Volume 29, Issue 3

Every year, approximately 600 000 women die of pregnancy-related causes – 98% of these deaths occur in developing countries. Complications of pregnancy and childbirth are the leading cause of death and disability among women of reproductive age in developing countries. Of all human development indicators, the maternal mortality ratio shows the greatest discrepancy between developed and developing countries. In fact, maternal mortality itself contributes to underdevelopment, because of its severe impact on the lives of young children, the family and society in general. Furthermore, in addition to more than half a million maternal deaths each year 7 million perinatal deaths are recorded and 8 million infants die during the first year of life. Maternal morbidity and mortality as well as perinatal mortality can be reduced through the synergistic effect of combined interventions, without first attaining high levels of economic development. These include: education for all; universal access to basic health services and nutrition before, during and after childbirth; access to family planning services; attendance at birth by professional health workers and access to good quality care in case of complications; and policies that raise women's social and economic status, and their access to property, as well as the labor force.

Development of antenatal care from the beginning of the 20th century and its relation to perinatal mortality in developed countries is presented. The role of socioeconomic factors, new diagnostic and therapeutic procedures, extended indications for cesarean section and of neonatal intensive care is also stressed. In the West- and Middle-European countries by the introduction of antenatal care the perinatal mortality (PNM) rate decreased from about 60.0‰ in the years 1920–1930 to about 40.0‰ in 1950s. Further decrease to about 25.0‰ in the 1970s was conditioned by an increase of number of antenatal visits and by extended indications for cesarean section. New technologies (amnioscopy, pH.metry, cardiotocography and ultrasound examinations) decreased the PNM rate to about 13.0‰ in the year 1980. Regional organization with neonatal intensive care units decreased PNM rate to low values of 5.0–9.0‰. The echo of the number of antenatal visits to PNM rate is illustrated on 36 855 deliveries at the University Clinic in Zagreb. In developing countries maternal and perinatal mortality is very high. The reason for that is a bad socioeconomic background and a lack of organized antenatal and perinatal health care system. The policy to decrease maternal and perinatal mortality is presented: the improvement of antenatal booking and of the number of prenatal visits of pregnant women; their childbearing under professional assistance. The organizing of maternity health care should be different from country to country, from region to region, respectively.

Prevention of prematurity and of low birth weight is – because of the associated increased risk of mortality and morbidity – one of the most urgent tasks of perinatal medicine. Whereas the rate of prematures all over the world does not vary very much (5–10 %), the rate of infants born with low birth weight lies between 3.6% and 10% in the industrial countries and between 9.8% and 43% in the developing countries, where the main cause of low birth weight is intrauterine malnutrition. As there are different causes for prematurity and low birth weight, but also because various countries have different resources and have therefore to set their priorities differently, there is no global solution. The situation in each country must be considered individually. However, as far as basic means are available for the majority – such as basic health care, monitoring the nutritional state of the mothers and acting to prevent infectious diseases (malaria in particular can cause prematurity) – determined prevention of prematurity should take the form of screening and the treatment of disturbances of the vaginal milieu or genital infections. This policy can be recommended because one of the most important avoidable causes of prematurity is ascending genital infection (mostly combined with bacterial vaginosis), which very frequently starts with a disturbance of the vaginal milieu and then often takes its course asymptomatically. Regular screening for signs of such a disturbance using vaginal pH-measurements (and if necessary further diagnostics and therapy) makes possible the detection of an “early marker” to prevent prematurity in an effective and inexpensive way. Our prematurity-prevention-program, which has been successful for many years, is based on an anamnestic assessment of prematurity risk, the early detection of warning signs (including regular measurement of the vaginal pH) and, if necessary, the appropriate therapeutic measures. In cases of disturbance of the vaginal milieu, the latter consists of a therapy with lactobacillus preparations or in a combination of lactobacillus preparation with an acidifying therapy which may lead to earlier normalization of the vaginal milieu. In cases of bacterial vaginosis local therapy, for example with metronidazol or clindamycin, is undertaken, and in other infections specific treatment. It is encouraging to note that particularly the rate of the very small prematures is reduced when pregnant patients take part in our self-care- program, measuring their own vaginal pH-value twice a week, and also searching for any other warning signs. In this way in our collective the rate of very small low birth weight infants could be reduced from 7.8% in the immediate previous pregnancy to 1.3 %. In a prospective study performed in Erfurt the rate of very early premature births (< 32 + 0 gw) amounted to only 0.3% in contrast to 3.3% in a control group who had not taken part in the self-care activity. According to a differentiated classification of the control group the success of the self-care activity was even clearer: In patients who did not take part because their doctors did not support the self-care activity, the rate of very early premature births amounted to 4.1 %. In patients who did not take part in the self-care activity, but who were in the care of doctors who were interested and had taken part in the prevention-program, the rate was 2.2 %; in the group with active participation in the self-care activity it was only 0.3 %. To date measurement of the vaginal pH-value was performed intravaginally using either indicator strips or pH-measuring test gloves. A short time ago we developed a panty liner coated with an indicator strip, which enables reading of the pH-value by just checking the indicator on the panty liner. First results with this panty liner are very promising.

