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I260 DIAGNOSIS AND STAGING OF OBSTETRIC FISTULA
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
IVF cycle, during controlled ovarian hyperstimulation (COH). Out of 121 patients in ovarian stimulation, long protocol, in 60 endometrial sampling was performed 10th day of stimulation, followed by oocyte pick up, fertilization and embryo transfer. Implantation rate was 33% versus 17.7% in control group, clinical pregnancy rate 48% v. 27%, and live birth rate 41.6% versus 22.9% in control group. During endometrial biopsy 10 collected samples on COH cycle day 10 were analyzed for gene chip hybridization. There was significant differences in expression of 218 genes in endometrial tissue, 41 out of them upregulated, 177 down regulated. The genes for laminin alpha 4 and MMP1 were upregulated, gene for integrin alpha 6 downregulated. Having in mind the place in uterine cavity where we usually perform embryo transfer, S.Y. Huang recently made hypothesis that endometrial injury during IVF cycle stimulation on specific spot could even more improve pregnancy rate in patients with previous implantation failure. Site specific hysteroscopy biopsy was performed during COH day 4–7, on posterior endometrial wall, at midline 10–15 mm below uterine fundus. Only patients with 2 and more unsuccessful IVF cycle with good quality embryos transfered were included in study, endometrial sampling was performed in 6 patients and 24 patients were control group. Even the study group was very small, result was surprising, and pregnancy rate was 100% in study group and 46% in control group. Conclusion: Hysteroscopy is best diagnostic tool for intrauterine and endometrial pathology, and in same time best way to do necessary and possible treatment. It is also control tool since performing MOC before hysteroscopy we can check and record for future IVF how to best make embryo transfer. A part of diagnosis and therapy, local endometrial injury modulate immune and genetic activity in endometrial tissue, providing better synchronization between embryo end endometrial developments, so crucial for implantation processes. This could be one of the ways how we can improve implantation especially in patients with previous IVF failure. Reference(s) [1] Jan Bosteels et al., The effectiveness of hysteroscopy in improving pregnancy rate I subfertile women without other gynaecological symptoms: a systematic review, Hum. Reprod. Update, Vol. 16, No I, pp 1–11, 2010. [2] Doldi N.et al., Pathological findings in hysteroscopy before in vitro fertilization-embryo transfer (IVF-ET), Health care, Vol. 21, No 4, pages 235–237, 2005. [3] Palshetkar N et al., Role of hysteroscopy prior assisted reproductive techniques, J Gynec. Endoscopy and Surgery, Vol. 1, Issue I, 2009. [4] El-Toukhy et al., Outpatient hysteroscopy and subsequent IVF cycle outcome: a systematic review and meta-analysis, Reprod Biomed Online, 2008 May; 16(5): 712–9. [5] Bozdag G et al., What is the role of office hysteroscopy in women with failed IVF cycles? Reprod Biomed Online, 2008 Sep., 17(3): 410–5. [6] Tomazevic T et al., Septate, subseptate and arquate uterus decrease pregnancy and live birth rates in IVF/ICSI. Reprod Biomed Online, 2010 Nov; 21(5): 700–5. [7] Kasius J.C. et al., Observer agreement in the evaluation of the uterine cavity by hysteroscopy prior in vitro fertilization. Hum Reproduction, Vol. 26, No. 4 pp. 801–807, 2011. [8] Li R et al., Local injury to the endometrium: its effect on implantation, Curr opin Obstet Gynecol. 2009 Jun; 21(3): 236–9. [9] Narvekar SA et al., Does local endometrial injury in nontransfer cycle improve the IVF-ET outcome in the subsequent cycle in patients with previous unsuccessful IVF? A randomized controlled pilot study, J Hum Reprod Sci, V. 3(1); Jan-Apr, 2010. [10] Kalma et al., Endometrial biopsy-induced gene modulation: first evidence for the expression of bladder-transmembranal uroplakin Ib in human endometrium, Fertility and Sterility, Vol. 91, Issue 4, pp 1042–49, 2009. [11] Zhou L et al., Local injury to the endometrium in controlled ovarian hyperstimulation cycles improves implantation rates, Fertil Steril. 2008 May; 89(5): 1166–76.
