Volume 31, Issue 5

The goal of antenatal care is to help the mother to maintain her well-being and achieve a healthy outcome for herself and her infant. Education about pregnancy, childbearing and childrearing is an important part of antenatal care. Because of the perception that pregnancy is a physiologic event, even today lots of women do not seek medical care until a problem occurs during their pregnancy. There are still unacceptable differences in the extent of perinatal problems in developed and developing countries. Over the last century almost all countries have accepted antenatal care principles. However, insufficiency of resources and a lack of women's compliance have proved to be obstacles in developing countries and have compelled the application of various standard programs. Unfortunately, these programs are not sufficiently effective in preventing and treating maternal mortality. A safe pregnancy and delivery is a human right. Maternal mortality and morbidity should not be ranked with other diseases, because child bearing is not a disease. For this reason a global ethical consideration imposes an obligation upon society to avoid these almost totally preventable deaths. Ensuring access to family planning is an important way of decreasing maternal death. 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 interventions include: education for all, universal childbirth, access to family planning services, attendance at birth by professional health workers, access to good quality care in case of complications, and policies that raise women's social and economic status and increase their access to property and the labor force.

The absence or non-availability of medical centers with inaccessible distance and delay in providing treatment is an insurmountable problem in backward regions. A pregnant mother from a developing country is 30 times more likely to die than a mother from a developed country and her newborn faces the same risk of mortality. The involvement of government is a vital part of the attempt to achieve improvements. Government has the power and obstetricians have the information to lead the way. No doubt even when the two cooperate there is still room for inadequacy, but perhaps partners like the WHO, UNFPA, UNICEF, IPPF, FIGO, World Bank, World Association of Perinatal Medicine, World Pediatric Association, International Midwives Confederation, etc. can help to achieve targets. There is urgent need for the twinning of the perinatal departments of developing countries with the perinatal departments of advanced countries and/or the twinning of countries or geographical areas, or of NGOs with government and change in mindsets where required. To obtain the maximum benefits from such an approach, it would be necessary to go a little beyond perinatal science.

Globally, the perinatal mortality rate (PMR) is 53/1000 (7.5 million annual perinatal deaths) and the neonatal mortality rate (NMR) is 36/1000 (5.1 million annual neonatal deaths). Of the 141 million annual livebirths, 127 million (90%) are born in developing countries, which, compared to developed countries, have a higher PMR (57/1000 vs 11/1000, 5.2 x) and NMR (39/1000 vs 7/1000, 5.6 x). Five million annual neonatal deaths (98% of the world's total) occur in developing countries. Regional annual livebirths figures are: Asia-Oceania 76 million, Africa 31 million, Central and South America 12 million, Europe 8 million, and North America 4 million. Regional annual neonatal death figures are: Asia- Oceania 3.3 million, Africa 1.3 million, Central and South America 0.3 million, Europe 0.07 million, North America 0.03 million. The Asia-Oceania region has a PMR of 53/1000 and a NMR of 41/1000. It has half of the world's livebirths and two-thirds of the world's neonatal deaths. The PMR and NMR have often been used as an indicator of the standard of a country's social, educational and healthcare systems. Strategies, which address inequalities both within a country and between countries, are necessary if there is going to be further improvement in global perinatal health.

All maternal deaths are considered as a social injustice. For this reason, governments should take necessary measures to make motherhood safer. In order to prevent premature deaths of women, causes of deaths must be known. In Turkey, the latest survey conducted in hospitals in selected 53 provinces. This hospital-based survey revealed that maternal mortalities make up 5% of all women deaths and maternal mortality is 49.2 per hundred thousand live births. Factors which are related with the status of women including, education, socio-economic conditions, early marriage age, and fertility level have influence on maternal mortality level in the community. Accessibility and availability of maternal health care services are also very important factors to reduce maternal mortality.

Of all health statistics mentioned by the World Health Organization (WHO), maternal mortality is unique in showing the largest discrepancy between developed and developing countries. Approximately 90% of maternal deaths (more than 0.5 million each year) occur in developing countries. Over the last century, almost all countries have accepted antenatal care principles. However, insufficiency of resources and lack of women's compliance were the main handicaps in developing countries and compelled these countries to apply various standard programs. Unfortunately, these programs are not sufficiently effective in the prevention and treatment of maternal mortality. Fixing the number (quantity) of antenatal visits and the static approach affect the “quality” of antenatal care. Bleeding, chronic anemia, hypertensive disorders, obstructed labor, unsafe abortions and infections are the main factors leading to maternal mortality. The majority of these factors are preventable. It is important to suspect the presence of any of these factors and to intervene promptly both during antenatal care and immediately after delivery. The evidence-based approach is a way of reaching this solution. Antenatal care is a concept that extends from pre-pregnancy to postpartum, leading to effective emergency care for unpredictable and predictable complications during pregnancy and childbirth. Worldwide policies are not always applicable to each country, coercing national policies. There is still a need for prospective randomized trials to clarify this concept and the relevant policies.

