5
Early Human Development, 29 (1992)5-13 ElsevierScientificPublishersIreland Ltd.
EHD 01244
Opening Lecture
Future horizons in perinatal medicine John J. Sciarra Northwestern
Introduction -
University
Medical
School
Chicago,
Illinois
(USA)
The pursuit of neonatal excellence
As the opening concept of this presentation on future horizons in perinatal medicine, I should like to propose that the goal of perinatal medicine for the next century will be the pursuit of neonatal excellence. Every baby should be born a healthy baby. My presentation today will cover four areas. All are future horizons in perinatal medicine and all are essential if we are to achieve neonatal excellence in the twentyfirst century. The topics I shall discuss today, are: (1) the use of appropriate technology, (2) international communication as a way to enhance quality of care, (3) maternal nutrition as a means improving perinatal outcome and (4) the WHO/FIG0 safe motherhood initiative. The use of appropriate technology Clinicians providing maternity services today are surrounded by high technology that must be integrated into clinical practice. In recent years, the technological advances in perinatal medicine have been extraordinary. The introduction of ultrasound, prenatal genetic diagnosis, electronic fetal monitoring and neonatal intensive care, to mention only four, have greatly improved obstetric and newborn care. These and other advances have contributed to the worldwide reduction of perinatal mortality that has occurred during the past two decades in developed nations such the United States, as well as here in Japan. In the United States, in Japan and in many industrialized countries, we are blessed with the technical knowledge and the financial resources to continually develop new and better equipment for medical and surgical care. Ultrasound is an excellent example of the introduction of a new technology into obstetrics and the program of this meeting is testimony to the importance of ultrasound in modern obstetric care. Professor Stuart Campbell will deliver his opening lecture on this topic later this morning. Developed four decades ago, ultrasound imaging has now become an important part of obstetric practice. And while there 037%3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
b
is no question that ultrasound has an enormous clinical value, it is important that we continually assess and determine the proper role for ultrasound and other technological advances in everyday clinical practice. There is no easy answer as to how we should assess the appropriate use of new technology in obstetric practice. One approach that I shall share with you is that developed under the sponsorship of the International Federation of Gynecology and Obstetrics (FIGO). Because of the modern role of high technology in clinical medicine, in 1988, FIG0 established a study group on, ‘The Assessment of New Technology,’ under the chairmanship of Professor Ermelando Cosmi of Rome. One of the first items on the agenda for the FIG0 study group was ultrasound. As the first step in this technology assessment program, a panel of international authorities representing both the developed and the developing countries of the world met in Italy in April 1991, Following two days of deliberations, the panel developed a series of recommendations on the use of ultrasound and doppler technology in obstetrics and gynecology. These recommendations will be published as a Committee Report in the FIG0 News section of the International Journal of Gynecology and Obstetrics (ZJGO) in the near future. One of the questions most frequently asked by practitioners is about the use of ultrasound in low risk pregnancy. This was one of the most difficult questions for the FIG0 study group to answer, because of the differences in obstetric practice throughout the world. However, they did arrive at a consensus and one of their recommendations is shown here [l]: If applicable, an ultrasound examination is recommended at least once in a low risk pregnancy. The optimum period for balancing pregnancy dating and detection of congenital anomalies is between 16 and 20 weeks of gestation. This advice is an example of the type of information that must be made available to clinicians struggling with an ever increasing array of new technological advances in the field of perinatal medicine. I should now like to continue the theme of the use of appropriate technology by moving from high technology to low technology. During the decade of the 1980s in the developed countries of the world a strong sentiment developed toward the use of a variety of obstetric interventions during labor and delivery. This reasonable approach was based on the assumption that the wide application of new technological innovations would enhance perinatal outcome. Electronic fetal monitoring (EFM), during normal labor is a good example. However, after a decade of experience and numerous large studies, it is now generally agreed that electronic fetal monitoring during labor has not provided us with a major decrease in perinatal mortality and morbidity or improved Apgar scores. Electronic fetal monitoring obviously has a place in intrapartum care but certainly its benefit has not been as great as originally expected. The American College of Obstetricians and Gynecologists (ACOG) stated in 1989, ‘It is now increasingly evident from available data, that EFM has no inherent benefit over intermittent auscultation in both high and low risk patients’ [2]. This statement was based on a series of studies comprising over 60 000 patients evaluated in several countries. In this regard, I should like to mention an interesting report from my own hospital, which is a private university maternity hospital in central Chicago, respon-
1
