BY

DR. ALEXANDER

E OMU

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY FACULTY OF MEDICINE, KUWAIT UNIVERSITY

LEARNING OBJECTIVES
• To understand basic concepts of new developments in different branches of Obstetrics and Gynaecology. • To understand the concept of evidence base- practice in Obstetrics and Gynaecology. * To be made aware of the significant role of medical audit in clinical practice and review basic vital statistics.

Since the description of the double helical structure of DNA by Watson and Crick in 1953 there have been many discoveries in the genetic and molecular function of the normal and abnormal.

1. One of such advances is in reproductive technology:
* Ovarian hyperstimulation * In vitro fertilization & ICSI / TSE ICSI * Human embryology cryopreservation * Pre-gestational diagnosis (PGD):FISH * Sex Pre-selection * Pregnancy in older women

2. Cloning in animals and tissue from stem cells

3. Laparoscopy
* diagnosis and treatment of ectopic pregnancy * Infertility: diagnosis and treatment * Therapeutic * Surgical contraception * Assisted vaginal hysterectomy * Myomectomy etc

4. Hysteroscopy
* Uterine polyp removal * Myomectomy * Uterine adhesions / syneciae

5. Ultrasound and 3D

- In fetal-maternal Medicine Diagnosis and treatment * intrauterine therapy * Congenital anomalies * Ectopic pregnancy * Multiple pregnancy

6. Magnetic Resonance Imaging and CT scan
Tumor volume – in Oncology and involvement of lymph nodes

7. T V T (Tension free Vaginal Tape) for stress
incontinence

8.

Internet Information technology
* General use of internet * Internet and research

9.

HUMAN GENOME

10. Evidence – based – practice - and Medical audit

( Vital statistic)

Vital statistics

In Obstetrics vital statistics are related to data about birth and deaths Birth rates Death of the fetus or newborn (stillbirth and neonatal death-perinatal death) Maternal deaths

Factors

Background Region or country of origin *Population at risk The period of time data is collected The source of the data (who dealt with the data Ministry of health or institute) Methods of expression as rates per 1000 or 100,000 or 1,000,000 (perinatal mortality) (Maternal

Uses of vital statistic
For planning of health services Hospital Regions Countries Comparison between Individuals Hospitals Countries As medical Audit

Birth Rate
1. Birth rate = number of birth in the year X 100 mid – year population

Source of information and notification of birth This rate has many flaws, because all ages are accounted for 2. General fertility rate = number of births in the year X 1000 number of women aged 15-44 years

3.

Total period fertility rate (TPFR). Average number of children who would be born per woman, throughout their fertile life span (15 – 44 years)

Birth rates in
Developing countries 35 – 50 per 1000 Developed countries 12 – 15 per 1000

Implications
Population increase + immigration/emigration Availability of resources or lack

Maternal Mortality
A maternal death is one that can be attributed to pregnancy or childbirth and up to the 6 weeks of the puerperium. In UK, deaths up to one year after child birth or an abortion a. Direct Obstetric haemorrhage Preeclampsia Infection b. Indirect: from previous existing disease mitral stenosis, hypertension c. Fortuitous: deaths not directly related to pregnancy e.g road traffic accidents

Maternal mortality =

Number of maternal deaths x1000 Total births Number of maternal deaths x1000 Live births

WHO and (MMR) US

=

Causes of drop of MMR
The control of infection Blood transfusion Operative delivery advance in anaesthesia and resuscitation

Causes of Maternal deaths Pulmonary embolism Hypertensive disorders of pregnancy Anaesthesia Amniotic fluid embolism Abortion Ectopic pregnancy Haemorrhage
Placenta praevia Abruptio placenta

Sepsis Ruptured uterus Other direct causes
Medical disorder Diabetes mellitus Acute fatty liver of pregnancy

Comparison of MMR in Developing and Developed countries and factors affecting MMR
Region Africa North West East Central Southern Asia West South Southeast East Latin America North America Oceania Europe No. of children Woman married 15-19 44 34 70 32 49 2 42 25 54 24 2 16 11 10 7 39 8 30 MMR(/100.000) live birth 640 500 700 660 690 570 420 340 650 420 55 270 50 100 30 450 30 390 Literacy of woman 15 18 6 14 9 56 34 31 17 53 92 70 99 88 93 32 97 54

per woman
6.4 6.2 6.8 6.6 6.0 5.2 3.9 5.8 5.5 4.7 2.3 4.5 1.8 2.8 2.0

Developing count. 4.4 Developed count 2.0 World 3.8

About 560,000 women die from pregnancy and childbirth every year

Strategies for reducing MMR
1. Education 2. Improving health care 3. Economic emancipation 4. Obstetric care ANC Labour facilities etc 5. Family planning 6. Other measures

Perinatal Mortality
Perinatal mortality is a term used for a total of all the stillbirths and the first week neonatal deaths. (from 24 weeks of gestation) Stillbirth (SB) Obstetric related early neonatal death Perinatal mortality rate (PNMR)

=
US

SB + One week neonatal death x 1000 Total births SB + One week neonatal death x 1000 Live births

(WHO) PNMR =

Neonatal death rate is the number of infants dying in the first month per 1000 live births Infant mortality rate is the number of infants dying in the first year of life per 1000 life births

Causes of Perinatal death
A. Still Birth Unknown (because of maceration) 25-40% Congenital abnormality 33% IUGR Preeclampsia SLE Diabetes mellitus Poor nutrition Placental disease abruptio placenta placental praevia Fetal infection Diabetes mellitus Rhesus isoimmunisation Cord accidents Prolapse, entanglement

Neonatal Causes of Perinatal Death
Preterm labour (Incidence 6-7%) RDS hyaline membrane disease Congenital anomalies Hypoxia Infection Intracranial haemorrhage Shoulder dystocia 25% 10% 60-80%

Factors affecting perinatal mortality
Age, Parity Socio-economic class Smoking Preterm IUGR Racial origin Poor obstetric care Grand multiparity Adolescent pregnancy

Reduction of Perinatal mortality
Maternal formal and informal education Improved socio-economic conditions (better standard of living) Reduction of births per woman Improved nutrition Family planning Improvement in obstetric technology Improvement in neonatal technology Reduce cigarette smoking

Prevalence of some Obstetric Procedures at the Maternity Hospital 2000 Caesarean section Vaginal delivery after a Previous C section Vacuum Extraction Forceps delivery Breech presentation at delivery Cervical Cerclage 19% 60% 3.5% 1.5% 4.0% 1.4%

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