here

Transcription

here - International Stillbirth Alliance

Presented by…
WHO
www.stillbirthalliance.org
ISA
www.who.int
Norsk
Perinatalmedisinsk forening
www.legeforeningen.no
LUB
www.lub.no
www.rikshospitalet.no
2008 ISC / NPF, November 5-7 – Oslo, Norway
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Utgitt av Norsk Perinatalmedisinsk Forening
Anvsvarlig redaktør: J. Frederik Frøen
Opplag: 550
Papir: 300 g Scandia 2000 / 90 g G-print
Grafisk utforming: Target Reklamebyrå AS
Trykk: Nordberg Trykk AS
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Sponsored by...
Norsk
Perinatalmedisinsk forening
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4
Welcome to the conference!
by Jan Holt, President of NSPM
Dear Colleagues and Guests.
On behalf of The Norwegian Society of Perinatal Medicine (NSPM) it is a great pleasure to welcome you
to Oslo, Norway, for the 2008 International Stillbirth Conference and the 21st Annual meeting of our
society.
Parents, doctors, midwifes, nurses and other colleagues are invited to participate in this joint conference
with the intention to reduce the incidence and the burden of stillbirths. We are convinced that the program for this conference will be of most interest for you and that you will benefit from the interdisciplinary
sessions and the Norwegian hospitality.
Enjoy your stay – and welcome to Oslo!
Kjære Perinatalere
De årvisse perinataldagene arrangeres i år i Oslo i samarbeide med International Stillbirth Alliance (ISA),
Verdens Helseorganisasjon (WHO), Landsforeningen Uventet Barnedød (LUB) og Perinatal Forskningssenter ved Rikshospitalet.
Det blir felles sesjoner hver morgen etterfulgt av tre faglige ”spor” hvorav Perinataldagene er ett. Vårt
program spenner over flere fagområder som lunge- og ernæringsproblemer for nyfødte, veksthemning og betydning av dette senere i livet, tvillinger, og overtidig svangerskap. Dessuten ønsker vi å sette
søkelyset på kommunikasjon og kulturelle ulikheter med våre ”nye landsmenn” og på uheldige hendelser og menneskelige feil som årsak til medisinske ulykker. Analyse av dagens fødselssituasjon i Europa
og flere foredrag med resultater fra den store Mor-Barn-undersøkelsen blir det også. Frie foredrag er
alltid viktige, og i år blir det to sesjoner vinklet mot nyfødtmedisin og to mot obstetriske og jordmorfaglige
problemer. Det er også mange spennende foredrag på ISA konferansen og under foreldreprogrammet –
mye bra å velge mellom. Industrien gir også i år et viktig bidrag til vårt felles arrangement.
For 21. gang har NPF sitt årlige treff. I år er stedet Plaza hvor man kan treffe perinatalere med forskjellig
ståsted, se det beste og nyeste fra industrien og ha det gøy i noen hektiske dager.
Så – engasjer og gled deg – velkommen til Oslo!
Jan Holt
Leder NPF / President of NSPM
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by Trond Mathiesen, Norwegian SIDS and Stillbirth Society
On behalf of the Norwegian SIDS and Stillbirth Society I welcome you to Oslo and the 2008
International Stillbirth Conference. Thank you for coming! Please, enjoy the program that
has been put together for you, and do enjoy your stay in Oslo!
The Norwegian SIDS and Stillbirth Society represent families that have experienced the loss
of a child. In all our activities – grief support, health promotion and research facilitation – we
have learned that more can be achieved through close collaboration and partnership between parents, health professionals and scientists. This conference will facilitate the much-needed exchange of experiences and knowledge
between the different groups involved. By joining forces and seeking collaboration we will easier solve the stillbirth
puzzles, more babies will be saved, and affected parents will receive better help and support!
The Norwegian SIDS and Stillbirth Society have been responsible for preparing the bereavement track of the 2008
International Stillbirth Conference. The dedication and hard work put in by Line Christoffersen and Trine Giving
Kalstad is much appreciated. Thank you! We are also grateful for the valuable input to the program from the Parent
Advisory Committee of the International Stillbirth Alliance. We thank the many volunteers for their contributions to
this conference, and we are especially grateful to the parents who bravely will share their experiences of loss at this
conference! Lastly, we would like to thank the Norwegian Society of Perinatal Medicine, Perinatal Research Center,
World Health Organization, International Stillbirth Alliance and their respective representatives for a rewarding partnership. We have learned a lot!
Trond Mathiesen
Secretary General
Norwegian SIDS and Stillbirth Society
by Vicki Flenady, Chair ISA
It is my very great pleasure and privilege to, on behalf of the ISA Board, welcome you to
Oslo for the International Stillbirth Conference 2008 – A joint conference of ISA and WHO
and the 4th International Stillbirth Alliance Conference. ISA is grateful for the support of
host organisations for making this conference possible: the Norwegian Society of Perinatal
Medicine, Norwegian SIDS and Stillbirth Society and Perinatal Research Center.
A stillborn baby is the tragic outcome of what we all expect and hope to be a very joyous and happy occasion – the
birth of a new life to love and to watch grow.
The vast majority of stillbirths occur in developing countries and concerted efforts are needed to address this inequality.
Building on the work of previous conferences, particularly the 2007 conference in the UK, this year the International Stillbirth Conference focuses on the challenges facing developing countries in reducing the numbers of stillborn babies.
No matter the region, the precious life lost when a baby is stillborn is devastating to mothers, fathers, families and friends
and to health care professionals and is a challenge to researchers in attempts to unfold the reasons why. ISA brings all
these people together to reduce stillbirth and improve the care provided for parents and families who suffer this loss.
This is your Alliance – you are the people who have made ISA what it is today and who will make it what it will become.
The belief and conviction that we can make a difference is what has brought us here to this conference. So, to you all,
I extend a warm welcome to the 2008 Conference and hope that this conference will fulfil your expectations and with
new-found friends and collaborators will enhance your work in addressing the problem of stillbirth across the globe.
Welcome
Vicki Flenady
Chair ISA
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by Frederik Frøen, Conference Chair
To me, going to a conference is often an opportunity to get an overview, and some inspiration leaving a narrow-sighted view on ongoing projects and an often-too-busy life behind for a few
days. If you are anything like me, you will enjoy seeing people whose work you have read or heard
about – the speakers here have published thousands of papers and books. Reading their work
is never the same afterwards. You will enjoy the people you meet in breaks and social gatherings – there are about five hundred people from more than fifty countries here. You might meet
someone different. And from time to time you happen to encounter a truly remarkable person,
get a great idea, or hear a thought-provoking presentation that you will remember for a long time.
During these three days, we wanted to offer you stillbirth sessions on the three topics we believe are the major challenges
– stillbirths in developing countries, fetal growth restriction, and delivery of the best available care. Our bereavement sessions should provide insight for the individual parent, how to provide support, and effective ways to work. The perinatal
sessions, “Perinataldagene”, should give you updates on contemporary issues in Scandinavian perinatal care. I hope you
will find the overview you came looking for.
But most of all I wish you inspiration.
Inspiration from those who come to the conference to share their hopes
or successes – progress can be made!
Inspiration from those who share their losses or failures
– still so much to do!
There are so many people I would like to thank for making this conference possible. Our welcoming hosts, collaborating organizations, tireless staff, skilled conference organizers, knowledgeable speakers, and exceptional individuals – I hope you all have experienced through our work together that this brief expression of gratitude is only
a repetition. And finally, but not the least, I want to thank our sponsors for making this conference possible, and in
particular to NORAD for making it possible for so many colleagues to attend from developing countries, and the
Norwegian Health Directorate and VOX Norwegian Institute for Adult learning for providing funding for so many affected parents. Without them, the conference would have lacked much. I wish you inspiration – and a pleasant stay
in Oslo.
Yours,
J. Frederik Frøen
Conference Chair
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Organizing Committee
Babill Stray-Pedersen
Perinatal Research Center, Rikshospitalet
Eli Saastad
Norwegian Society of Perinatal Medicine
Guttorm Haugen
J. Frederik Frøen
International Stillbirth Alliance
Jan Holt
Line Christoffersen
Mai-Irene Austgulen
Trine Giving Kalstad
Trond Mathiesen
With the greatly appreciated assistance of
Dept. for Making Pregnancy Safer
World Health Organization
Jørn Holst Kristiansen
Thue & Selvaag Forum
Kristin Tomren
Norwegian Institute of Public Health
Anne Marie Trebo Frøvig
Scientific Advisory Committee
Parental Advisory Committee
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Exhibitors at the conference
Company
Name
Stand
Sandvik as
Puls as
Medinor AS
Scan-Med.A/S
NOR-DAX AS
Nestlé Infant Nutrition
AGA AS, Linde Gas Therapeutics
Siemens Medical Solutions
Imatis a/s
Techno Systems AS
GE Healthcare Clinical Systems Norway AS
Vingmed AS
Avalon Medical AS
Covidien Norge AS
Norwegian SIDS and Stillbirth Society and
Laerdal Medical AS
Pampers
Philips Avent & Midelfart Sonesson
Axellus
Ferring Legemidler
Wadel, Nina
Søgård, May Kristin
Sylling, Kristine Hellandsvik
Solum, Tor
Nilsen, Kari
Mortensen, Trude
Marthinsen, Siri
Johnsrud, Nils Arne
Bergius-Tveit, Marianne
Humlen, Per K.
Berge, Morten
Aabrekk, Atle
Løvstad, Frank
Johne, Bjørn-Egil
1
3
4
5
6
7
8
9
10
11
12
13
14
15
Kalstad, Trine G.
Sønstelien, Knut
Tømmerbakken, Marit
Wennerholm, Matilda
Tokheim, Anna
Antonsen, Hanne
16
17
18
19
20
21
30m
2
3
4
6
5
17
18m
8
7
6m
4m
11
18
12
10
3m
19
9
5m
21
13
3m
20
3m
4m
17m
5m
15
16
14
3m
5,2m
Hosts’ Desk
1,4m
Service Center
9
5,5m
10
Contents
Conference Program
12
Stillbirth
Bereavement
Perinatal
Speakers
38
Keynote speakers
38
Invited speakers
40
Free Communications - Oral
40
Oral Stillbirth
73
Oral Developing Countries
83
Oral Bereavement
90
Oral Perinataldagene
95
Free Communications - Poster 108
Poster Stillbirth
109
Poster Developing Countries
127
Poster Bereavement
139
List of Participants
142
Social Program
154
Practical Info / Map
156
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Program
How to navigate the program?
1. Find the session of interest in this overview – notice the pagenumber.
2. Go to the indicated page of the main program to read the details – notice the speaker’s
name.
3. Find the speakers who are listed alphabetically by their last name in the sections for Keynote Speakers, Invited Speakers or Oral communications in Stillbirth, Developing Countries,
Bereavement or Perinataldagene.
4. All posters in the sections Stillbirth, Developing Countries and Bereavement are numbered
and they are found in the same sequence in the poster halls.
Tuesday – November 4 (Pre-conference)
PRE-CONFERENCE
11:00
11:15
11:30
11:45
12:00
12:15
12:30
12:45
13:00
13:15
13:30
13:45
14:00
14:15
14:30
14:45
15:00
15:15
15:30
15:45
16:00
16:15
16:30
16:45
17:00
17:15
17:30
17:45
18:00
18:15
18:30
18:45
19:00
19:15
19:30
19:45
20:00
12
16
• Stepping Up Stillbirth
• Prevention in Developing
16
• Biobanking for Stillbirths in Europe
16
• Building Synergies for Parents, NGOs and Professional’s
• Stillbirth Efforts – I: Introduction
Break
• Open meeting with the ISA
• Parental and Scientific Advisory
• Committees – Future Directions
of the International Stillbirth
Alliance
16
Break
16
• NPF Board Meeting
16
• ISA Board Meeting
2008 ISC / NPF, November 5-7 – Oslo Norway
Wednesday – November 5
STILLBIRTH TRACK
08:00
08:15
08:30
08:45
09:00
09:15
09:30
09:45
10:00
10:15
10:30
10:45
11:00
11:15
11:30
11:45
12:00
12:15
12:30
12:45
13:00
13:15
13:30
13:45
14:00
14:15
14:30
14:45
15:00
15:15
15:30
15:45
16:00
16:15
16:30
16:45
17:00
17:15
17:30
17:45
18:00
18:15
18:30
18:45
19:00
19:15
19:30
19:45
20:00
BEREAVEMENT TRACK
PERINATALDAGENE
• Building Synergies
for Parents, NGOs
and Professional’s
Stillbirth Efforts – II
17 17
• ISA Forum for
Developing
Countries
Break
Opening session
• The Global Burden of Stillbirths
• Being a Stillbirth Parent – Life without Oliver
• A Global Review of the Burden and Interventions to Address Stillbirths in Developing Countries
• Lessons Learned for Stillbirth from Countdown 2015
18
Break
• Making Stillbirths Count – Making Numbers Talk
• Risk Factors for Stillbirth in Developing Countries
• Estimating Preventable Stillbirth in
Developing Settings
• Counting Stillbirths: A Global Network
Perinatal Mortality Study
19
• Writing as a Tool in the Grief Process
• Virtual Support Groups
• Voices of Sorrow – a Book Project
• Indelible Isabella – the Permanence of her
Presence
21
18
• Inngifte i Norge: utbredelse og medisinske
konsekvenser
22
• Kommunikasjon og kulturulikhet
Lunch
Stillbirth Lunch Poster Walk (Posters 1 - 26)
• Role of Basic Prenatal Care in the
Prevention of Stillbirths
• Prevention of Intrapartum Stillbirths
• Involving Communities to Reduce Stillbirths
• Social Management of Pregnancy Loss in
Tanzania
• Reducing Maternal and Fetal Mortality in
Nigeria
• Birth Registry to Improve Reproductive Health
in Russia
19
21
• How to Involve the Social Network after
Perinatal Loss - Interactive Session
• Are There Strategies To Prevent or Treat
Bronchopulmonary Dysplasia?
• Persisting Pulmonary Hypertension of the
Newborn – a Wide Range of Challenges and
Outcomes?
• Diaphragmatic Hernia in the Era of Prenatal
Diagnosis and Gentle Ventilation
22
Break
• Reducing Infection–Related Stillbirths:
Program and Research Implications
• Global Elimination of Congenital Syphilis
Initiative
• Eliminating Syphilis-Associated Perinatal
Death: The Challenge of Developing
Appropriate Targets
• Can DHS Surveys be used to Measure
Congenital Syphilis Elimination Impact on
Stillbirth?
19
21
• Den støttende samtalen –
interactive session in Norwegian
22
22
• Kangaroo Care
• Synkende fertilitetsrater i Europa
Break
22 22
• Generating Global Political Priority for the
Issue of Stillbirths
• Panel discussion: Next steps for global
leaders
20
• Frie foredrag i
neonatologi/
obstetrikk
Break
18
Memorial
Break
Get-together22
at Oslo City Hall
• Frie foredrag i
obstetrikk
Thursday – November 6
STILLBIRTH TRACK
08:00
08:15
08:30
08:45
09:00
09:15
09:30
09:45
10:00
10:15
10:30
10:45
11:00
11:15
11:30
11:45
12:00
12:15
12:30
12:45
13:00
13:15
13:30
13:45
14:00
14:15
14:30
14:45
15:00
15:15
15:30
15:45
16:00
16:15
16:30
16:45
17:00
17:15
17:30
17:45
18:00
18:15
18:30
18:45
19:00
19:15
19:30
19:45
20:00
BEREAVEMENT TRACK
PERINATALDAGENE
24
Building Synergies for Parents, NGOs and
Professional’s Stillbirth Efforts – III
Break
24
Fetal Growth: Evolutionary History & Future Consequences
Break
• WHO Workshop –
• Epidemiology of
FGR and Later-Life
Preventing
Risk of Diseases
Stillbirths in
• Recurrence and
Developing
Family Exposure
Countries
of FGR
• Neonatal Death: A Mother’s Experience of
Support when Her Baby Dies
• Care and Support Program in a NICU
• Clinical Care Implications of Pregnancy
after Perinatal Loss
• Mechanisms: Haemo- • WHO Workshop –
dynamic Causes of
Preventing
FGR and Death
Stillbirths in
Developing
• Placental Causes of
Countries
Growth Restriction
• Parent’s Needs for Care and Support
When a Child Dies in Stillbirth
• Mothers Feelings when Holding their
Stillborn Baby
• Caregivers and Perinatal Death
• Support for Mothers, Fathers and
Families after Perinatal Death
25 25
• Elektiv single embryo transfer ved IVF
• Økende tvillingforekomst i Norge 1967- 2004.
Betydningen av mors alder og assistert
befruktning
• Assistert vaginal tvillingfødsel
30
28
Break
26 25
28
24
30 30
• Frie foredrag i
neonatologi
• Frie foredrag i
obstetrikk/amming
Lunch
Developing Countries Poster Walk (Posters 27 - 45)
• Early Markers and Early Screening –
Future Possibilities?
• Customized Growth Charts
– Principles and Application
• Customized Growth Charts
– What Defines Optimal Growth?
26
• A Stillbirth- the Routines at
Ullevål University Hospital
• Models of Care – a Case Study from
Akershus Hospital
• A Model for Support Groups
• Peer Support Training Programme
28
• Long Term Consequences of Early Growth
• Medical and Neurological Aspects
• Neuropsychological Aspects in Moderate
Term SGA
31
Break
• Current Standards
of Care in the SGA
Fetus
• Managing the FGR
Fetus: Where can
Progress be Made?
26 26
• Free Communications
Developing Countries
• The Global Alliance to Prevent Prematurity
and Stillbirth Initiative
27
• Embracing Diversity in Descriptions of
Children and Grief
• Play and Conversation Box
– A Method for Sibling Care
• Back to Work After a Loss
• Grief in the Workplace
29
• Parenteral ernæring av fullbårne og
premature nyfødte
• Peroral ernæring – forsterkning til
morsmelk?
• Amming av premature barn
31
Break
27 27
• General Assembly of • Free Communications
the ISA
Stillbirth
29
• Free Communications
Bereavement
Break
24
Refreshments
24
Conference Dinner
31
• Generalforsamling NPF
Friday – November 7
STILLBIRTH TRACK
08:00
08:15
08:30
08:45
09:00
09:15
09:30
09:45
10:00
10:15
10:30
10:45
11:00
11:15
11:30
11:45
12:00
12:15
12:30
12:45
13:00
13:15
13:30
13:45
14:00
14:15
14:30
14:45
15:00
15:15
15:30
15:45
16:00
16:15
16:30
16:45
17:00
17:15
BEREAVEMENT TRACK
PERINATALDAGENE
32
• Building Synergies for Parents, NGOs and
Professional’s Stillbirth Efforts – IV
Break
32
Patient Safety in Obstetrics
Break
• Post-Term Pregnancy – How Long is Too
Long?
• Active Management of Risk and Early Term
Inductions in Preventing Birth Adverse
Outcomes
33
• Preparing for Autopsy: A Parent Perspective
• Preparing for Autopsy: A Pathologist’s
Perspective
• How Guidelines can Enable Health Professionals to Prepare Parents for Autopsy
36
• Pasientsikkerhet – uheldige hendelser,
forebygging og håndtering
• Menneskelige feil som årsak til medisinske
ulykker – kan problemet reduseres?
37
Break
33
• Early Delivery - All Good? From the
Neonate’s Point of View
• Confidential Enquiries: A Powerful Tool for
Stillbirth Prevention
36
32
36
• Couple Relationships and Intimacy after the
Loss of a Child
• Post-terme svangerskap. Resultater fra en
randomisert, kontrollert studie
• Post-terme svangerskap - tid for
revurdering?
• Rutineinduksjon av fødsel ved 41 uker:
Nonsensus consensus
37
Lunch
Bereavement Lunch Poster Walk (Posters 46 - 49)
33
• Investigations of Stillbirths
• Management of Subsequent Pregnancy
after Stillbirth
• Knowing What to Expect in the Subsequent
Pregnancy
• Clinical and Emotional Needs During a
Subsequent Pregnancy
• Ten Questions to Ask your Doctor
• Complicated Grief: A Group Intervention
Fra den norske Mor-Barn-undersøkelsen:
• Gener og miljø ved spontan preterm fødsel
• Årsaker til preeklampsi
• Spiseforstyrrelser i svangerskap
• Overgrep som barn og redsel for å føde
• Risiko for angst og depresjon i svangerskapet
37
Break
• State of the Science
Related to Psychosocial Issues in Pregnancy after Perinatal
Free Communications
Loss
Stillbirth
• Free
Communications
Bereavement
33
33
33
34
Free Communications
Closing Ceremony
37
• Utdeling av NPF-priser 2008
• Utdeling av priser for beste frie foredrag i
neonatologi og obstetrikk
Tuesday – November 4
Registration and Pre-Conference Meetings
Registration
14:00 – 19:00 Ground Floor Lobby
Stepping Up Stillbirth Prevention in Developing Countries
11:00 – 13:00 Salome
Meeting Chair(s): Robert Pattinson, University of Pretoria, South Africa and Vicki Flenady, Mater Mother’s Hospital,
QLD, Australia
Intended for: By invitation
Biobanking for Stillbirths in Europe
13:00 – 14:00 Vampyr
Meeting Chair(s): Fabio Facchinetti, University of Modena, Italy
Intended for: Researchers and public health officials interested in the development of a European biobank network for stillbirths. This interactive session will explore the feasibility and possible pathways to develop a European biobanking network
for stillbirths, as well as preliminary research priorities in such a network. The following issues will be discussed through
brief presentations: Why biobanking is necessary for stillbirth understanding. Biobanking in Norway – cohorts and clinical
biobanks. Issues in Placental biobanks. Existing biobanks – an overview. Harmonization initiatives for biobanks in Europe.
Building Synergies for Parents, NGOs and Professional’s Stillbirth Efforts – I: Introduction
14:00 – 15:00 Madonna
Meeting Chair(s): Chris Wildsmith, SANDS, UK and Ruth C. Fretts, Harvard Vanguards Medical Associates, MA, USA
Intended for: Health professionals and representatives of NGOs and parental groups.m This highly interactive session
with introductions will initiate a series of three breakfast meetings throughout the conference on how health professionals and NGOs and parental groups may work together to deliver improvement.
Open meeting with the ISA Parental and Scientific Advisory Committees – Future
Directions of the International Stillbirth Alliance
15:30 – 17:30 Madonna
Meeting Chair(s): Ruth C. Fretts, Harvard Vanguards Medical Associates, MA, USA and Liz Davis, International
Stillbirth Alliance, QLD, Australia
Intended for: Individuals and representatives of member organizations of the International Stillbirth
interested in contributing to the work of the alliance.
ISA Board Meeting
18:00 – 20:00 Room 411
Meeting Chair(s): Vicki Flenady, Mater Mother’s Hospital, QLD, Australia
Styremøte NPF
17:00 – 20:00 Room 412
Møteleder: Jan Holt, Nordlandssykehuset, Bodø
16
Alliance
Wednesday––November
November55
Wednesday
Registration and Pre-Conference Meetings
Registration
07:30 – 20:00 Ground Floor Lobby
ISA Forum for Developing Countries
08:00 – 09:15 Kunst
Meeting Chair(s): Robert Pattinson, University of Pretoria, South Africa
Intended for: Open network meeting for health care professionals, health care program managers, parental and
funding organizations and researchers. The forum aims to strengthen, coordinate and guide the ISA network and
commitment in stillbirth research and prevention in developing countries.
Building Synergies for Parents, NGOs and Professional’s Stillbirth Efforts – II
08:00 – 09:15 Vampyr/Madonna
Meeting Chair(s): Chris Wildsmith, SANDS, UK and Ruth C. Fretts, Harvard Vanguards Medical Associates, MA, USA
Intended for: Health professionals and representatives of NGOs and parental groups.
When Parents and Researchers Raise Stillbirth Awareness: Examples of what can be done.
17
Wednesday––November
November55
Wednesday
Plenary Sessions
Opening session
09:30 – 10:15 Olympia/Film
Session Chair(s): Vicki Flenady, International Stillbirth Alliance, QLD, Australia and Monir Islam, World
Health Organization, Switzerland
Welcome to Oslo
Jan Holt, Norwegian Society of Perinatal Medicine, Norway
Welcome address from the Norwegian Government
Ellen Pedersen, Deputy Minister of Health and Care Services, Norway
Norwegian Tunes
The University of Oslo’s Women’s Choir of 1895 – Kvindelige Studenters Sangforening – the world’s first
academic women’s choir performs
Welcome to the Conference
J. Frederik Frøen, Conference Chair, Norway
Developing Countries and Social Inequities
Session Chair(s): Jan Holt, Norwegian Society of Perinatal Medicine, Norway and Neal Long, International
Stillbirth Alliance, UK
The Global Burden of Stillbirths
Monir Islam, World Health Organization, Switzerland
Being a Stillbirth Parent – Life without Oliver
Luke and Ellisiv Marley – Norwegian SIDS and Stillbirth Society, Norway
A Global Review of the Burden and Interventions to Address Stillbirths in Developing Countries
Craig Rubens, Seattle Children’s Hospital, WA, USA
Lessons Learned for Stillbirth from Countdown 2015
Anuraj Shankar, World Health Organization, Switzerland
Lunch Poster Walk
12:30 – 13:30 1st Floor Poster Hall
Stillbirth Poster Walk (Posters 1 – 26) – Authors are present
Memorial
18:45 – 19:30 Munchsalen (Salome/Vampyr/Madonna)
Doors open from 18:30
Hosted by the Norwegian SIDS and Stillbirth Society
Get-together at Oslo City Hall
20:00 – 21:30 Oslo City Hall
A social get-together with refreshments and finger-food hosted by the City and Mayor’s Office of Oslo.
Please see details in the section for the Social Program.
Venue: Oslo City Hall
18
Stillbirth Track
Stillbirths in Developing Countries – Identifying Problems and Solutions
Session Chair(s): Trond Mathiesen, Norwegian SIDS and Stillbirth Society, Norway and Anuraj Shankar, World Health
Organization, Switzerland
Making Stillbirths Count – Making Numbers Talk
J. Frederik Frøen, Norwegian Institute of Public Health, Norway
Risk Factors for Stillbirth in Developing Countries: A Systematic Review of the Literature
Lale Say, World Health Organization, Switzerland
Estimating the Extent of Preventable Stillbirth in Developing Settings: A Review of Existing Data
Jennifer Mark, Centers for Disease Control and Prevention, USA
Counting All Stillbirths: A Global Network Perinatal Mortality Study
Linda L. Wright, National Institute of Child Health and Human Development, NIH, MD, USA
Stillbirths in Developing Countries – Preventing and Caring
13:30 – 15:00 Olympia
Session Chair(s): Robert Pattinson, University of Pretoria, South Africa
Role of Basic Prenatal Care in the Prevention of Stillbirths: Health benefits and Implementation strategies
Maurice Bucagu, World Health Organization, Switzerland
Intrapartum Stillbirths: A Preventable Occurrence
Jiji Elisabeth Mathews, ,Christian Medical College & Hospital, India
Involving Communities to Reduce Stillbirths
Cicely Marston, London School of Hygiene and Tropical Medicine, UK
Social Management of Pregnancy Loss in Rural Southern Tanzania: Loss-Associated Stigma and Unmet
Psychological Needs
Rachel A. Haws, Johns Hopkins Bloomberg School of Public Health, MD, USA
A Model to Reduce Maternal Mortality and Fetal Mortality in Ten Hospitals in Kaduna and Kano State, Nigeria, by
Continuously Conducted Quality Assurance in Obstetrics
Wolfgang Künzel, University Giessen, Germany and Hadiza Galadanci, Aminu Kano Teaching Hospital, Nigeria
A Birth Registry as a Tool to Improve Maternal and Child Health in a Russian Population
Jon Øyvind Odland, University of Tromsø, Norway
Preventing Stillbirths in Developing Countries - Infections
15:30 – 17:00 Olympia
Session Chair(s): Babill Stray-Pedersen, University of Oslo, Norway and Kenneth Wind-Anderson, World Health Organization, Switzerland
Reducing Infection-Related Stillbirths: Program and Research Implications
Elizabeth McClure, University of North Carolina School of Public Health, NC, USA
19
Global Elimination of Congenital Syphilis Initiative
Nathalie Broutet and Kenneth Wind-Anderson, World Health Organization, Switzerland
Eliminating Syphilis-Associated Perinatal Death: The Challenge of Developing Appropriate Targets
Stuart M. Berman, Centers for Disease Control and Prevention, GA, USA
Can DHS Surveys be used to Measure Congenital Syphilis Elimination Impact on Stillbirth?
Fuji Xu, Centers for Disease Control and Prevention, GA, USA
Discussion
Making Changes in Stillbirth Prevention
17:30 – 18:30 Olympia
Session Chair(s): Monir Islam, World Health Organization, Switzerland
Advocacy:
Generating Global Political Priority for the Issue of Stillbirths: Lessons From Maternal and Newborn Survival Initiatives
Jeremy Shiffman, Maxwell School of Syracuse University, NY, USA
What are the Next Steps for Global Leaders?
Panel discussion
20
Bereavement Track
Coping Strategies for Parents
Session Chair: Liz Davis, International Stillbirth Alliance, QLD, Australia and Stephanie Fukui,
International Stillbirth Alliance, Japan
Writing as a Tool in the Grief Process
Bodil Furnes, University of Stavanger, Norway
Virtual Support Groups
Anita Owren, www.englesiden.com, Norway
Voices of Sorrow – a Book Project
Kjersti Wold, Norwegian SIDS and Stillbirth Society, Norway
Indelible Isabella – the Permanence of her Presence
Cecilie Nome, Norwegian SIDS and Stillbirth Society, Norway
Social Network
Session Chair: Kari Dyregrov, Center for Crisis Psychology, Norway
How to Involve the Social Network after Perinatal Loss - Interactive Session
Kari Dyregrov, Center for Crisis Psychology, Norway
Supportive Conversation
Session Chair: Oddbjørn Sandvik, Norway
Den støttende samtalen – interactive session in Norwegian
Session Chair: Oddbjørn Sandvik, Norway
21
Perinataldagene
Kulturulikhet og perinatal helse
11:30 – 12:30 Kunst
Møteledere: Eli Saastad, Høgskolen i Akershus og Siri Vangen, Rikshospitalet, Oslo
Inngifte i Norge – utbredelse og medisinske konsekvenser
Pål Surén, Nasjonalt Folkehelseinstitutt
Kommunikasjon og kulturulikhet
Fahim Naeem, Internasjonal Helse- og Sosialgruppe, Oslo
Pulmonary Illness in the Newborn
13:30 – 15:00 Kunst
Session Chairs: Ola Didrik Saugstad, Rikshospitalet University Hospital, Norway and Rønnaug Solberg,
Rikshospitalet University Hospital, Norway
Are there strategies to prevent or treat bronchopulmonary dysplasia (BPD)?
Christian P. Speer, University Children’s Hospital Würzburg, Germany
Persisting pulmonary hypertension of the newborn - a wide range of challenges and outcomes
Thor Willy Ruud Hansen, Rikshospitalet University Hospital, Norway
Diaphragmatic hernia in the era of prenatal diagnosis and gentle ventilation
Hans Skari, Rikshospitalet University Hospital, Norway
Discussion
What are the main current challenges and promises in treatment of pulmonary illness in the newborn?
Kangaroo Care
15:30 – 16:15 Kunst
Session Chairs: Laila Kristoffersen, St. Olavs Hospital, Norway and Kjell Å. Salvesen, St. Olavs Hospital,
Norway
Kangaroo Care
Susan Ludington, Case Western Reserve University, OH, USA
Demografi
16:15 – 17:00 Kunst
Møteledere: Laila Kristoffersen, St. Olavs Hospital, Trondeim og Kjell Å. Salvesen, St. Olavs Hospital,
Trondheim
Fertilitetsrater i Europa
Arne Sunde, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim
Frie foredrag i neonatologi/obstetrikk (presented in Norwegian)
17:30 – 18:30 Film
Møteledere: Marianne Skreden, Sykehuset Sørlandet, Arendal og Thor Willy Ruud Hansen, Rikshospitalet, Oslo
22
Neonatal group B streptococcus (GBS) infections
Eileen Wittmann, Sykehuset i Vestfold, Tønsberg
Medfødte misdannelser i nyrer og urinveier.
Hans Randby, Sykehuset i Vestfold, Tønsberg
Diagnosis of critical congenital heart defects – the effect of pulse oximetry screening
Alf Meberg, Sykehuset i Vestfold, Tønsberg
Breastfeeding of infants with congenital heart disease throughout the first six months after birth. The MOBA
cohort study.
Bente Silnes Tandberg, Rikshospitalet, Oslo
Forekomst og risikofaktorer for sfinkterruptur i forbindelse med fødsel
Ragnhild Klokk, Sykehuset Innlandet, Lillehammer
Frie foredrag i obstetrikk (presented in Norwegian)
17:30 – 18:30 Kunst
Møteledere: Marit Tjessem, Stavanger Universitetssykehus og Guttorm Haugen, Rikshospitalet, Oslo
Rutinemessig ultralyd i svangerskapet
Liv Merete Reinar, Nasjonalt kunnskapssenter for helsetjenesten
Uniform information on fetal movement reduces reporting delays and stillbirths in primiparous women – a clinical
quality improvement project
Eli Saastad, Høgskolen i Akershus, Lillestrøm
Skulderdystosi ved andre forløsning - gir tidligere skulderdystosi økt risiko?
Eva Øverland, Akershus Universitetssykehus, Lørenskog
Postpartum blødning; profylakse og behandling i Norge i 2007
Anne Sofie Fossum Engnæs, St. Olavs Hospital, Trondheim
Antiangiogene faktorer og blodtrykksøkning i normotensive svangerskap
Kristin Brække, Ullevål Universitetssykehus, Oslo
23
Breakfast Meeting
Building Synergies for Parents, NGOs and Professional’s Stillbirth Efforts – III
Meeting Chair(s): Chris Wildsmith, SANDS, UK and Ruth C. Fretts, Harvard Vanguards Medical Associates,
MA, USA
How can collaboration improve legislation and policy?
Plenary Sessions
The Challenge of Fetal Growth Restriction
Session Chair(s): Guttorm Haugen, Rikshospitalet University Hospital, Norway and Ron Gray, National
Perinatal Epidemiology Unit, University of Oxford, UK
Fetal Growth: Evolutionary History & Future Consequences
Mark Hanson, University of Southampton, UK
Lunch Poster Walk
12:30 – 13:30 Ground Floor Poster Hall
Developing Countries Poster Walk (Posters 27 – 45) – Authors are present
Refreshments
19:30 – 20:00 1st Floor Lobby
Conference dinner
20:00 Sonja Henie Ballroom
Hosted by the Norwegian Society for Perinatal Medicine
The main social gathering of the conference will include a three-course dinner from the Chefs at Plaza,
performance by the vocal ensemble “Mezzo”, and Sandvika Big Band will follow into the night. Please see
details in the section for the Social Program.
24
Stillbirth Track
Epidemiology of Fetal Growth Restriction
10:15 – 11:15 Olympia
Session Chair(s): Russell Kirby, University of South Florida, FL, USA and Jan Jaap Erwich, University Medical Centre Groningen, Netherlands
Epidemiology of FGR and Later-Life Risk of Diseases
Pål R. Romundstad, Norwegian University of Science and Technology, Norway
Recurrence and Family Exposure of FGR
Rolv Skjærven, Norwegian Institute of Public Health, Norway
Discussion
WHO Workshop: Improving Quality of Care for Effective Prevention of Stillbirths
in Developing Countries
10:15 – 12:30 Salome
Session Chair(s): Monir Islam, World Health Organization, Switzerland
As an ongoing policy and process, The WHO MPS department has the goal of further strengthening collaboration
with partners working in the area of Maternal and Newborn Health and contribute to more effective work in countries.
In developing countries, available evidence shows that higher stillbirth rates are associated with less prenatal
care, unattended deliveries or deliveries by TBAs, out-of-hospital births, and lower rates of caesarean section.
Furthermore, recognizing the fact that much is still unknown about stillbirths and the need for making health professionals, researchers & partners fully aware of the scope of MPS strategies, approaches and tools, WHO/MPS is
proposing to hold a workshop focusing on the following topic:’ Improving quality of care for effective prevention of
stillbirths in developing countries’.
Session objective: The overall objective of this session is to provide technical update on strengthening quality of
care in developing countries as an adequate strategy to improve adverse pregnancy outcomes.
Specifically, by the end of the session, participants will:
• Be aware of the burden of disease due to stillbirths in developing countries;
• Be familiar with reasons for not using MNH services in developing settings;
• Be aware of available data suggesting that stillbirth rates could be reduced by higher quality of care;
• Be aware of innovative ways for increasing use of MNH services and improving performance;
• Understand the importance of use of data for effective implementation of MNH programs.
Outline:
• Quality of care and perinatal outcomes;
• Reasons for not using MNH services;
• Innovative ways to improve performance of health providers and to increase use of MNH services;
• Use of data for effective implementation of MNH programs.
Panel members & topics:
• B. Pattinson: ”Quality of care & perinatal outcomes: SA experience”.
• C. Marston: ”Reasons for not using MNH services”.
• M. Bucagu: ”Innovative ways to improve performance of health providers and increase use of MNH services in
developing settings: Rwanda experience”.
• A.Shankar: ”Use of data to improve program implementation”.
25
Mechanisms and Causes in Fetal Growth Restriction
11:30 – 12:30 Olympia
Session Chair(s): Russell Kirby, University of South Florida, FL, USA and Jan Jaap Erwich, University
Medical Centre Groningen, Nederlands
Mechanisms: Haemodynamic Causes of FGR and Death
Torvid Kiserud, University of Bergen, Norway
Placental Causes of Growth Restriction
Borghild Roald, University of Oslo, Norway
Discussion
Screening and Detection of Fetal Growth Restriction
13:30 – 15:00 Olympia
Session Chair(s): Guttorm Haugen, Rikshospitalet University Hospital, Norway and Rolv Skjærven,
Norwegian Institute of Public Health, Norway
Early Markers and Early Screening – Future Possibilities?
Gordon C.S. Smith, Cambridge University, UK
Customized Growth Charts – Principles and Application in the Study of Adverse Outcome
Jason O. Gardosi, West Midlands Perinatal Institute, UK
Customized Growth Charts – What Defines Optimal Growth?
J. Frederik Frøen, Norwegian Institute of Public Health, Norway
Panel discussion
Management of Fetal Growth Restriction
15:30 – 16:30 Olympia
Session Chair(s): Errol Norwitz, Yale University School of Medicine, NH, USA and Karin Pettersson,
Karolinska University Hospital, Sweden
Current Standards of Care in the Small for Gestational Age Fetus
Gordon C.S. Smith, Cambridge University, UK
Detection, Monitoring and Delivery of the FGR Fetus: Where can Progress be Made?
Gerard H. A. Visser, University Medical Center of Utrecht, Netherlands
Discussion
Free Communications Developing Countries
15:30 – 16:30 Film
Session Chair(s): Kari Klungsøyr Melve, Norwegian Institute of Public Health, Norway
Stillbirths in sub-Saharan Africa: Illustration from Cameroon
Elisabeth Sommerfelt, Academy for Educational Development, DC, USA
26
Fetal Outcome in Severe Maternal Morbidity: Too Many Stillbirths
Mamady Cham and Johanne Sundby University of Oslo, Norway
Institutionalizing Maternal and Perinatal Death Review System in Nepal
Sharad Kumar Sharma Department of Health Services Family Health Division Teku, Kathmandu, Nepal
Pattern and Correlates of Viable Stillbirths in Nigeria
Bolajoko O. Olusanya, University of Lagos, Nigeria
The GAPPS Initiative
16:30 – 17:00 Olympia
Session Chair(s): Errol Norwitz, Yale University School of Medicine, NH, USA and Karin Pettersson, Karolinska University Hospital, Sweden
The Global Alliance to Prevent Prematurity and Stillbirth Initiative
Craig Rubens, Seattle Children’s Hospital, WA, USA
Free Communications Stillbirth
17:30 – 19:00 Film
Session Chair(s): Craig Rubens, Seattle Children’s Hospital, WA, USA
Maternal Perception of Reduced Fetal Movements for Detection of the Fetus at Risk: The Australian
Arm of the international Femina Collaboration
Julie MacPhail, Mater Mothers’ Hospital, Australia
Time Trends In Risk Of Recurrent Stillbirth: Gestational Age And Birth Weight Matters
Kari Klungsøyr Melve, Norwegian Institute of Public Health, Norway
Neonatal outcomes after planned home births in Norway 1990-2007
Anette Schaumburg Huitfeldt, Rikshospitalet University Hospital, Norway
Chorionic Surface Vessels as Midgestational Influences on Term Birth Weight: Implications for Genesis
of Stillbirth
Carolyn M. Salafia, Institute for Basic Research, NY, USA
Variations in placental shape may time gestational events key to late stillbirth
Carolyn M. Salafia, Institute for Basic Research, NY, USA
Infection in Fetal Losses between 16 and 24 Weeks Gestation
Adrian Charles, King Edward Memorial Hospital, Australia
Does Ljungan Virus Cause Malformation, Intrauterine Fetal Death and Sudden Infant death syndrome?
Bo Niklasson, Uppsala University, Sweden
General Assembly of the International Stillbirth Alliance
17:30 – 19:00 Madonna
Session Chair(s): Vicki Flenady, International Stillbirth Alliance, QLD, Australia
Intended for: Representatives of the ISA member organizations. Open for observers from non-members.
27
Bereavement Track
Care and Support after Perinatal Death I
Meeting Chair(s): Leanne Raven, International Stillbirth Alliance, Australia and Ingela Rådestad,
Mälardalan University, Sweden
Neonatal Death: A Mother’s Experience of Support when Her Baby Dies
Else Louse Hoen Meløe, Norwegian SIDS and Stillbirth Society, Norway
A Care and Support Program for Families in a Neonatal Intensive Care Unit
Kari Lowzow, Ullevål University Hospital, Norway
Clinical Care Implications of Pregnancy after Perinatal Loss
Marianne H. Hutti, University of Louisville, KT, USA
Discussion
Care and Support after Perinatal Death II
Session Chair: Marianne H. Hutti, University of Louisville, KT, USA
Parent’s Needs for Care and Support When a Child Dies in Stillbirth
Janne Teigen, Norwegian SIDS and Stillbirth Society and Telemark Hospital, Norway
Mothers Feelings when Holding their Stillborn Baby
Ingela Rådestad, Mälardalens University, Sweden
Caregivers and Perinatal Death
Claudia Ravaldi, CiaoLapo Onlus, Italian Charity Organization for Perinatal Grief Support,Italy
Support for Mothers, Fathers and Families after Perinatal Death: A Cochrane Review
Vicki Flenady, Mater Health Services, QLD, Australia
Models of Care and Support
Session Chairs: Mona Degrell, Rikshospitalet University Hospital and Ingela Rådestad, Mälardalens
University, Sweden
A Stillbirth – the Routines at Ullevål University Hospital
Bente Guildal, Ullevål University Hospital, Norway
To Help Parents Cope Through Stillbirth and Grief: Models of Care - a Case Study from Akershus
University Hospital
Kari E. Bugge and Tanja Bårdsen, Center for Grief Support, Akershus University Hospital, Norway
A Model for Support Groups – Aftercare from the Hospital
Mariëtte de Groot-Nordenbos, University Medical Centre of Groningen, The Netherlands
28
Peer Support Training Programme
Trine Giving Kalstad, Norwegian SIDS and Stillbirth Society, Norway
Childrens’ Grief and Grief in the Workplace
15:30 – 17: 00 Vampyr/Madonna
Session chair: Kari Bugge, Akershus University Hospital, Norway
Embracing Diversity in Descriptions of Children and Grief
Eline Grelland Røkholt, Akershus University Hospital, Norway
Play and Conversation Box - A Method for Sibling Care
Eline Grelland Røkholt, Akershus University Hospital, Norway and Toril M. Kristoffersen, Norwegian SIDS
and Stillbirth Society, Norway
Back to Work After a Loss
Annelise Olsen, Norwegian SIDS and Stillbirth Society, Norway and Trine Giving Kalstad,
Norwegian SIDS and Stillbirth Society, Norway
Grief in the Workplace
Liz Davis, Parent Advisory Committee, International Stillbirth Alliance, Australia.
Free Communications Bereavement
17:30 – 19:00 Vampyr
Session Chairs: Claudia Ravaldi, PAC, Italy and Janne Teigen, Norwegian SIDS and Stillbirth Society and
Telemark Hospital, Norway
Women Wish to Talk About Their Fetal Loss
Anjana Karki Rayamajhi, Kathmandu University School of Medical Sciences, Nepal
Demetra project. Psychopatological Impact of Perinatal Death in Italian Families
Claudia Ravaldi, CiaoLapo charity organization for grief support after perinatal death, Italy
Parental Reflections Upon the Loss of Their Healthy First Born Child Due to Grave Misconduct by Health
Practitioners During Labour
Ingunn Meyer Knutsen and Karl Marius S. Norschau, Norway
Understanding Pregnancy Loss in Taiwan
Hui-Lin Sun, Nursing and Management College,Taipei, Taiwan
Providing Peer Support
Susan Ann Hale, Sands, UK
Support Groups – What Role do they have in Supporting Bereaved Parents?
Liz Davis, Parent Advisory Committee, International Stillbirth Alliance, Australia.
29
Perinataldagene
Tvillinger
10:15 – 11:15 Kunst
Møteledere: Kjell Å. Salvesen, St. Olavs Hospital, Trondheim og Lillian Berge, Ullevål Universitetssykehus, Oslo
Elektiv single embryo transfer ved IVF/ICSI
Tom Tanbo, Rikshospitalet, Oslo
Økende tvillingforekomst i Norge 1967- 2004. Betydningen av mors alder og assistert befruktning
Anne Tandberg, Universitetet i Bergen
Assistert vaginal tvillingfødsel
Per E. Børdahl, Universitet i Bergen
Frie foredrag i neonatologi (presented in Norwegian)
11:30 – 12:30 Film
Møteledere: Nina Jamissen, Nordlandssykehuset, Bodø og Kåre Danielsen, Sørlandet sykehus, Kristiansand
Måling av hjertefunksjonen hos nyfødte med strain og strain rate med vevsdoppler første tre levedøgn
hos friske terminfødte
Eirik Nestaas, Sykehuset i Vestfold, Tønsberg
Resuscitation with different oxygen concentrations gives a dose dependent increase in metalloproteinases (mmps), and a decrease in bdnf expression and activity in newborn pigs brain
Rønnaug Solberg, Rikshospitalet, Oslo
Simulering – en utfordring på linje med virkeligheten
Hilde Stuedahl Mohn, St. Olavs Hospital, Trondheim
Utfører sykepleiere faglig forsvarlig vurdering av premature barns oksygenbehov? En kartlegging av
hvordan sykepleiere oppfatter sine vurderinger når de tilpasser oksygen til premature barn tilkoblet
respirator
Marianne Trygg Solberg, Lovisenberg Diakonale Høgskole, Oslo
Venepunksjon versus hælstikk ved blodprøvetaking hos nyfødte
Andreas Andreassen, Haugesund Sjukehus
Frie foredrag i obstetrikk/amming (presented in Norwegian)
11:30 – 12:30 Kunst
Møteledere: Amiri Nimrose, Sykehuset Telemark, Skien og Jon Tuveng, Ringerike sykehus, Hønefoss
Love at first sight – smell – taste – touch: Possible also with caesarean section? Evidence for effects of
early skin-to-skin contact
Gro Nylander, Rikshospitalet, Oslo
Skin-to-skin mother-child contact during cesarean section and the first hours postoperative: How did
we go about it?
Gro Nylander og Anne Gro Areklett, Rikshospitalet, Oslo
Systematisk pre- og postnatal ammeveiledning ved leppe-kjeve-ganespalte – en oppfølgings- undersøkelse
Elisabeth Tufte, Rikshospitalet, Oslo
30
Androgener i svangerskapet og amming
Eszter Vanky, St. Olavs Hospital, Trondheim
Amming hos kvinner med Polycystisk Ovariesyndrom (PCOS)
Eszter Vanky, St. Olavs Hospital, Trondheim
Consequences of Fetal Growth Restriction
13:30 – 15:00 Kunst
Session Chairs: Jan Holt, Nordland Hospital, Norway and Kristin Brække, Ullevål University Hospital, Norway
Long term consequences of early growth
Johan G. Eriksson, University of Helsinki, Finland
Medical and neurological aspects
Jon Skranes, Norwegian University of Science and Technology, Norway
Neuropsychological functions in moderate term SGA
Gro C. C. Løhaugen, Norwegian University of Science and Technology, Norway
Ernæring av syke og premature nyfødte
15:30 – 17:00 Kunst
Møteledere: Alf Meberg, Sykehuset i Vestfold, Tønsberg og Dag Moster, Universitetet i Bergen
Parenteral ernæring av fullbårne og premature nyfødte
Morten Grønn, Rikshospitalet, Oslo
Peroral ernæring – forsterkning til morsmelk?
Christine Gørbitz, Rikshospitalet, Oslo
Hvordan fremme amming av premature – er vår praksis kunnskapsbasert?
Anna-Pia Häggkvist, Rikshospitalet, Oslo
Diskusjon
Generalforsamling Norsk perinatalmedisinsk forening
17:30 – 19:00 Kunst
For medlemmer i NPF, men ikke-medlemmer ønskes velkommen som observatører.
31
Breakfast Meeting
Building Synergies for Parents, NGOs and Professional’s Stillbirth Efforts – IV
Meeting Chair(s): Chris Wildsmith, SANDS, UK and Ruth C. Fretts, Harvard Vanguards Medical Associates,
MA, USA
How can collaboration improve research, clinical practice and bereavment care?
Plenary Sessions
Excellence of Care
Session Chair(s): J. Frederik Frøen, Norwegian Institute of Public Health, Norway and Marian Sokol,
International Stillbirth Alliance, TX, USA
Patient Safety in Obstetrics
Stephen D. Pratt, Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA
Lunch Poster Walk
12:30 – 13:30 Ground Floor Poster Hall
Bereavement Poster Walk (Posters 46 – 49) – Authors are present
Closing Ceremony
17:05 – 17:30 Olympia
Session Chair(s): J. Frederik Frøen, Norwegian Institute of Public Health, Norway
Closing Address of the WHO
Monir Islam, World Health Organization, Switzerland
Welcome to the Norwegian Perinatal Society 2009 in Tønsberg
Alf Meberg, Norwegian Society for Perinatal Medicine, Norway
Welcome to the International Stillbirth Conference 2009
Robert Pattinson, International Stillbirth Alliance, South Africa
Welcome to the International Stillbirth Conference 2010
Vicki Flenady, International Stillbirth Alliance, Australia
Closing the Conference
J. Frederik Frøen, Conference Chair, Norway
32
Stillbirth Track
Excellence in Prevention – Part I
10:15 – 11:15 Olympia
Session Chair(s): Ruth C. Fretts, Harvard Vanguards Medical Associates, MA, USA and Torvid Kiserud,
University of Bergen, Norway
Post-Term Pregnancy – How Long is Too Long?
Errol Norwitz, Yale University School of Medicine, NH, USA
Active Management of Risk and Early Term Inductions in Preventing Birth Adverse Outcomes
James M. Nicholson, University of Pennsylvania Health System, PA, USA
Discussion
Excellence in Prevention – Part II
11:30 – 12:30 Olympia
Session Chair(s): Babill Stray-Pedersen, University of Oslo, Norway and Jason O. Gardosi, West Midlands
Perinatal Institute, UK
Early Delivery – All Good? From the Neonate’s Point of View
Ola Didrik Saugstad, University of Oslo, Norway
Confidential Enquiries: A Powerful Tool for Stillbirth Prevention
Jason O. Gardosi, West Midlands Perinatal Institute, UK
Discussion
Excellence in Clinical Care and Subsequent Pregnancies
13:30 – 15:00 Olympia
Session Chair(s): Gordon C.S. Smith, Cambridge University, UK
Investigations of Stillbirths
Vicki Flenady, Mater Health Services, QLD, Australia
Management of Subsequent Pregnancy after Stillbirth
Fabio Facchinetti, University of Modena, Italy
Discussion
Excellence in Psychosocial Care after Stillbirth
15:30 – 16:15 Olympia
Session Chair(s): Ingela Rådestad, Mälardalens University, Sweden and Liz Davis, International Stillbirth
Alliance, QLD, Australia
State of the Science Related to Psychosocial Issues in Pregnancy After Perinatal Loss
Discussion
33
Free Communications Bereavement
16:15 – 17:00 Olympia
Session Chair(s): Ingela Rådestad, Mälardalens University, Sweden and Liz Davis, International Stillbirth
Alliance, QLD, Australia
Meeting the Needs of Grieving Families after Perinatal Death in Slovenia
Vislava Globevnik Velikonja, University Medical Centre Ljubljana, Slovenia
Development and Implementation of an Intervention to Promote Coping of Grieving Fathers
Anna Liisa Aho, University of Tampere, Finland
Do Couples Stay Together after a Baby Dies? Marriage and Cohabitation Outcomes after Miscarriage and
Stillbirth
Katherine J. Gold, University of Michigan, MI, USA
Free Communications Stillbirth
15:30 – 17:00 Film
Session Chair(s): Ron Gray, University of Oxford, UK and Per E. Børdahl, University of Bergen, Norway
Classification of Intrauterine Fetal Death (IUFD) in the Oslo Area 1990-2003
Linda Björk Helgadóttir, Ullevål University Hospital, Norway
Policy Into Practice: Skills Training Using the Scorpio Method to Implement Clinical Practice Guidelines
for Perinatal Mortality Audit in Australia and New Zealand
Adrienne Gordon, University of Sydney & Royal Prince Alfred Hospital, Australia
Stillbirth and Slow Metabolizers of Caffeine – Comparison of Genotypes
Bodil Hammer Bech, University of Aarhus, Denmark
Q Fever During Pregnancy As A Cause Of Stillbirth
Xavier Carcopino, Hôpital Nord, France
A Prospective Evaluation of Stillbirth Looking at Causes of Death
Fabio Facchinetti, University of Modena and Reggio Emilia, Italy
Potentially Preventable Stillbirths in Australasia; A Systematic Review og the literature
Laura Koopmans, Mater Mothers’ Hospital, Australia
The Effect of Socioeconomic Status, Acceptance of Pregnancy and Prenatal Care on Fetal Mortality in
São Paulo City, Brazil
Gizelton Pereira Alencar, University of São Paulo, Brazil
Free Communications Developing Countries
15:30 – 17:00 Vampyr / Madonna
Session Chair(s): Sven Gudmund Hinderaker, University of Bergen, Norway.
Stillbirths in Rural India: Rates, Determinants and Implications for Maternal and Newborn Health
Interventions
Vishwajeet Kumar, King George Medical University, India
A Community Survey on Awareness, Beliefs and Socio-Cultural Implications of Stillbirth Among
Nigerian Women
Imran O. Morhason-Bello, University College Hospital, Ibadan, Nigeria
34
Why Babies Die – a Perinatal Care a Ugandan Cohort Study
Waiswa Moses, The African child care Alliance Development, Uganda
Validation of Perinatal Care Indicators
Robert Clive Pattinson, University of Pretoria, South Africa
Still-Births- Causes, Treatment Seeking Practices and Reliability Of Routine Health System in Still Birth
Registration - Some Lessons From North India
Arun Kumar Aggarwal, School of Public Health, PGIMER, Chandigarh, India
Free or Paid Maternity Care: Differences in Care and in Birth Outcomes
Sreevidya Subramoney, Gøteborg University, Sweden
35
Bereavement Track
Autopsy
Session Chair(s): Arne Stray-Pedersen, University of Oslo, Norway and Trine G. Kalstad, Norwegian SIDS
and Stillbirth Society, Norway
Preparing for Autopsy: A Parent Perspective
Line Christoffersen, Norwegian School of Management, Norway
Preparing for Autopsy: A Pathologist’s Perspective
Borghild Roald, University of Oslo, Norway
How Guidelines can Enable Health Professionals to Prepare Parents for Autopsy
Åshild Vege, University of Oslo, Norway
Discussion
Couples and Grief
Session Chair(s): Line Christoffersen, Norwegian SIDS and Stillbirth Society, Norway
Couple Relationships and Intimacy after the Loss of a Child
Atle Dyregrov, Center for Crisis Psychology, Norway
Discussion
The Subsequent Pregnancy
Session Chair(s): Sue Hale, SANDS UK and Ingela Rådestad, Mälardalens University, Sweden
Knowing What to Expect in the Subsequent Pregnancy
Dealing with Clinical and Emotional Needs During a Subsequent Pregnancy
Line Christoffersen, Norwegian School of Management, Norway
Ten Questions to Ask Your Doctor
Liz Davis, Parent Advisory Committee, International Stillbirth Alliance, Australia
Professional Counselling When Grieving
Session Chair(s): Sue Hale, SANDS UK and Ros Richardson, SIDS and Kids, Australia
Complicated Grief: A Group Intervention
Atle Dyregrov, Center for Crisis Psychology, Norway
Discussion
36
Perinataldagene
Pasientsikkerhet og kvalitetsforbedring ved sykehus
10:15 – 11:15 Kunst
Møteledere: Jan Holt, Nordlandssykehuset, Bodø og Per E. Børdahl, Haukeland Universitetssykehus, Bergen
Uheldige hendelser, forebygging og håndtering
Peter F. Hjort, prof.em. Universitetet i Oslo
Menneskelige feil som årsak til medisinske ulykker – kan problemet reduseres?
Sigurd Fasting, St. Olavs Hospital, Trondheim
Overtidig svangerskap
11:30 – 12:30 Kunst
Møteledere: Kjell Å. Salvesen, St. Olavs Hospital, Trondheim og Marit Tjessem, Stavanger Universitetssykehus
Post-terme svangerskap. Resultater fra en randomisert, kontrollert studie
Runa Heimstad, St. Olavs Hospital, Trondheim
Post-terme svangerskap – tid for revurdering?
