Cases Of Perinatal Death Research Articles

Implementation of the Perinatal Death Surveillance and Response guidelines: Lessons from annual health system strengthening interventions in the Rwenzori Sub-Region, Western Uganda.

AimTo determine the health facility‐based perinatal mortality rate, its causes and avoidable factors using the perinatal mortality surveillance and response guidelines.DesignThis was an action study conducted in one of the districts in Western Uganda from 1 January–31 December 2019.MethodsA total of 20 perinatal death cases were recruited consecutively. Data were collected using a Ministry of Health Perinatal Death Surveillance and Response (PDSR) questionnaire containing questions on pregnancy, delivery and immediate postnatal care. We used descriptive statistics to describe key data elements.ResultsWe found a health facility‐based perinatal mortality rate of 17.3 deaths per 1,000 live births. Birth asphyxia was the most common cause of perinatal deaths. Seven, three and ten mothers delayed seeking, reaching and receiving appropriate health care, respectively.

Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18years of follow-up.

Since introduced, the Apgar score has remained the most widespread predictor for neonatal morbidity and mortality. We aimed to investigate the association between low 5-min Apgar score and long-term infectious pediatric morbidity. A population-based cohort analysis was performed comparing total and specific subtypes of infectious morbidity leading to hospitalization among term newborns with normal (≥ 7) and low (< 7) 5-min Apgar scores, born between 1999 and 2014 at a single tertiary regional hospital. Infectious morbidity included hospitalizations involving a pre-defined set of infection-related ICD-9 codes. A Kaplan-Meier survival curve was constructed to compare cumulative infectious morbidity incidence and a Cox proportional hazards model to adjust for confounders. The long-term analysis of 223,335 children (excluding perinatal death cases) yielded 585 (0.3%) infants with low 5-min Apgar scores. The rate of infection-related hospitalizations was 9.8% and 12.4% among newborns with normal and low 5-min Apgar scores, respectively (p = 0.06). Adjusting for maternal age, gestational age, hypertension, diabetes, cesarean delivery, and fertility treatments, the association proved to be statistically significant (adjusted HR = 1.28; 95% CI 1.01-1.61).Conclusion: Term infants with low 5-min Apgar scores may be at an increased risk for long-term pediatric infectious morbidity.What is Known:• Though not meant to be a prognostic tool for long-term morbidity, studies assessing the correlation between low Apgar score and long-term outcomes were and are being performed, reporting significant associations with many outcomes-such as cerebral palsy (CP), ophthalmic disorders, GI disorders, and several types of malignancies.• Yet, an association between low Apgar scores and future health remains a matter of controversy.What is New:• Our work shows that a low 5-min Apgar score is independently associated with long-term pediatric infection-related hospitalizations among term singleton newborns.

Parvovirus B19 DNAemia in pregnant women in relation to perinatal death: A nested case-control study within a large population-based pregnancy cohort.

Parvovirus B19 (B19V) is the infectious cause of exanthema infectiosum. In Europe around 40% of pregnant women are susceptible to infection. Having small children at home is the main risk factor for contracting an infection during pregnancy. The association between B19V-infection and perinatal death is not yet settled. The aims of the study were to estimate the association between maternal parvovirus B19 infection in pregnancy and perinatal death, and to assess the significance of a positive B19V PCR in pregnancy. The study population consists of women included in the Norwegian Mother and Child Cohort Study, a prospective population-based pregnancy cohort of nearly 100000 women. Blood samples were obtained during weeks 17-18 in pregnancy (M1), at birth, and in umbilical cord blood. Within participants in the pregnancy cohort, 138 cases of perinatal death and 1350 controls with live-born children were included in a nested case-control study. Samples were analyzed with B19V serology and B19V PCR according to a predefined test algorithm. For cases, medical records and laboratory results from hospitals were combined with the results of B19V serology and PCR. The reported causes of perinatal death were categorized using the classification system: Causes Of Death and Associated Conditions (CODAC). The B19V seroconversion rates were 9.8% for cases and 6.8% for control mothers. The odds ratio for maternal B19V infection in cases compared with controls was 1.28 (95% CI 0.35-4.70), adjusted for age, parity, body mass index and tobacco use. B19V-PCR-positive samples were detected at weeks 17-18 of gestation in both cases and controls. The proportion of positive samples was similar in cases and controls, 24% and 28.2%, respectively. Mothers with PCR-positive M1 samples transmitted B19V vertically in 9.1% of cases and in 11.9% of the controls. Of all perinatal deaths, 53% were attributed to placental pathology or unknown causes. B19V PCR positivity was high and similar in both cases and controls. In our study B19V DNAemia was not seen to be associated with fatal outcome of pregnancy. The clinical significance of B19V DNA detection during pregnancy is uncertain. Caution is needed when diagnosing a B19V infection based only on B19V DNAemia.