sible for approximately 5000 deliveries per year, 25% high risk and 75% low risk. This paper was published in the IJGO this year and is entitled ‘Recommendations for the management of low risk obstetric patients’ [3]. The authors have selected for review specific interventional procedures, which have enjoyed widespread popularity in the United States in the routine management of low risk obstetric patients. AQ objective assessment of these procedures suggested that often interventional procedures lead to a higher incidence of operative delivery. Intervention often results in this cascade effect that is well known to all clinicians (Fig. 1). The authors of this study suggest that ineffective therapies may be prescribed during labor without consideration or regard to their need and consequences. This is particularly true in the United States, where technological resources are widely available and viewed as evidence of superior medical care and therefore are applied to low risk as well as to high risk patients. Therefore, as we develop standards for maternity services that can be applied to the developed countries as well as to the developing countries of the world, it is particularly prudent for us to reevaluate the need for routine procedures that may complicate rather than simplify maternity care. Our goal should be for all patients to enjoy quality maternity care supported by appropriate technology. Many discussions about technology fail to assessthe cost of such care both to the individual hospital and to society. Nowhere is this more obvious than in the area of neonatal intensive care. The costs of neonatal intensive care are not standard throughout the world but are expensive by any criteria. In France, for example the generally quoted rate is 6000F per day. In the United States the cost is a minimum of $1000 per day [4]. I am now going to share with you some information drawn from the experience in dealing with multiple pregnancy, because twins, triplets and higher order births provide a good background for any discussion of one of the most pressing worldwide problems in perinatal medicine, the management of preterm labor and the low birth weight neonate. In one recent analysis performed by members of my department, a total of 36 days
Uncomplicated
Pregnancy
/-----AIntravenous Fluids \/I Anxiety Discomfort
Fetal Monitoring Inactivity
\ Pain \ Analgesia Anesthesia Slowed
Questionable Electronic Fetal Monitor Tracing
Labor
Pitkin
I Amniotomy
HyGrstimulation I Fetal Heart Rate Changes Cesarean
Section
Fig. 1. The cascade effect. Use of benign interventions resulting in the need for additional technologies.
8
of neonatal intensive care were required per 1000 live births of singletons at a cost of $36 000 [4]. This same study estimated that a total of 44 158 neonatal intensive care days would be required per 1000 live births of twins, at a cost of 4 168 000. This represents more than a lOO-fold difference. The costs for higher order multiple births are even greater. The higher the number of fetuses, the lower the gestational age at delivery, the lower the birth weight, and the longer the length of stay in the hospital. Now, I should like to present to you the case of an unusual premature birth in Chicago that illustrates both medical and ethical issues that we must face as one of the horizons in perinatal medicine. The patient was 36 years old and this was her only pregnancy following therapy for infertility. Ultrasound revealed a triplet pregnancy with monozygotic twins and a singleton. Because of the likelihood of poor outcome, the twin pregnancy was reduced with an intracardiac injection of potassium chloride into each twin at 10 weeks of gestation, The pregnancy continued as a single pregnancy but late in the second trimester the patient developed severe pre-eclampsia. The pregnancy was terminated by cesarean section at 26 weeks and six days with the delivery of a growth retarded, 280 g female. This infant required assisted ventilation for 61 days and was discharged home from the neonatal intensive care nursery on the 120th day of life with a weight of 1900 gm. The hospital bill for intensive care was approximately $150 000 [5]. This is probably the smallest infant ever to survive. She is now 2 years old and still small for her age. This case stresses not only the expense of neonatal intensive care but also raises the contemporary question regarding the role of selective reduction of multifetal pregnancy. The selective fetal reduction procedure was originally reported in 1988 and has been proposed as an answer to the epidemic of iatrogenic higher order multiple pregnancies that have occurred since the introduction of assisted reproductive technology. In selective reduction, injections of potassium chloride are administered using ultrasound guidance to one or more fetuses in higher order multiple pregnancies. Treated fetuses are resorbed and the pregnancy continues as a lower order gestation. The rationale behind the therapy is to increase the likelihood of survival of a smaller number of fetuses. It appears to be realistic therapy until we are able to control the number of pregnancies from the various assisted reproductive technologies and eliminate the large number of higher order multiples. As of this year, there have been only about 200 published cases with a 90% success rate. By success I mean that the reduction was successful and the pregnancy continued. Only careful clinical research will tell us if selective fetal reduction is the appropriate method for improving perinatal survival in multiple gestation. The medical and ethical issues raised by this procedure present an important modern-day challenge in the field of perinatal medicine. Enhanced international communication
Perinatal medicine is an international specialty and enhanced international communication is essential if progress is to be made and if information is to be transmitted to the largest possible clinical audience, particularly in the developing
9
countries of the world. The rapid transfer of clinical information is important if we are to enhance, on a worldwide basis, the quality of care within our discipline: Such communication is achieved through congresses such as this First International Congress of Perinatal Medicine, but also through written material. One of the goals of FIG0 for the next decade is to enhance international communication in obstetrics and gynecology through the FIGG publications and the International Journal of Gynecology and Obstetrics.