Jakob Nakling, Sykehuset Innlandet, Lillehammer
Rutineinduksjon av fødsel ved 41 uker: Nonsensus consensus
Kåre Augensen, Haukeland universitetssykehus, Bergen
Paneldebatt
Den Norske Mor-Barn-undersøkelsen
13:30 – 15:00 Kunst
Møteledere: Per Magnus, Nasjonalt folkehelseinstitutt og Eli Saastad, Høgskolen i Akershus
Gener og miljø ved spontan preterm fødsel
Nils-Halvdan Morken, Haukeland universitetssykehus, Bergen
Årsaker til preeklampsi
Per Magnus, Nasjonalt folkehelseinstitutt
Spiseforstyrrelser i svangerskapet
Leila Torgersen, Nasjonalt folkehelseinstitutt
Overgrep som barn og redsel for å føde
Jorid Eide, Nasjonalt folkehelseinstitutt
Risiko for angst og depresjon i svangerskapet
Gun-Mette Brandsnes Røsand, Nasjonalt folkehelseinstitutt
Panel
Muligheter for forskning i den norske kohorten med 100 000 svangerskap
Prisutdelinger i NPF
15:30 – 17:00 Kunst
Utdeling av NPF-prisene 2008
Utdeling av priser for beste frie foredrag i obstetrikk og neonatolgi
37
Keynote speakers
38
FETAL GROWTH: EVOLUTIONARY
HISTORY & FUTURE CONSEQUENCES
Mark Hanson, UK
University of Southampton
[email protected]
Professor Mark Hanson is the founding Director of the Institute of Developmental Sciences at the University of Southampton, Director of the Division of Developmental Origins
of Health and Disease in the University’s School of Medicine and British Heart Foundation
Professor of Cardiovascular Sciences. Mark’s research concerns severl aspects of development and health, ranging from the molecular epigenetic mechanisms underlying the
effects of developmental environment on phenotype, to population studies aimed at early
identification of risk. He is interested in evolutionary medicine and the reintroduction of a
developmental perspective into human biology and medicine. His recent books include
Mismatch - The lifestyle diseases timebomb (2008). He has appeared on a variety of TV
and radio programmes, in many newspaper and magazine articles and on public lecture/
understanding of science platforms
THE GLOBAL BURDEN OF STILLBIRTHS
Monir Islam, Switzerland
Dept. for Making Pregnancy Safer,
[email protected]
Dr Quazi Monirul Islam, is the Director of the Department of Making Pregnancy Safer,
World Health Organization, responsible for maternal and newborn health. Dr Islam is
a public health specialist qualified from Dhaka University, Bangladesh and received
MPH from Amsterdam University and the Royal Tropical Institute in the Netherlands.
He was awarded FRCOG by the Royal College of Obstetrics and Gynaecology, UK. He
worked in a rural health complex in Bangladesh before going to Botswana in 1981.
There he worked for ten years as a Medical Officer in District Hospitals; as Hospital
Superintendent and as a Senior District Medical Officer responsible for all Primary
Health Care programmes. He joined the Ministry of Foreign Affairs in the Netherlands
as a Public Health Consultant advising the Ministry on their bilateral and multilateral
contributions to health and population-related programmes and projects. In 1992
he was invited to join the Global Programme on AIDS in the World Health Organization in Geneva, Switzerland and was responsible for Sexually Transmitted Diseases
programme. and thereafter joined the Reproductive Health Programme as Chief of
Population and Family Planning Unit and subsequently as Team Coordinator, Norms
and Tools in the Reproductive Health and Research Department. In 2002, he was
appointed as Director, Family and Community Health Department, which included
Reproductive Health and Research, Making Pregnancy Safer, Child and Adolescent
Health, Nutrition, Nursing and Midwifery, Human Resources and Essential Drugs
programme, in the WHO Regional Office for South-East Asia, New Delhi, India. Dr
Islam took up his current post as Director, Making Pregnancy Safer with global responsibility for maternal and newborn health, in Geneva in January 2005.
PATIENT SAFETY IN OBSTETRICS
Stephen D. Pratt, USA
Beth Israel Deaconess Medical Center, Harvard Medical School
[email protected]
Dr. Pratt is the Director of Quality Improvement and the Clinical Director of
Obstetric Anesthesia for the Department of Anesthesia at Beth Israel Deaconess Medical Center. He is the Chair of the Patient Safety Committee for the
Society for Obstetric Anesthesia and Perinatology, and sits on the state board
for patient safety in Obstetric in Massachusetts. He has helped author two
curricula for team training on Labor and Delivery and was instrumental in developing and publishing clinically relevant outcomes for assessing quality of
Obstetric care. He has lectured nationally and internationally on patient safety
and team training in obstetrics.
39
Invited speakers
40
NONSENSUS CONSENSUS/ ROUTINE INDUCTION OF LABOUR
AT 41 WEEKS GESTATION: NONSENSUS CONSENSUS
Kåre Augensen, Norway
Kvinneklinikken,
Haukeland University
Hospital
[email protected]
Consultant in Obstetrics. Special interest:
Clinical obstetrics. Chair of The Quality Commitee of the Norwegian Society of Gynecology and
Obstetrics.
From the mid 1990s obstetric policies on induction of labour in postterm pregnancy have been influenced by The Canadian multicenter trial (Hannah 1992) The
1999 Cochrane Review The 2006 Cochrane Review. In the Cochrane 2006 Review,
the conclusion is that labour induction at 41 completed weeks should be offered
to low-risk women. There were, however, no significant statistical differences between the induction group and the expectant group for perinatal death, transferral
to NICU or Apgar scores <5 after 5 minutes. Moreover, few or any of the deaths can
be attributed to the postterm pregnancy itself, nor could most of them have been
avoided by earlier induction. Approximately 1000 inductions would have to be carried out at 41 weeks to avoid one perinatal death in the following week, assuming
a causal relationship between the death and the duration of the pregnancy. At 41
weeks, 25% of pregnant women are still undelivered. About 80% of them will give
birth in the following week. In a clinic with 5000 deliveries per year, routine induction at 41 weeks will mean 975 extra inductions. For these reasons, Norwegian
national guidelines do not follow the recommendations given in the Cochrane Review. The Norwegian guidelines will be presented.
ELIMINATING SYPHILIS-ASSOCIATED PERINATAL DEATH:
THE CHALLENGE OF DEVELOPING APPROPRIATE TARGETS
Stuart M. Berman, USA
Division of STD
Prevention, CDC
[email protected]
Dr. Stuart M. Berman is chief of the Epidemiology
and Surveillance Branch in the Division of STD Prevention at CDC in Atlanta, Georgia, USA. The Branch
monitors and interprets STD rates across the nation;
investigates increases in STDs; produces the CDC
STD Treatment Guidelines; develops, conducts, and
oversees research addressing STD prevention. Dr
Berman coordinated the development of the performance management system for the national STD
prevention program, conducted a variety of of studies
on congenital syphilis and chlamydia infections, and
had developed the congenital syphilis surveillance
case definition used in the United States. He is board
certified in Pediatrics and Preventive Medicine.
WHO has launched an initiative to achieve the global eliminatation of congenital syphilis. Congenital syphilis is an eminently preventable conditioin which,
though rare in most developed countries, is all common in many developing locales. Tracking and monitoring progress made in reducing congenital syphilis
and preventing the serious outcomes associated with the condition – stillbirths
in particular – is a critical component of this international elimination effort.
However, there are significant epidemiologic limitations associated with the
usual approaches available for monitoring congenital syphilis rates. Case-report
based surveillance data are unlikely to be representative, and would not be expected to capture stillbirth outcomes. Sentinel hospital approaches are limited
in coverage, and are to not include events occurring in more remote areas with
compromised antenatal care. Process measures that address gestational age
at syphilis testing and treatment can be very effective for monitoring program
performance but don’t directly assess improvements in health status. However,
population-based surveys may offer real promise in providing a valid approach
for monitoring reductions in adverse pregnancy outcomes associated with congenital syphilis.
GLOBAL ELIMINATION OF CONGENITAL SYPHILIS
INITIATIVE
See Abstract registered on Kenneth Wind-Andersen
Nathalie Broutet,
Switzerland
[email protected]
41
ROLE OF BASIC PRENATAL CARE IN THE PREVENTION OF
STILLBIRTHS: HEALTH BENEFITS AND IMPLEMENTATION
STRATEGIES
Bergsjø P.(1), Kuti O (2), Bucagu M (3,)
(1) Norwegian Institute of Public Health Division of Epidemiology
(2) Obafemi Awolowo University TeachingHospital Ile-Ife, Nigeria.
(3) WHO Department of Making Pregnancy Safer. Geneva
Better understanding of fetal growth and development in relation to the mother’s
health has resulted in increased attention to the potential of antenatal care as an
intervention to improve both maternal and newborn outcomes. In developing countries, with high infection-related stillbirth rates, achieving a substantial reduction in these
stillbirths should be possible simply by reducing maternal infections during pregnancy.
Skilled birth attendance and antenatal care are strongly associated with lower incidence
of intrapartum stillbirth and decreased maternal mortality rates. A study on cost effectiveness analysis of strategies for maternal and newborn health (2005) showed that
preventive interventions at the primary level (such as antenatal care) for mothers and
newborn are extremely cost effective in developing countries. The major factors that
can affect the uptake of antenatal care services in developing countries are maternal
education, husband’s education, marital status, availability, cost, household income,
women’s employment, media exposure and having a history of obstetric complications. Strengthening weak existing service delivery systems is the most promising
approach to enhance a successful implementation of the basic antenatal care, particularly in developing countries.
TO HELP PARENTS COPE THROUGH STILLBIRTH AND GRIEF,MODELS OF CARE, A CASE STUDY FROM AKERSHUS UNIVERSITY HOSPITAL
A multi professional care model to help parents cope through stillbirth and grief created by; Midwifes, Gynaecologists, Vicars, Autopsy specialists, Social workers and
Child-carers in cooperation with Section for bereavement support and research. The
goal of the model is to create safe predictable environment with right amount of information, support and medication before, under and after delivery og the stillborn baby.
To help parents to understand and cope with own feelings, physical and psychological
reactions and practical issues. To make connection and memories of the baby. To
make rituals after parents belief and cultural background. To understand and support
their partner and social network, and if children in the family, how to include and support them. The model also incorporate long-time follow up through initial bereavemnet talks with the parents and bereavement support groups and special follow up in
next pregnancy if wanted by the parents. The contents of the models will be specified
and examples given under the presentation.
Maurice Bucagu,
Switzerland
WHO Dept. of Making
Pregnancy Safer
[email protected]
Dr. Maurice Bucagu, MD, MMED OB.GYN, MPH,
PHD (candidate) Since September 2007, I have
been working for WHO Making pregnancy Safer
Department as Focal Point for the Sub Saharan
Africa. Before that, as Director of the Rwanda
National Population Office (1994-2001), I have
been involved in creation of ‘Community - based
Health Insurance’ with membership of 75% of the
Rwandan population (2007). In 2001, I joined the
Rwanda School of Public Health as Head of Department of Reproductive Health. I also took the
lead in developing 3 project proposals submitted
to Global Fund worth over 100 million USD, all of
them approved.
Kari Elisabeth Bugge,
Norway
Center for Health Promotion,
Akershus University
Hospital
[email protected]
Kari E. Bugge is Associate Professor,RN, MNSC and
Head of Bereavement Support and Research, Akershus University Hospital. Works together with midwifes at the Hospital to give bereavement support to
parents after stillbirth.
ASSISTERT VAGINAL TVILLINGFØDSEL
Vaginal assistert tvillingfødsel med hovedvekt på overvåking under fødselens første
stadium og fødsel av tvilling 2
Per E. Børdahl, Norway
Gyn Obst Dept, Haukeland
University Hospital,
University of Bergen
[email protected]
Per E Børdahl, MD Ph.D Klinikkoverlege KK (KKB),
Haukeland Universitetsklinikk siden 2002. Spesialist
i gyn/obst fra 1978, dr.med. 1985. Arbeidet med obstetrikk og særlig flersvangerskap gjennom snart en
mannsalder. Ansatt flere steder i Norge og Danmark,
nesten 20 år på KK, Rikshospitalet
42
TO HELP PARENTS COPE THROUGH STILLBIRTH AND GRIEF,MODELS OF CARE, A CASE STUDY FROM AKERSHUS UNIVERSITY HOSPITAL
Tanja Bårdsen, Norway
Akershus University
Hospital,
Sorgruppesenteret
tanja@fitnesstanja.com
See abstract registered on Kari Elisabeth Bugge
I am a midwife working at Akershus Unviersity
Hospital. I also work at “sorggruppesenteret”
with groups of parents, who lost a child before,
during or after pregmancy.
PREPARING FOR AUTOPSY: A PARENT PERSPECTIVE
Line Christoffersen,
Norway
Norwegian School of
Management
[email protected]
Associate Professor and Vice Rector Norwegian School
of Management Bereaved parent. Herman was born
dead 2. October 2004
Research method: Using Critical Incidents Technique we interviewed 40 parents (20
families interviewing mothers and fathers separately) during 2006/2007 about their
experiences with the health care system when loosing a baby aged between 26 and
42 weeks in stillbirth. During two to three hour interviews, we asked them to tell their
story and define critical incidents regarding, among other topics, the autopsy of their
stillborn baby.Main findings: Generally we found that parents are unprepared to make
a decision when the question of performing an autopsy or not is raised. Parents’ advice
is to introduce the thought of having an autopsy early – preferably before birth. Reality
is often less dramatic than parents’ fantasy, parents want to be told: -How an autopsy
is performed; -Why it is important to perform it as soon as possible. Most parents face
a dilemma when wanting to spend time with their child versus sending him or her to
autopsy. -What is done with the baby’s organs; -How the baby will look after the autopsy; -If and when they can see the baby again. It is important for parents that health
professionals do not reduce the question of an autopsy to an information task. Parents
need to have their questions answered by qualified personnel. Parents want to see,
hold and care for the baby after the autopsy, and those who do arenot reg. this retrospectively. Parents want the autopsy results presented as soon as possible – preferably
before a next pregnancy. They want the hospital to go through the autopsy report with
the parents – preferably with the pathologist present.
DEALING WITH CLINICAL AND EMOTIONAL NEEDS DURING A
SUBSEQUENT PREGNANCY
Research method: In depth interviews during 2006/2007 with 20 women about their
experiences with the health care system in Norway after stillbirth. Q&A on Norway’s
largest virtual bereavement site for parents. Research Question: What clinical and
emotional needs do women experience during a subsequent pregnancy after the loss
of a baby? What women want: -Health professionals who have time to listen to their
stories, and who take their worries seriously during the mental rollercoaster of being
pregnant after a loss. -Ideally, women want one contact person at the local hospital.
-Predictability: Women need to be in control and discuss the difficult choice between
vaginal birth and a caesarean section early in the pregnancy. Further, most women
prefer to have the baby no later than end of week 38. -Women need to feel safe. Early
ultrasound, combined with frequent ultrasounds and an open door policy during a subsequent pregnancy become important. - Continuity is important. Most women prefer
an individual plan for care from first trimester. Some women need frequents check ups
from the first day of pregnancy.
43
TEN QUESTIONS TO ASK YOUR DOCTOR
Questions to Ask is a joint project from the members of the Parent Advisory Committee of ISA. The members of the PAC are all bereaved parents and felt that this project would help to improve support services for bereaved parents around the world.
Questions to Ask is broken into three sections - questions to ask during a normal
pregnancy, questions to ask after a baby has died and questions to ask during a subsequent pregnancy. It is hoped that Questions to Ask will encourage parents to become more knowledgeable about their pregnancy and the health of their baby; have
an understanding of issues facing them after the death of their baby; provide support
and information for future pregnancies.
GRIEF IN THE WORKPLACE
Grief and bereavement are part of our lives and our workplaces. A positive return to work
experience is fundamentally important for bereaved employees, their employers and the business. When a person experiences the death of someone close to them, they will often reflect
on the meaning of their activities including their work. If they do not have a positive return
to work, they may choose to change their job or career, often taking years of experience and
training with them. They may then enter a workplace that does not know their history and
because of this may not be able to offer any support. It has become increasingly evident that
a positive return to work experience for bereaved employees significantly supports all concerned – manager, colleagues, business and of course the bereaved. The Grief in the Workplace package was developed in response to a need expressed by bereaved employees for
education when their return to work experiences may have been either negative or positive.
The Grief in the Workplace package has been developed to assist employees who are returning to the workplace following the loss of a parent, spouse, sibling or child. Managers and
business owners will gain a better understanding of the grief process that occurs when a
work colleague experiences the death of someone close to them. They will also learn of the
support that they can provide and the tools that will assist the employee to effectively return
to work. Protocols for the workplace and for the bereaved worker have been developed to enable all parties to understand the grief process and to allow a smooth return to work for the
bereaved employee
Liz Davis, Australia
Sands Australia
[email protected]
Liz Davis is the State Coordinator of Sands in
Queensland, Australia. Sands is a support group
for parents who experience the death of their
baby. Through her involvement with Sands, Liz
has been fortunate to have supported many
parents in their grief journey and be able to use
parents’ experiences to further develop support
mechanisims. Liz is the Co-chair of the Parent
Advisory Committee of the International Stillbirth
Alliance and is passionate advocate for parents
who have experienced the death of their baby.
COUPLES AND GRIEF: COUPLE RELATIONSHIPS AND
INTIMACY AFTER THE LOSS OF A CHILD
To broaden our knowledge about sexuality and intimacy following the loss of a child,
a multimethod study was conducted. A questionnaire on intimacy and sexuality was
sent to 1027 members of the two major bereavement support organisations for parents who have lost children in Norway. A total of 321 (33 %) were returned. In addition
10 couples were interviewed in depth about their experiences. The presentation will
focus on the couples in the study. The results showed that around two thirds of the
parents had resumed sexual contact within the first three months after their child’s
death. Around a third had their activity reduced. Significantly fewer mothers than fathers experienced sexual pleasure and close to 30 % of the mothers experienced that
this had been reduced since the death. Only 10 % had experienced that sexuality as
an issue was raised in follow-up conversations. The provision of verbal and written
information would help families through the post loss period and may lower parental
conflict and better relational coping.
COMPLICATED GRIEF: A GROUP INTERVENTION
A program aimed at reducing the negative effects of traumatic grief including three
types of interventions in separate modules was developed. Ninety-three parents who
lost a child to different causes took part in the first module, where information on normal reactions related to grief was in focus. Based on selection criteria (cut-off scores
on certain measures) 37 participants were offered the second module; therapeutic
weekend gatherings and 19 accepted the invitaton. The last module, individual psychotherapy, was offered the 11 participants with the highest level of traumatic grief and
psychosocial problems and 8 participated. Participants answered the Impact of Event
Scale (IES), the Inventory of Complicated Grief (ICG) and the General Health Questionnaire (GHQ) before the first module, within a few weeks of completing the second module and 9 months after this. Scores on all measures dropped significantly from the
first to the second measurement and from the second to the third. It is concluded that
participation in the intervention had a clear beneficial effect for the participants.
44
Atle Dyregrov, Norway
Center for Crisis
Psychology, Bergen
[email protected]
Dr. Atle Dyregrov is the director of the Center for
Crisis Psychology in Bergen, Norway. He is a clinical and research psychologist, who during most
of his career has worked with families who lose
children, also his dissertation subject in 1988. Dr.
Dyregrov is the author of numerous publications,
journal articles and more than 10 books. He has
conducted research on various subjects relating
to the loss of a child, such as parental reactions,
differences between mother’s and father’s grief,
siblings’ experience, and most recently how the
loss of a child influences intimacy and sexuality.
HOW TO INVOLVE THE SOCIAL NETWORK AFTER PERINATAL
LOSS - INTERACTIVE SESSION
Kari Dyregrov, Norway
Center for Crisis
Psychology/
Norwegian Institute of
Public Health
[email protected]
Kari Dyregrov is a doctor in sociology from the
University of Bergen. Since 1995, she has been
working as a researcher of traumatic bereavement, and has conducted several research
projects covering; grief reactions and self-help
strategies in bereavement, social network responses to traumatised people, organisation of
psychosocial assistance in the communities and
ethical and methodological aspects of research
on adverse life-situations. She has been lecturing nationally and internationally, and has written many papers and book chapters. Her, and
her husband Atle Dyregrov’s book “Effective Grief
and Bereavement Support” came out in English
in August 2008.
This workshop will start with a presentation of K. Dyregrov that is based on her research with bereaved parents that have lost a child suddenly. She will talk about how
the parents and their networks (e.g. friends, family, neighbours, and work-colleagues)
have experienced the encounters after the tragic loss of a child. Also, she will speak
about the importance of network support in general, and the difficulties with such support as seen from both parties. Whereas networks describe the support processes as
incredibly rewarding, they also experience it to be difficult and hard. They encounter
the parents’ large human challenges, resulting in a sense of powerlessness and helplessness. Although the bereaved are disappointed at times, they do understand that
the networks may feel unsecure and want to help, in order to improve the support they
may get from the networks. After the initial introduction, the workshop will be interactive. Through the overall issue: “What contributed to the best/wished for support
from the networks”, the participants will discuss their good and bad experiences with
social networks. Finally, K. Dyregrov will summarise what can be done to improve the
great resources that network support represent to bereaved after a child loss.
CHILD ABUSE AND FEAR OF CHILDBIRTH
Jorid Eide, Norway
Public Health, Div.
Epidemiology
[email protected]
Jorid Eide, Midwife, Msc. She has earlier worked
as a Midwife in department of obstetrics at The
Hospital of Asker and Bærum HF. Now she is
working as a research coordinator at the Norwegian Institute of Public Health, Div. of Epidemiology with the Mother and Child Cohort Study and
The FEMINA collaboration.
The Mother and Child Cohort Study (MoBa): Child abuse and fear of childbirth Jorid Eide,
Ragnhild Hovengen and Rannveig Nordhagen Norwegian Institute of Public Health Background and aim: Child abuse might be one of many factors that influence fear of childbirth.
The quality of reports varies. The aim is to look for associations between sexual and/or
physical abuse before the age of 18 and fear of childbirth. Material and method: Two self
administrated questionnaires (17th and 30th week) in The MoBa Cohort Study are merged
with data from the Medical Birth Registry of Norway. Our study includes 58 110 pregnant
women (1999-2006). The participation rate is 42.7 %. Multiple logistic regressions are used.
Results: Physical and/or sexual child abuse are associated with fear of childbirth. A combination shows the strongest associations. If we add earlier negative birth experiences, there
is no association between physical and/or sexual child abuse and fear of childbirth. Marital
status, adult abuse, pelvic pain, quality of antenatal care and self-efficacy are associated
with fear of childbirth. Conclusions: There are associations between physical and/or sexual
child abuse and fear of childbirth, even if the associations are not strong. However, earlier negative birth experiences act stronger in multi pregnant women. Fear of childbirth is
complex and associated with many elements of risk..
LONG TERM CONSEQUENCES OF EARLY GROWTH
Johan G. Eriksson,
Finland
University of Helsinki
johan.eriksson@helsinki.fi
Johan G. Eriksson, MD, PhD is professor of General
Practice at University of Helsinki. and he is the PI of
Helsinki Birth Cohort Study (HBCS). Professor Eriksson is trained at the University of Helsinki and he is
specialised in internal medicine and general practice.
He has previously been working for over 10 years at the
Finnish National Public Health Institute focusing upon
prevention of type 2 diabetes and related metabolic
traits and has been involved in the Finnish Diabetes
Prevention Study since its beginning. In 1994 he initiated the HBCS, a collaborative study with University of
Southampton. He has over 170 international publications and is currently involved in studies focusing upon
health and disease from a life-course perspective
45
MANAGEMENT OF SUBSEQUENT PREGNANCY AFTER STILLBIRTH
The risk of recurrent stillbirth (SB) is increased twofold to tenfold depending on characteristics of the prior event. Thus the management of subsequent pregnancy depends on informations about the previous SB. Categorization of the cause will allow better estimation and guide
management individually. If a previous SB was associated with placental abruption the recurrence rate of abruption is 9-15%, if it was associated with preeclampsia or fetal growth restriction the recurrence of such situations is about 20%. If previous SB remains totally unexplained,
subsequent pregnancies still present an increased risk of adverse pregnancy outcomes such
as placental abruption, preterm delivery and low birth weight infants. With a preconceptional
counselling, some risk factors could be modifiable, i.e. obesity and smoking. Again, appropriate treatment of maternal medical disorder such as diabetes, (with early screen, diagnosis
and insulin therapy), or hypertension (with frequent monitoring blood pressure) will decrease
the risk of SB. The risk associated with antiphospholipid antibody syndrome is possibly decreased by prophylactic aspirin and low molecular weight heparin (LMWH), while the positive effects of thromboprophylaxis with LMWH in thrombophilic women is under evaluation
in different international trials. In any case it’s important to ensure an appropriate antenatal
care and antepartum testing, together with psychological support. Serial sonograms for fetal
growth starting 28 weeks, twice weekly, nonstress tests and amniotic fluid index twice weekly
starting 2 weeks before the gestational age of previous SB have been proposed. Maternal
assessment of fetal movement or fetal kick counts starting at 28-30 weeks has been found
preventive in some populations. Timing of delivery depends on maternal anxiety, cervical ripeness and the cause of previous SB. In most cases, elective induction at 39 weeks of gestation
may be appropriate. Conflict of interest: NO
Fabio Facchinetti, Italy
Mother Infant Dept.,
University of Modena and
Reggio Emilia
[email protected]
Associate Professor of Obstetrics and Gynecology. Responsible for the Alternative Birth Centre
of the University Hospital. Director of the School
of Midwifery, University of Modena and Reggio
Emilia. Researcher in the Field of Perinatology
(Preterm Delivery, Preeclampsia, Stillbirth).
MENNESKELIGE FEIL SOM ÅRSAK TIL MEDISINSKE
ULYKKER - KAN PROBLEMET REDUSERES?
Sigurd Fasting, Norway
Dept of Anesthesiology,
St Olavs Hospital
[email protected]
Head of Anesthesilogy Department. PhD thesis
related to patient safety, and mechanisms behind medical adverse events.
SUPPORT FOR MOTHERS, FATHERS AND FAMILIES AFTER
PERINATAL DEATH: A COCHRANE REVIEW
Vicki Flenady and Trish Wilson.
Provision of an empathetic caring environment, and strategies to enable the mother,
father and family to accept the reality of perinatal death, are now an accepted part of
standard nursing and social support in most of the developed world. Provision of interventions such as psychological support or counselling, or both, has been suggested to improve outcomes for families after a perinatal death. Objectives The objective
of this review was to assess the effects of the provision of any form of medical, nursing,
social or psychological support or counselling, or both, to mother, father and families after perinatal death. Search strategy. We searched the Cochrane Pregnancy and
Childbirth Group’s Trials Register (30 October 2007) for randomised trials of any form of
general support aimed at encouraging acceptance of loss, specific bereavement counselling, or specialised psychological support/counselling including psychotherapy for
mother, father and families experiencing perinatal death. Main results and Reviewers’
conclusions No trials were included. We conclude that there is currently insufficient information available from randomised trials to indicate whether there is or is not a benefit
from interventions which aim to provide psychological support or counselling for mothers, fathers or families after perinatal death. Methodologically rigorous trials are needed.
An example of a current model of care at a large tertiary hospital will be presented.
46
Vicki Flenady, Australia
Mater Mothers’ Research
Centre, Mater Health
Services
vicki.fl[email protected]
Vicki Flenady has a background in midwifery and neonatal intensive care nursing and since leaving clinical
practice in 1995 and completing masters in clinical
epidemiology at the University of Newcastle Australia
and is completing her PhD in unexplained stillbirth.
Vicki has, for many years, participated in the review
of stillbirths and neonatal deaths within the region of
Queensland, Australia – over 500 deaths each year.
Vicki is actively involved in supporting standards of
best practice for stillbirth through the development
and implementation of national guidelines for perinatal mortality. Another of her interests is systematic reviews and meta analysis for the Cochrane Collaboration, as a reviewer for both the Pregnancy and
Childbirth and Neonatal Groups. Vicki became Chair
of the International Stillbirth Alliance in 2007 and has
recently, with her regional colleagues, established a
local office for ISA – the Australian and New Zealand
Stillbirth Alliance.
INVESTIGATION OF STILLBIRTHS
Vicki Flenady1, Bob Silver 2, Marc Incerpi 3, Bob Pattinson 4, Yee Khong 5.
1Mater Mothers’ Research Centre, and Department of Obstetrics, University of Queensland,
Mater Health Services, Brisbane Australia; 2University of Utah, Dept of Obstetrics and Gynecology, Salt Lake City, Utah, USA; 3Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology. Los Angeles County/University of Southern California Medical Centre, USA; 4Maternal and Infant Health Care Strategies Research Unit, South Africa; 5South
Australian Pathology Women’s and Children’s Hospital, North Adelaide Australia.
Stillbirth is now recognised globally as a major public health problem. However, in both
developed and developing countries, efforts to address this problem are limited by the
lack of information on the causes and contributing factors for stillbirth. Underpinning this lack of information are suboptimal approaches to data collection including
the classification systems used. Aside from these limitations (which require urgent
attention), the value of any data collection and classification system for stillbirth is
dependent on first gathering all the important information for each case. This is best
achieved through a systematic approach to diagnostic workup and review of findings
in the context of the clinical setting in which the death occurred. While for many developing countries the ability to undertake the most basic diagnostic tests is extremely
limited or even impossible, a systematic approach to collection and review of basic information from clinical history and examination of mother and baby should be achievable in the majority of settings. Such data collection, if put in place, would constitute a
major step forward in addressing stillbirth prevention on a global scale. In developed
countries, stillbirth now makes up the majority of perinatal deaths. With improvements in care and reductions in intrapartum fetal deaths and deaths from other conditions, unexplained antepartum fetal death has emerged as the leading category of fetal
deaths and represents a major challenge in further reduction of the stillbirth rate. The
reported contribution of unexplained fetal deaths varies quite markedly and while differences in classification systems plays a major role in this variation, thoroughness of
investigation is a key factor. In developing countries, many stillbirths occur as a result
of infection and lack of appropriate maternity care. While some prevention strategies
are clear, such as interventions to combat malaria, adequate information on the aetiology of stillbirth to inform the development and monitoring of comprehensive effective
prevention strategies is lacking. This lack of information requires urgent attention. We
propose an international investigation protocol for stillbirth which takes into consideration limited resources in developing country settings.
MAKING STILLBIRTHS COUNT – MAKING NUMBERS TALK
J. Frederik Frøen,
Norway
Dept. of Genes and
Environment, Norwegian
Institute of Public Health
[email protected]
Dr. Frøen, MD, PhD, is a perinatal epidemiologist who
has been involved in a series of stillbirth research projects related to unexplained stillbirths, fetal growth and
movements, classification and registration of stillbirths.
He has been involved in the International Stillbirth Alliance since it was founded, and works with stillbirth research and prevention issues as a Department Director
at the Norwegian Institute of Public Health and through
collaborations with the World Health Organization.
Stillbirths need to count. The majority of the world’s perinatal deaths have been invisible, and
the lacking data on these vastly preventable deaths diminishes measures of success for maternal and infant health improvements. Yet, simply counting stillbirths is barely the first step.
From a public health perspective, the cost is matched in value by the opportunity to collect
pertinent information to target, guide and monitor efforts to prevent stillbirths and improve
quality of care. For this, we need information on the timing and circumstances of death, the
underlying cause and associated conditions, as well as on the availability and quality of care.
Such quality data will necessitate more consistently defined stillbirths, systematic population-based registrations, better tools for surveys and verbal autopsies, capacity building and
training in procedures to identify cause of death, locally adapted quality indicators, improved
classification systems, and effective registration and reporting solutions. It will be worth it.
CUSTOMIZED GROWTH CHARTS - WHAT DEFINES OPTIMAL
GROWTH?
The growth restricted fetus is at considerable risk of death, and identifying the pregnancy at risk is one of the most important tasks, and challenges, of antepartum care.
Failure to identify, monitor and act appropriately on suspicion of fetal growth restriction are some of the most frequently expressed concerns in audits of events prior to
stillbirth in developed countries. In developing countries, with much higher incidence of
fetal growth restriction, the challenges are even more prominent. The ability to identify
the pregnancy at risk entails that a key factor to success is the ability to distinguish the
unhealthy small fetus (due to complications of pregnancy) from the healthy small fetus
(due to normal constitutional factors). A rapidly spreading innovation is the customiza-
47
tion of growth charts and birth weight percentiles according to constitutional factors,
which has been shown to enable better identification of high risk populations. Yet, the
optimal set of factors to be included, and how, remains to be developed and tested.
This presentation will discuss to what extent currently included and proposed factors
aid in distinguishing normal from abnormal growth, and a framework for future discussions and developments.
WRITING AS A TOOL IN THE GRIEF PROCESS
The study includes 13 adult bereaved relations who were participants in two groups
in a writing program. Writing was performed in a grief-writing group and at home in a
diary. The program lasted for 5 months during which the participants should do both
freewriting and focused writing. The empirical material was report texts written personally and handed in anonymised. Analysis and discussion show that the bereaved
finds it possible to express grief through writing. An exploratory, expressive form of
writing encompasses the grief utterance and can offer relief by the act of expression.
This is a painful process, but also a relief. The creative element of the writing process enables the bereaved to move during the process as writing becomes a tool for
acknowledgement and kvowledge. To write about memories is enriching, it develops
coherence. “Memorywriting” helps sustain ties to the deceased. Writing connected
with conversations in grief-working groups seems particularly valuable. Writing a diary at home may be a valuable contribution, but it appears that writing at home with
no group-talks or other follow-up is experienced as an additional strain. The results
indicate that writing is an alternative and/or supplement to follow-up and care for the
bereaved in their grief process.
A MODEL TO REDUCE MATERNAL MORTALITY AND FETAL
MORTALITY IN TEN HOSPITALS IN KADUN AND KANO STATE
BY CONTINOUSLY CONDUCTED QUALITY ASSURANCE IN
OBSTETRICS
See Abstract registered on Wolfgang Künzel.
Bodil Furnes, Norway
Faculty of Social Sciences,
Dept. of Health
Studies, University of
Stavanger
[email protected]
Registrated Nurse (RN). Doctoral thesis
encompasses Writing in the grief process.
Main research interests are epistemological
and methodological aspects of caring science.
More specifically phenomenological and qualitative approaches. Responsibel for parts of The
Master’s Degree Programme in Health and
Social Sciences focusing on User Involvement
Perspectives.
Hadiza S. Galadanci,
Nigeria
Dept. of Obstetrics and
Gynaecology, Aminu Kano
Teaching Hospital, Kano
[email protected]
Dr Galadanci has an MBBS degree from Amadu
Bello University, A masters degree from University
College London (MSc in reproductive and sexual
health research), a diploma from London School
of Tropical Medicine and Hygiene (DLSTM&H),
a fellow of the West-African college of surgeon
(FWACS) and a member of the Royal College of
O&G (MRCOG) She is a senior lecturer/consultant
with major interest in maternal and child health,
prevention of mother to child transmission, and
cervical cancer in Nigeria. She has published over
30 articles related to above, in reputable journals.
She held the post of Head of Department.
CUSTOMIZED GROWTH CHARTS – PRINCIPLES AND
APPLICATION IN THE STUDY OF ADVERSE OUTCOME
This talk will give an overview of the evidence for customised growth charts to
assess fetal growth, and their application in the analysis of databases to study
perinatal morbidity and mortality.
CONFIDENTIAL ENQUIRIES: A POWERFUL TOOL FOR
STILLBIRTH PREVENTION
Confidential Enquiries will be presented as a method of assessing adverse outcome,
with international examples and lessons learnt about system failures which contribute to avoidable deaths.
48
Jason O. Gardosi, UK
West Midlands Perinatal
Institute
[email protected]
Jason is an Obstetrician & Gynaecologist by background, Director of the West Midlands Perinatal
Institute (Birmingham), and Professor of Maternal and Perinatal Health (University of Warwick).
The Perinatal Institute (www.pi.nhs.uk) is an NHS
organisation which aims to distil the evidence,
understand the causes and develop pro-active
strategies for the prevention of adverse perinatal
outcome.
A MODEL FOR SUPPORTGROUPS- AFTERCARE FROM THE HOSPITAL
Mariëtte De
Groot-Noordenbos,
Netherlands
UMCG Groningen
m.de.groot-noordenbos@
psb.umcg.nl
Mariëtte de Groot-Noordenbos (1953 has been
working in the UMCG for over 30 years, in different fields of psychosocial care. Since 1993 in the
department of Obstetrics. She developed with dr.
JJHM Erwich and his collegues, the psychosocial
aftercare path in the UMCG.
M. De Groot-Noordenbos, Pv.d. Berg, L. Wieman, H M Erwich
The main aim in the care of perinatal death, is offering a strategy for coping with loss (or
coping with impending loss), which facilitates the final goodbye. A range of intense care and
support is offered by the obstetrics centre at the UMCG by doctors and nurses. Parents are
encouraged to spend all available time with their baby. These actions of cuddling, holding, caressing, stroking and taking photographs are very important steps of making the (impending)
loss tangible. Also hand and footprints are made. Virtually without fail parents reflect on this
period as being incredibly powerful, allowing them to create a lasting memory. All parents
who have had to cope with intra uterine deaths are invited to choose a Quilt of Love. These
quilts have been hand stitched by volunteers as a lasting keepsake (and physical recognition)
of their unviable but much loved and desired child. Again, the tangibility of this keepsake has
a positive impact on the coping with loss skills of the bereaved parents.
Parents are invited to meet the gynaecologist 3 to 6 weeks after their child’s death. Should
parents not cope as expected under the circumstances they will be invited to contact the
obstetrics social worker and a referral will be made by the gynaecologist. Although individual
aftercare is a possibility, the UMCG prefers to offer aftercare in a group context. An information evening on the subject of neonatal death is held twice a year, and has been available for
the last 9 years. This has evolved to a second yearly information evening for parents who have
lost their child prior to birth. Doctors and nurses are available during these evenings of information sharing, in order for medical questions to be asked and to be adequately answered.
Interested parties can put their names forward for the group counselling sessions (minimal
3 couples, maximum 6 couples). The meetings are held every fortnight for the duration of 6
sessions. A follow-up is organised 6 months after the last session.
The essence of group counselling is for parents to receive recognition and support for their loss
and to freely speak about their child in a safe and respectful environment. Legitimacy for the
existence of their child is a second important factor. Parents are still often encouraged ‘to let
go’ after a certain period of time has passed and to look to the future. Yet, how can anyone deny
one has become a parent? The fact there is no physical child to show for many months of pregnancy does not equal not being a parent. It is this important issue of being a parent without a
child which gets facilitated in the group. The loss of a baby needs not be ‘let go of’’ but indeed to
be integrated into the parent’s lives and to become part of their present and their future. Every
subsequent child will be second (etc) child for the first child died. It is this heartfelt knowledge
which needs integration if one is to overcome the loss and rejoin life. The group has themed
sessions to encourage integration of the experience:
• How did you say goodbye.
• Which memories do you have, how do you keep them, how do you share them?
• Were you happy about the care you received at the UMCG. How could it have been improved.
• How do you cope with other people’s reactions to your loss.
• What impact does the loss have on your relationship and on the relationship you
have with your other children.
• The future, how do you and your spouse feel about ever falling pregnant again?
It can be concluded that the aftercare group counselling sessions have met a strong
patient need. Sometimes networks do not have this flexibility or do not offer the safety
to explore the depths of despair. It is often in sharing with people who have had a similar experience that true loss is being worked through. Mothers have empty arms and
empty laps. Fathers feel their expectations have been killed and buried.
These parents deserve our support not only during the immediate aftermath of the loss,
but also for the year that follows. Indeed, possibly in particular for the duration of their next
pregnancy since good psychosocial aftercare following bereavement can greatly reduce
the chance of postnatal depression and overprotective parenting in years to come.
PARENTERAL NUTRITION FOR TERM AND PRETERM INFANTS
Morten Grønn, Norway
Departement of pediatrics,
Rikshospitalet
morten.gronn@
rikshospitalet.no
Consultant NICU, Rikshospitalet, Oslo Md, PhD
Ernæring er av stor betydning for premature og syke nyfødte barns helse og utvikling.
Premature barn er også ofte underernært in utero. Ett mål for postnatal ernæring for
premature kan være å etterligne intrauterin vekst. For de minste barna kan vekten femdobles
under sykehusoppholdet, som er unikt. Det finnes ingen norske retningslinjer for ernæring
av premature barn. Premature barn har svært små energireserver og er avhengig av tidlig
tilførsel av eksterne næringsstoffer. De fleste barn med fødselsvekt < 1500 gram, og mange
av de alvorlig syke fullbårne barna vil ha behov for parenteral ernæring kort eller lengre tid
etter fødselen. Ernæring forordnes aktivt og individuelt. Premature barn som ikke får tilført
adekvat ernæring enteralt, må starte parenteral tilførsel av fett, protein og karbohydrater
fra første levedøgn. Nyere internasjonale retningslinjer anbefaler økt væsketilførsel, økt
protein og økt energitilførsel sammenlignet med tidligere. Næringstette løsninger med høy
konsentrasjon av de aktive stoffer må benyttes. Vedlikeholdsløsninger inneholdende NaCl
som barnet ikke har behov for de første levedøgnene, erstattes med aminosyreløsninger.
Adekvat tilførsel av karbohydrater medfører ofte hyperglykemi og et økt behov for kontinuerlig insulintilførsel. I tillegg til parenteral ernæring startes hvis mulig “minimal enteral feeding” med morsmelk fra første levedøgn.
49
A STILLBIRTH- THE ROUTINES AT ULLEVÅL UNIVERSITY
HOSPITAL
UUS is an university clinic with aproximately 6.500 births annualy.Of these there is
between 60-70 stillbirths ,where the child dies before, during or the first days after
the birth. Our wish for the families in this situasion is that they will meet staff that
are educated in taking care of their needs and capable of guiding them throug difficult decisions they have to make. This happens throug lecturing and supervision of
staff and having well written guiding instructions available.
Bente Guildal, Norway
Ullevål University Hospital
[email protected]
I am working as a midwife at Ullevål hospital.As
of part off my job I have the responsibility of taking care of the families and the routines that the
maternity clinic follows when a child dies.
PERORAL ERNÆRING - FORSTERKNING TIL MORSMELK?
Morsmelk alene er ikke bra nok for det premature barnet og gir verken nok energi,
protein, vitaminer eller mineraler. Morsmelk alene vil føre til alvorlig veksthemming og
feilernæring. Det er derfor svært viktig å berike morsmelken, og det finnes to produkter på det norske markedet, Nutriprem og FM85. Med full berikning av Nutriprem
eller FM85, vil morsmelken i stor grad dekke det premature barnets behov, og det er
ikke nødvendig med ytterligere tilskudd. Berikningen av morsmelk bør opprettholdes
under sykehusoppholdet og etter hjemreise til barnet veier ca. 4 kg. Eventuelt kan en
morsmelkerstatning for premature barn, PreNanHy eller Enfalac, benyttes.
PERSISTING PULMONARY HYPERTENSION OF THE NEWBORN - A WIDE RANGE OF CHALLENGES AND OUTCOMES
Transition from intra- to extrauterine life involves a rapid changeover in the circulatory patterns. Systemic vascular resistance increases dramatically when the umbilical cord is cut,
while pulmonary vascular resistance is reduced rapidly at first, and then more gradually. This
transitional phase is quite vulnerable, and occasionally the process is thwarted. This leads to a
resurgence of high pulmonary blood flow resistance, a condition now referred to as “persistent
pulmonary hypertension of the newborn (PPHN)”, but previously also known as “persistent fetal circulation.” It may be triggered by a variety of insults, such as asphyxia, hypoxia, acidosis,
infection, hypercarbia, or a combination of these. This condition, unless reversed, may be lifethreatening. However, newer diagnostic techniques, such as echocardiography, have taught
us that increased pulmonary blood pressure is not unusual in sick newborn infants. Indeed, it
appears that in most infants this condition can be managed with fairly simple techniques. This
lecture will address the various approaches to diagnosis and therapy of PPHN. It will review
the various steps that may be taken to reduce pulmonary blood flow resistance, starting with
the simple expedient of administering sufficient oxygen, and progressing to such extreme
measures as extracorporeal membrane oxygenation (ECMO). Historical treatments will be
discussed in light of newer approaches to management. The listener should expect to take
home a number of practical suggestions for management of PPHN.
SOCIAL MANAGEMENT OF PREGNANCY LOSS IN RURAL
SOUTHERN TANZANIA: LOSS-ASSOCIATED STIGMA AND
UNMET PSYCHOLOGICAL NEED
Introduction: In southern Tanzania, pregnancy and the puerperium are periods when women
are considered especially vulnerable to physical and spiritual harm. Understanding how pregnancy losses are socially managed may reveal unmet physical and psychological health needs.
Methods: Reproductive narratives from 40 women in 7 southern Tanzanian villages reporting
recent pregnancy loss or early neonatal death from March-August 2007 were contextualized using in-depth interviews with female elders, infertile women, and new mothers (N=31). Data were
analyzed using NVivo7. Results: Purification and healing rituals and burial rites corresponded
to perceived fetal maturity, and were most secretive for pregnancy losses after 5-6 months’ gestation. Women were advised not to mourn to prevent recurrence, although respondents insisted
they could never forget. Most pregnancy losses and all early neonatal deaths were attributed to
God or bad luck and were unstigmatized. However, severe or drawn-out sickness and bleeding
were considered signs of induced abortion, which justified withholding of household resources,
emotional abandonment, and divorce. Of 30 women reporting spontaneous pregnancy losses,
12 reported abortion accusations, and 3 subsequently were divorced. Conclusions: Norms suppressing discourse about reproductive loss may thwart care-seeking for underlying conditions
and natural grieving processes. Privacy issues and stigma pose challenges to identifying and
addressing post-loss/post-abortion psychological needs in this and similar settings.
50
Christine Gørbitz
Barneklinikken,
Rikshospitalet
christine.gorbitz@
rikshospitalet.no
Christine Gørbitz, Klinisk ernæringsfysiolog, cand.
scient., Har jobbet i 10 år på Barneklinikken,
Rikshospitalet. Ser barn med svært mange ulike
diagnoser.
Thor Willy Ruud Hansen,
Norway
Division of Paediatrics,
Rikshospitalet and
Faculty of Medicine,
University of Oslo
t.w.r.hansen@medisin.
uio.no
Professor and staff neonatologist in the NICU at Rikshospitalet University Hospital, Oslo, Norway. Trained
in neonatology at Brown University, RI, USA. Associate professor in the NICU at Children’s Hospital of
Pittsburgh 1994-7. Chief of neonatology at Rikshospitalet 1998-2007. Currently chair of the Clinical Ethics Commmittee at Rikshospitalet and vice president/
president elect of the Norwegian Pediatric Society.
Main research focus is the neurobiology of bilirubin
toxicity, combining both basic science and clinical
studies. Other research interests include pediatric
pharmacology and medical ethics. Associate editor of
Pediatric Critical Care Medicine.
Rachel A. Haws, USA
Department of
International Health,
JohnsHopkins Bloomberg
School of Public Health
[email protected]
Rachel Haws completed master’s degrees in international relations at the University of St. Andrews (M.Litt.), and in international health (MHS)
at The Johns Hopkins Bloomberg School of Public Health, where she is a doctoral candidate in
the Department of International Health. For 4
years, she has worked with Save the ChildrenUS/Saving Newborn Lives to assess the evidence
base for neonatal and stillbirth interventions.
Her dissertation research explores local understandings and perceived social consequences
of stillbirth in Tanzania, highlighting issues to
consider in behaviour change communications,
demographic data collection, and psychological
service provision. She has worked previously in
Ethiopia and India.
POST-TERM PREGNANCY. RESULTS OF A RANDOMISED
CONTROLLED TRIAL
Runa Heimstad, Norway
Dept. of Obstetrics,
St.Olavs Hospital,
Trondheim,
[email protected]
Defended my thesis on post-term pregnancy
december 2007. Have been consultant in obstetrics at St.Olavs Hospital, Trondheim since 1995
Induction of labour or serial antenatal fetal monitoring in post-term pregnancy. A
randomised controlled trial. Induction of labour at gestational age 41 weeks was compared with expectant management in regards to neonatal morbidity, mode of delivery
and maternal complications. Further, women’s attitudes towards post-term pregnancy
and induction of labour, and preferences of post-term pregnancy management were
explored. Between 2002 and 2004 a total of 508 women entered the study, and were
randomized to induction of labour at 289 days or antenatal fetal surveillance every third
day until spontaneous labour. At inclusion women answered a questionnaire about
their attitudes towards post-term pregnancy. This was repeated in a follow-up phone
interview 6 months later, including questions about their experiences of labour and
perspective for future deliveries. No differences were found between the induced and
monitored groups regarding neonatal morbidity or mode of delivery, and the outcomes
were generally good. Women preferred induction of labour to serial antenatal monitoring beyond 41 weeks. Labours were shorter, and contractions were reported to be
more frequent and intense in the induction group compared with the monitored group.
However, their experience with labour induction was positive.
UHELDIGE HENDELSER, FOREBYGGING OG HÅNDTERING
Peter F. Hjort, Norway
University of Oslo,
Daglig skjer det uhell og begås alvorlige feil ved norske sykehus og helseinstitusjoner,
ofte med alvorlige følger for pasienten og deres pårørende. Mange av disse hendelsene
kunne vært unngått ved enkle forebyggende tiltak, men når de først har skjedd, er
det av stor betydning å sette inn de rette tiltakene for å begrense skadene. Hva kan
gjøres for pasientene og ders pårørende? Hvordan kan helsepersonellet takle slike
hendelser?
Tidligere prof ved Rikshospitalet, hematolog. Fra
1969 formann for interimsstyret for UITØ, fra
1975 leder for NAVF`s gruppe for helsetjenesteforskning.. I dag Prof emeritus og beskrives som
Den helhetlige legen. Sier selv at hans mest verdifulle erfaring var da han i fire år var pårørende
til en alvorlig syk og pleietrengende kone. Det gav
ham et helt nytt perspektiv på helsetjenetsen.
STATE OF THE SCIENCE RELATED TO PSYCHOSOCIAL ISSUES
IN PREGNANCY AFTER PERINATAL LOSS
Marianne H. Hutti, USA
University of Louisville
[email protected]
Dr. Marianne Hutti is a Women’s Health Nurse
Practitioner in a private OB/GYN practice where
she does perinatal bereavement counseling.
She is a Professor of Nursing and Associate
Director of the Delphi Center at the University of Louisville. She has conducted research
and published on perinatal loss since the early
1980’s. She is a National Institutes of Healthfunded scientist on the topic of pregnancy after
perinatal loss, and will be reporting findings
from that study at this conference. In addition
to being an active educator, researcher, and clinician, Dr Hutti speaks nationally and internationally on the topic of pregnancy loss.
The purpose of this presentation is to review the body of English language literature related to the psychosocial issues associated with a pregnancy subsequent to a perinatal
loss. Participants may download a table that summarizes the body of literature including the literature citation, purpose, sample description, outcome measures used and
major findings for each of the studies included in the review at the following website:
http://delphi.louisville.edu/faculty/programs/pregnancy.doc From this review, participants will examine major findings related to depressive symptoms, anxiety, grief, and
attachment associated with the subsequent pregnancy after a loss. Last, areas for
continued research will be identified in the study of pregnancy after perinatal loss.
CLINICAL CARE IMPLICATIONS OF PREGNANCY AFTER PERINATAL
LOSS
The purpose of this presentation is to review the literature related to subsequent
pregnancy after perinatal loss. In addition, participants will examine reasons why
parents may experience a perinatal loss differently from each other, and how these
differences may influence their grief response. Last, participants will examine the
body of literature to help determine the interventions of healthcare providers that are
most effective in aiding families to cope with the unique stressors of the pregnancy
after a perinatal loss.
51
KNOWING WHAT TO EXPECT IN THE SUBSEQUENT PREGNANCY
Parents never go into a pregnancy expecting a loss, and when one occurs, the subsequent
pregnancy is never the same for them. There is a loss of innocence and a feeling of vulnerability that can never be replaced in any subsequent pregnancy. This session will use
an interactive approach to identify common concerns among parents experiencing a subsequent pregnancy after a perinatal loss, as well as the research basis for the common
concerns identified. It is hoped that by acknowledging the commonality of these feelings,
parents may find them less stressful when experienced in the subsequent pregnancy.
AMMING AV PREMATURE BARN/BRESTFEEDING
PREMATURE INFANTS
The road to successful breastfeeding of premature infants is filled with a number
of challenges. These infants are in special need for the breast milk’s immunological and nutritional benefits. The infants and their mothers represent a group who
needs extraordinary support to succeded in breastfeeding. It is well documented that
the ten steps to successful breastfeeding from the Baby-Friendly Hospital Initiative
(BFHI), launched by WHO/UNICEF in 1991, is effective in promoting and supporting
breastfeeding. This concept has been successfully adapted to the neonatal intensive
care units in Norway. A structured and systematic approach like the BFHI concept
makes an important basis for the neonatal units’ efforts in breastfeeding support.
Still there are many unanswered questions concerning the best possible actions regarding the establishment of breastfeeding premature infants. This presentation will
discuss the evidence for different measures to support mothers and infants on their
way to breastfeeding. Hopefully the presentation will give inspiration and new ideas
about areas of research in this field.
Anna-Pia Häggkvist,
Norway
National Breastfeeding
Resource Centre,
Rikshospitalet
[email protected]
Anna-Pia Häggkvist, has been working several
years as a neonatal intensive nurse and have a
MSc in Health from the University of Oslo. She
is an international certified lactation consultant
(IBCLC) and has been involved in breastfeeding
promotion support since the eighties including
The Baby-Friendly Initiative from WHO/Unicef.
The special interests are breastfeeding of premature and ill infants and factors associated to
early cessation of breastfeeding. She is involved
in research, is the author of several book chapters, books and articles, and is giving lectures.
PEER SUPPORT TRAINING PROGRAMME
The parental bereavement support of the Norwegian SIDS and Stillbirth Society is based on a
peer-to-peer principle: volunteers who have lost their child due to SIDS and Stillbirth provide
bereavement support to other bereaved families. In order to prepare and train the volunteers
(peers), they attend a two weekend process-oriented seminar on how to support bereaved
families. To constantly assure the quality of the peer support, Norwegian SIDS and Stillbirth
Society has established a quality assurance programme consisting of five initiatives: 1) process-oriented seminar, 2) a seminar compendium describing how to provide peer support, 3)
a training seminar every year offered to all the peers, 4) a counselling service offered to the
volunteers and 5) quality assurance routines are established at the Society’s secretariat for the
follow-up of bereaved families and their volunteers. In the peer support training programme
the crucial issue is to learn how to make use of personal experiences of loss in a helpful and
meaningful way to the newly bereaved parents. It is also important to take care of your self as
a “peer supporter”. Therefore all the volunteers have to attend a two-weekend preparation
seminar before acting as a peer and they are obliged to participate in the quality assurance
programme. In this presentation I will describe the Society’s peer support training program
and the positive effects and results of this programme
Trine Giving Kalstad,
Norway
Landsforeningen
Uventet Barnedød
[email protected]
Trine Giving Kalstad has been working in the
Norwegian SIDS and Stillbirth Society since 1999
as the Director of public health and bereavement
support. She is Cand.Polit, graduated from the
University in Bergen/Oslo i 1998 , with Social Anthropology as her main subject. She is 39 years
and has two children.
BACK TO WORK AFTER A LOSS
See Abstract registered on Annelise Olsen
MECHANISMS: HAEMODYNAMIC CAUSES OF FGR AND DEATH
Healthy growth and survival are closely linked to circulation. The present talk discusses how placental compromise is reflected in the hemodynamic adaptation of
the fetus, and how abnormal hemodynamics may impact growth or threaten fetal
survival. The conditions are illustrated with clinical cases.
52
Torvid Kiserud, Norway
Dept. Clin Med, University
of Bergen, & Dept.
Obstet/Gynecol,
Haukeland University
Hospital
[email protected]
Obstetrician with long experience in developing
countries, now running a centralised service for gynaecological fistulas in Bergen. For the last 20 years,
specific focus at fetal medicine with the emphasis on
physiological background, i.e. fetal growth and circulation using ultrasound techniques. Is known for developing this field. In charge of the Clinical Physiology
Research Group at the university, linked to Centre for
International Health, and leading the initiative of Reproductive Health Cluster at the same university.
THE PLAY AND CONVERSATION - BOX
– A METHOD FOR SIBLING CARE
Toril M. Kristoffersen,
Norway
Norwegian SIDS and
Stillbirth Society
[email protected]
See Abstract registered on Eline Grelland Røkholt
I am working as a psychiatric nurse in a hospital
in north of Norway, Nordlandssykehuset. I’m a
bereaved mum who have lost two children, Sølve
41/2 mnd in sids and Rikke 6 year in a tractor
acident. I have my experience from working with
my own and others children. I am married whit
Rune and we have a daugther Tonje 32 year and a
son Åke 23 year and 4 grandchildren.
Wolfgang Künzel,
Germany
Dept. Obst/Gynaecol.
University Giessen
wolfgang.kuenzel@gyn.
med.uni-giessen.de
Prof. Dr. Wolfgang Künzel, FRCOG, hFEBCOG,
Emeritus Professor and Chairman of Dept. Obstetrics &Gynaecology University Giessen, Germany
1980 - 2002. He held beside others the following
positions: 1991-1997 Chairman Standing FIGO Committee Perinatal Health, 1994-1996 President German Society of Obstetrics & Gynaecology, 1999-2002
President European Board and College of Obstetrics
& Gynaecology. Research focused on uterine blood
flow and fetal oxygenation, fetal heart rate and fetal
shock syndrome, Quality assurance Obstetrics & Gynaecology State of Hesse, Germany. Publication: 30
Books and 290 papers in scientific journals. Since
2002 Co-Editor in Chief European Journal of Obstetrics and Gynaecology and Reproductive Biology.
A MODEL TO REDUCE MATERNAL MORTALITY AND FETAL
MORTALITY IN TEN HOSPITALS IN KADUNA AND KANO, NIGERIA CONTINUOUSLY CONDUCTED QUALITY ASSURANCE IN OBSTETRICS
2. Wolfgang Künzel(1) (4), Hadiza Galadanci (2), Dolapo Shittu (3), Manfred Gruhl (4),
Robert Zinser (4)
1. Department of Obstetrics and Gynaecology, University Giessen, Germany
2. Aminu Kano Teaching Hospital, Kano, Nigeria
3. Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
4. Rotary Action Group on Population and Development (RFPD)
5. [email protected]
Introduction: Maternal (MMR) and fetal mortality ratio (FMR) are in Northern Nigeria
one of the highest world wide. The causes are well known: high rate of home deliveries,
delayed access to skilled care, insufficient structure of the hospitals and unqualified
medical personnel.
Objectives: The activities are aimed to establish an Institute of Quality Assurance in
Obstetrics (IQAO) to improve the outcome of mothers and their children. The steps
are: analyse the structure of the hospitals, raise the quality of obstetrical service, e.g.
to make the operating theatre and delivery rooms functional, train doctors and midwifes to improve the quality of process and outcome, e.g. maternal and child health.
