Oral Presentations, FC1 - Wiley Online Library

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Aug 16, 2013 - predicting factors including pre-pregnancy NYHA class, poor left ...... Malaysia; 2 Department of Medical
DOI: 10.1111/j.1471-0528.2012.03375.x

Abstracts

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Oral Presentations

Perinatal/Maternal-Fetal Medicine FC1.01 Prospective risk of late stillbirth in twins of known chorionicity: the stork multiple pregnancy cohort data and systematic review

Dias, T; Patel, D; Bhide, A; Thilaganathan, B On behalf of The Southwest Thames Obstetric Research Collaborative (STORK) St George’s University of London, Cranmer Terrace, London, United Kingdom Objective: Monochorionic (MC) pregnancies are routinely

delivered electively at various late preterm gestations with the intention of avoiding stillbirth. The aim of this study was to evaluate the prospective risk of late stillbirth in a large regional cohort and undertake a systematic review of the literature on routinely managed twin pregnancies of known chorionicity. Methods: A retrospective study of all twin births of known chorionicity from a large regional cohort of nine hospitals (STORK collaborative) taken over a 10 year period matched to a mandatory national register of stillbirth (CMACE). The data of the current study was included in a systematic review of selected studies of stillbirth in routinely managed twin pregnancies of known chorionicity. Results: A total of 3005 twin pregnancies delivered after 26 weeks of gestation in the STORK collaborative, and this was combined with data from eight studies selected from the systematic review of the literature. The total risk of stillbirth after 26 weeks in MC twins (21.7/ 1000 fetuses) was significantly higher (OR 3.26, 95% CI 2.36–4.5) than in DC twins (6.7/1000 fetuses). The prospective risk of stillbirth in MC twins did not change significantly between 26+ weeks (3.6/ 1000 fetuses) and 36+ weeks (5.2/1000 fetuses, OR 1.85, 95% 0.3–13.2). The equivalent figures for DC twins were 0.8/1000 fetuses and 1.7/1000 fetuses, respectively (OR 3.4, 95% 0.9–13.2). Conclusion: The risk of stillbirth in MC twins does not appear to increase significantly near term. This observation may be due to a policy of routine surveillance and elective delivery from 36 weeks. The data does not support a policy of elective birth before 36 weeks of gestation in MC pregnancies.

FC1.02 Dignity in maternity care: literature review and audit of complaints

Parry-Smith, W; Morad, S; Shrewsbury, R; McSherry, W Centre for Practice and Service Improvement, Staffordshire University, United Kingdom

In the UK the concept of dignity and respect in health care commands much public and media interest, predominantly in

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elderly care. However, there is a paucity of work regarding dignity and respect in obstetrics and gynaecology despite its important and topical nature. In order to begin exploring how the concept might be studied in our specialty we undertook a literature review on dignity and respect in obstetrics and gynaecology from 2001 to 2011 and identified key themes. Formal complaints to the department over a 2 year period were then mapped to the themes identified in the literature review. The following threats to dignity were identified: discrimination against women, fear, pain, intimate examinations, power of caregiver over the woman, over-medicalisation, excessive form-filling and staff shift changes. Dignity was maintained by the woman herself through control of the private sphere, setting appropriate boundaries and retaining ownership of pregnancy, childbirth and post-natal care. It was also maintained by healthcare teams that treated women as individuals, ensured the patient was not exposed either physically or emotionally, and allowed women their desired level of control. Maintenance of dignity required women to have a relationship based on trust in the knowledge and skills of their health care provider and was strongly associated with honouring requests for pain relief. The analysis of departmental complaints revealed clustering around domains addressing pain management, communication and attitude, not around areas such as autonomy, personal hygiene, privacy or safety. When compared with the literature review we had fewer complaints than expected regarding autonomy, but the complaints revealed no additional themes that had not been identified in the literature. Combining the results of the complaint analysis exercise and the literature review enabled us to plan future service user based feedback, allowing active quality assurance based on sound evidence rather than solely relying on a complaint driven system to effect change. Finally we regard this as a chance to highlight areas within our specialty that we can reflect on to bring the best to women’s health care.

FC1.03 Informed Consent – What is the evidence?

Robertson, C1; Verco, C2 1

Flinders Medical School; 2 Flinders Medical Centre, Australia

Background: Informed consent, a fundamental ethical and legal

aspect of medical care, is part of a continuum which is the clinical encounter. The documentation of ‘informed consent’ may not always accurately reflect what has been discussed due to time constraints and other variables common to hospital medicine. Correct documentation of consent is important because it accurately records what has been discussed, when the discussion

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

took place and particular issues raised in relation to the proposed intervention or procedure. Objective: To determine how effectively the documentation of informed consent is carried out at a busy Australian teaching hospital. Aims: To identify areas where documentation is lacking and propose how shortcomings, if any, may be addressed. Methods: Caesarean section is a common operation at Flinders Medical Centre (FMC) (approximately 75–100 operations monthly). Through an audit of 101 case files of women who underwent caesarean sections at FMC in August and September of 2011 (50 emergency, 51 elective) we examined how informed consent was documented. Results: Two of the 101 files did not contain any written evidence of consent. An average of 4.2 (range 2–6) maternal risks out of a possible seven were recorded for each elective case and average of 3.3 (range 0–5) maternal risks were recorded for each emergency case. Risks to future pregnancies in the elective group were recorded on average 0.3 of 3 (range 0–2) and 0.2 (range 0.1) risks were recorded in the emergency group. Over the two groups 75% (76) of the cases didn’t have a single risk to future pregnancies recorded. A record of written information being given was recorded in 16% (8) of elective cases and in only 2% (1) emergency cases. Procedures that were not to be done were recorded in three of the emergency cases and in none of the elective cases. Conclusion: The documentation of informed consent is universally poor across all of the examined categories. A structured consent proforma may facilitate the recording of informed consent.

gestation) and 304 had late preterm births (34–37 weeks of gestation). Logistic regression models adjusted for covariates including race, recruitment center, and education measured at baseline; as well as parity, time between blood pressure measure and conception, and BMI measured at the visit prior to the index pregnancy; and finally age at delivery. Results: The highest quartile (range 111–165 mmHg) as compared to the lowest quartile (range 84–98) of the systolic blood pressure closest to conception was significantly associated with early preterm birth (adj OR 1.86, 95% CI 1.01, 3.44) and late preterm birth (adj OR 1.56, 95% CI 1.03, 2.34). Additional adjustment for a self-reported pre-pregnancy diagnosis of hypertension and for self-reported gestational hypertension only modestly attenuated the relationship with both early preterm (adj OR 1.81, 95% CI 0.97, 3.36) and late preterm births (adj OR 1.46, 95% CI 0.96, 2.20). Neither diastolic blood pressure nor mean arterial blood pressure were consistently elevated among women bearing early and late preterm births. Whereas neither race nor parity interacted with blood pressure to elevate preterm birth risk, obesity exaggerated the link (adj OR 14.32, 95% CI 1.55, 135.10) and the association was unapparent in non-obese women. Conclusions: These results suggest that pre-pregnancy systolic blood pressure in the presence of obesity elevates the risk for both early and late preterm birth.