Identifying risk factors for perinatal death at Tororo District Hospital, Uganda: a case-control study

BackgroundSub-Saharan Africa faces a disproportionate burden of perinatal deaths globally. However, data to inform targeted interventions on an institutional level is lacking, especially in rural settings. The objective of this study is to identify risk factors for perinatal death at a resource-limited hospital in Uganda.MethodsThis is a retrospective case-control study at a district hospital in eastern Uganda using birth registry data. Cases were admissions with stillbirths at or beyond 24 weeks or neonatal deaths within 28 days of birth. Controls were admissions that resulted in deliveries immediately preceding and following each case. We compared demographic and obstetric factors between cases and controls to identify risk factors for perinatal death. Subgroup analysis of type of perinatal death was also performed. Chi square, Fisher’s exact, t-test, and Wilcoxon-Mann-Whitney rank sum tests were utilized for bivariate analysis, and multiple logistic regression for multivariate analysis.ResultsFrom January 2014 to December 2014, there were 185 cases of perinatal death, of which 36% (n = 69) were macerated stillbirths, 40% (n = 76) were fresh stillbirths, and 25% (n = 47) were neonatal deaths. The rate of perinatal death among all deliveries at the institution was 35.5 per 1000 deliveries. Factors associated with increased odds perinatal death included: prematurity (adjusted odds ratio (aOR) 19.7, 95% confidence interval (CI) 7.2–49.2), breech presentation (aOR 7.0, CI 1.4–35.5), multiple gestation (aOR 4.0, CI 1.1–13.9), cesarean delivery (aOR 3.8, CI 2.3–6.4) and low birth weight (aOR 2.5, CI 1.1–5.3). Analysis by subtype of perinatal death revealed distinct associations with the aforementioned risk factors, in particular for antepartum hemorrhage, which was only associated with fresh stillbirths (aOR 6.7, CI 1.6–28.8), and low birth weight.ConclusionsThe rate of perinatal death at our rural hospital site was higher than national targets, and these deaths were associated with prematurity, low birth weight, breech presentation, multiple gestation, and cesarean delivery. This data and the approach utilized to acquire it can be leveraged to inform targeted interventions to reduce the rate of stillbirths and neonatal deaths in similar low resource settings.

Effects of maternity waiting homes on perinatal deaths in an Ethiopian hospital. A case-control study

Abstract Background A Maternity Waiting Home (MWH) is a residential facility located near a medical facility, where women with high risk pregnancies can await and be transferred to the medical facility shortly before delivery or earlier if a complication arise. MWH are widespread in the developing countries, to reduce the long distances to reach health facilities. The aim of this study was to investigate whether MWH was an effective strategy in reducing perinatal deaths at Wolisso Hospital in Ethiopia, from 2014 to 2017. This hospital is supported by the Italian NGO Doctors With Africa CUAMM, with a strong commitment to reduce maternal and child mortality. Methods Through a case-control study, we compared perinatal mortality among women admitted via MWH and women admitted directly to the hospital. Cases were mothers who experienced at least a perinatal death before discharge. For each case, two mothers who gave birth to one or more babies alive until discharge were selected as controls. 3 groups of confounding variables were considered: maternal conditions or related to the current pregnancy, variables related to the delivery and neonatal characteristics. A regression model was built adjusting for each group. Statistically significant variables were combined in a final model. Results 1175 cases and 2350 controls were included. Women admitted through MWH showed a OR 0.49 (95%CI:0.33-0.71; p &amp;lt; 0.000) for perinatal mortality when adjusted for the maternal/current pregnancy conditions, and a OR 0.60 (95%CI:0.40-0.90, p = 0.013) when adjusted for the delivery variables. In the final model the risk of perinatal mortality for women admitted to MWH was 54% less than those admitted directly to the hospital (OR = 0.46, 95%CI:0.30-0.70; p &amp;lt; 0.000). Conclusions Our results show a more than halved risk of perinatal death cases for women admitted to the hospital through a MWH in rural Ethiopia, and support the policy implemented by the government in building such structures nearby each hospital. Key messages Maternity Waiting Home is a structure near a health facility, where pregnant women at risk wait for their delivery. MWH is an easy and effective tool to reduce perinatal deaths in rural Ethiopia.