Methods: Since January 2008 five hospitals in Kaduna State and five hospitals in Kano
State participate in a continuous monthly data collection of maternal and child mortality, maternal disorders during pregnancy and delivery. In quarterly quality circles the
doctors and midwifes from the hospitals discuss under supervision of a head midwife
and representatives from the department of OB/GYN in Kano and Kaduna University
hospitals the “blinded” results of each hospital. Maternal death forms will in addition
deliver a profound insight in the causes of maternal death.
Results: The analysis of the structure of the hospitals exhibited deficits in many areas,
such as equipment in the delivery rooms, operating theatres and staff. The protocols
of deliveries have been insufficient. The maternal mortality ratio (MMR) varied among
the participating hospitals and ranged from 170 to 6000 maternal death per 100 000
deliveries. The analysis of the data provides a continuous awareness of the tragedy and
will stimulate discussions among doctors and midwifes and generate ways to prevent
MM and FM.
Conclusion: Quality assurance in obstetrics is a continous process of analysing and
discussing the MMR and FMR under guidance of an Institute of Quality Assurance
(IQA) that collects on a routine basis the obstetrical data according to standardized
protocols. With the introduction of quality circles and regular meetings the blinded results among the hospitals are compared and discussed and future pitfalls eliminated.
Acknowledgement and source of financing: We thank The Rotary Foundation (TRF), the
Rotary district 9120 Northern Nigeria, Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung (BMZ), Aventis Foundation, IAMANEH German section and
RC’s from Germany and Austria for their generous support.
Conflicts of interests: There are no conflicts
53
A CARE AND SUPPORT PROGRAM FOR FAMILIES IN A
NEONATAL INTENSIVE CARE UNIT
There is no right way to grieve, but some ways are more effective and can help a
person work through sorrow in a healthier way. We know that a good start on a grief
process is important for how people handle a loss of a child. At Ullevål University
Hospital we have since 1992 been working specially with grief support groups for
parents and educating the staff at the unit so they can handle and help the parents. I
would like to use this time to share with you some of what our team has learned from
our experiences through the years.
Kari Lowzow, Norway
Nyfødt intensiv
Ullevål sykehus
[email protected]
Kari Lowzow is a nurse who has been working
in neonatal care since 1988. From 1992 has she
been leading groups of parents in grief process
after losing their child in neonatal death. Kari has
lectured on the subject.
KANGAROO CARE
A brief overview of the latest findings of Kangaroo Care for preterm infants will be
presented as will evidence supporting the use of Kangaroo Care in anticipated endof-life experiences. The audience will learn common effects of Kangaroo Care on
infant physiology, behavior, growth, development, and pain as well as common infant
and family responses to Kangaroo Care with dying infants.
Susan Ludington, USA
Care Western Reserve
University, OH
[email protected]
Dr. Ludington earned her Bachelors of Science in Cell
Biology from Univ. California at Santa Barbara and
her Bachelors of Science in Nursing from Univ. California San Francisco. She got her Masters of Science
with a major in Nursing from Univ. of California at San
Francisco also, and then went on for her Ph.D. in Nursing and in Child Development and Psychology from
Texas Woman’s University in Denton, TX, a year later
becoming a Certified Nurse Midwife. In 1980 Dr. Ludington established the Infant Development and Education
Association of America after studying the effects of early
sensory stimulation on newborn development. She became known for her pioneering work in black and white
visual stimulation for newborns and her book “How to
Have A Smarter Baby” based on her infant stimulation
research at UCLA is still available at any bookstore. Dr.
Ludington was the first United States researcher funded
by the National Institutes of Health to study the effects of
Kangaroo Care on infant development. As a result of her
research program in Kangaroo Care, Kangaroo Care has
become the gold standard for family centered care and
developmental care of infants. To share her research
findings with consumers she wrote “Kangaroo Care:
The Best You Can Do for Your Preterm Infant” which is
available through Amazon.com. Dr. Ludington’s Kangaroo Care research earned her the Lifetime Achievement
Award in Research from the Midwest Nursing Research
Society and the national Excellence in Research award
from the Association for Women’s Health, Obstetric, and
Neonatal Nursing in 2007. She continues her research
and teaching
NEUROPSYCHOLOGICAL FUNCTIONS IN MODERATE TERM SGA
Small for gestational age (SGA) children are known to have subtle neurological
deficits. Few studies have investigated neuropsychological outcome in term born
SGA later in life. We aimed to assess aspects of neuropsychological performance in
moderate (< 10th percentile) term SGA at 19 years of age compared with term born
controls with birth weight > 10th percentile.
54
Gro C. C. Løhaugen,
Norway
Sørlandet Hospital,
Arendal and faculty of
Medicine, NTNU
[email protected]
Education Cand.psychol: University of Bergen, Norway. June 1999 Specialist in clinical psychology,
neuropsychologist January 2007 Work Experience
Neuropsychologist and researcher Department of
Research, Sørlandet hospital, Arendal/ Phd student, Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University
of Science and Technology, Trondheim, Norway.
January 2007 - present (100%). Specializing in
Neuropsychology Department of research, Sørlandet hospital, Arendal August 2006-January 2007
(100%) Specializing in Neuropsychology, Department of Neurology, Sørlandet hospital, Arendal
January 2006-August 2006 (50%) Psychologist, Department of Pediatrics Sørlandet Hospital, Arendal, Norway August 2002-August 2006 (100%)
CAUSES OF PREECLAMPSIA
Per Magnus, Norway
Public Health
[email protected]
Per Magnus is Director of the Division of Epidemiology at the Norwegian Institute of Public Health and
Professor of Community Medicine at the Institute of
General Practice and Community Medicine at the
University of Oslo. He is Principal Investigator of the
Norwegian Mother and Child Cohort Study. Prof.
Magnus has a background in medical genetics and
general epidemiology and his present research
interest concerns the links between genetic and
environmental factors in the development of
disease. He has published more than 250 scientific
articles in a variety of peer-reviewed journals.
Background: The causes of preeclampsia are unknown. The Norwegian Mother and
Child Cohort Study (MoBa) is an important resource for causal research. Biological
material and exposure and confounder information from questionnaires are available.
This presentation will give results from two recent studies: the relationship between
exercise in pregnancy and preeclampsia, and the effect of previous abortions on the
risk of disease. Materials and methods: Both subprojects use information from the 17
week questionnaire linked to preeclampsia as registered in the Medical Birth Registry
of Norway, using version 2 and 3 of the quality-assured datafiles. Results: The relative
risk of preeclampsia was 0.79 (95% CI 0.65-0.96) for women who exercised 25 times
or more per month compared to women with no exercise (n=59,573). The effect was
strongest for women with body mass index below 25, and was absent for women with
BMI above 30. Two previous abortions had a strong protective effect (OR=0.36, 95 % CI
0.18-0.73) on the risk of preeclampsia in primiparous women (n=20,846).Conclusion:
Physical exercise may be beneficial for a subgroup of women. The effect of previous
abortions suggests that normal pregnancies induce immunological changes that reduce the later risk of preeclampsia.
ESTIMATING THE EXTENT OF PREVENTABLE STILLBIRTH IN
DEVELOPING SETTINGS: A REVIEW OF EXISTING DATA
Jennifer Mark, USA
Centers for Disease
Control and Prevention
[email protected]
Jennifer Mark is a third year Oak Ridge Institute
for Science and Education (ORISE) research fellow at the United States Centers for Disease
Control and Prevention. Within the International
Activities Unit at the Division of Sexually Transmitted Disease Prevention, the majority of Ms.
Mark’s activities include supporting the Global
Congenital Syphilis Elimination Initiative in collaboration with colleagues at the World Health
Organization (WHO), where she is exploring potential program indicators. Ms. Mark holds an
MPH in epidemiology from Johns Hopkins School
of Public Health.
Ellisiv and
Luke Marley,
Norway
Norwegian
SIDS and
Stillbirth
Society.
luke.marley@
losmail.no
Our firstborn, Oliver, was stillborn. He was born
4 days over his due date. Doctors have not been
able to expliain why he died.
Background: We compared patterns of stillbirth to understand the extent to which disparities are associated with preventable causes, such as maternal syphilis, and whether stillbirth rates suggest specific gestational dates for syphilis screening. Learning
Objective: To understand the extent of presumably preventable stillbirth and consider a
potential target rate for prevention strategies at which to aim. Methods: We searched
published literature to identify stillbirth studies that included gestational age. Using
the Delft method, we calculated the prospective risk (PR) of stillbirth from populationbased data of live deliveries and stillbirths. We used true and logarithmic scales to
compare stillbirth frequencies and timing graphically. Results: Based on publications
through July 2006, we identified 1,794 stillbirth studies. After review, 14 had collected
data that potentially allowed for calculation of PR. We obtained data from 11 (79%), representing 7 nations, for further analysis. Most (88%) were conducted from 1980-2000.
Of these 11 studies, 4 were from the US over different time periods, 5 from other developed nations, and 2 from developing nations. Data from 6 studies in developed nations
after 1980 showed markedly consistent curves with low PRs. US data from 1958-80 had
an intermediate PR curve. The 2 recent developing nation studies and the US 1946-53
data (prior to widespread maternal syphilis screening) showed PRs for stillbirth 7 to 11
times higher than the New York City 1987-89 data. PRs generally declined consistently
until average time of delivery (40 weeks). Conclusions: The higher PR in developing
settings describes substantial preventable fetal mortality, presumably due to syphilis.
The steady decline of PRs across gestational ages to full pregnancy term week suggests no obvious gestation age target for antenatal health interventions, supporting
WHO recommendations for seeking early antenatal services. These data also suggest
stillbirth surveillance is a potential impact indicator of national screening programs.
BEING STILLBIRTH PARENTS – LIFE WITHOUT OLIVER
Oliver was stillborn in January 2006 during week 41 of his mother’s pregnancy. Ellisiv
and Luke Marley talk about how they dealt with the immediate shock and aftermath
of his death and the help that they received from the Norwegian Health Sector during
those early weeks and months. They also discuss the coping strategies they have adopted in subsequent years to help deal with the grief of losing their first born; their
continuing relationship with health professionals and their family and friends. Finally
they discuss the experience and mixed emotions surrounding the pregnancies and
births of Oliver’s two younger sisters.
55
INVOLVING COMMUNITIES TO REDUCE STILLBIRTHS
Cicely Marston, Ellen Brazier, Anayda Portela
Reducing stillbirths requires quality maternity services, but this alone is not enough.
Efforts to engage the community in improving the care provided in the home and
in identifying the many different factors that may create barriers to access to
services are also crucial. Involving women, their partners, their families and key
community actors beyond the health services is vital to finding appropriate solutions and
ensuring that services meet the community’s needs. In this paper, we argue that
combining community involvement and improved services in a comprehensive
strategy is likely to have a synergistic effect to improve stillbirth rates. Because the
other articles in the series focus on improving services, we give examples to illustrate factors that affect use of services. We then review available evidence of effectiveness of programmes relevant to stillbirth prevention, which include interventions to strengthen the care in the home in addition to strengthening services, as
well as ensuring community participation. Finally, we provide a framework to guide
programmes in strengthening the role of women, families and communities for
stillbirth prevention and for improving maternal and newborn health.
Cicely Marston, UK
London School of Hygiene
& Tropical Medicine
[email protected]
Cicely Marston is Senior Lecturer in Social Science at the London School of Hygiene & Tropical
Medicine. She specialises in research on sexual
and reproductive health.
INTRAPARTUM STILLBIRTHS : A PREVENTABLE OCCURANCE
All intraprtum stillbirths should be considered avoidable. Incidence of still births and
Neonatal deaths due to an intrapartum event is a sensitive measure of the quality
of care given around the time of labour and birth in any setting. Causes of intrapartum still births should be broadly classified as direct clinico-pathological causes or
indirect health system causes. Intrapartum asphyxia is the commonest cause for
death. Better fetal monitoring either by intermittent auscultation or continuous
electronic monitoring where necessary is very essential. In resource poor setting use
of Doppler devices were found to be superior to use of Pinard stethoscope. Failure
to interpret an abnormal CTG precedes intrapartum death. RCOG and NICE have
published guidelines on the use and interpretation of CTG. Regular training of
midwives and registrars on CTG interpretation and obstetrics and labour ward drills
is important. Use of the WHO partograph would help identify abnormal labours that
need prompt action. Audits of perinatal deaths in health care setting or at national level play a vital role in identifying the cause and executing measures to prevent
the same. WHO recommends a minimum package of intervention for maternal and
newborn health. With good care no normally formed baby > 2500 gms alive at the
onset of labour should die during or immediately after labour.
Jiji Elisabeth Mathews,
India
Christian Medical College
and hospital, Vellou
[email protected]
Jiji Elizabeth Mathews, Professor of Obstetrics
and Gynaecology of Christian Medical College
& Hospital Vellore, completed her undergraduate and post graduation from same institution in
1997. She was sent from the institution to train in
Adelaide, South Australia for 2 years. She has a
keen interest in the field of perinatal medicine.
She has been conducting the monthly perinatal
audits for the last 5 years. She is involved with
training post graduates and under graduates
students.
REDUCING INFECTION–RELATED STILLBIRTHS: PROGRAM
AND RESEARCH IMPLICATIONS
In developed countries, 10%-25% of stillbirths are caused by infection, whereas in
developing countries, with much higher stillbirth rates, the contribution of infection is g
reater. The likely reasons for the high level of infection-related stillbirth in developing countries include environmental pressure from large quantities of urogenital organisms plus
poor host defenses associated with malnutrition. Specific infections that are causally associated with SB include syphilis, malaria, Lyme disease, African tick-bourne relapsing fever,
listeria and tularemia and the intrauterine organisms causing chorioamnionitis, such as
group B streptococcus, E coli, and the mycoplasmas. Syphilis, where prevalent, causes the
majority of infectious stillbirths and is the maternal disease most amenable to a screening
and treatment program. Maternal malaria, because of high prevalence in many areas and
associated placental damage, likely accounts for large numbers of stillbirths. While more
difficult to screen for and treat than syphilis, programs featuring intermittent prophylaxis
and insecticide-impregnated bednets should have an important impact on stillbirth rates.
In many areas, ascending bacterial infection is a common infectious cause of stillbirth, but
prevention of this condition has proven elusive. A number of viral infections are causal for
stillbirth including rubella, parvovirus and Coxsackie virus, but aside from vaccination, it
is not clear how stillbirths related to most viral infections may be prevented. In areas of
the world where stillbirths most commonly occur, there is minimal information available
about the infectious causes of stillbirth. Further study of vector-borne parasitic infections
will likely find them an important cause of stillbirths in many developing countries.
56
Elisabeth McClure, USA
Dept. of Epidemiology,
University of North
Carolina School of
Public Health
[email protected]
Elizabeth McClure, a Research Health Analyst at
Research Triangle Institute and research fellow in
perinatal epidemiology at the University of North
Carolina School of Public Health, has been a coinvestigator on the US National Institute of Health-funded Global Network for Women’s and Children’s Health
Research since 2001. With the Global Network, she has
participated in numerous multi-site, multi-country research addressing maternal perinatal outcomes in sites
in Asia, Africa and Latin America. She has published
numerous studies of stillbirth in developing countries.
Prior to her work with the Global Network, she spent
5 years at the National Institute of Child Health and
Human Development in neonatal research.
NEONATAL DEATH: A MOTHER’S EXPERIENCE OF SUPPORT
WHEN HER BABY DIES
Else Louise Hoen Meløe,
Norway
Norwegian SIDS and
Stillbirth Society
[email protected]
I am 39 years old, married to Lars and we live
in Asker, just outside Oslo. We have three girls,
Linn, Sara and Lisa. We often say that we have
three girls to think on and two to take care of.
Linn died in the hospital after her birth, Sara will
become two years in november and I am now
home with Lisa, she was born this june. As a profession I work with Marketing, product developement and organisation
GENES AND ENVIRONMENT IN SPONTANEOUS PRETERM
BIRTH
Nils-Halvdan Morken,
Norway
Gynecology, Haukeland
University Hospital
[email protected]
Consultant in Obstetrics and Gynecology
at Haukeland University Hospital. MD from
University of Oslo 1995. Medical Specialist in
Obstetrics and Gynecolgy 2003. PhD from
Sahlgrenska Academy, University of Gothenburg
2008 on epidemiology of preterm birth. Has worked
with the MoBa cohort since 2004.
Spontaneous preterm birth is the most important subgroup of preterm delivery. This
subgroup is a research challenge, but most important no causal treatment modalities are available. Treatment of infections and contractions has marginal effect on
morbidity and mortality. The clinician is reduced to a spectator of an ongoing biological
process. The present understanding is that the mechanisms of this entity is limited
to four main pathways; inflammation/infection, HPA-axis, decidual haemorrhage and
uterine over-distension. This hypothesis has been the leading approach for at least
the last decade. Several findings suggest that genes are important in birth timing
together with environmental factors. Genetic factors are particularly interesting as biomarkers as they are stable over time and may be better predictors of risk than serum or
amniotic fluid proteins. Another benefit from genetic studies is that this kind of studies may identify novel proteins and/or pathways especially by using the agnostic research approach of new techniques such as genome-wide association studies. For the
clinician it is a hope that these short-term benefits in the long run will result in biomarkers that could help in identifying the patient at risk and hopefully, causal treatment modalities will become available.
KOMMUNIKASJON OG KULTURULIKHET
I am going to talk about the challenges people with minority background find in meetings with the health care sector, with spesial emphasis on children and women. I will
also give som advic, both to the health care sector and to the minority groups.
Fahim Naeem, Norway
IHSG NETTVERK
[email protected]
I was born in Karachi and came to Norway when
I was 11 years old. I am working in NAV ( social
security office ) and do volontary work as chairman in IHSG ( International health and social
network ). I do have contact with minority community at my work and with IHSG network. We do
have good dialog with Norwegian health ministry
office and with health sector in Norway.
57
INDUCTION OF POST TERM PREGNANCY – TIME TO
RECONSIDER?
Evidence based medicine have been introduced to the obstetric community for
several years. EBM are integrating knowledge from science, clinical experience and the
patients need and knowledge. There is an overwhelming amount of studies showing that there is an increasing risk of mortality and morbidity when the pregnancy
are passing 41 weeks. There are no arguments, for the benefit of the foetus, to be
in the intrauterine environment, when the pregnancy is post term. In a RCT done
by Heimstad et al, the CS rate was 11% in the induction group and 13% in the
monitored group, p<0.5. Operative delivery was 12,6% in the induction group and 10,6%
in the monitored group, p<0.49. The active second stage of labour lasted significantly
shorter in the induction group. The RCT showed that the mothers (84%) would prefer
induction rather than surveillance if they were to go another pregnancy post term. Only
two of five women who had surveillance would prefer this option again. The evidence
is convincing for offering the post term pregnant women induction at 41+ weeks of
gestation. The benefit is avoiding or reducing possible morbidity and mortality for the
foetus. The risk is a not significant risk of operative delivery. The last and not at least
argument is that the women prefer induction rather than antenatal monitoring.
ACTIVE MANAGEMENT OF RISK AND EARLY TERM
INDUCTIONS IN PREVENTING ADVERSE BIRTH OUTCOMES
Aim: To discuss a preventive approach to term pregnancy management that has the
potential to prevent term stillbirths. Background: The Active Management of Risk in
Pregnancy at Term (AMOR-IPAT) uses a risk scoring system to estimate an upper limit
of the optimal time of delivery (UL-OTD) for each pregnancy, and then uses preventive
labor induction to ensure that women deliver by their UL-OTD. AMOR-IPAT has been
successfully used to lower rates of both cesarean delivery and neonatal intensive care
unit admission. For this study, we wished to evaluate the preventive potential of the
AMOR-IPAT protocol on the incidence of term stillbirth. Methods: Term stillbirths that
occurred within the University of Pennsylvania Health System between 1994 and 2008
were evaluated for the presence of risk factors. The AMOR-IPAT risk scoring system
was then used to determine if the fetal death in each case occurred before or after the
estimated UL-OTD. Results: Over 75% of nearly 200 non-anomalous term stillbirths
could have been prevented through the use of AMOR-IPAT. Most stillborn infants were
born to women with significant risk profiles. Conclusion: The regular use of AMORIPAT has the potential to significantly reduce the incidence of adverse birth outcomes,
including term stillbirth.
Jakob Nakling, Norway
Sykehuset Innlandet HF,
Lillehammer
jakob.nakling@
sykehuset-innlandet.no
Senior consultant in gyn/obst since 1987. Ph.D in
obstetrics. Studies and articles concerning post
term pregnancies.
James M. Nicholson, USA
Dept. of Family Medicine
and Community Health,
University of Pennsylvania
Health System
james.nicholsonMD@
uphs.upenn.edu
Between 1984 and 1997 I worked in a rural private
family practice that included obstetrics. During
this time I witnessed the development of the Active
Management of Risk in Pregnancy at Term (AMORIPAT), which uses preventive labor induction to
lower cesarean delivery risk. In 1997 I returned to
academic medicine, obtained a Masters Degree in
Clinical Epidemiology, and focused my research
activity exclusively on the use of AMOR-IPAT. I
have completed five retrospective studies and one
randomized prospective study that all found
significant associations between the increased use
of preventive labor induction and improved rates of
various adverse birth outcomes.
INDELIBLE ISABELLA - THE PERMANENCE OF HER PRESENCE
What could Angelina Jolie and Brad Pitt possibly have in common with us? And why did
Spanish actress Penelope Cruz stir such feelings in me? Taking just one glance at their
pictures and my very own Isabella`s presence would be clear before my eyes. This is
my story. How Isabella, and the loss of her 30 months ago – still remains with me each
day. How her light of daily presence helped and supported me on the path along grief.
Passing through the cruel phases of grief, step by step, trying to avoid the dangerous
down hills of depression, all the while managing to look forward. How special elements
and tools accompanied me in this process of making my life livable without her. Slowly,
hopes and colors of life folding back into my life. She is my indelible Isabella – my truly,
beautiful daughter. Isabella came to remain in my life forever.
58
Cecilie Nome, Norway
Norwegian SIDS and
Stillbirth Society
[email protected]
This is my story how I lost my first daughter Isabella in stillbirth, 30 months ago. Back then, I
never thought my life would be complete again.
Today, I now that time can cure and life can feel
good, but I never forget. This is my first hand
knowledge as a Mom how to survive this terrible and dark moment of my life and what was
important to me to slowly build up my life again.
POST-TERM PREGNANCY: HOW LONG IS TOO LONG?
Errol R. Norwitz, USA
Ob/Gyn, Yale University
School of Medicine
[email protected]
Dr. Errol Norwitz is Professor of Obstetrics,
Gynecology & Reproductive Sciences at Yale
University School of Medicine as well as Co-Director
of Division of Maternal-Fetal Medicine, Director of
Maternal-Fetal Medicine Fellowship Program, and
Director of Ob/Gyn Residency Program at Yale-New
Haven Hospital in New Haven, CT. He completed his
medical training at University of Cape Town (South
Africa), his Ph.D. at Oxford University (England) on
a Rhodes Scholarship, and his Ob/Gyn Residency
and Maternal-Fetal Medicine Fellowship at Harvard
University in Boston. His research has been
supported by N.I.H./N.I.C.H.D. and March of Dimes.
His primary research interest is in the molecular
regulation of parturition, both term and preterm.
The timely onset of labor and birth is a critical determinant of perinatal outcome. Postterm pregnancy (>42 weeks) complicates 10% of low-risk singleton pregnancies, and
is associated with risks to both the fetus (stillbirth, macrosomia, birth injury, neonatal
death) and mother (severe perineal injury, postpartum hemorrhage, cesarean delivery). The management of postterm pregnancy will be discussed in detail, including
appropriate use of antepartum fetal surveillance and the optimal timing of delivery. We
will attempt to answer the question: Is routine induction of labor indicated at 40, 41, or
42 weeks’ gestation?
A BIRTH REGISTRY AS A TOOL TO IMPROVE MATERNAL AND
CHILD HEALTH IN A RUSSIAN POPULATION
Jon Øyvind Odland,
Norway
Institute of Community
Medicine, University of
Tromsø
[email protected]
Gynecologist, epidemiologist. Professor of International Health, University of Tromsø, Norway.
20 years of experience with antenatal care programs in the Arctic with special emphasize on
the Russian Arctic after the perestrojka. app.50
publications on reproductive and environmental
health issues. Ongoing projects in the 8 Arctic
countries as well as a number of countries in the
southern hemisphere related to climate change,
living conditions and reproductive health.
The essential features of the newly established Murmansk County Birth Registry (MCBR) is the
basis for a project to improve the reproductive health, pregnancy care, and maternal and child
health in the Russian Arctic. Selected variables related to pregnancy and delivery for the northern counties of the Nordic countries and Murmansk County [Murmanskaja Oblast (MO)] are
compared. The MCBR is based on a long term Norwegian-Russian intervention project in the
Kola Peninsula with the main aim to improve the pregnancy care in a broad sense; medical, socioeconomic, and prophylactic measures at community and county level. It includes the more active
role of midwives and other health professionals, like nurses and psychologists. Resources are
put into education of the teenagers in school, with emphasize on the education of the age-groups
12-16 years, both boys and girls. The education of the young boys by competent health workers
has been shown to be especially helpful. For the pregnant women a Pregnancy Calendar, with
medical, socio-economic, and human-rights-as-pregnant information is included in a language
for the common people. One interesting result of the project so far is the significant reduction of
induced abortions, a huge health problem in Russia. The MCBR was established in 2005 with
registration starting January 1st 2006. A registry form draws upon both hospital files and information from the mother. There are 54 major fields consisting primarily of tick-off boxes and
International Classification of Diseases (ICD)-10 codes. A quality control exercise was conducted
in each of 2006 and 2007. During 2006, 8468 births were registered in MO (coverage = 98.9%);
in 2007 there were registered 8834 births. The proportion of errors was below 1% in both years.
Limiting the descriptive statistics to 2006, compared to counties of the Nordic countries in the
Barents Region, the delivering women in MO were younger, had fewer and lighter (mean of 200g)
babies. The gestational age was shorter in MO than in the Nordic counties and fewer babies had
a birth weight above 4500 g. The perinatal mortality corresponding to a gestational age (GA) of
either 22 or 28 completed weeks was higher (p<0.02) in MO than the Nordic counties in this
study. In MO, the birth rate does not balance the reported increase in death rate. It is concluded
that a medical birth registry of satisfactory quality has been established for the world’s largest
arctic population. There will be possibilities for a number of projects for clinical and scientific
purposes in the future, as well as using the registry as a tool for further improvement of the
reproductive health in the region. The simple design of the project creates basis for the transfer of
the project to other areas in the Arctic as well as the possibility to implement it in selected areas
in developing countries.
59
BACK TO WORK AFTER A LOSS
In which way can you motivate yourself to return to work after the loss of a baby? How can your
manager and colleagues provide support and assist you to a positive return to work? How do
you handle the first meeting with your colleagues; all their thoughts, emotions and questions?
To most people the return to work is an essential part of the grieving process and a positive
return will gain their process of creating a meaningful every day life after the death of a child.
“I have a demanding and visible job as quality director in the pharmaceutical industry with
the responsibility of 16 people and a big field of activity both towards colleagues and towards
customers and the authorities. In the first face after loosing I was in chock. I though I would
manage work without making any changes for me and my colleagues. Slowly the reality “hit
me”, and with the help from my GP I realized the urgent need of some time away from job. I
needed time to grief and to regain some feel of reality. I also needed to do some adjustments
at work for a period”. In this presentation we will share experiences and reflections about
returning to work after a shorter or longer leave of absence. We will describe the need of
finding an inner strength and the significance of understanding and flexibility from manager
and colleagues. The paradox of being a manager when you barely can take care of yourself
will also be discussed. The Norwegian SIDS and Stillbirth Society, in collaboration with Dr
Philos Atle Dyregrov and Dr Philos Kari Dyregrov, have issued the booklet “When one of your
employees is grieving”. We will give a brief introduction to this booklet and highlight what is
experienced as helpful and to support, both from your manager and your colleagues, when
returning to work.
Annelise Olsen, Norway
Norwegian SIDS and
Stillbirth Society
[email protected]
Annelise is the mother of two children; Asbjørn (7) and
Linnea who was stillborn. Linnea was born in August
2006 at the end of a normal pregnancy. No reason
was found as the cause of the death. Annelise has
a degree in Pharmacy from the Danish University of
Pharmacy. She graduated in 1991 and has worked
in the pharmaceutical industry since then. First job
was in Lundbeck in Denmark, working with Quality
Control of sterile and oral medicines for the central
nervous system. Later she headed a department implementing quality systems in the R&D departments
with regards to producing medicines for clinical trials. In 1999 she moved to Norway to head the quality departments at Nycomed Norway who produces
and markets pharmaceutical products in Europe and
some foreign markeds. In 2007 she headed a project
to establish an internal training academy at the Asker
plant in Norway. This with the aim of creating an attractive work environment for the employees at the
plant. Since August 1st 2008 she is back in the role
as Quality Director, Plant Asker.
VIRTUAL SUPPORT GROUPS
In the presentation I will tell my own story and why I in 2004 started the online
community called englesiden.com. Englesiden is Norway’s biggest forum of its kind
and have over 400 members how has posted 250.000 posts. The forum is a free offer,
open to parents who have lost a child after the 15th week of pregnancy. I will explain
how the forum works and how it is being used by its members.
Anita Owren, Norway
[email protected]
My name is Anita Owren, i am 28 years old
from Norway. In 2003 i lost my son Odin during
labor,and inthe search for eqals online i early
in 2004 i startet an internet forum called englesiden.com. Today we have 350 users hwo have
written 236.000 posts. The forum is a free offer,
open to parents hwo have lost a child after the 15.
week of pregnancy.
CAREGIVERS AND PERINATAL DEATH
It is well known that stillbirth exerts a profound psychological effect on parents and
families; the care of mothers, fathers and babies is usually perceived as an intense
and stressful experience also by professionals, often unskilled in coping with such
a tragic and unexpected termination of pregnancy. Although in Italy the culture and
psychological care of perinatal death is still very underdeveloped, the recently founded charity organization CiaoLapo (www.ciaolapo.eu) is trying to address this issue. In
particular, we recently conducted a survey among obstetricians, midwives, nurses
and psychologists involved in the care of parents before, during and after stillbirth,
using validated psychometric instruments. According to our experience in Italian
settings, addressing the stress of healthcare professionals, in particular midwives, facing stillbirth and perinatal death is of paramount importance, since this
experience could lead to professional burnout and emotional exhaustion. High level
of burnout could in turn impair communication skills of caregivers, resulting in poor
quality of assistance for bereaved parents, a well known factor in determining longterm psychological distress and poor quality of life.
60
Claudia Ravaldi, Italy
CiaoLapo Onlus, Italian
charity organization for
perinatal grief support
[email protected]
Claudia Ravaldi is a psychiatrist and psychotherapist, author of several international articles and
book chapters on eating disorders, anxiety and
depression. After the stillbirth of her second son,
Lapo, she decided to apply herself mainly to the
field of grief, beginning the study and the clinical
application of validated international protocols
for perinatal grief support. Since in Italy very few
hospitals offer a structured service for parents’
grief, she decided to create with her husband the
charity organization CiaoLapo (www.ciaolapo.
eu) to spread the culture of perinatal support in
Italy and to offer free psychological support to
bereaved parents.
PLACENTAL CAUSES OF GROWTH RESTRICTION
Borghild Roald, Norway
University of Oslo.
borghild.roald@medisin.
uio.no
MD PhD, Professor in Medicine (Pathology)
at the University of Oslo, Norway. Also consultant in pathology, and Head, Center for
Pediatric and Pregnancy Related Pathology at the
Department of Pathology, Ullevål University
Hospital, Oslo, Norway. More than 100 scientific
publications (international scientific publications,
books, chapters in books, reviews). Scientific
interests include pediatric neoplasms, placental
dysfunction and trophoblast function.
Information achieved by the macroscopic and microscopic examination of the
placenta often helps to explain an abnormal neonatal or prenatal outcome. Systematic
studies during the last decades have led to a better understanding of the dynamic
structure and functions in this complex organ. From a pathologist’s point of view, the
current knowledge and hypotheses related to placental causes of growth restriction
will be presented. This includes defect placentation, aspects of villous maturation,
fetal thrombotic vasculopathy, deposits of intervillous fibrin or fibrinoid, infarctions and
inflammatory changes.
PREPARING FOR AUTOPSY: A PATHOLOGIST’S PERSPECTIVE
The purpose of the perinatal and pediatric autopsy is to establish the cause of death
and the events that lead to the death of the infant or child. Amid the tragedy of death,
the pathologist is, via the autopsy, able to provide information to achieve a fuller
understanding of the circumstances of death in a particular baby. The information
gained from the autopsy is an essential part of counseling parents about possible outcome of future pregnancies and is also an important step in helping the parents to go
on with their lives. The information gained will in turn be used to direct the health care
and to increase the common medical knowledge.
EPIDEMIOLOGY OF FGR AND LATER-LIFE RISK OF DISEASES
Pål Romundstad, Norway
Dept. of Public Health, NTNU
[email protected]
Associated professor in Epidemiology. Main
research interest: Perinatal and reproductive epidemiology, life course & generational studies. In my research I have been focusing on factors in pregnancy and risk of
disease later in life for mother, father and child
Epidemiologic studies have shown that low birth weight is associated with cardiovascular and other metabolic diseases in adulthood. Different hypotheses have been proposed to explain these findings. Two of these hypotheses are discussed. “The fetal
origin hypothesis” and the “Familial aggregation hypothesis”. The fetal origin hypothesis suggest that programming or imprinting due to malnutrition in utero may lead to
increased risk of metabolic diseases in adulthood. The familial aggregation hypothesis
suggests that shared environment or genes that are both associated with low birth
weight and an increased risk of disease may explain the findings. Both hypotheses are
supported by available evidence, and the presence of one does not necessarily exclude
the other.
PLAY-AND-CONVERSATION BOX – A METHOD FOR SIBLING
CARE
Eline Grelland Røkholt,
Norway
Seksjon for sorgstøtte,
Akershus
Universitetssykehus
[email protected]
Trained Pedagogical-psychological consellor at
the University of Oslo, and masterstudent in Early
Childhood Education and Care at Oslo University
College. Wide experience in bereavement support,
working with families, children and adolecents.
Specialized at working with small children age 1-6.
Lost little babybrother at age 14.
Eline Grelland Røkholt, Akershus University Hospital and Torill M. Kristoffersen, Unexpected Child Death Society of Norway
The Unexpected Child Death Society of Norway has 40-50 volunteers who have experienced the loss of a child and are willing to provide bereavement support to other
bereaved families. A central aim of the society is to support the entire family, but volunteers often find it difficult to approach beraved children. The goal of this project is to
provide better volunteer bereavement support to children. The play-and-converstation
box had been created based on experience with bereavement support in hospitals. It
consists of toys, books, pencils and other items that are useful when playing and talking with beraved children between 2 and 12 years of age. A guide for volunteers on
how to use the box has been developed. Sixteen volunteers participated in a tow-day
course regarding the play-and-conversation box. The society’s volunteers are the participants in this project and may use this resource in their bereavement support during
the 1-1/2 year project period, with professional couselling available to the volunteers.
The project will be evaluated after one year. If the experience is positive, the play-andconversation box will be a permanent tool for the society’s volunteers.
61
EMBRACING DIVERSITY IN DESCRIPTIONS OF CHILDREN
AND GRIEF
Working with bereavement support and with theorising grief, I try to expand the understandings about children and grief. Troubling theory implies that any description
of children and grief always will be a simplification of realities. Children do not act
out grief through reactions on the content of the crisis. Children act out their grief in
concrete everyday situations. Strong and unfamiliar feelings are acted out through
actions which are familiar to the child. What may be familiar, ordinary and therefore
meaningful will vary from child too child. This way every child’s “story about loss”,
and expressions of this, will be unique and specific. In working with children I find
the use of concrete objects best in capturing the child’s own perspective. This can be
objects I have chosen to trigger relevant topics to process, or more important objects
and things the children themselves find important. The stories and feelings revealed
when working with these objects open up and broaden the understandings of children
and grief.
RISIKO FOR ANGST OG DEPRESJON I SVANGERSKAPET.
Bakgrunn: Prevalens og risikofaktorer forbundet med post partum depresjon er mye
studert, men man har mindre kunnskap om angst og depresjon i svangerskapet og
risikofaktorer for dette. Formål: Formålet er å studere risikofaktorer for angst-og
depresjonssymptomer hos kvinner i svangerskapet (uke 17), med særlig fokus på
familiefaktorer. Metode: Studien er en del av Den norske mor og barn-undersøkelsen ved Folkehelseinstituttet. Den aktuelle studien inkluderer 54074 mødre. Data er
hentet fra mødrenes svar på spørreskjema i svangerskapsuke 17. Angst- og
depresjonssymptomer er målt gjennom SCL-5, en kortversjon av Hopkins Symptom
Checklist (SCL-25). Av mulige risikofaktorer har vi bl.a undersøkt kvinnenes sosiale
nettverk, mistilfredshet med parforholdet, flytting, forhold ved jobbsituasjonen, fysisk
sykdom, samt demografiske variabler. Vi har benyttet multiple regresjonsanalyser
for å identifisere risiko- og beskyttelsesfaktorer. Preliminære resultater: Sentrale
risikofaktorer for angst- og depresjonssymptomer i svangerskapet var lav tilfredshet
med parforholdet, jobbstress, mistrivsel på jobb og fysisk sykdom. Størst risiko var
forbundet med mistilfredshet med parforholdet. Konklusjoner: Mange av risikofaktorene som gjelder for post partum depresjon gjelder også for angst- og
depresjonssymptomer i svangerskapet, men kvaliteten på parforholdet synes spesielt
viktig i fasen hvor paret venter barn. Mors psykiske helse i forbindelse med svangerskap og fødsel har stor betydning også for barnet, noe som har fått økt oppmerksomhet de siste årene.
Gun-Mette
Brandsnes Røsand
Divisjon for psykisk helse,
Nasjonalt folkehelseinstitutt
gun-mette.brandsnes.
[email protected]
Psykologspesialist med klinisk spesialitet i
barne- og ungdomspsykologi. Videreutdanning
også i familieterapi. For tiden stipendiat ved
Nasjonalt folkehelseinstitutt.
MOTHERS FEELINGS WHEN HOLDING THEIR STILLBORN
BABY
We investigated mothers’ feelings when holding their stillborn baby. Data were collected by postal questionnaires in one region in Sweden, including all five hospitals
with maternity wards, in 2001. Thirtythree mothers who had given birth to a stillborn
baby after 22 weeks of gestation participated. The mothers were asked what they felt
before they met their stillborn baby after birth and to what extent they experienced
feelings of grief, tenderness, warmth, pride, fear, uneasiness or insecurity when they
held the baby. The mothers were also asked whether they thought that the time spent
with their stillborn baby was sufficient. All the women saw their baby and thirty (94%)
held their baby. All the mothers (100%) felt tenderness towards their babies, all but
one (97%) had feelings of warmth and all but three mothers (89%) were proud when
they held their baby. Beside these positive feelings, some mothers felt fear, insecurity
and discomfort when they held their baby. In retrospect most mothers thought that
the time they had spent with the stillborn baby was too short even though they felt at
the time, when holding the baby, that they were given sufficient time.
62
Ingela Rådestad, Sweden
School of Health Care and
Welfare,
Mälardalens university
[email protected]
Ingela Rådestad is a midwife and professor in
Caring Sciences. Her research focuses long-term
outcomes after stillbirths and women’s experiences of the care. She is the author of the book:
When a meeting is also farewell, coping with a
stillbirth or neonatal death. Ingela Rådestad is a
member of the board of Swedish national child
foundation and the scientific committee of International Stillbirth Alliance.
DEN STØTTENDE SAMTALEN - INTERACTIVE SESSION IN
NORWEGIAN
Oddbjørn Sandvik,
Norway
Psychologist
[email protected]
Ola Didrik Saugstad,
Norway
Department of Paediatric
Research. Rikshospitalet
Medical Center,
University of Oslo
[email protected]
Professor of Pediatrics and Director of the
Department of Paediatric Research, at
Rikshospitalet, The Medical Faculty, University of
Oslo representing the largest pediatric research
mileu in Norway. Since 1973 I have been involved
in research in perinatal medicine. The main
topics being perinatal hypoxia, effects of oxi
dative stress and free radicals. Injury mechanisms of premature infants are one topic of interest. The last 20 years I have mainly been interested in resuscitation of newborn infants especially
room air resuscitation. The last years I have also
been involved with WHO in different campaigns
with the aim of reducing maternal and childhood mortality and morbidity. President of the
Norwegian Perinatal Society 1987-89. Secretary
of the ESPR working group on Neonatology 199093. Member of executive board of European Association of Perinatal Medicine from 1996-2006,
and President from 2002-2004. Member of editorial board of 6 pediatric/perinatal journals. I have
given 250 invited lectures and written about 300
articles - of these 270 listed in Pubmed. The Arvo
Ylppo medal 1997, The Virginia Apgar Prize 2001,
The Maternite Prize 2008, Honoured by “Recent
Advances of Neeborn Medicine”, 2008. Honorary member of the Norwegian, finnish and European Perinatal Association and the Hungarian
Pediatric Society
EARLY DELIVERY- ALL GOOD? FROM THE NEONATE’S POINT
OF VIEW
The question of optimal timing of delivery is related to several important problems in
newborn medicine. At one end of the scale is the situation where preterm infants may
benefit to be delivered from an unfriendly environment for instance due to infection/
inflammation or placental failure. On the other end of the scale is the need to find
the optimal time for delivery of post term infants. Optimal delivery of fetuses with
congenital anomalies, multiples, or if a maternal disease is present is also needed to
be defined. In this lecture these aspects will be discussed. Further, the benefits of
tocolytics and antenatal steroids, use of early amniotomy on spontaneous labor, early
delivery in some congenital malformations, and handling of post term pregnancies will
be discussed from the perspective of the newborn.
RISK FACTORS FOR STILLBIRTH IN DEVELOPING COUNTRIES:
A SYSTEMATIC REVIEW OF THE LITERATURE
Lale Say, Switzerland
Department of
Reproductive Health and
Research, World Health
Organization
[email protected]
Lale Say has a degree in Medicine from University
of Istanbul and an MSc in Reproductive Health Research from the Edinburgh University. She is currently working at the World Health Organization
(Department of Reproductive Health and Research)
in Geneva, responsible for monitoring and evaluation activities. She has previously worked in Turkey
within the Ministry of Health maternal and child
health/family planning and primary health care
programmes and then at the Medical Faculty of Istanbul (Department of Obstetrics and Gynaecology)
before joining WHO.
OBJECTIVE: To identify risk factors for stillbirth in developing countries and to measure
their impact by calculating the population attributable fraction (PAF) for each risk factor. STUDY DESIGN: Systematic review of published studies on risk factors for stillbirth
within 3 broadly defined categories: infections, other clinical conditions, and contextdependent conditions such as socioeconomic status, maternal literacy, and receipt of
antenatal care. Where statistically significant associations were found between a risk
factor and occurrence of stillbirth, the PAF (the proportion of cases occurring in the
total population that would be avoided if the exposure was removed) was calculated.
RESULTS: A total of 33 studies, conducted in 31 developing countries, were included
in the review. The definition of stillbirth varied widely in these studies. Risk factors for
stillbirth having a PAF higher than 50% were maternal syphilis, chorioamnionitis, maternal malnutrition, lack of antenatal care, and maternal socioeconomic disadvantage.
CONCLUSIONS: Maternal syphilis prevention, screening and treatment together with
other interventions targeting universal use of antenatal care (that includes screening
for syphilis) and improving the socioeconomic conditions including nutritional status of
the mother, could effectively contribute towards reducing the unacceptably high burden due to stillbirth in developing countries.
63
LESSONS LEARNED FOR STILLBIRTH FROM THE COUNTDOWN
2015
The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage
of priority interventions that can reduce maternal and child mortality in 68 countries
which have 97% of maternal and child deaths worldwide. However, despite over 3
million annual stillbirths globally, reporting of stillbirths or coverage of effective interventions in the specific context of stillbirths is lacking. As such, there is interest
in improving the visibility and data availability and quality regarding stillbirths. Interestingly, the Countdown showed that routinely scheduled interventions, such as immunization and antenatal care, had much higher coverage than those requiring functional health systems and 24-hour availability of clinical services, such as skilled or
emergency care at birth and care of ill newborn babies. Focused and targeted efforts
based on local data will be needed to improve coverage of high quality antenatal and
childbirth care to reduce both early and late fetal deaths, and to document program
effectiveness. The Countdown, and related global initiatives can help in this process
through catalyzing local action based on data to improve the quality of care that will
result in reduction of stillbirths.
Anuraj H. Shankar,
Switzerland
World Health Organization,
Dept. of Making
Pregnancy Safer
[email protected]
Anuraj Shankar is the Coordinator of Surveillance,
Monitoring and Evaluation in the Department of
Making Pregnancy Safer at the WHO Head-quarters since 2007. After working in Mauritania as a
US Peace Corps volunteer in primary health care
from 1984-87, he completed his Doctoral degree in
Tropical Public Health and Imunology at Harvard University in 1993. Subsequently, as a faculty
member of the Johns Hopkins School of Public Health he conducted research and program
assessment in maternal and child health, and infection and nutrition in Latin America, Africa, and Asia.
His primary interest is in the development of robust
processes for obtaining and using data and information to guide and enhance the scale up of effective
programs for maternal and newborn health.
GENERATING GLOBAL POLITICAL PRIORITY FOR THE ISSUE
OF STILLBIRTHS: LESSONS FROM MATERNAL AND NEWBORN SURVIVAL INITIATIVES
Prior to 2000 most global health organizations and governments of countries with high neonatal mortality paid little explicit attention to the issue of newborn survival, despite approximately four million deaths each year to children in the first 28 days of life. Since that year
many of these institutions have come to give the issue attention. This being said, as of early
2008 newborn survival has yet to be afforded high-level political priority, particularly when
compared with other health issues such as HIV/AIDS. Such neglect is even starker for the
issue of stillbirths. Drawing on documentary analysis and in-depth interviews with key actors
in global newborn survival initiatives from Save the Children, the World Health Organization,
UNICEF, the United States Agency for International Development and other institutions involved in global health, we analyze the state of political priority for global newborn survival
efforts and the political challenges this initiative will face as it seeks to raise the issue’s global
profile. We draw on an agenda-setting framework developed from collective action theory,
recently published in The Lancet (Jeremy Shiffman and Stephanie Smith. 2007. “Generation
of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal
Mortality,” The Lancet 370 (9595): 1370-1379). We focus on three factors: 1)Issue framing (the
public positioning of the issue used to attract attention from international leaders). 2) Guiding
institutions (the strength of and quality of linkages among the organizations involved in global
efforts) 3)Intervention consensus (the extent to which core actors agree on what needs to be
done). We then draw on the data and analysis to consider global advocacy for the issue of stillbirths, and what lessons the case of newborn survival offers to enhance the likelihood that the
neglected issue of stillbirths will receive global political priority in the future.
64
Jeremy Shiffman, USA
Public Administration,
Syracuse University
[email protected]
Jeremy Shiffman is Associate Professor of Public
Administration at the Maxwell School of Syracuse
University in the United States. His research
focuses on global health agenda-setting: why
some issues receive attention and resources and
others are neglected. He has published in many
journals, including the Lancet, the Bulletin of the
World Health Organization, the British Journal
of Obstetrics and Gynecology, and the American
Journal of Public Health. He holds a bachelor’s
degree in philosophy from Yale University, a master’s degree in international relations from Johns
Hopkins University, and a doctorate in political
science from the University of Michigan.
DIAPHRAGMATIC HERNIA IN THE ERA OF PRENATAL
DIAGNOSIS AND GENTLE VENTILATION
Hans Skari, Norway
Rikshospitalet University
Hospital
[email protected]
Hans Skari Birthdate: November 26, 1963 Consultant
at Section of Pediatric Surgery, Surgical Dept, Rikshospitalet, Oslo (2004-) General surgeon The Norwegian
Board of Health 2005 Pediatric Surgeon The Norwegian
Board of Health 2007 • Coordinating doctor for Prenatal
counselling, Rikshospitalet from 1998 • Leader of The
Norwegian Pediatric Surgeons Associationfrom 2005
•Representative, Education Office, EUPSAfrom 2007 Academic background: University of California, Los Angeles
MPH 1988 University of Bergen MD 1989 University of
Oslo PhD 2006 CDH research was an important aspect of
my PhD research. Postdoc ongoing CDH reseach.
Rolv Skjærven, Norway
Medical Birth Registry
of Norway, Norwegian
Institute of Public Health
and Department of Public
Health and Primary
Health Care, University of
Bergen, Norway
[email protected]
Professor of Medical Statistics and Epidemiology,
University of Bergen. Many years of experience
in reproductive epidemiology, mainly using data
from the Medical Birth Registry of Norway
Jon Skranes, Norway
Dep of Laboratory
Medicine, Children’s and
Women’s Health,
Norwegian University of
Science and Technology
[email protected]
J Skranes is a paediatrician with child neurology and neonatology as main interests. Together
with Professor Ann-Mari Brubakk Skranes is
head of the research project: Low birth weight in
a lifetime perspective. This is a follow-up study
of mental health, cognitive functioning, physical
health and growth, motor abilities, and vision
in children with low birth weight from birth to
adulthood. The clinical results of these studies
are compared to the results of different quantitative cerebral MR techniques. The project involves
several departments at the University in Trondheim, and collaboration with University of California, San Diego, USA.
Diaphragmatic hernia in the era of prenatal diagnosis and gentle ventilation Outcome for children with congenital diaphragmatic hernia (CDH) has improved over the last decades. The
treatment protocol of Rikshospitalet University Hospital was revised in year 2000 focusing on
“gentle ventilation”. The aim of the presentation is present the experience from Rikshospitalet
and to relate these results to the literature. Methods: 41 liveborn CDH patients were identified
from 01.01.2000-31.07.2007. Clinical data was retrieved from the institutions registry of neonatal surgery. Moreover data was extracted retrospectively from the charts. Long-term survival
was checked with census data by August 31st 2007. Fisher’s exact test was used. Results: 21
boys and 20 girls were included. 32% (13/41) were diagnosed prenatally. Precise description
of the hernia anatomy was available in 39 of 41 children: 30 left-sided and 6 right-sided Bochdalek hernias, 2 Morgagni hernias and 1 bilateral hernias. 30 children had early symptoms (<24
hours) and 11 children had late onset of symptoms. 17% (7/41) had major associated anomalies. 88% (36/41) of the CDH patients were stabilized and operated (delayed surgery). 3 neonates
were treated with ECMO. Neonatal survival was 73% (22/30) in the group with early symptoms
and all patients (11/11) with late onset survived. Long-term survival in the early onset group
was 70% (21/30). In the early onset group, long-term survival was 88% (15/17) with postnatal
diagnosis and 46% (6/13) with prenatal diagnosis (p=0.02). Conclusions: During the study period
(2000-2007) overall neonatal survival for liveborn children with CDH was 80% (33/41). In the
subgroup of early presenters neonatal survival was 73%. Prenatal diagnosis was associated
with higher mortality than postnatal diagnosis, probably indicating a more severe degree of
malformation in the group with prenatal diagnosis.
RECURRENCE AND FAMILY EXPOSURE OF FGR
This presentation will demonstrate shortcomings of cross-sectional data as the basis for epidemiological and clinical research and practice, with a focus on familiar recurrence of low birth
weight and fetal growth restrictions (SGA). Family data are usually ignored in growth standards.
However, data from the Medical Birth Registry of Norway have for decades been used to demonstrate the strength of family data, both for studied of recurrence of low birth weight, smallfor-gestational age and preterm birth, as well as studies on variation of perinatal mortality.
Birthweight and gestational age are strongly linked within families, in part due to influences
from environmental factors that work through successive pregnancies and even through generations, but mostly due to strong genetic factors. Women have different reproductive capabilities that effect perinatal statistics. An important set of variates related to these capabilities is
found in previous pregnancies. Heterogeneity in perinatal outcome among women affects not
only the occurrence of adverse outcome, but also the criteria for what is considered normal.
There is a considerable variability in viability between small infants, therefore lack of sibshiporganized data or other family data (generations) is an obstacle to further progress in perinatal
epidemiology as well as in clinical research.We will use data from the population based Medical Birth Registry of Norway, covering the years 1967-2006. Data are organized into 1.1 million
sibship units, and 550.000 mother-child units where both the mothers birth record and her
offspring’s record are available.
HVORDAN GÅR DET MED SGA BARNA I UNGDOMSÅRA OG
TIDLIG VOKSEN ALDER? MEDISINSKE ASPEKTER MED
HOVEDVEKT PÅ NEVROLOGI.
Denne forelesningen vil omhandle resultater fra en oppfølgingsstudie av barn med lav
fødselsvekt født i perioden 1986-88 ved St Olavs hospital i Trondheim. Studien omhandler
både for tidlig fødte barn med fødselsvekt under 1500 gram, og såkalte SGA (small for gestational age)- barn som var født til termin, men med fødselsvekt mindre enn 10 percentilen
korrigert for gestasjonsalder. I tillegg deltok en kontrollgruppe, dvs. fullbårne barn med fødselsvekt mer enn 10 percentilen. Det er samlet inn data fra svangerskap og fødsel, og det er
gjort kliniske undersøkelser av barna ved 1, 6, 15 og 19 års alder. Det er også gjort avansert
hjerne-MR diagnostikk ved 15 og 19 års alder. Noen av resultatene vil bli presentert i forelesningen.
65
EARLY MARKERS AND EARLY SCREENING - FUTURE
POSSIBILITIES?
“Early markers and early screening - future possibilities?” A number of biochemical
and ultrasonic measurements made in early pregnancy are associated with adverse
outcome of pregnancy. This lecture will review some of these associations, discuss their
potential utility in clinical screening and discuss future research strategies for the early
identification of women at risk of stillbirth and other complications of pregnancy.
CURRENT STANDARDS OF CARE IN THE SMALL FOR
GESTATIONAL AGE FETUS
“Current standards of care in the small for gestational age fetus” The current methodologies for the identification, assessment and management of small for gestational
age fetuses will be discussed. The lecture will cover (1) screening for growth restriction, (2) definition of growth abnormalities, (3) the use of 2D ultrasound, Doppler flow
velocimetry and computerized CTG, and (4) interventions to improve outcome.
Gordon C. S. Smith, UK
Dept. of Obstetrics &
Gynaecology,
University of Cambridge
[email protected]
Professor Smith is Head of the Department of Obstetrics and Gynaecology, University of Cambridge.
His undergraduate and post-graduate training
were in Glasgow, except for a three year Wellcome
fellowship at Cornell University (USA). He is subspecialist trained in Maternal-Fetal Medicine and
divides his time equally between academic work
and clinical practice in this area. He has published
over 80 peer reviewed papers in national and international journals, including Nature, NEJM,
JAMA and Lancet. He is a Senior Investigator of the
National Institute for Health Research (UK) and a
Clinical Professor in the Department of Obstetrics
& Gynecology at the UTMB, Galveston, USA.
ARE THERE STRATEGIES TO PREVENT OR TREAT
BRONCHOPULMONARY DYSPLASIA (BPD)?
Many strategies to prevent or ameliorate BPD have been evaluated so far. Evidence for a short
term preventive effect exists for the repetitive intramuscular administration of high doses of
vitamin A. Oxygen supplementation remains an important therapeutic strategy for patients
with established BPD. Targeting the infants at lower oxygen saturation seems to reduce long
term pulmonary morbidity without increasing the risk of adverse neurosensory outcome. In
addition, prophylactic or very early surfactant administration in very immature infants may
have a beneficial effect on the incidence of BPD. Currently there is no sufficient evidence for a
routine use of inhaled nitric oxide (iNO) for the prevention of BPD. A temporary use of diuretics
can improve lung function and oxygenation in these infants. Nonetheless existing data do not
justify a sustained diuretic therapy. As the pathogenesis of BPD is multifactorial, it is unlikely
that one single agent will be identified as a ‘miracle drug’ in the prevention or treatment of
the disease. The ‘miracle drug’ of the 1990s, dexamethasone, has almost completely lost its
role in the management of extremely premature infants. Superoxide dismutase (SOD) and
1-Proteinaseinhibitor have not proved to reduce the risk of moderate or severe BPD yet.
Effects of other anti-inflammatory substances still have to be assessed in detail. The early
administration of caffeine for prophylaxis and treatment of apnea of prematurity has been
shown to reduce the risk of BPD and to improve the rate of survival without neurodevelopmental disability at follow-up.
Christian P. Speer,
Germany
Director and Chairman
University Children’s Hospital
speer_c@kinderklinik.
uni-wuerzburg.de
Prof. Christian P. Speer, MD, FRCPE is Chairman
and Director of the University Children’s Hospital
in Würzburg, Germany. Prof. Speer’s main areas of
research interest include host defense mechanisms
in neonates, early detection of neonatal systemic
infections, clinical surfactant trials, basic surfactant
research and inflammatory mechanisms in acute
and chronic lung diseases of preterm infants. He has
published more than 240 scientific articles in international and national journals and is author of many
book chapters on acute and chronic pulmonary diseases in neonates. Since 1996 he has regularly organized the international symposium Recent Advances
in Neonatal Medicine”
DEMOGRAPHY IS DESTINY – EUROPEANS AND FERTILITY
RATES
Arne Sunde, Norway
Fertility Clinic, St. Olav’s
University Hospital in
Trondheim
[email protected]
He has an MSc in biophysics and PhD in molecular endocrinology from the NTNU in Trondheim. He worked in the team responsible for
the first IVF-children in Norway and for the first
child born after cryopreservation of embryos in
the Nordic countries. He served as the laboratory
director of the ART-laboratory at St. Olav’s University hospital in Trondheim since 1984 and was
appointed Head of the Fertility Clinic in 2006. He
is formally one of the founders of, and has been
a chairman of, the European Society for Human
Reproduction and Embryology. He is the current
chairman of the Norwegian Association of Assisted Reproduction (NOFAB).
66
INNGIFTE I NORGE - UTBREDELSE OG MEDISINSKE
KONSEKVENSER
Pål Surén, Norway
Public Health.
[email protected]
Pål Surén er utdannet lege fra Universitetet i
Oslo og Master of Public Health fra Harvard
School of Public Health i Boston, USA. Han
arbeider som rådgiver ved Divisjon for epidemiologi ved Folkehelseinstituttet, og deltok i
arbeidet med rapporten “Inngifte i Norge - utbredelse og medisinske konsekvenser”, som ble
publisert våren 2007.