FC1.05 Transabdominal cervical suture for the prevention of pregnancy loss: the next 42 cases

Gibb, D The Birth Company, London, United Kingdom

FC1.04 Pre-pregnancy blood pressure among women with and without preterm birth from the CARDIA cohort

Ness, RB1; Lewis, CE2; Catov, J3; Jacobs, D4; Tolan, K5; Gunderson, EP6 1 The University of Texas School of Public Health; 2 University of Alabama School of Medicine Division of Preventive Medicine; 3 University of Pittsburgh School of Medicine; 4 University of Minnesota School of Public Health; 5 Kaiser Permanente Medical Care Program; 6 Division of Research, Kaiser Permanente

Objective: Prematurity is largely a condition of unknown cause,

although a handful of studies have related it to pre-pregnancy cardiovascular risk factors including hyperlipidemia, diabetes, and self-reported hypertension. No studies to date have assessed prepregnancy blood pressure measurements in connection with prematurity and thus it was our objective to do so. Methods: CARDIA is a multi-center, prospective observational study of risk factors for coronary heart disease in young black and white men and women. Of the 2787 female participants enrolled in 1985–1986 aged 18–30, 1301 were evaluated who had a birth of known, self-reported gestational age after the baseline visit and had blood pressure measurements prior to that subsequent birth. One hundred sixteen had early preterm births (60 min). P value of < 0.05 was significant. Results: Over the period, 204 women underwent emergency caesarean sections. The mean age of women was 26.8 ± 4.6 years. The mean gestational age at delivery was 38.0 ± 3.0 weeks. The mean decision delivery interval in the cohort was 42.5 ± 19.4 min. The decision delivery interval of £30 min was achieved in 19% of the deliveries; another 60% deliveries were achieved within 60 min, while the remaining 21% delivered after 60 min. There was no significant difference in the perinatal outcome between babies delivered within 30 min and 31–60 min of decision delivery intervals. However, there was a significantly higher risk

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for poor perinatal outcome for babies with decision delivery intervals of > 60 min [OR-6.9, 95% CI: 2.37–20.18]. Conclusion: The perinatal outcome between decision delivery interval of £30 and 31–60 min was statistically not different, however the £30 min decision delivery interval should remain as the gold standard.

FC1.07 Quality of detection of pregnancy induced hypertension to reduce maternal mortality to one digit in Sri Lanka

Prathapan, R1; Prathapan, S2; Lindmark, G3; Fonseka, P4; Lokubalasooriya, A5 1 Base Hospital Kanthale, Sri Lanka; 2 Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka; 3 Department of International Maternal and Child Health, University Hospital, Uppsala, Sweden; 4 Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka; 5 Family Health Bureau, Ministry of Health, Sri Lanka

Introduction: One of the leading causes of maternal mortality in

Sri Lanka for the last two decades has been pregnancy induced hypertension (PIH). Disparities between high attendance rates at field clinics and high maternal deaths from PIH raise questions about the quality of detection of PIH in field antenatal clinics. Improving the detection rate of PIH could help Sri Lanka in reducing maternal mortality to a single digit. Objective: To describe the quality of detection of PIH in pregnant women in the field antenatal clinics of Sri Lanka. Methods: A cross-sectional study design was used. In the Colombo district, of the 11 MOH areas, according to the Lot Quality Assurance Sampling method, five field antenatal clinics were randomly selected (n = 55 clinics). In each of these clinics, five women in their booking visit (n = 275 women) were sampled. A checklist was used to observe and the following indicators were used to assess the quality of services. History and clinical examination, measuring the BP, explaining the findings, investigation for urine albumin, explaining the results of the investigation. Results: Due to the unavailability of the doctor in 12% of clinics, a history, a clinical examination and the BP measurement could not be performed in 60 (21.8%) women. A history was obtained in only 8 (2.9%) women and a clinical examination with regards to diagnosis of PIH/PET was performed in 48 (17.5%) women. Among the women whom were seen by the doctor at the clinic, the BP was measured in 185 women (86%). Only 1/3 of these measurements were according to standards. The blood pressure readings recorded on the pregnancy card was compared with results of the principal researcher. The sensitivity for systolic BP and Diastolic BP was 57.1% (95% CI: 47.4% -66.8%) and 16.7% (95% CI: 9.4% -24%) respectively. The urine albumin was investigated according to standards in 7% of the women. The quality of services was unacceptable in all the MOH areas for four of the six indicators.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

Conclusions: The need for quality improvement is evident and

urgent steps should be taken to pave the way to reduce the maternal mortality rate.

FC1.09 Psychological issues in reproduction – why it matters

Chung, T The Chinese University of Hong Kong, Hong Kong, China

FC1.08 Fetal fibronectin rapid test versus phosphorylated insulin-like growth factor-1 (phIGFBP-1) as bedside test kits for prediction of preterm delivery in the clinical setting

Thandayathany, V; Yassin, MAJM; Omar, MH; Ismail, NAM; Tamil, AM; Kampan, NC Hospital Universiti Kebangsaan, Malaysia Objective: The objective of this study is to compare

Phosphorylated insulin-like growth factor-1 (phIGFBP-1) test and fetal fibronectin (fFN) test in the prediction of preterm delivery. Methods: All patients between the gestations of 24–34 weeks with documented contraction on the cardiotocography were recruited. phIGFBP-1 test and fetal fibronectin test were done on all patients. The fetal fibronectin test results were blinded and the patient was managed as per standard protocol for preterm delivery. The administration of tocolysis, steroids and antibiotics were based on clinical judgement of the attending obstetrician. The outcome of pregnancy and delivery were analysed. Results: One hundred and seventy four patients were recruited. The negative predictive value for phIGFBP-1 test was 97.3, 94.0, 89.3, and 92.0 for 48 h, 7 days, 14 days and £34 weeks respectively. The NPV for fFN test was 96.7, 92.7, 88.0, and 90.6 for 48 h, 7 days, 14 days and £34 weeks respectively. The mean gestational age at delivery was 35.8 ± 3.81 weeks for women with positive phIGFBP-1 test and 36.5 ± 3.54 weeks for women with a positive fFN test. For women with both tests positive, the mean delivery was 35.8 ± 3.62 weeks. The delivery interval from initial presentation was 2.16 weeks shorter in women with phIGFBP-1 test positive as compared to women with negative phIGFBP-1 test (3.67 vs. 5.83 weeks). It was 1.8 weeks shorter in women with fFN test positive than those with negative FfN test (3.96 vs. 5.77 weeks). Both phIGFBP-1 and fFN test have high negative predictive value in predicting risk of preterm delivery. Both the test had a fair kappa agreement i.e 0.21–0.40. The area under the curve for phIGFBP-1 test and fFN test is 0.766 and 0.720 respectively. Conclusion: Both phIGFBP-1 and fFN test are good diagnostic tools in prediction of preterm delivery. A negative phIGFBP-1 test or fFN test will confer that the patient has a 92.7% to a 94% changes of not delivering in the next 7 days. phIGFBP-1 test may be a better diagnostic tool with higher negative predictive value, longer delivery interval and a higher kappa agreement.