Since the introduction of ultrasound scanning in early pregnancy, transabdominal or transvaginal ultrasonography has taken on an important role in routine clinical practice in terms of the care of the fetus and the mother. The use of ultrasound in very early pregnancy makes it possible to confirm the intrauterine living embryo or diagnose the extrauterine pregnancy in which medical treatment with low morbidity is feasible with early detection. Early scanning can provide exact dating with acceptable error, which is one of problems encountered in clinical practice. Chorionicity can be correctly established by early scanning (before 14 weeks of gestation) to manage multiple pregnancies properly. The nuchal translucency, which is a transitory abnormality, can be measured for the early screening of Down's syndrome, trisomy-18, trisomy-13, Turner's and some other aneuploidy at the 11–14 weeks gestation with approximately 80% detection rate. Early diagnosis of somemajor abnormalities such as anencephaly,megacystis, polycystic kidney, omphalocele is also possible by early scanning. This provides great advantages as the clinical management will be quite different for a case of omphalocele or megacystis. Therefore the early ultrasound scanning has become a routine standard method in the care of the pregnant woman.

Intrauterine growth restriction (IUGR) should be defined on the basis of a prenatally recognized defective growth compared to that expected for this fetus. This condition is encountered in 10–15% of the pregnancies and the perinatal outcome is impaired mainly as a consequence of fetal hypoxemia that is present in 30% of IUGR fetuses. In order to allow for proper management, the IUGR should be recognized prenatally and the method of choice for this purpose is ultrasound fetal biometry. After the identification of IUGR, 2 nd level tests should be performed in order to assess the fetal oxygenation conditions. The validity of Doppler investigation on fetal and umbilical vessels is discussed, and the importance of using computer assisted cardiotocography instead of traditional eye ball evaluation of the non-stress test is emphasized.

The authors summarize the perinatal effects of the main genetic disorder groupings. Diseases of autosomal dominant inheritance are usually less severe and postnatal life is possible. Diseases of autosomal recessive inheritance are serious in most cases, causing severe symptoms in postnatal life. Diseases of X-linked recessive inheritance manifest themselves in male embryos and may be mild or serious; the more severe forms may influence the perinatal outcome. Diseases of X-linked dominant inheritance occur less frequently and manifest themselves in both sexes: in some cases the life expectancy is not favorable. Chromosomal anomalies, unbalanced rearrangements and autosomal trisomies may cause severe multiplex malformation syndromes and mental retardation. The diseases are serious in most cases and intrauterine mortality is high. Conversely, in cases of numerical differences of the sex chromosomes perinatal mortality does not increase remarkably, except in X-monosomy. Diseases of multifactorial origin lead to isolated malformations, but many civilization diseases originate from similar causes. In a few cases, severe diseases (i. e. congenital heart defects and neural tube defects) occur which may influence the outcome of the pregnancy. In terms of teratogenic effects, taking medication or undergoing X-ray examination or infections during early pregnancy indicates only a small risk in most cases. The authors emphasize that genetic centers significantly influence the perinatal outcome of pregnancies with their complex activity and their role in prenatal diagnostics.