Presentasjonen går gjennom hovedfunnene i Folkehelseinstituttets rapport “Inngifte i
Norge - utbredelse og medisinske konsekvenser”, som ble publisert våren 2007. Beregninger og analyser i denne bygger på data fra Medisinsk fødselsregister, Statistisk
sentralbyrå, Folkeregisteret og Dødsårsaksregisteret, og inkluderer alle barn født i
Norge i årene 1967-2005. De høyeste andelene inngifte ble funnet hos norsk-pakistanske førstegenerasjonsinnvandrere, hvor 44% av foreldreparene var søskenbarn. Det
ser ut til at inngifte-andelene synker fra førstegenerasjon til etterkommere, og at den
også er synkende over tid. Det er også relativt mye inngifte blant personer med opprinnelse i Tyrkia, Iran, Irak, Sri Lanka, Marokko og Somalia. Inngifte øker risikoen for
dødfødsel, medfødte misdannelser og spedbarnsdød. Når foreldrene er søskenbarn,
er risikoen økt med hhv. ca. 60% for dødfødsel, ca. 100% for medfødte misdannelser
og ca. 150% for spedbarnsdød. Det er også en økt risiko for dødsfall på alle alderstrinn
opp til voksen alder (gjennomsnittlig 75%).
ELECTIVE SINGLE EMBRYO TRANSFER IN IVF/ICSI
Tom Tanbo, Norway
Gynecology,
Rikshospitalet University
Hospital
[email protected]
Graduated Medical School, University of Oslo,
Norway 1974. 55 months registrar in general
surgery and 60 months in ob/gyn. Board certified specialist in obstetrics and gynecology 1986.
Consultant in Reproductive Medicine 1986, Rikshospitalet University Hospital. PhD 1991 University of Oslo, Norway. Director of Reproductive
Medicine 1994. Director of National Resource
Centre for Women’s Health 2006. Professor in
Ob/Gyn 2008.
Anne Tandberg, Norway
Dep. of Public Health and
Primary Care, Univ. of
Bergen, and Dep. of
Obstetrics and Gynaecology,
Haukeland Univ Hospital
[email protected]
Cand.med at the University of Oslo 1983. Specialist in Gynecology and Obstetrics in 1996. Senior
doctor Haukeland Univ Hospital, Women`Hospital
from 1996. Head of the Section of assisted reproductive technologies from 2002. PhD student,
University of Bergen from April 2008.
The number of embryos transferred is one of several factors affecting outcome of in
vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). With increasing
number of embryos transferred the risk of twins and high order multiple pregnancies increases which was one among several causes to the almost doubling of the
frequency of twin pregnancies observed in Norway during the last two decades of the
previous decennium. To reduce the frequency of triplets or more, most countries in
the Northern part of Europe reduced the number of embryos transferred during the
nineties. This strategy resulted in a significant reduction in high order multiple pregnancies, but not in twins. In order to reduce the number of twin pregnancies after IVF/
ICSI , attempts at transferring one embryo only in ”good” patients were started in the
late nineties. The results of these studies indicated that, on the condition of an efficient
cryopreservation program, the cumulative live pregnancy rate per cycle was similar in
elective single embryo transfer (eSET) compared with double embryo transfer (DET).
In countries implementing eSET a substantial reduction in twin pregnancies has been
observed; however, in unselected patient populations DET has been shown to be more
effective but also more expensive. Among professionals as well as patients there is
substantial doubt as to a rigorous implementation of eSET, emphasizing the need for
an individualization of treatment programs.
INCREASING TWINNING RATES IN NORWAY 1967-2005. THE
INFLUENCE OF MATERNAL AGE AND ASSISTED REPRODUCTIVE TECHNOLOGY.
Twinning and triplet rates in Norway, 1967-2004 Tandberg, A.; Bjørge, T.; Skjaerven, R.
Background: The incidence of multiple pregnancies is rising in industrialized countries. In the present nationwide study, we aimed to evaluate the effect of assisted reproductive technologies (ART) and delayed childbearing age on the twin and triplet
pregnancy rates. Material and method: Altogether 2.25 million pregnancies, including
28,266 twin pairs, 511 triplet pregnancies and 28 quadruplet pregnancies were included in this population-based study with data from the Medical Birth Registry of Norway
(MBRN), covering the years 1967-2004. The study period was divided into two, 1967-87
and 1988-2004, respectively. Since 1988, pregnancies from ART were available through
a separate registration. This record was linked based on the mother’s personal identification number, with the MBRN birth record for the period 1988-2004. Twinning rates
from natural conception were compared in the two time periods in relation to maternal
age. Perinatal mortality was defined as all fetal death from the 22. gestational week
until six days after birth. Logistic regression was used for odds ratio estimation. SPSS
version 14 was used for the statistical analysis. Results: During 1967-1987, the twinning rate remained constant at about 1.0 % of the total number of births in Norway.
Thereafter we observed a consistent rise. The total twin birth rate increased from 1.1%
in 1987 to 1.9% in 2004, a relative yearly increase of 3.3% (95% CI 3.0% - 3.5%). The twin
birth rate excluding ART pregnancies, increased from 1.1% in 1987 to 1.6% in 2004, a
relative yearly increase of 2.0% (95% CI 1.8% - 2.3%). There was a significantly higher
twinning rate in all age groups in the time period 1988-2004 compared with 1967-1987.
67
In naturally conceived pregnancies, OR for twins were 1.11 ( 95% CI 1.05-1.18) in the
age group 20-24 years, 1.25 (95% CI 1.19-1.31) in age group 30-34 and 1.37 (95%CI
1.12-1.68) in age group 40-44 comparing the two time periods. The total triplet rate
increased four-fold during the years 1988-2004 from 0.3/1000 births in the time period 1967-87 to 1.1/ 1000 births in the period 1988-2004. Excluding ART, this ratio
was still high (OR=2.3; 1.8-2.9). Maternal age had a strong effect on spontaneous
triplet rates. In the period 1967-1987, the perinatal mortality for twins was 7.8 % in
the first period, compared to 3.1 % in the last period, (OR 0.37; 0.34-0.41) For triplets,
the perinatal mortality was 15.4 % in the first period and 7.4 % in the last period (OR
0.44; 0.29-0.65) For comparison, the perinatal mortality for singleton was 1.7% in the
first time period and 1.1% in the last time period (OR 0.66%; 0.65-0.68). Conclusions:
The multiple pregnancy rates in Norway doubled during the time period 1988-2004.
We excluded pregnancies from ART and adjusted for maternal age, but still there
was a considerable increase in all age group. The perinatal mortality for twins and
triplets was reduced with 63% and 56 %, respectively, during the same time period.
Although, compared to the outcome singletons, multiple gestations are still high risk
pregnancies. Key words: Twinning rates, assisted reproduction, maternal age, perinatal mortality.
PARENTS’ NEEDS FOR CARE AND SUPPORT WHEN A CHILD DIES
IN STILLBIRTH
The presentation includes findings from the study “Parents tell their story about
loosing a baby in stillbirth, a user perspective of the health care system in Norway.”
The purpose of the study was to understand how health professionals should guide
parents through the meeting and the goodbye with their stillborn baby. Design and
method: 40 one to two hour interviews were conducted with mothers and fathers. Using Critical Incident Technique, the informants were encouraged to tell their story and
describe their interaction with the health care system before, during and after a stillbirth, including guidance to meet and say goodbye to their baby. This presentation will
concentrate on four main topics: Preparing for the “still” birth, giving birth to a dead
baby, the important memories, and the importance of creating precious moments.
The whole report is published at www.lub.no, currently in Norwegian only.
Janne Teigen, Norway
Norwegian SIDS and
Stillbirth Society and
Telemark Hospital.
[email protected]
Born in 1964, registered nurse since 1995 and
educated midwife since june 2007. I am the editor of the Norwegian book “Small feet, deep impressions”. Together with Line Christoffersen I
interviewed 40 parents of stillborn babies. These
interviews resulted in the report “Parents tell
their story - a users perspective of the health
care system after stillbirth”, published at www.
lub.no. I am also a bereaved parent loosing my
first child, Ida 4 days after birth.
EATING DISORDERS DURING PREGNANCY
Background: We explored the impact of eating disorders on birth outcomes in the
Norwegian Mother and Child Cohort Study. Method: Of 35,929 pregnant women, 35
reported broad anorexia nervosa (AN), 304 bulimia nervosa (BN), 1,812 binge eating
disorder (BED), and 36 EDNOS-purging type (EDNOS-P) in the six months prior to
or during pregnancy. The referent comprised 33,742 women with no eating disorder
(no-ED). Results: Pre-pregnancy BMI was lower in AN and higher in BED than the
referent. AN, BN, and BED mothers reported greater gestational weight gain and
smoking was elevated in all eating disorder groups. BED mothers had higher birth
weight babies, lower risk of small for gestational age, and higher risk of large for
gestational age and cesarean section than the referent. Pre-pregnancy BMI and gestational weight gain attenuated the effects. Conclusions: BED influences birth outcomes either directly or via higher maternal weight and gestational weight gain. The
absence of differences in AN and EDNOS-P may reflect small numbers and lesser
severity in population samples. Adequate gestational weight gain in AN may mitigate
against adverse birth outcomes. Detecting eating disorders in pregnancy could identify modifiable factors (e.g., high gestational weight gain, binge eating, smoking) that
influence birth outcomes.
68
Leila Torgersen, Norway
Public Health
[email protected]
Leila Torgersen is a Psychologist and a researcher
at the National Institute of Public Health (NIPH).
She is a coordinator of an eating disorder project
funded by NIH, with Ted Reichborn-Kjennerud as
the project manager together with Cynthia Bulik
at University of North Carolina.
HOW GUIDELINES CAN ENABLE HEALTH PROFESSIONALS TO
PREPARE PARENTS FOR AUTOPSY
Åshild Vege, Norway
Institute of Forensic
Medicine, University of Oslo
[email protected]
Specialist in pathology and medical microbiology
and professor of Forensic Medicine. Involved in SIDS
research since 1992. Presented the doctoral thesis
on “Clues to understanding the death mechanism
in sudden infant deaths syndrome (SIDS)” in 1998,
with focus on immunological, biochemical and
epidemiological factors. Has been involved in a research project with examination of sudden deaths in
neonates and small children, and a visit to the bereaved families shortly after the autopsy. Is currently
engaged in the examination and research on sudden
unexpected child death.
To inform parents about the need to perform an autopsy is a difficult and demanding
task. In Norway there previously was a so called presumed consent; i.e. if no-one had
expressed their opinion against autopsy, it was considered that they accepted it. According to changes in laws and regulations, parents now have to be informed about the
wish to perform an autopsy, and that they have a right to decline. There is however an
exception from this. Forensic autopsies are performed after demand from the prosecuting authority. The regulations state that the next of kin should be informed and given
the possibility to express their wishes, but the police decide whether the autopsy shall
take place. The duty to inform parents about the autopsy and what it implies is left to
health personnel. Often it is the doctor on call that is given the task, among all other
urgent matters he has to deal with. In 2001 a working group was appointed to elaborate
both guidelines for and information concerning pediatric autopsies. Members from parental organizations participated in this work. These guidelines may assist the health
personnel in meeting the bereaved families and give them proper information.
DETECTION, MONITORING AND DELIVERY OF THE FGR FETUS:
WHERE CAN PROGRESS BE MADE?
Gerard H. A. Visser,
Netherlands
Obstetrics, University
Medical Center, Utrecht
[email protected]
Gerard H.A.Visser is an obstetrician, who trained
in Groningen the Netherlands and is now head of
Obstetrics in Utrecht,NL. His long time research
interests concern the development of the fetal
nervous system (fetal behavioural studies),early
detection of fetal compromise and relationships
between perinatal events and outcome of the
infant
Intrauterine or fetal growth restriction ( IUGR/FGR) is usually defined as a fetus that is
too small for the duration of gestation, due to placental insuffiency. In case this occurs
preterm, then usually a concomitant maternal disease ( pregnancy induced hypertension/preeclampsia/HELLP syndrome) is present, which facilitates early recognition of
the fetal problem. Moreover, blood flow patterns over the umbilical artery are generally
abnormal. So, this disease entity can well be diagnosed. However, early and severe fetal growth restriction and need for early delivery, is associated with a high incidence of
perinatal mortality and morbidity, which can not easily be prevented by further refining
the timing of delivery. Prevention of IUGR and pregnancy induced hypertension will be
the only way to reach a real breakthrough. At term the small baby at risk of intrauterine
death cannot easily be detected since traditional monitoring techniques, including umbilical blood flow patterns, fail. Liberal induction of labour in case of suspected IUGR is
the best option to prevent mortality and morbidity in this group.
GLOBAL ELIMINATION OF CONGENITAL SYPHILIS INITIATIVE
Kenneth Wind-Andersen,
Switzerland
WHO Dept. of
Reproductive Health and
Research
[email protected]
Working in WHO Family and Community Health
Cluster in the Department of Reproductive Health and Research and focal point for
the Global Elimination of Congenital Syphilis.
Demonstrated a long track record in communication and knowledge management. Demonstrated
broad knowledge in Sexual and Reproductive
Health (SRH) and its public health aspects.
Entrusted to represent the WHO in areas of
advocacy on SRH-HIV linkages etc. WHO
Adviser on GF. Leading Botswana’s first PHC model
project in late 1970’ies; prepared WHO
Programme Plan 20010-2015 and Investment Case for Global Elimination of Congenital
Syphilis as proxy for functioning MNCH using PHC and HSS. Strong track record of
leadership with vision and communication, diplomatic and fund raising skills. Being WHO Special Representative. Being UCC
in India and Chief Medical Officer under UK
Government attached to FCO.
The Global Elimination of Congenital Syphilis Initiative Congenital syphilis contributes
substantially to high rates of illness, disability, stillbirth, neonatal death and low birth
weight, especially in high prevalence settings. Worldwide about 4 million (3.1%) of liveborn babies die in the neonatal period (first 28 days of life) each year and another 4
million die in utero in the last trimester (stillbirths). If 20% of the 2.1 million syphilisaffected pregnancies end in spontaneous abortions or stillbirths, syphilis would account for 10.5% of the 4 million stillbirths per year. Syphilis remains a global problem
with up to 1.5 million pregnant women infected each year despite the existence of effective and affordable treatment options. The World Development Fund cites antenatal
services and treatment for syphilis as one of the most health interventions available. It
is estimated that investment in Improving Access to and Quality of Integrated Antenatal
Care would avert more than 700,000 cases of congenital syphilis per year. The Global
Elimination of Congenital Syphilis Initiative was launched at the Women Deliver Conference in London, 18-20 October 2007, where a WHO/UNFPA Statement of Commitment towards this goal supported by several governments, international organizations
and Nongovernmental Organizations was released. At the WHO/CDC Technical Consultation on the Global Elimination of Congenital Syphilis in Geneva, 10-12 July 2007,
it was recommended to develop an investment case for the elimination of congenital
syphilis. At the workshop in Atlanta, 13-14 December 2007, the scope of an investment case was defined, including the preparation of a detailed outline, the budget, the
distribution of roles and responsibilities, the way forward. A second Investment Case
for Improving Access to and Quality of Integrated Ante- and Perinatal Care was conducted in Ferney-Voltaire, 24-25 June 2008, has set the Investment Case on track. This
presentation is the introduction of several WHO and CDC presentations, which focus
on the most recent findings on congenital syphilis and stillbirths. Global Elimination of
Congenital Syphilis has as its long term goal an elimination of congenital syphilis as a
public health problem.
69
“VOICES OF SORROW” A BOOK PROJECT PRESENTED BY
KJERSTI WOLD
Jane Flohr and Kjersti Wold met during a workshop in creative writing, August 2004.
They discovered that they both had the painful experience of losing their child half way
in pregnancy. By sharing their own experiences of grief, guilt and bewilderment, they
understood the healing and relief that can happen by expressing thoughts and feelings connected to loss. This initiated the idea of writing a book about loosing a child
during pregnancy, and in February 2005 they opened a website targeting people that
had experienced miscarriage and stillbirth. Thousands of people used the website
to read about others or express their own despair, their sadness, their shame, their
unanswered questions - and their longing for the child that died before they got to
know him or her. These voices of sorrow are now heard in the book “The child that was
meant to be.” This is the first book of its kind in Norway and is created in cooperation
with Norwegian SIDS and Stillbirth Society.
COUNTING ALL STILLBIRTHS: A GLOBAL NETWORK
PERINATAL MORTALITY STUDY
Authors: Linda L. Wright (1), Waldemar A. Carlo (2) and Elizabeth M. McClure (3) for the Global
Network for Women’s and Children’s Health Research Institutional/Organizational/Country
Affiliations: 1. Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 2. Division of Neonatology, Department of Pediatrics, University of
Alabama at Birmingham, Birmingham, AL 3. Department of Statistics and Epidemiology, Research Triangle Institute, Research Triangle Park, NC Correspondence: [email protected]
Introduction: WHO estimates that there are 3 million stillbirths (SB) per year in the developing
world; poor data are attributed to lack of registries, equipment and skill; home births; traditional belief systems; avoidance of culpability; and financial burdens of burial. Objectives: We
evaluated the effect of WHO Essential Newborn Care (ENC) training on perinatal mortality
in a population-based multi-country study. Methods: Certified local staff trained all birth
attendants from 95 rural communities in 6 countries. Following baseline training, data were
collected prospectively on all deliveries ≥1500g for 6±1 mos before and 8±2 mos after ENC
training. Community registries were established before the study; birth attendants received
bags and masks, scales and stethoscopes; training included assessment of fetal heart rate
before delivery, maceration and Apgar scores to differentiate SBs vs. early neonatal deaths.
Results: Consent was obtained on 99.7% of 57,847 births ≥1500g. 56% were born at home;
19% were attended by family members. In communities where early monitor noted very high
SBs rates, additional training in accurate classification was provided. After ENC training, the
population-based PMR decreased from 46 to 39/1000 births (RR 0.85, CI 0.64-1.13) and from
43 to 33/1000 births among trained birth attendants (RR 0.85; CI 0.44-0.88) due to decreased
SB rates (23 to 16/1000, RR 0.63, CI 0.44–0.88) or ~1 in 3 reduction in SB. Rates of macerated
SBs were unchanged. PMR and SB rates decreased in 5 of 7 and 6 of 7 sites, respectively. Sites
without reductions had low baseline rates or increased registration rates post ENC. Conclusions: We recorded reductions in SB rates after provision of site registries, equipment
and WHO ENC training of community birth attendants. Detailed training was required to differentiate SBs vs. neonatal deaths. Our data are consistent with recent reports of decreased
SBs after resuscitation training in two Indian sites. Misclassification of SB has important
implications for global strategies to reduce perinatal mortality and resource allocation. If ~1
in 3 SBs is a viable newborn who was not resuscitated, improved resuscitation skills might
save 1 million lives each year. Acknowledgements and source of funding: Funded by National
Institutes of Health Conflicts of Interest: None
70
Kjersti Wold, Norway
Norwegian SIDS and
Stillbirth Society.
[email protected]
On daily basis I am a writer of fiction books, but 4
years ago I started a book project togheter with
Jane Flohr. We have both lost a daugheter half way
through pregnancy, and we opened a website for
people that have lost their children in miscarriage
and stillbirth. We have collected their voices and now
we let them be heard in a book called: The child that
was ment to be.”
Linda L. Wright,
United States
Eunice Kennedy Shriver
National Institute of
Child Health and Human
Development
[email protected]
Dr. Wright is the Director of the NIH Global Network for Women’s and Children’s Health Research (GN)., a consortium of seven pairs of US
and developing world sites on three continents.
The goal of the GN is to conduct collaborative
research to create scientific capacity and sustainable research infrastructure in order to
develop evidence-based solutions to the major
causes of morbidity and mortality. The GN recently completed a cluster-randomized trials of
two types of neonatal resuscitation training that
included ~100 clusters. Trial registries recorded
stillbirths, early neonatal deaths and 28-day outcomes. Dr. Wright is the former Director of the
NIH Neonatal Research Network.
CAN DHS SURVEYS BE USED TO MEASURE CONGENITAL
SYPHILIS ELIMINATION IMPACT ON STILLBIRTH?
Fujie Xu, USA
Division of STD Prevention,
Centers for Disease
Control and Prevention
[email protected]
Dr. Fujie Xu received her medical training from
Beijing University, Beijing, China and training
in epidemiology from Emory University, Atlanta,
USA. She has been working at the Division of
STD Prevention, CDC for 10 years, working on
both bacterial and viral STDs, including HIV. Her
expertise is monitoring disease trends using
population-based surveys. She has published
multiple papers using the National Health and
Nutrition Examination Surveys in the United
States.
The Demographic and Health Surveys (DHS) can provide reliable and nationally representative data on fertility, family planning, and health of populations in developing nations. A contraceptive calendar is included in the woman’s questionnaire for the 60-month period before
interview and it documents women’s monthly pregnancy status, providing data for the number
of pregnancy losses occurred during the seventh month or later of pregnancy. We used the
most recent DHS data to estimate the potential reduction in stillbirth rates if maternal syphilis
screening and treatment is added in antenatal care in African countries where the prevalence
of syphilis in pregnant women is high (ranked among the top 25 countries). Our estimates have
taken into account of the timing and coverage level of prenatal care, and thus the timing and
coverage level of testing and treatment of syphilis, in these countries.
71
Free Communcations Oral
72
Oral Stillbirth
73
Oral Developing Countries
83
Oral Bereavement
90
Oral Perinataldagene
95
ORAL Stillbirth
THE EFFECT OF SOCIOECONOMIC STATUS, ACCEPTANCE OF
PREGNANCY AND PRENATAL CARE ON FETAL MORTALITY
IN SÃO PAULO CITY, BRAZIL
Gizelton P. Alencar (1), Marcia F. Almeida (1), Oona Campbell (2), Laura C. Rodrigues (2)
1. Department of Epidemiology, University of São Paulo, Brazil.
2. Department of Epidemiology and Population Health, London School of Hygiene and Tropical
Medicine, UK.
Correspondence: [email protected]
Introduction: Many studies pointed out the importance of socioeconomic status (SES), pregnancy acceptance and pre-natal care on fetal deaths, but its pathway is not clear.
Objective: To identify the role of SES, pregnancy acceptance and prenatal care on fetal deaths
in São Paulo city, Brazil.
Methods: Data were obtained from birth and death certificates, hospital records and home interviews in São Paulo (Aug2000-Jan2001). This is a case-control study: cases were 164 antepartum
fetal deaths and 313 live births were controls. The negative social economic situation (nSES)
construct was obtained from income, schooling of head of family and mother, head of family
occupation and presence of health plan insurance. Negative acceptance of pregnancy (nAoP)
included reactions of mother, father and family (good / not good acceptance), planned gestation
(y/n) and attempted abortion (y/n). Pre-natal care was grouped into inadequate and adequate.
Gestation intercurrences were measured by presence of hypertension, bleeding, diabetes and
renal disease. IUGR was based on Williams’s curve. Structural equation models (SEM) with WLS
estimator were used (software Mplus).
Results: The effect of both constructs nSES and nAoP on fetal deaths is through pre-natal
care, after excluding the non-significant direct path from nSES and nAoP to fetal deaths. The
effect of previous low birth weight gestation on fetal deaths is through gestation intercurrences. The model included also a direct effect of IUGR to fetal death. Fit indexes were considered
reasonable (CFI=0.95;TLI=0.95;RMSEA=0.05;WRMR=0.99).
Conclusion: Our findings suggest that prior negative mother’s biological condition is expressed
by previous low birth weight and acts trough gestational intercurrences. The effect of poor SES
and negative acceptance of pregnancy on fetal deaths is mediated through inadequate prenatal
care.
Acknowledgements and sources of financing: FAPESP,CNPq,CAPES.
Conflicts of interest: There is no conflict of interest.
Figure. SEM for fetal mortality.
73
INFECTION IN FETAL LOSSES BETWEEN 16 AND 24 WEEKS
GESTATION.
Ben Allanson, Belinda Jennings, Adrian Charles, Tony Kiel, Jan Dickinson
1 Department of Obstetrics and Gynaecology, King Edward Memorial Hospital, Subiaco, Australia
2 Department of Pathology, Pathwest, King Edward Memorial Hospital, Subiaco, Australia
Correspondance: [email protected]
Introduction: Chorioamnionitis features is a common cause of pregnancy loss during the second trimester. In most cases this has been ascribed to an ascending infection. This study compares the cases
of loss due to infection to a control group of with loss due to a congenital abnormality.
Method: The records of King Edward Memorial Hospital, the main tertiary obstetric hospital in
Western Australia were reviewed. Fetal losses were identified between the ages of 16 weeks and
24 weeks gestation from the obstetric database and the pathology department records over a
three year period. The cases with full autopsy and placental examination were identified, the pathology reports reviewed, and the maternal features noted.
Results: 661 pregnancy loss cases were identified. Of these 545 had pathological examination
(82%). There were 105 cases with spontaneous loss with no congenital abnormality and not
macerated, and 103 control cases of induced loss for anomaly. 78 of the 105 had chorioamnionitis 46% (37) of these cultured an organism. Only 3 cases without chorioamnionitis cultured
an organism. 38 of the 78 showed a fetal reaction in the chorionic plate of the cord. Ureaplasma
(10), Mycoplasma (4), Group B Streptococci (4) were common pathogens. Chorioamnionitis was
not present in the control group.
Conclusion: Chorioamnionitis is rare in induced labour for congenital abnormality. Culture of
the fetus is usually negative if taken under appropriate conditions unless there is chorioamnionitis. Fetal reaction is often seen indicating the chorioamnionitis preceeded fetal demise. Chorioamnionitis is a common finding in pregnancy/ fetal loss in the second trimester of otherwise
normal appearing fetuses. The reason /factors involved in for this needs further investigation.
No conflicts of interest and no other financial resources.
STILLBIRTH AND SLOW METABOLIZERS OF CAFFEINE – COMPARISON OF GENOTYPES
Bodil Hammer Bech (1), Herman Autrup (2), Ellen Aagaard Nohr (1), Tine Brink Henriksen (3)
and Jørn Olsen (1,4)
1 The Danish Epidemiology Science Centre, Department of Epidemiology, Institute of Public
Health, University of Aarhus, 8000 Aarhus (DK).
2 Department of Environmental and Occupational Medicine, Institute of Public Health, University of Aarhus, 8000 Aarhus (DK).
3 Perinatal Epidemiology Research Unit, Department of Obstetrics and Paediatrics Aarhus
University Hospital, Skejby (DK).
4 Department of Epidemiology, School of Public Health, UCLA, Los Angeles.
Introduction: Cytochrome P-4501A2 (CYP1A2) and N-acetyltransferase2 (NAT2) are key enzymes in
the metabolism of caffeine. Polymorphism in these genes makes it possible to divide the population
into fast and slow metabolizers. If caffeine is causally related to stillbirth, we expect slow metabolizers to have a higher risk. Gluthatione S-transferaseA1 (GSTA1) conjugates gluthatione into aromatic
amines and may also be active in the metabolism of caffeine.
Objectives: To study whether genotypes related to caffeine metabolism and oxidative stress
were associated with the risk of stillbirth.
Methods: We made a nested case non-case study among women who participated in The Danish
National Birth Cohort: 142 cases of singleton stillbirths and 157 controls of singletons live births.
Results: Slow CYP1A2, slow NAT2, and low activity of GSTA1 were not individually associated
with the risk of stillbirth (OR=1.06, 95% CI: 0.67-1.67, OR=0.95, 95% CI: 0.60-1.51 and OR=1.42,
95% CI: 0.88-2.28, respectively). We did, however observe that subjects with a combination of
slow CYP1A2, slow NAT2, and low GSTA1 genes had almost a twofold risk of stillbirth compared
to subjects with other combinations of genotypes.
74
Conclusion: We found no link between any single genotype and the risk of stillbirth. An association between a combination of genotypes and stillbirth was discovered. Caffeine may be
causally related to stillbirth but larger studies using Mendelian randomization are needed
to verify this.
Acknowledgements and sources of financing: This work was supported by a grant from
the Danish Centre for Environmental Health, Danish Ministry of the Interior and Health.
The Danish National Research Foundation established the Danish Epidemiology Science
Centre that initiated and created the Danish National Birth Cohort. The cohort is furthermore a result of a major grant from this Foundation. Additional support for the Danish
National Birth Cohort is obtained from the Pharmacy Foundation, the Egmont Foundation,
the March of Dimes Birth Defects Foundation, and the Agustinus Foundation. Thanks to
Duy Ahn Dang and Karsten Henning Sørensen for technical assistance
Conflicts of interest: None
Q FEVER DURING PREGNANCY AS A CAUSE OF STILLBIRTH
Xavier Carcopino (1), Didier Raoult (2), Florence Bretelle (1), Léon Boubli(1), Andreas Stein (2)
1. Service de Gynécologie Obstétrique, Hôpital Nord, Chemin des Bourrely, 13915 Cedex
20, Marseille, France
2. Unité des Rickettsies, Unité Mixte de Recherche 6020, Université de la Méditerranée.
Faculté de Médecine, 27 Boulevard Jean Moulin, 13385 Marseille Cedex 5, France
Corresponding author : Xavier Carcopino, MD
Introduction: Q fever is a zoonosis caused by Coxiella burnetii. During pregnancy it may
result in obstetrical complications such as spontaneous abortion, stillbirth, intrauterine
growth retardation (IUGR) and premature delivery.
Objectives: To evaluate the risk of stillbirth in pregnant women with Q fever, the role of
placentitis defined as the presence of Coxiella burnetii on placenta and the efficacy of
long-term co-trimoxazole therapy.
Methods: We included 53 pregnant women diagnosed with Q fever. We compared incidence
of stillbirth for women who did (16) vs. did not (37) receive long-term co-trimoxazole treatment, defined as oral administration of trimethoprim-sulfamethoxazole during at least 5
weeks of pregnancy. Incidence of other obstetrical complications and of placentitis was
also compared.
Results: Stillbirth occurred in 10 (27%) pregnant women who did not receive receive long-term
co-trimoxazole therapy. In that group, overall obstetrical complications were observed in 81.1%
of pregnant women, with 5 (13.5%) spontaneous abortions, 10 (27%) IUGR, 4 (10.8%) oligoamnios
and 10 (27%) premature deliveries. The outcome of the pregnancy was found to depend on placentitis (p=0.013). Long-term co-trimoxazole treatment protected against placentitis (p=0.038) and
obstetrical complications (p=0.009), especially stillbirth (p=0.018), with no case observed among
patients who were given that therapy. All cases of stillbirth were observed in the pregnancies in
which placentitis was identified, while none was observed in the pregnancies whose fetus was alive
at delivery (p=0.008).
Conclusion: Q fever during pregnancy can result in severe obstetrical complications such
as stillbirth which is related to placentitis. Because of its ability to protect against placentitis, and stillbirth, long-term co-trimoxazole treatment should be used to treat women
with Q fever while pregnant.
Acknowledgements and sources of financing: None.
Conflicts of interest: All authors have no conflicts of interest.
75
A PROSPECTIVE EVALUATION OF STILLBIRTH LOOKING AT
CAUSES OF DEATH
Fabio Facchinetti (1), Sabrina Cozzolino (2), Valentina Vaccaro (1), Francesca Ferrari (1),
Francesco Rivasi (3), Patrizio Antonazzo (4), Giancarlo Gargano (5), Elisa Pozzi (2), Manuela Bellafronte (1), Patrizia Vergani (2), Irene Cetin (4), Dante Baronciani (6).
1 Mother-Infant Dept., Unit of Obstetrics, Univ. of Modena and Reggio Emilia, Italy
2 Dept. of Obstetrics and Gynaecology, Univ. of Milano-Bicocca, Monza, Italy
3 Dept. of Pathology and Legal Medicine, Univ. of Modena and Reggio Emilia, Italy
4 Unit of Obstetrics & Gynecology, “L. Sacco” Hosp., Univ. of Milan, Italy
5 Mother-Infant Dept., Unit of Neonatology, Univ. of Modena and Reggio Emilia, Italy
6 CeVEAS, Modena, Italy
Introduction: Few efforts have been dedicated until now to Stillbirth (SB) understanding..
Objectives: Within a comprehensive program, this study was aimed at describing SB phenomenon, looking at causes of death.
Methods: In a prospective design, every SB of >22 weeks of pregnancy (or >500 g if gestational
age was not available), occurring in a 24 months period, was included. Every centre adopted
the same work-up protocol including “ad hoc” clinical description, neonatal examination, cytogenetics, placental histology, fetal autopsy, feto-placental cultures. Data were audited in a
multidisciplinary team and cases classified according to both Wigglesworth (and Aderdeen,
W+A) and ReCoDe (RCD) systems.
Results: One-hundred and eleven cases were included. 26.1% were at term (≥37 weeks), 39.6%
were preterm (between 37 and 29 weeks), 34.2% were early preterm (<28 weeks). Intrapartum
SB seldom occurred (4.5%). Lethal malformations were detected in 6.3% of cases as well as
infections, whereas other specific causes (hydrops, twin-to-twin transfusion, …) were detected
in 13.5 %. Catastrophic placenta abruption occurred in 6.3%. The rate of small for gestational
age was 18.0%. According to W+A, 35.1% of the cases remain unexplained whereas with RCD
they were reduced to 28.8%, mainly due to death attribution to growth restriction. On the other
hand, W+A included preeclampsia as cause of death. The limit of both classifications is to consider clinical circumstances as causes of death whereas fetal demise occurring in a growth
restricted fetus or in a preeclamptic mother is just a risk condition frequently associated to
lack/suboptimal antenatal care.
Conclusions: Both clinical circumstances and exhaustive work-up are necessary to explain SB.
Actual classification do not take into account such concept. A major proportion of deaths remain
unexplained, further demonstrating the need of bio-clinical research in this field.
MATERNAL PERCEPTION OF REDUCED FETAL MOVEMENTS
FOR DETECTION OF THE FETUS AT RISK: THE AUSTRALIAN
EXPERIENCE OF THE INTERNATIONAL FEMINA
COLLABORATION.
Flenady V1, Frøen F2, MacPhail J1, Gilshenan K1, Mahomed K3, Gardener G1, Chadha Y4, Gray P1,
Fretts R5. Femina (Fetal Movements Intervention and Assessment) Collaboration.
1
Mater Mothers’ Research Centre, Mater Mothers’ Hospital Brisbane, Australia; 2Norwegian
Institute of Public Health, Oslo, Norway; 3Department of Obstetrics, Ipswich Hospital, Ipswich,
and Mater Mothers’ Research Centre, Brisbane, Australia; 4Royal Brisbane and Women’s Hospital, Brisbane, Australia; 5Harvard Medical School, Boston, USA.
Correspondence: vicki.fl[email protected].
Background: Maternal perception of decreased fetal movements (DFM) has been shown to
identify pregnancies at increased risk of stillbirth.
Methods: A prospective cohort study and a nested case control study was undertaken including
women > 28 weeks with a singleton pregnancy in 6 maternity hospitals. Outcome measures included: antenatal investigations and follow up care for women with DFM; Fetal Growth Restriction (FGR)
(customized birthweight <10th and <3rd centile); preterm birth; admission to neonatal intensive
care; emergency caesarean section; stillbirth and neonatal deaths.
Results: Over the study period of March 2006 to May 2008, 1371 women with DFM were identified (range 4 to 7% of all births across the hospitals). Of these 161 (11.7%) were investigated
with an ultrasound scan ranging from 4% to 25% and 139 (13%) had FGR at birth. 30% of women
wait more than 48hours from first noticing DFM to notifying a health care provider. Case control
study results including 800 women will be presented.
76
Conclusions: Maternal perception of RFM may be associated with an increased risk of FGR.
Further exploration of this association using data from a large well designed case control study
will be presented. The wide variation in the rate of ultrasound scans at the time of presentation
with RFM may reflect the lack of evidence to guide the management of women with RFM.
POTENTIALLY PREVENTABLE STILLBIRTHS IN AUSTRALASIA; A
SYSTEMATIC REVIEW OF THE LITERATURE
Flenady V1, Koopmans L1, Middleton P2, Dodd J2, Brown J3, Fretts R4, Frøen F5, Smith G6.
1
Mater Mothers’ Research Centre, Mater Mothers’ Hospital, South Brisbane, Australia; 2ARCH:
Australian Research Centre for Health and Wellbeing for Women and Babies, Department of
Obstetrics and Gynaecology, University of Adelaide, South Australia; 3Stillbirth Foundation;
4
Harvard Medical School, Harvard Vanguard Medial Associates, USA; 5Norwegian Institute of
Public Health, Oslo, Norway; 6 Department of Obstetrics, University of Cambridge, UK. International Stillbirth Alliance and the Australian and New Zealand Stillbirth Alliance. www.stillbirthalliance.org; www.stillbirthalliance.org/anz
Introduction: In Australia the stillbirth rate is 7.5/1000 births (≥ 20 weeks gestation), accounting
for 70% of all perinatal deaths and of which approximately 25% remains unexplained. Since the
1980’s this stillbirth rate has not seen any improvements. Indigenous women from the Australasian region have between 2-3 times the stillbirth rates of non-Indigenous populations; a stillbirth rate that is very similar to other developing countries in the world.
Objective: The identification of potentially preventable risk factors of stillbirth related to maternal lifestyle factors.
Methods: A systematic review using Medline, Embase, OVID and the Cochrane Library (19982008) to identify case control and cohort studies. We also hand-searched bibliographies of
retrieved articles and other literature (i.e. conference abstracts, official websites, university
theses). An English language restriction was imposed.
Results: We identified 23 studies within Australasia which fulfilled our inclusion criteria. Another
445 studies were identified in the international literature. Commonly reported potentially preventable risk factors of stillbirth were maternal age over 35, obesity and smoking. The stillbirth
risk in rural/remote communities was increased compared to urban counterparts. Other risk
factors included: fetal growth restriction; women reporting reduced fetal movements during the
pregnancy; and previous caesarean section. Post-term pregnancy is also a well documented risk
factor for stillbirth. In Papua New Guinea (neighbouring Australia) syphilis and malaria make a
significant contribution to stillbirth. Prevalence and the population attributable risk for stillbirth
for these factors will be presented.
Conclusions: Reduction in the stillbirth rate may be possible by focussing on potentially avoidable risk factors. With maternal smoking rates up to 70% for Indigenous women and with other
behavioural risks known to be associated with smoking (e.g. alcohol/ drugs), this is an area
where gains could be made. Further, as a substantial proportion of our indigenous populations live in rural/remote areas, where the risk of stillbirth is increased, there is a need to
improve access to appropriate care if improvements are to be seen. With Australia now being
the “fattest” country in the world, “twin epidemics” of obesity and diabetes are likely to make
an increasing contribution to the static and possibly increasing stillbirth rates. Some stillbirths
associated with fetal growth restriction may be preventable through early detection and appropriate management. This may also apply to women with decreased fetal movements. The
burden of stillbirth in developing country settings can be reduced by simple inexpensive treatments and interventions.
Acknowledgements: Funded by the Stillbirth Foundation and the Department of Health and
Ageing Canberra, Australia
77
POLICY INTO PRACTICE: SKILLS TRAINING USING THE
SCORPIO METHOD TO IMPLEMENT CLINICAL PRACTICE
GUIDELINES FOR PERINATAL MORTALITY AUDIT IN AUSTRALIA AND NEW ZEALAND
Jeffery HE1, Arbuckle S2, Gordon A3, Flenady V4, Hill DA5, Hirst J6, Morris J7, Richardson R8.
1,3. Neonatologist, University of Sydney & Royal Prince Alfred Hospital, Sydney 2. Paediatric pathologist, Childrens Hospital, Sydney 4.Epidemiologist, University of Queensland,,
Mater Mothers’ Hospital, Brisbane. 5. Medical Education Consultant, Sydney 6,7. Obstetrician, University of Sydney and Royal North Shore Hospital. 8. Midwife counsellor, SIDS and
KIDS, NSW. (on behalf of the Australia and New Zealand Stillbirth Alliance).
Introduction: The Perinatal Society of Australia and New Zealand has, over five years,
refined clinical practice guidelines (CPG’s) for perinatal mortality audit1. These have been
accepted widely and incorporated into policy. However, evidence from a National audit indicate poor uptake2 and hospitals use a selective approach rather than recommended
core investigations 3.
Objectives: i) To translate the CPG’s into an evidence based teaching method addressing
core skills ii) To pilot and evaluate the SCORPIO teaching method amongst a wide range of
experienced stakeholders for suitability for National implementation.
Methods: A SCORPIO workshop using small group, interactive, multi professional skills training techniques was chosen as evidence indicates that moderate to large changes in clinician behaviour are associated with such a method 4,5. SCORPIO is an acronym referring to
a teaching method which is Structured, Clinical, Objective-Referenced, Problem-orientated,
Integrated and Organised 6. SCORPIO is based on a study guide, rotating teaching stations and
formative assessment. Six, 25 minute teaching stations addressing key recommendations in
the CPG’s were 1.Communication with families regarding autopsy 2. Placental and post mortem examination 3. Investigation of perinatal deaths 4. Examination of babies who die in the
perinatal period 5. Perinatal mortality classifications 6. Psychological and social aspects of
perinatal bereavement. The teachers and participants were multi-professional and the latter
included senior members from Government, hospital and non government organisations.
Results: The SCORPIO program was completed by 32 participants and evaluated by 27
(84%). On a 5 point Likert scale from poor to excellent, participants completed an anonymous questionnaire. Overall rating, 93% rated the day as “very good” or “excellent”, 7%
rated the day as “average”. Participants indicated on a pre / post teaching questionnaire
marked improvement in confidence, practice and recognition of perinatal mortality audit.
Conclusion: This pilot program to implement best evidence CPG’s and educational practice received positive evaluation by senior stakeholders and suggests funding for National
implementation is justified. This should result in optimal parental counselling, targeted
prevention and improved health outcomes in the area of perinatal mortality...
References: 1. http://www.materresearch.org/psanzpmg/guideline.html 2. Flenady V et
al for the Perinatal Society Australia and New Zealand 10th Congress, Proceedings, 2007
3. Headley E, Gordon A, Jeffery HE Perinatal Society Australia and New Zealand 12th Congress, Proceedinga, 2008 4. Thompson O’Brien et al Cochrane database systematic reviews 2002. 5. Jeffery HE, Kocova M, Tozija etal Medical Education 2004;38(4):435-47.
6 Hill DA Medical Teacher 1997:19:24-28
CLASSIFICATION OF INTRAUTERINE FETAL DEATH (IUFD)
IN THE OSLO AREA 1990-2003
Linda Björk Helgadóttir (1), Finn Egil Skjeldestad (3), Anne Flem Jacobsen (1), Gitta Turowski (2), Borghild Roald (2), Frederik Frøen (4), Per Morten Sandset (5), Eva-Marie Jacobsen (5).
1. Dep. of Obstetrics, Ullevål University Hospital, Oslo, Norway
2. Dep. of Pathology, Ullevål University Hospital, Oslo, Norway
3. Dep. of Epidemiology, SINTEF, Trondheim, Norway
4. Div. of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
5. Dep. of Haematology, Ullevål University Hospital, Oslo, Norway
Introduction: Few studies report epidemiology of stillbirth in Norway. Several international
reports have shown that risk factors differ by etiology. It is therefore necessary to investigate risk
78
factors according to the cause of death. Different definitions of stillbirth, different routines in investigating and different methods of classifying stillbirths have made it difficult to compare results on issues
related to stillbirth across studies. An international group of investigators has developed a practical
and thorough classification system for perinatal deaths – Causes of Death and Associated Conditions
(CODAC). CODAC is designed to retain information on the main cause of death as well as two associated conditions. International use would ease the comparison of incidence, causes and risk factors for
stillbirth.
Objectives: To investigate the incidence of stillbirth and to classify cause of death.
Methods: Retrospective study of women diagnosed with IUFD, according to the WHO criteria, from
January 1st 1990 through December 31st 2003, at the 2 largest delivery wards in the Oslo-area. The
women were identified from the Norwegian Patient Register by selected ICD-9/ICD-10 codes. Information in medical records was transferred to a standardized case-report-form. Available placental
tissue was reviewed with focus on maturation, ischemia, vascular pathology and inflammation. Primary causes of foetal death and up to two associated conditions were assigned according to CODAC.
Results: We will present data on the incidence of IUFD in the Oslo-area, Norway, and causes
of death according to the CODAC classification system.
Acknowledgements and sources of financing: Scientific scholarship from Ullevål University
Hospital (VIRUUS).
Conflicts of interest: None.
NEONTAL OUTCOMES AFTER PLANNED HOME BIRTHS IN
NORWAY 1990-2007
Ellen Blix (1), Anette S. Huitfeldt (2) and Pål Øian (3)
1. Department of Gynaecology and Obstetrics, Hammerfest Hospital, Norway
2. Rikshospitalet Midwifery Unit, Rikshospitalet University Hospital, Oslo, Norway
3. Department of Gynaecology and Obstetrics. Northern Norway University Hospital, Tromsø, Norway
Introduction: Outcomes after planned home births have not been systematically evaluated in Norway.
Women seeking information about home births from midwives and general practitioners are often
given advises biased with the personal opinion of the caregiver instead of objective information.
Objectives: To evaluate neonatal outcomes after planned home births in Norway.
Methods: Data from 1592 planned home births between 1990-2007, assisted by 16 midwives, were
retrospectively analysed.
Results: Totally 145 women (9 %) were transferred to hospital during labour. In six cases, the reason
for transfer was suspected or manifest fetal distress. Two infants were delivered by caesarean section
(CS), the others had spontaneous vaginal deliveries. One was born during transport to the hospital.
One born vaginally in hospital was transferred to Neonatal Intensive Care Unit (NICU) because of
meconium aspiration. None of the six infants needed any kind of rescusitation after birth, and all of
them were discharged and in normal condition one week after birth. Of the 139 transfers of other
reasons than fetal distress, seven infants were transferred to NICU. One woman was transferred
because the fetal heart could not be ausculted upon the arrival of the midwife. The infant was stillborn
in hospital. Twenty-two infants born at home were transferred to hospital during the first five days
after birth. Seven because of hypoxemia during birth, five because of congenital malformations, three
because suspected infection, four because of jaundice and four for other reasons. Of the seven infants
with hypoxemia, two had five minutes Apgar score of 6, the others had 7 or more. All seven were
discharged within one week after birth. In 47 cases, the woman gave birth before the arrival of the
midwife. All were multiparas, and there were no neonatal complications. Six infants with undetected
breech presentation were delivered at home because there was not time for transfer, all six were
uncomplicated. Among the 1592 planned home deliveries, there were one case of perinatal death and
one case of neonatal death.
Conclusion: Among women planning home, 1.6 % was transferred to hospital for fetal or neonatal
indications. Neonatal outcomes among those transferred and born at home were good.
Sources of financing: Finmark Health Trust supported the study financially.
79
TIME TRENDS IN RISK OF RECURRENT STILLBIRTH:
GESTATIONAL AGE AND BIRTH WEIGHT MATTERS
Kari Klungsøyr Melve (1,2), Rolv Skjærven (1,2), Lorentz M Irgens (1,2), Svein Rasmussen (1,2)
1. The Medical Birth Registry of Norway / the National Institute of Public Health, Norway
2. Department of Public Health and Primary Health Care / University of Bergen, Norway
Address of corresponding author:
Background / methods: Women with a stillbirth in their first pregnancy have an increased risk
of stillbirth in their second pregnancy compared to women with a first live birth. Studies report
different recurrence risks, however, partly due to differences in classification. In the present
study we classified stillbirths by their gestational age and birth weight. We studied recurrence
risk and time trends using data from the population based Medical Birth Registry of Norway
from 1967 to 2004. Births were linked to their mothers by the unique national identification
numbers. We analysed 650,573 first and second singleton births with gestational ages from 16
weeks. Time trends were studied by grouping year of first birth into three 11-year categories.
Results: We found a significant increased risk of a second stillbirth among women whose first
infant was stillborn relative women whose first infant was live born (odds ratio (OR) 5.8 (95% CI
5.2; 6.5)). In spite of a significant decrease in overall stillbirth rate over time, the overall recurrence risk did not decrease (not shown). However, recurrence risks depended on the gestational
age of the stillbirth, with highest risks of repeating a stillbirth in the same gestational age group
as the first stillbirth (Table).
Table: Risk (OR with 95% CI) of stillbirth in second pregnancy for women with a first stillbirth
relative women with a first live birth, by gestational age categories.
Second sib: Gestational age categories (completed weeks)
First sib:
Gest age
categories
16-21
22-27
28-32
33-36
37+
16-21
20.4
23.2
3.3
1.4
0
(13.4; 30.8) (15.2; 35.4) (0.8; 13.2) (0.2; 10.3)
22-27
9.8
(5.9;16.3)
18.9
6.6
2.1
(12.9; 27.8) (2.9; 14.9) (0.5; 8.3)
28-32
1.7
(0.4; 6.9)
5.4
(2.4; 12.2)
8.8
5.5
4.1
(3.9; 20.0) (2.0; 14.8) (1.7; 10.0)
33-36
2.4
(0.8; 7.4)
0.8
(0.1; 5.8)
4.1
12.7
0.8
(1.3; 12.8) (6.7; 24.0) (0.1; 5.5)
37+
1.2
(0.5; 3.3)
1.3
(0.5;3.6)
1.1
(0.3; 4.5)
4.1
(2.0; 8.2)
3.1
(1.3; 7.5)
2.2
(1.03;4.6)
Similar results were found when grouping the stillborn infants by birth weight categories.
Time trend analysis showed that risk of recurrence of a similar aged stillbirth was high and
remained high over the time period for very preterm stillbirths (<33 weeks), whereas risk of
repeating a stillbirth in the two highest gestational age groups (34+ weeks) was significantly
increased only in the first time period of the study.
Conclusion: Mothers with a fetal loss in their first pregnancy are at higher risk of repeating this outcome in their second pregnancy compared to mothers with a live first born. The
highest risk is found for repeating a stillbirth with a similar gestational age or birth weight
group as the first loss. Over time, the risk of repeating a preterm stillbirth has not decreased,
whereas women who had a first stillbirth at term no longer are at increased risk of repeating
this outcome compared to women with a first live born.
Acknowledgements: None
80
DOES LJUNGAN VIRUS CAUSE MALFORMATION, INTRAUTERINE FETAL DEATH AND SUDDEN INFANT DEATH SYNDROME?
Bo Niklasson (1), Annika Samsioe (2), Petra Råsten Almqvist (3), Nikos Papadogiannakis
(4) and William Klitz (5)
Department of Medical Cell Biology, Uppsala University, Box 571, SE-751 23
Uppsala and Apodemus AB, Grevgatan 38, SE-114 53 Stockholm, Sweden
Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Section of Internal Medicine. SE-118 83 Stockholm, Sweden
National Board of Forensic Medicine in Stockholm, 171 65 Solna, Sweden
Department of pathology, Karolinska University Hospital, Huddinge,
SE-141 86 Stockholm, Sweden
School of Public Health, University of California, 50 University Hall, Berkeley, CA 947207360 and Public Health Institute, Oakland, CA 94607-4046, USA
Objective: The Ljungan virus (LV), a member of the Parecho virus genus, and Picornaviridae family, was originally isolated from its wild reservoir, the bank vole (Myodes glareolus),
at the Ljungan River in central Sweden. Ljungan virus is associated with diseases such as
myocarditis, encephalitis, pregnancy-related diseases and diabetes in several species of
wild rodents. The same outcomes can be induced in CD-1 mice under controlled laboratory conditions. The present study investigates whether malformation, intrauterine fetal
deaths (IUFD) and sudden infant death syndrome (SIDS) in humans may have Ljungan
virus as a common zoonotic etiology.
Methods. Formalin fixed tissues from IUFD, SIDS and hydrocephalus cases were investigated using LV specific immunohistochemistry (IHC). Tissues from elective abortions due
to Trisomia 21 were used as controls. Frozen specimens were analyzed for presence of LV
specific RNA using a real time RT PCR.
Results: Ljungan virus was detected by IHC in the majority of IUFD (7/16), SIDS (6/8) and
hydrocephalus (9/10) cases while only 1 of 18 Trisomia 21 control cases investigated by
immunohistochemistry. The IHC results have been confirmed by RT PCR.
Conclusions: The available evidence points to a widespread role for Ljungan virus in a variety
of perinatal conditions. This newly identified agent may prove to be a major explanatory factor in a number or reproductive outcomes, each with currently unsolved etiologies.
CHORIONIC SURFACE VESSELS AS MIDGESTATIONAL
INFLUENCES ON TERM BIRTH WEIGHT: IMPLICATIONS FOR
UNDERSTANDING THE TIME COURSE TO STILLBIRTH.
Carolyn M Salafia (1,2), Jenny Lie (3), Adam Oberman, (3), Danielle H Mandel (1), John M
Thorp (4), MD, Barbara Eucker (4)
Placental Analytics, LLC, New York, USA
Institute for Basic Research, New York, USA
Department of Mathematics, Simon Fraser University, Canada
Department of Obstetrics and Gynecology, North Carolina, USA
Correspondence: carolyn.salafi[email protected]
Introduction: The placenta is the prime determiner, genetics aside, of fetal growth and birth
weight (BW). Its chorionic vasculature (CV), readily visible on the chorionic plate, is a high
capacitance low resistance transport system that is (1) laid down early in pregnancy and (2)
may affect placental transport efficiency. Its complex branched structure has not to date
been quantified.
Objective: We propose a metric for CV and demonstrate its predictive value for birth weight
(BW) in a pilot sample.
Methods: 25 digital images of tha placental chorionic plate collected from an archival birth
cohort were selected. The CV was manually traced on a digital tablet; mean CV distances from each pixel on the chorionic plate to the nearest chorionic vessel was calculated
and normalized to the plate diameter. Correlations were tested among normalized mean
chorionic vascular distance (NMCVD), and BW, placental weight (PW) and gestational age
(GA).
81
Results: Mean CV distance was 5.7+1.7mm (range 3.4-10.1mm). Mean NMCVD was 0.029
+0.008 mm (range 0.0162-0.0482 mm). Mean BW, PW and GA were 3327+113 g (range 30603497g), 280+7 d (range 266-292d), and 516+28 g (range 471-570g). NMCVD was correlated with
BW (r=0.512, r2 =0.25, p=0.015) but was uncorrelated with either PW (p=0.52) or GA (p=0.11). BW
was uncorrelated with GA (p=0.13) and PW (p=0.69).
Conclusions: We present a novel metric reflecting the extent of chorionic vascular “coverage”
that accounts for 25% of BW variance independent of GA and PW. This previously unmeasured
aspect of placental structure appears to be important to placental function and fetal growth,
and may clarify the sequence of events that culminate in late stillbirth that, at least in some
cases, have been initiated long before fetal death.
Acknowledgments and financing: K23
MITACS.
MH067857-NIMH,
Placental
Analytics,
LLC,
Conflicts of Interest: None
VARIATIONS IN PLACENTAL SHAPE MAY TIME
GESTATIONAL EVENTS KEY TO LATE STILLBIRTH
Michael Yampolsky (1), Carolyn M Salafia (2, 3), Oleksandr Shlakter (1), Danielle H Mandel (2),
John Thorp (4), Barbara Eucker (4)
1. Department of Mathematics, University of Toronto, Canada
2. Placental Analytics, LLC, New York, USA
3. Institute for Basic Research, New York, USA
4. Department of Obstetrics and Gynecology, North Carolina, USA
Correspondence: carolyn.salafi[email protected]
Introduction: Placental shape is generally round-oval, but “irregular” shapes are common and
have been associated with lower birth weight (BW) for placental weight (PW).
Objectives: We tested an empiric model for generation of placental shapes based on Diffusion
Limited Aggregation (an accepted model for generating highly branched fractals), and tested
whether variably shaped placentas have altered function.
Methods: (I) A DLA model was run with the branching density parameter fixed, or perturbed at
0.5%, 5-7% or 50% of model growth. (II) In a modern birth cohort with 1207 detailed measures
of placental perimeters, radial standard deviations (RSD) were calculated from the perimeter
to the umbilical cord (UC) insertion and from the shape centroid (a biologically arbitrary point).
Spearman’s rank correlation compared these to the difference between the calculated scaling
exponent (based on BW and PW) and the Kleiber scaling exponent (0.75, considered optimal for
vascular fractal transport systems).
Results: (I) Fixed growth parameter values created round-oval fractals. Perturbations at 0.5%,
5-7% and 50% of model growth created bilobate, multilobate and “star-shaped” fractals, respectively. (II) The RSD of the perimeter from the UC (but not from the centroid) was correlated
with differences from the Kleiber exponent (p=0.006).
Conclusion: Dynamical DLA models recapitulate clinically common abnormal placental shapes
via altered fractal branching. We suggest that (1) irregular placental shapes reflect deformation
of placental fractal vascular networks, (2) such irregularities indicate sub-optimal branching
structure of the vascular tree, and (3) this accounts for the lower BW observed in non-round/
oval placentas. The differences in timing the create these different placental shapes may help
understand the pathologic sequence that may underlie late stillbirth.
Acknowledgments and financing: K23 MH067857-NIMH, Placental Analytics, LLC, MITACS.
Conflicts of Interest: None
82
ORAL Developing Countries
STILL-BIRTHS- CAUSES, TREATMENT SEEKING
PRACTICES AND RELIABILITY OF ROUTINE HEALTH
SYSTEM IN STILL BIRTH REGISTRATION - SOME LESSONS
FROM NORTH INDIA
Rajesh Kumar (1), Arun K Aggarwal (1), Parveen Kumar (2)
Affiliations
1. School of Public Health, PGIMER, Chandigarh
2. Department of Pediatrics, PGIMER, Chandigarh
Introduction: Reliability of routine data for still births and community based information on
causes of still-births and associated factors is not known. Objectives: a) To determine the reliability of routine health system in reporting still-births, b) to determine the causes of still-births
and associated treatment seeking practices.
Methods: Complete house to house survey was conducted in 1,31,866 population in four blocks
of Himachal Pradesh in India to record the number of live births and still births. Total of 48 subcentres were covered that was 20% of the total sub-centres in these blocks. Still births identified
during the survey were investigated using semi-structured verbal autopsy tools to determine
the probable medical causes of death and associated factors that had influenced the treatment
seeking behaviour. Reliability of still birth registration was determined by comparing the results
of our sample survey with the state health service reports.
Results: Under reporting for still births by the state health services was 44%. In 34.2% cases
travel time to reach a hospital from their home was more than 2 hours. In 71% cases consultation
was availed at home by calling the traditional birth attendants. Only in 14 cases (45.2%) condition of the women was considered serious by the health service providers. Prolonged labour and
antepartum haemorrhage were the major underlying causes of still births (21% each).
Conclusions: There is gross underreporting of still-births by the routine health system. Delay
in consultation at the appropriate level is the most important barrier contributing to still births.
Community awareness about possible maternal complications and appropriate place of management, and skill building of health personnel for prompt management of maternal complications are required.
Acknowledgements: The study was funded by UNFPA, Himachal Pradesh.