In many countries, suicide has become the post common cause of maternal death. This is especially so in countries where historical causes of maternal mortality such as haemorrhage, infection and severe hypertensive disease have been mitigated to a large extent. However, where there is reasonable investment by governments in maternal health, there is a accelerating trend in reduction in maternal mortality even in relatively resource poor countries. It is reasonable to anticipate that mental health causes of maternal mortality will become more prominent and will need preparation and planning in order to address this. A 15 year experience describing initial research and implementation of a service programme using local research will be presented. Potential future developments will be discussed.

FC1.10 Fetal gender determination in early pregnancy using PCR analysis of maternal serum

El Razik, AA1; El Missiry, AG2 1

Ain Shams University, Faculty of Medicine, Obstetrics & Gynaecology Department, Cairo, Egypt; 2 Medical Research Centre, Ain Shams University, Faculty of Medicine, Obstetrics & Gynaecology Department, Cairo, Egypt Objective: Fetal DNA has been found in maternal serum.

Diagnosis of fetal gender using maternal serum has been attempted in an effort to develop a new non-invasive method of prenatal diagnosis. Methods: Peripheral blood samples were obtained from 25 Egyptian pregnant women at 9–12 weeks of gestation. DNA was extracted from 800 lL of each serum sample. To detect Ychromosome-specific sequences DYS14 in the maternal serum, 40 cycles of PCR were carried for each DNA extract. The PCR products were analysed by 2.5%agarose gel electrophoresis and ethidium bromide staining, and the results were compared with the results of ultrasound scan which done at 21 weeks of gestation for all the 25 pregnant women for determination of fetal gender. Results: Ultrasound scan at 12 weeks of gestation revealed that 13 pregnant women had a male fetus and the remaining 12 women had a female fetus. DYS14 was not detected in serum samples obtained from any of the 12 women carrying a female fetus. Fetal gender was determined successfully in all the 25 Egyptian pregnant women. So our method had the highest sensitivity (100%) reported to date. Conclusion: PCR analysis of maternal serum can be used to diagnose fetal gender in first trimester.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

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Oral Presentations

FC1.11 Incidence of cardiac events amongst pregnant women with cardiac disease – HUSM experience

FC1.12 Metabolomic approach to diagnosis of labour

Lee, SJ ; Nik Mohamed Zaki, NM ; Ng, SL ; Zurkurnai, Y2

Meloni, A1; Caboni, P2; Manconi, F2; Atzori, L3; Lussu, M3; Murgia, F3; Barberini, L4; Noto, A5; Fanos, V5; Paoletti, A1; Ragusa, A6

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Department of Obstetrics & Gynaecology, Hospital Universiti Sains Malaysia; 2 Department of Internal Medicine, Hospital Universiti Sains Malaysia Introduction: It has long been recognized that certain cardiac

predicting factors including pre-pregnancy NYHA class, poor left ventricular function, presence of pulmonary hypertension or cyanosis, outflow tract obstruction and prosthetic valves adversely influences pregnancy outcome. Objective: The primary objective of this study was to determine the incidence of cardiac events amongst pregnant women with cardiac disease in HUSM. The secondary objectives were to specifically indentify incidence of primary and secondary cardiac events in the studied population, to identify presence of CARPREG predictors amongst pregnant women with cardiac disease, to formulate a risk stratification index for the prediction of cardiac events during pregnancy and to look into neonatal and obstetric outcomes in studied group. Methods: A total of 200 patients aged 18 years old and above with underlying or newly diagnosed cardiac disease were recruited into this prospective cohort study. At entry, any presence of cardiac event predictors was identified from history, physical examination, ECG and echocardiography findings. Follow up data were obtained during clinical visits. Data analysis using Chisquare test followed by univariate analysis using Simple Logistic Regression analysis. Following this, a Multivariate Logistic Regression analysis was performed. Result: The incidence of cardiac events among 200 studied patients in HUSM was 14%. The incidences of primary and secondary cardiac events were 9.5% and 7.0% respectively. Out of total studied patients, there were 150 patients with no cardiac event predictor, 41 patients with 1 cardiac event predictor and nine patients with more than one cardiac event predictors. Correlation between occurrence of cardiac event and number of cardiac event predictor which were analyzed using Chi-square test, simple logistic regression and multiple logistic regressions, had all consistently shown presence of cardiac event predictor would strongly predict occurrence of cardiac event (all with P < 0.001). The risk of cardiac event in pregnancies with 0, 1 and >1 predictors were estimated to be 2%, 43.9% and 77.8% respectively. Conclusion: This study had shown that the incidence of cardiac events was almost similar as estimated during the beginning of study when the sample size was calculated (14% vs. 13%). The number of cardiac event predictor(s) identified at entry were highly predictive of occurrence of cardiac events. This can be put up as risk stratification index to identify those patients who are at high risk of developing cardiac events during the prepartum, peripartum and postpartum period.