EP19.22: Detection rate and outcome of small‐for‐gestational‐age fetuses using a routine third trimester ultrasound scan in our population

Fetal growth restriction is a common pregnancy complication related to placental insufficiency and poor perinatal outcome. The aim of our study was to evaluate our pregnancy control performance using an ultrasound scan at 32-34 and 38-40 weeks of gestation in our population. We define SGA to fetuses with EFW below 10th percentile and normal Doppler, and IUGR when EFW below 3rd percentile or between 3rd and 10th percentile with abnormal Doppler. A retrospective study was conducted using our data base from all the pregnancies during July 2016 until August 2018 in our Hospital. We selected all newly born babies with weight below 10th percentile according to gestational age and gender using a calculator. We studied maternal and obstetric parameters, diagnosis of FGR and perinatal outcomes. We excluded multiple pregnancies and intrauterine fetal death. We had a total of 2088 deliveries in the mentioned period, from which 266 (12.7%) were below 10th percentile of weight. Our detection rate was 37.2% (n = 99). In this group 37.4% corresponded to SGA and 62.6% to IUGR. From the not detected group (n = 167), 19.2% had a weight below 3rd percentile. We found statistically significant differences towards the group where FGR was detected, when comparing serum PAPP-A levels less than 0.3 MoMs (OR 5.32 IC 1.05-26.91), gestational hypertensive disorders (OR 5.34 IC 1.86-15.32), use of vaginal prostaglandins (OR 2.74 IC 1.64-4.58) and induction of labour (OR 2.61 IC 1.52-4.46). There were no differences in maternal age, parity, smoking habits, BMI, type of delivery, APGAR or pH minor 7.20 in both groups. There were no cases of perinatal death. FGR affects almost 13% of our population. Despite our third trimester ultrasound screening process our detection rate is low. Improvement of our method should be considered in order to achieve a higher detection rate. Nevertheless, no differences were found in perinatal outcomes in both groups. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Pregnancy outcomes in patients with rheumatoid arthritis and systemic lupus erythematosus. Part II. Neonatal outcomes

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are the most common autoimmune rheumatic diseases (RD) that occur mostly in women of childbearing age, and the occurrence of pregnancy is an expected fact. Due to the ongoing disputes over the ethics of maintaining birth rates among an unhealthy population, modern researchers focus attention on studies of the mutual impact of RD and pregnancy, on the safety of pharmacotherapy during conception and gestation, and on the health of the offspring born to female patients with RD.Objective: to evaluate the neonatal outcomes of pregnancy in patients with RA and SLE.Subjects and methods. An investigation was conducted to study the health status of 73 babies born to 72 female patients with RD (76 cases of pregnancy), of whom 29 patients with RA (32 cases of pregnancy) and 43 with SLE (44 cases of pregnancy) were followed up prospectively at the V.A. Nasonova Research Institute of Rheumatology and the Academician V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology. The health status of the babies was evaluated in the first year of their life. Supervising neonatologists and pediatricians recorded abnormalities in the newborns and subsequently analyzed using their medical records (extracts from maternity hospitals, children's hospitals, and outpatient cards).Results and discussion. Of the 76 supervised pregnancies, 72 (94.7%) resulted in 73 live births (one twin pregnancy in a patient with SLE). There were three (6.8%) cases of pregnancy loss in the second trimester in patients with SLE having antiphospholipid syndrome (APS) and one (3.1%) case of perinatal death (a boy and a girl from a monochorionic diamniotic twin with reversed arterial perfusion) in a patient with seropositive RA. The height and body weight of all the newborns conformed to gestational age. Patients with RA and SLE compared to the population more often gave birth to low birthweight babies (9.7 and 21.4% versus 60.9 per 1,000 live births in the Russian population). In the groups of mothers with RA and SLE, their infants had a high Apgar score of 8–9 at one and five minutes. Various abnormalities were detected in 5 (16.1%) and 15 (35.7%) babies born to mothers with RA and to those with SLE, respectively. Among the neonatal congenital anomalies (malformations), there was patent foramen ovale, patent ductus arteriosus, and hip joint dysplasia, which were more common in the babies born to mothers with SLE having APS and exceeded the population-based incidence of these anomalies. The babies were more commonly diagnosed with congenital pneumonia than those in the population; there were single cases of umbilical hernia, hemangioma, thrombocytopenia, hemorrhagic disease of the newborn, perinatal encephalopathy, and congenital hearing loss.Conclusion. The mothers with RA and SLE more often gave birth to low birthweight babies than did those in the population. The infants born to mothers with RA and SLE had significantly more frequently congenital heart defects (patent foramen ovale, patent ductus arteriosus) and congenital pneumonia. The detected abnormalities were more common in the newborns born to mothers with SLE having APS. Maternal RA and SLE activities and/or performed therapy were not found to have a negative impact on the incidence of abnormalities in babies.