An important example of a FIG0 publication that has the potential for significant international impact, is the FIG0 Manual of Human Reproduction, which is now in its second edition and is currently available with teaching slides. These publications will soon be available in French, in addition to English and eventually, possibly in Spanish. Another example, of course, is the International Journal of Gynecology and Obstetrics for which I have served as the editor for the past several years. This year we are publishing, in addition to the FIG0 committee reports, the ‘Technical Bulletins,’ and the ‘Committee Opinions,’ of the American College of Obstetricians and Gynecologists and for the first time this information will be available to the full international community on a timely basis. Improving perinatal outcome through improving maternal nutrition In the areas of the world where socioeconomic conditions are poor, pregnant women often suffer the most. Clearly, improving maternal nutrition will improve perinatal outcome. This should be a social as well as a medical goal for the next decade. Members of my department have published several papers in relation to maternal nutrition. I shall again draw on multiple pregnancy for my example because the problems seen in twin pregnancies are a magnification of problems we see in singleton pregnancy, particularly in relation to preterm labor and low birth weight infants. In normal pregnancy there is a strong relationship between maternal pregravid weight, gestational weight gain and birth weight. This has been shown in several published studies [6-121. With regard to twins, recent research indicates that a weight gain of 35-40 [13- 151 pounds and specifically, a gain of 24 pounds by 24 weeks, results in the highest birth weight for gestational age. Figure 2 shows the actual birth weight distributions for 1985 United States twin and singleton live births. It also shows a theoretical distribution of twin birth weights based on a shift in birth weight distribution by 500 g. Therefore, if enhanced maternal nutrition could add 500 g to the birth weight of twins, this would result in 50% of newborn twins having birth weights in the optimal range of 2500-3000 g. The proportion of birth weights of twins above 3000 g would remain the same but the percentage of birth weights below 2500 g would be reduced by more than half and consequently, so would perinatal mortality and morbidity. In addition, the length of neonatal intensive care stay would probably be sharply reduced and so would the associated costs. While this analysis may be oversimplified, it does raise the possibility that a dramatic reduction in perinatal mortality and morbidity could theoretically be accomplished without the introduction of any new technology but simply by an improvement in
10 65 60 55
I
I
E 40 8
35
&
30
p
25
I
Actual Singles
50 t
I
TheoryTwins
20 15 10 5 0 500
l.ooo
1.500
2,000
2,500
3,000
3.500
4,600
4,500
5,ooo
Birthweight Categories (grams) * adapted
irom Vital Statistics
of the U.S., 1965
Fig. 2. Actual percent distribution of twin versus singleton birthweights (adapted from Vital Statistics of the US, 1985) and theoretical distribution of twin birthweights.