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Department.of Obstetrics and Gynaecology San Giovanni di Dio Hospital; 2 Department.of Life Science and Environment; 3 Department.of Toxicology; 4 Department.of Cardiovascular and Neurological Sciences; 5 Department.of Neonatal Intensive Care Unit, Puericulture Institute and Neonatal section, University of Cagliari, Italy; 6 UOC di Ostetricia e Ginecologia, Ospedale Sesto S, Giovanni Milano, Italy Objective: Currently there are few studies that may clearly

establish scientific criteria for diagnosis of labour. We conducted a prospective cohort study to evaluate if metabolomic analysis of urine samples collected from term pregnant women could represent a new tool for diagnosis of labour. Methods: Urine samples were collected from 45 women with physiological singleton pregnancy at 37–42 weeks of gestation referred to our delivery settings for term pregnancy monitoring or admitted for labour. Written informed consent was obtained from each woman. After aliquoting samples were stored at )80 C. Urines were chemically analysed by means of GC/MS and 1HNMR techniques as described before.1 Data matrix generated by these procedures were analysed by means of PLS-DA models (Partial least squares discriminant analysis; SIMCA-P+ version 12.0, Umetrics, Sweden) to test the hypothesis of the discriminating power of urinary metabolites concentrations as labour starts. The analysis on the variables of primary importance in this separation was applied to evaluate the set of discriminating metabolites. Results: PLS-DA models from both 1H-NMR and GC/MS analysis were able to discriminate between the pregnant women in labour state (n = 20) from the ones far from the delivery (n = 25) [PLS-DA_NMR (R2X = 0.46; R2Y = 0.753 Q2 = 0.573; Pvalue = 0.002); PLS-DA_GC_MS (R2X = 0.3; R2Y = 0.8; Q2 = 0.4; P-value = 0.005)]. A metabolic fingerprint based mainly on: succinate, hyppurate, creatinine, alanine, X267, hydroxybutanoic acid, X175, hetanedioic acid, ribonic acid, glicine, galactose, xilitol, was identified as metabolic pattern responsible of this separation. Conclusions: Wrong diagnosis of labour can lead to inadequate management of labour with possible adverse maternal outcome and fetal distress. Correct diagnosis of labour can reduce caesarean sections and instrumental delivery rate and improve perinatal outcomes. Our experimental data confirm the hypothesis that urine is a biological fluid adequate to identify pregnant women in labour. Collecting urine is a simple and non invasive technique, and it is extremely relevant from a clinical point of view because it makes possible for the first time to diagnose labour prospectively. Moreover by the identification of the discriminating metabolites we may better understand the molecular pathways of labour.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

Reference:

1. Fabiano A,et al. Metabolomic analysis of bronchoalveolar lavage fluid in preterm infants complicated by respiratory distress syndrome: preliminary results. Matern Fetal Neonatal Med, 2011;24(S2):55–8.

FC1.13 A novel regimen for HBV PMTCT – based on the international cooperative clinical study (ICCS)

Inaba, N; Hayashida, S; Shu-Kang, X; Oshima, K; Inaba, M; Inaba, F; Fukasawa, I Dokkyo Medical University, Japan

The ICCS was done to establish the new regimen for HBV PMTCT (prevention of mother-to-child transmission), which should be most economic and realize the smallest patients’ load and fewest dropouts by comparing the three regimens, i.e. the regimen recommended by the Japan Ministry of Health and Welfare (JMHW-R) in 1985, Inaba Regimen (Inaba-R) established in 1984 by me, and a new Inaba-R (n-Inaba-R) established recently. Three hundred and seventy two infants received JMHWR (G0,2/V2,3,5; G represents HBIG, V stands for HB vaccine. Zero means the period within 7 days after birth and the other numbers mean infants’ age by months), 135 did Inaba-R (G0/V0, 1, 3–5; V0 means the period within 24 h after birth) and 50 received n-Inaba-R (G0/V0,1). All these infants underwent HBsAg-screening and tests for serum levels of HBsAb, AST and ALT, and Hb, at least for 12 months after birth. Among these three groups, no differences were found statistically regarding infants’ development of carrier-state, their serum levels of HBsAb, sAST and sALT, and their Hb concentration. These results demonstrate that n-Inaba-R is equal to the other two regimens (JMHW-R and Inaba-R) with HBV PMTCT. Besides, n-Inaba-R is completed within 1 month after birth, which dramatically saves the dropouts, medical bills and works of both puerperas and obstetricians.

FC1.14 Induction of labour in outpatient setting in District General Hospital

Anita Rao, C; Joshi, M Broomfield Hospital, Essex, United Kingdom Objective: The primary aim of the study was to determine

whether the procedure was feasible, effective and safe for mother, foetus, and baby. The secondary aim was to examine the outcomes of various aspects of labour and mode of delivery. Methods: A prospective study involving 210 low risk women which includes well controlled hypertension and Diabetes in pregnancy was undertaken in the year 2011. Outpatient setting of induction of labour (IOL) was defined as initial treatment and monitoring in hospital and discharged home. We chose Propess slow release prostaglandin E2 preparation 10 mg (releasing 300 mg/h). Propess was inserted high into the vagina to sit behind the posterior lip of cervix. Women were sent home 6 h after

insertion of Propess. Patients were advised to return when in labour or 24 h after insertion. Results: Of the 210 women in this study 131 were Primigravida and 79 were Multigravida. Pre induction cervical Bishop’s score was 4 or less in 88% (186) women. The mean insertion Propess delivery interval was 30 h. Onset of labour (reaching to 4 cm dilatation) in the first 24 h was noted in 63% (132) women. Spontaneous rupture of membranes in the first 24 h occurred in 38% (80) women. Artificial rupture of membranes and Syntocinon was required in 76.6% (160) women. 71% (49) of women had vaginal births and 29% (61) had caesarean sections. The higher caesarean section was observed among Primigravidas. 60% (120) of women delivered before midnight and 40% (90) of women delivered after midnight. Neonatal outcome, the mean birthweight, was 3651 g. In one baby, Apgar score was less than 7 at 5 min. Neonatal admission was reported in four babies. Hyper stimulation of the uterus occurred in 1% (2) women. Conclusion: Outpatient setting of IOL in low risk women is feasible, effective and safe. The secondary outcomes were similar to that of inpatient induction of labour. This procedure had the advantage of less usage of medical professional time and NHS resources.

FC1.15 Fetal pillow: a novel device to reduce morbidity in a second stage caesarean section. a case controlled study

Seal, SL1; Dey, A2; Barman, SC3; Kamilya, G4; Mukherji, J5; Mahsud-Dornan, S6 1 R G Kar Medical College, Kolkata; 2 R G Kar Medical College, Kolkata; 3 Bankura Sammilani Medical College, Bankura; 4 Bankura Sammilani Medical College, Bankura; 5 R G Kar Medical College, Kolkata; 6 The Royal Jubilee Maternity Hospital, Belfast

There is some evidence that the rates of caesarean section at full dilation (CSFD) have increased disproportionately to the overall rise in caesarean section rates. The reasons for this are unclear but reduction in instrumental delivery rates, use of epidural analgesia, fear of litigation and changes in training have been cited. There is evidence that CSFD carries much higher morbidity for both the mother and the baby. There is a higher incidence of uterine incision extensions into the broad ligament, postpartum haemorrhage, increased operating time, blood transfusion, ITU admission and increased length of hospital stay for the mother. For the baby, there is an increased risk of admission to NICU and birth injury. Intraoperative complications account for most of morbidity related to a CSFD. These often occur as result of increased manipulation required for delivery of the head due to reduced liquor, thin overstretched and edematous lower segment, excessive caput and moulding, and often a deeply engaged head. Fetal Pillow (FP) is a silicone balloon that is inserted vaginally prior to carrying out a CSFD. The inflation of the balloon produces a bubble of fluid in the pelvic cavity and results in a 3– 4 cm upward displacement of fetal head.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