Prevalence of Perinatal Deaths in A Tertiary Care Hospital of Nepal

Perinatal mortality indicates quality of maternal and neonatal care and is high in Nepal. This study was conducted to find out the prevalence of perinatal deaths in a tertiary care center. This descriptive cross-sectional study was conducted from July 2017 to June 2018 at KIST Medical College and Teaching Hospital. Details of each perinatal death were filled in predesigned proforma from hospital in-patient records within 24 hours of perinatal death. The total of 1088 cases were selected for the study and convenience sampling was done. Statistical analysis was done with Statistical Package for Social Sciences version 17.0. Prevalence of perinatal death is 16 (1.46%) out of 1095 births. In the same way, perinatal mortality rate, stillbirth rate and early neonatal mortality rate were calculated and found to be 14.61 per 1000 births, 8.21 per 1000 births and 6.44 per 1000 live births respectively. Preterm neonates constituted of 71.4% of early neonatal deaths. Perinatal mortality rate was 50% lower than that of national survey, however comparable with study at another tertiary care center at Kathmandu. Stillbirth and prematurity contributed significantly to perinatal mortality. Provision of good antenatal surveillance, identification of high risk pregnancies and good neonatal care to preterm neonates would be required to reduce perinatal mortality.

Somatic features and reproduction characteristics of patients with perinatal fetal death

Aims of study. The current analysis was undertaken to determine risk factors for perinatal losses and assess the possibility of their prediction.&#x0D; Study design, materials and methods. We analyzed 307 cases of perinatal death in obstetric facilities of the Leningrad region (main group). 357 women who gave birth to living children who lived 7 days of the perinatal period represented the control comparison group. A retrospective analysis was carried out based on medical hospital records: an examination of events during pregnancy, childbirth, postpartum, and early infancy, as well as afterbirth study findings and autopsy reports.&#x0D; Results. We performed a retrospective analysis of the social (3 factors), somatic (28 factors), and reproductive (15 factors) statuses of patients with perinatal losses in order to try to assess the possibility of identifying risk groups and predicting perinatal and fetal mortality.&#x0D; Conclusion. The predictors of perinatal mortality were determined, namely features of social status (absence of a marriage record and a permanent job, low level of education), somatic status (diabetes, cardiovascular pathology, arterial hypertension, chronic hemocontact infections), and reproductive status (late menarche, early sexual debut, previous infectious genital pathology, childbirth at a young age, etc.).

Analysis of Causes of Death and Related Factors of 102 Perinatal Infants in Chongqing.

To analyze the causes of perinatal death and related factors from the perspective of forensic medicine, and to provide references for reducing perinatal mortality and guidance for forensic identification. A retrospective analysis was performed on 102 cases of perinatal autopsy with clinical data from the Department of Forensic Medicine of Chongqing Medical University in 2004-2016. Of the 102 cases of perinatal deaths, 66 （64.71%） were neonatal deaths, 24 （23.53%） were stillborn foetuses, and 12 （11.76%） were stillbirths. Among the 66 neonatal death cases, 39 （59.09%） died within 1 d, 19 （28.79%） died within 1-3 d, and 8 （12.12%） died within >3-7 d of birth. The top 3 causes of neonatal death were pulmonary diseases, congenital malformation, umbilical cord and placental abnormalities. The causes of stillborn foetus and stillbirth were mainly umbilical cord and placental abnormalities, and intrauterine asphyxia. Pulmonary diseases, umbilical cord and placental abnormalities, and congenital malformations are the main causes of perinatal death. In order to reduce the perinatal mortality, pre-pregnancy examination and prenatal care should be strengthened, and the knowledge of pregnancy care should be popularized.