S227
[12] Huang SY et al., Site specific endometrial injury improves implantation and pregnancy in patients with repeated implantation failures, Reprod Biol Endocrinol, 2011, 9–140.
I259 COMMUNITY-BASED DISTRIBUTION MODELS FOR ROLLING OUT MISOPROSTOL FOR PPH PREVENTION: EXPERIENCE AND LESSONS LEARNED FROM UGANDA AND TANZANIA S. Mukasa. Population Services International/PACE-Uganda Reducing maternal mortality from PPH is a global priority. Increasing access to misoprostol at the community level for PPH prevention has been the focus of considerable debate. Population Services International (PSI)/PACE-Uganda and PSITanzania are piloting strategies to roll-out community-based distribution (CBD) of misoprostol. Through an open randomized cluster clinical trial, PACE-Uganda and its research partner Makerere University, distributed misoprostol to women in clean delivery kits (Mamma Kits) through health facilities, government community health workers, and PACE community health workers. Descriptive analysis compared maternal outcomes and the timing, safety and acceptability of misoprostol use among a total of 3,116 deliveries. PPH was assessed through women’s self-reported subjective measure of blood loss. Analysis revealed that the majority of women used misoprostol at the correct time, reaffirming that community agents can be empowered to safely distribute and educate women on use of misoprostol. Mama Kits were the preferred method of distribution of misoprostol among women. Antenatal attendance remained high, indicating that community and health service delivery models can be complementary. PSI-Tanzania is integrating misoprostol into Clean Delivery Packs (CDPs) to be distributed through pharmaceutical channels and health facilities. Pharmacy and clinical staff will counsel women to bring the CDPs to facilities for delivery and on the correct use of misoprostol should they not reach the facility for delivery. The Ugandan study suggested that CBD of misoprostol is safe, acceptable, and feasible. Misoprostol is an essential intervention for the prevention of PPH and should be scaled up in countries with a high burden of unskilled birth attendance. Advocacy for CBD of misoprostol to prevent PPH is paramount. I260 DIAGNOSIS AND STAGING OF OBSTETRIC FISTULA M. Muleta Bedane Diagnosis and staging of obstetric fistula is an uninterrupted process, necessary to plan patient treatment, communicate treatment results, determine cases for training, and to predict prognosis and obtain informed consent. Different tools are used to reach a diagnosis of obstetric fistula. Patient history is a key first step; pelvic examination enables to detect, locate and specify the extent of injury; use of Sims speculum, proper positioning of the patient and adequate light are aid tools to locate small fistulae. Dye test in small fistulae; indigo-caramine test, cystoscopy and Intra Venous Urography for ureteric fistula are some of the important procedures used to support diagnosis of obstetric fistula. Professionals formerly used different parameters, such as anatomical location, complexity, extent of the injury and different scoring systems to classify obstetric fistula. However, they did not develop a standard classification system, and classification could not attain its purpose. Although these parameters are believed to predict the prognosis of treatment, a lack of objective assessment and complexity of the classification process limited prognostic ability of most of these classifications. Obstetric fistula can be diagnosed using cheap and affordable tools, but a standard and simple classification system which can prognosticate the treatment result is missing. It is an urgent priority
S228
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