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Oral Presentations

We report a prospective study of the FP use in 50 patients undergoing a CS at full dilation. The study was carried during a 5-month period in one of the teaching institution of West Bengal (India). The data was compared to a group of 124 patients who underwent CSFD without the use of FP. Maternal and fetal data recorded were maternal age, weight at delivery, gestational age at delivery, duration of first and second stage of labour, the position and station of fetal head, birthweight and operating time. Maternal morbidity outcomes studied were intra-operative trauma, need for blood transfusion, postpartum haemorrhage (blood loss > 1000 mL), admission to intensive care unit, febrile morbidity and length of hospital stay. Neonatal morbidity characteristics recorded were a low 5-min Apgar score need for intubation, septicemia, neonatal trauma, admission to NICU for more than 24 h and neonatal death. In the FP group there was reduction in incision delivery interval, time taken for the procedure, length of hospital stay, need for transfusion and extension of uterine incisions. The results are very encouraging and a RCT is in progress to assess the routine use of fetal pillow in CSFD.

FC1.16 Escaped maternal deaths in a remote district of Sri Lanka

Fernando, TRN Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka Objective: (i)To find out the escaped maternal deaths in

Anuradhapura district. (ii) Find out the causes of maternal deaths and compare it with Sri Lankan country statistics. Methods: Data collection and analytic study. Data collected from maternal death review reports from the regional health office in Anurdhapura district, of Sri Lanka, during the years 2007–2009. Results: Total number of maternal deaths is 40, in Anuradhapura district (AD), during the years 2007–2009. The leading cause of death in pregnant mothers in AD 2007–2009 is suicide. That is nine deaths out of total 40 deaths. Three of them were unmarried pregnant mothers. Seven out of nine suicides were among primi para. Six of these women had committed suicide by ingesting poison. The time of suicide had been before the 28 weeks of gestation in six of these women. Second leading cause of maternal death in AD is postpartum haemorrhage (PPH), with six deaths. Heart disease is the third leading cause, with five maternal deaths. The leading cause of maternal death in Sri Lanka for the past decade had been PPH. When comparing to the national statistics of 2006 the 2nd leading cause of maternal death had been septic termination of pregnancy (TOP). However septic TOP were very low in AD, only one documented death in 2007–2009. Only 2 (5%) deaths were due to hypertensive diseases during 2007–2009. This is a significant improvement compared to national statistics in 2004 where hypertensive disease caused 17% of maternal deaths. 52% of maternal deaths in Anuradhapura district in 2007– 2009 have occurred during antenatal period, compared to Sri Lankan country statistics in 2006, majority of maternal deaths occurring during the postpartum period.

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Conclusions: According to the WHO definition of maternal

deaths suicides are categorized as ‘‘accidental or incidental cause’’.

FC1.17 Human chorionic gonadotrophin hormone for preventing recurrent miscarriage

Morley, LC1; Tang, T2; Simpson, N1 1

Department of Obstetrics and Gynaecology, The General Infirmary of Leeds, Leeds, United Kingdom; 2 Obstetrics and Gynaecology, Bradford Teaching Hospitals NHS Trust, Bradford, United Kingdom

Objective: Recurrent miscarriage (RM) is the loss of three or

more consecutive pregnancies, which can have a significant physical and psychological impact on a couple. The aetiologies underlying RM remain poorly understood, with up to half of cases remaining of unknown cause. As such, further research is needed to explore the mechanisms involved in successful pregnancies. Human chorionic gonadotrophin (hCG) is vital for maintaining the corpus luteum, but may have additional roles during implantation which support its use as a therapeutic agent for RM. The aim of this systematic review and meta-analysis is to determine the efficacy of hCG in preventing further miscarriage in women with a history of unexplained RM. Methods: The review was conducted following publication of our protocol by the Cochrane Collaboration (2010). The primary outcome was the efficacy and safety of prophylactic hCG. Selection criteria included all randomised controlled trials (RCTs) investigating hCG versus placebo or no treatment in preventing RM. The search was conducted by the Cochrane Pregnancy and Childbirth Group’s Trial Register (to week 4, September 2011). Results: Five studies met the inclusion criteria, totalling 302 participants. The meta-analysis suggested a statistically significant reduction in miscarriage rate in the hCG groups (RR 0.51; 95% CI 0.32–0.81 (I2 = 39%)). The number needed to treat was 7.14. A sensitivity analysis combined only the results from the largerpowered, more recent studies. Combining this data no longer suggested a statistically significant benefit (RR 0.74; 95% CI 0.44– 1.23). These results showed less heterogeneity when combined (I2 = 0%). However, removing these studies reduces the data from which conclusions can be drawn, thus limiting the power of this meta-analysis to exclude any possible treatment effect. As such, the role of hCG in preventing RM remains uncertain. There were no reported adverse effects of using hCG. Conclusion: Each study indicated that hCG was safe, with no adverse events reported as a direct result of hCG. However, the evidence to support hCG supplementation in preventing RM remains equivocal. A well designed RCT of adequate power and methodology is required to establish whether hCG may have an evidence-based role in preventing further miscarriages. The efficacy of hCG in preventing RM should be compared to other interventions, such as progesterone.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

FC1.18 Postpartum posterior reversible encephalopathy syndrome without hypertension

Kuntal, S; Raheem, T; Parveen, S Royal Gwent Hospital, Newport South Wales, United Kingdom

We report a case of a patient who developed posterior reversible encephalopathy syndrome (PRES) in puerperium without Preeclampsia, eclampsia or chronic hypertension. The woman a P3, presented on day 4 after an uneventful spontaneous normal vaginal delivery. She complained of severe occipital headache, neckpain, seizure and loss of consciousness. There was no relevant past medical history, no proteinurea and her BP was 140/86. She was treated with magnesium sulphate anticipating imminent eclampsia the CT scan Brain, Lumbar puncture Carotid Doppler and Venogram was normal. Her full blood count, calcium, TFT, CRP were in the normal range. The normal investigations posed a challenge to the diagnosis. The MRI showed presence of oedema involving the white matter of parieto-occipital regions in keeping with changes consistent with posterior reversible encephalopathy syndrome. The patient was treated symptomatically and made a full recovery. The posterior reversible encephalopathy syndrome is a clinicoradiological diagnosis. The other causes could be autoimmune diseases, immunosuppresants, thrombotic thrombocytopenic purpura, sepsis etc. The pathogenesis is thought to be a disturbed cerebral auto regulation with endothelial injury or dysfunction which results in increased vascular permeability in posterior circulation. The MRI head including the T1 weighted image, fluid attenuation inversion recovery, diffusion weighted imaging; apparent diffusion coefficient and Magnet resonance arteriography are the imaging options available. Early diagnosis followed by appropriate treatment is associated with good outcome and reversal of the clinicoradiological changes. The case is presented here due to puzzling constellation of signs and symptoms for both the Obstetricians and Neurologists. It also reflects on the fact that postpartum women may be at risk of posterior reversible encephalopathy syndrome without pre-eclampsia, eclampsia and high degree of suspicion and multidisciplinary approach is key to timely diagnosis and treatment.