1) Conflict of interest: None
INSTITUTIONALIZING MATERNAL AND PERINATAL
DEATH REVIEW SYSTEM IN NEPAL
Sharma S. Kumar and Suvedi B. Krishna
Department of Health Services
Family Health Division
Teku, Kathmandu, Nepal
Introduction: Maternal and neonatal mortality is very high in Nepal; it is therefore a challenge to achieve Millennium Development Goals. As majority of the deaths occur in the community, it is difficult to capture them for intervention before death. It is also not clear why a
large number of women and perinates are dying even after reaching to the hospital. To address these issues, maternal and perinatal death review system is implemented in Nepal.
Objective: To discuss the types and causes of perinatal deaths and to describe the program implication and quality of the review system.
Methods: Perinatal death review forms, manuals and guidelines were developed and orientation was given to 12 hospitals in 2006. Seven out of 12 hospitals provide the form
regularly. Analysis is based on the 221 perinatal death review forms received at the Family
Health Division from five hospitals.
83
Results: Out of the 221 perinatal deaths, 67% were stillbirths and about 35% of the stillbirths
were fresh. Sixty-two percents of the perinatal death were reported from illiterate women.
One-third of the women were from Terai origin followed by Brahmin/Kshetri, Tharu and minority groups. Majority of the deaths occurred within 24 hours of admission. Severe asphyxia,
congenital anomalies, prematurity and septicaemia were the major causes of death.
Conclusion: The result indicates that the illiterate, poor and marginalized groups are suffering from the problem of perinatal death. Majority of the perinatal deaths occur within 24 hours
of admission due to asphyxia, prematurity and congenital anomaly, this further indicates that
there is some delay in the community to bring the women in the hospital and after arrival, they
are also not receiving quality service. Use of partograph with proper foetal heart monitoring,
quality delivery care and initiation of perinatal death review immediately after death will help to
identify avoidable factors and to take corrective action to reduce the facility perinatal death.
Acknowledgements: We thank WHO for technical and financial support and Mechi, Bheri,
Koshi, Lumbini and Seti Zonal hospital for providing us the perinatal death review forms
STILLBIRTHS IN RURAL INDIA: RATES, DETERMINANTS
AND IMPLICATIONS FOR MATERNAL AND NEWBORN
HEALTH INTERVENTIONS
Vishwajeet Kumar1, 4,7, Rajendra P. Misra1,7, Vivek Singh1,7, Aarti Kumar1,7, Ramesh C. Ahuja2,7,
Abdullah H. Baqui4,7, Saroj K. Mohanty1,7, JV Singh1,3,7, Shally Awasthi1,2,7, Gyanendra K. Malik1,2,7
, Sujit Verma1,7, Lovy Shukla5,8, Jason F. Solus6,8, Akanksha Rastogi1,7, Prashant K. Sharma1,7,
Robert E. Black3,8, Mathuram Santosham3,8 and Gary L. Darmstadt3,8 * for Saksham Study Group
1
KGMC Institute of Clinical Epidemiology, King George Medical University (CSMMU), Lucknow, India
2
Department of Paediatrics, King George Medical University (CSMMU), Lucknow, India
3
Department of Social and Preventive Medicine, King George Medical University (CSMMU), Lucknow, India
4
International Center for Advancing Neonatal Health (ICANH), Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore,
MD, USA
5
George Washington University School of Medicine, Washington DC, USA
6
Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
7
India
8
USA
* Currently works for the Bill and Melinda Gates Foundation, USA
Introduction: Despite being one of the most common adverse outcomes of pregnancy, stillbirths remain under-reported, under-studied and programmatically under-addressed.
Objectives: Ascertain stillbirths and establish stillbirth rates (SBR) using two different
data collection methods. Determine community risk factors and underlying socio-culturalgender constructs.
Methods: The study was conducted in Shivgarh (population – 104,123), rural India as part of
a cluster randomized controlled trial evaluating the impact of community-based essential
newborn care (ENC) on neonatal mortality rate (NMR). At baseline, the entire population
was enumerated; NMR and SBR were assessed retrospectively based on a truncated pregnancy history. Demographic Surveillance System prospectively followed-up pregnancies
for outcome. All neonatal deaths and stillbirths were administered verbal (including social)
autopsies (n= 315). An endline survey was conducted to document household practices
regarding maternal care and ENC (n = 3400). Qualitative data on stillbirths was collected
through a combination of in-depth interviews (n=21) and focus group discussions (n=6).
Results: At baseline, SBR and NMR was 27.2/1000 births and 54.2/1000 live births,
respectively. Prospectively, the SBR and NMR was 54.1 and 84.2, respectively. Difference
in SBR between the two methods was 8.9 – 44.7 (95% CI). Qualitative reasons for stillbirth
under-reporting included socio-cultural perception and notion of shame, pain and blame of
mothers. Key risk factors associated with stillbirths included, lack of TT vaccination (OR=0.35
95% CI: 0.38-1.09), problems (e.g., ) and complications during pregnancy (e.g., ) (OR=3.58,
95% CI: 2.35-5.47) and (OR=5.36, 95% CI: 3.83-7.52), respectively, delayed maternal careseeking (OR=3.69, 95% CI: 2.55-5.33), delivery at health facility (ö 2 =19.29, p=0.00), delivery attended by unqualified medical practitioners (ö 2 =20.51, p=0.00), induction of delivery
(OR=1.73, 95% CI: 1.10-2.71) and low standard of living index (ö 2 =8.90, p=0.01). 85.1% of
84
stillbirths were fresh and 7.1% were reported with congenital malformation. Social autopsy
revealed delayed and inappropriate care-seeking as pervasive. Qualitative research found
that unlike neonatal deaths, the community closely associated stillbirths with maternal care
and actions during the antenatal period, particularly antenatal care and care-seeking.
Conclusion: Retrospective ascertainment substantially undercounted stillbirths compared
to prospective follow-up of pregnancies. Stillbirths, more so than neonatal health, provide
a strategic locus for mobilizing community action for the mother and integrating maternal
and newborn health.
Acknowledgements and Sources of Financing: USAID-India and Washington, DC; Save
the Children-US through a grant from the Bill & Melinda Gates Foundation.
Conflict of Interest: None
A COMMUNITY SURVEY ON AWARENESS, BELIEFS AND
SOCIO-CULTURAL IMPLICATIONS OF STILLBIRTH AMONG
NIGERIAN WOMEN
Imran O. Morhason-Bello1©, Babatunde O. Adedokun2, Adesina Oladokun1, Christopher O.
Aimakhu 1, Obehi O. Enabor1, Arafat A. Ifemeje1, Oladosu A. Ojengbede1
1. Department of Obstetrics & Gynaecology, University College Hospital, Ibadan, Oyo state
NIGERIA.
2. Department of Epidemiology, Medical Statistics, and Environmental Health, College of
Medicine, Ibadan, Oyo state, NIGERIA.
© - Corresponding Author –
Telephone: 2348034784402
Introduction: Despite Nigeria’s significant contribution to the global perinatal mortality,
little research has been conducted locally to unravel peculiarities of awareness on causal
factors, community beliefs and the implications of delivering a stillbirth. This information
may provide clues to formulating holistic preventive strategies.
Objective: To determine the awareness and socio-cultural perceptions towards stillbirth
among married women.
Methods: A community survey of 187 consenting women was performed at Mokola in Ibadan, Nigeria in 2008. Respondents were selected using cluster sampling technique. Interviewer administered questionnaires were used to obtain information on sociodemographics, causes and opinions concerning stillbirth.
Results: The mean age was 39.6±13.3years. They were mostly traders (70%), married
(89%) and had monogamous marriage (73%). The median parity was 3. A quarter knew
someone with stillbirth. About 4.3% reported ever having a still birth. About 62% knew that
stillbirths could be prevented. The cause of stillbirth was correctly identified by 58.9%. The
causes mentioned included maternal illness (11.2%), prolonged labour (9.1%), poor health
care utilization (7.0%), destiny (5.9%), witchcraft/other evils (5.3%), poor nutrition (3.7%),
stress (2.7%), medical illness in wife or husband (1.6%) while others constituted 10.7%.
About 43% were not aware of any causes. On logistic regression, tribe was significantly
related to knowledge of cause of stillbirth. Women of local Yoruba ethnic group were 2.4
times more likely to know the correct cause of stillbirth compared to others (95% CI=1.06 –
5.41). The commonest sociocultural belief was to label the woman a “witch” (36.9%).
Conclusion: Although, the proportion of women with stillbirth is low, however, 1 in 4 knew
someone. It is worrisome that over 40% do not know the correct cause. Stillbirth is associated with sociocultural beliefs that could threaten harmonious matrimony. Correct
information should be shared to minimise these misconceptions.
Acknowledgements and sources of financing: None
85
PATTERN AND CORRELATES OF VIABLE STILLBIRTHS IN
LAGOS, NIGERIA
BOLAJOKO O. OLUSANYA (1), Olumuyiwa A. Solanke (2)
1. Maternal and Child Health Unit, Institute of Child Health and Primary Care, College of
Medicine, University of Lagos, Lagos, Nigeria
2. Lagos Island Maternity Hospital, Lagos, Nigeria
Introduction: Nigeria is a leading contributor to the global burden of stillbirths but limited
data exists on the proportion and correlates of viable (foetal weight ≥2,500g) stillbirths.
Objectives: To determine the rates, pattern and correlates of stillbirths in an inner-city
maternity hospital in Lagos, Nigeria.
Methods: Stillbirth rates were derived from hospital records for the 3 year period January
2005 to December 2007. About one third of all documented stillbirths were analysed to
determine factors that correlated with viability based on adjusted odds ratio (aOR) at 95%
confidence interval (CI) using multiple logistic regression.
Results: Of the total 7,216 deliveries, there were 1,056 stillbirths yielding a stillbirth rate
of 146.3 per 1,000. Overall, 774 (73.3%) stillbirths were viable, 483 (45.7%) were macerated and only 9 (0.9%) were identified with congenital anomalies. Of the 356 cases for
which complete data were available for this study, majority of the mothers were unbooked
(90.4%), had no antenatal care (87.6%) and 36.8% were delivered by emergency caesarean
section. The most common adverse perinatal conditions were spontaneous premature
labour (33.4%), prolonged obstructed labour necessitating emergency caesarean section (30.3%), ante-partum haemorrhage (23.9%) and pre-eclampsia/eclampsia (23.8 %).
Mothers with viable stillbirths were more likely to have attended antenatal care (aOR:3.46,
CI:1.45-8.27), had prolonged obstructed labour (aOR:3.18, CI:1.84-5.50) and cephalopelvic disproportion (aOR:4.72, CI:2.41-21.04). However, they were less likely to have premature rupture of membranes (aOR:0.23, CI:0.09-0.57) or spontaneous premature labour
(aOR:0.04, CI:0.01-0.37).
Conclusion: While the uptake of antenatal care was generally poor, most factors associated with the unacceptably high proportion of viable stillbirths in this population are preventable and can be effectively managed with improved maternal education and obstetric
care.
Conflicts of interest: None declared
VALIDATION OF PERINATAL CARE INDICATORS
Robert Pattinson*, Stuart Whittaker**
* MRC Maternal and Infant Health Care Strategies research Unit, Dept. O&G University of
Pretoria, RSA
**COHSASA, Cape Town, RSA
Introduction: Very few of the perinatal care indicators have been validated by independent
means of assessing quality of care.
Objective: To validate perinatal care indicators by an independent means of assessing the
quality of care
Methods: The Council for Health Service Accreditation of Southern Africa (COHSASA) is an nongovernmental organisation that scores hospitals on their quality of care for accreditation purposes
and is recognised by the International Society for Quality in Health Care. The Perinatal Problem
Identification Programme (PPIP) is an audit system aimed at improving the quality of care. Health
institutions audit every perinatal death and enter each death and the monthly births in weight categories in the programme. The programme calculates various perinatal care indices to measure the
quality of care over time. Approximately 150 hospitals have been accredited by COHSASA in South
Africa and PPIP is used by 180 hospitals. There is an overlap if 70 hospitals. The COHSASA score
for overall performance of the hospital and that of the maternity section was compared with the
PPIP perinatal care indicators, namely perinatal mortality rate (PNMR); neonatal deaths (NNDR)
between 1-2 kg; the perinatal care index (PNMR/Low birth weight rate); and the fresh stillbirths and
early neonatal deaths >2500g/births rate (a proposed measure of the quality of intrapartum care)
86
were correlated. The 70 hospitals were divided into those that did not receive referrals from outside
their sub-district and those that received referrals from outside their sub-districts.
Results: For the hospitals that did not receive referrals from outside their sub-districts, there
was a negative significant correlation between the COHSASA scores overall and PNMR (r= 0.527, p<0.000), NNDR (1-2kg) (r=-0.421, p=.0.01) perinatal care index (r= 0.610, p=0.000) but not
with the intrapartum care indicator. This was true also for the COHSASA maternity scores. There
was no correlation with the hospitals receiving referrals from outside their sub-districts.
Conclusion: The PNMR, NNDR (1-2kg) and the perinatal care index can be used as a measure of quality of perinatal care.
Finances: MRC South Africa and COHSASA, South Africa
Conflict of interest: None
PRIVATE/PAID VERSUS PUBLIC/STATE SPONSORED
MATERNITY CARE:
DIFFERENCES IN CARE AND IN BIRTH OUTCOME.
Sreevidya Subramoney1,2 and Prakash C Gupta2
Affiliations:
Doctoral student, Sahlgrenska Akademin, Goteborg University, Sweden
Healis Sekhsaria Institute for Public Health, Navi Mumbai, India.
Background: Appropriate antenatal care and care during labor is expected to decrease
developing country stillbirth rates. A striking reduction in rates between free and paid care
has been observed in Latin America.
Objective: A stillbirth rate of 41/1000 births was observed in our cohort of pregnant women; we investigated if paid care resulted in better stillbirth rates in this cohort.
Methods: 1084 lower and middle class women were selected from our sample of 1217 women,
after excluding home deliveries, twin pregnancies and women with incomplete data. Women delivering in govt. and private settings were compared using univariate and multivariate analyses.
Results: Of 1084 women 22.6% accessed lower-cost paid care (PCW) (defined as costing <=5000Indian Rupees), 14.6% paid care higher grade (PCHG) (>5000Rs) and 62.8% free care (FCW) for their delivery. 31% and 49% of lower and middle-income women used private sector for delivery care respectively. PCHG were better educated (p<0.000), and nourished (p<0.02), had highest no: of sono-graphies
(p<0.000), and antenatal visits (p<0.000), and were least likely to use smokeless tobacco (p<0.001).
PCW were more likely to be primipara (p<0.000), have severe anemia (9.7% vs 4.5% p<0.02), start
antenatal care late (in the second trimester or later) (p<0.002), and less likely to be employed (3% vs
8 and 9%). All three groups had similar stillbirth rates (4.1, 3.8, 3.8%, p=0.98), and gestational age at
delivery. Mean birthweight of FCW births was 160 and 232g less than PCW and PCHG respectively.
Provider type was not a significant predictor for stillbirth in forward LR but was a significant predictor
of cesarean section rates (2.2%, 32.1% and 12.2% respectively p<0.000).
Conclusions: Higher cost care results in higher use of medical technology and interventions, but not in improved birth outcomes. Improving the quality of antenatal care across
all sectors of health care is thus of great importance.
Acknowledgements and sources of financing: We thank the BrihanMumbai Municipal
Corporation for facilitating this study and WHO SEARO for financing it.
87
STILLBIRTHS IN SUB-SAHARAN AFRICA: FINDINGS FROM
CAMEROON SURVEY
A. Elisabeth Sommerfelt (1), Holley Stewart (2), Doyin Oluwole (1), Magdalene Serpa (1),
Reena Borwankar (1).
(1) Academy for Educational Development (AED), Washington, DC, USA (2) Population Reference Bureau, Washington, DC, USA
Correspondence: [email protected], [email protected]
Introduction: Maternal health care influences stillbirth rates. Formulation of questions to
elicit stillbirth information may influence responses.
Objectives: Examine stillbirth reporting patterns by women according to background
characteristics.
Methods: The women’s questionnaire of the Cameroon 2004 DHS—a nationally representative household survey—included questions on total number of live births, total number of
stillbirths, and delivery care for live births in the past 5 years. Stillbirth results are for ~7500
women who ever had a live birth/stillbirth; delivery care results are for ~8000 live births.
Results: Overall 5% reported 1+ stillbirths. Predictably, fewer younger women than older
women reported a stillbirth, increasing monotonically from 2% for ages 15-19 to 8% for
ages 45-49 (p<0.01). Considering total number of pregnancies ending in live birth or stillbirth each woman experienced, the picture changed: 15.5 of 1000 pregnancies ended in
stillbirth; differences by age were not statistically significant. The rate was highest for rural
women with some education (20.8/1000), lowest for urban women with some education
(12.4/1000), and intermediate for rural women with no education (13.6/1000) and urban
women with no education (16.9/1000). The differences between the highest and lowest
were statistically significant (p<0.01). Facility delivery ranged from 14% (rural women without education) through 47% (urban women without education) and 61% (rural women with
education) to 88% (urban women with education).
Conclusion: Under-reporting of stillbirths seems most marked for rural women without
education. Research on stillbirth, including formulation of simple questions to elicit accurate information in household surveys, is needed. Equitable access to improved girl’s
education, quality maternal care, and family planning services are required to reduce stillbirth rates.
Acknowledgement and source of funding: USAID via DHS and Africa 2010.
FETAL OUTCOME IN SEVERE MATERNAL MORBIDITY: TOO
MANY STILLBIRTHS
Mamady Cham 1*, Johanne Sundby 1, Siri Vangen 2
1. University of Oslo, Norway
2. Rikshospitalet Medical Centre, Oslo, Norway
Introduction: The contribution of severe obstetric complications on stillbirths in Gambian
hospitals, where access to emergency obstetric care is widely not available, was evaluated.
Objective: To determined the stillbirth rates among singleton births with contribution of
health service factors given special attention.
Methods: A multi-center retrospective study involving three obstetric referral hospitals
was implemented. All women with severe maternal morbidity between January and June
2006 were identified and reviewed. In each case information about fetal outcome and the
mother’s age, parity, obstetric complications and delivery mode was abstracted from maternity records.
Results: We found excessively high stillbirth rates with an eight-fold increased risk in
women with severe obstetric complications (310 per 1000 births) compared to women
without such complications (51/1000 births). Hemorrhage, anemia, sepsis and hypertensive pregnancy disorders were associated with the highest stillbirth rate. Dystocia cases
had a relatively lower stillbirth rate. Mode of delivery was an important determinant of
88
stillbirths. In women with severe obstetric complication vaginal delivery carried a fourfold
increased risk of stillbirth compared to newborns delivered by cesarean section in women
with complication (Odd ratio 4.40 95% CI 2.99 – 6.48).
Conclusion: Severe maternal morbidity has significant impact on stillbirth rates. Better
access to emergency obstetric care and improved intrapartum care will significantly reduce stillbirth rates in poor settings of the world such as The Gambia.
Acknowledgements and source of funding: We thank the women and research assistants
who made it possible. This project was funded by the Institute of General Practice and
Community Medicine University of Oslo.
WHY BABIES DIE A PERINATAL CARE A UGANDAN
COHORT STUDY
Waiswa M1 , Ruth Nakadama1 , Patrick .K.K2, Muwanga M2,
1The African child care Alliance Development, 2Bahai international Medical Centre,
Department of obstetrics and Gynecology. P.o.Box 2270, kampala Uganda.
Objectives:To identify the major causes of perinatal mortality in both public and private
hospitals in kampala, Uganda.
Methods:Users of the perinatal problem identification programme (PPlP) amalgamated
their data to provide descriptive information on the causes of perinatal deaths and the
avoidable factors, missed opportunities and standard care in kampala Uganda.
Results: A total of 5,085 perinatal deaths among babies weighting 1,000g or more were reported from 210,716 births at the PPlP user sites. The perinatal mortality rates of the city,
town and rural groupings were 36.2,38.6 and 26.7/1,000 birth respectively. The neonatal
death rate was highest in the city and town group (14.5/1,000 live birth) followed by the rural areas (11.3) and 10.0/1,000 live birth respectively). The low birth weight rate was highest
in the rural areas (19.6%) followed by the city and town group (16.5%) and the rural group
(13.0%). The most primary caues of perinatal death in the rural group was intrapartum
asphyxia and birth trauma rate (6.92/1,000 births) followed by the spontaneous preterm
delivery (5.37/1,000 births). The most common primary causes of death in the city and town
group was spontaneous preterm delivery (6.79/1,000 births) followed by intrapartum asphyxia and birth trauma (6.21/1,000 births) and antepartum haemorrhage (5.7/1,000biths).
The city groups most common primary causes were antepatum haemorrhage (7.14/1,000
births) comlications of hypertension in pregnancy (5.0/1,000 births) and spontaneous preterm labour (4.01/1,000 births). Unexplained intrauterine deaths were the most common
recorded primary obstetric cause of death in all areas. Complicationa of prematurity and
hypoxia were the most common final causes of neonatal death in all groups.
Conclusion: Intrapartum asphyxia, birth trauma, antepartum haemorrhage, complications
of hypertension in pregnancy and spontaneous preterm labour account for more than 80%
of the primary obsteric causes of death.
89
ORAL Bereavement
DEVELOPMENT OF AN INTERVENTION TO PROMOTE COPING
OF GRIEVING FATHERS
Anna Liisa Aho¹ & Marja-Terttu Tarkka² & Päivi Åstedt-Kurki³ & Marja Kaunonen³
¹MNSc, Doctoral-student, RN, University of Tampere, Department of Nursing Science, SIDS Finland
²PhD, RN, University of Tampere, Department of Nursing Science
³PhD, RN, University of Tampere, Department of Nursing Science/ Pirkanmaa Hospital District,
Science Center
Introduction: Systematic development of interventions is essential to interpretation of effects in
developing the components of the intervention. Promotion evidence-based nursing requires the
development of interventions as well as evaluation of their effectiveness in natural environment.
Intervention development for grieving fathers has several unique characteristics such as low mortality rates and sensitivity.
Objectives: The purpose of this presentation is to describe the development of an intervention
to promote coping of grieving fathers.
Methods: The intervention was developed by using the action research method.
Results: Intervention development started by diagnosing a problem area and
developing a plan of intervention and action which included base line study about
fathers’ grief and social support after death of a child. In addition a systematic
review previous research about fathers’ grief and results of previous intervention
research studies and other intervention frameworks was implemented. Evidence was also searched
from the current support methods used in Finnish hospitals. During the development process an
intensive collaboration with healthcare professionals and peer-supporters was implemented.
Conclusion: Synthesis of clinical and scientific knowledge with understanding of the participant perspective fosters a comprehensive approach to intervention development.
SUPPORT GROUPS – WHAT ROLE DO THEY HAVE IN
SUPPORTING BEREAVED PARENTS?
Liz Davis
Organisational / country affiliation
Sands Queensland Australia
Introduction: There is often discussion surrounding the role that support groups may play in the
grief journey of bereaved parents. The phenomena of support groups have really taken affect
over the past thirty years. But does this model of care suit all bereave parents? Do bereaved
parents even know what style of care they need when newly bereaved?
As the needs of bereaved parents change over time, support groups need to be able to adjust to
the changing needs of parents and to meet their needs.
Emerging needs have to be anticipated and catered for.
The way support is delivered has changed with the advent of the internet and email.
Is there a place for parent centred care or do all parents need care that is delivered by professionals?
Conclusion: This abstract seeks to ascertain the different models of care available in the community; what needs parents may have and whether the needs of bereaved parents are addressed
fully by any of the models of care.
90
DO COUPLES STAY TOGETHER AFTER A BABY DIES?
MARRIAGE AND COHABITION OUTCOMES AFTER
MISCARRIAGE AND STILLBIRTH
Katherine J. Gold (1,2), Ananda Sen (1,3), and Rodney A. Hayward (4,5)
1. Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
2. Department of Obstetrics and Gynecology, University of Michigan,
Ann Arbor, MI, USA
3. Department of Statistics, University of Michigan, Ann Arbor, MI, USA
4. Department of Internal Medicine, Department of Health and Health Policy,
and Robert Wood Johnson Clinical Scholars Program, University of
Michigan, Ann Arbor, MI, USA
5. United States Office of Veteran Affairs, Health Services Research and
Development Center of Excellence, Ann Arbor, MI, USA
Introduction: The death of a child is a devastating event which places significant stress on parental relationships. Most of the research on marriage outcomes has focused on parents who
lose infants and older children, but far more parents experience miscarriage and fetal death.
Although men and women experience and express grief in different ways, it is not known
whether parents bereaved by pregnancy loss are at higher risk of separation and divorce.
Objective: To evaluate risk of separation or divorce for married and cohabitating parents who
have experienced miscarriage or stillbirth compared to parents with a live birth.
Methods: This was a retrospective analysis of the National Survey of Family Growth (NSFG) which is a population-based sample of men and women in
the United States surveyed on family life and reproductive health. The analysis
identified the maternal marital relationship present at the time of a birth and used survival
analysis to measure time to relationship end as the censoring event. The study controlled for
known risk factors for marriage and cohabitation dissolution, including maternal age, race,
absence of children at the start of the relationship, lower income, lower education, and lack of
religious affiliation and also controlled for time in the relationship prior to a birth.
Results: Of the 13,795 pregnancies included in the NSFG, 7770 were eligible for inclusion,
including 6409 (82%) live births, 1225 (16%) miscarriages, and 136 stillbirths (2%). Relationships which endured pregnancy loss were significantly more likely to dissolve, with the majority
of this effect seen within the first 3 years after loss. These differences persisted through a 16
year analysis period. Risk was highest for couples with stillbirth and intermediate for couples
with miscarriage.
Conclusion: Miscarriage and stillbirth both were associated with a higher probability of failed
marriage or cohabitation, with couples experiencing stillbirth at highest risk. These differences could be due to the stress of the pregnancy loss on the couple or could be related to
unmeasured variables which confer risk for both pregnancy loss and for relationship dissolution. This is the first large study to report on the association between pregnancy loss and
relationship outcomes, and the information may help providers to identify vulnerable couples
and provide additional support, resources, or assistance after a loss.
Acknowledgements and sources of financing: The National Institutes of Health Office of
Women’s Health provided partial salary support for Dr. Gold.
PROVIDING PEER SUPPORT
Sue Hale; Erica Stewart
Sands, UK
Sands, like many other charities, carries out a large proportion of its support work through local
groups of which there are 80 spread across the UK. This enables us to reach many more parents
than we could through head office alone and also allows parents to share with other parents,
helping them not to feel so isolated. Each group has a large degree of autonomy with their own
bank account, responsibility for fundraising and a committee who decide the activities of the
group.
91
A challenge we face is to ensure that these groups are properly supported, feel part of the
charity as a whole and have a good understanding of the widening agenda of Sands. This
presentation will explore the ways that we seek to achieve this through the Sands group
constitution, group handbook and networking of groups.
Within the group there are individuals who take the role of befriender, or peer supporter. They
will take the initial call from bereaved parents, offer telephone support, facilitate group support meetings and sometimes offer one to one support. They are not counsellors but bereaved
parents or other family members who have been through Sands befriender training. Anyone
looking to come on the training programme must be at least 1 year since their bereavement, be
a member of Sands and be part of a local Sands group. Our initial training programme, which
is very interactive, takes place over 2 days. It is an opportunity for both the participant and the
facilitator to decide if they feel ready to begin befriending. There is a further 3rd day which befrienders are asked to attend after a period of about 12 months.
This presentation will give an outline of the befriender training programme and also look at the way
Sands addresses any concerns they may have with a potential befriender.
“PARENTAL REFLECTIONS UPON THE LOSS OF THEIR
HEALTHY FIRST BORN CHILD DUE TO GRAVE MISCONDUCT
BY HEALTH PRACTITIONERS DURING LABOUR”.
Ingunn Meyer Knutsen and Karl Marius S. Norschau, Arendal, Norway
This presentation is in memory of Sam, our son who was born on the 26th of April this year
at a hospital in the southern part of Norway. Sam died after four days due to a fatal hospital
mistake. Our aim is to present a parental view on the whole experience of induced labor
that went so horribly wrong. At this moment this case is being investigated at The National
Board of Health in Oslo.
The subjects we wish to cover are as following:
• The need for information around the physical and psychological effects induced labor
may have on the female body.
• The importance of professional and human empathy.
• The reassurance through continuous contact with gynecologist.
• The experience of being a victim of poor cross disciplinary communication among
health professionals.
• The underlying feelings of experiencing how medical intervention can fail.
• A brief view on how successful follow up treatment can be after stillbirth. This includes
our work in creating a beautiful garden named “Sam’s garden”.
Our presentation is based on personal experience. The decisions we made regarding induced
labor was based solely on the advice from health professionals. In retrospect the advice and
treatment received can be questioned over and over again.
However, constructive dialogs with family and health professionals involved have been
helpful in our recovery. To prevent this from happening to other families we find it important to share our story.
DEMETRA PROJECT. PSYCHOPATOLOGICAL IMPACT OF
PERINATAL DEATH IN ITALIAN FAMILIES.
Claudia Ravaldi (1), Francesco Lapi (1,2), Dianora Torrini (1,2), Leonardo Rimediotti (1,2),
Claudia Vanni (2), Giorgio Mello (1,2), Vania Valoriani (1,2), Alfredo Vannacci (1,2)
1. CiaoLapo charity organization for grief support after perinatal death, Prato, Italy www.
ciaolapo.eu
2. Florence University, Careggi General Hospital, Florence, Italy
Introduction: Actions taken after perinatal death can affect long-term psychological wellbeing of mothers and fathers. To date, little is known on the effect of good clinical practice when
assisting parents in hospital after perinatal death and subsequent psychological disorders.
92
Objectives: Our objective was to study how neonatal and maternal cares after perinatal
death are associated with grief and psychopathological symptoms in both parents.
Methods: Mothers and fathers after perinatal death will be recruited by means of a specific call on the website www.ciaolapo.it. Women whose children died in Careggi General
Hospital, Florence, in the last 3 years will also be recruited by telephone calls. Each subject (the mother and her partner) will be evaluated by means of the following psychometric
tests: Symptom Check List 90 (SCL90), Impact of Event Scale (IES), Davidson Trauma Scale
(DTS), Perinatal Grief Scale (PGS), Short Form 36 (SF36) and Interpersonal Reactivity Index
(IRI). Sociodemografic and anamnestic data (included a specific interview on hospital care)
will be collected by means of an interview specifically developed and validated by us: The
Memory Box Interview. Each subject will be evaluated every 3 months for the first year, every
6 months for the second year and after 36 months.
Results: We will describe characteristics and methods of the study, as well as preliminary
results.
Acknowledgements and sources of financing: CiaoLapo Onlus
Conflicts of interest: none
WOMEN WISH TO TALK ABOUT THEIR FETAL LOSS
Rayamajhi Karki, Anjana (1, 2), Basnyat Bina (1, 2), Shrestha Prativa (2)
1.
2.
Department of Obs/Gyn, Kathmandu University School of Medical Sciences, Dhulikhel,
Nepal
Department of Obs/Gyn, B&B Kathmandu University Teaching Hospital, Gwarko, Lalitpur,
Nepal
Introduction. In Nepal, fetal deaths are very silent issues regarded as best forgotten.
There are no rites and rituals of burial or mourning for a dead fetus in most of the Nepalese cultures. Even tertiary care centers, are not offering professional psychological help
routinely.
Objective. To find out whether women wish to talk about their fetal loss.
Method. In depth interview was conducted with 52 women who experienced third trimester fetal loss during the past six months. These women came for postnatal check-ups,
other reproductive health and gynecological check-ups. The interview was conducted by a
trained counselor covering different aspects of their emotional reactions to fetal loss.
Results. 52 consented for the interview. For 48 this was the first time that someone had
enquired them about their feelings. They felt they were informed very late and inadequately
about the fetal death. Forty women neither saw the dead fetus nor were never asked whether
they wished to see it. Both the health care providers and family members were reluctant to
sit and talk to them about the cause of fetal death with the woman herself. Majority felt that
they could not share their grief even with their partners. All 48 women felt that they underwent significant psychological stress after the delivery but were never offered professional
help. Majority of these women had cried alone in silence while trying to overcome the grief.
Of these52, 16 knew friends and relatives who had suffered similar fetal loss but they never
approached them to talk about their loss. All were very scared of planning their next pregnancy and had not discussed with their partners yet.
Conclusions. Many women would like to speak about their loss despite our culture of silence.
These women undergo a lot of emotional stress and many seem to require professional help.
The medical team needs to adopt a woman friendly approach while providing care to these
unfortunate women.
Acknowledgement: B& B Katmandu University Teaching Hospital, Gwarko, Lalitpur ,Nepal who funded this study.
93
UNDERSTANDING PREGNANCY LOSS IN TAIWAN
Hui-Lin Sun (1, 2), Marlene Sinclair (2), W George Kernohan (2), Hilary Patterson (3) and Te-Hsin
Chang (4)
1. Mackay Medicine, Nursing and Management College, Taipei, Taiwan
2. Institute of Nursing Research, University of Ulster, N.I., UK
3. Ulster Hospital, N.I., UK
4. Nursing Department, Mackay Memorial Hospital, Taipei, Taiwan
Introduction: The experience of pregnancy following a previous pregnancy loss can be difficult and psychologically challenging. Over 34,000 women experience pregnancy loss in Taiwan every year. Objectives: This
paper reports an action research project that mapped the journey of Taiwanese women who have suffered
previous pregnancy loss.
Methods: The methodology was participative and cyclical. Ethical approval was obtained from University of
Ulster and the medical center in Taiwan. Women were invited to participant in the study and bereavement support was available for all participants. Initially, interviews were used with six Asian women living in Taiwan to
elicit their perspectives on their journey. The second phase was the translation of the SANDS information pack
from English to Mandarin. The third phase was interviewed the reference mothers and health providers evaluated the value and acceptability of information pack. Results: The data of the first stage from six women was
analyzed. A metaphor of “sailing against the tide” emerged from the data to depict three stages of the journey
from grief to joy. The second phase involved translation and adaptation of the SANDS pack into mandarin with
the support and advice of the expert reference groups including women, midwives, nurses, a social worker,
and doctors. The analysis indicated an overall acceptance of the support pack with cultural modified required.
There included removal of information about autopsy, clear indication that the majority of cases of the caused
death is unknown, providing footprints of deceased baby as mementoes and more funeral information.
Conclusion: The findings have been used to draft a theoretical cameo of the journey and provide
challenging insight into the needs of mothers. The information pack will be revised based on the
culture difference and will support other women in similar circumstances. Perinatal bereavement care with cultural sensitivity has potential in an Asian context.
Acknowledgements: Thank the mothers and health providers whose commitment and generosity
in sharing their stories and opinions made the research possible.
MEETING THE NEEDS OF GRIEVING FAMILIES AFTER
PERINATAL DEATH IN SLOVENIA
Vislava Globevnik Velikonja
Department of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
Introduction: In Slovenia the old ways of dealing with perinatal death by ignoring the loss, coexist with newer ways, which include keeping mementos, creating memories, naming and talking
about the baby. In the last 10 years over 1500 families encountered perinatal death.
Objective: Our aim was to present some milestones regarding humanization of the management of
perinatal death in Slovenia, and some procedures applied in different phases of mourning.
Methods: The assistance of professionals to the grieving family should be provided at multiple
levels, aiming at reaching two main target groups: the grieving family by providing direct counselling and support in the hospital and in the community, and those assisting the bereaved by
providing training and support.
Results: In 1997 we organized the first educational training for professionals in order to learn more about
the feelings and experiences of grieving families, to understand their own feelings, and to develop counselling skills. With the support of the Ljubljana municipality, we created the first of the five memorial
parks named Snowdrop Garden in 2000. In 2002 the Association of Grieving Parents was established, and
the book “An Empty Cot, A Broken Heart” dealing with the mourning process and the rights of babies and
their parents after perinatal death was published.
Conclusions: A death changes the dynamics in the family creating new roles, and undermining
the accepted behaviour patterns. Different ways of mourning may create conflicts and misunderstandings. Family therapy is a frequent method of working with the bereaved, since grief
affects everyone in the family: each parent as an individual, both parents in their relationship,
siblings and grandparents.
Sources of financing: Much work has been done by enthusiasts, financial support for individual
projects has been provided by the local community; we, the promoters of the process, have paid
every attention to avoid conflicts of interests.
94
ORAL Perinatal
VENEPUNKSJON VERSUS HÆLSTIKK VED BLODPRØVETAKING HOS NYFØDTE
Andreas Andreassen (1), Jan Magnus Aase (2), Dag Moster (2), Tore Wentzel-Larsen (3)
1. Kvinne-/Barnklinikken, Haugesund Sjukehus, Haugesund
2. Barneklinikken, Haukeland Universitetssykehus, Bergen
3. Kompetansesenter for klinisk forskning, Haukeland Universitetssykehus, Bergen
Korrespondanse: [email protected]
Introduksjon: Ved blodprøvetaking foretrekkes venepunksjon fremfor hælstikk ved flere nyfødtavdelinger. Det er imidlertid lite data om barnets smerteopplevelse ved disse metodene.
Studiene er små og vanskelig overførbare til daglig klinisk virksomhet.
Mål: Formålet var å undersøke om venepunksjon er mer smertefullt enn hælstikk og om
venepunksjon øker risiko for gjentatt stikk eller komplikasjoner.
Metode: Prospektiv og blindet studie der 140 friske nyfødte som skulle ta Føllings prøve ble
randomisert til hælstikk eller venepunksjon. Alle barna fikk smertelindring med 1 ml sukkervann før stikking. To observatører skåret smerterespons etter ”Premature Infant Pain
Profile” (PIPP) på bakgrunn av videoopptak der stikkeprosedyren var blindet. Foreldre ble
oppringt etter en uke for å registrere komplikasjoner.
Resultater: Av 140 barn som inngikk i studien ble 73 randomisert til venepunksjon og 67 til
hælstikk. Totalt 96 barn fikk PIPP-skåre 0-5,5 (ingen/liten smerte), 43 fikk 6-12 (moderat
smerte) og 1 barn > 12 (sterk smerte). Det var ikke statistisk signifikant forskjell i gjennomsnittlig PIPP-skåre ved venepunksjon eller hælstikk (4,42 vs 4,94, p=0,37). Signifikant
flere barn behøvde gjentatt stikk ved venepunksjon enn ved hælstikk (48 % vs 30 %, p =
0,04). Behov for gjentatt stikk ved venepunksjon avtok muligens med økt trening (43 % i
siste halvpart av perioden vs 53 % i første halvpart, p=0,48). Det var flere komplikasjoner ved
venepunksjon enn ved hælstikk både ett døgn etter prøvetaking (15 % vs 1,5 %, p=0,005) og
en uke etter (8 % vs 0, p=0,03). Komplikasjonene var bagatellmessige (hematom, rubor) og
ikke behandlingskrevende.
Konklusjon: Følling prøve er forbundet med liten eller ingen smerte hos et flertall av friske
nyfødte barn. Studien gir ikke holdepunkt for at venepunksjon er mer smertefullt for nyfødte
enn hælstikk, men flere trenger gjentatt stikk. Det er ingen behandlingskrevende komplikasjoner.
Acknowledgements: Personalet ved Nyfødtavdelingen, Haugesund Sjukehus
Mats Eriksson, Svensk Barnsmärtförening
Finansiell støtte: Regionalt Kompetansesenter for Klinisk Forskning, Helse Vest.
Ingen interessekonflikter.
ANTIANGIOGENE FAKTORER OG BLODTRYKKSØKNING I
NORMOTENSIVE SVANGERSKAP
Staff AC1, Harsem N1, Brække K2, Hyer M3, Hoover R4, Troisi R5
1. Kvinneklinikken, Ullevål Universitetssykehus, Oslo
2. Barneklinikken, Ullevål Universitetssykehus
3. Information Management Services, Rockville
4. Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, USA
5. Department of Community and Family Medicine, Dartmouth Medical School, Hanover, USA
Bakgrunn. Angiogene faktorer har to viktige funksjoner:
1) bidrar til dannelse av kar; ved placentering, og ved sykdomsprosesser som kreft/metastaser.
2) bidrar til opprettholdelse av normal endotel-funksjon.
Sirkulerende antiangiogene proteiner er viktig for utviklingen av preeklampsi. Konsentrasjonen
av “antiangiogene faktorer” sFlt1 (soluble fms-like tyrosine kinase receptor) og sEng (soluble
endoglin) er vanligvis lavere, og “proangiogen faktor” PlGF (placental growth factor) er vanligvis
høyere i ukompliserte svangerskap enn ved preeklampsi.
95
Mål: Er angiogene faktorer korrelert med blodtrykksøkning gjennom svangerskapet ved normotensive svangerskap?
Metode. Vi har tidligere publisert analyser av blod fra fastende gravide tatt før keisersnitt fra
ukompliserte (n= 43) og preeklampsisvangerskap (n= 44); serum undersøkt for PlGF, sFlt1 og
sEng. Nå gjorde vi videre statistiske analyser for å undersøke om blodtrykksendringer gjennom
svangerskapet var assosiert med maternell angiogen profil.
Resultater. I ukompliserte svangerskap hadde kvinnene med den største økningen i diastoliske og gjennomsnittsblodtrykk den mest antiangiogene profilen; dvs lavest (proangiogene PlGF og høyest (antiangiogen) sEng konsentrasjon og høyest (antiangiogen) sFlt1/PlGF ratio. Preeklampsigruppen hadde
generelt mye høyere nivåer av antiangiogene faktorer ved forløsning enn den normotensive gruppen. De
absolutte blodtrykksendringene var imidlertid ikke assosiert med forskjeller i antiangiogen profil innen
preeklampsigruppen.
Konklusjon. Angiogene faktorer er involvert i blodtrykksmodulering også i normotensive svangerskap. Epidemiologiske studier har vist lavere brystkreftrisiko hos kvinner som har hatt preeklampsi
og større blodtrykksøkningene fra andre til tredje trimester svangerskap er i normotensive svangerskap assosiert med lavere brystkreftrisiko. De biologiske mekanismene er ukjente, men kunne involvere en relativ antiangiogen profil.
Interessekonflikter: ingen
POSTPARTUM BLØDNING; PROFYLAKSE OG BEHANDLING I
NORGE I 2007
Engnæs ASF, Frydenlund K, Gjessing LK, Salvesen KÅ
Norges Teknisk Naturvitenskapelige universitet (NTNU) og Kvinneklinikken St. Olavs Hospital
Målsetting. Studere profylakse mot og behandling av postpartum blødning (PPB) ved norske
fødeinstitusjoner i 2007.
Materiale og metode. Et spørreskjema ble sendt til 56 norske fødeinstitusjoner våren 2007. Tre fødeinstitusjoner ble ekskludert, fordi de ikke hadde fødsler i 2007. Vi spurte om rutiner for profylakse
og behandling ved alvorlig PPB. Institusjonene ble delt inn i grupper på bakgrunn av vaktordning og
etter årlig antall fødsler. Av et årlig fødselstall på 58964 skjedde 69% ved 13 Kvinneklinikker (> 1500
fødsler), 25% ved 20 større sykehus (400-1500 fødsler), 5% ved 10 små sykehus (< 400 fødsler) og
1% ved 10 fødestuer.
Resultater. 72 % av norske fødeinstitusjoner brukte medikamentell profylakse mot PPB.
Små sykehus (< 400 fødsler årlig) brukte sjeldnest profylakse. Oksytocin ble oftest brukt. Som
medikamentell primærbehandling ble oksytocin og misoprostol mest brukt. Flere sykehus
bruker intravenøs behandling med 15-methyl-PGF-2 selv om slik praksis bryter med norsk
veileder i fødselshjelp fra 2006. B-lynch sutur var det mest brukte sekundærtiltaket uavhengig
av størrelse på fødeinstitusjonen. Intrauterin ballong ble brukt som førstevalg ved noen kvinneklinikker. Analyse av vaktordninger og sykehusstørrelse gav omtrent like resultater, men vi
påviste interessante forskjeller i vaktbelastning i forhold til sykehusenes fødselstall.
Fortolkning. Det anbefales bruk av blødningsprofylakse, og dette burde være spesielt viktig
ved fødeinstitusjoner med leger i hjemmevakt. Intrauterin ballong burde brukes av flere institusjoner, fordi inngrepet er lett å lære og gir raskt svar på om det hjelper. Vi foreslår følgende
rekkefølge ved sekundærbehandling av PPB som skyldes uterusatoni:
1.
Uterustamponade med ballong
2.
Kompresjonssuturer (B-lynch eller andre)
3.
Ligering av arterier
4.
Embolisering
5.
Peripartum hysterektomi
Det er fortsatt uklart på hvilket stadium Novoseven bør settes inn i behandlingskjeden.
Interessekonflikter: Ingen
96
FOREKOMST OG RISIKOFAKTORER FOR SFINKTERRUPTUR I
FORBINDELSE MED FØDSEL
Ragnhild Klokk (1), Toril Kolås (1), Trond Markestad (2)
1. Sykehuset Innlandet, Lillehammer, 2. Universitetet i Bergen, Bergen
Bakgrunn: Sfinkterruptur (grad 3 og 4) er en alvorlig komplikasjon ved vaginal fødsel. Norge
har relativt høy forekomst av sfinkterruptur og årsaksforhold er mangelfullt kartlagt.
Mål: Undersøke forekomst av sfinkterruptur ved Fødeavdelingen, Sykehuset innlandet, Lillehammer i tiden 01.01.90 – 31.12.2002 og sammenheng mellom forhold knyttet til svangerskap,
fødselen og den nyfødte og forekomst av ruptur.
Metoder: Kvinner med sfinkterruptur grad 3 og 4 er identifisert gjennom registrering av fødselen i
fødeprotokoll og partogram. Øvrige opplysninger er innhentet i etterkant ved gjennomgang av journaler og et spørreskjema kvinnen fikk tilsendt ett år etter fødsel. For å belyse risikofaktorer er hver
kvinne med ruptur matchet med den neste kvinnen med samme paritet som fødte uten ruptur.
Resultater: Forekomsten av sfinkterruptur økte fra 2,4 % i 1990 til 5,9 % i 2002. Dette til tross
for at andelen keisersnitt økte fra 9,1 % til 14,3 % i samme tidsrom. Høy alder hos mor, stort
barn, lang varighet av fødselen, lang utdrivningstid, amniotomi, episiotomi, stimulering av
fødselen, instrumentell forløsning, og fødsel på krakk eller i ryggleie, men ikke induksjon av
fødsel og fundustrykk, var forbundet med økt risiko for ruptur. I en logistisk regresjonsanalyse
med justering for alle signifikante enkeltfaktorer var det en signifikant økt relativ risiko for
følgende forhold (angitt som odds ratio med 95% konfidensintervall): Amiotomi 3,6 (2,3-5,6),
instrumentell forløsning 2,4 (1,6-3,7), fødselsvekt over gjennomsnittet 2,0 (1,5-2,7), mors alder
over gjennomsnittet 1,5 (1,1-2,0), stimulering av fødselen 1,5 (1,1-2,1) og episiotomi 1,4 (1,01,9).
Konklusjon: Forekomsten av alvorlig sfinkterruptur har økt i løpet av de siste 10 år. Økningen
kan ha sammenheng med økende alder hos de fødende og fødselsvekt, men har også sammenheng med en rekke intervensjoner under fødselen, spesielt øker amniotomi og instrumentell forløsning risikoen betydelig. Ingen interessekonflikter.
DIAGNOSIS OF CRITICAL CONGENITAL HEART DEFECTS
– THE EFFECT OF PULSE OXIMETRY SCREENING
Alf Meberg (1), Andreas Andreassen (2), Leif Brunvand (3), Trond Markestad (4), Dag Moster (5),
Lutz Nietsch (6), Inger Elisabeth Silberg (7), MD, Jan Einar Skålevik (8), Angelique Tiarks (9)
Departments of Paediatrics:
1. Vestfold Hospital, Tønsberg
2. Haugesund Hospital, Haugesund
3. Ullevål University Hospital, Oslo
4. Innlandet Hospital, Gjøvik
5. Haukeland University Hospital, Bergen
6. Ålesund Hospital, Ålesund
7. The National Hospital, Oslo
8. University Hospital of Northern Norway, Tromsø
9. Innherred Hospital, Levanger, Norway
Objective: To compare strategies with and without first-day of life pulse oximetry screening to
detect critical congenital heart defects (CCHDs) (ductus dependent, cyanotic).
Method: Population based study including all live born infants in Norway in 2005 and 2006 (n = 115
301). In half of the population postductal (foot) arterial oxygen saturation (SpO2) was measured in
apparently healthy newborns after transferral to the nursery, with SpO2 < 95% as cut-off point. Of 57
959 live births in the hospitals performing pulse oximetry screening, 50 008 (86%) were screened.
Results: A total of 136 CCHDs (1.2 per 1000) were diagnosed, 38 (28%) of these prenatally. Of the
CCHDs detected after birth, 44/50 (88%) CCHDs were detected before discharge in the population offered pulse oximetry screening, 25 by pulse oximetry. In the population not screened 37/48
(77%) CCHDs were detected before discharge (p = 0.15). Median time for diagnosing CCHDs in
hospital before discharge was 6 h (range 1-48 h) in the screened population, compared to 16 h
(range 1-120 h) in the population not screened (p < 0.0001). In the screened population 6/50 (12%)
CCHDs were missed and recognized after discharge because of symptoms. 2 of the 6 missed cases
failed the pulse oximetry screening, but were overlooked (echocardiography not performed before
discharge). If these cases had been recognized, 4/50 (8%) would have been missed compared to
97
11/48 (23%) in the non-screened population (p = 0.05). Of the cases missed, 14/17 (82%) had
left-sided obstructive lesions, and 14/17 (82%) were readmitted with circulatory collapse or
severe heart failure.
Conclusions: Diagnostic strategies which include first-day of life pulse oximetry screening
provides early in-hospital detection of CCHDs and may reduce the number overlooked and
diagnosed after discharge.
SIMULERING – EN UTFORDRING PÅ LINJE MED
VIRKELIGHETEN
Hilde Stuedahl Mohn (1), Anne Småland (1), Harald Dalen (1), Ragnhild Støen (1), Håkon
Trønnes (2) og Stine Gundrosen (3)
1. Nyfødt Intensiv, St. Olavs Hospital, Trondheim
2. Klinikk for Anestesi og Akuttmedisin, St. Olavs Hospital, Trondheim
3. Medisinsk Simulatorsenter. Det medisinske fakultet, NTNU, Trondheim
Introduksjon. Akutte, livstruende situasjoner er sjeldne men når de oppstår er vi avhengige
av at alle vet hva de skal gjøre, uavhengig om det skjer på fødestue eller intensivavdeling for
nyfødte. Barne- og Ungdomsklinikken ved St. Olavs Hospital ønsket å etablere et treningstilbud
i Medisinsk Simulatorsenter og vi beskriver her våre erfaringer med dette prosjektet.
Mål. Teamtrening i simulator gir mulighet for å opprettholde og øke kompetansen i det
felles arbeid med de minste pasientene.
Metode. En prosjektgruppe bestående av anestesilege, pediater og intensivsykepleier ble
opprettet for å drive kurset og denne gruppen fikk egen trening i simulering som pedagogisk verktøy. Kursdeltagerne skulle diagnostisere og behandle et akutt sykt terminbarn
med meconiumsaspirasjon. Deltagerne startet med en vaktrapport hvorpå de følgelig slapp
til rundt barnet som ble tiltagende dårlig respiratorisk. Scenarioet ble avsluttet med bag/
maskeventilasjon eller intubasjon og eventuelt thoraxdren avhengig av hvilke tiltak deltagerne satte i verk underveis. Debriefing, refleksjon rundt hendelsene i scenarioet, er sentralt i denne treningsformen. Det er en strukturert samtale umiddelbart etter scenarioet.
Sammen med instruktøren (facilitator) og ved hjelp av video-opptak fra treningen ble det
fokusert spesielt på positive episoder og egenskaper ved de ulike teamenes arbeid. Målet
var alltid at deltagerne skulle avslutte scenarioet med en følelse av mestring.
Resultater. Deltagerne fremhevet spesielt betydningen av tidlig avklaring av lederskap og
behov for økt tydelighet i forhold til egen kommunikasjon med kolleger. Simulatortrening
avdekket i flere tilfeller konkret kunnskapsbrist, prosedyrefeil og behov for rutineendinger.
Konklusjon. Prosjektet har vært vellykket. Erfaring og tilbakemelding fra deltagerne viser
at dette er et svært nyttig treningsverktøy, og det er spesielt samhandlingen i teamene
som blir fremhevet.
Ingen interessekonflikter
MÅLING AV HJERTEFUNKSJONEN HOS FRISKE
TERMINFØDTE MED STRAIN OG STRAIN RATE MED
VEVSDOPPLER FØRSTE TRE LEVEDØGN
Eirik Nestaas1,2, Asbjørn Støylen3,4, Leif Brunvand2, Drude Fugelseth2, 5
1 Barne- og Ungdomssenteret - Sykehuset i Vestfold HF
2 Barneklinikken – Ullevål Universitetssykehus HF
3 Hjertemedisinsk avdeling - St. Olavs Hospital HF
4 Institutt for sirkulasjon og bildediagnostikk – DMF – NTNU
5 Det Medisinsk Fakultet – UiO
Innledning: Med vevsdoppler kan hjertefunksjonen måles med parametrene strain og strain
rate. Strain og strain rate måles i segmenter av hjertemuskelen, som regel i lengderetningen.
Prosentvis endring av segmentlengde måles som strain. Strain rate er strain per tidsenhet. Vi
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ønsket å studere disse parametrene hos friske nyfødte til termin de første tre levedøgn.
Mål: Måle hjertefunksjonen i tidlig neonatal periode hos friske terminfødte med strain og strain rate.
Materiale og metode: Peak systolisk strain (PSS) og peak systolisk strain rate (PSSR) ble målt
første, andre og tredje levedag hos 48 friske terminfødte i 18 segmenter av hjertemuskelen.
Resultater: For hver undersøkelse var gjennomsnittlig PSS -21,8% (-22,1, -21,4) (gjennomsnitt (95% konfidensintervall) og PSSR -1,78/s (-1,81, -1,74). Alder (dager), føtale shunter,
hjertefrekvens og forkortningsfraksjon hadde liten eller ingen innvirkning på verdiene. Det
var signifikant variasjon mellom segmenter og mellom individer (p<0,05). Verdiene var lavere
(nærmere null) i opptak av lav enn av høy kvalitet (p<0,05). Både apikale og basale verdier var
mer uttalte i høyre vegg og lavere i septum enn i venstre vegg (p<0,05), med unntak av at det
ikke var forskjell for PSSR mellom venstre og høyre basale segmenter. Apikale verdier var høyere enn basale verdier i høyre ventrikkel (p<0,05), men ikke i septum eller venstre ventrikkel.
Konklusjon: Strain og strain rate kan måles hos nyfødte. Alder, føtale shunter, hjertefrekvens og forkortningsfraksjon hadde liten eller ingen innvirkning på verdiene. Målingene varierte signifikant mellom segmenter, individer og billedkvalitetskategorier. Strain
og strain rate er mer egnet til å påvise forskjeller mellom segmentgrupper og pasientgrupper enn mellom individer og segmenter innen enkeltindivider.
Acknowledgements og finansiell støtte: Helse Sør-Øst; Renée og Bredo Grimsgaasd´s
stiftelse; Weiby, Shreiner og Jervell fond.
Interessekonflikter: Ingen.
LOVE AT FIRST SIGHT - SMELL - TASTE – TOUCH:
POSSIBLE ALSO WITH CAESAREAN SECTION?
EVIDENCE FOR EFFECTS OF EARLY SKIN-TO-SKIN CONTACT
Gro Nylander
National Resource Centre for Breastfeeding
The Department of Obstetrics, Rikshospitalet University Hospital
Evidence points to an impact on physiology, psychology, subsequent behaviour and breastfeeding when a newborn infant is placed skin-to-skin (STS) with it’s mother: Right after birth
infants STS more easily establish optimal respiration with higher oxygen levels also in prematures. STS-contact with mother is ideal for regulating the baby’s temperature. A mother’s
chest gets warmer during STS, and lactating breasts are warmer than non-lactating ones.
Babies maintain their blood glucose better STS. Newborns placed STS cry much less than those
separated. “Separation distress calling” may also be recognised also in humans. Most newborns
make small sounds which usually elicit a verbal response from the mother. The human voice seems
to have an organizing effect on the developing brain. Newborns usually have a period when their
eyes are wide open. They have visual preferences. An organized prefeeding behaviour takes place
in most unsedated newborns STS the first hour after birth. The tactile sensitivity of the areola increases just before delivery, and stimulation releases surges of the “love-hormone” oxytocin, which
also flood the brain. A crying, upset newborn will usually become quiet after tasting a few drops of
breastmilk. Most mothers will greet their babies with repeated soft moist kisses, releasing olfactory
signals. The smell of the breast seems to act as a “nipple-search pheromone”. Many blind-folded
mothers are quickly able to pick out their own babies by smell after an initial period STS. STS may
change the brains of both infants and mothers and seems to facilitate attachment and basic trust.
Oxytocin, the hormone released during STS and breastfeeding reduces anxiety in adult humans.
The exclusivity, duration and ease of breastfeeding is positively correlated to STS post partum. Continous mother-child STS-contact during and after a caesarean will be briefly demonstrated with a
few minutes from the new film Breast is best.
No conflicts of interest. Please contact the author for references.
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SKIN-TO-SKIN CONTACT MOTHER-CHILD DURING CAESAREAN
SECTION AND THE FIRST HOURS POSTOPERATIVE: HOW DID WE
GO ABOUT IT?
Gro Nylander (1), Anne Gro Areklett (2), Kaja Hellenes (2), Karin Forfang (2),
Sissel Holmark Kongsrud (3)
1) National Resource Centre for Breastfeeding, Department of Obstetrics
2) Department of Obstetrics
3) Department of Recovery
All: Rikshospitalet Universitetssykehus
Correspondance: Gro Nylander [email protected]
Introduction Scientific evidence for favourable effects of skin-to-skin contact (STS) post-partum
has fascilitated a “Cesarean-STS” project at our hospital.
Aim To enhance contact and an early start of breastfeeding Methods Staff The departments of Recovery, Anestesiology, Obstetrics, Maternity, NICU and Operating theatre cooperated in working out practical
guidelines. Initial misgivings, mainly from Recovery, was met by information, and by Obstetrics taking the
formal responsibility for infants. Nurses at Recovery were given lectures about basic lactation management
and the importance of breastfeeding and STS. Key persons from the departments most involved took part in
preparing written information, procedures and questionnaires for evalutation. Parents are prepared during
a consultation as well as in writing. It is stressed that STS may not be possible if any complications arise.