to develop standard and simple classification system if proper training, patient care and clear communication about obstetric fistula are required at a global level. I261 REACHING “LOW-RISK” WOMEN: EXPERIENCES WITH THE INTEGRATION OF STI SERVICES INTO REPRODUCTIVE AND MATERNAL HEALTH SERVICES IN SUB-SAHARAN AFRICA S. Mullick Summary of presentation: The presenter will briefly review the literature on sexually transmitted infection (STI) and sexual/ reproductive health services integration over the last 10 years and present some key issues arising from the work of the Population Council around STI integration with antenatal care, post-natal care, family planning, and post-rape care clients in several countries of east and southern Africa. I262 ADVOCATING FOR IMPROVEMENT OF MATERNAL AND CHILD HEALTH SERVICES IN UGANDA: THE ROLE OF THE NATIONAL OBSTETRICS & GYNAECOLOGICAL PROFESSIONAL ASSOCIATION D. Murokora, J. Beyeza, F. Kaharuza Maternal mortality in Uganda has had a slow decline over three decades (527, 505, 435 and 310/100,000 in 1995, 2001, 2006 and 2010 respectively). Inefficient health systems, poor management and funding constraints have contributed to this slow progress. The Association of Obstetricians and Gynaecologists of Uganda (AOGU) has used multiple approaches to advocate for improvements in maternal and child health at the political/policy level, as well as the programmatic/service level. AOGU has – through FIGO LOGIC and supported by the Gates Foundation – worked with four regional hospitals to institutionalize Maternal and Perinatal Death Reviews (MPDRs). The MPDRs have identified health system gaps and influenced the design of interventions. For example, Mulago hospital in Kampala has used MPDR data to improve neonatal resuscitation; use of partograph; and management of hypertension in pregnancy. However, sustained advocacy efforts are required to ensure MPDR data translate into improvements in care. Health workers are still fearful of lack of confidentiality and being blamed for maternal and newborn deaths. AOGU contributes to the national Reproductive Health (RH) agenda through the Ministry of Health (MoH) Maternal & Child Health Technical Working Group and a Memorandum of Understanding, which mandates AOGU to lead on RH, including MPDRs, on behalf of the MoH is in progress. AOGU works with partners, including White Ribbon Alliance, Save the Children, UNFPA, and the private sector, to engage Parliament and the first Lady of Uganda in advancing maternal health. This has for example resulted in a 30% increase in government funding for RH. I263 NONINVASIVE PRENATAL TESTING OF FETAL DNA FROM MATERNAL BLOOD: A NEW ERA FOR FETAL TRISOMY DETECTION T.J. Musci The advent of new DNA genetic sequencing technology has allowed the non-invasive detection of common fetal trisomy by examining cell-free DNA (cfDNA) in maternal plasma. Directed analysis of cfDNA from maternal blood provides a sensitive, specific and efficient method for non-invasive prenatal testing (NIPT). With detection rates greater than 99% for trisomy 21 and false positive rates less than 0.1%, the potential to reduce the number of unnecessary invasive diagnostic procedures compared to conventional serum aneuploidy screening is profound. However, despite excellent detection and low false positive rates, NIPT using cfDNA should not be regarded as a diagnostic test, as published data
demonstrate less than 100% specificity. Recent data indicate that important characteristics of cfDNA testing for aneuploidy risk are constant across a wide range of risk categories and when applied to a routinely screened population, NIPT using chromosome selective sequencing identified trisomies 21 and 18 with high sensitivity and a low false positive rate (0.1%). These data, and the improved performance over conventional serum screening for aneuploidy, support the use of NIPT for the general prenatal population. I264 EVALUATION OF PROJECTS S. Nam, L. Hulton, on behalf of Dr Rachel Grellier, SRH Advisor, Options consultancy Ltd. Introduction: The Saving Mothers and Newborns (SMN) Initiative (2006–2011) comprised ten country projects led by professional associations of obstetricians and gynaecologists funded by Sida and FIGO. Method: The final evaluations were undertaken through either field visits or desk-based reviews lasting 5-days. Field visits were made to projects which had faced on-going challenges or had achieved exceptional outcomes (Haiti, Nigeria, Peru, Pakistan, Uganda and Ukraine). Desk reviews were undertaken for projects in the remaining countries: Kenya, Kosovo, Moldova and Uruguay. Progress was assessed against logframes and baseline reviews and evaluations reported on opportunities and challenges to sustainability of project achievements. Findings: Projects covered a wide range of activities