Vaginal birth after prior myomectomy

ObjectiveThe aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery. Study designWe analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed. Results469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported. ConclusionsA successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option.Obstetricians’ attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

Perinatal death beyond 41\xa0weeks pregnancy: an evaluation of causes and substandard care factors as identified in perinatal audit in the Netherlands

BackgroundLate- and postterm pregnancy are associated with adverse perinatal outcomes, like perinatal death. We evaluated causes of death and substandard care factors (SSFs) in term and postterm perinatal death.MethodsWe used data from the Perinatal Audit Registry of the Netherlands (PARS). Women with a term perinatal death registered in PARS were stratified by gestational age into early−/full-term (37.0–40.6) and late−/postterm (≥41.0 weeks) death. Cause of death and SSFs ≥41 weeks were scored and classified by the local perinatal audit teams.ResultsDuring 2010–2012, 947/479,097 (0.21%) term deaths occurred, from which 707 cases (75%) were registered and could be used for analyses. Five hundred ninety-eight early−/full-term and 109 late−/postterm audited deaths were registered in the PARS database. Of all audited cases of perinatal death in the PARS database, 55.2% in the early-/fullterm group occurred antepartum compared to 42.2% in the late−/postterm group, while intrapartum death occurred in 7.2% in the early−/full-term group compared to 19.3% in the late−/postterm group in the audited cases from the PARS database. According to the local perinatal audit, the most relevant causes of perinatal death ≥41 weeks were antepartum asphyxia (7.3%), intrapartum asphyxia (9.2%), neonatal asphyxia (10.1%) and placental insufficiency (10.1%). In the group with perinatal death ≥41 weeks there was ≥1SSF identified in 68.8%. The most frequent SSFs concerned inadequate cardiotocography (CTG) evaluation and/or classification (10.1%), incomplete registration or documentation in medical files (4.6%) or inadequate action on decreased foetal movements (4.6%).ConclusionsIn the Netherlands Perinatal Audit Registry, stillbirth occurred relatively less often antepartum and more often intrapartum in pregnancies ≥41 weeks compared to pregnancies at 37.0–40.6 weeks in the audited cases from the PARS database. Foetal, intrapartum and neonatal asphyxia were identified more frequently as cause of death in pregnancies ≥41 weeks. The most identified SSFs related to death in pregnancies ≥41 weeks concerned inadequate CTG monitoring (evaluation, classification, registration or documentation) and inadequate action on decreased foetal movements.

Peculiarities of the construction of the placentary complex and the main causes of perinatal losses

The article presents the analysis of the massometric parameters of the fetoplacental complex (weight of the placenta of full-term newborns, placental-fetal coefficient (PPC), linear mass of the umbilical cord (LMU). Indicators that alarm the neonatologist doctor as possible markers of perinatal losses are: a decrease in the placenta mass, an increase in PPC, high LMU (a consequence of ascending bacterial infection (funiculitis) and the development of circulatory umbilical edema in acute right ventricular failure, for example, in viral atrial myocarditis). A histological study of newborn children of the main and control group was carried out to identify the main types of histological structure of the placenta: normal structure, ascending infection of the placenta, hematogenous infection of the placenta, chronic placental insufficiency, acute placental insufficiency. revealed a different frequency of occurrence of these conditions in patients of the main and control groups. The main causes of perinatal losses are analyzed. It is determined that more than half of cases of perinatal fetal death is infectious pathology: viral, bacterial and mixed viral-bacterial. About a quarter of cases of perinatal death is caused by acute heart failure with placental abruption and a complex of cardiovascular and respiratory disorders in premature infants. In 18% of cases, congenital malformations of the fetus lead to perinatal death. CRF causes perinatal fetal death in approximately 10% of cases.

933: Comparing potential risk factors for perinatal death in singleton and twin pregnancies at a rural hospital in Uganda

Perinatal deaths, defined as stillbirths (fetal deaths before delivery, at or after 22 weeks gestation) and neonatal deaths within 7 days of birth, occur more frequently in twin gestations than singleton gestations. Given the limited data on this phenomenon in low resource areas, our study aims to compare risk factors associated with perinatal death in singleton and twin pregnancies in rural Uganda. We conducted a retrospective case-control study using data from birth registers at Tororo District Hospital, a regional hospital in rural Uganda. All cases of perinatal deaths from January to December 2014 were collected. Controls were derived from the labor admissions immediately preceding and following the cases of perinatal death. Each pregnancy was the unit of analysis. Statistical comparisons were performed using Fisher’s exact test, chi-square and t-test. During the study period, there were 185 cases of perinatal death, including 19 twin pregnancies. There were 354 control pregnancies, including 5 twin pregnancies. Twin gestation was associated with an odds ratio (OR) of 8.0 for perinatal death compared to singleton gestation (95% confidence interval (CI) 2.8 - 27.7, p = 0.0000). Perinatal deaths among twins were more likely to be fresh stillbirths (e.g. without findings suggestive of death prior to labor) (68.4% vs 35.8%, OR 3.9, CI 1.28 - 13.1, p = 0.0057) and more likely to be affected by low birth weight than singleton gestations (93.3% vs 33.1%, OR 28.3, CI 4.0 - 1209.6, p = 0.0000). There were no statistically significant associations between twin gestation and maternal age or gravidity, premature delivery, or mode of delivery. Our results confirm a higher frequency of perinatal deaths in twin gestations compared to singleton gestations in Tororo and identity an association with low birth weight. The greater proportion of fresh stillbirths among twins compared to singletons implies more deaths shortly before delivery for the former. Prenatal identification of twin pregnancies may reduce the perinatal loss rate in similar settings.