Universally 4 million newborns die and another 4 million are stillborn every year. 98% of these neonatal deaths take place in the developing countries. Looking at the state of the world's newborns one can see that neonatal mortality rate is about 4–5 per 1000 in the developed countries and nearly 10 fold this in the developing world. Causes that underlie these newborn deaths differ according to a country's development rank. According to the WHO estimates for the year 2001, newborns die due to infections (32%), birth asphyxia and trauma (29%), prematurity (24%) and congenital anomalies (10%), mostly in the developing countries. When organizing neonatal care services in a country or a region, priorities should be decided by looking at neonatal and perinatal mortality rates and causes of neonatal and perinatal deaths. Causes of neonatal and perinatal deaths in the developing countries have been documented and reflect some common underlying problems in the health systems. Starting points in the organization of neonatal health care services seem to include: improving women's health and social status, family planning practices, antenatal care and safe delivery conditions. Attention should also be paid to neonatal resuscitation, essential newborn care and sick newborn care practices. Communities and health professionals should be advocates of newborn health in order to seek and deliver newborn health care. Existing health systems should be re-organized to host regionalized perinatal care.

Aim: To investigate the advantage of performing cesarean section using the Misgav-Ladach method and to justify its use in everyday practice. Methods: In a prospective study we analyzed over a two year period (2000–01) cesarean sections carried out using the Misgav-Ladach method at our clinic. We compared both 550 cases of Misgav-Ladach (ML) and 100 cases of Pfannenstiel (PH) cesarean section. In the group that had undergone the Misgav-Ladach method we sutured the uterus in one layer and left the peritoneum non-sutured, and in the group who had undergone Pfennenstiel we sutured the uterus in two layers and also sutured the visceral and parietal peritoneum. In every case we analyzed: maternal age, gestational age, duration of operation, consumption of suture material, duration of hospitalization, and surgical complications. Results: Incidence of postoperative febrile morbidity was 5.45%, in the Misgav-Ladach group compared with 13.2% in the Pfannenstiel group (p < 0.05). Local infection of the wound in the Misgav-Ladach group was found in 4.54% and in the Pfannenstiel group in 9% (p < 0.05). Mean time of extraction of the newborn in the Misgav-Ladach group was 1.25 minutes, and in the Pfannenstiel group 4.10 minutes (P<0.05). Mean duration of operation in the Misgav-Ladach group was 10.98 min, and in the Pfannenstiel group 25 min (p < 0.05). Mean duration of hospitalization in the Misgav-Ladach group was 4.75 days, and in the Pfannenstiel group 6.32 days (p > 0.05). Mean consumption of suture material in the group Misgav-Ladach was 3.10 sutures per operation, and in the Pfannenstiel group was 9.5 sutures. Conclusion: Our study shows that the Misgav-Ladach method of cesarean section enables fast recovery and shorter hospitalization, and reduces the length of the operation, the incidence of surgical complication and the consumption of surgical materials.

Monitoring of the intrauterine growth retarded fetus in order to improve fetal outcome and define precisely the timing of delivery, when necessary, is based on the study of changes in vital functions observable in cases of hypoxemia. It is easy to believe that ultrasound equipment with Doppler facilities is present in the majority if not in all gynecological units. Cardiotocography is also widely used and the addition of a computerized evaluation system is not expensive and therefore should be available when facing high risk pregnancies such as intrauterine growth retarded cases. IUGR can be recognized through the use of ultrasound fetal biometry and clinical examination of maternal conditions in order to assess fetal conditions. If the above technologies are available further action, such as fetal Doppler study of fetal vessels and cardiotocography, can then be undertaken. In this paper, we will be discussing the issue of monitoring the fetus for fetal well-being, particularly in cases of intrauterine growth retarded fetuses.