including clinical training, development and introduction of standards, protocols and clinical audit, refurbishment of health facilities, and advocacy for policy and legislative change around abortion. A key feature of the Initiative was North-South mentoring by obstetricians and midwives. Overall, the mentoring process was considered useful and added value to the overall initiative resulting in two-way learning, additional resources being leveraged and strengthening of project activities and reports. A key lesson learned was the importance of funding for regular mentor visits and clarity about the role mentors to avoid mixed expectations. In many cases the scale of achievements were beyond initial expectations. The majority of projects are also continuing beyond the period of funding. The SMN Initiative has increased the capacity of FIGO itself and broadened its role to enable it to become an active initiator and manager of field-based multi-country projects. I265 NEURO-PROTECTIVE EFFECT OF ANTENATAL MAGNESIUM SULFATE A.H. Nassar. Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon Preterm birth is a leading risk factor for the development of cerebral palsy (CP), an infrequent, non-progressive disorder with devastating neurologic consequences. This risk increases inversely according to gestational age at delivery: approximately 10% at <28 weeks, 6% at 28–29 weeks, and 1.4% at 30–33 weeks. As early as the 1980’s it was noted that VLBW infants born to preeclamptic women had decreased rates of IVH and it was questioned whether this could this be explained by exposure to MgSO4 . Later, case-control studies also showed a reduction in IVH in infants exposed to tocolytic MgSO4 . Recent randomized trials and several meta-analyses have evaluated the role of antenatal MgSO4 for neuro-protection. The results of 4 trials found no differences in the rate of the primary outcome (death/CP) with the use of MgSO4 but secondary analysis of outcomes in 3 trials found a significant reduction in the rate of neonatal CP among those exposed to MgSO4. The results of the meta-analyses support the effectiveness of antenatal MgSO4 for neuro-protection of the fetus, infant, and child prior to very preterm birth. However, some remain skeptical and believe that
IVF cycle, during controlled ovarian hyperstimulation (COH). Out of 121 patients in ovarian stimulation, long protocol, in 60 endometrial sampling was performed 10th day of stimulation, followed by oocyte pick up, fertilization and embryo transfer. Implantation rate was 33% versus 17.7% in control group, clinical pregnancy rate 48% v. 27%, and live birth rate 41.6% versus 22.9% in control group. During endometrial biopsy 10 collected samples on COH cycle day 10 were analyzed for gene chip hybridization. There was significant differences in expression of 218 genes in endometrial tissue, 41 out of them upregulated, 177 down regulated. The genes for laminin alpha 4 and MMP1 were upregulated, gene for integrin alpha 6 downregulated. Having in mind the place in uterine cavity where we usually perform embryo transfer, S.Y. Huang recently made hypothesis that endometrial injury during IVF cycle stimulation on specific spot could even more improve pregnancy rate in patients with previous implantation failure. Site specific hysteroscopy biopsy was performed during COH day 4–7, on posterior endometrial wall, at midline 10–15 mm below uterine fundus. Only patients with 2 and more unsuccessful IVF cycle with good quality embryos transfered were included in study, endometrial sampling was performed in 6 patients and 24 patients were control group. Even the study group was very small, result was surprising, and pregnancy rate was 100% in study group and 46% in control group. Conclusion: Hysteroscopy is best diagnostic tool for intrauterine and endometrial pathology, and in same time best way to do necessary and possible treatment. It is also control tool since performing MOC before hysteroscopy we can check and record for future IVF how to best make embryo transfer. A part of diagnosis and therapy, local endometrial injury modulate immune and genetic activity in endometrial tissue, providing better synchronization between embryo end endometrial developments, so crucial for implantation processes. This could be one of