142: Safety of in utero exposure to granisetron in first and second trimester

Granisetron may represent an optional treatment for hyperemesis-gravidarum not responsive for commonly used anti-emetic drugs. However, data regarding safety of Granisetron during pregnancy is lacking. We aimed to investigate the risk of adverse neonatal outcomes associated with Granisetron administered during first and second trimester of pregnancy. Medical records of gravid patients treated for hyperemesis-gravidarum during their stay in the gynecologic ER were reviewed. Patients exposed to Granisetron during the first or second trimester were included. Patients were contacted by phone and were asked to participate in the study by answering a detailed questionnaire. Questions were related to prenatal surveillance, exposure to additional medications, smoking status, various neonatal outcomes, and neuro-developmental milestones. Obtained data was cross-checked with data extracted from patient’s medical files. Between 9/2013 and 9/2015, a total of 101 gravid patients were treated with Granisetron to relief nausea and vomiting of pregnancy. A total of 81 agreed to participate (80.1%), 13 declined participation (12.9%) and 7 (6.9%) were unavailable. Of those who agreed to participate, one patient was excluded due to fetal trisomy 21. Of the 80 patients included, 76 had singleton pregnancy. The remaining four had dichorionic-diamniotic twins pregnancy. 74 (92.5%) were spontaneous pregnancies, while 6 (7.5%) were obtained by IVF. Mean gravidity and parity were 3.23±1.78 and 2.56±1.36 respectively. Mean maternal age was 30.67±5.18. Exposure to Granisetron took place during the first trimester in 68 patients (85%). Mean gestational age at exposure was 10.1±3.3 weeks. Preterm delivery rate was 12.5%. Mean birth-weight was 3090±534. Two cases (2.5%) of major congenital malformations (VSD, Diaphragmatic hernia) and one case (1.25%) of neuro-developmental delay were detected. There were no cases of perinatal deaths. To the best of our knowledge, this is the first study to report on neonatal outcomes following exposure to Granisetron during pregnancy. As there was no evidence for association between Granisetron and adverse neonatal outcomes, these findings provide preliminary reassurance regarding the safety of Granisetron exposure during pregnancy.

P 21 Clinical utility of sFlt1/PlGF in management of hypertensive pregnancies in India

Introduction Timing of delivery among women with hypertension remains a balance between prevention of adverse maternal/fetal outcomes and gestational age of delivery. Angiogenic biomarkers have been researched to accurately predict adverse outcomes in women with hypertension, however their use in routine clinical care has not been studied. Objectives To study the outcomes of hypertensive pregnancies with real time assessment and incorporation of knowledge of sFlt1/PlGF ratio performed in the third trimester. Material and methods It is a prospective descriptive cohort study done in a tertiary center in India for a planned total enrollment of 100 patients. Singleton pregnancies with chronic/gestational HTN between 28 to 37 weeks were enrolled.sFlt1/PlGF was measured in serum samples on Roche platform. The results were stratified as Screen negative, borderline positive or Screen positive as per the cut offs (Fig. 1). Patients with Screen negative results underwent conventional testing for maternal fetal wellbeing every 2 weeks along with testing of the sFlt1/PlGF ratio until 35 weeks gestation. Borderline positives underwent testing every week while patients with positive results underwent testing for maternal and fetal wellbeing twice weekly. Once tested positive, the ratio was not repeated. Beyond 37 weeks biweekly clinical surveillance was carried out in the screen negatives and a birth plan was given at 38 to 39 weeks. In the screen positives, the decision to deliver was to be based only on worsening clinical status. Results Data on 21 patients resulting in 54 samples was analysed. Results were compared to 21 contemporaneous pregnancies with HTN from previous years before the use of sFlt1/PlGF ratio. Use of sFlt1/PlGF ratio for monitoring resulted in reduction of deliveries less than 30 weeks, increase in deliveries beyond 37 weeks, delayed delivery in patients with fetal growth restriction resulting in reduction in neonatal intensive care unit stay. There were no cases of perinatal death, eclampsia or maternal death (Fig. 2). Conclusion Clinical extrapolation of sFlt1/PlGF values in hypertensive pregnancies may help prolong stable pregnancies beyond 37 weeks without increase in perinatal mortality. Larger studies need to be done to confirm these findings.