Procedure After a check of vital signs the baby is dried before being placed across mothers chest.
There it stays STS during the rest of the operation, both while mother is lifted off the operating
table, during transport to Recovery and during the time spent there. The father is responsible for
checking the baby. If problems arise a midwife or paediatrician is paged. After about two hours
the family goes to Maternity. Evaluation was by questionnaires to parents, midwives and nurses
at Recovery, and informal interviews with other departments
Results All mothers offered the opportunity wanted STS. Most families went through with it according
to protocoll. An average number of infants were transferred to NICU. All mothers were enthusiastic, not
least those with a previous caesarean without STS. A few fathers had felt a bit worried about the responsibility, but even those were very content. Staff were mainly positive. No doctors reported misgivings.
Conlusion “Cesarean STS” is now the standard procedure on offer at our hospital for planned
c- sections with expected normal outcome.
No conflicts of interest.
MEDFØDTE MISDANNELSER I NYRER OG URINVEIER
Hans Randby (1), Alf Meberg (1), Yassin Hussain (2), Line Merete Tveit (2), Ole Jørgen Moe (3),
Sara Viksmoen Watle (4)
Barnesentrene ved
1. Sykehuset i Vestfold HF, Tønsberg
2. Sykehuset Telemark HF, Skien
3. Ringerike sykehus HF, Hønefoss
4. Sykehuset Buskerud HF, Drammen
Introduksjon: Tidlig diagnose av medfødte misdannelser er av betydning for å oppnå et godt
behandlingsresultat.
Mål. Å kartlegger panoramaet av medfødte misdannelser i nyrer og urinveier mht diagnostikk,
behandling og resultater.
Materiale og metode. Retrospektiv populasjonsbasert studie. Observasjonstid 1-21 år.
Resultater. Av 142 986 levende fødte hadde 389 (2,7 per 1000) misdannelser i nyrer/urinveier. Prevalensen var signifikant høyere for barn født i perioden 1997-2006 (241/70 217; 3,4 per 1000) enn 19871996 (148/72 769; 2,0 per 1000) (p < 0,0001). Andelen barn med prenatalt påviste nyre/urinveisanomalier økte signifikant fra første tiårskohort (35/148; 24%) til siste (125/241; 52%) (p < 0,0001). Urosepsis
forekom hos 8 (1,1 per 1000) i første kohort, og 9 (1,3 per 1000) i siste (p = 0,75). 137 (35%) har gjennomgått kirurgiske inngrep, hvorav 68 (0,9 per 1000) født 1987-96 og 69 (1 per 1000) født 1997-2006
(p = 0,8). Hos barn født 1987-96 og 1997-2006 forekom kronisk nyresvikt hos 6 (1 per 10 000) i begge
kohorter (p = 0,95), og henholdsvis 4 (0,5 per 10 000) og 11 (1,6 per 10 000) døde (p = 0,07).
Fortolkning. Bedre prenatal diagnostikk har ført til 69% økning av prevalensen av misdannels-
100
er i nyrer/urinveier. Dette tyder på overdiagnostisering. Antall pasienter behandlet kirurgisk,
forekomst av urosepsis, kronisk nyresvikt eller død i populasjonen er uendret.
RUTINEMESSIG ULTRALYD I SVANGERSKAPET
Reinar LM (1), Smedslund G (1), Fretheim A (1), Hofmann, B (1), Thürmer H (2).
1. Nasjonalt kunnskapssenter for helsetjenesten, Oslo
2. Blefjell sykehus
Introduksjon: Ultralydundersøkelse tilbys i dag alle gravide i 17. til 19. svangerskapsuke. Gravide
får i dag ikke tilbud om rutinemessig ultralydundersøkelse i første eller i tredje trimester.
Mål: Hensikten med denne rapporten er å vurdere effekten av rutinemessig ultralyd i første,
andre og tredje trimester i svangerskapet, både på mors og fosterets helse.
Metode: Systematiske kunnskapsoppsummeringen. Vi søkte etter rapporter, systematiske
oversikter og nyere primærstudier i juni 2006 og november 2007, i flere databaser.
Resultater: Vi inkluderte åtte rapporter (Health Technology Assessments), seks systematiske oversikter, ni primærstudier og supplerte med 27 nye rapporter og enkeltstudier (søk nov 2007).
Konklusjon: Det synes ikke å være forskjeller av betydning mellom ultralydundersøkelse i
første eller andre trimester på terminfastsettelse. Ultralydundersøkelse for nakkeoppklaring i
svangerskapsuke 11+0 til uke 13+6 supplert med blodprøve(r) (KUB), er en effektiv metode for å
finne fostre med økt risiko for Downs syndrom og gir en høyere sensitivitet enn ultralydundersøkelse kun i andre trimester, eller risikovurdering basert på mors alder. Alvorlige strukturelle
utviklingsavvik (som for eksempel hjertefeil og ryggmargsbrokk) der det ikke foreligger kromosomfeil, vil avdekkes med større sikkerhet i andre enn i første trimester. Vi fant lite dokumentasjon for at rutinemessig ultralydundersøkelser i tredje trimester gir økt helsegevinst.
Rutinemessig ultralydundersøkelse i første og/eller andre trimester øker ikke forekomsten
av angst, uro eller bekymring hos flertallet av kvinnene. For de få kvinner som opplever positive funn (økt risiko for avvik) øker angstnivået, og selv om funnet avkreftes vil de være mer
engstelige enn andre i resten av svangerskapet. Nyere enkeltstudier tyder på at kvinner får
god informasjon om ultralydundersøkelsene, men at det er en utfordring å informere godt om
nakkeoppklaringer og blodprøver.
Acknowledgements Takk til professor, overlege Kjell Å. Salvesen (St. Olavs Hospital, NTNU)
og jordmor/stipendiat Anne Kaasen (Rikshospitalet).
Finansiering: Nasjonalt kunnskapssenter for helsetjenesten
Ingen oppgitte interessekonflikter
BREASTFEEDING OF INFANTS WITH CONGENITAL HEART
DISEASE THROUGHOUT THE FIRST SIX MONTHS AFTER
BIRTH. THE MOBA COHORT STUDY
Bente Silnes Tandberg (1), Henrik Holmstrøm (2), Eivind Ylstøm (3)
1. Barneklinikkens sykepleiefaglige senter, Rikshospitalet, Oslo.
2. Lunge-hjerte-allergiseksjonen, barneklinikken, Rikshospitalet, Oslo.
3. Avdeling for Psykosomatikk og Helseatferd, Nasjonalt Folkehelseinstitutt, Oslo.
Objectives. To explore differences in breastfeeding frequency between infants with CHD and
infants in general population first six months postpartum.
Study design. This prospective cohort study is part of the Norwegian Mother and Child Cohort
Study, conducted at Norwegian Institute of Public Health. A total of 56 973
Mothers completed a questionnaire about infant feeding at 6 months postpartum. Infants with
CHD (N=245) were identified by means of CHD registry at Department of Paediatric Cardiology, which include almost all cases of detected paediatric heart disease in Norway. Data were
merged with data from Norwegian Medical Birth Registry. Feeding status was classified at 1,
4 and 6 months postpartum in categories of predominant breastfeeding, mixed breastfeeding
and bottle-feeding.
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Results. Mothers of infants with CHD are not more likely to be mixed breastfeeding (odds ratio
(OR); 0,89; 95% confidence interval (CI) 0,57-1,41) or bottle feeding (OR, 1,11; 95% CI 0 45 – 2,71)
1 month postpartum. At 4 months postpartum mothers of infant with CHD were not more likely
to be mixed breastfeeding (OR, 0,91; 95% CI 0,65- 1,29) or bottle feeding (OR, 0, 93; 95% CI 0,551,57). At 6 months postpartum mothers of children with CHD were not more likely to be mixed
breastfeeding (OR, 1,10; 95% CI 0, 68-1,74), but they were more likely to be bottle feeding (OR,
1,73; 95% CI 1, 04-2,91). Mothers of infants with additional diagnoses or problems beyond CHD,
are not more likely to be mixed breastfeeding (OR, 0,79; 95% CI 0,34-1,84) but for being bottle
feeding (OR, 4,10; 95% CI 1, 75-9,60) at 1 month postpartum. At 4 months postpartum they were
more likely to be mixed breastfeeding (OR, 2,53; 95% CI 1,44-4,46) and to be bottle feeding (OR,
4,94; 95% CI 2,64-9,26). When the infants with additional diagnoses or problems beyond CHD
reached 6 months of age mothers were not more likely to be mixed breastfeeding (OR, 0,99; 95%
CI 0,41-2,40 ) but more likely to be bottle feeding (OR, 5,00; 95% CI 2,10-11,96).
Conclusions. This is the first population based cohort study that shows there is no significant difference in breast milk feeding status between infants with CHD and healthy infants throughout the first
4 months after birth. When infants reach 6 months of age they are more likely to be bottle fed rather
than predominantly breastfed. If infants have additional diagnoses or problems to CHD, they have are
substantially more likely to be both mixed breastfed and bottle feed throughout their first 6 months.
Acknowledgement: The Norwegian Mother and Child Cohort Study is supported by the Norwegian
ministry of Health, NIH/NIEHS (grant no N01-ES-85433), NIH/NINDS (grant no.1 UO1 NS 04753701), and the Norwegian Research Council (grant no 151918/S10). The breastfeeding children with
CHD study was supported by Division of Paediatrics, Rikshospitalet University Hospital.
UTFØRER SYKEPLEIERE FAGLIG FORSVARLIG VURDERING
AV PREMATURE BARNS OKSYGENBEHOV?
En kartlegging av hvordan sykepleiere oppfatter sine vurderinger når de tilpasser oksygen til
premature barn tilkoblet respirator.
Marianne Trygg Solberg
Videreutdanning i intensivsykepleie
Lovisenberg Diakonale Høgskole, Oslo
Hensikt: Hensikten med studien var å kartlegge hvordan sykepleiere oppfatter sine vurderinger
av premature barns oksygenbehov når de tilpasser oksygen i inspirasjonsluften. Barna er i uke
24-28 og får respiratorbehandling.
Metode: Det er benyttet et Survey design med beskrivende statistikk. Den empiriske delen er en spørreundersøkelse til sykepleiere tilknyttet neonatalavdelingene ved landets fem regionsykehus. Antall
respondenter var totalt 221. Spørreskjemaet er inndelt i tre deler og består av lukkede spørsmål. Del
A innhenter demografiske data samt hvordan sykepleiere vekter holdninger til klinisk praksis. Del B
er et validert Nursing decision-making instrument utarbeidet av Lauri og Salanterä. Del C etterspør
kriterier sykepleiere mener inngår i deres vurderinger når de tilpasser oksygen. Antall besvarelser er
111 skjema (50,2%). Dataene ble lagt inn i SPSS versjon 15.
Resultat: Et fremtredende funn er spriket mellom gitte kriterier fra fag- og forskningslitteratur og
kriteriene sykepleierne mente de brukte ved vurdering av premature barns oksygenbehov. Ved tilpasning av oksygen vurderte respondentene barnas oksygenbehov ut i fra oksygenmetningen. Derimot
krever forskere at helsepersonell skal vurdere barnas oksygenbehov med å vurdere forholdet mellom SpO2 og PO2. Svært få sykepleiere (17%) brukte hemoglobin oksygen dissosiasjonskurven i sine
vurderinger (3,6% ikke besvart). De som mente de brukte kurven, brukte den ikke rett (ble undersøkt
samvarians mellom SPO2, PO2, PCO2, PH og temperatur og bruk av kurven med Spearman Korrelasjon). Sykepleiere kan redusere faren for hyperoksi med oftere å trekke inn PO2 (PaO2)og hypoksi ved
å bruke Hb, BT og puls i sine vurderinger. Som eksempel svarte respondentene at 29% brukte aldri
PO2 mens 26% brukte PO2 av og til. Over 40% av respondentene mente de ikke brukte PCO2 i sine
vurderinger, mens like mange anså at de brukte denne faktoren. Nærmest 60% forholdt seg verken til
pH verdien eller temperaturen til barnet. Respondentene viste gode holdninger vedrørende tilpasning
av oksygen. Eksempelvis ønsket de fleste retningslinjer og mange gav inntil 5-10 % oksygen ved hver
justering. Innstilling av pulsoksymeterets alarmgrenser ble oppfattet som viktig, men få sykepleiere
ville opprettholde øvre alarmgrense om alarmen gikk ofte. Tilnærmet to av tre sykepleiere anså sin
beslutningsprosess til å være blandet analytisk-intuitiv orientert. Størst grad av analytisk kognisjon
forekom ved vurderinger under datainnsamling og gjennomføring av handlingen. Høyest grad av intuitiv orientert kognisjon ble brukt ved vurdering under planlegging av handling.
Konklusjon: Ved tilpasning av oksygen ble beslutningen gjerne tatt på et for lavt kognitivt nivå
fordi sykepleierne ikke tok i bruk alle relevante kriterier i sin vurdering av premature barns
oksygenbehov.
102
Betydning for praksis: Det bør innledes endringer i praksis med opplæring i teori relatert til de
kriterier som må brukes for å sikre faglig forsvarlig vurdering av oksygenbehov til barna.
Ingen finansiell støtte utenom 30% FOU tid fra arbeidsgiver.
RESUSCITATION WITH DIFFERENT OXYGEN CONCENTRATIONS
GIVES A DOSE DEPENDENT INCREASE IN METALLOPROTEINASES
(MMPS), AND A DECREASE IN BDNF EXPRESSION AND ACTIVITY
IN NEWBORN PIGS BRAIN
Rønnaug Solberg1, Marianne Wright1, Eliane Charrat2, Michel Khrestchatisky2,
Santiago Rivera2, Ola Didrik Saugstad1.
1. Department of Pediatric Research, University of Oslo, Rikshospitalet University
Hospital, N-0027 Oslo, Norway
2. Neurobiologie des Interactions Cellulaires et Neurophysiopathologie, UMR6184 CNRSUniversité de la Méditerranée, Marseille, France.
Introduction: Hypoxic-ischemic injury of the brain in the neonatal period often leads to longterm neurological deficits. An increase in MMP activity is generally observed in pathological
conditions and is of great importance in hypoxia-reoxygenation induced injury. Brain-derived
neurotrophic factor(BDNF) plays a crucial role in neuronal survival and maintenance, neurogenesis, learning and memory. Caspase-3 plays a major role in cell death in immature neurons
after brain injury.
Objective: Our aim was to study changes in MMPgelatinase activity in brain tissue of newborn pigs
resuscitated with 21, 40 or 100% O2 and to study the expression and activity of BDNF and Caspase-3.
We also included a group exposed to 100%O2 for 30 min without preceding hypoxia.
Methods: Global hypoxia was induced following a standardized model; followed by resuscitation with 21, 40 or 100% oxygen for 30 min and observation for 9 hours (n=10,12,10). For in situ
zymography, sections of snap-frozen brain-tissue from corpus striatum were incubated and
the tissue gelatinases measured as released fluorescence (representative for the net proteolytic activity). RNA was isolated from prefrontal cortex and gene expression levels for BDNF
and Casp-3 were determined by RT-PCR. Brain tissue from the same area was used for Immunoassay (ELISA).
Results: Net gelatinolytic MMP activity increases in corpus striatum after hypoxia-reoxygenation in a dose dependant manner (21% (50.6), 40% (55.3), 100% (59.5)), vs the Control- or
Hyperoxia group (p<0.02). Both RT-PCR and the Immunoassay showed a dose-dependant decrease in BDNF in the hyperoxic groups (p=0.006 and p=0.033 for 21 vs 100% respectively).
Caspase-3 correlated negatively with BDNF (r=-0.49, p=0.024) and was significantly increased
already by 40%.
Conclusions: Hyperoxia by resuscitation gives a dose-dependant increase in MMP activity and
a decrease in BDNF suggesting a lower neuroprotection with higher Caspase-3 activity and
neuronal apoptosis.
Acknowledgements and sources of financing: Norwegian SIDS and Stillbirth Society has
supported this study
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UNIFORM INFORMATION ON FETAL MOVEMENT REDUCES
REPORTING DELAYS AND STILLBIRTHS IN PRIMIPAROUS
WOMEN – A CLINICAL QUALITY IMPROVEMENT PROJECT
Eli Saastad, CNM, MSc (1,2,4), Julie Victoria Holm Tveit, MD (3,4), Babill Stray-Pedersen, MD,
PhD (3,4), Vicki Flenady, CNM, MMedSc (5), Ruth Fretts, MD, MPH (6), Per E. Børdahl, MD, PhD
(7), J. Frederik Frøen, MD, PhD (1)
1. Norwegian Institute of Public Health, Division of Epidemiology, Oslo, Norway
2. Akershus University College, Lillestrøm, Norway
3. Dept of Obstetrics and Gynecology, Centre for Perinatal Research, Rikshospitalet University
Hospital
4. University of Oslo, Norway
5. Dept of Obstetrics and Gynecology, University of Queensland, Mater Mothers’ Hospital, South
Brisbane, Australia
6. Brigham and Women’s Hospital, Division of Maternal-Fetal Medicine, Harvard Medical
School, Boston, MA and Harvard Medical Associates, Wellesley, MA
7. Institutes for Clinical Medicine, Section for Gynecology and Obstetrics, Haukeland University
Hospital, Bergen and University of Bergen, Norway
Corresponding author: Akershus University College, PB 423, N-2001 Lillestrøm, Norway
[email protected]
Objectives: Delayed maternal reporting of decreased fetal movement (DFM) is associated with
adverse pregnancy outcomes. We aimed to evaluate the effects of providing uniform information
about fetal activity on maternal behavior if DFM was perceived and if this information made a
difference in maternal awareness, concerns and outcomes.
Method: A prospective clinical quality improvement intervention was evaluated using a beforeand-after study design. The intervention included distribution of information on fetal activity
across a total population. Outcome measures were maternal behavior, concerns and stillbirth
rates. All singleton third trimester pregnancies presenting DFM or stillbirth were registered.
Baseline and intervention cohorts included 19,407 vs. 46,143 births and 1215 vs. 3038 women
with DFM. Cross-sectional studies of all women giving birth were performed before and after
intervention (n=692 and n=734 respectively).
Results: On average, women perceiving DFM contacted hospital two days earlier in pregnancy in the
intervention. Among primiparous women, the intervention was associated with reduced delayed reporting of DFM and less stillbirths, OR 0.36 (95% CI 0.19-0.69), without causing increased maternal
concerns or frequencies of examination. The intervention failed to change behavior and stillbirth rates
among mothers who were non-Western, smokers, overweight or > 34 years old.
Conclusions: Uniform information on fetal activity is associated with reduced expectance with DFM and
reduced stillbirth rates among primiparous mothers; no increased maternal concerns or rates of examination. Other measures are required to change behavior in other risk populations.
No conflicts of interest
SYSTEMATISK PRE OG POSTNATAL AMMEVEILEDNING VED
LEPPE-KJEVE-GANESPALTE- EN OPPFØLGINGSUNDERSØKELSE
Elisabeth Tufte (1), Nina Lindberg (2)
1. Nasjonalt kompetansesenter for amming, Rikshospitalet, Oslo
2. ØPO-klinikken, Rikshospitalet, Oslo
Bakgrunn: Ved leppe-kjeve-ganespalte blir det vanskelig for barna å danne vakuum/undertrykk i
munnen. Dette kan redusere evnen til å die effektivt og å etablere melkeproduksjon.
Hensikt: Vi ønsket å besvare 2 spørsmål: Under forutsetning av at kvinnene får veiledning pre
og postnatalt:
i) I hvilken grad klarer mødre å etablere en god melkeproduksjon og deretter opprettholde denne?
ii) I hvor stor grad er det mulig å amme barn med leppe-ganespalte?
Metode: Ni gravide kvinner ble tilbudt individuell pre og postnatal ammeveiledning etter å ha fått påvist
ved ultralyd at de sannsynligvis kom til å føde et barn med en eller annen form for spalte.
Resultater: Det var syv av ni som klarte å etablere en så god melkeproduksjon at barnet var tilnærmet
morsmelksernært frem til tre måneder. Ved seks måneder fikk fortsatt fem barn morsmelk. Tre av ni barn
tok mer enn 50% av melken fra brystet med noe tillegg ved koppmating eller flaske.
104
Konklusjon: Pilotstudien understøtter at pre- og postnatal ammeveiledning øker muligheten for å etablere en god melkeproduksjon over en lengre periode og å øke muligheten
for å amme barn med LKG, sammenlignet med det som tidligere er rapportert.
Finansiell støtte: Ingen ekstern finansiering
Interessekonflikt: Ingen
ANDROGENER I SVANGERSKAPET OG AMMING
Sven M. Carlsen,1,3, G Jacobsen2, E Vanky1,4
1
Institutt for laboratoriemedisin, barne- og kvinnesykdommer, NTNU, 2 Institutt for samfunnsmedisin, NTNU og 3Avdeling for endokrinologi, 4Kvinneklinikken St. Olavs Hospital,
Universitetssykehuset i Trondheim
Introduksjon: Amming er avhengig av mange faktorer, blant annet endokrine forandringer
under svangerskapet. Sammenhengen mellom hormonelle forhold og senere amming er lite
undersøkt. Oftest har man ingen forklaring på hvorfor noen kvinner ikke kan amme på tross av
stor motivasjon og god hjelp. Siden testosteron tidligere ble brukt til å hemme amming, var vår
hypotese at høye nivå av mannlige kjønnshormoner er negativt forbundet med ammingen.
Mål: Undersøke sammenhengen mellom mannlige kjønnshormoner under graviditet og amming.
Metode: Prospektiv observasjonsstudie av para en eller para to kvinner med singelt
svangerskap. Vår analyse omfattet et tilfeldig utvalg (n = 63) og en gruppe kvinner med
økt risiko for å føde lavvektig (SGA-) barn (n = 118). Androgennivåer hos mor ble målt i
svangerskapsuke 25. Uni- og multivariate regresjonsanalyser ble brukt for å belyse assosiasjonen mellom androgennivåer (testosteron, androstenedion, DHEAS og fri testosteron
index) og amming 6 uker, 3 måneder og 6 måneder post partum.
Resultater: Korrigert for mors alder, utdanning og røyking (ja/nei) fant vi negativ assosiasjon mellom fri testosteron index og amming ved 3 og 6 måneder etter fødsel i gruppen
av tilfeldig utvalgte kvinner. Hos kvinner med økt risiko for å føde SGA-barn, fant vi en
negativ sammenheng mellom DHEAS og amming 6 uker og 3 måneder postpartum også
etter en tilsvarende korreksjon for alder, utdanning og røyking.
Konklusjon: Høye androgennivåer målt i andre trimester av svangerskapet var negativt
assosiert med amming fram til 6 måneders alder. Funnet vedvarte etter korreksjon for
faktorer som tidligere er vist å ha sammenheng med amming.
Acknowledgement: SGA studien ble initiert og organisert av Professor Leiv S. Bakketeig.
Kristin Rian, BSc, gjorde laboratorieanalysene.
AMMING HOS KVINNER MED POLYCYSTISK OVARIE
SYNDROM (PCOS)
Eszter Vanky1,3, Hege Isaksen1, Mette H. Moen1,3, Sven M. Carlsen1,2
1Institutt for laboratoriemedisin, barne- og kvinnesykdommer, NTNU, 2 og Avdeling for
endokrinologi og 3Kvinneklinikken St. Olavs Hospital, Universitetssykehuset i Trondheim,
Trondheim
Introduksjon: PCOS kvinner har økt forekomst av infertilitet. Svangerskapskomplikasjoner som spontanabort, svangerskapsdiabetes, pre-eklampsi og fortidlig fødsel forekommer
også oftere hos PCOS kvinner sammenlignet med ”normale” kvinner. PCOS kvinners evne
til å amme er ikke undersøkt tidligere.
Mål: Å undersøke PCOS kvinner evne til å amme.
Materiale og metode: Spørreskjemabasert ”case-control”-studie. 37 PCOS kvinner og
108 kontroller besvarte spørsmål om amming 6-12 måneder postpartum. Gruppene var
matchet for alder, paritet og svangerskapslengde.
105
Resultater: En måned postpartum fullammet 75 % av PCOS kvinnene, mens 14 % ammet ikke
i det hele tatt. Blant kontrollene fullammet 89 % og 2 % ammet ikke (p = 0.001). Ved tre og seks
måneder postpartum fant vi ingen forskjeller mellom gruppene. Forhøyd DHEAS under graviditet assosierte negativt med amming hos PCOS kvinner. Gruppene var like mhp. såre brystvorter
og antall konsultasjoner for ammehjelp.
Konklusjon: PCOS kvinner synes å ha vanskeligere for å komme i gang med amming
sammenlignet med ”normale kvinner”. Årsaken kan være relatert til økt androgennivå.
Acknowledgement: Prosjektet er gjennomført innen rammen av et postdoktorstipend ved
NTNU/DMF.
NEONATAL GROUP B STREPTOCOCCUS (GBS) INFECTIONS
Eileen Wittmann (1), Alf Meberg (1), Veslemøy Benjaminsen (2), Astrid Bjerklund Nilsson (3), Jakob
Grundt (4), Martin Lundgren-Andræ (5), Ole-Jørgen Moe (6), Lutz Nietsch (7), Terje Selberg (8),
Ragnhild Sivertsen (9), Kenneth Strømmen (10), Sara Viksmoen Watle (11)
Departments of Pediatrics:
1. Vestfold Hospital, Tønsberg
2. Haugesund Hospital, Haugesund
3. Telemark Hospital, Skien
4. Innlandet Hospital, Lillehammer
5. Nordland Hospital, Bodø
6. Ringerike Hospital, Hønefoss
7. Ålesund Hospital, Ålesund
8. Østfold Hospital, Fredrikstad
9. Sørlandet Hospital, Arendal
10. Sørlandet Hospital, Kristiansand
11. Buskerud Hospital, Drammen
Introduction: Invasive infection with group B streptococcus (GBS) remains a severe disease in
newborns.
Objective: To register epidemiological data for neonatal GBS-infections.
Methods: Population-based retrospective multicenter study. Case ascertainment from hospital
records and relevant ICD-10 diagnosis in infants born alive 1999-2007.
Results: Out of 165 342 live born infants, 184 developed early onset GBS infections (EOGBS) (<
7 days after birth) (1.1 per 1000) and 30 late onset disease (LOGBS) (≥ 7 – 90 days after birth) (0.2
per 1000). 93 (51%) EOGBS had positive blood and/or cerebrospinal fluid cultures, 84 (46%) positive surface cultures and 7 (4%) positive urine antigen test combined with symptoms of disease
and elevated C-reactive protein. 32 (17%) infants with EOGBS and 18 (60%) with LOGBS were born
preterm (p = 0.0001). In 68 (37%) with EOGBS, symptoms were present within the first hour after
birth, and in 156 (85%) within the first 24 hours. Of the mothers 109/184 (59%) had one or more
risk factors. Only 41 (38%) of these received intra partum antibiotics. Median start of antibiotic
treatment in babies with EOGBS was 4 hours after symptoms of disease were registered. More
infants with LOGBS were in need of ventilator treatment (9; 30%) than in those with EOGBS (15;
8%) (p = 0.0004). Combined death/survival with cerebral damage was higher in LOGBS (7; 23%)
than in EOGBS (12; 7%) (p = 0.003).
Conclusions: Neonatal GBS-infection is a severe illness, especially LOGBS. Antibiotic treatment often starts several hours after symptoms occur. Clear guidelines for intra partum antibiotic prophylaxis are needed for prevention of EOGBS.
106
SKULDERDYSTOSI VED ANDRE FORLØSNING
- GIR TIDLIGERE SKULDERDYSTOSI ØKT RISIKO?
Øverland E1, Spydslaug A2, Nielsen CS3, Eskild A1,3
1
Kvinneklinikken, Akershus Universitetssykehus, Lørenskog, 2Kvinneklinikken, Ullevål
Universitetssykehus, Oslo, 3Divisjon for psykisk helse, Nasjonalt folkehelseinstitutt, Oslo.
Bakgrunn. Skulderdystosi er en sjelden, men dramatisk obstetrisk situasjon med potensielt alvorlige maternelle og føtale komplikasjoner. Kunnskap om risikofaktorer er
nødvendig for å unngå situasjonen og for å gi råd til den fødende om forløsningsmetode.
Tidligere skulderdystosi er antatt å være en risikofaktor for å oppleve denne alvorlige tilstanden også i neste svangerskap.Hensikten med vår studie var å studere om skulderdystosi i første forløsning økte risikoen for skulderdystosi i andre forløsning.
Metode. Vår studie baserer seg på data fra Medisinsk fødselsregister. Vi inkluderte samtlige kvinner i Norge med to påfølgende ( første og andre) vaginale fødsler med ett barn i
hodeleie i perioden 1967-2005, totalt 597 144 kvinner.
Resultat. Insidensen av skulderdystosi ved første fødsel var 0.5%. For andregangsfødende
var insidensen 0.8%. Hos kvinner som hadde opplevd skulderdystosi ved første fødsel,
var gjentagelsesrisikoen 7.3%. Imidlertid forekom hele 96.2% av alle skulderdystosier ved
andre forløsning hos kvinner som ikke hadde opplevd dette tidligere. Barnets fødselsvekt
var den absolutt mest betydningsfulle risikofaktoren for skulderdystosi i andre forløsning,
justert oddsratio 245.7 ( 95% KI;199.1-303.3) hvis vi sammenligner svært høy fødselsvekt
(>5 000gram ) med barn som veide 3 000 -3 499 gram. Hvis man fødte et barn med lav
eller normal fødselsvekt (<4 000 gram) var risikoen for å oppleve skulderdystosi i andre
svangerskap lav uavhengig om man hadde opplevd en tidligere skulderdystosi eller ikke
( 1,7% hvis man hadde opplevd en skulderdystosi tidligere og 0,2% hvis man ikke hadde
opplevd skulderdystosi tidligere).Imidlertid økte gjentagelsesrisikoen dramatisk hvis man
fikk et stort barn. Risikoen er nær 30% hvis man fødte et barn som veide mer enn 5 000
gram.
Konklusjon. Tidligere skulderdystosi øker risikoen for å oppleve skulderdystosi på nytt.
Imidlertid er det fødselsvekten som er den altoverskyggende risikofaktoren for å oppleve
en skulderdystosi. Å føde et stort barn gir en betydelig økt risiko for skulderdystosi uavhengig om kvinnen har opplevd dette tidligere. Hos en kvinne som har opplevd en tidligere
skulderdystosi og som i neste svangerskap bærer på et barn med en antatt vekt over 4 500
gram, kan planlagt keisersnitt være en fornuftig forløsningsmetode.
Acknowledgment. We acknowledge the work that is being done by the personnel responsible for the deliveries in Norway and also the staff at the Medical Birth Registry responsible for making data available for research.
Interessekonflikter. Det foreligger ingen interessekonflikter.
107
Free Communcations Poster
108
Poster Stillbirth
109
Poster Developing Countries
127
Poster Bereavement
139
1
POSTER Stillbirth
PERINATAL DEATH FROM THE AFRICAN AMERICAN
PERSPECTIVE
Nicole F. Alston(1)
The Skye Foundation, Trenton, NJ, USA
In the early morning of April 30, 2005, things went very wrong for expectant first-time parents,
Paul and Nicole. Doctors were unable to detect their baby’s heartbeat. Hours later, their
daughter Skye, was born still. As with most uneventful pregnancies, there were no major warning bells. Except that, Nicole was African American. This illustration is not just my story. It
reflects the stories of many African Americans, most of whom, are completely unaware that
they are at an increased risk for poor birth outcomes, such as stillbirth.
Additionally, many of these parents are faced with the challenge of finding those within the
medical community who have a cultural understanding of the complicated grieving process
germane to African Americans. From a historical and cultural context, many Blacks, following
the death of their babies, have suffered in silence. The underpinnings of this behavior, may be
due, in part, to our long history of feeling that we do not have the space or permission to grieve.
This complicated grieving process, coupled with scant research done on how best to serve
this population during moments of acute grief and beyond, does not bode well for bereaved
parents.
In an effort to bridge the gap of understanding between Blacks and the medical community, I
produced a video – Perinatal Death: From the (African American) Parent’s Perspective – with
interviews from bereaved parents interspersed with commentary from medical professionals. Common threads emerge from the interviews (despair, devastation and prolonged grief) .
These factors may forecast strong implications for the health of these mothers and families in
subsequent pregnancies.
By creating a healthy dialogue about how best to serve the population disproportionately affected by adverse birth outcomes, it is my hope that the net effect will result in an increased
understanding of the emotional needs of African Americans.
There are no conflicts of interest.
2
RECURRENT
NEONATAL
LOSSES:
SEVERE
FETAL
HEMOLYTIC DISEASE CAUSING HYDROPS FETALIS BY
ANTI-E IMMUNIZATION
An-Shine Chao*, Angel Chao, SY Ho, YT Lin, Reyin Lien
Department of Obstetrics and Gynecology
Chang Gung Memorial Hospital and University
Tao-Yuan, Taiwan
*Correspondence: [email protected]
Introduction: Although there are more than 100 different RBC antigens capable eliciting an
maternal antibody immunization response, only less than 5 percent of the severe perinatal
anemia were caused other from the D ,K, c antigens. There are only a few cases reported in the
literature where anti-E have caused severe fetal anemia.
Objectives: To prevent repeated fetal losses in autoimmune hemolytic diseases.
Methods: Case report on a 36 year,G5P2AA1, was referred at pregnancy 27 weeks for hydrops
fetalis. She had twice previous sections without history of blood transfusion. The first baby was
a term live birth while the second baby had neonatal death with hepatosplenomegaly noted
postnatally 3 years ago. Ultrasonography show no detectable structural abnormalities except
for marked skin edema, cardiomegaly, hepatosplenomegaly, pleural effusion, ascites, placentomeagly and polyhydramnios (fig.1a). The Doppler peak systolic velocity of mid.cerebral artery
was 0.8 m/s (>2.5 MoM) (fig.1b). Chromosome, thalassemia, Parvovirus B19, cytomegalovirus,
Toxoplasmosis and ANA titer studies were negative. Both the parent’s blood group phenotype
was O, D+. Coombs’ test was positive. An antibody screen and identification revealed the very
high titer of anti-E antibodies at 1:1280.The mother was E -Ag negative. Severe fetal ane-
109
mia confirmed by percutanoeus umbilical cord blood sampling before fetal transfusion with
minimum hemoglobin level 2.1 g/dl and hematocrit 6.1 l/l. The fetal RBC phenotype was O,
D+C+E+c+e+ with strong positive in direct Coombs’ test (++++). Three antenatal intravascular
and intraperitoneal transfusions each 10 ml and 20 ml irradiated group O,D+ PRBC respectively were performed between 28 and 30 weeks of gestation. Despite the transfusions, fetal
anemia persisted with slightly increased hemoglobin level and mirror syndrome developed in
the mother. Cesarean section performed and a 2000g male baby, Apgar score 2’-3’ and a 1300g
placenta were delivered, both had grossly edematous appearance. The newborn succumbed 2
days after. Autopsy was declined.
Results: This case demonstrated despite repeated intra-uterine transfusions, severe fetal anemia and circulation was unable to correct, resulting a neonatal death at 31 weeks of gestation.
Conclusion: Screening and quantification of alloantibodies is important during the early trimester of pregnancy, especially to those had previous uncertain fetal loss or abortion, for determination of uncommon antibodies
Conflicts of interest: No
IMPLEMENTATION OF STRUCTURAL FEEDBACK TO CAREGIVERS BY MEANS OF AUDIT IN CASES OF PERINATAL MORTALITY IN THE NORTHERN REGION OF THE NETHERLANDS:
WORK IN PROGRESS
Van Diem MT (1), Reitsma B (2), Bergman KA (3), Bouman K (4), Ulkeman AHM (1), Timmer A (5),
van Egmond N (6), Stant AD(7), Veen WB (8), Erwich JJHM (1)
1. Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The
Netherlands
2. Wenckebach Institute, University Medical Centre Groningen, Groningen, The Netherlands.
3. Department of Paediatrics, University Medical Centre Groningen, Groningen, The Netherlands.
4. Department of Clinical Genetics, University Medical Centre Groningen, Groningen, The Netherlands.
5. Department of Pathology, University Medical Centre Groningen, Groningen, The Netherlands.
6. General Practice “De Kompe”, Gorredijk, The Netherlands
7. Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands.
8. Juridical staff, University Medical Centre Groningen, Groningen, The Netherlands.
Introduction: Compared to other west European countries, the Netherlands has a high perinatal mortality rate.1 A substantial part can be attributed to the quality of the perinatal care. With
perinatal audit this can be improved.2 In local audit meetings perinatal caregivers evaluate the
care process in cases of perinatal mortality from their own practice area
.
Objectives: To implement local perinatal audit in 15 perinatal cooperation units in the northern
part of the Netherlands.
Methods: The implementation strategy has an information plan, a training plan and an organisation plan. Information consists of a mailing with general information and progress reports in
newsletters for all perinatal caregivers. During semi-structured interviews with representatives
of all groups of perinatal caregivers detailed information was given.3 During a conference for all
perinatal caregivers local perinatal audit will be placed in the context of national developments.
The training plan consists of instruction in writing a narrative and the classification of cause of
death. In introductory audit meetings in all perinatal cooperation units perinatal audit in general, the emotional aspects of perinatal audit and the audit methodology are addressed.4 The
organisation-plan consists of protocols for the organisation of audit meetings.
Results: All 15 perinatal cooperation units participated and intend to continue with regular audit meetings. Attendance rate of perinatal caregivers to the introductory audit meetings is high
(82%). The overall evaluation for these meetings is 4.2 (scale 1neg-5 pos). Actions to improve
care that have been undertaken after the introductory meetings will be shared. We will report on
the results of the workshops on several aspects of the implementation of local perinatal audit.
Conclusion: With respect to intention to continue perinatal audit meetings the implementation
strategy appears to be successful for all cooperation units.
This project is funded by ZONMW (the Netherlands organisation for health research and development), The Hague, The Netherlands
110
3
References:
(1) Buitendijk S, Zeitlin J, Cuttini M, Langhoff-Roos J, Bottu J. Indicators of fetal and infant
health outcomes. Eur J Obstet Gynecol Reprod Biol 2003; 111 Suppl 1:S66-S77.
(2) Dunn P.M., MacIlwaine G. Perinatal Audit. A report produced for the European Association of
Perinatal Medicine. Dunn P.M., MacIlwaine G., editors. 5-43. 1996. Carnforth, Lancashire, The
Parthenon Publishing Group Ltd.
(3) Offenbeek MAGV, Koopman PL. Scenarios for system development: matching context and
strategy. Behaviour & Information Technology 1996; 15(4):250-265.
(4) Vincent C. Understanding and responding to adverse events. N Engl J Med 2003; 348(11):10511056.
4
RISK OF STILLBIRTH IN TYPE 1 DIABETES PREGNANCIES
IN NORWAY 1985-2004
Ingvild Eidem (1), Lars C. Stene (2), Tore Henriksen (3,4), Kristian F. Hanssen (5), Siri Vangen
(2,6), Stein E. Vollset (7,8), and Geir Joner (1,9)
1. Dept of Pediatrics, Ullevål university hospital, Oslo
2. Division of Epidemiology, Norwegian Institute of Public Health, Oslo
3. Dept of Gynecology and Obstetrics, Rikshospitalet, Oslo
4. Faculty Division Rikshospitalet, University of Oslo, Oslo
5. Dept of Endocrinology, Aker university hospital, Oslo
6. National Centre of Women’s Health, Dept of Gynecology and Obstetrics, Rikshospitalet, Oslo
7. Medical Birth Registry, Norwegian institute of Public
Health, Bergen.
8. Department of Public Health and Primary Health Care University of Bergen, Bergen
9. Institute of Health Management and Health Economics, University of Oslo, Oslo, Norway
Background: Despite substantial improvement in the treatment of diabetes the last decades and extensive care for pregnant women with type 1 diabetes, most studies indicate that pregnancies complicated with type 1 diabetes still have excess risk of stillbirth compared to the background population.
Methods: By linkage of records from the Norwegian Diabetes Registry and records from the Medical
Birth Registry of Norway, we performed a national population based cohort study. In the period 19852004, 1306 births after 22 weeks of gestation or more occurred among women registered with type 1
diabetes in our cohort. These were compared to all other births with corresponding gestational age
in Norway within the same period (n=1.16 mill).
Results: Among women with type 1 diabetes the rate of stillbirth was 2.0 % compared with 0.6
% in the background population, RR 3.4 (95 % CI 2.3-5.0). Divided into 3 periods, 1985-1991,
1992-1998 and 1999-2004, the RRs were 3.3 (95% CI: 1.7-6.6), 3.8 (95 % CI 2.2-6.7) and 3.0 (95
% CI 1.4-6.8), respectively. Eleven of 26 stillbirths (42 %) in the diabetes group had a gestational age of 37 weeks or more. The corresponding percent among stillbirths in the background
population was 31 (difference n.s.).
Conclusion: The rate of stillbirth in pregnancies complicated with type 1 diabetes in Norway has
during recent years been about threefold that of the background population. Based on these results,
the challenge to further improve the prognosis of type 1 diabetes pregnancies is still existent, also in
Norway.
Acknowledgements and sources of financing: The study was supported by The South-Eastern
Norway Regional Health Authority.
111
ILLICIT SUBSTANCE USE: A PREDICTOR OF IN-UTERO
GROWTH RESTRICTION IN AFRICAN AMERICAN URBAN WOMEN IN WASHINGTON DC.
Ayman El-Mohandes (1), Marie G Gantz (2), M Nabil El-Khorazaty (2), Michele Kiely (3)
Department of Prevention and Community Health, School of Public Health and Health Services,
George Washington University, Washington DC, USA.
Statistics and Epidemiology Unit, RTI International, Rockville, MD,USA.
Collaborative Studies Unit, Division of Epidemiology, Statistics and Prevention Research.
NICHD/NIH/HHS, Rockville, MD, USA.
5
Introduction: In-utero growth restriction (IUGR) remains a domain for health disparity in US
populations. Many contributing factors could be implicated as causal associations.
Objectives: This study examines associations between risk factors and small for gestational
age (SGA) status at birth in a population of African American (AA) mothers.
Methods: An RCT was conducted in 6 clinics in Washington DC. AA pregnant women were
screened for eligibility and risk: smoking, environmental tobacco smoke exposure, depression
and intimate partner violence. Baseline and two follow up data collections were conducted by
phone. Medical outcomes were collected from the mothers’ medical records during pregnancy
and after delivery. Multiple imputation was used to estimate values for missing data. Bi-variate
analysis was conducted using socio-demographic, medical risk and behavioral risk data. Variables retained in the reduced logistic were those at p value <0.15.
Results: Outcomes were available on 989 pregnancies, 152 resulted in SGA births (15.4%).Demographics, smoking, alcohol use, depression, and chronic hypertension were not associated
with SGA births. The logistic model included: late prenatal care (PNC) initiation, previous miscarriage and still birth, primipara status, pregnancy induced hypertension, and illicit drug use
(IDU) in pregnancy. The factor retaining significance at 5% level was IDU during pregnancy.
Factors significant at 10% level were late PNC intiation, pregnancy induced hypertension, and
primipara status.
Conclusion: IDU predominates as a risk association with IUGR in pregnant African American
mothers. When IUGR is suspected during pregnancy, IDU should be ruled out and if present
treatment should be sought.
Acknowledgement and sources of funding: The National institute of Child Health and Human Development, and the NIH Center for Research on Minority Health and Health Disparities.
Conflict of interest: None of the authors have any conflict of interest to declare.
CHRONIC HYPERTENSION IS A SIGNIFICANT PREDICTOR OF
PERINATAL MORTALITY IN HIGH RISK AFRICAN AMERICAN
WOMEN IN WASHINGTON DC.
Ayman El-Miohandes (1), M Nabil El-Khorazaty (2), Michele Kiely (3), Marie G Gantz (2)
Affiliations: Department of Prevention and Community Health, School of Public Health and
Health Services, George Washington University, Washington DC, USA.
Statistics and Epidemiology Unit, RTI International, Rockville, MD,USA.
Collaborative Studies Unit, Division of Epidemiology, Statistics and Prevention Research.
NICHD/NIH/HHS, Rockville, MD, USA.
Introduction: Pregnancies in African American (AA) mothers are associated with higher perinatal mortality. Research to clarify causal factors is needed.
Objectives:To examine association between demographic, biological and behavioral risk factors in pregnancy and perinatal mortality (20 week gestation up to 4 weeks neonatal deaths) in
a population of AA mothers.
Methods:An RCT testing the efficacy of a behavioral intervention to reduce risk was conducted
in 6 clinics in Washington DC. AA pregnant women were screened for eligibility and risk: Women
18+ years old exposed to smoking, environmental tobacco smoke exposure, depression and intimate partner violence during pregnancy were recruited. Baseline and 2 follow up data collections were conducted by phone. Medical outcomes were collected from medical records during
112
6
pregnancy and after delivery. Bivariate analysis was conducted using demographic, medical
risk and behavioral risk data. Variables retained in the reduced model were those at p value
<0.15.
Results: In 887 pregnancies (excluding miscarriages) 13 still births, and 4 neonatal deaths
occurred. Factors retained in the reduced logistic model included maternal education, active
smoking in pregnancy, chronic hypertension, diabetes. In the logistic model the only factor retaining significant association with perinatal mortality in this high risk population was chronic
hypertension (OR=3.9, 95% C.I.= 1.1-13.4).
Conclusion: Chronic hypertension preceding pregnancy in AA women is threat to their pregnancy with a significant association to perinatal mortality. This risk association needs to be
addressed during inter-conceptional care, and dealt with effectively during pregnancy.
Acknowledgement and sources of funding: The National institute of Child Health and Human
Development, and the NIH Center for Research on Minority Health and Health Disparities.
Conflict of interest: None of the authors have any conflict of interest to declare.
7
THE RISK OF LATE STILLBIRTH IN OLDER WOMEN
Ruth C Fretts MD, MPH,
Obstetrics and Gynecology, Assistant Professor Harvard Medical School and Harvard
Vanguard Medical Associates, Boston MA.
Introduction: The risk of late stillbirth has been under-appreciated especially for older women.
Much attention has been paid to the detection of chromosomal anomalies that occur in older
women. In the United States there are more than 5 different strategies available to women for
the detection of chromosomal anomalies, serial sequential screening, first trimester screening, second trimester screening and invasive testing. The screening for Down’s Syndrome has
been the subject of large prospective trials including 40,000 participants.
Objective: We undertook this analysis to compare the risks of late stillbirth of normally formed
babies late in pregnancy from a paper previously published by Reddy et al and compared the
rate of these losses to other obstetric outcomes.
Results:
Maternal Age Risk of Trisomy
at Delivery
21
Risk of any Risk of stillbirth
Chromosomal after 37 weeks
Abnormality
Multipara
Risk of stillbirth
after 37 weeks
Nulliparous
20 to 34
1/1667-1/485*
1/562-1/538*
1/775
1/269
35-39
1/378
1/192
1/502
1/156
40+
1/106
1/66
1/304
1/116
Rates of Stillbirth by Maternal Age and Gestational Age
Estimates range from 20 years to age to 34 years of age*. Adapted from Hook EB Rates of
chromosome abnormalities at different maternal ages. Obstetrics and Gynecology(1981) reference 14 and from Reddy UM et al. maternal age and the risk of stillbirth throughout pregnancy
in the United States. AJOG 2006
Conclusions: The comparison of data suggests that the magnitude of losses of normal-
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ly formed babies late in pregnancy warrant a large randomized trial to assess the risk and
benefits prevention and intervention strategies.
The author reports no funding or conflicts of interest in the presentation of this paper.
REDUCTING STILLBIRTH IN DEVELOPING AND
DEVELOPED COUNTRIES.
Ruth C Fretts MD, MPH, Department of Obstetrics and Gynecology, Harvard Vanguard Medical
Associates and Assistant Professor, Harvard Medical School, Boston MA;J.Frederik Frøen,
Associate Professor, MD, Norwegian Institute of Public Health; Vicki Flenady CNM, MMedSc
Mater Mothers’ Hospital and University of Queensland, Brisbane, Australia. Corresponding
author: [email protected].
Introduction: There are significant differences in the magnitude of stillbirths and the types of
stillbirth seen in developing and developed countries. We present a review on the most common
causes of stillbirth and strategies for prevention in both developing and developed countries.
Developed Countries
Intrapartum related stillbirths
Unexplained stillbirths
Hypertension related stillbirths
Stillbirths in growth restricted babies
with evidence of placental dysfunction
Infections, (placental and ascending)
Abruptio Placenta with or without hypertension
Congenital anomalies
Congenital anomalies
Strategies for Prevention
Strategies for Prevention
Develop a system of registering all
stillbirths including a death certificate
that captures key maternal and obstetric
information. Improve data collection from
the stillbirth including a cost effective
fetal and maternal evaluation.
Improve access and quality of obstetric
care for minorities, recent immigrants,
poor and less educated women.
Improve management in the intrapartum
period with trained birth attendants.
Develop infrastructure that improves the
transportation of patients to a center
that can perform a cesarean section and
administer antibiotics to reduce the risk
of obstructed/prolonged labor and associated asphyxia, infection and birth injury.
Screening for congenital/karyotypic
anomalies with the availability of termination of pregnancy
Antepartum care to assess hypertensive
disease of pregnancy and improve management of pre-eclampsia/eclampsia
Promote healthy habits with smoking
cessation and optimal weight before and
during pregnancy.
Encourage longer intervals between
pregnancies with the availability of contraceptive technologies.
Reduction of multiple gestations by
reducing the number of embryos transferred in the reproductive technologies
Screen and treat acquired infections
especially syphilis malaria and Gram
negative infections
Improve strategies for the detection and
management of fetal growth restriction
Improve nutritional status (folic acid, iron,
calcium)
Optimise the management of decreased
fetal movement in the preterm and term
pregnancies.
Screen for congenital anomalies and
increase access to terminations of pregnancy.
Improve the management of hypertensive
disease/preeclampsia and other medical
diseases such as diabetes, systemic lupus erythematosus, renal disease, thyroid
disorders, thrombophilias, cholestasis of
pregnancy, and issues related to multiple
medical risk factors and late pregnancy.
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8
Improve the detection and management
of fetal growth restriction
Improve data collection and audit processes including cost effective fetal and
maternal evaluation and revision of death
certificate COD following full investigation
The authors of this paper have no conflicts of interest, nor funding to report.
9
MATERNAL HEMOGLOBIN VALUES AT HIGH ALTITUDE AND
STILLBIRTH RATES
Gustavo F. Gonzales1, M.D., D.Sc.
1
Department of Biological and Physiological Sciences. Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia
Summary: Background Some 140 million persons live permanently at >2500 m in America,
East Africa, and Asia. The World Health Organization has recommended that the cutoff
to define anemia should be corrected at high altitude (HA), where hemoglobin levels are
increased to compensate hypoxia. To date little is known about the association of both low
and high hemoglobin levels with fetal outcome at HA. This study examines the relationship
between maternal hemoglobin and stillbirth rates at HA.
Methods: We studied 35,449 pregnancies of women from public hospitals in Lima (150 m)
and six cities above 3000 meters (3,070 – 4,340 m). Anemia was defined as hemoglobin
values <110 g/L. Moderate and severe anemia was defined as values between 70–89 g/L
and <70 g/L, respectively.
Findings: Uncorrected for altitude, the relation of anemia to birth outcomes did not change
substantially between Lima and HA. An analysis combining Lima with the six HA cities, after adjustment for confounders, showed that severe to moderate anemia had odds ratios
of 4.8 (3.1-7.2), 2.3 (1.7-3.0), and 1.5 (1.1-1.9) for stillbirths, pre-term, and SGA births respectively, compared to women with normal Hemoglobin (110-129 g/L). Further exploration of high hemoglobin levels among women living at HA revealed that hemoglobin >155
g/L had odds ratios of 1.3 (1.1-1.8), 1.6 (1.4 -1.9), and 2.0 (1.8–2.3) for stillbirths, pre-term
births, and SGA births respectively.
Interpretation: Both low (Hb<90 g/L) and high (Hg>155 g/L) maternal hemoglobin values at HA were related to high stillbirth rate.
10
MISSED OPPORTUNITIES? A RETROSPECTIVE ANALYSIS OF
THE MANAGEMENT OF STILLBIRTH IN A UK OBSTETRIC UNIT
BETWEEN 2006-2007.
Heazell; Alexander (1,2), Claire Jackson (3), Uzma Nafees (2), Gillian Stephen (2), Elizabeth
Martindale (2)
1. Maternal and Fetal Health Research Group, University of Manchester, UK.
2. Department of Obstetrics and Gynaecology, Royal Blackburn Hospital, East Lancashire
Healthcare NHS Trust, Blackburn, UK.
3. Department of Clinical Audit, Royal Blackburn Hospital, East Lancashire Healthcare
NHS Trust, Blackburn, UK.
Introduction: The incidence of stillbirth in the UK has not decreased for 10 years, affecting 0.53%
of pregnancies after 24 weeks gestation. The incidence of stillbirth is increased by social deprivation and in ethnic minority groups. A recent study highlighted evidence of suboptimal care in
pregnancies complicated by stillbirth, particularly in ethnic minorities. Our unit cares for a socially and ethnically diverse population providing challenges in the management of stillbirth.
Objective: To evaluate antenatal and postnatal care provided in cases of stillbirth.
Methods: A retrospective review of 71 stillbirths in East Lancashire Hospitals from
1/1/2006-31/12/2007.
Results: The median gestation of stillbirth was 35 weeks (Range 24-42). 49% of stillbirths
occurred in patients from ethnic minority groups. English was not the preferred language
in 25% of cases. 17% of cases occurred in consanguinate relationships. Antenatal risk
factors for stillbirth were assessed in 91-100% of cases. Stillbirths were associated antenatally with pre-eclampsia (17%), intra-uterine growth restriction (12%) and diabetes (3%).
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Growth was assessed with customised growth charts (CGCs) in 27% of cases. At delivery,
57% of infants were small for gestational age.
In the postnatal period, 30% of patients had an invasive post-mortem and 51% had placental
histology. 89% had maternal blood investigations, although these were only comprehensive in
11% of patients. 70% of patients were seen for counselling and review of investigations after
the stillbirth, 6% of patients declined to see a clinician. Using the Wigglesworth classification
59% of stillbirths were unexplained, this decreased to 19.7% using the ReCoDe classification.
Conclusion: – This study identified aspects of care that could be improved in cases of stillbirth. Our plan to improve care includes : 1) Increased use of CGCs, 2) A leaflet to explain
postnatal investigations and 3) Implementation of the ReCoDe classification.
Source of Funding – This study was funded by East Lancashire Hospitals NHS Trust.
There are no conflicts of interest for the authors of this study.
EXAMINATION OF THE PLACENTA FOLLOWING
STILLBIRTH – CAN HISTOPATHOLOGY HELP DETERMINE
THE CAUSE OF STILLBIRTH?
Alexander Heazell (1,2), Elizabeth Martindale (2)
1. Maternal and Fetal Health Research Group, University of Manchester, UK.
2. Department of Obstetrics and Gynaecology, Royal Blackburn Hospital, East Lancashire
Healthcare NHS Trust, Blackburn, UK.
Introduction – Effective placental function is essential for the maintenance of healthy
pregnancy. Placental dysfunction is thought to be involved in a significant proportion of
stillbirths, particularly those complicated by intra-uterine growth restriction. Recently, the
ReCoDe classification included histological evidence of chorioamnionitis and ‘placental
insufficiency to aid categorisation of stillbirths.
Objective – To investigate whether placental measurements and histology assist with determining the cause of stillbirth.
Methods – A retrospective case note review of stillbirths in East Lancashire Hospitals from
01/01/2006 to 31/12/2007.
Results – The placenta was examined in 38 (54%) of cases. In these 38 cases, the median
customised birthweight centile (CBC) was 1 (Range 0-100); 68% of cases had CBC < 10.
The median fetal : placental weight ratio was 5.6 (Range 1.3-14.3). The placentas studied here were not discoid. The median difference between the two longest axes was 20%
(Range 0-70), one placenta had an eccentric cord insertion. The most common histological
abnormalities were infarction, decreased villous vascularity, perivillous fibrin deposition
and focal calcification. Placental infarction was present in 16 (42%) of cases; and was
greater in cases with an IBC < 10 (Figure 1A, ** p<0.01). Decreased vascularity of fetal
villi was present in 6 (16%) of cases; there was no statistically significant decrease in villous vascularity in pregnancies with an IBC < 10 (Figure 1B, p=0.053). 4 (11%) cases had
histological evidence of chorioamnionitis. Histological assessment aided the classification
in 23 (61%) of cases of stillbirth.
Conclusions – Detailed assessment of the placenta, particularly histopathological assessment of villous morphology can aid classification of stillbirth. Further studies are required
to determine differences between placentas from live and stillborn infants. Such studies
may highlight changes which underly the origins of stillbirth.
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12
MATERNAL OBESITY AND ANTEPARTUM FETAL DEATH:
A POPULATION-BASED STUDY IN URUGUAY
Alicia Matijasevich (1), Fernando C. Barros (2), Adriana Decker (3), Dorcas Taylor (3),
Michael S. Kramer (3, 4)
1 Post-graduate Program in Epidemiology, Federal University of Pelotas, Brazil
2 Catholic University, Pelotas, Brazil
Departments of (3) Epidemiology & Biostatistics and of (4) Pediatrics, Mc Gill University,
Faculty of Medicine, Montreal, Quebec, Canada
Introduction: In Uruguay, in the recent years, fetal mortality rates have shown a very slow
decline. At the same time, overweight and obesity have become increasing health problems, especially in women at reproductive age.
Objective: to examine the influence of maternal pre-pregnancy obesity, height and
weight gain during pregnancy on antepartum fetal death (APFD) in Uruguay taking into
account several potential confounding factors.
Methods: This population-based, historical cohort study included 2814 fetal deaths -1786
APFD, 263 intrapartum fetal deaths and 765 deaths with unknown timing of death- and 326
080 live births of the public and private maternity hospitals of Uruguay from 1992 to 2001.
The analysis excluded multiple births and fetal deaths with less than 20 completed weeks
of gestational age.
Results: In the adjusted analysis obese women (pre-pregnancy body mass index, BMI, ≥30 kg/
m2) showed an increased risk of antepartum fetal death relative to women with BMI 18.5-<25
kg/m2 (OR 1.40, CI 95% 1.16, 1.68, P<0.001). Women with low weight gain rate during pregnancy (<0.18 kg/week) showed increased risk of APFD relative to those gaining 0.25-<0.35 kg/
week, and maternal height did not show an association with APFD. When women with chronic
hypertension and pregnancy-related complications were excluded from the analysis, prepregnancy obesity continued to be associated with APFD showing that the risk of APFD among
obese women was independent on the presence or not of such complications.