maternal nutrition and, of course, good prenatal care. If prospective studies confirm the concept that early pregnancy weight gain results in higher birth weights in twins these findings may be applicable to singleton pregnancies as well. Safe motberbood On a worldwide basis, one of the great challenges to the specialty of perinatal medicine is safe motherhood. FIGG is committed to working toward the three goals of: (1) Safe motherhood, (2) A safe and healthy birth, and (3) A healthy infancy for all newborns. To achieve these goals, it is imperative that we work toward improving reproductive health for women worldwide. This includes not only the social goal of elevating the status of women in society but improving health care services in family planning and in maternity care. The World Health Organization (WHO) has established the goal of ‘Health for all by the year 2000. While this may be ambitious, it should be focal point for medical and political efforts in the decade of the 1990s. There is an urgent need to educate the medical profession and the general public in the value of safe motherhood. This is the term used by Dr Halfdan Mahler, the former Director General of WHO, in his address to a world congress in Nairobi in February 1987 [17]. Maternal mortality varies enormously between the industrializ-
11
ed nations and the developing countries of the world. For industrialized nations the risk of death averages 30 per 100 000 live births. In contrast, there are 450 maternal deaths per 100 000 live births in developing countries. The comparative risk of such death in a developing country can be as high as 200 times that in an industrialized nation. The number of pregnancies and deliveries also determines a woman’s lifetime risk of maternal death [18]. In Africa, this may be as high 1 in 21 while in northern Europe it may be as low as 1 in 10 000. If you look at international maternal mortality statistics another way, we can make the dramatic statement that each year 500 000 women die in childbirth from complications of pregnancy, problems during delivery, or unsafe abortion 1181. The real tragedy of modem obstetrics is that the majority of these deaths are preventable. If all women had access to adequate prenatal monitoring and intrapartum care, as well as postpartum family planning, many of these problems would solve themselves. In many instances the difficulties are more social than medical. For example, in one study in Tanzania it was found that 63% of the women who died had no means of transport and lived more than 10 km from the hospital and 37% lived more than 30 km away [19]. In another study, from India, 70% of pregnant women with serious complications came to the hospital by public bus [19]. A study in rural China showed that half of the maternal deaths were due to hemorrhage in areas where adequate blood replacement was unavailable [19]. Universally available family planning to prevent unwanted pregnancies, aid in family limitation and assistance in birth spacing would make a significant impact on reducing reproductive mortality. This is particularly true in Latin America, where it is estimated that as many as 50% of the maternal deaths may be secondary to unsafe abortion [ 191. In this regard, in many developed nations, we now have a situation where the number deaths of reproductive age women attributed to contraceptive use and procedures exceeds the number of maternal deaths. This paradoxical situation arises because the number of women using contraceptives is far greater than the number of women who are pregnant. The reverse, however, is the situation in developing countries, where mortality due to contraception is insignificant in comparison to maternal mortality. I stated earlier that 500 000 women die each year in childbirth. Looked at on an individual basis, one woman dies each minute of every hour of every day of the year from pregnancy, complications of pregnancy, or unsafe abortion. All but 6000 of these deaths take place in developing countries. For many years women of all societies sought measures to ensure safe motherhood and safe delivery. Not far from here is the Meiji-Jingu shrine, established in 1920 in memory of Emperor Meiji and his consort Empress Shoken. At the shrine it is possible for women to purchase a charm in the hope for a safe delivery. This is the goal of our patients and so it should become the goal of modern perinatal medicine. Four elements of the WHO/FIG0 program for safe motherhood and safe delivery are: (1) Adequate primary health care, including family planning for all women everywhere. (2) Comprehensive prenatal care, adequate nutrition and referral of high risk patients to appropriate centers.
12
(3) The assistance of trained delivery personnel for all women in childbirth, at home and in hospitals. (4) For women in high risk and for women in dire emergencies of pregnancy, childbirth, and puerperium, effective access to the essential elements of comprehensive quality obstetric care. A component of safe motherhood is safe birth and a healthy infancy. A painting by Girard David in the National Gallery of Scotland, painted in the sixteenth century, shows St. Nicholas giving thanks for his safe birth. A safe birth is the beginning of a healthy infancy. Closing remarks As we work toward the pursuit of neonatal excellence for the next century we must remember the expectations of our patients. I believe that in all countries, all cultures and all societies, patients want and deserve quality maternity services delivered in a compassionate manner. As we get increasingly specialized we run the risk of providing fragmented and sometimes impersonal care. Sir William Ossler made the following statement early in this century and the words remain a caution for us today: The extraordinary development of modern science may be her undoing. Specialism, now a necessity, has fragmented the specialists themselves in a way that makes the outlook hazardous. Obviously there are many other important horizons in perinatal medicine than the four I focused on today and it would be inappropriate not to recognize the other challenges in this exciting area of obstetrics. These include: Preterm labor and postdate pregnancy AIDS Substance abuse Prenatal genetic diagnosis Fetal therapy IUGR Early pregnancy loss Computer assisted care It is always worth restating that the goal of modern obstetrics is a healthy mother and a healthy baby. References 1 FIG0 Study Group on The Assessment of New Technology (1992): Recommendations on the Use of Ultrasound and Doppler Technology in Clinical Obstetrics and Gynecology. Elba island, Italy April 1991. Int. J. Gyn. Obstet., 37 (2), 221-227. 2 American College of Obstetricians and Gynecologists (1989): Newsletter 32:4, 1989. 3 Davis, L. and Riedmann, G. (1991): Recommendations for the management of low risk obstetric patients. Int. J. Gyn. Ob., 35 (2), 107. 4 Keith, L.G., Papiernik, E. and Luke, B. (1992): The costs of multiple pregnancy. Int. J. Gyn. Ob., 36 (Z), 109-l 14. 5 Muraskas, J.K., Carlson, N.J., Halsey, C., Frederiksen, M.C. and Sabbagha, R.E. (1991): Survival of a 280 g infant. New Eng. J. Med., 324 (22), 1598-1599.