Can we perform a prenatal diagnosis of vasa previa to improve its obstetrical and neonatal outcomes?

IntroductionVasa previa (VP) is defined as a condition in which the fetal blood vessels, unsupported by the placenta or the umbilical cord, run through the membranes of the lower uterine segment. It is associated with a high risk of stillbirth by exsanguination. This study aimed to assess the clinical context of diagnosis of VP in order to elaborate a strategy for its prenatal diagnosis and to improve its obstetrical and neonatal outcomes. Material and methodsThis historical cohort study covered the period from January 1, 2011 to December 31, 2015. All women who gave birth at our obstetrics and gynecology department (level 3 university hospital) and who had a VP were included. ResultsEight cases of VP among 18,152 deliveries were observed (0.04%). Transvaginal sonography (TVS) with color Doppler allowed a prenatal diagnosis of VP in all cases. The mean gestational age at diagnosis was 26 weeks. Placental abnormalities were noted in 7 cases (87.5%) as bipartita or low-lying placenta. In one case (12.5%), the placenta appeared normal while umbilical cord insertion was velamentous. In 2 cases (25%), concomitant placental and cord abnormalities were objectified. The mean gestational age at delivery was 37±2.1 weeks. Seven deliveries (87.5%) had been by caesarean sections, except one, which occurred by vaginal route at 33 weeks of gestation (twin pregnancy). No case of perinatal death was observed. DiscussionPrenatal diagnosis of VP during screening ultrasounds appears easy to perform and can improve obstetrical and neonatal outcomes. For this purpose, TVS with color and pulsed Doppler remains essential, particularly when an anomaly of the umbilical cord insertion and/or placental location is diagnosed.

Quality of Services Need All Round Critical Appraisal for Decreasing Perinatal Deaths

Background: Perinatal mortality rates (PMR), index of quality of maternity, neonatal services, are still high in developing countries with regional variability. Material and Methods: Present study was done by analysis of case records of mothers who had perinatal deaths (PD). During period of analysis, there were 81051 births, 5235 PD, [3923 stillbirths (SB) 1312 neonatal deaths (NND)] with decreasing trends of PMR, from 95.18 to 34.93. For analysis, cases were divided into 10 blocks. Objective: Study was done to know trends of factors responsible for PD at rural referral hospital in Central India, so as to look into possible preventive strategies. Results: More teenagers had more often PD in each block, 1203 (22.97%) mothers were severely anemic, problem persisted over years, 20.15% in Block A, 20.96% in Block J. Cases with hypertensive disorders with PD increased from 19.62% in Block A to 21.14% in Block J, with preterm births decreased from 52.52% to 41.26%, with antepartum haemorrhage (APH), mostly placental abruption, increased from 1.31% to 1.59%. Nine hundred twenty one (17.59%) women who had PD delivered between of 28 to 34 to <37 weeks gestation, but 3040 (58.78%) were term births, Overall 41.92%. PD was preterm, significantly higher than over all 14% preterm births. Of all cases with PD, 3753 (71.69%), were after vaginal birth [2274 (60.60%) term, 1479 (39.40%) preterm], 500 (9.55%) after elective caesarean sections (CS), 982 (18.7%) emergency CS. Overall 1482 (28.3%) babies lost were after CS. Analysis revealed that 218 (43.6%) PD were due to respiratory distress syndrome (RDS), 123 (24.6%) prematurity with low birth weight (LBW) with septicemia, 104 (20.8%) meconium aspiration, 30 (0.6%) sudden infant death syndrome, 25 (5.0%) congenital heart disease. Overall 89% babies were LBW. Major factors which lead to PD and were persisting over years were anemia, hypertensive disorders in mother, sepsis, prematurity with LBW. Of all cases of PD, 8% were after elective, 18% emergency CS, majority done in fetal interest. Conclusion: PMR continues to be very high. Anemia, hypertensive disorders, preterm births, sepsis were major factors, persisting over years, almost all preventable. Of PD, 8% births were after elective CS, 18% emergency CS, majority CS done for fetal interest, a matter of real concern.

Increases in perinatal mortality in prefectures contaminated by the Fukushima nuclear power plant accident in Japan: A spatially stratified longitudinal study.