Massive obstetric haemorrhage is a major cause of maternal death and morbidity; abruption of the placenta, placenta praevia and postpartum haemorrhage being the main causes of haemorrhages. A delay in the correction of hypovolaemia, diagnosis and treatment of defective coagulation and/or surgical control of bleeding are the avoidable factors in most maternal deaths caused by haemorrhage. The main goal is to maintain effective circulating intravascular volume by prompt and adequate replacement of blood, crystalloids or fresh-frozen plasma through more than one intravenous line (it might be necessary to pump blood under pressure) with constant monitoring of the pulse rate and the arterial blood pressure. The rapid correction of hypovolaemia with crystalloids and red cells is the first priority, followed by blood component therapy. Oxytocin and prostaglandin will correct uterine atony, and appropriate surgical intervention is required for traumatic bleeding. Ligation of the uterine arteries, ovarian arteries and hypogastric arteries will usually control uterine bleeding and arterial embolization is also effective. Hysterectomy should also be considered in severe cases. All gynecologists should be able to perform without delay the operative maneuvers which are necessary to control the bleeding, including hypogastric artery ligation, or even emergency hysterectomy. This topic may have received little attention because it is perceived as being associated with maternal morbidity rather than mortality in developed countries; it is only recently that the extent and importance of postnatal maternal morbidity has been recognized.

Breech presentation is the most common malpresentation, with about 3–4% of singleton fetuses presenting breech at delivery. Management of breech presentation has been a contentious issue with a lowering threshold for cesarean section in recent years. Perinatal mortality and morbidity are estimated to be three times that of comparable infants with vertex presentation. Breech presentation is commonly associated with certain adverse maternal and fetal factors which inherently give rise to increased perinatal morbidity and mortality. At present, most obstetricians favor cesarean delivery for uncomplicated pre-term breech. Controlled prospective studies have shown that the outcome of breech fetuses weighing more than 1500 g was not dependent on the mode of delivery. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for pre-term breech. Vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500–3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia under continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. If these criteria are not fulfilled, or fetal monitoring cannot be performed, cesarean section is advisable.

Iron deficiency is the most common nutritional disorder in the world. Pregnant women are at especially high risk for iron deficiency and iron deficiency anemia. A considerable proportion of pregnant women in both developing and industrialized countries become anemic during pregnancy. The prevalence of anemia in pregnant women has remained unacceptably high worldwide despite the fact that routine iron supplementation during pregnancy has been almost universally recommended to prevent maternal anemia, especially in developing countries over the past 30 years. The major problem with iron supplementation during pregnancy is compliance. Despite many studies, the relationship between maternal anemia and adverse pregnancy outcome is unclear. However, there is now sufficient evidence that iron supplements increase hemoglobin and serum ferritin levels during pregnancy and also improve the maternal iron status in the puerperium, even in women who enter pregnancy with adequate iron stores. Recent information also suggests an association between maternal iron status in pregnancy and the iron status of infants postpartum. The necessity of routine iron supplementation during pregnancy has been debated in industrialized countries and routine supplementation is not universally practiced in all these countries. In view of existing data, however, routine iron supplementation during pregnancy seems to be a safe strategy to prevent maternal anemia in developing countries, where traditional diets provide inadequate iron and where malaria and other infections causing increased losses are endemic.

In this report, two conjoined twin cases that were diagnosed at the 19 th and 25 th week of gestational age are reported. In the first case the pregnancy was terminated because of the very poor prognosis. In the second case the decision was made to continue the pregnancy after counseling explaining the possibility of a separation procedure with good prognosis being carried out after birth. The babies were delivered at 38 weeks of gestation and the separation procedure was carried out at ten months of age without any complications. In selected cases, there is no need to abort, because of the possibility of a separation procedure after birth with good prognosis. Color Doppler ultrasound examination in an early stage of pregnancy in cases of conjoined twin can make it possible to decide which cases are candidates for a separation procedure after birth.

Object: Several patterns of fetal breathing movements (FBMs), i.e. abdominal wall movements (AWm), thoracic wall movements (TWm) and nasal fluid flow velocity waveforms (NFFVW), were investigated by ultrasound (US) technology and related to fetal pulmonary maturity and immaturity, i.e. fetal lung maturity (FLM) tests, in order to validate the hypothesis that they may indicate whether the fetal lung is mature or immature, regardless of gender, weight and gestational age. Material and methods: We prospectively enrolled 143 high-risk pregnancies in which a complete US study of FBMs and FLM tests was performed. Among them 43 women satisfied the inclusion criteria. US-FLM was defined as the presence of regular NFFVW detected by pulsed Doppler and spectral analysis, or irregular NFFVW synchronous with TWm detected by M-mode. An US guided amniocentesis was performed in order to collect amniotic fluid (AF) and FLM was evaluated by L/S (lecithin/sphingomyelin) determination, presence of phosphatidylglycerol (PG) and lamellar bodies (LBs) count. At the end of the study the diagnostic accuracy of US-FLM was compared to that of FLM tests. Results: Diagnostic accuracy for US evaluation of FLM was as follows: sensitivity: 89,6%; specificity: 85,7%; PPV: 92,8%; NPV: 80%. Diagnostic accuracy of FLM tests was as follows: sensitivity: 100%;specificity: 51,7%; PPV: 100%; NPV: 50%. L/S determination predicted lung maturity with a sensitivity of 100%; specificity of 93,1%; PPV of 100%; NPV of 87,5%. Conclusion: Presence of regular NFFVW or irregular NFFVW and TWm correlate accurately with conventional FLM tests. We suggest that this noninvasive procedure may be helpful for assessing FLM, particularly under certain circumstances, e.g., oligo-anhydramnios, laboratory logistic equipment difficulties or heavily stained AF samples, amniocentesis refusal, religious concerns.