the ways how we can improve implantation especially in patients with previous IVF failure. Reference(s) [1] Jan Bosteels et al., The effectiveness of hysteroscopy in improving pregnancy rate I subfertile women without other gynaecological symptoms: a systematic review, Hum. Reprod. Update, Vol. 16, No I, pp 1–11, 2010. [2] Doldi N.et al., Pathological findings in hysteroscopy before in vitro fertilization-embryo transfer (IVF-ET), Health care, Vol. 21, No 4, pages 235–237, 2005. [3] Palshetkar N et al., Role of hysteroscopy prior assisted reproductive techniques, J Gynec. Endoscopy and Surgery, Vol. 1, Issue I, 2009. [4] El-Toukhy et al., Outpatient hysteroscopy and subsequent IVF cycle outcome: a systematic review and meta-analysis, Reprod Biomed Online, 2008 May; 16(5): 712–9. [5] Bozdag G et al., What is the role of office hysteroscopy in women with failed IVF cycles? Reprod Biomed Online, 2008 Sep., 17(3): 410–5. [6] Tomazevic T et al., Septate, subseptate and arquate uterus decrease pregnancy and live birth rates in IVF/ICSI. Reprod Biomed Online, 2010 Nov; 21(5): 700–5. [7] Kasius J.C. et al., Observer agreement in the evaluation of the uterine cavity by hysteroscopy prior in vitro fertilization. Hum Reproduction, Vol. 26, No. 4 pp. 801–807, 2011. [8] Li R et al., Local injury to the endometrium: its effect on implantation, Curr opin Obstet Gynecol. 2009 Jun; 21(3): 236–9. [9] Narvekar SA et al., Does local endometrial injury in nontransfer cycle improve the IVF-ET outcome in the subsequent cycle in patients with previous unsuccessful IVF? A randomized controlled pilot study, J Hum Reprod Sci, V. 3(1); Jan-Apr, 2010. [10] Kalma et al., Endometrial biopsy-induced gene modulation: first evidence for the expression of bladder-transmembranal uroplakin Ib in human endometrium, Fertility and Sterility, Vol. 91, Issue 4, pp 1042–49, 2009. [11] Zhou L et al., Local injury to the endometrium in controlled ovarian hyperstimulation cycles improves implantation rates, Fertil Steril. 2008 May; 89(5): 1166–76.
S227
[12] Huang SY et al., Site specific endometrial injury improves implantation and pregnancy in patients with repeated implantation failures, Reprod Biol Endocrinol, 2011, 9–140.
I259 COMMUNITY-BASED DISTRIBUTION MODELS FOR ROLLING OUT MISOPROSTOL FOR PPH PREVENTION: EXPERIENCE AND LESSONS LEARNED FROM UGANDA AND TANZANIA S. Mukasa. Population Services International/PACE-Uganda Reducing maternal mortality from PPH is a global priority. Increasing access to misoprostol at the community level for PPH prevention has been the focus of considerable debate. Population Services International (PSI)/PACE-Uganda and PSITanzania are piloting strategies to roll-out community-based distribution (CBD) of misoprostol. Through an open randomized cluster clinical trial, PACE-Uganda and its research partner Makerere University, distributed misoprostol to women in clean delivery kits (Mamma Kits) through health facilities, government community health workers, and PACE community health workers. Descriptive analysis compared maternal outcomes and the timing, safety and acceptability of misoprostol use among a total of 3,116 deliveries. PPH was assessed through women’s self-reported subjective measure of blood loss. Analysis revealed that the majority of women used misoprostol at the correct time, reaffirming that community agents can be empowered to safely distribute and educate women on use of misoprostol. Mama Kits were the preferred method of distribution of misoprostol among women. Antenatal attendance remained high, indicating that community and health service delivery models can be complementary. PSI-Tanzania is integrating misoprostol into Clean Delivery Packs (CDPs) to be distributed through pharmaceutical channels and health facilities. Pharmacy and clinical staff will counsel women to bring the CDPs to facilities for delivery and on the correct use of misoprostol should they not reach the facility for delivery. The Ugandan study suggested that CBD of misoprostol is safe, acceptable, and feasible. Misoprostol is an essential intervention for the prevention of PPH and should be scaled up in countries with a high burden of unskilled birth attendance. Advocacy for CBD of misoprostol to prevent PPH is paramount. I260 DIAGNOSIS AND STAGING OF OBSTETRIC