Conclusions: The high prevalence of obesity in women of reproductive age in Uruguay, and
the association found with APFD is a cause for concern. Pre-pregnancy obesity is one of
the most important preventable factors for APFD in this population.
Acknowledgements: PAHO/WHO, Uruguay, made the database available for those analyses.
There are no conflicts of interest
13
FOLLOW-UP AND OUTCOME OF PREGNANCY AFTER 2ND OR
3RD TRIMESTER FETAL DEATH
Amélie Nguyen, Evelyne Cynober, Marie Gonzales, Vanina Castaigne, Bruno Carbonne
Department of Obstetrics and Gynecology, Hôpital Saint-Antoine, Paris, France
Introduction: Fetal death is considered at high risk of recurrence
Objective: To describe the follow up and outcome of pregnancy after 2nd or 3rd trimester fetal death
Methods: Women with a history of 2nd or 3rd trimester fetal death were seen during preconception period, and then monitored prospectively during the next pregnancy. Follow-up
and treatments were decided according to the main cause of fetal death when known. The
main outcome criterion was a recurrence of fetal death.
Results: seventy consecutive pregnancies were followed in 55 women with ≥ 1 previous fetal death during the 2nd trimester (27 pregnancies) or 3rd trimester (43 pregnancies). The
cause of previous fetal death was unknown (15 cases), vascular (43), ovular or funicular
(8), or related to morphologic anomaly (4). Seven recurrences of fetal death were observed,
of which 3 occurred in the same woman. All recurrences but one were associated with
fetal growth retardation and were considered of vascular origin. One was associated with
a Down syndrome. Four out of the 7 recurrences occurred in women with > 1 previous
fetal death (relative risk 10.7 [1.5 - 80.5]). However, no recurrences were observed when a
maternal thrombophilia was found and treated (29 cases), even in cases with more than 1
previous fetal death.
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Conclusion: The main criterion associated with the risk of recurrence was multiple previous
fetal deaths (>1). An identified and treated thrombophilia could be of good prognosis.
STILLBIRTHS IN SWITZERLAND BETWEEN 1979 AND 2006
Katharina C. Quack Loetscher (1), Matthias Bopp (2), Ursula Ackermann-Liebrich (3)
Clinic of Obstetrics, University Hospital Zurich, Switzerland
Institute of Social and Preventive Medicine, University of Zurich, Switzerland
Swiss School of Public Health+, Zurich, Switzerland
14
Introduction: The stillbirth rate is an important indicator for health care in a population.
In Switzerland, certificates of life and stillbirth are analysed in detail since 1979, including
the information on trends and influencing factors.
Objectives: To describe the stillbirth rates in Switzerland from 1979 - 2006 and whether a
change by maternal age, nationality and causes of death has occurred.
Methods: We analysed all birth certificates of stillbirth form the Federal Office of Statistics
by maternal age, nationality of the mother and cause of death. Stillbirth rates were calculated by number of stillbirth divided by all born infants in the same year.
Results: Between 1979 and 2006, 8’874 stillbirths and 2’181’191 live infants were born
in Switzerland. Overall, the stillbirth rate (per 1000 born infants) decreased from 5.1 in
1979/82 to 3.5 in 2003/06 (-31%). Differences in the decrease were not the same in all
age groups, i.e. while for mothers younger than twenty years it decreased from 8.0 to 3.8
(-53%), the decrease in mothers above 40 was 12.4 to 5.0 (-60%). The improvement was
more pronounced for infants from non-Swiss mothers (7.0 to 4.0, -43%) compared to infants from Swiss mothers (4.7 to 3.2, -32%). Placental and/or umbilical cord dysfunction
remained the most common cause of death over the whole period with a decreasing rate
of 36% (1979/82) to 32% (2002 - 2005).
Conclusion: With 3.5 per thousand in 2003-06, Switzerland has a higher stillbirth rate
than the Scandinavian countries, more similar to Southern European countries like Italy
(3.1), Spain (3.2) and Portugal (3.4). The improved stillbirth rates in known risk groups have
contributed to the decreasing rates over the last decades. However, all these risk groups
have still higher stillbirth rates than the average population.
Acknowledgement and sources of financing: Fonds fuer Akademischen Nachwuchs
(FAN), University of Zurich, Switzerland
RISK OF UNEXPLAINED INTRAUTERINE DEATH IN TWINS:
A REGISTER-BASED STUDY
Madhumi Obeysekera (1), Svetlana V. Glinianaia (1), Ruth Bell (1)
1. Institute of Health and Society, Newcastle University, UK
Introduction: The risk of antepartum stillbirths is much higher in twins than in singletons
with a substantial proportion of unexplained stillbirths. Little is known about the risk of
genuinely unexplained stillbirth by chorionicity on a population base.
Objectives: To determine the contribution of unexplained stillbirths to stillbirth rate in
twins, and to compare the risks of unexplained stillbirth in dichorionic (DC) and monochorionic (MC) twin pregnancies.
Methods: The study population included 3585 twin maternities (twin pregnancies with at
least one stillbirth or live birth, 7170 twins) delivered in the Northeast of England during
1998-2005. Data were obtained from the population-based Northern Survey of Twins and
Multiple Pregnancies (NorSTAMP). Ascertainment is from the earliest antenatal scan on
which a multiple pregnancy is detected. Final diagnosis of chorionicity is based on placental examination and histology.
Results: The antepartum stillbirth rate in twin maternities was 17.8 per 1000 twins. Cho-
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rionicity was determined in 90% of twin maternities. In MC twins, the antepartum stillbirth
rate was 50.6 per 1000 compared to 9.6 per 1000 in DC twins (Rate Ratio, RR=5.3, 95% CI
3.7-7.5). Among antepartum stillbirths with unexplained cause of death (39% of all causes),
the rate in MC twins was 11.9 compared to 5.1 per 1000 in DC twins (RR=2.3, 95% CI 1.34.3). In preterm twins (<37 weeks of gestation), the risk of unexplained stillbirth was significantly higher in MC than in DC twins, while in term twins the risk was comparable.
Conclusion: Compared to DC twins, MC twins have significantly higher risk of antepartum
stillbirth, including those with unexplained cause of fetal death. The higher risk for MC
twins was restricted to preterm twins.
Acknowledgements and sources of financing: We acknowledge the contribution of all the
North of England district convenors and coordinators to the NorSTAMP.
Conflicts of interest: There are no conflicts of interest.
Characters (with spaces) count: 1988
16
PARTICULATE AIR POLLUTION AND RISK OF STILLBIRTH:
THE UK PAMPER STUDY, 1961-92
Mark S. Pearce (1,2), Svetlana V. Glinianaia (1), Judith Rankin (1), Tanja Pless-Mulloli (1)
Presented by Madhumi Obeysekera
1. Institute of Health and Society, Newcastle University, UK
2. School of Clinical Medical Sciences (Child Health), Newcastle University; UK
Introduction: A growing body of evidence suggests that exposure to ambient air pollutants
can adversely affect the growth and development of the fetus. Much less is known regarding the potential for an association between black smoke (BS) air pollution and stillbirth
risk.
Objectives: To examine the relationship between BS air pollution and stillbirth risk using
individual-level data from the Particulate Matter and Perinatal Events Research (PAMPER)
cohort study of all singleton births in Newcastle upon Tyne during 1961-92.
Methods: Weekly BS levels were obtained from routine data recorded at 20 air pollution
monitoring stations over the study period. A two-stage statistical modelling strategy was
used, incorporating temporally and spatially varying covariates to estimate BS exposure
during each trimester and for the whole pregnancy period for each individual pregnancy.
Associations between BS exposure and stillbirth risk were estimated using logistic regression, adjusting for potential confounders.
Results: The PAMPER database consists of 90,537 births with complete gestational age
information, of which 812 were stillborn. Using a linear term for BS exposure, an odds
ratio of 1.04 per each 10 (μg/m3) increase in BS levels (95% CI 1.035-1.051) was estimated.
However, this association was shown to be non-linear. Using fractional polynomials and
adjusting for year of birth, parity, sex and Townsend deprivation score, the significantly
increased risk with increasing BS exposure during pregnancy remained.
Conclusion: This large study over a 30 year period has shown an association between
BS exposure during pregnancy and risk of stillbirth. If causal, this would be of particular
relevance to parts of the world with high levels of BS seen in Newcastle early in the study
period.
Acknowledgements and sources of financing: The study was funded by the UK charity,
the Wellcome Trust, grant No 072465/Z/03/Z.
Conflicts of interest: There are no conflicts of interest.
Character (with spaces) count: 1982
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DECREASING PERINATAL MORTALITY IN THE NETHERLANDS, 2000-2006: THE IMPACT OF RISK FACTORS
Anita C.J. Ravelli (1), Miranda Tromp (1), Marian van Huis (2), Eric AP Steegers (3), Pieter
Tamminga (4) Martine Eskes (1), Gouke J Bonsel (5)
1) Department of Medical Informatics, Academic Medical Center, Amsterdam, the Netherlands
2) Department of Obstetrics & Gynecology, Academic Medical Center, Amsterdam, the Netherlands
3) Division of Obstetrics and Prenatal Medicine, University Medical Center, Rotterdam, the Netherlands
4) Department of Neonatology & Pediatrics, Academic Medical Center, Amsterdam, the Netherlands
5) Department of Health Policy and Management, Erasmus MC, Rotterdam, the Netherlands.
17
Introduction: The PERISTAT-1 study showed that perinatal mortality, especially fetal mortality, is substantially higher in the Netherlands as compared to other European countries.
Civil registration issued crude perinatal mortality data showing a decline in Dutch perinatal mortality since 2000.
Objectives: To describe the trend in Dutch perinatal mortality and the impact of risk factors.
Methods: Retrospective national cohort study of 1,246,440 singleton births in 2000-2006.
The cohort dataset has been created by a validated probabilistic record linkage algorithm
of the three health care registries (midwives, obstetricians and pediatricians) without a
personal identifier. Perinatal mortality is defined as the sum of stillbirth and early neonatal mortality (less than 7 days) from gestational age 22.0 weeks onwards. Prevalence and
impact of risk factors on perinatal mortality were analysed using logistic modeling.
Results: Perinatal mortality declined from 10.55 to 9.05 per 1000 total singleton births.
A calendar year effect OR 0.95 (95%CI 0.94-0.97) was still visible after full adjustment
for risk and intermediate risk factors. The most significant adjusted risk factors were
maternal age <20 years (OR 1.57 (95%CI 1.41-1.75)), age ≥ 40 years (OR 1.53 (95%CI
1.39-1.68)), parity 4+ (OR 1.97 (95%CI 1.78-2.18)), non-Western ethnicity (OR 1.40 (95%CI
1.33-1.47)), assisted conception (OR 1.71 (95%CI 1.54-1.90)) and maternal medical condition (OR 1.59 (95%CI 1.52-1.68)). There was a negative interaction between year and
gestational age ≥37.0 weeks, birth weight ≥2500 gram, non severe congenital anomalies
and term breech.
Conclusions: The decline in Dutch perinatal mortality could be partly explained by changes in impact of risk factors. Indications exist for improvement in health care.
Acknowledgements: The authors would like to thank all Dutch perinatal health care providers and the Foundation of the Dutch Perinatal Registry .
ETHNIC DIFFERENCES IN FETAL MORTALITY IN THE
NETHERLANDS
ACJ Ravelli (1), M Tromp (1), M Eskes (1), JC Droog (2), JAM van der Post (3), KJ Jager (1),
BW Mol (3), JB Reitsma (4)
1. Department of Medical Informatics, AMC, Amsterdam, The Netherlands
2. Department of Obstetrics and Gynaecology, Leiden, The Netherlands
3. Department of Obstetrics and Gynaecology, AMC, Amsterdam, The Netherlands
4. Department of Clinical Epidemiology, AMC, Amsterdam, The Netherlands
Introduction: Fetal mortality in The Netherlands is known to be high compared to other
European countries.
Objective: To describe differences in fetal mortality between women of different ethnic
origin and to explore if the prevalence of risk factors for fetal mortality known early in
pregnancy could explain any differences.
Methods: This was a population based cohort study. We analysed 554.234 singleton births
of nulliparous women over the period 2000-2006 from the national linked midwifery, obstetrics and neonatology registries in the Netherlands. The outcome measurement was
fetal mortality from 24.0 weeks onwards. The prevalence of demographic, socio-economic,
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behavioural and biological risk factors for fetal mortality was analysed for different ethnic
groups. In addition, logistic modelling was used.
Results: Over the period 2000-2006 fetal mortality was 5.7 per 1000 births in the Netherlands. In Surinamese-Creole and Surinamese-Hindustani fetal mortality was twice as
high and in Moroccan/Turkish women and other non-Western it was increased by 33%,
50% respectively compared to native Dutch women. Many risk factors for mortality were
more prevalent among these groups such as teenage pregnancy, living in an urban area,
low socio-economic status and pre-existing diseases like hypertension and diabetes mellitus. Adjusted for these risk factors the odds ratio (OR) of ethnicity on fetal mortality was
for Surinamese-Creole 1.9 (95%CI 1.6 to 2.3), for Surinamese-Hindustani 1.9 (95%CI 1.4
to 2.5), for Moroccan/Turkish 1.3 (95%CI 1.1 to1.5) and for other non-Western women OR
1.6 (95%CI 1.4 to 1.8).
Conclusion: There are important ethnic differences in fetal mortality in the Netherlands
with increased risk among women of African or South Asian origin. These differences
could not be explained by risk factors assessed early in pregnancy. Further study is needed in different gestational age groups to assess how risk factors contribute to increased
mortality risk.
Acknowledgements and sources of financing: The authors would like to thank all Dutch
midwives, obstetricians, neonatologist and other perinatal health care providers for the
registration of perinatal information. We also like to thank the Foundation of the Dutch
Perinatal Registry for the permission of using the registry data.
Conflict of interest: none
19
UMBILICAL VEIN CONSTRICTION: NEGLECTED REASON
FOR PRENATAL COMPLICATIONS
Agnes Christine Schwarze (1,2), Svein Magne Skulstad (1,2), Svein Rasmussen (1,2,3),
Torvid Kiserud (1,2)
1. Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen,
Norway
2. Department of Clinical Medicine, University of Bergen, Bergen, Norway
3. Medical Birth Registry of Norway, Locus of Registry Based Epidemiology, University of
Bergen and the Norwegian Institute of Public Health, Bergen, Norway
Introduction: Causes of sudden antenatal death (SAD) are poorly understood. Umbilical
cord complications have been discussed as one possible mechanism.
Objectives: To test the hypothesis that umbilical vein (UV) constriction at the umbilical ring
(UR) is a risk factor affecting fetal hemodynamics and perinatal outcomes.
Methods: High-risk pregnancies referred for Doppler assessment had also an evaluation of
the UV. UV blood velocities >90 centile for GA at the umbilical ring was defined as constriction
and included in the present study. Placental weight and fetal outcome were noted. Standard
deviation score (SDS), Fisher exact test and Chi square test were used to determine the effect
of UV constriction to hemodynamics and fetal outcome compared to low-risk pregnancies.
Results: 20 fetuses (18 singelton, 2 twins) were included. SDS for UV velocities at UR were
1,702 (95% CI: 1,269-2,135; p<0.0001). In these fetuses UV diameter at UR was decreased,
whereas intra-abdominally increased (SDS: -1,716 (95% CI: -2,505--0,928), p<0.0001 vs.
SDS: 4,838 (95% CI: 4,26-5,416), p<0.0001). Placental-/birthweight ratio was enlarged in fetuses with UV constriction (SDS: 4,079 (95% CI: 3,226-4,933), p<0.0001). 3 trisomy 21 (T21),
4 SAD’s (1xT21) and 1 induced abortion (T21) were observed. T21’s and twins were excluded
from further analysis. Occurrence of SAD (3/15 vs. 0/381), IUGR< 5th centile (6/15 vs.9/375)
and prematurity < 32nd weeks (4/15 vs.2/381) were related to UV blood velocities >90 centile (p<0.0001). 25% of these fetuses had APGAR-scores at 1 and 5 minutes <7 vs. 3.5% and
0.3% (p<0.0001). No significant difference was found regarding fetal gender (p=0.604).
Conclusion: Extreme venous constriction at the umbilical ring affects fetal hemodynamics
and is associated with increased perinatal complications and fetal death.
Acknowledgements and sources of financing: This study was funded by Norwegian SIDS
and Stillbirth Society.
.
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DISTINCT REGIONAL DIFFERENCES IN PERINATAL
MORTALITY IN THE NETHERLANDS
Miranda Tromp (1), Martine Eskes (1), Johannes B. Reitsma (2), Jan Jaap H.M. Erwich(3), Hens
A.A. Brouwers (4), Greta C. Rijninks-van Driel (5), Gouke J. Bonsel (6), Anita C.J. Ravelli(1)
Department of Medical Informatics, Academic Medical Centre, Amsterdam, The Netherlands.
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands.
Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands.
Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands.
Department of Health Policy and Management, Erasmus MC, Rotterdam, The Netherlands.
20
Introduction: Perinatal mortality is an important indicator of health. International comparisons
of perinatal mortality show variation between countries, with an unfavourable position for the
Netherlands. The observed differences in perinatal mortality across Europe are difficult to explain unequivocally because of many potential reasons like variation in registration practice,
variation in definitions and variations in demographic structure. On the national level fair comparisons can be achieved more easily.
Objective: To study the regional variation in perinatal mortality of singletons in the Netherlands
for the period 2000-2004.
Methods: Our study population comprised of all singleton births (906,152) derived from the
Netherlands Perinatal Registry for the period 2000-2004. Perinatal mortality including stillbirth
from 22.0 weeks gestation and early neonatal death (0-6 days) was our main outcome measure.
Differences in perinatal mortality were calculated on the level of 4 geographical regions (Figure
1); region west is the most urbanized and densely populated region. Differences were analysed
both unadjusted and adjusted for demographic and socio-economic factors.
Results: Overall, perinatal mortality was 10.1 per 1,000 total births over the period 2000-2004.
Perinatal mortality was higher in the northern region (11.2 per 1,000 births). Both stillbirth
and early neonatal death were elevated in region north. Adjustment for demographic factors
increased the perinatal mortality risk in region north (odds ratio 1.2, 95% CI 1.1-1.3, compared
to reference region west), subsequent adjustment for socio-economic status and urbanization
only explained a small part of the elevated risk (odds ratio 1.1, 95% CI 1.1-1.2).
Conclusion: Regional differences in perinatal mortality exist in the Netherlands. These differences could not be explained by demographic or socio-economic factors.
Acknowledgements and sources of financing: We gratefully acknowledge the investment of
numerous caregivers in the Netherlands providing the registry information. We thank The Netherlands Perinatal Registry (www.perinatreg.nl) for her permission to use the data. No funding.
CARE IN ADVERSE OUTCOME VERSUS UNEVENTFUL
OUTCOME: A RESEARCH PROTOCOL
Rijninks , Greta C. (1) & Joris A.M. van der Post (1)
Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
Introduction: Perinatal audit of cases of perinatal mortality will be implemented nationally in
the Netherlands in 2009. One of the outcome of perinatal audit is the identification of substandard care-factors. It is assumed that substandard care-factors in cases of perinatal mortality
are a proxy for all cases with adverse outcome; however this has never been the subject of research, nor is it compared with cases with uneventful outcome. Because of the small incidence
of perinatal mortality in low risk population, audit of mortality seems a less suitable quality instrument for these health care providers. Because of underreporting effort has to be designated
to complete the mortality group. We assume that the instrument audit performs irrespective of
the three groups.
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Objectives: To propose a study to have the opportunity to discuss the design of the study
and to initiate discussion about the most appropriate design for perinatal audit as a quality
instrument to reduce sub-standard care factors and improve perinatal outcome. To compare the percentage of substandard care-factors in three groups: mortality, morbidity and
controls with uneventful outcome
Setting and population: Singletons without congenital malformations from the prospective collected ABCD cohort, collected between 2003 and 2004 in Amsterdam, the Netherlands. From this cohort 6497 women gave permission to add data from the Dutch Perinatal
Registration (PRN) providing comprehensive data on pregnancy and pregnancy outcomes.
In this group cases for audit will be identified.
Methods: Execute a systematic audit of cases of perinatal mortality, morbidity and controls. We defined morbidity as preterm birth between 22 and 34 weeks gestation, Small for
Gestational Age (< P 2,3) and birth with a 5-minute Apgar below 7. We will also add a random selected control group with uneventful outcome. Controls will be selected as the next
birth without uneventful outcome in the same practise or hospital as every third case per
morbidity group. The multidisciplinary audit team will consist of obstetricians, midwives,
paediatricians, General Practitioners, nurses and a pathologist. Plenary audit sessions will
be executed in obstetric cooperation of midwifery practices and the obstetric and neonatal
departments of the hospital they mostly refer to.
Research hypothesis: Our hypothesis is that in the mortality group will have the same
amount of substandard care factors as in the morbidity group or the controls. If our hypothesis is confirmed, perinatal audit could be performed in a stratified random selection
of cases of these three groups in stead of only the mortality group.
Acknowledgements and sources of financing: The research is funded by Department of
Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
22
STILLBIRTHS AMONG MIGRANTS IN EUROPE
Mika Gissler1, 2, Sophie Alexander3, Alison Macfarlane4, Rhonda Small5, Babill StrayPedersen6, Jennifer Zeitlin7, Megan Zimbeck7, Anita Gagnon8, 9 for the ROAM collaboration
(Reproductive Outcomes and Migration: An International Research Collaboration)
1 STAKES National Research and Development Centre for Welfare and Health, Helsinki,
Finland
2 Nordic School of Public Health, Gothenburg, Sweden
3 Université Libre de Bruxelles, Brussels, Belgium
4 City University of London, United Kingdom
5 Mother & Child Health Research, La Trobe University, Melbourne, Australia
6 University of Oslo, Faculty of Medicine, Div OB/Gyn, Rikshospitalet, Oslo Norway
7 INSERM, UMR S149, Epidemiological Research Unit on Perinatal and Women’s Health,
Paris, France
8 McGill University, Montreal, Canada
9 McGill University Health Centre, Montreal, Canada
Background: Studies on perinatal health outcome among migrants are contradictory.
Some migrant groups have similar or even better infant outcomes than children from the
receiving country, but several studies have reported increased risk for adverse infant outcomes for some other migrant groups. Most migrant studies on newborn outcomes have
investigated outcomes other than stillbirth.
Methods: We conducted a literature review to identify migrant groups in European countries with increased stillbirth risk.
Results: Of the eight observed studies from Italy, the Netherlands, Norway, Spain and
Sweden, four studies reported worse outcomes and four reported no differences compared
to the receiving country population. Registered refugees or women originating from refugee source countries (at the time of their arrival) had raised stillbirth rates (RR=2.01, 95%
CI 1.47-2.73). Similar risk was also found for non-refugee migrants from non-European
countries (RR=1.88, 95% CI 1.58-2.23), but not for migrants originating from other European countries (RR=0.90, 95% CI 0.75-1.08). We found no studies analysing causes of
stillbirths among migrants. The increased stillbirth rates among some migrant groups can
be related to restricted access to screening, but also to diverging attitudes to screening,
termination of pregnancy and consanguinity.
Conclusion: To better understand the variation in migrants’ risk for stillbirth, better infor-
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mation is needed about migrants’ background, such as migrant status and reasons for migration. The impact of biological, medical, demographic, and socioeconomic risk factors should be
analysed in more detail.
Acknowledgements and sources of financing: We acknowledge the support to ROAM of a Canadian Institutes of Health Research International Opportunities Collaborative Research Project Grant (2006-2007).
HISTORY OF CESAREAN SECTION AND STILLBIRTH
INCIDENCE: EVIDENCE FROM A POOR AND MIDDLE
INCOME POPULATION IN INDIA.
Sreevidya Subramoney1,2 and Prakash C Gupta2
Doctoral student, Sahlgrenska Akademin, Goteborg University, Sweden
Healis Sekhsaria Institute for Public Health, Navi Mumbai, India.
23
Introduction: The association between a prior cesarean delivery and a subsequent stillbirth has
been controversial. Community-based epidemiological data on stillbirth risk from a previous
cesarean from developing countries are scarce.
Objective: We examine the association between prior cesarean delivery and risk of stillbirth in
a subsequent singleton pregnancy.
Methods: A cohort of 1217 pregnant women who were recruited on a house-to house basis in Mumbai,
India were followed up after delivery at their residences. Adjustment for the effect of other determinants
was through Cox regression, using gestational age in days as the time scale.
Results: Of 844 women that had experienced previous pregnancies, 10.4% had a previous cesarean section. The incidence of stillbirths in the index pregnancy was 3.8% without a previous cesarean and 9.2% with a previous cesarean. The determinant variables for inclusion in
the regression model were selected by forward stepwise cox regression (p value for inclusion
of a variable = 0.05, p value for subsequent removal = 0.1) in three blocks; the demographic,
maternal variables and tobacco use in the first; history of previous stillbirth, previous cesarean
and inter-pregnancy interval in the second; and complications in the current pregnancy and
antenatal care in the third. The final model included age of mother and smokeless tobacco use,
pregnancy interval and previous cesarean, number of TT doses and history of bleeding episodes
during the index pregnancy. The adjusted risk for stillbirth in women with a previous cesarean
was 3.14 (95% CI 1.4-7.0).
Conclusion: Our analysis detected a highly significant association between previous cesarean
section and subsequent stillbirth, after adjustment for important maternal and obstetric risk
factors, and use of health care. The high rate of cesarean section in vulnerable low and middleincome populations underscores its great public health importance.
Acknowledgements and sources of financing: We thank the BrihanMumbai Municipal Corporation for facilitating this study and WHO SEARO for financing it.
Is fetal life riskier than neonatal life?
Jagjit Teji, William Meadow. Pediatrics, University of Chicago and Mercy Hospital, Chicago, IL, USA.
Background: Perinatal statistics are reported as a gestational-age based mortality, either as
stillbirth or neonatal mortality rate. There are no data on the outcome of pregnancies comparing the mortality risk whether intra- or extra-uterine for each gestational age.
Objective: The aim of this study is to compare risk for fetal death, greater than or equal to 20
weeks gestation, and neonatal death, less than 28 days, after each gestational age for the prevailing pregnancies.
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Design/methods: We used the NCHS linked birth and death files for 1999 and 2000. Variables used in
the analysis were clinical gestational age, live births, Neonatal death at less than 27 days age of death
(ND), and stillbirth (SB) more than and equal to 20 wks. SB risk (SBR) was calculated as SB for each
gestational age per 1000 total births (TB) (total live births and total stillbirths) at risk. The neonatal
mortality risk (NMR) was calculated as ND per 1000 TB at risk.
Results: In 1999 and 2000, total pregnancies at risk were 8,076,923 comprising 8,025,028 live
births and 51,895 stillbirths for GA 20-46wks. SBR was higher than NMR for every GA except
for 23 thru 25 wks. see Figure. There was no difference for mortality in GA from 41 thru 43;
however, at 44 wks SBR becomes significantly higher. Analysis for GA > 44 wks was not possible due to very small numbers.
Conclusions: 1) Stillbirth rate is higher than neonatal mortality rate for every gestational age
between 20 - 44 wks, with the exception of 23-25 wks. 2) Perinatal statistics should be presented as mortality, both intrauterine and extrauterine, for pregnancies at risk at each gestational age. The impact of stillbirth on potential life lost would be emphasized by this strategy.
3) Improvement of fetal life would impact the neonatal outcome also.
Acknowledgements and sources of financing: Not applicable.
Conflicts of interest: No conflicts of interest.
25
MORBIDITY OF PREMATURE INFANTS WITH INTRAUTERINE
GROWTH RETARDATION
Natasa Trninic (1), Milena Djukic (2)
1. Institute for Neonatology, Belgrade, Serbia
2. Institute for Mother and Child, Belgrade, Serbia
Introduction: The children with intrauterine growth retardation are exposed to higher risk of
morbidity.
Objectives: To establish the incidence of perinatal asphyxia and severe forms of respiratory distress syndrome (RDS) in premature infants with intrauterine growth retardation (IGR).
Methods: The retrospective study covered 173 premature infants with IGR and 268 premature
infants of growth appropriate for gestation (GAG). The estimation of IGR was made on the basis
of the body mass (BM) under 10 of percentile curve of growth according to Lubchenko and ponderal index (PI) < 2.1. GAG had BM between 10 and 90 of percentile curve of growth. The degree
of asphyxia was analysed on the basis of Apgar score (AS) and the most severe degree of RDS
which required mechanical ventilation support.
Results: In the group of infants with IGR, 39 out of 173 had a severe degree of asphyxia as compared
to 32 infants out of 268 in the group of infants with GAG. OR = 2.14; CI 95% = 1.285 - 3.586. A moderate
degree of asphyxia in the group with IGR occurred in 89 infants out of 173, and in the group of GAG, 135
infants out of 268. OR 1.044; CI 95% = 0.712 - 1.53. The severest form RDS which required mechanical
ventilation support in the group of infants with IGR occurred in 52 infants out of 173, and 81 infants out
of 268 in the group D=GAG. OR = 0.992; CI 95% = 0.654 – 1.505.
Conclusion: The incidence of IGR in our examinees is very high. IGR is and additional risk for a
severe form of perinatal asphyxia, but not for moderate forms of asphyxia and a severe form of
RDS requiring mechanical ventilation support.
Acknowledgements and sources of financing: We thank Dr Slavisa Djuricic for his critical review.
Conflicts of interest: We have no conflict of interest regarding our article.
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MANAGEMENT OF SIX ADVANCED ABDOMINAL PREGNANCIES INITIALLY MISTAKEN FOR INTRAUTERINE STILLBIRTHS AT AN EAST AFRICAN HEALTH CENTER
Zeck, Willibald (1, 2), Olola Oneko (1), Joseph Obure (1) Uwe Lang (2), Edgar Petru (2)
1 Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Center, Tumaini University, Tanzania, East Africa
2 Department of Obstetrics and Gynecology, Medical University of Graz, Austria
Correspondence:
Willibald Zeck, M.D., M.A. email: [email protected] or [email protected]
Introduction: Advanced abdominal pregnancy, defined as a pregnancy of more than 20 weeks inside
the peritoneal cavity, is rare and accounts for about 1 among 10,000 live births. However, the incidence
of abdominal pregnancies varies widely with geographical area, degree of antenatal attendance, level
of medical care, and socio-economic status and is most prevalent in developing countries.
Objectives: We describe the experience in managing six advanced abdominal pregnancies
being initially mistaken for intrauterine stillbirth at an East African Health Center. Focus
has been given to the lessons learned from these cases.
Methods:Extrauterine pregnancies occurring between 1999 and 2007 were identified from
hospital records of the Kilimanjaro Christian Medical Center in Tanzania.
Results: Between 1999 and 2007 a total of 3940 extrauterine pregnancies were diagnosed,
of which a total of six were of a gestational age more than 20 weeks. These six pregnancies
were initially diagnosed to be intrauterine stillbirths, but were found to be located in the
peritoneal cavity during laparatomy. The placenta was left in situ in three of six cases. All
four mothers survived and were well six months after delivery.
Conclusion: Extrauterine stillbirth is rather difficult to detect in a low-resource setting of a
developing country. We recommend the following most reliable clinical signs of abdominal
pregnancy to midwives and physicians which may see patients in remote areas: 1.) Persistent abdominal pain and tenderness are frequent symptoms. 2.) Fetal presentation in the
upper abdomen and abnormal fetal lie should alert the clinician. 3.) The lack of cervical
changes or a displaced cervix should lead to the suspicion of an abdominal pregnancy.
There are no funding sources and/or author conflicts of interest to be stated
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POSTER Developing Countries
27
EPIDEMIOLOGY OF STILLBIRTH IN SUDAN
Ishag Adam, Elsheik Bader, Amel Mustafa
Department of Obstetrics, Faculty of Medicine, University of Khartoum, Sudan
Correspondence:[email protected]
Introduction: Since there is no published data concern stillbirth in Sudan, this research is of
paramount importance in order to provide health care-givers with fundamental data.
Objective: This is an ongoing study in the Omdurman maternity hospital in Sudan to investigate
the epidemiology of stillbirth
Study design: a cross sectional study.
Results: The stillbirth rate was 28.4 of 1000 births. The majority (61.4%) of stillbirths occurred
at ≥ 37 weeks of gestation. Only 2% of the births had congenital anomalies. Lack of antenatal
care (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04), anaemia (OR = 2.3, 95% CI = 1.1-4.7, P = 0.01), and
preeclampsia (OR = 3.62, 95% CI = 1.2-4.5) were associated with increased risk of stillbirth in
this study.
Conclusion: Thus, in this study, the rate stillbirth was much higher than reported before in
other countries. Most of the stillbirths were term; many of these stillbirths could have been
prevented with higher quality of reproductive health care like antenatal care.
No conflict of interest
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AN ANALYSIS OF STILLBIRTHS IN AN UNBOOKED OBSTETRIC
POPULATION IN A TERTIARY HEALTH FACILITY IN NIGERIA
List of authors: dr.nwadiuto afonne Akani(1), dr. Chris acho Akani(2)
Institutional affiliation
(1) Dept of paediatrics, university of port-harcourt Teaching hospital, port-harcourt, Nigeria
(2) Dept of obstetrics and gynaecology, University of Port-harcourt teaching hospital, portharcourt, Nigeria
Abstract text
Introduction: Stillbirth rates contribute significantlly to the high perinatal and infant mortality
rates in Nigeria.Identification of the causes and focused planned interventions will help the
country towards the attainment of MDG 4.
Objectives: To determine the maginitude of stillbirths. To identify causes and correlates of
stillbirths in the study area
Method: A retrospective analysis of 81 cases of stillbiths recorded over a period of eight months
at the University of Port-Harcourt Teaching Hospital was carried out.Data analysed include
sociodemographic characteristics of mothers,and fetal particulars including birth and external
morphology.
Results: A total of 81 stillbirths were documented over the period with 51 macerated and 27
fresh stillborn. Fifty three of affected mothers were between 25 and 34years. 71.6% of the stillbirths occured between 33 and 40 weeks gestational age. Majority(53.1%) had a birth weight
of 2.6- 4.0kg. Associated obstetric complcations included prolonged unrelieved obstructed labour, eclampsia, obstetric haemorrhages and traumatic uterine rupture.
Conclusion: There is a very high still birth rate among unbooked rural women and a strong
correlation between stillbirth rate and maternal obstetric complication,illiteracy and poverty.
Articulate and strategic intervention through good antenatal care, mass female education and
economic empowerment is likely to reverse this picture.
Acknowledgements/ Source of finance: We acknowledge the efforts of the nursing staff and
resident doctors in the department of obstetrics and gynaecology in keeping these records.This
work was financed by the authors.
Conflicts of interest: We declare that there are no conflicts of interest.
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COMPARISON OF FETAL AND NEONATAL MORTALITY
RISK FACTORS IN SAO PAULO CITY, BRAZIL
Gizelton P. Alencar (1), Marcia F. Almeida (1), Oona Campbell (2), Laura C. Rodrigues (2)
1. Department of Epidemiology, University of São Paulo, Brazil.
2. Department of Epidemiology and Population Health, London School of Hygiene and
Tropical Medicine, UK.
29
Introduction: Risk factors for early neonatal and fetal deaths are considered as perinatal deaths
and usually are studied together, because they usually share the same mechanisms, but differences in these risk factors may be present mainly in areas of unfavorable social conditions.
Objectives: To compare risk factors for fetal and neonatal mortality São Paulo city, Brazil.
Methods: A population-based case-control study was carried out in São Paulo (Aug2000Jan2001). Cases were 164 antepartum fetal deaths, 146 neonatal deaths and 313 controls
with information from certificates, hospital records and home interviews. A hierarchical
conceptual framework guided the logistic regression analysis.
Results: Statistically significant factors associated for both outcomes were: inadequate
prenatal-care (fetal:OR=2.5;95%CI 1.5-3.96; neonatal:OR=2.6;95%CI 1.3-5.3); no prenatal
care (2.1;1.2-3.7; 15.7;3.4-71.8); vaginal bleeding (7.2;2.6-20.2; 11.6;3.5-71.8); congenital
malformation (3.8;1.4-10.2; 29.9;12.2-73.4); previous LBW (2.3;1.3-4.1; 3.3;1.8-5.5); recent
marital union (2.5;1.2-5.3) or no union (2.1;1.2-3.7). Factors only for fetal deaths were: diabetes (5.2;1.4-19.7); gestational hypertension (5.7;3.0-10.4); IUGR (2.5;1.5-4.2). Factors only for
neonatal deaths were: household with 1 room(2.6;1.3-5.1); residence in slum (2.1;1.2-3.5);
household head <4yrs of study (1.6;1.1-2.5); adolescent mother (2.6;1.1-6.3); hospitalization
(2.8;1.3-6.0); less than 32 weeks of gestation (83.7;31.6-221.7); male sex (2.4;1.3-4.7).
Conclusion: The outcomes share biological factors (hypertension, bleeding and previous LBW) and inadequate/no prenatal care. Socioeconomic variables are more frequent
in neonatal deaths. As expected congenital malformation plays a major role on neonatal
deaths. IUGR is present only for fetal deaths and low gestational age for neonatal deaths.
Acknowledgements and sources of financing: FAPESP, CNPq, CAPES.
Conflicts of interest: These are no conflicts of interest.
FETAL MORTALITY BY HOSPITAL LEVEL IN SÃO PAULO
CITY, BRAZIL
Marcia F de Almeida (1); Zilda P Silva (1,2); Luiz P Ortiz(2); Gizelton P Alencar(1); Airlane P
Alencar(3); Elaine G Minuci(2); Daniela Schoeps(1); Maria D Novaes(4);
School of Public Health - University of São Paulo
State Data Analysis System Foundation (Seade)
Mathematics and Statistics Institute - University of São Paulo
School of Medicine - University of São Paulo
Introduction: Fetal deaths have not been much studied although fetal mortality rate (FMR) was
7.4%o births and represented 57% of perinatal mortality in São Paulo city, Brazil in 2006.
Objective: To study the distribution of fetal mortality by type of hospital
Methods: A linked dataset of live births, neonatal, fetal deaths (FD) certificates and national
hospital registry was employed with 80 hospitals and 97,483 events (jan-jun) 2006, of São
Paulo city. Hospitals were categorized by cluster (CA) and factor analysis (FA) employing
variables from hospitals: live births volume, presence of NICU, adult ICU, teaching activities
and referral for high risk births and variables from patients: % low/very low birth weight, %
preterm births, % mothers<18 yrs, 35 yrs and over; % mothers <8 yrs of study and <4 prenatal care visits. Hospitals were separated in 2 groups: with and without public resources
Results: Up to 96% of FD occurred in hospitals. Hospitals with public resources respond for 57.5%
of all deliveries. FA identified two factors that explain hospitals groups: birth risk and mother’s
social risk. CA identified 4 care groups of public hospital. Level of care IV has 2 public university
hospitals and very high FMR (congenital anomalies referral). Non-public hospitals were categorized into 3 groups. FA showed that public level III hospitals has high values of both factors (birth
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and mother’s social risk) and high frequency of NICU, teaching activities and high delivery volume
and FMR of 8.7%o. Private level III hospitals showed positive birth risk and negative mother’s
social risk factor and FMR of 4.5%o. FMR was lower in less complex public hospitals and differences between public and private hospitals decreases (30% level II and 20% level I).
Conclusion: The results indicate general adequacy between hospital care level and birth risk profile, but further studies are needed to understand specific variations between hospital categories.
Financial support: The State of São Paulo Research Foundation – FAPESP
There is no conflict of interest.
31
THE ONGOING STILLBIRTH BURDEN IN A RURAL COMPREHENSIVE EMERGENCY OBSTETRIC CARE FACILITY IN
BANGLADESH.
Felicity Mussell (1), Louise T. Day (2)
Department of Obstetrics and Gynaecology, LAMB Hospital, Dinajpur, Bangladesh
Department of Paediatrics and Obstetrics and Gynaecology, LAMB Hospital, Dinajpur, Bangladesh.
Introduction: Perinatal mortality is an important indicator of socio-economic status and
standard of health care. Monitoring a referral facility’s stillbirth burden can potentially
reflect progress in maternal care in the community it serves. LAMB Hospital is a busy
comprehensive emergency obstetric care unit in low resource setting in rural North West
Bangladesh with referral linkages from the community programme.
Objectives: Monitor and evaluate the perinatal deaths in our facility.
Methods: An ongoing active perinatal death audit process attributed cause of death and
identified avoidable factors. Cases were discussed at monthly multidisciplinary meetings
and changes to routine care and clinical guidelines were implemented.
Results: From Jan 2001 to Dec 2007 years a total of 20,433 babies were born at LAMB
Hospital: 19,371 (94.8%) were born alive and 1062 (5.2%) were stillborn. Of the stillbirths,
18% were initially alive on admission, 43% were fresh stillbirths (but dead on admission)
and 36% were macerated stillbirths. Antenatal care rate was 73.5%. Low birth weight
rate was 29.5%. Caesarean section rate 20%. All mortality rates decreased over the 7
year period: perinatal mortality rate from 90 to 66 per 1000, stillbirth rate from 61 to 44
per 1000 and early neonatal mortality from 34 to 29 per 1000. The leading avoidable factor
was lack of antenatal care.
Conclusion: The death audit process has demonstrated a substantial reduction in perinatal mortality rate in this referral facility over the last 7 years. The contributing factors to
this reduction are likely to be manifold. However, the continuing burden of 1 in 19 babies
being stillborn remains an ongoing challenge and low-cost interventions are desperately
needed to avert these tragic deaths.
Acknowledgements and sources of financing: Johan Coetzee for permission to use Perinatal Problem Identification Programme.
32
SUPPLEMETATION WITH LOW DOSE ASPIRIN/CALCIUM
FOR THE PREVENTION OF PREECLAMPSIA & REDUCTION
OF PERINATAL MORTALITY IN PAKISTAN: COMMUNITY
BASED CLUSTER RANDOMIZED, PLACEBO-CONTROLLED
TRIAL RESEARCH PROPOSAL
Abdul Hakeem Jokhio (1, 2)
Depts. of Community Health Sciences & Obstetrics/Gynecology, The Aga Khan University,
Karachi, Pakistan
Abstract
Hypertensive disorders of pregnancy are responsible for 12% of the all the maternal deaths
worldwide, the 2nd leading cause of maternal death and a major contributor to perinatal
mortality in Pakistan. These are also associated with significant short term and long term
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maternal, as well as fetal/neonatal morbidities. Once the disease is established the only reliable
treatment is delivery which poses significant fetal/neonatal risks. Lack of resources, absence of
skilled person and non-availability of EOC services often create situations leading to maternal
and perinatal deaths. Calcium and Low Dose Aspirin (LDA) interventions have shown promising results to prevent preeclampsia. However there is still a need to explore further and test
whether offering universal application of these interventions is safe, feasible and acceptable to
women in developing world.
A community-based, cluster randomized placebo-controlled trial is proposed to evaluate the impact of
prophylactic supplementation with Calcium and LDA or placebo in pregnant women for the prevention
of preeclampsia and reduction of perinatal mortality in Pakistan.
All recruited pregnant women will be included and randomized to the different interventions by
Lady Health Workers at the nearest public health center and responsible for pregnant women in their
catchment area. The LHWs will be given appropriate training on this, with clear guidelines when and
how the women should use these medicines.
The intervention could prevent up to 50% of hypertensive disorders of pregnancy and 10% of the perinatal deaths estimated to occur each year. If the intervention is shown to be effective would be recommended one a larger scale for the prevention this major cause of maternal/perinatal mortality in rural
Pakistan and other similar settings.
The study aims to implement and ascertain whether supplementation of pregnant women with LDA
and calcium can improve maternal/perinatal health in a population deficient in resources.
Acknowledgements and sources of financing: The possible source of financing will be Higher
Education Commission Pakistan.
Conflicts of interest: I declare that I have no any conflicts of interest.
ANALYSIS OF PERINATAL MORTALITY AT A TEACHING
HOSPITAL IN DAR ES SALAAM, TANZANIA, 1999-2003
Hussein L Kidanto1,4, Siriel Massawe1, Lennarth Nystrom4 ,Gunilla Lindmark3
1. Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam,
Tanzania
3. International Maternal and Children’s Health, University of Uppsala, Uppsala, Sweden
4. Division of Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine, , Umeå University, Umeå, Sweden
Introduction : The perinatal mortality rate (PMR) is not only related to maternal health status
but also a sensitive indicator of quality of maternal and neonatal health care. PMR in developing
countries is more than 10 times higher than in developed countries. The proportion of potentially avoidable perinatal deaths is also higher in resource poor countries with higher PMR and it
is likely that a significant reduction can be achieved by minor improvements in the organization
and quality of health care.
Objectives: To categorize/classify perinatal deaths as well as to identify key factors in perinatal
care that could be improved in order to lower the perinatal mortality.
Methods We conducted a retrospective analysis of perinatal mortality at Muhimbili National
Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register.
The study includes all fetuses weighing =500g. A modified Nordic-Baltic classification was used
for classification of perinatal deaths
Results : Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of
124 per 1000 births, 78% of which was labour related stillbirth.
The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for
babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26%
of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of
neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal
mortality were birth asphyxia (37%) and prematurely (29%). Labour related deaths were more
common in multiple pregnancies.
Conclusion: The majority of the perinatal deaths should be essentially avoidable through
improved quality of intrapartum care.
Establishment of perinatal audit at MNH can help identify key actions for improved care.
Acknowledgement: Financial assistance from SIDA/SAREC made it possible for this study to
be done
Conflict of interest: None declared
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34
RISK FACTORS FOR PERINATAL MORTALITY AMONG BABIES
BORN UNDER A PMTCT PROGRAM IN ZIMBABWE
Kurewa EN1, Gumbo F2, Pazvakavambwa I2, Chirenje MZ1, Mapingure P.M3, Stray-Pedersen B4
Department of obstetrics and gynaecology, University of Zimbabwe, Medical school, Zimbabwe
Department of Paediatrics, University of Zimbabwe, Medical School, Zimbabwe
Department of Biochemistry, University of Zimbabwe
Department of obstetrics, Rikshospitalet, University of Oslo, Norway
Introduction: The perinatal mortality indicator helps in explaining the health status of pregnant
women and their newborns. Objective:To describe maternal and neonatal risk factors for
perinatal mortality. SETTING: Three peri-urban primary health clinics around Harare offering
maternal and child health services.
Methods: Information from a cohort of pregnant mothers enrolled at 36 gestational weeks and
followed up until 9 months was assessed for maternal demographic, clinical, obstetric and
neonatal risk factors for perinatal mortality.
Results: A total of 1050 pregnant women were enrolled, 7(0,6%) had stillbirths, whereas 6(0.6%)
babies died within the first week of life giving a perinatal mortality rate after 36 gestational
weeks of 12 per 1000 total births. Mothers with low haemoglobin (hb) were more likely to suffer from perinatal death: mean Hg (s.d) 10.27(2.01.85) compared to 11.35(1.55) for those with
living children (p=0.011). Maternal HIV status was associated with higher mortality, relative risk
(RR) = 3.97; 95% CI 1.10-14.36, previous treatment for abnormal vaginal discharge: RR = 4.70;
95% CI 1.53-14.4, current genital ulcer RR= 9.79; 95% CI 2.21-43.19 and current sexual partner
with penile discharge RR = 5.66; 95% CI 1.2-24.86. Mother’s death within the first year post delivery was associated with higher perinatal mortality, RR =20.25; 95% CI 6.01-68.30. Low birth
weight was associated with higher mortality mean (grams) (s.d) 2 205(831.43) compared to 3
038.33(425.30) for surviving infants p= 0.002, also low apgar, mean score (s.d) 3.5(2.12) compared to 9.38(0.74) for surviving infants (p< 0.001). Conclusion: Maternal haemoglobin, genital
infections and HIV serostatus were the strongest predictors of this perinatal mortality.
Infant risk factors were low Apgar score and low birth weight. Correction of anaemia and
screening for genital infections should be done in the first trimester. Pregnant women should
be encouraged to report early when in labor.
Acknowledgement: The Letten Foundation of Norway and a special thanks to Professor Letten
Saugstad herself for funding this study.
Conflict of interest: There is no conflict of interest in carrying out this study from both the
financiers and authors.
35
ANALYSIS OF PERINATAL MORTALITY IN A NIGERIAN
TEACHING HOSPITAL
KUTI O (1,2), ORJI E.O (1,2), OGUNLOLA I.O (1,2)
Institutional affliations:Department of Obstetrics, Gynaecology and Perinatology.
Obafemi Awolowo University Teaching Hospital, Ile-Ife. Nigeria.Ile – Ife, Nigeria.
Correspondance: E-mail: [email protected].
Introduction: Perinatal mortality rate is generally high in most developing countries due to the
low socio-economic conditions and poor standard of obstetric and neonatal services. There is
a need for a review of the perinatal mortality in each establishment in order to identify areas
requiring priority attention for addressing the high perinatal mortality rate.
Objective: The aim of the study is to determine the perinatal
Mortality rate and to analyse the perinatal deaths at Wesley Guild Hospital Unit of Obafemi
Awolowo University Teaching Hospital Nigeria.
Methods: A 5-year retrospective analysis of all perinatal deaths was carried out at Wesley
Giuld Hospital Ilesa, Nigeria between January 1996 and December 2000. The records of these
babies were obtained from the maternity and neonatal ward admission registers. Case notes
of both mothers and infants were reviewed and information about the maternal demographic
and obstetric details and type of perinatal deaths was retrieved. The Wiggleworth classification
was used in this study. This is the preferred method in a low resource setting like ours as it does
not require sophisticated diagnostic method and is based on pathological groupings that carry
implication for clinical management. Data analysis was by SPSS package version 9. Proportions
were compared using the X2 test and the level of significance was set at P<.05.
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Results: The perinatal mortality rate during the study period was 77.03 per 1000 total births.
There was a steady increase in rate over the study period.
The most common cause of perinatal death was asphyxia(55.2%), immaturity(23.1%) and macerated stillbirth(18.3%). The majority(79.1%) of the asphyxia deaths were labour related (from
obstructed labour and birth asphyxia).
The high incidence of unbooked patients, multiple pregnancy and low birth weight babies were the
main reasons for the high perinatal mortality rates in our environment.
Conclusion: Perinatal mortality is high in our society and the rate is increasing. The majority of
the perinatal deaths are due to intrapartum complications. A high incidence of low birth weight
babies and unbooked mothers are major contributing factors to the high perinatal mortality
rate.
Acknowledgement: We hereby acknowledge (1) the help of our colleagues in the neonatal unit
for supplying us with records of perinatal deaths in their unit (2) Mr Oloidi of the records department for retrieving all the case notes (3)Professor S O Ogunniyi for his useful suggestions.
Conflict of interest: No conflict of interest
EXPOSURE OF PREGNANT RATS TO SUBLETHAL DOSES OF
INSECTICIDES MAY INDUCE STILLBIRTHS AND
CONJUNCTION SUPPLIMENTATION OF ASCORBIC ACID
MAY REDUCE FETUS MORTALITY: PRELIMINARY STUDIES
Sameeh A. Mansour (1) and Tarek M. Heikal (1)
Environmental Toxicology Research Unit (ETRU), Pesticide Chemistry Dept., National Research
Centre, Dokki, Cairo, Egypt
Introduction: Women in rural communities in developing countries, even during pregnancy,
share in farm work where exposure to pesticides may be unavoidable and the effects may extend to the fetus.
Objectives: The study was undertaken to assess the hazards of sublethal doses of some insecticides to pregnant rats and their fetuses, and to test the efficiency of ascorbic acid (vitamin C)
in reducing fetuses’ mortality and ameliorating toxic effects to the dams.
Methods: The insecticides avermectin, imidacloprid, fenvalerate and their 3 binary combinations were orally administered to pregnant rats from days 7-21 of gestation at dose levels of
1/10 LD50s. Another similar six groups were administered vitamin C, as an antioxidant, in conjunction with the insecticides. Two groups more served as controls; one received distilled water
and the other was given the same dose of vitamin C. The dams were subjected to physiological, biochemical and histopathological examinations. The letters were removed, weighed and
examined.
Results: The activity of ALT, AST, ALP, SOD and AChE as well as levels of total protein, total
lipids, progesterone and prolactin in the sera of insecticides-treated rats, showed significant
alterations in comparison with control results. Supplementation of vitamin C minimized the
differences between results of treatments and control groups. Sections in livers, kidneys, ovaries and brains from the dams showed many toxic manifestations due to different insecticidal
treatments. Normal appearance was regarded in the liver of avermectin and avermectin + imidacloprid treatments following administration of the antioxidant. Also, the latter normalized the
number of fetuses (ca. 9.0 fetuses/dam) in imidacloprid + fenvalerate treatment and decreased
implantation losses.
Conclusion: The study shed light to the necessity of elucidating the association between pesticide exposure and stillbirths among women involved in farm works in developing countries.
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37
ETHNIC GROUP DISPARITIES IN FETAL MORTALITY OVER
TWO DECADES: COMPARISON OF THREE BIRTH COHORTS
IN SOUTHERN BRAZIL
Alicia Matijasevich (1), Cesar G. Victora (1), Aluísio J. D. Barros (1), Iná S. Santos (1), Fernando C. Barros (2)
1 Post-graduation Programme in Epidemiology, Federal University of Pelotas, Brazil
2 Catholic University, Pelotas, Brazil
Introduction: Although fetal mortality decreased in Brazil, wide social differentials still persist.
Objectives: Analyze trends in fetal mortality between white and black/mixed women.
Methods: Three birth cohorts representing all births in 1982, 1993 and 2004 in Pelotas,
Southern Brazil, were studied using the same methodology. Births were assessed by daily
visits to all maternity hospitals. Mothers were interviewed regarding potential risk factors.
Fetal deaths were defined as in utero deaths occurring at 28 or more completed weeks of
gestation. Mother’s skin color was classified by the interviewers as white or black/mixed.
Differences and trends across the three cohorts were analyzed separately for white and
black/mixed women. Adjusted analyses were done with logistic regression.
Results: Between 1982 and 2004, fetal mortality rate (FMR) among singleton infants fell by
40% in the city. FMR in white women decreased from 14.9 in 1982 to 8.7 in 1993 and 7.2 per
thousand live births in 2004 while FMR in black/mixed women hardly changed (19.8, 16.8
and 16.7 in 1982, 1993 and 2004, respectively).
Adjusted analyses for potential confounders (family income, marital status, education, smoking during pregnancy and antenatal consultations) showed that ethnic group
differences were partly explained by characteristics of the mothers and of prenatal care.
Conclusions: over a 22-year period, better maternal indicators and improvements in FMR
were restricted to white women. The widening race gap in fetal mortality merits attention.
Policy makers should give special attention to the needs of black/mixed women in order to
narrow this inequity and improve fetal mortality in the city.
Acknowledgements: The 1982 study was financed by IDRC. The 1993 study was financed
by the European Union and FAPERGS. The 2004 study was financed by WHO, CNPq and
Pastoral da Criança. The Wellcome Trust supported the analyses of the 1982 and 1993
cohort studies.
38
NIGERIAN WOMEN WITH PREVIOUS STILLBIRTH
EXPERIENCE: INSIGHT FROM IN-DEPTH INTERVIEWS
Imran O. Morhason-Bello1©, Babatunde O. Adedokun 2, Arafat A. Ifemeje 1, Ikeoluwapo O.
Moody2, Adesina Oladokun 1, Obehi O. Enabor1, Oladosu O. Ojengbede1
Department of Obstetrics & Gynaecology, University College Hospital, Ibadan, Oyo state
NIGERIA.
Department of Epidemiology, Medical Statistics, and Environmental Health, College of
Medicine, Ibadan, Oyo state, NIGERIA.
Corresponding Author ©: E- mail: [email protected], Telephone: 2348034784402
Introduction: Stillbirth is a devastating psychological problem to the woman, her family and the medical team. Many of these bereaved women are not offered circumstantial
explanation and ways to prevent future occurrences. In addition, little is known about emotional and psychological consequences of this mishap in communities where live birth is a
measure of blissful marital union.
Objective: To identify the views of women with previous stillbirth about the cause, their
perception of quality of care received and family’s disposition towards them.
Methods: In-depth interviews were conducted on six women with previous stillbirth who
are being treated for other conditions. The themes discussed included their perceptions,
experience and feelings of family members towards stillbirth as well as quality of care
received during the incident.
133
Results: They were all married with an average age of about 30years and a median parity of 3. Three had tertiary level of education; two had no formal education while one had
secondary education. Two of them had more than one previous stillbirth. The causes of
stillbirth included delayed second stage, eclampsia; prolonged labour and prolonged pregnancy. The role of the facility where antenatal care services were received may be an important contributor to having stillbirths as women blamed their private hospital or primary
health care centre for poor monitoring. An interesting finding however was the degree of
support reported from their spouse following the event. Concerning the views expressed
by society, the comments reflected that the causes and circumstances concerning stillbirths were generally related to the ‘supernatural’. They also generally expressed poor
attitude of health staff to disclosure of diagnosis.
Conclusion: The causes of stillbirth highlighted are preventable and most resulted from
poor quality of care. The community misconceptions about the cause may constitute a
major barrier to preventive strategies.
Acknowledgements and sources of financing: None
STILLBIRTH RATE IN PREGNANCIES COMPLICATED WITH
OBSTRUCTED LABOUR AND SUBSEQUENT OBSTETRIC
FISTULA
Muleta B. Mulu (1,2), Svein Rasmussen (3,4), Catherine Hamlin (1) and Torvid Kiserud (2,3)
1.
2.
3.
4.
Addis Ababa Fistula Hospital, Addis Ababa, Ethiopia
Centre for International Health, University of Bergen, Bergen, Norway
Department of Clinical Medicine, University of Bergen, Bergen, Norway
Medical Birth Registry of Norway, Locus of Registry Based Epidemiology,
University of Bergen and the Norwegian Institute of Public Health, Bergen, Norway
Introduction: Obstetric fistula is an injury predominantly caused by obstructed labour that
leaves the woman with severely impaired health and disrupted social status in developing
countries. Such a labour also causes severe damage and death to the child. However, the
extent of fetal loss in these cases is rarely addressed.
Objectives: The aim of the present study was to quantify stillbirths associated with birth
trauma that causes obstetric fistula.
Methods: We used the Addis Ababa Fistula Hospital registry to assess stillbirth and neonatal deaths in women admitted with an obstetric fistula. Information on live birth or stillbirth had been entered at the time of admission based on the woman’s own information.