13 6 Abrams, B.F. and Laros, R.K. (1986): Prepregnancy weight, weight gain and birth weight. Am. J. Obstet. Gynecol., 154, 503-509. Brown, J.E., Berdan, K.W., Splett, P. and Robinson, M. (1986): Prenatal weight gains related to the birth of healthy-sized infants born to low-income women. J. Am. Diet. Assoc., 86, 1679-1683. 8 Luke, B., Dickinson, C. and Petrie, R.H. (1981): Intrauterine growth: Correlations of maternal nutritional status and rate of gestational weight gain. Eur. J. Obstet. Gynecol., 12, 113- 121. 9 Seidman, D.S., Ever-Hadani, P. and Gale, R. (1989): The effect of maternal weight gain in pregnancy on birth weight. Obstet. Gynecol., 74, 240-246. 10 Taffel, S. (1986): Maternal weight gain and the outcome of pregnancy, United States, 1980. Vital and Health Statistics, Series 21, No 44. Hyattsville, MD, National Center for Health Statistics. 11 Eastman, N.J. and Jackson, E. (1968): Weight relationships in pregnancy: The bearing of maternal weight gain and pre-pregnancy weight on birth weight in full term pregnancies. Obstet. Gynecol. SW., 23, 1003-1025. 12 Niswander, K.R. and Jackson, E. (1974): Physical characteristics of the gravida and their association with birth weight and perinatal death. Am. J. Obstet. Gynecol., 119, 306-313. 13 Brown, J.E. and Schloesser, P.T. (1990): Prepregnancy weight status, prenatal weight gain and the outcome of term twin gestations. Am. J. Obstet. Gynecol., 162, 182-186. 14 Pederson, A.L., Worthington-Roberts, B. and Hickok, D.E., (1989): Weight gain patterns during twin gestation. J. Am. Diet. Assoc., 89, 642-646. 15 Institute of Medicine/National Academy of Sciences (1990): Nutrition During Pregnancy. Washington DC: National Academy Press. 16 Luke, B. and Johnson, T.R.B. (1991): Nutrition and pregnancy: a historical perspective and update. Women’s Health Issues, 1 (4) 177-186. 17 Mahler, H. (1987): Safe motherhood. Remarks made at the World Congress on Safe Motherhood, Nairobi. Geneva, World Health Organization. 18 Fathalla, M. (1991): Reproductive health: a global overview. Annu. N.Y. Acad. Sci., June 28. 19 World Health Organization (1991): Maternal Mortality: A Global Fact Book. Division of Family Health, World Health Organization, Geneva.
Early Human Development, 29 (1992)5-13 ElsevierScientificPublishersIreland Ltd.