FISTULA M. Muleta Bedane Diagnosis and staging of obstetric fistula is an uninterrupted process, necessary to plan patient treatment, communicate treatment results, determine cases for training, and to predict prognosis and obtain informed consent. Different tools are used to reach a diagnosis of obstetric fistula. Patient history is a key first step; pelvic examination enables to detect, locate and specify the extent of injury; use of Sims speculum, proper positioning of the patient and adequate light are aid tools to locate small fistulae. Dye test in small fistulae; indigo-caramine test, cystoscopy and Intra Venous Urography for ureteric fistula are some of the important procedures used to support diagnosis of obstetric fistula. Professionals formerly used different parameters, such as anatomical location, complexity, extent of the injury and different scoring systems to classify obstetric fistula. However, they did not develop a standard classification system, and classification could not attain its purpose. Although these parameters are believed to predict the prognosis of treatment, a lack of objective assessment and complexity of the classification process limited prognostic ability of most of these classifications. Obstetric fistula can be diagnosed using cheap and affordable tools, but a standard and simple classification system which can prognosticate the treatment result is missing. It is an urgent priority
S228
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
to develop standard and simple classification system if proper training, patient care and clear communication about obstetric fistula are required at a global level. I261 REACHING “LOW-RISK” WOMEN: EXPERIENCES WITH THE INTEGRATION OF STI SERVICES INTO REPRODUCTIVE AND MATERNAL HEALTH SERVICES IN SUB-SAHARAN AFRICA S. Mullick Summary of presentation: The presenter will briefly review the literature on sexually transmitted infection (STI) and sexual/ reproductive health services integration over the last 10 years and present some key issues arising from the work of the Population Council around STI integration with antenatal care, post-natal care, family planning, and post-rape care clients in several countries of east and southern Africa. I262 ADVOCATING FOR IMPROVEMENT OF MATERNAL AND CHILD HEALTH SERVICES IN UGANDA: THE ROLE OF THE NATIONAL OBSTETRICS & GYNAECOLOGICAL PROFESSIONAL ASSOCIATION D. Murokora, J. Beyeza, F. Kaharuza Maternal mortality in Uganda has had a slow decline over three decades (527, 505, 435 and 310/100,000 in 1995, 2001, 2006 and 2010 respectively). Inefficient health systems, poor management and funding constraints have contributed to this slow progress. The Association of Obstetricians and Gynaecologists of Uganda (AOGU) has used multiple approaches to advocate for improvements in maternal and child health at the political/policy level, as well as the programmatic/service level. AOGU has – through FIGO LOGIC and supported by the Gates Foundation – worked with four regional hospitals to institutionalize Maternal and Perinatal Death Reviews (MPDRs). The MPDRs have identified health system gaps and influenced the design of interventions. For example, Mulago hospital in Kampala has used MPDR data to improve neonatal resuscitation; use of partograph; and management of hypertension in pregnancy. However, sustained advocacy efforts are required to ensure MPDR data translate into improvements in care. Health workers are still fearful of lack of confidentiality and being blamed for maternal and newborn deaths. AOGU contributes to the national Reproductive Health (RH) agenda through the Ministry of Health (MoH) Maternal & Child Health Technical Working Group and a Memorandum of Understanding, which mandates AOGU to lead on RH, including MPDRs, on behalf of the MoH is in progress. AOGU works with partners, including White Ribbon Alliance, Save the Children, UNFPA, and the private sector, to engage Parliament and the first Lady of Uganda in advancing maternal health. This has for example resulted in a 30% increase in government funding for RH. I263 NONINVASIVE PRENATAL TESTING OF FETAL DNA FROM MATERNAL BLOOD: A NEW ERA FOR FETAL TRISOMY DETECTION T.J. Musci The advent of new DNA genetic sequencing technology has allowed the non-invasive detection of common fetal trisomy by examining cell-free DNA (cfDNA) in maternal plasma. Directed analysis of cfDNA from maternal blood provides a sensitive, specific and efficient method for non-invasive prenatal testing (NIPT). With detection rates greater than 99% for trisomy 21 and false positive rates less than 0.1%, the potential to reduce the number of unnecessary invasive diagnostic procedures compared to conventional serum aneuploidy screening is profound. However, despite excellent detection and low false positive rates, NIPT using cfDNA should not be regarded as a diagnostic test, as published data