Descriptive observational studies showed upward jumps in secular European perinatal mortality trends after Chernobyl. The question arises whether the Fukushima nuclear power plant accident entailed similar phenomena in Japan. For 47 prefectures representing 15.2 million births from 2001 to 2014, the Japanese government provides monthly statistics on 69,171 cases of perinatal death of the fetus or the newborn after 22 weeks of pregnancy to 7 days after birth. Employing change-point methodology for detecting alterations in longitudinal data, we analyzed time trends in perinatal mortality in the Japanese prefectures stratified by exposure to estimate and test potential increases in perinatal death proportions after Fukushima possibly associated with the earthquake, the tsunami, or the estimated radiation exposure. Areas with moderate to high levels of radiation were compared with less exposed and unaffected areas, as were highly contaminated areas hit versus untroubled by the earthquake and the tsunami. Ten months after the earthquake and tsunami and the subsequent nuclear accident, perinatal mortality in 6 severely contaminated prefectures jumped up from January 2012 onward: jump odds ratio 1.156; 95% confidence interval (1.061, 1.259), P-value 0.0009. There were slight increases in areas with moderate levels of contamination and no increases in the rest of Japan. In severely contaminated areas, the increases of perinatal mortality 10 months after Fukushima were essentially independent of the numbers of dead and missing due to the earthquake and the tsunami. Perinatal mortality in areas contaminated with radioactive substances started to increase 10 months after the nuclear accident relative to the prevailing and stable secular downward trend. These results are consistent with findings in Europe after Chernobyl. Since observational studies as the one presented here may suggest but cannot prove causality because of unknown and uncontrolled factors or confounders, intensified research in various scientific disciplines is urgently needed to better qualify and quantify the association of natural and artificial environmental radiation with detrimental genetic health effects at the population level.

Is a fractured skull discovered in the neonate after caesarean section delivery always evidence of negligence?

What is the incidence of fetal trauma at caesarean section? In 2006, Alexander et al. published a study of 37 110 caesarean deliveries at 13 university centres in the USA (Obstet Gynecol 2006;108:885–90) and reported 418 cases of injury. Most were skin lacerations (n = 272) or cephalohaematomas (n = 88). There were 11 cases of facial nerve palsy and nine brachial plexus injuries (potentially congenital). In terms of fractures, there were 11 of the clavicle, eight of long bones but only six of the skull. Three of these followed a failed trial of forceps or vacuum (compared with only one of the long-bone fractures) so three occurred when a caesarean section was the primary intended mode of delivery. Blickstein (J Perinat Med 2004;12:465–9) suggested that caesareans at full dilatation of the cervix have become increasingly common because of a growing reluctance to embark on vaginal mid-cavity instrumental deliveries (which in turn leads to a lack of training and expertise) in case a traumatic injury leads to litigation. Jeve, Navti and Konje in this journal highlight the problem of how best to deliver a deeply impacted fetal head at full dilatation. They report that the pull method (‘reverse breech’) is faster and resulted in less maternal morbidity than push from below, but that there was no difference in birth trauma. However, in the 455 cases in their meta-analysis, fetal injuries were all minor except one case of fractured humerus. The question ‘difficult caesarean delivery of an impacted head and neonatal skull fracture: can the morbidity be avoided?’ has been posed by Tan (J Obstet Gynaecol 2007;27:427–8), who described a primary caesarean section for the delivery of a 5.11-kg baby with an assistant pushing up from the vagina; the baby survived a right posterior parietal fracture with intra-cranial bleeding. He commented that ‘perhaps in this case, the pull method of extraction could have been considered’. Since 2012 I have reviewed four cases of perinatal death associated with skull fracture and caesarean section (no prior attempt at instrumental delivery) at full dilatation. The common feature was repeated attempts to deliver the impacted head by passing the obstetricians’ hands from the uterus down past the fetal head, in order to get underneath and pull it up. There was also upward pressure from an assistant's hand in the vagina. A report of fetal demise during delivery at caesarean despite normal cord gases and without skull fracture (Case Rep Obstet Gynecol 2015;2015:318350) described similar difficulties with delivery—an impacted head, and ‘a number of maneuvers … to accomplish delivery including an attempt to dislodge the head from below by an assistant’. These cases suggest that it may be best to avoid further compressing an impacted fetal head by pushing a hand past it while also applying force from below. However, such anecdotal evidence does not necessarily mean that on the balance of probability the injury would have been avoided if the pull method had been employed. The jury is still out. None declared. Completed disclosure of interests form available to view online as supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.