Eclampsia is the occurrence of generalized convulsions during pregnancy, labor or within seven days of delivery, not due to epilepsy or other convulsive disorders. It is largely a preventable disease provided the pregnant women get regular antenatal care. Despite all prevention measures, diagnostic modalities and intensive treatment, it is still one of the leading causes of maternal mortality in the developing world. In this review, we present definitions, epidemiologic data, pathophysiology, diagnosis and management of this life threatening condition.

Normal pregnancy and childbirth are known to be associated with marked changes in the coagulation and fibrinolytic systems. Generally, enhancement of clotting activity persists to prevent the risk of major hemorrhage. Hemostatic problems, either associated with a specific complication of pregnancy and labor or due to a hereditary or acquired bleeding diathesis or thrombophilias, present a significant cause of maternal and neonatal morbidity and mortality. This article reviews hemostatic disorders in pregnancy and the peripartal period from the standpoint of the obstetrician.

Aim: The aim of the study was to investigate the most frequent causes of perinatal mortality in Bosnia and Herzegovina Methods: We analyzed in a retrospective study over a one year period (1999) the folloving cantons: Sarajevo, Mostar, Tuzla, Bihać, Goražde, Travnik, Zenica, which represent about one half of the population of Bosnia and Herzegovina. Results: Perinatal mortality in the analyzed regions within Bosnia and Herzegovina was 19.55 ‰, which is unacceptable in comparison with developed countries. Early neonatal mortality (9‰) was lower than late fetal mortality 10.55 ‰. The most frequent causes of death were: premature birth, 6.32% of all deliveries; EPH gestosis with a rate of 9% of all deliveries and fetal anomalies with 0.68% of all deliveries. In Bosnia and Herzegovina, prematurity is the cause of early neonatal mortality in 78.5% of cases, while fetal anomalies are the cause in the early new-born period in 10.70% of cases. Conclusion: The results of perinatal mortality analyses in Bosnia and Herzegovina confirm that perinatal mortality directly depends on the development of the health care system, economic sustainability, and living conditions. Our results show that Bosnia and Herzegovina fall into the category of developing country with a perinatal mortality rate of 19.55 ‰.

Aim: To investigate the safety of vaginal delivery for term breech fetuses in a tertiary-care hospital of Pakistan. Methods: We reviewed the medical records of all live singleton breech deliveries at or beyond 37 weeks of gestation, at the Aga Khan University Hospital, Karachi, from January 1988 to December 1995. Results: Rate of cesarean section increased from 48% (1988) to 74% (1995). Out of 287 subjects, 158 underwent elective cesarean section while 129 received a trial of labor, 77% of which delivered vaginally. There was no neonatal or maternal death. Compared to babies delivered by emergency or elective cesarean section, those delivered vaginally had significantly more neonatal intensive-care unit admissions (none and 5% versus 13 %) and higher rates of birth trauma (none and 0.6% versus 7%). However, there was no significant difference in the Apgar score at 5 minutes and the risk of maternal complications by delivery mode. Conclusion: Allowing trial of labor to carefully selected mothers can result in vaginal delivery in 77% of the cases. However, the risk of trauma and neonatal intensive-care unit admissions, among vaginal births may favor the decision of elective cesarean section, unless rigorous pre-delivery assessment and conduct of delivery by adequately trained obstetricians is performed.

This retrospective case analysis is performed in order to analyze post-partum hysterectomies in St. Mary's Hospital, Manchester during the last thirteen years and to compare it with the published results twenty years ago. We wanted to determine any possible changes in trends as well as to discuss the place of post-partum hysterectomy in modern obstetric practice. The main outcome measurements were incidence, maternal mortality and morbidity, indications and risk factors for post-partum hysterectomy in our hospital today and twenty years ago. Obtained results were compared to the same data and trends world-wide. There has been a fall in the incidence of both, elective and emergency post-partum hysterectomies in St. Mary's Hospital. All together, 28 women underwent post-partum hysterectomy electively or as an emergency in the period between l985 and 1997. Mortality rate was 1 in 28 cases and morbidity rate was 65% in emergency group and 37.5% in elective group. The most common indication for elective post-partum hysterectomy is cervical intraepithelial neoplasia. The most important risk factor for emergency post-partum hysterectomy is previous cesarean section especially related to placenta accreta. There was no significant changes in trends, maternal mortality and morbidity and indications related to emergency post-partum hysterectomies today and twenty years ago, while the indications for elective cases were changed.