Information on age, parity and duration of labour were also registered.
Results: Out of 16384 women registered during1974–2006, 14928 cases with complete
information were analyzed. 4407 (29.5%) were <20 years of age, 8479 (56.8%) primiparous
and 10401(72.8%) had been in labour for ≥3 days. There was information on the child in
14763 cases (98.9%), 27 being twin deliveries, making a total of 14790 children. Of these,
13817 (93.4%) were dead at delivery, 973 (6.6 %) were alive, but of the latter 126 (12.9%)
died within the first week.
Conclusion: In a developing country, prolonged labour due to obstruction and lack of appropriate health services may end with severe pelvic injuries to the woman causing urinary
or fecal incontinence or both, a physical, mental and social disaster. Here we have shown
that the overwhelming majority (>93%) of these women also loose their child adding substantially to their suffering and loss of status.
Acknowledgements: Addis Ababa Fistula Hospital, University of Bergen and NORAD
(through the QUOTA-program) supported the study.
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40
41
STILLBIRTHS IN MYANMAR
Dr Theingi
g Myint,
y
Mathernal and Child Health, Ministryy of Health, Myanmar
y
COMMUNITY INTERVENTIONS TO REDUCE NEONATAL AND
INFANT MORTALITY IN BANGLADESH
Shariful Islam, S. M .
Partners in Population and Development (PPD), PPD Secretariat, Dhaka, Bangladesh
Introduction: Infant and neonatal mortality accounts for almost one in two deaths under the
age of five in Bangladesh. While under-five mortality has been decreasing worldwide, among
newborns mortality has remained constant. A newborn’s risk of death during the first month
is 15 times higher than any other month during the first year of life. Community interventions
through a cadre of female health care workers have shown to reduce neonatal mortality in
Bangladesh.
Objectives: To develop a sustainable program at the community level for reducing infant and
neonatal mortality and morbidity and improve the health of the people in general.
Methods: 50 volunteer females interested to serve their own community were recruited by
the help of local leaders in three selected sub-districts of Chittagong in Bangladesh. They
provided with 3 months of extensive training in a hospital followed by on the job training by
skilled health workers, training on counseling skills and monthly follow up by a physician. The
female workers were trained to identify common childhood illness, provide simple treatments
and were supplied with basic commodities.
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Results: The female community based village health workers treated more than 2550 cases of
ARI, 3313 cases of diarrhea, counseled 921 mothers on child care and family planning, breastfeeding and nutrition, hygiene and malaria. Neonatal deaths reduced to more than 42 % compared to previous year and other health and nutrition indicators showed significant improvements.
Conclusion: Community interventions can be a cheap and sustainable method to reduce infant
and neonatal mortality especially in resource poor areas and hard to reach areas. Seed funding
and initial government support will be needed for the initiative.
Acknowledgements and sources of financing: UNDP Bangladesh, CHTDF Health Unit
TRENDS AND CAUSES OF PERINATAL DEATHS: AN
ANALYSIS OF THE EFFECTIVENESS OF PERINATAL DEATH
AUDIT SYSTEM IN PAROPAKAR MATERNITY AND WOMEN’S
HOSPITAL KATHMANDU,NEPAL
Prof. Sudha Sharma, Director, Paropakar Maternity and Women’s Hospital
Correspondence to be directed to: [email protected]
42
Puri M, Malla K, Aryal DR, Shrestha M
Introduction: Perinatal mortality, which includes both deaths in the first week of life (ENND) and
stillbirths, is an important indicator of the quality of care of the mother and that of the fetus during
pregnancy, childbirth and the post partum periods. Perinatal death audit provides information to allow the decision-makers to identify problems, track temporal and geographical trends and disparities and assess changes in public health policy and practice (WHO, 2006b).
Objective: This study was conducted to evaluate the effectiveness of the National perinatal
death audit process as part of a multi centre study.
Methodology: A retrospective analysis of case notes for a period of two years - 2005 to 2007.
The data were analyzed using the SPSS. Data from Paropakar Maternity and Women’s Hospital
is presented in this paper.
Results: PNMR ranged at 31 to 37 per 1000 live births in the last ten years. During the study
period there were 36,109 total births with 1193 perinatal deaths - PNMR of 33 per 1000 live
births. 49% ENND in first born. Two-thirds of mothers with PNM had antenatal care. Maternal
complications were detected for 793 cases. 57% of ENND were preterm .Two-thirds of babies
with PNM had birth weight less than 2500 grammes. 37 per cent died within 4 hours of birth.
Intra uterine asphyxia was the main (34%) cause of stillbirth, followed by hypertensive disorder,
extreme prematurity, congenital abnormalities, and antepartum haemorrhage.
Conclusion: Recommendations coming from the perinatal audit should be implemented effectively. Good monitoring of labour and skilled newborn care are keys to reducing PNMR. Kangaroo Mother Care to low birth weight infants, infection control measures, use of antibiotic needed
strengthening Acknowledgements:This study was funded by Support to Safe Motherhood Programme (SSMP) of DFID/ UK. This was a multi centre study done by Centre for Research on
Environment Health and Population Activities (CREHPA) for the Family Health Division / Department of Health Services at Paropakar Maternity and Women’s Hospital, Tribhuwan University
Teaching Hospital and BP Koirala Institute of Health Sciences.
PERINATAL DEATH REVIEW PROCESS IN NEPAL:
ASSESSMENT OF FACTORS RELATED TO STILLBIRTHS
Dr Mahesh Puri, Dr Kasturi Malla, Dr Dhan Raj Aryal, Moni Shrestha, Dr Louise Hulton, Ajit Pradhan
Presenter: Dr Sudha Sharma
The 2006 Nepal Demographic and Health Survey showed a perinatal death rate of 45 per 1,000
live births, with 22 stillbirths (gestation above 28 weeks) per 1,000 live births. Facility based
perinatal death review is a powerful tool for understanding the factors behind stillbirths and
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neonatal deaths, and the process was initiated in the Maternity Hospital in Kathmandu in
2005.
In 2007 a study was undertaken to identify the challenges and opportunities of the death
review process and recommend improvements.
Records were reviewed for the 1,193 perinatal deaths that had occurred in the two years, of
which 682 were stillbirths. Key informant interviews were also carried out.
Key findings were that only 38% of the stillbirths were fresh. The main causes of death
recorded were: asphyxia (34%), hypertensive disorders (14%), congenital abnormalities
(11%) and antepartum haemorrhage (8%). Records showed that two thirds of the women
had received at least one antenatal check-up, but only 19.1% had the recommended four.
The proportion was the same for women who had stillbirths with congenital abnormalities
and those with macerated stillbirths. Very few abnormalities were detected prior to the
stillbirth. On admission to hospital, the foetal heart function was not recorded for 78% of
cases and the partograph was only used for 1% of the deliveries.
The study concluded that many deaths were due at least in part to avoidable medical service related factors and provided recommendations for addressing these through improved
quality of antenatal care and counselling, encouraging women to go for the recommended
four check-ups and improved admission care and monitoring. Improvements to the perinatal
death review process were also recommended through the establishment of facility perinatal
death review committees, simplified review forms that are consistent with other medical
recording systems with clear classification of causes of death and central level support.
Acknowledgements and sources of funding
Support to the Safe Motherhood Programme, Kathmandu, Nepal (managed by Options UK)
Department for International Development, UK (funder)
Family Health Division, Department of Health Services, Kathmandu, Nepal
Centre for Research in Environment Health and Population Activities (CREHPA), Kathmandu,
Nepal (consultant contracted to carry out study)
Paropakar Maternity and Women’s Hospital (Maternity Hospital), Kathmandu, Nepal.
44
CONTRIBUTORS TO STILL BIRTHS IN SHAMA AHANTA EAST
METROPOLIS
Linda Amarkai Vanotoo, Esther Yaa Duah, Gifty Francisca Abeka
Supporting institutions:
1.
Metropolitan Health Directorate, Ghana
Public Health Division- Western Region, Ghana
Introduction: Stillbirth is the most common cause of perinatal loss globally. In Western Region
skilled delivery rate is less than 50% and stillbirth rate is about 2.6%. In 2007 1176 stillbirths were
recorded. No study has been carried out on the causes of stillbirths; this has to be done if
efforts can be made to reduce them; hence this study.
Objectives:
Determine among women who delivered stillbirths
Proportion with diabetes in pregnancy
Proportion with hypertension during pregnancy.
Ante-natal clinic attendance
Ages of mothers
Gestational age and weight of the babies.
Proportion of babies with abnormalities
Method: Four health facilities were selected in the Shama Ahanta East Metropolis. Data
was collected from folders of women who delivered stillbirths from January to December
2006. Data entry and analysis were done using EpiInfo.
Results: 195 folders were retrieved. None of the women had sugar in the urine; 87.2% had
blood pressure reading below 140/90mmHg; 76.6% attended antenatal clinic; 89.6% were
between 20 to 39 years old; 3 babies had visible abnormalities; 56.8% had birth weight
greater than 2.5kg; 90.8% had gestational age between 28 to 40 weeks.
137
Conclusion: Hypertension was of statistical significance in delivery of macerated stillbirths.
Diabetes and low birth weight did not contribute to the delivery of stillbirth in the study.
There is need to carry out further research on causes of stillbirths in the Western Region.
Acknowledgement:
Regional Director of Health Services
Staff of Metropolitan Health Directorate.
Agudey Daniel Tetteh
Financing: Ghana Health Service- Western Region
IMPACT OF STILL BIRTHS (IUDS) TO THE PERINATAL
MORTALITY RATE (PMR) IN A TERTIARY CARE SETTING IN
SIRI LANKA
Dr. S.C. Wickramasinghe(1), DR. S.M. Dharmaratne(2)
Department of Neonatology, General Hospital (Teaching) Kandy, Sri Lanka
Department of Paediatric Surgery, Sirimawo Bandaranaike Specialized Children Hospital,
Peradeniya, Sri Lanka
Introduction : The late foetal – early neonatal period is the time of life with the highest mortality
rate of any age interval. According to the definition, PMR includes both Still Births (IUDs), and
Early Neonatal Deaths (ENNDs).
Sri Lanka has been successful in bringing down PMR from over hundreds in 1950 to 18.1 in
1997. Thereafter, it has been stagnated around the same value despite significant improvements in neonatal care facilities in most of the hospitals.
In an attempt to find out reasons behind this observation, a retrospective analysis of PMR data
over a period of 36 months in a tertiary care institution was done.
Objective: To determine the percentage of contribution, the IUDs made to PMR in a tertiary care
unit.
Method: A retrospective analysis of IUDs, births and early neonatal deaths from January 2005
to December 2007 was done at Teaching Hospital - Kandy, Sri Lanka. Data analysis was done by
using Minitab14 package and means, and standard deviations were calculated for IUDs, ENNDs
and PMR for the 36 month period. Percentage contributions of IUDs and ENNDs to PMR were
compared by using the software to establish the significance of difference.
Results: 34985 deliveries took place at TH/Kandy during the study period. The total number of
Early Neonatal deaths (ENND) recorded was 245 and the total number of Intra Uterine deaths
was 515 for the same period. PMR was found to vary between 13.01/ 1000 births and 34.42/1000
births, with a mean of 21.77 and a Standard deviation of 4.66. Mean contribution of ENND to
PMR was 31.82% while IUDs contributed for rest of the 68.18%. This contribution by IUDs was
highly significant (P = 0.759, p < 0.001)
Conclusion:IUDs are having a significantly higher contribution than ENNDs for PMR at Teaching
Hospital Kandy for the years of 2005, 2006 & 2007.
Acknowledgements: Staff in 2 obstetric units and Neonatology unit in our hospital
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POSTER Bereavement
46
PREGNANCY LOSS AND THE DEATH OF A BABY:
GUIDELINES FOR PROFESSIONALS – PUTTING THEORY
INTO PRACTICE
Judith Schott, Sue Hale
Sands, UK
The 2007 edition of the Sands Guidelines are widely recognised as an essential bench mark
for good practice, not only in the UK but elsewhere in the world. This new edition is based
on research findings and on widespread discussions with health care professionals, parents and voluntary organisations. It covers loss at any stage during pregnancy, including
early and late miscarriage and termination for abnormality as well as stillbirth and care for
very ill babies and those who are likely to die shortly after birth. As well as describing what
constitutes good care, the Guidelines offer practical guidance on how to meet parents’
needs. They are rooted in the principles of informed choice and parent-led care.
The challenge now is to ensure that not only do all UK hospitals know that the Guidelines
have been published but they are using them as a guide to good practice.
This poster will demonstrate how we have risen to this challenge and worked closely with
Sands (Stillbirth and Neonatal Death Charity) in the UK at both national and local level to
introduce training days in hospitals. It will outline the way in which we have adapted the
training to suit different needs and also how this work has had the added benefit of ensuring hospitals are fully aware of the work of Sands on both a local and national level.
47
RAISING THE PROFILE OF STILLBIRTH - SANDS WHY 17?
CAMPAIGN
Janet Scott, Sue Hale, Katie Duff
Sands, UK
17 babies die every day in the UK through stillbirth or neonatal death.
This shocking figure - the loss of 6,500 babies every year in the UK - goes largely unnoticed.
While neonatal death rates have fallen, stillbirth rates have barely changed in the last ten
years. One in 200 babies is stillborn; stillbirth accounts for 60% of perinatal deaths and is
10 times more common than cot death. Yet most people think stillbirths don’t happen in
the 21st century – until it happens to them or someone they know.
This level of baby loss is unacceptable and unnecessary. Sands has launched its Why17
campaign to raise public awareness of this ignored problem and to ask the question; «Why
are 17 babies a day dying and what can be done to halt this national tragedy?»
Sands Why17 campaign seeks to raise £1.7 million to:
Bring stillbirth to public attention and increase awareness of risk factors for stillbirth
Push for a national strategy to reduce the number of stillbirths
Fund key research to improve understanding of why stillbirths happen and to identify high
risk pregnancies and develop effective interventions.
This poster will outline key elements of the campaign and look at some of the approaches
we will take to enable us to achieve our goal.
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PSYCHOLOGICAL IMPACT OF STILLBIRTH CORRELATES
WITH PROFESSIONAL BURNOUT IN ITALIAN MIDWIVES
Claudia Ravaldi (1), Francesco Lapi (1,2), Ametista Biagini (1), Erika Cialdi (1), Giorgio Mello (1,2),
Alfredo Vannacci (1,2)
1. CiaoLapo charity organization for grief support after perinatal death, Prato, Italy
www.ciaolapo.eu
48
Introduction: Perinatal death and stillbirth are dramatic events, and the care of mothers, fathers and babies is usually perceived as an intense and stressful experience by professionals,
often unskilled in coping with such a tragic and unexpected termination of pregnancy.
Objectives: It could be speculated that care-givers exposed to stressful stillbirth experiences, in
the absence of a specific training and support, may develop some form of professional burn-out
which in turn could impair their communication skills with bereaved parents.
Methods: Here we report the results of a preliminary investigation conducted in Florence, Italy in
a sample of 60 healthcare professionals (midwives, nurses and obstetricians) involved in stillbirth
care and a successive investigation conducted in a sample of 120 midwives. Each subject was
administered the Impact of Event Scale (IES), oriented on stillbirth experiences, and the Maslach
Burn-Out Inventory (MBI) to assess the level of professional burn out. The relationship between
IES and MBI was computed by means of covariance analysis and correlation analysis ranks test.
Results: Part 1. Midwives seem to be more easily exposed to the psychological impact of stillbirth compared with other healthcare professionals. They also present a higher level of professional burn-out. Part 2. The explorative study showed an extremely significant relationship
between IES and MBI total scores, as well as main subscales.
Conclusion: Specific training courses for healthcare professionals are warranted in order to
provide, in Italy as in other developed countries, a correct support to bereaved parents, maintaining also a good level of professional gratification in healthcare providers. In particular, specific interventions should be targeted on midwives, a professional category here shown to be
more easily affected from the impact of perinatal death assistance, with the risk of developing
professional burnout.
WWW.CIAOLAPO.IT: AN ITALIAN ONLINE SELF-HELP
RESOURCE FOR PERINATAL GRIEF
Claudia Ravaldi (1), Valentina Pontello (1,2), Carla Maria Xella (1), Simona Agosti (1), Simona
Minniti (1,3), Alfredo Vannacci (1,2)
1. CiaoLapo charity organization for grief support after perinatal death, Prato, Italy www.
ciaolapo.eu
3. Mother-Infant Department, University Hospital, Modena, Italy
Introduction. Stillbirth and neonatal death are severe life events with a notable impact on mothers’ psychological and social wellbeing. The availability of a social support network influences
the course of grieving process, enhancing the ability of mothers in managing perinatal loss
consequences, and reducing the risk of complicated grief.
Objectives: The non-lucrative charity association CiaoLapo (www.ciaolapo.eu) was recently
founded to promote research and assistance on stillbirth in Italy, aiming to provide a free service
of psychological support to grieving parents.
Methods: Here we describe the onset of three different on line self help resources for bereaved
parents in Italian language (forum, chat-rooms and moderated self help groups).
Results: Since April 2006 the website was visited by nearly 40000 unique visitors, with a current daily rate of about 130 and nearly 500 bereaved parents registered as users. Through the
forum users can easily access online free consultations on obstetrics and gynaecology, grief
psychology and child psychology. In July 2007, a 24h/7d chat room service was started, as well
as a weekly on line self help group, directed by a trained supervisor. Since May 2008, a specific
self-help group for pregnancies after a loss is also offered every 2 weeks. The self help groups
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were attended by a total of 40 registered parents. According to a qualitative analysis, main
results self-reported by users were: better awareness of one’s own emotions, lower levels
of anger, better evolution of grieving process, lower social isolation. A detailed qualitative/
quantitative analysis of self-help resources is in progress.
Conclusion: CiaoLapo is the only available structured self-help resource in Italian language for the support of grief after perinatal death. Online resources are generally appreciated by users, with a self-reported feeling of ease in their grief process. To better address this point, a structured psychometric evaluation of website users will be conducted
in the next months.
141
142
Last name
First name
Affiliation
Country
Aabrekk
Atle
Vingmed AS
Norway
Aakre
Gunvor
Flora kommune
Norway
Aanderaa
Mikkel
Norway
Aanestad
Aasa Vinje
Norway
Aas
Ingunn
St. Olavs Hospital
Norway
Aas
Saana
Sykehuset i Telemark
Norway
Adam
Ishag
University of Khartoum
Sudan
Adolfsen
Mette Lise
Helgelandssykehuset
Norway
Adoyi
Ediga Michael
Ahmadu Bello University Teaching Hospital
Nigeria
Aggarwal
Arun Kumar
Postgraduate Institute of Medical Education and Research
India
Ahmed
Nasr Ali
Ministry of Public Health & Population
Yemen
Aho
Anna Liisa
University of Tampere, SIDS Finland
Finland
Akani
Nwadiuto
University of Port-Harcourt Teaching Hospital
Nigeria
Akani
Chris
University of Port-Harcourt Teaching Hospital
Nigeria
Aksnes
May Britt
Haukeland Universitetssykehus
Norway
Alencar
Gizelton Pereira
FSP - University of Sao Paulo
Brazil
Almeida F de
Marcia
University of São Paulo
Brazil
United States
Alston
Nicole
The Skye Foundation, Inc.
Alvestad
Ellen
Norway
Amiri
Nimrose
Norway
Amougou
Mballa Regine
Mbonge General Hospital
Cameroon
Anabrah
Stephenson
Springtime College of Prof.studies
Ghana
Andreassen
Tove
Sørlandet Sykehus HF, Arendal
Norway
Norway
Andreassen
Andreas
Haugesund sjukehus
Anker
Kate
Sands
United Kingdom
Antonsen
Hanne
Ferring Legemidler
Norway
Asare
Gloria Q.
Ghana Health Service
Ghana
Askevold
Aud Garmann
Sørlandet sykehus Kristiansand
Norway
Atanga
Maureen Anwi
Ministry of Public Health
Cameroon
Augensen
Kåre
Norway
Aunan
Tone Bø
Norway
Austgulen
Mai Irene
Akershus Universitetssykehus
Norway
Ayomo
Clementina Mampo
Prison Fellowshi
Cameroon
Bakke
Knut Håkon
Haukeland Universitetsykehus
Norway
Battin
Katja
Liberal Midwife
Luxembourg
Bauer-Nilsen
Monica
Stavanger universitetssykehus
Norway
Baustad
Ann-Åse
Brønnøysund Fødestue
Norway
Beaumont
Svanhild T.
Norway
Bech
Bodil Hammer
Institute of Public Health, University of Aarhus
Denmark
Ben Cheikh
Hassen
University of Monastir-Faculty of Medicine
Tunisia
Norway
Benonisen
Hege
Berge
Lillian Nordbø
Ullevål universitetssykehus
Norway
Berge
Morten
GE Healthcare Clinical Systems Norway AS
Norway
Berger
Inger
Norway
Berger
Sissel
Norway
Berger
Carl-Even
Norway
Bergius-Tveit
Marianne
Imatis a/s
Norway
Bergsholm
Arne
Vingmed AS
Norway
Berko
Peter
Borsod-A.-Z. County and University Teaching Hospital
Hungary
Berman
Stuart
Centers for Disease Control and Prevention
United States
Bevan
Charlotte
Sands
United Kingdom
Bildøy
Tone Eimhjellen
Norway
Björk
Tomas
Östersunds sjukhus
Sweden
Bjørk
Merethe Dalholt
Sørlandet sykehus Arendal
Norway
Blystad
Anne
Perinatalkommiteen
Norway
Boorsma
Reinder
Laboratorium Volksgezondheid friesland
Netherlands
143
Last name
First name
Affiliation
Country
Breidvik
Laila
Akershus University Hospital
Norway
Brobak
Helge
Helse Nord-Trøndelag HF
Norway
Broen
Lise
Sykehuset Buskerud HF
Norway
Broutet
Nathalie
World Health Organisation
Switzerland
Brække
Kristin
Norway
Buaas
Kirsti
St. Olavs Hospital
Norway
Switzerland
Bucagu
Maurice
Bugge
Kari Elisabeth
Akershus universitetssykehus
Norway
Bårdsen
Tanja
Norway
Bødtker
Anne T. Sejersted
Sykehuset Buskerud
Norway
Bøe
Reidun Sæland
Stavanger Universitetssjukehus
Norway
Børdahl
Pert E.
Haukeland University Hospital
Norway
Carcopino
Xavier
Hopital Nord
France
Casteels
Martine
AZ Maria Middelares Gent
Belgium
Taiwan
Chao
An-Shine
Chang Gung Memorial Hospital
Charles
Adrian
Pathwest
Australia
Chi
Vitalys
HOPE Foundation
Cameroon
Christoffersen
Line
Norwegian School of Management
Norway
Cielecka-Kuszyk
Joanna
Child Health Center
Poland
Norway
Collett
Elisabeth
Den regionale perinatalkomite Helse Øst
Coward
Ingebjørg
Ullevål Universitetssykehus
Norway
Cregan
Mairie
University College Cork
Ireland
Dahl
Lauritz Bredrup
UNN
Norway
Dahlø
Raija
Høgskolen i Sør-Trøndelag
Norway
Dale
Vibeke G
NTNU
Norway
Dalhaug
Randi-Elisabeth
Helse Bergen
Norway
Danesi
Jafar Abdulkadir
Centre for Enlightenment and Development Intervention (CEDI) Formerly Policy Research Services (PRS) Nigeria
Danielsen
Kåre
Sørlandet sykehus HF
Norway
Davis
Liz
Sands
Australia
Day
Louise Tina
LAMB Integrated Rural Health and Development
Bangladesh
Degrell
Mona
Norway
Delphin
Sissel
Dissen
Lina-Helen
Djoumou
Adiland
Bethel Mission Health Services
Djukic
Milena
Mother and Child Health Care Institute of Serbia
Serbia
Duwe
Christina
Molde sykehus
Norway
Norway
Norway
Norway
Cameroon
Dyregrov
Kari
Center for Crisis Psychology/ Norwegian Institute of Public Health
Dyregrov
Atle
Center fro Crisis Psycology in Bergen
Norway
Egenæs
Synnøv
Norway
Eger
Hanne
Norway
Eggen
Karoline Olsen
Norwegian board of Health Supervision
Norway
Eide
Jorid
MoBa, Folkehelseinstituttet
Norway
Eidem
Ingvild
Norway
Eileraas
Inger
Helse Fonna
Norway
Ekhougen
Anders
Norway
El-Mohandes
Ayman
George Washington University
United States
Elgmork
Inger
Norway
Ellingsen
Liv
Rikshospitalet
Norway
Ellwood
David
Australian National University Medical School
Australia
Norway
Engnæs
Anne Sofie
DMF, NTNU
Enoksen
Lars
Norway
Envik
Marius
Covidien Norge AS
Norway
Eriksen
Stig
Imatis
Norway
Eriksen
Maren
Sandvik
Norway
Eriksson
Johan
University of Helsinki
Finland
Netherlands
Erwich
Jan Jaap
University Medical Centre Groningen
Evers
Annemieke
University Medical Center Utrecht
Netherlands
Facchinetti
Fabio
University of Modena
Italy
Fagerli
Ingebjørg
Nordlandssykehuset HF
Norway
144
Last name
First name
Affiliation
Country
Fallan
Marte
St. Olavs Hospital
Norway
Farias
Guillermo
Norway
Fasting
Sigurd
St. Olavs Hospital
Norway
Felix
Wilhelmina
Grooteschuur Hospital
South Africa
Ferdinand Chi
Mancho
Ministry Of Public Health
Cameroon
Fiaz
Muhammed
Surayya Azeem Hospital
Pakistan
Fiksdal
Berit
Norway
Flenady
Vicki
Mater Health Services
Australia
Forgaard
Anikken
Stavanger Universitetssykehus
Norway
Foss
Hilde
Neonatal intensiv Ålesund Sykehus
Norway
Fraas
Ida
Landsforeningen til støtte ved Spædbarnsdød
Denmark
Fredriksen
Ingrid Glad
Norway
Fretts
Ruth
Harvard Vanguard Medical Associates
United States
Frisch
Jorunn Kverndalen
Norway
Frydenlund
Kristin
DMF, NTNU
Norway
Frøen
J. Frederik
Norway
Frøvig
Anne Marie T.
Norway
Fujita
Noriko
International Medical Center of Japan
Japan
Fukui
Stephanie
SIDS Family Association
Japan
Furnes
Bodil
University of Stavanger
Norway
Furuheim
Vivi
Sykehuset Asker og Bærum
Norway
Fykse
Anne Kristin
Trondheim Kommune
Norway
Fylling
Ellen
Helse Sunnmøre
Norway
Gabrielsen
Gunn
Helse-Bergen, HUS
Norway
Gade
Inge
Norway
Galadanci
Hadiza
Aminu Kano Teaching Hospital
Nigeria
Galta-Opheim
Marit
Norway
Gangfløt
Gro
Norway
Ganters
Marie
The Swedish National Infant Foundation
Sweden
Garberg
Astrid
Sykehuset Levanger
Norway
Gardosi
Jason
West Midlands Perinatal Institute
United Kingdom
Norway
Gaudernack
Lise Christine
Rikshospitalet
Gautvik
Helge
Norway
Gichaba
Kennedy
Heideliberg Christian Community & Medical Centre
Kenya
Giertsen
Anne
Foreningen “Vi som har et barn for lite”
Norway
Gold
Katherine
University of Michigan
United States
Gonzales
Gustavo
Universidad Peruana Cayetano Heredia
Peru
Gordon
Adrienne
Royal Prince Alfred Hospital
Australia
United Kingdom
Gray
Ron
University of Oxford
Gregori
Sigrun Farstad
Norway
Grinden
Martine
Covidien Norge AS
Norway
Grønberg
Martin
UNN-HF
Norway
Grønn
Morten
Rikshospitalet
Norway
Gudmundsen
Camilla
Guildal
Bente
Gumbo
Felicity
Gustafson
Monica Wold
Jordmortjenesten,Trondheim kommune
Gørbitz
Christine
Rikshospitalet
Norway
Haga
Sølvi
Medinor AS
Norway
Norway
Norway
Zimbabwe
Norway
Hakuzimana
Alex
IntraHealth International Inc
Rwanda
Hale
Sue
Sands
United Kingdom
Hals
Marit Nesbu
Norway
Halvorsen
Thomas
Covidien Norge AS
Norway
Hannestad
Elin
Norway
Hansen
Thor Willy Ruud
Rikshospitalet University Hospital
Norway
Hansen
Elin Anita
UNN
Norway
Hanson
Mark
University of Southampton
United Kingdom
Haug
Kjersti Rønning
Norway
Haugen
Guttorm
Rikshospitalet
Norway
145
Last name
First name
Affiliation
Country
Haws
Rachel
Johns Hopkins Bloomberg School of Public Health
United States
Heazell
Alexander
University of Manchester
United Kingdom
Heiberg
Elisabeth
Sykehuset Innlandet HF
Norway
Heiberg
Marit
Den Norske Jordmorforening
Norway
Heide
Helene
Sykehuset Asker og Bærum
Norway
Heien
Claudia
Stavanger Universitetssykehuset
Norway
Heimstad
Runa
St. Olavs Hospital
Norway
Helbig
Anne
Rikshospitalet
Norway
Helgadóttir
Linda Björk
Norway
Helgø
Lillian Elin
Norway
Norway
Helk
Annette
Hengsle
Ranveig
SØF
Norway
Henriksen
Espen
Laerdal Medical AS
Norway
Heringa
Martijn
Universite Medical Centre Utrecht
Netherlands
Hermanrud
Marit Lie
Norway
Hinderaker
Sven Gudmund
Norway
Hirst
Jane
Royal North Shore Hospital
Australia
Hjelseth
Bente
Helgelandssykehuset Mo i Rana
Norway
Hjorth
Peter F.
University of Oslo
Norway
Hjorth-Johansen
Elin
Rikshospitalet-Radiumhospitalet
Norway
Holdø
Bjørn
Norway
Holm
Anita Melting
St. Olavs Hospital
Norway
Holt
Jan
Norway
Hompland
Oddrun Dorthea
Norway
Hopland
Anne
Flora kommune
Norway
Hopland
Johanne
Fødeavdeling Ålesund Sykehus
Norway
Horn
Synnøve
Ahus
Norway
Horrigmoe
Marianne
Norway
Hovland
Jorun Slettebø
Norway
Huitfeldt
Anette Schaumburg
Rikshospitalet-Føderiket
Norway
Humlen
Per K.
Techno Systems AS
Norway
Husby
Henrik
Bærum Sykehus
Norway
Huseby
Ulla Vinding
Clinsoft AS
Norway
Hustad
Berit Lunden
Sørlandet sykehus Kristiansand
Norway
Hutti
Marianne
University of Louisville
United States
Häggkvist
Anna-Pia
Rikshospitalet
Norway
Irgens
Kathrine
Norway
Isaksen
Christina Ella Stray Vogt Dept. of Pathology and Medical Genetics
Norway
Islam
Quazi Monirul
Switzerland
Islam
Shariful
PPD
Bangladesh
Jacobsen
Sissel
Covidien Norge AS
Norway
Jamil
Abderrahim
Jamissen
Nina
NLSH
Norway
Jammeh
Abdou
National Aids Control Programme
Gambia
Jensen
Heidi Wataker
Sykehuset Vestfold
Norway
Jensen
Kirsten Abild
Norway
Jenssen
Kirsti Lunden
Sørlandet sykehus Arendal
Norway
Johannesen
Trude Knag
Norway
Johansen
Lars
Sykehuset i Vestfold, Tønsberg
Norway
Johansen
Daniel
Norway
Johne
Bjørn-Egil
Covidien Norge AS
Norway
Norway
Morocco
Johnsrud
Nils Arne
Siemens Medical Solutions
Jokhio
Abdul Hakeem
Aga Khan University
Pakistan
Jonsdottir
Ingibjörg
University Hospital Akureyri
Iceland
Norway
Jørve
Håkon
Puls as
Kaasen
Anne
Rikshospitalet
Norway
Kalstad
Trine G.
Norway
Karlsen
Torill
Norway
Karoliussen
Margaret
Sykehuset Buskerud
Norway
146
Last name
First name
Affiliation
Country
Kasonde
Prisca
Family Health International/ZPCT
Zambia
Katre
Sunanda
UNN Harstad sykehus
Norway
Kidanto
Hussein
Muhimbili National Hospital
Tanzania
Kinge
Ragnhild
Norway
Kippervik
Ingrid
Kristiansund sykehus
Norway
Kirkhusmo
Anne
Folkehelseinstituttet
Norway
Kiserud
Torvid
Norway
Kjøllesdal
Anne Molne
Norway
Kleppa
Lilly
Norway
Klokk
Ragnhild
Sykehuset Innlandet
Norway
Knutsen
Ingunn
Norway
Knutsen
Kjetil
Norway
Knutsen
Cathrine
Kofod
Ester Holte
Landsforeningen til støtte ved Spædbarnsdød
Denmark
Kolbræk
Camilla
Norway
Kolbusch
Karin
ALSF
Luxembourg
Kolstad
Alice
Norway
Kolås
Toril
Sykehuset Innlandet Lillehammer
Norway
Norway
Koopmans
Laura
Mater Mothers Hospital
Australia
Kopp
Nina
The Swedish National Infant Foundation
Sweden
Norway
Kristiansen
Jørn Holst
Thue & Selvaag Forum as
Kristiansen
Kristian
Norway
Kristoffersen
Laila
St. Olavs Hospital
Norway
Kristoffersen
Rune
Norway
Kristoffersen
Toril Marianne
Norway
Kristoffersen
Tove
Norway
Kuenzel
Wolfgang
University Giessen
Germany
Kumar
Vishwajeet
King George Medical University
India
Kurewa
Nyaradzai Edith
University of Zimbabwe. Medical school
Zimbabwe
Kuti
Oluwafemi
Obafemi Awolowo University
Nigeria
Laache
Ingebjørg
St. Olavs Hospital
Norway
Laake
Kirsten
Norway
Ladehaug
Bjørg
Førde Sentralsjukehus
Norway
Lande
Liv
Norway
Langeland
Trine
IMATIS AS
Norway
Langstrand
Elisabeth
Norway
Larsen
Helen Marie
Norway
Larssen
Unni
Norway
Leinum
Kari
St. Olavs Hospital
Norway
Letting
Anne-Sofie
Rikshospitalet
Norway
Lichtenberg
Sissel Moe
Norway
Lien
Per Arne
Laerdal Medical AS
Norway
Lilleberg
Liv
St. Olavs Hospital
Norway
Lillesæter
Anita
Dybwadsgate Legesenter
Norway
Lindgaard
Cecilia
Strømmen Skjetten Helsestasjon
Norway
Lingetoft
Lene
Norway
Lingetoft
Pontus
Norway
Little
George
Dartmouth Hitchcock Medical Center
United States
Switzerland
Loetscher
Katharina Quack
Clinic of Obstetrics, University Hospital Zurich
Long
Neal
Sands
United Kingdom
Lorentzen
Anita
Medinor AS
Norway
Lowzow
Kari
Norway
Ludington
Susan
Case Western Reserve University
United States
Lund
Liv
Rikshospitalet
Norway
Lunde
Hilde
SSHF
Norway
Lærdal
Tore
The Laerdal Foundation for Acute Medicine
Norway
Løhaugen
Gro C C
Løvhøiden
Andrine
Norway
Norway
Løvstad
Frank
Avalon Medical AS
Norway
147
Last name
First name
Affiliation
Country
MacPhail
Julie
Mater Mother’s Hospital
Magnus
Per
Australia
Norway
Mahomed
Kassam
Ipswich Hopsital
Australia
Mamuya
Albart
Mansour
Sameeh
National Research Centre
Egypt
Tanzania
Mark
Jennifer
United States
Marley
Ellisiv
Norway
Marley
Luke
Norway
Marston
Cicely
London School of Hygiene & Tropical Medicine
United Kingdom
Marthinsen
Siri
AGA AS, Linde Gas Therapeutics
Norway
Martinussen
Marit
St. Olavs Hospital
Norway
Mathews
Jiji
Christian Medical College and Hospital, Vellore
India
Mathiesen
Trond
Norway
Matijasevich
Alicia
Postgraduate Programme in Epidemiology, Federal University of Pelotas
Brazil
Mbo
Marie Louise
Public Health Ministry
Congo (Kinshasa)
Mbonye
Anthony
Ministry of Health
Uganda
McClure
Elizabeth
UNC School of Public Health, Research Triangle Institute
United States
Meberg
Alf
Sykehuset i Vestfold HF
Norway
Mek
Vibeke
Ålesund sjukehus
Norway
Meland
Iris
Molde sjukehus
Norway
Mella
Astrid
SØF
Norway
Melve
Kari Klungsøyr
University of Bergen and the Norwegian Institute of Public Health
Norway
Meløe
Else Louise Hoen
Norway
Midbøe
Grete
Kvinneklinikken Haukeland sykehus
Norway
Mikkelsen
Berit
St. Olavs Hospital HF
Norway
Mikkola
Jutta
Norway
Millard
Caron
Sands
Antigua and Barbuda
Mohammed
Jemal
Shadan college
India
Mohn
Hilde Stuedahl
St. Olavs Hospital
Norway
Monari
Francesca
University of Modena
Italy
Nigeria
Morhason-Bello
Imran
University College Hospital Ibadan
Morken
Nils-Halvdan
Norway
Mortensen
Trude
Nestlé Infant Nutrition
Norway
Norway
Mortveit
Ingebjørg
Haugesund sjukehus
Moses
Waiswa
The African Child Care Alliance Development
Uganda
Moster
Dag
Norway
Mshare
Rajabu Hassan
Regional Faciltating Agency
Tanzania
Muleta
Mulu
CIH, Bergen University
Ethiopia
Music Trninic
Natasa
Institute for neonatology
Serbia
Myckland
Kristiane
Norway
Myhr
Siv Svennevik
Kvinneklinikken, Sykehuset i Tønsberg
Norway
Myhre
Ronny
Norway
Myint
Theingi
Maternal and Child Health Section
Burma
Myking
Solveig
Nasjonalt Folkehelseinstitutt
Norway
Myklebust
Bjørn
Helse Nord-Tøndelag
Norway
Myrset
Synnøve
Norway
Møkkelgård
Målfrid
St. Olavs Hospital
Norway
Møller
Torhild Hvaal
Føden ABC Ullevål universitetssykehus
Norway
Naeem
Fahim
IHSG Nettverk
Norway
Najeeb Ur Rehman
Najeeb
Surayya Azeem Hospital
Pakistan
Nakling
Jakob
Sykehuset Innlandet
Norway
Natvik
Eli
Midwifery services of Lambton Kent
Canada
Norway
Nedrebø
Kari
Haukeland universitetssykehus
Ness
Tone
Norway
Nestaas
Eirik
Sykehuset i Vestfold
Norway
Nguyen
Amelie
Nicholson
James M.
University of Pennsylvania Health System
United States
France
Niklasson
Bo
Uppsala Universitet
Sweden
Nilsen
Haldis
Helse-Sunnmøre HF
Norway
148
Last name
First name
Affiliation
Country
Nilsen
Kari
NOR-DAX AS
Norway
Nissen
Linn-Hege Myrvang
Norway
Nissen
Gunnar
Norway
Noet
Randi Listad
Sykehuset Innlandet HF
Norway
Nome
Cecilie
Norway
Nordal
Åsa
Norway
Nordlie
Tom
Avalon Medical AS
Norway
Norway
Normann
Helene
Ullevaal University Hospital
Norschau
Karl Marius
Norway
Norwitz
Errol
Yale University School of Medicine
United States
Nshimyumukiza
Lèon
Ministère de la santé du Rwanda/ Université Laval/Canada
Rwanda
Ntolo
Balbine Claire
Mbonge General Hospital
Cameroon
Nygård
Sissel
Norway
Nylaner
Gro
Rikshospitalet
Norway
Nzeribe
Emily
Federal Medical Centre, Owerri, Imo state
Nigeria
O’connell
Orla
Cork Universary Maternity Hospital, Cork
Ireland
Obeysekera
Madhumi
University of Newcastle upon Tyne
Odland
Jon Øyvind
United Kingdom
Norway
Odunna
Joy
Univerisity of Ibadan
Nigeria
Odyssius Tegha
Kum
Cameroon
Ojengbede
Oladosu
University College Hospital Ibadan
Nigeria
Oksfjellelv
Hilde
St. Olavs Hospital
Norway
Oladokun
Adesina
University of Ibadan
Nigeria
Olsen
Magnar Haaland
Norway
Olsen
Turid
UNN - KK
Norway
Olsen
Annelise
Plant Asker/Nycomed Pharma
Norway
Olusanya
Bolajoko
College of Medicine, University of Lagos
Nigeria
Omvik
Marianne
Helse Sunnmøre
Norway
Oppong Gyima
Samuel
G. Bro Enterprise
Ghana
Orstad
Olena
Stavanger Universitetssjukehus KK 7G
Norway
Osughe
Mary
University of Benin Teaching Hospital
Nigeria
Otten
Aase Signe
Rikshospitalet
Norway
Owren
Anita
Norway
Pattinson
Robert
University of Pretoria
South Africa
Paulsen
Inger-Lise
Perinatalkomiteen Helse Sør-Øst
Norway
Pay
Aase Devold
Norway
Pedersen
Berit Brenna
Karlsrud helsestasjon
Norway
Peters
Cecelia
Grooteschuur Hospital
South Africa
Pettersen
Berit
Norway
Petterson
Mariana
Norway
Pettersson
Karin
Karolinska University Hospital
Sweden
Pfeffer
Anne Hedvig Mellbye Rikshospitalet
Norway
Polvinen
Hannele
Ullevål universitetssykehus HF
Norway
Italy
Ponchia
Rossella
Centro prenatale Ospedale di Padova
Portaankorva
Sari Kristiina
St. Olavs Hospital
Norway
Pratt
Stephen
Beth Israel Deaconess Medical Center
United States
Rasmussen
Klara
Ravaldi
Claudia
CiaoLapo Onlus
Norway
Italy
Ravelli
Anita
Academic Medical Center
Netherlands
Raven
Leanne
Australia
Rayamajhi
Anjana Karki
Kathmandu Univesrity School of Medical Sciences
Nepal
Reiersølmoen
Bente Karin
Sørlandet Sykehus, Arendal
Norway
Reinar
Liv Merete Brynildsen Nasjonalt kunnskapssenter for helsetjenesten
Rengård
Elise
St. Olavs Hospital
Norway
Richard Njomo
Sinkam
Cameroon
Norway
Richardson
Ros
SIDS and Kids NSW
Australia
Rijninks-van Driel
Greta
AMC
Netherlands
Roald
Borghild
Norway
Roland
Brit
Rikshospitalet/Helsedirektoratet
Norway
149
Last name
First name
Affiliation
Country
Rom
Ane
Frederiksberg Hospital, Copenhagen, Denmark
Denmark
Romunstad
Pål R.
Norwegian University of Science and Technology
Norway
Norway
Rosenberg
Margit
Rubasha
Makudanu
SØF
Norway
Rubens
Craig
Seattle Children’s Hospital Research Institute
United States
Russell
Donna
Seattle Children’s Hospital Research Institute
United States
Russell
Kirby
University of South Florida
United States
Norway
Rustad
Elin Børnich
Jordmortjensten DA
Rustamova
Mekhriniso
Scientific and Research Institute of Obstetrics, Gynecology and Perinatology
Tajikistan
Rådestad
Ingela
School of Health Care and Welfare
Sweden
Rød
Irene
Norway
Rødal
Lise
SIV
Norway
Røkholt
Eline Grelland
Norway
Røsand
Gun-Mette
Norway
Røstad
Marit
Jordmor, Trondheim kommune
Norway
Saastad
Eli
Akershus University College
Norway
Saini
Radha
MM University,MM college of nursing,mullana,Dist.Ambala,Haryana
India
Salafia
Carolyn
Placental Analytics, LLC
United States
Salvesen
Kjell
National Center for Fetal Medicine
Norway
Samura
Ibrahim
Community Health Care Service Volunteer
Sierra Leone
Sandmo-Naimakka
Aina
UNN
Norway
Sandvik
Oddbjørn
Private Psycology
Norway
Sanne
Eli
Stavanger universitetssjukehus
Norway
Sarfraz
Aahshi
Norway
Norway
Saugstad
Ola Didrik
Rikshospitalet/Universitetet i Oslo
Say
Lale
WHO
Switzerland
Schrader
Line
Norway
Schwarz
Christiane
Deutsche Hebammenzeitschrift
Germany
Schwarze
Agnes
Norway
Scott
Janet
Sands
United Kingdom
Sesay
Issa
National School of Midwifery
Sierra Leone
Switzerland
Shankar
Anuraj
Sharma
Sharad Kumar
Family Health Division
Nepal
Sharma
Sudha
Maternity Hospital
Nepal
Shiffman
Jeremy
Syracuse University
United States
Silseth
Torborg
Molde sjukehus
Norway
Simonsen
Ragna Stene
Brønnøysund Fødestue
Norway
Simonsen-Nordström
Agneta
Borgå Sjukhus
Finland
Sjelmo
Sigrid
Norway
Sjøbrend
Jane
Norway
Skaar
Monica Jane
Norway
Skahjem
Gro Svennevig
Jordmortjenesten DA
Norway
Skari
Hans
Rikshospitalet University Hospital
Norway
Skaugerud
Jane
Skjærven
Rolv
Norway
Norway
Skogeng
Janita
Helse Sunnmøre HF
Norway
Skogmo
Tone Kirksæther
St. Olavs Hospital
Norway
Skranes
Jon
Norway
Skreden
Marianne
Sørlandet sykehus HF
Norway
Skreosen
Elisabeth Moe
Sykehuset Telemark HF
Norway
Smith
Eli
Sykehuset i Vestfold
Norway
Smith
Gordon
University of Cambridge
United Kingdom
Småland
Anne
Nyfødt Intensiv BUK
Norway
Sneddon
Anne
Australian National University Medical School
Australia
Sokol
Marian
United States
Solberg
Marianne Trygg
Lovisenberg Diakonale Sykehus
Norway
Solberg
Rønnaug
Rikshospitalet/Sykehuset i Vestfold
Norway
Sollesnes
Vanja
Norway
Solli
Astrid
Sykehuset Levanger
Norway
Solum
Tor
Scan-Med.A/S
Norway
150
Last name
First name
Affiliation
Country
Sommerfelt
Speer
A. Elisabeth
Academy for Educational Development
United States
Christian P.
University Children’s Hospital
Germany
Spence
Dale
Queens University Belfast
United Kingdom
Stangeland
Kjersti
Steffensrud
Bente Tellefsen
Stenseth
Trine
Stensøe
Bjørg Inger
Helse Sunnmøre
Norway
Stewart
Erica
Sands
United Kingdom
Stokker
Marit
Rikshospitalet
Norway
Storey
Claire
Sands
United Kingdom
Stray-Pedersen
Arne
Norwegian Institute of Forensic Medicine, University of Oslo
Norway
Stray-Pedersen
Babill
Rikshospitalet
Norway
Strøm-Roum
Ellen Marie
NGF
Norway
Subramoney
Sreevidya
Healis Sekhsaria Institute of Public Health
India
Norway
Ringerike sykehus HF
Norway
Norway
Sun
Hui-Lin
University of Ulster
United Kingdom
Sundby
Johanne
University of Oslo
Norway
Norway
Sunde
Arne
Sundli
Heidi Moen
Kristiansund sykehus
Norway
Sundt
Rebekka
Norway
Surén
Pål
Norway
Svenningsen
Leif
Norway
Svensen
Hanne-Lovise
Norway
Svensen
Rune
Norway
Svindland
Per
Sykehuset Telemark HF
Norway
Swain
Pushpanjali
National Institution of Health and Family Welfare
India
Sylling
Kristine Hellandsvik
Medinor AS
Norway
Søgnen
Anne
Helse Førde
Norway
Søgård
May Kristin
Puls as
Norway
Sønstelien
Knut
Laerdal Medical AS
Norway
Sønsterud
Anne
SØF
Norway
Sønstlien
Ingrid
Norway
Sørland
Karin
Helse Sunnmøre
Norway
Sørnes
Torgrim
Tanbo
Tom Gunnar
RIKSHOSPITALET UNIVERSITY HOSPITAL
Norway
Tandberg
Anne
Norway
Tandberg
Bente Silnes
Rikshospitalet
Norway
Taraldsen
Solveig
Sørlandet Sykehus HF, Arendal
Norway
Teigen
Janne
Norway
Teji
Jagjit
University of Chicago
United States
Thodenius
Kersti
Thomassen
Lise
UNN-KK
Norway
Thomassen
Ingeborg
Molde sjukehus
Norway
Norway
Sweden
Thorud
Marie Bjerke
Norway
Tiisala
Sinikka
Medinor AS
Norway
Tjessem
Anne Holm
Norway
Tjessem
Marit
Norway
Norway
Tokheim
Anna
Axellus AS
Tomren
Kristin
Norway
Tomter
Tore
Togemo AS
Norway
Torblå
Sigrid
Orkdal Sjukehus
Norway
Torgersen
Leila
Nasjonalt Folkehelseinstitutt
Norway
Torvet
Bjørnar
Rikshospitalet
Norway
Tran
Maria Rosa
Centro Prenatale Ospedale di Padova
Italy
Troøyen
Mona Rognlien
Norway
Norway
Tufte
Elisabeth
Rikshospitalet
Tunestveit
Jorunn
Helse-Bergen
Norway
Tuveng
Jon M.
Ringerike Sykehus HF
Norway
Norway
Tveit
Julie Victoria Holm
Perinatalt forskningssenter
Tømmerbakken
Marit
Pampers
Norway
Uahomo
Sunday
African Christian Care Trust Organisation
Nigeria
151
Last name
First name
Affiliation
Country
Ufuoma
Okpugwo
Youth Federation for World Peace
Nigeria
Ulkeman
Lida
Netherlands
Utne
Kari
Stavanger University Hospital
Norway
Uttgaard
Else
Sykehuset Østfold Fredrikstad
Norway
Norway
Valderhaug
Harald
Techno Systems AS
Vangen
Siri
Rikshospitalet
Norway
Vanky
Eszter
Inst. for laboratoriemedisin, barne og kvinnesykdommer
Norway
Vanotoo
Linda
Ghana Health Service
Ghana
Vege
Åshild
Institute of Forensic Medicine
Norway
Veinan
Ellen
Norway
Velikonja
Vislava Globevnik
University Medical Centre Ljubljana
Slovenia
Venheim
Marit Alice
Helse Fonna / Jordmorforbundet NSF
Norway
Verling
Anna Maria
CUMH, HSE Southern
Ireland
Visser
Gerard H A
University Medical Center of Utrecht
Netherlands
Vollen
Eli Margrete
Molde sjukehus
Norway
Wadel
Nina
Sandvik as
Norway
Wennerholm
Matilda
Philips Avent & Midelfart Sonesson
Sweden
Wickramasinghe
Chandani
General Hospital (Teaching) Kandy
Sri Lanka
Wielandt
Hanne
Sygehus Lillebælt
Denmark
Wiig
Camilla Grefstad
Norway
Wiig
Kjetil
Norway
Wilberg
Ann Kristin
Norway
Wildschut
Hajo
Erasmus University Medical Hosptial
Netherlands
Wildsmith
Chris
Sands UK
United Kingdom
Wind-Andersen
Kenneth
Switzerland
Wittman
Eileen
Vestfold Hospital
Norway
Wold
Kjersti
Norway
Woldseth
Kari
Perinatalkomiteen, Helse-Vest
Norway
Wolff
Kerstin
Södertälje sjukhus
Sweden
Norway
Wollen
Heidi
Haukeland universitetssykehus
Wright
Linda
Eunice Kennedy Shriver National Institute of Child Health and Human Development
United States
Xu
Fujie
United States
Ynkouuan
N.Aurelie Idosile Mbiatchet Bethel Mission Health Services
Ytterbø
Elin J. Hansen
Helse Sunnmøre, Ålesund sjukehus
Cameroon
Norway
Zand Baharami
Ardashir
Gafgaz University
Azerbaijan
Austria
Zeck
Willibald
Medical University of Graz
Zwaig
Einar
Tyristrand Legekontor
Norway
de Groot-Noordenbos
Mariëtte
UMCG
Netherlands
Netherlands
de Reu
Paul
Midwifery Centre Midden Brabant
van Diem
Mariet
Netherlands
van der Worp
Erik
Pathology LVF
Netherlands
von Brandis
Philip
Norway
Økland
Inger
Norway
Østebøvik
Silje
Norway
Øverland
Eva Astrid
Norway
Øye
Reidun
Ålesund sykehus
Norway
152
153
Social & Cultural Program
154
Social & Cultural Program
Opening ceremony, November 5th
Time: 09.30-10.15
Place: Sonia Henie Ballroom
During the opening ceremony Kvindelige Studenters Sangforening will perform.
Kvindelige Studenters Sangforening is the official women’s choir of the University of Oslo, and was founded in 1895. The
choir is today a young student-based choir with about 60 singers.
Reception, November 5th
Time: 20.00 - 21.30
Place: Oslo City Hall
The Oslo City Hall is situated in the city centre and within walking distance of the Royal Palace and the Parliament building. The walking distance from the Radisson SAS Plaza Hotel to the City Hall is approximately 15 minutes.
Located on the waterfront, overlooking the bay of the Oslofjord, the City Hall reflects the historic role of Oslo as the
capital of a seafaring nation.
The Oslo City Hall is known for its special atmosphere and its art-gallery. You may know the Hall from the Nobel Peace
Prize ceremony; witch takes place here every year. For those who want to learn more of this interesting building, there
will be time allocated for a guided tour.
The Mayor of Oslo has invited us to a reception where we will have a light meal, but most of all get a chance to meet other
conference participants and make contacts. You will find an invitation in your registration envelope. If you have someone
accompanying you to the Conference, please feel free to bring him or her along to the reception. Just remember to collect one extra invitation at the Registration Desk.
Conference Dinner, November 6th
Time: 20.00
Place: Sonia Henie Ballroom
The Norwegian Society of Perinatal Medicine welcomes you to a Conference Dinner at the Radisson SAS Plaza Hotel.
The Hotel is known for its good food, and we look forward to a lovely meal.
During dinner:
We will have entertainment by the vocal group Mezzo.
Mezzo is a small vocal group with six female singers. This evening they will be accompanied by a pianist.
After dinner:
As soon as they cleared the dancing floor, one of Norway’s best big band, Sandvika Storband, will inspire us to seek to
the dance-floor.
155
Practical Info/Maps
156
Practical Info/Maps
Admission to conference sessions
Please make sure you wear your badge whenever you want to participate in events organized by this
conference, as this is your sign of admission.
Badges
Name badges are to be worn at all conference events.
Colour codes:
Participant – white badges
Exhibitors – grey badges
Committee members/conference hosts – yellow badges
Concierge
Radisson SAS Plaza hotel has a concierge service which will be of assistance to conference speakers
and participants: [email protected].
Conference dinner
If you have pre-ordered participation at the Conference dinner on Thursday night during registration,
you will have received tickets for this at the registration desk. If not, please contact us at the
registration desk.
Dinner
Please see “Conference dinner”.
Evaluation
An evaluation form will be available electronically and mailed shortly after the conference.
Get-together
Please see “Invitation to the City Hall”.
Internet connection
Radisson SAS Plaza Hotel offers free internet access to all conference participants using their own
computer. If you are a resident of the hotel, please log in with your room number + name. If you are
not staying at the hotel, please ask for access code in the conference secretariat or hotel reception.
The hotel also offers computer services at your own expense found in the reception area.
Invitation to the City Hall
All participants have received an invitation to the Get-together at Oslo City Hall on Wednesday night
at the registration desk. If not, please come to us at the registration desk.
Lunch
If you have pre-ordered you lunch during registration, you will have received tickets for this at the
registration desk. If not, please contact us at the registration desk.
157
Memorial
Wednesday, November 5th in Munchsalen. Time: 18:45 – 19:30. Doors open from 18:30
The Memorial is open to all conference attendees. When entering the room, bereaved parents are
invited to write the names of their dead children on memory “leaves”. These “leaves” are to be put
into a basket before the memorial starts. We will make a memory tree to be put on the wall decorated
with all the “leaves”. During the memorial parents are invited to light a candle in memory of their
child/children. There will be music performed by bereaved mother and professional singer Åshild
Skiri Refsdal accompanied by guitar players.
The doors will be open from 18:30 to give parents enough time to make their memory “leaves”. If you
wish, you are also welcome to the Stand of Landsforeningen uventet barnedød/Norwegian SIDS and
Stillbirth Society in order to prepare your memory “leaves”.
Name badges
Please see ”Badges”
Posters
All posters are welcome to be exposed throughout the conference in the Poster halls on the 1st floor
(posters 1 – 26) and ground floor (posters 27 – 49). As a minimum, it should be mounted on the board
at least one hour before the scheduled poster walk for your poster. Adhesives to mount your poster
can be found at the boards. You will find your numbered poster in the list of posters in alphabetic
order, and should mount your poster on the equivalent board.
Powerpoint presentations
Please see “Speakers”
Presentations
Quiet Room
Place: Room 302. Opening hours: All day
The Quiet Room is open all day during the whole conference and available for those who require
some time away from the conference for reflection, prayer, or simply have some quiet and relaxed
time. The room is open for all conference attendees.
Registration desk
The registration desk/secretariat is located on the ground floor, next to the hotel reception.
Opening hours:
Tuesday
4 Nov 14.00h – 19.00h
Wednesday
5 Nov 07.30h – 20.00h
Thursday
6 Nov 07.30h – 20.00h
Friday
7 Nov 07.30h – 17.00h
Practical Info
Slides
158
Speakers
We ask speakers to hand in their presentations (CD, USB stick etc) in the speaker’s
room, room no 305, 2nd floor, at least 2 hours before their presentation.
Room 305 has the following opening hours:
Tuesday
4 Nov 14.00h – 19.00h
Wednesday 5 Nov 08.00h – 16.00h
Thursday
6 Nov 08.00h – 16.00h
Friday
7 Nov 08.00h – 16.00h
Conference Hotels
159
Floor maps
First Floor
Lobby lounge
Salome
Vampyr
Madonna
Pos
ter
Exh
ibito
Wardn
Lobby bar
Registration Desk
Main Entrance
Reception
robe
WC
WC
WC
Elevators
Galway Bay
Second Floor
Post
er E
xhib
iton
Kunst
Sonja Henie Ballrom
Film
Olympia
Exhibiton
Area
Elevators
Restaurant Gaio
Practical Info
WC
Restaurant Lakata
160
161
Notes
162
Notes
163
Notes
164
Notes
165
Notes
166
Notes
167

here - International Stillbirth Alliance

Transcription

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