FC1.19 Role of abdominal packing in management of postpartum haemorrhage

Yahaya, AS; Shaffie, Z Department of Obstetrics & Gynaecology, Tuanku Fauziah Hospital, Perlis, Malaysia Introduction: Postpartum haemorrhage (PPH) is an important

cause of maternal morbidity & mortality. Standard measures to control PPH include medical therapy, surgical intervention such as repair of genital tract trauma, evacuation of retained product of conception, uterine balloon tamponade, exploratory laparotomy and uterine compression sutures, uterine arteries & internal iliac arteries ligation, systemic vascular devascularization and

abdominal hysterectomy. Abdominal packing had been used as a useful alternative to control pelvic bleeding when standard measures fail. Objective: To study the effectiveness of abdominal packing in management of massive postpartum haemorrhage. Methods: Retrospective study of 10 cases of uncontrollable haemorrhage following emergency peripartum hysterectomies where abdominal packing were used as a last resort over a period from March 2007 to September 2011 in Tuanku Fauziah Hospital, Perlis, Malaysia. Results: Total deliveries during the period studied were 19 666, in which 30 emergency peripartum hysterectomies were done (1.525/ 1000 deliveries) following massive PPH. Out of these, 10 cases were followed with abdominal packing as a last intervention for management of massive blood loss. Packing were done using 2–5 abdominal packs (abdominal gauze pack size 29 · 29 cm) left intra-abdominally. Relaparotomy for removal of packing were done 33–60 h after packing surgery. Abdomen were closed in layers after removal of abdominal packs and no active bleeding noted in all of the cases. No relaparotomy indicated after removal of pack in all cases. No documented sepsis or peritonitis attributed to abdominal packing in the case series. No bowel obstruction or organ injury noted and no maternal mortality reported from these cases. Conclusions: In the event of massive postpartum haemorrhage, bleeding that is uncontrolled by surgical intervention may be controlled with abdominal packing. The packing technique we described was able to achieved complete haemostasis which we believe may have been impossible using alternative measures.

FC1.20 Multiple pregnancy in assisted reproductive technology (ART): is there heritable factor?

Gupta, M; Vaidya, A; Al Saffar, N Department of Obstetrics and Gynaecology, Farwaniya Hospital, Kuwait Objective: Multiple pregnancy is a major complication of assisted

reproductive technology (ART) because of associated Obstetric, Neonatal complications, and financial, psychological impact. The aim of our study was to determine whether women with a family history of multiple pregnancies are more prone to have multiple pregnancies through ART. Methods: A comparative prospective case controlled study carried in Farwaniya Hospital. Four groups of pregnant women with 100 women each were studied. (i) Multiple pregnancies following ART (ii) Singleton pregnancy following ART (iii) Spontaneous multiple pregnancy (iv) Spontaneous singleton pregnancy ART included In-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) and induction of ovulation with gonadotropins. Background history of multiple pregnancies in mothers, sisters, grandmothers, aunts or any other close relative was documented. The pregnancies were followed up till delivery and obstetric complications, mode of delivery and neonatal outcome were documented.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

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Oral Presentations

Results: Women with Multiple pregnancies from ART have significant family history of multiple pregnancies than their ART counterparts with singleton pregnancies (46% vs. 18%; P < 0.01). Spontaneous multiple pregnancy was significantly associated with family history of multiple pregnancy compared to spontaneous singleton pregnancy (48% vs. 16%; P < 0.01). There was no significant difference in the family history of multiple pregnancy between women with spontaneous multiple pregnancies and those through ART (46% vs. 48%; P = 0.8%). More multiple pregnancies through ART ended in preterm delivery compared with spontaneous multiple pregnancies (84–44%; P < 0.04%). Conclusion: (i)Those with a genetic predisposition to multiple pregnancy appear to have a higher risk of multiple pregnancy even with ART. (ii) There is need for prenatal education for women referred for ART and tailor treatment to the background of the patient. (iii) Probably a risk scoring system for patients undergoing ART involving family history of multiple pregnancies should be adopted. In these patients treatment should be individually tailored in terms of controlled use of inducing agent, limiting the number of embryos transferred and delaying embryo transfer.

FC1.21 The value of prenatal diagnosis for lethal fetal abnormalities in the United Arab Emirates (UAE)

Ramanathan, G1; Lo, W2; Mustafa, A3; Jahangir, FB3; Lee, J4 1

Consultant ObGyn, Director of Fetal Medicine; 2 Senior Charge Midwife, Fetal Medicine; 3 Specialist ObGyn & Fetal Medicine; 4 Chief Medical Officer Corniche Hospital, UAE Objective: The management of serious fetal abnormalities

includes the option of continuing the pregnancy with surveillance, or termination of pregnancy (TOP). The UAE Abortion Law states TOP is only permissible if a mother’s life is at risk, or there is a lethal fetal abnormality, in both the pregnancy must be 15 min, there were significant differences in cord blood pH (P = 0.02) and BE (P = 0.01) between twin siblings. From the scatted plot graph, we are able to identify that at 21 min, BE dropped down to )6.8. At 32 min, pH dropped to 7.2. Prediction made from the graph is that at 53 min BE will drop to )12. Conclusion: Our study showed that an acceptable time interval between the 1st and 2nd twin was 21 min after which the BE begin to deteriorate. The delivery should be competed within 32 min after which pH begin to deteriorate. Hence, all deliveries of 2nd twin should be within 21 min but not beyond 32 minutes.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

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Oral Presentations

FC1.30 The effect of reflexology on the pain and outcomes of the labour on the primiparous women

