have vastly increased. Until now, affected fetuses and neonates were only diagnosed in the presence of, invariably totally unexpected, clinical symptoms, when treatment was often too late. The current management only consists of offering preventive measures including intravenous immunoglobulin (IVIG) treatment in a subsequent pregnancy. Our protocol for these patients will be briefly discussed, with (excellent) results. Recently, a large prospective antenatal screening and intervention program in Norway was performed, screening more than 100,000 women, showing feasibility and cost-effectiveness with an estimated reduction of severe FNAIT-related complications to one fourth. The protocol for a screening program in the Netherlands will be discussed.
I243 Should chemotherapy replace radiotherapy in high risk cases? K. Ochiai Postoperative therapy of endometrial cancer patients should be based on prognostic factors determined by surgical and pathologic staging. Patients can generally be classified into three treatment categories i.e. low risk, intermediate risk and high risk. Patients who have high rate of recurrence and low survival rate without postoperative treatment fall into high risk group. Options for postoperative management in these patients include vaginal vault irradiation, external pelvic irradiation, extended-field irradiation, whole-abdominal irradiation or systemic chemotherapy. Although the GOG 122 trial was the first to suggest an improvement in outcome for advanced endometrial cancer patients for use of adjuvant chemotherapy compared with whole-abdominal irradiation, toxicity was more prevalent with chemotherapy. JGOG 2033 trial compared wholepelvis irradiation versus cyclophosphamide/doxorubicin/cisplatin chemotherapy again demonstrated chemotherapy provides survival benefits for those patients. Controversy, however, still exists regarding how postoperative treatment should be performed. Recent survey we conducted in Japan reveled that among 4090 endometrial cancer patients underwent surgery in 2004, 1675 (41%) patients received postoperative chemotherapy while 273 (7%) received adjuvant radiation therapy. Regarding regimen of chemotherapy, 67% of them received taxanes/platinum chemotherapy regimens, while 24% received anthracycline/platinum regimens. At most Japanese institutions, adjuvant chemotherapy was routinely delivered to high-risk groups. Although the optimal regimen and duration have not been defined, taxanes/platinum combinations are commonly used in the adjuvant setting at many institutions. It remains unclear, however, whether these combinations have a greater efficacy and less toxicity than anthracycline/platinum. Therefore, JGOG is now conducting a RCT to evaluate this question. I244 Cigarette smoking and perinatal mortality H. Odendaal Several meta-analyses have confirmed the association of common complications during pregnancy such as placenta praevia, abruptio placentae, premature rupture of membranes, preterm delivery, low birth weight, intrauterine growth restriction, perinatal complications of pre-eclampsia and intrapartum asphyxia with cigarette smoking during pregnancy. All these conditions carry a higher perinatal mortality. There is also more direct evidence as cigarette smoking during pregnancy is associated with more unexplained intrauterine deaths. Furthermore, it is well known that sudden infant death syndrome (SIDS) is associated with cigarette smoking during and after pregnancy. There are several mechanisms by which smoking could harm the pregnancy such as hypoxia and poor uterine blood flow to the uterus due to vasoconstriction of the uterine arteries. Additionally, cigarette smoking could cause endothelial damage which may lead to a decline in microcirculation. Cigarette smoking also has several effects on nutrition. Generally it causes oxidative stress, thereby reducing circulating anti-oxidants. In addition, cigarette smoking reduces dietary anti-oxidants and micronutrient intake. Zinc transport to the fetus is reduced. In addition, smoking reduces the preferences for vitamin C rich foods and reduces these levels independently of intake. It should be remembered that many smokers consume alcohol and smoke more during binge drinking. The combined effects of alcohol and smoking should therefore be addressed. Little information is available on the combined effect but a recent meta-analysis has shown that it increases the risks of preterm birth, term birth weight and low birth weight to a larger extent than any of the substances on their own.
S61
I245 A critical review of electronic fetal heart rate monitoring in labour H. Odendaal When fetal heart rate (FHR) monitoring during labour was introduced commercially, no randomized trials had been done to assess reduction of stillbirths during labour or birth asphyxia. Much later well conducted randomized controlled trials demonstrated no superiority to regular auscultation of the fetal heart in low risk pregnancies. For high risk pregnancies there is circumstantial evidence that fetal monitoring is beneficial. However, FHR monitoring is associated with increased caesarean section and operative delivery rates. It is essential that FHR monitoring is used where it could make its greatest impact, both in high and low-income countries. Such an example is induction of labour with either prostaglandin or oxytocin or during augmentation of labour with oxytocin. The use of oxytocin for induction or augmentation of labour is extensive. In low-income countries, up to 50% of hospital-based deliveries are associated with the use of oxytocin or misoprostol. As the use of oxytocin during labour is closely associated with adverse neonatal outcome and is one of the main reasons for litigation against labour ward personnel, it is essential to ensure that oxytocin is administered safely. Although augmentation of labour is recommended for the primigravida only, some obstetricians unfortunately also use it for slow progress in the multigravida. If this potential dangerous practice is performed, it is essential that the fetal heart rate and strength of contractions are accurately monitored. For the monitoring of contractions the use of an intrauterine catheter is strongly recommended as overstimulation of the uterus can be detected in time. I246 Current management of platelet alloimmunisation D. Oepkes. Leiden, Netherlands Fetal and Neonatal Alloimmune Thrombocytopenia is the most common cause of severe thrombocytopenia in neonates. The disease is analogous to fetal or neonatal anemia due to red cell (Rhesus) allommunisation in pregnancy. Maternal-paternal incompatibility for antigens on platelets leads to production of antibodies against fetal platelets during pregnancy. The resulting low platelet count in the fetus or neonate can cause bleeding complications, of which the most feared is intracranial hemorrhage (ICH). Many of these children suffer form life-long handicaps, cerebral palsy, cortical blindness and mental retardation. In the last decade, our insights in the pathophysiology, laboratory methods for detection of pregnancies at risk and treatment options have vastly increased. Until now, affected fetuses and neonates were only diagnosed in the presence of, invariably totally unexpected, clinical symptoms, when treatment was often too late. The current management only consists of offering preventive measures including intravenous immunoglobulin (IVIG) treatment in a subsequent pregnancy. Our protocol for these patients will be briefly discussed, with (excellent) results. Recently, a large prospective antenatal screening and intervention program in Norway was performed, screening more than 100,000 women, showing feasibility and cost-effectiveness with an estimated reduction of severe FNAIT-related complications to one fourth. The protocol for a screening program in the Netherlands will be discussed.