demonstrate less than 100% specificity. Recent data indicate that important characteristics of cfDNA testing for aneuploidy risk are constant across a wide range of risk categories and when applied to a routinely screened population, NIPT using chromosome selective sequencing identified trisomies 21 and 18 with high sensitivity and a low false positive rate (0.1%). These data, and the improved performance over conventional serum screening for aneuploidy, support the use of NIPT for the general prenatal population. I264 EVALUATION OF PROJECTS S. Nam, L. Hulton, on behalf of Dr Rachel Grellier, SRH Advisor, Options consultancy Ltd. Introduction: The Saving Mothers and Newborns (SMN) Initiative (2006–2011) comprised ten country projects led by professional associations of obstetricians and gynaecologists funded by Sida and FIGO. Method: The final evaluations were undertaken through either field visits or desk-based reviews lasting 5-days. Field visits were made to projects which had faced on-going challenges or had achieved exceptional outcomes (Haiti, Nigeria, Peru, Pakistan, Uganda and Ukraine). Desk reviews were undertaken for projects in the remaining countries: Kenya, Kosovo, Moldova and Uruguay. Progress was assessed against logframes and baseline reviews and evaluations reported on opportunities and challenges to sustainability of project achievements. Findings: Projects covered a wide range of activities including clinical training, development and introduction of standards, protocols and clinical audit, refurbishment of health facilities, and advocacy for policy and legislative change around abortion. A key feature of the Initiative was North-South mentoring by obstetricians and midwives. Overall, the mentoring process was considered useful and added value to the overall initiative resulting in two-way learning, additional resources being leveraged and strengthening of project activities and reports. A key lesson learned was the importance of funding for regular mentor visits and clarity about the role mentors to avoid mixed expectations. In many cases the scale of achievements were beyond initial expectations. The majority of projects are also continuing beyond the period of funding. The SMN Initiative has increased the capacity of FIGO itself and broadened its role to enable it to become an active initiator and manager of field-based multi-country projects. I265 NEURO-PROTECTIVE EFFECT OF ANTENATAL MAGNESIUM SULFATE A.H. Nassar. Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon Preterm birth is a leading risk factor for the development of cerebral palsy (CP), an infrequent, non-progressive disorder with devastating neurologic consequences. This risk increases inversely according to gestational age at delivery: approximately 10% at <28 weeks, 6% at 28–29 weeks, and 1.4% at 30–33 weeks. As early as the 1980’s it was noted that VLBW infants born to preeclamptic women had decreased rates of IVH and it was questioned whether this could this be explained by exposure to MgSO4 . Later, case-control studies also showed a reduction in IVH in infants exposed to tocolytic MgSO4 . Recent randomized trials and several meta-analyses have evaluated the role of antenatal MgSO4 for neuro-protection. The results of 4 trials found no differences in the rate of the primary outcome (death/CP) with the use of MgSO4 but secondary analysis of outcomes in 3 trials found a significant reduction in the rate of neonatal CP among those exposed to MgSO4. The results of the meta-analyses support the effectiveness of antenatal MgSO4 for neuro-protection of the fetus, infant, and child prior to very preterm birth. However, some remain skeptical and believe that