Valiani, M; Shiran, E; Kianpour, M; Hasanpour, M Isfahan University of Medical Sciences, Iran Background: Reflexology is one of the non-pharmacological pain

relief methods, and since it is a non-invasive, inexpensive and applicable technique, it can be used by a skilled and trained midwife. This study aimed to review the effect of reflexology on the pain and outcomes of the labour. Methods: In this quasi-experimental study, 88 primiparous mothers referred to selected hospitals of Isfahan for vaginal delivery were selected using simple random sampling method and then randomised in two groups. Data collection tools were the demographic data questionnaire, profile and outcomes of the labour and the short-form of the McGill Questionnaire for Pain Rating Index (PRI) assessment. The intervention was general and specific reflexology in the active phase of labour. PRI was assessed before the intervention and four times after the intervention (3–5 cm, 6–8 cm and 9–10 cm dilatations and second stage of labour. Results: There was no significant difference between groups before intervention. In the reflexology group, there was a significant difference between the PRI before and after the four stages intervention (P < 0.001). PRI was different significantly between studied groups after intervention (P < 0.001). The length of active phase of labour was different significantly between the two groups; but this difference was not significant during the second (P = 0.29), and the third (P = 0.27) stages. The difference between the 1st min and the 5th min Apgar score (P < 0.001) and rate of hemorrhage between the two groups were different significantly (P = 0.02). Conclusions: Reflexology can lead to decrease in the labour pain. Therefore, regarding to the safety of this technique, it can be replaced as an alternative for pharmacological methods.

FC1.31 Epidemic of obesity in a South East England NHS hospital

Hussain, U; Qayam, L; Khan, R

Objective: To assess the incidence, antenatal and postnatal

complication of raised BMI in pregnant women. To examine the fetal risks of adverse pregnancy outcome in relation to obesity. Methods: Retrospective and prospective analysis of 12 000 pregnant women from Pembury Hospital NHS Trust, Kent between January 2001 and 2007. Data collected from EUROKING system and statistically analysed. A comparison of pregnancy outcome was based on the basis of maternal BMI at booking. Data presented as frequencies and adjusted odds ratios. Results: Fourty-five per cent of women were found to be preobese or obese. Women of Caucasian origin were more likely to be obese (P < 0.001) as compared to Black and Asian women. The caesarean section rate was 32.5% in obese women as compared to 15.3% in women with normal BMI (statistically significant). The rate of pre-existing diabetes mellitus was between 3.8% in obese women as compared to 1% in normal population (P value < 0.0001). Similarly, pre-existing hypertension was found in 10% of obese women as compared to 2% in women with normal BMI (P value < 0.0001). 4.1% of babies born to mothers of normal BMI were admitted as opposed to 6.9% born to obese mothers. The still birth rate was 1% in obese women as compared to 0.25% in normal BMI mothers. Up to 20.5% of babies born to obese mothers weighed >4 kg as compared to 8.6% in normal BMI (statistically significant). Conclusion: This study shows that obesity has a negative impact on pregnancy by increasing antenatal and postnatal complications. MATERNAL: pregnancy induced hypertension, gestational diabetes, caesarean delivery, postpartum haemorrhage NEONATAL: macrosomia and stillbirth. Recommendation: A multidisciplinary weight management clinic is suggested to optimise weight control and identify risk factors.Any woman with a BMI > 35kg/m2 should be identified as high risk patients and treated with respect, dignity alongside increased obstetric surveillance.

FC1.32 Comparison between amnisure placental alpha microglobulin-1 rapid immunoassay and standard diagnostic methods for detection of rupture of membranes

Ng, BK; Lim, PS; Mohamad Nasir, S; Nur Azurah, AG; Nor Azlin, MI; Mohd Hashim, O; Muhammad Abdul Jamil, MY

The Princess Alexandra Hospital NHS Trust, Essex, United Kingdom

Department of Obstetrics and Gynaecology, UKM Medical Centre, Malaysia

Background: The UK incidence of pregnant obese women

Background: Management of prelabour rupture of membranes

ranges from 18.5% to 38.35% and is rising. According to recent CEMACH report, 35% of maternal and 30% of neonatal deaths were in obese pregnant women. Obesity in pregnancy was selected as CEMACH‘s principal project with a maternal health focus for 2008–2011. Increasing body mass index BMI is associated with increased magnitude of risks for the mother and fetus.

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poses one of the most important therapeutic dilemmas in current obstetric practice. Conventional clinical methods for diagnosing rupture of membranes are associated with high false-positive rate. Absence of an accurate non-invasive diagnostic test for fetal membrane rupture resulted in the emergence of other tests eg placental alpha microglobulin-1.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

Objective: To determine the diagnostic accuracy of placental

alpha microglobulin-1 assay and standard diagnostic methods for detecting rupture of membrane. Methods: A prospective diagnostic study was carried out between June 2011 and November 2011. Patients who presented with symptoms suggestive of rupture of membranes to Patient Admission Centre (PAC) PPUKM were recruited. Intial evaluation included both the standard diagnostic methods for rupture of membranes (if two of the following three conditions were present: pooling of fluid at Pouch of douglas, positive nitrazine test, or ferning) and placental alpha microglobulin-1 immunoassay. The actual rupture of membranes was diagnosed definitely on review of the medical records after delivery (absent of membrane or pad chart positive). Results: A total of 211 patients were recruited. Review of the medical records confirmed that 187 of 211 patients (88.6%) had ruptured membranes at their initial presentation, whereas 24 patients (11.4%) had intact membranes. Placental alpha microglobulin-1 immunoassay confirmed rupture of membrane at initial presentation with a sensitivity of 95.7% (179 of 187), specificity of 100% (24 of 24), positive predictive value of 100% (179 of 179), and negative predictive value of 75.0% (24 of 32). By comparison, the conventional standard diagnostic methods (pooling, nitrazine, and ferning) had a sensitivity of 78.1% (146 of 187), specificity of 100% (24 of 24), positive predictive value of 100% (146 of 146), and negative predictive value of 36.9% (24 of 65) in diagnosing rupture of membrane. Conclusion: The placental alpha-microglobulin-1 immunoassay is a rapid and accurate method for confirming the diagnosis of rupture of membrane. Moreover, it was found to be superior to conventional standard diagnostic methods (pooling, nitrazine, ferning), the nitrazine test alone or Fern test alone.