Aims: To determine the causes of perinatal mortality and to calculate perinatal mortality rates at Hacettepe University Hospital. Material and Methods: In 1998 the Perinatal Mortality Study Group was established at Hacettepe University. The study group was constituted by the Department of Pediatrics, Units of Pediatric Pathology, Pediatric Cardiology, Pediatric Surgery, Genetics and Neonatology and the Department of Obstetrics and Gynecology, Perinatology Unit. At the end of every month, each case (including autopsy results if available) was discussed among the group, and the cause of mortality was determined according to the Modified Wigglesworth Classification, by the consensus of the group members. Perinatal mortality rates at Hacettepe University were prospectively calculated. Perinatal mortality figures of two periods were compared (1998–1999: Group A and 2000–2001: Group B). Results: Total number of births over 500 grams was 3173 in Group A and 3013 in Group B. Perinatal mortality rate was 33.72/1000 in Group A and 16.92/1000 in Group B. Of the perinatal deaths, 61.46% were intrauterine deaths and 38.54% were early neonatal deaths in Group A. In Group B, 58.83% were intrauterine deaths and 40% were early neonatal deaths. In Group A, 72% of the deaths were < 1500 grams, and 53.3% were 500–1000 grams. The most common cause of death during this period was prematurity (Modified Wigglesworth Group III) (29.3%), followed by lethal congenital malformations (Group II) (26.6%) and macerated intrauterine deaths (Group I) (22.9%). Autopsy was available in 70.7% of the cases and micronecropsy was available in 12%. Genetic studies were performed in 24% of the cases and termination of pregnancy was carried out for fetal anomalies in 10.7% of the cases. In Group B, 72.6% of the cases were < 1500 grams and 47.1% of the cases were 500–1000 grams. The most common cause of death during this period was lethal congenital malformations (Group II) (31.4%), followed by macerated intrauterine deaths (Group I) (21.5%) and specific causes (Group V) (21.5%). Autopsy was available in 70.17% of the cases and micronecropsy was obtained in 10.52% of the cases. 20% of the cases underwent genetic studies during pregnancy and termination of pregnancy was carried out in 19.29% of the cases. Conclusions: Perinatal mortality rate has decreased at Hacettepe University over the last two years. The authors believe that this is a result of the multidisciplinary work which has had an impact on perinatal and neonatal care. The most common cause of mortality has changed from prematuriy to lethal congenital malformations in this period. Since our institution is a referral center, around 60% of mortality is due to intrauterine deaths and around 30% of the deaths are due to lethal congenital malformations. Unfortunately lethal congenital malformations are referred to our center at an advanced stage of pregnancy.

Aim: Premature birth is the single largest cause of perinatal mortality and morbidity in non-anomalous infants in all developed nations. The aim of this study is to survey the role of glucocorticoid therapy in decreasing early neonatal complications in preterm delivery. Methods: A case control study was carried out on 300 preterm labors. Half the women received one to four 6 mg doses of dexamethasone every 6 hours, depending on the interval between admission and delivery. Neonatal complications were compared between the two groups. Results: Corticosteroid therapy was observed to have the greatest effect in preventing respiratory distress and neonatal mortality between 29–34 gestational weeks. There was a significant relationship between antenatal corticosteroid therapy interval and mortality of preterm neonates. Complications such as respiratory distress, sepsis, pneumonia, and hyperbilirubinemia were significantly lower in the case group than in the control. Conclusion: It is recommended that all women at high risk for preterm labor before 35 gestational weeks be given glucocorticoid at least 24 hours before delivery in order to markedly reduce neonatal mortality and morbidity.