FC1.33 Haemoperitoneum in pregnancy

Karmarkar, R; Mahfous, I; Sohail, A

FC1.34 Preliminary report on retrospective case-controlled study on singleton term low birthweight (TLBW) babies, maternal risk factors and neonatal outcome

Yee, LE1; Eugene Leong, WK2; Lim, CT3; Quek, KF4 1

Department of Obstetrics and Gynaecology, University Malaya Medical Centre; Eugene; 2 Department of Obstetrics and Gynaecology, University Malaya Medical Centre; 3 Department of Paediatric, University Malaya Medical Centre; 4 Community Health, Sunway Monash University, Sunway Background: There is a need to obtain data regarding the

magnitude, determinants of singleton TLBW babies 140/90 and 1+ proteinuria at a gestational age >20 weeks were recruited through outpatient and emergency department by performing a dipstick examination. The first sample on the first post-admission day provided a spot midstream urine sample for urine P:C ratio. From the next voided specimen till the first sample on next morning were collected for a 24-h urinary protein determination. Results: The mean age of the patients was 27.56 ± 4.4 years and the mean gestational age was 34.9 ± 2.87 weeks. 115 (76.67%) patients had positive 24-h urine protein test for significant proteinuria. Out of these 115 (100%) also had a positive spot urine protein creatinine ratio test and none (0%) had a negative spot urine protein creatinine ratio test. Thirty-five (23.3%) patients had negative 24-h urine protein test for significant proteinuria. Out of these 1 (2.8%) had a positive spot urine protein creatinine ratio test and 34 (97.2%) had a negative spot urine protein creatinine ratio test. Spot urine protein creatinine ratio test had an accuracy of 99.3%. The mean 24-h urine protein of the patients was 1909.5 ± 1437 mg/day and the mean spot urine protein creatinine ratio was 1.85 ± 1.5. Both had a positive linear correlation, which was statistically significant (Pearson Correlation coefficient 0.896; P = 0.00). The calculated sensitivity and specificity of the Spot urine protein creatinine ratio test in comparison to 24-h urine protein test was 100% and 97.14% respectively and a positive predictive value (PPV) and negative predictive value (NPV) of 99.1% and 100% respectively. Conclusion: We conclude that the P:C in spot urine specimens is an accurate method to estimate the protein excretion in urine and there is a strong correlation between the protein:creatinine ratio in a random urine sample and 24-h protein excretion.

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Bintulu Hospital Sarawak, Malaysia Background: Bintulu Hospital is the referral centre where

problematic cases were anticipated. From year 2007 to 2009, there have been more than 2% of total vaginal delivery mothers per year experiencing third degree tear. The study is to ensure quality improvement in the service and patient care. Objective: This study is specifically designed for nurses to identify contributing factors to third degree tear, implement remedial action and evaluating the effectiveness of the implemented measures ensuring reduction in the number of incidences of third degree tear from above 2% to not more than 1% of total vaginal deliveries per year. Methods: Validated questionnaires and interview methods were used. Mothers admitted from January to June 2010 were interviewed and supervision on nurses conducting deliveries was also done. Assessment and evaluation was carried out from July to December 2010. Remedial measures were evaluated by monitoring all high risk mothers. Finding: Total of 1514 vaginal deliveries in January–June 2010 and noted that primigravida, mothers with history of big baby and non ante-natal mothers were at risk. After analyzing and interpreting the finding, improvement steps were taken to ensure reduction in third degree tear among the targeted group. Remedial action taken: Discussion with health clinic staff was conducted and an ante-natal class was recommended. Hospital staff will re-enforce on the education, supervised delivery, protect perineum, appropriate time for episiotomy and no sweep and stretch was implemented. Lateral episiotomy training, continuous nursing education and hands-on practice was implemented for better knowledge and skills. Shortage of staff is a major issue and negotiation with higher authority to provide more staff has been done. Early pushing is one of the contributing factors, therefore pain relief like pethidine and entonox were given to ensure relaxation and less pain. Husband friendly is encouraged, good teamspirit ensure success and target achieved. Conclusion: The group had achieved the set standard in reducing the incidence of third degree tear to not more to 1% of total vaginal delivery. We have identified the contributing factors and learned that antenatal education and good delivery technique is critically important. Therefore; preventing third degree tear will definitely lessen time in post delivery management thus quality patient care is achieved.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Oral Presentations

FC1.52 Pregnancy outcome following LLETZ; 12 years retrospective study

Mohanty, AK; Sibtain, S; Sinha, P; Zaidi, J Conquest Hospital, United Kingdom Background: Because of the advent of effective screening

programmes, large loop excision of transformation zone (LLETZ) has been established as the accepted method of treatment for cervical intraepithelial neoplasia / microinvasive cervical cancer especially in young women.1 Published studies, which looked in to the outcome of pregnancies following LLETZ remain inconclusive.1,2,3 Method: We conducted a retrospective analysis of pregnancy outcomes over last 10 years (2000–2009) for those women who were cared for their pregnancy in our Trust after having LLETZ. Data were collected retrospectively from the euroking and joe system and were analysed. During this period there were 409 women who were pregnant beyond 16 weeks gestation following LLETZ, of whom 45 had their pregnancies ending before 37 completed weeks. This amounts to 11% of this population. Out of these 45 women fourteen have had term pregnancies prior to LLETZ. Others had been pregnant for the first time beyond 16 weeks after the LLETZ. Three women from the study had their pregnancy ended before 28 completed weeks, while eight other delivered between 28 and 34 weeks of gestation. All women who delivered before 34 weeks gestation (n = 11) had some evidence of infection/inflammation as per either the high vaginal swab culture / mid specimen urine culture / placental swab culture / placental histology report. On the contrary those women who delivered between 34 and 37 completed weeks gestation had no significant evidence of infection although these group did not have the placental swab nor the placental histology routinely. Conclusion: In our study we found LLETZ to be associated with increased incidence of preterm deliveries, which is in accordance with other studies. Although preterm birth is defined as being before 37 completed weeks, most mortality and morbidity is experienced by babies born before 34 weeks. We found preterm deliveries before 34 weeks are associated with some evidence of infection which can be prevented in most if not all of the cases. References:

1. Kyrgiou M et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet. 2006 Feb 11;367(9509):489–98. 2. Arbyn M. et. al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008 Sep 18;337:a1284. 3. Cruickshank ME et. al. Fertility and pregnancy outcome following large loop excision of the cervical transformation zone. BJOG 1995; 102: 467–470.

FC1.53 The impact of body mass index on maternal and neonatal outcomes: a retrospective study of 30 298 singleton pregnancies in a tertiary referral hospital in Northern Ireland, 2004–2011

Scott-Pillai, R1; Spence, D1; Cardwell, C2; Hunter, A3; Holmes, VA1 1

School of Nursing and Midwifery, Queen’s University Belfast, United Kingdom; 2 Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, United Kingdom; 3 Royal Jubilee Maternity Service, Belfast Health and Social Care Trust, Belfast, United Kingdom Objective: To assess the prevalence of overweight and obesity in a

UK obstetric population and to explore the impact of body mass index (BMI) on maternal and neonatal outcomes. Methods: Retrospective data were obtained from the Northern Ireland maternity system for 30 298 singleton pregnancies with a BMI recorded before 16 weeks’ gestation, delivered over an 8 year period, 2004–2011. Women were categorised according to the WHO classification into underweight (BMI