EHD 01244
Opening Lecture
Future horizons in perinatal medicine John J. Sciarra Northwestern
Introduction -
University
Medical
School
Chicago,
Illinois
(USA)
The pursuit of neonatal excellence
As the opening concept of this presentation on future horizons in perinatal medicine, I should like to propose that the goal of perinatal medicine for the next century will be the pursuit of neonatal excellence. Every baby should be born a healthy baby. My presentation today will cover four areas. All are future horizons in perinatal medicine and all are essential if we are to achieve neonatal excellence in the twentyfirst century. The topics I shall discuss today, are: (1) the use of appropriate technology, (2) international communication as a way to enhance quality of care, (3) maternal nutrition as a means improving perinatal outcome and (4) the WHO/FIG0 safe motherhood initiative. The use of appropriate technology Clinicians providing maternity services today are surrounded by high technology that must be integrated into clinical practice. In recent years, the technological advances in perinatal medicine have been extraordinary. The introduction of ultrasound, prenatal genetic diagnosis, electronic fetal monitoring and neonatal intensive care, to mention only four, have greatly improved obstetric and newborn care. These and other advances have contributed to the worldwide reduction of perinatal mortality that has occurred during the past two decades in developed nations such the United States, as well as here in Japan. In the United States, in Japan and in many industrialized countries, we are blessed with the technical knowledge and the financial resources to continually develop new and better equipment for medical and surgical care. Ultrasound is an excellent example of the introduction of a new technology into obstetrics and the program of this meeting is testimony to the importance of ultrasound in modern obstetric care. Professor Stuart Campbell will deliver his opening lecture on this topic later this morning. Developed four decades ago, ultrasound imaging has now become an important part of obstetric practice. And while there 037%3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
b
is no question that ultrasound has an enormous clinical value, it is important that we continually assess and determine the proper role for ultrasound and other technological advances in everyday clinical practice. There is no easy answer as to how we should assess the appropriate use of new technology in obstetric practice. One approach that I shall share with you is that developed under the sponsorship of the International Federation of Gynecology and Obstetrics (FIGO). Because of the modern role of high technology in clinical medicine, in 1988, FIG0 established a study group on, ‘The Assessment of New Technology,’ under the chairmanship of Professor Ermelando Cosmi of Rome. One of the first items on the agenda for the FIG0 study group was ultrasound. As the first step in this technology assessment program, a panel of international authorities representing both the developed and the developing countries of the world met in Italy in April 1991, Following two days of deliberations, the panel developed a series of recommendations on the use of ultrasound and doppler technology in obstetrics and gynecology. These recommendations will be published as a Committee Report in the FIG0 News section of the International Journal of Gynecology and Obstetrics (ZJGO) in the near future. One of the questions most frequently asked by practitioners is about the use of ultrasound in low risk pregnancy. This was one of the most difficult questions for the FIG0 study group to answer, because of the differences in obstetric practice throughout the world. However, they did arrive at a consensus and one of their recommendations is shown here [l]: If applicable, an ultrasound examination is recommended at least once in a low risk pregnancy. The optimum period for balancing pregnancy dating and detection of congenital anomalies is between 16 and 20 weeks of gestation. This advice is an example of the type of information that must be made available to clinicians struggling with an ever increasing array of new technological advances in the field of perinatal medicine. I should now like to continue the theme of the use of appropriate technology by moving from high technology to low technology. During the decade of the 1980s in the developed countries of the world a strong sentiment developed toward the use of a variety of obstetric interventions during labor and delivery. This reasonable approach was based on the assumption that the wide application of new technological innovations would enhance perinatal outcome. Electronic fetal monitoring (EFM), during normal labor is a good example. However, after a decade of experience and numerous large studies, it is now generally agreed that electronic fetal monitoring during labor has not provided us with a major decrease in perinatal mortality and morbidity or improved Apgar scores. Electronic fetal monitoring obviously has a place in intrapartum care but certainly its benefit has not been as great as originally expected. The American College of Obstetricians and Gynecologists (ACOG) stated in 1989, ‘It is now increasingly evident from available data, that EFM has no inherent benefit over intermittent auscultation in both high and low risk patients’ [2]. This statement was based on a series of studies comprising over 60 000 patients evaluated in several countries. In this regard, I should like to mention an interesting report from my own hospital, which is a private university maternity hospital in central Chicago, respon-
1
sible for approximately 5000 deliveries per year, 25% high risk and 75% low risk. This paper was published in the IJGO this year and is entitled ‘Recommendations for the management of low risk obstetric patients’ [3]. The authors have selected for review specific interventional procedures, which have enjoyed widespread popularity in the United States in the routine management of low risk obstetric patients. AQ objective assessment of these procedures suggested that often interventional procedures lead to a higher incidence of operative delivery. Intervention often results in this cascade effect that is well known to all clinicians (Fig. 1). The authors of this study suggest that ineffective therapies may be prescribed during labor without consideration or regard to their need and consequences. This is particularly true in the United States, where technological resources are widely available and viewed as evidence of superior medical care and therefore are applied to low risk as well as to high risk patients. Therefore, as we develop standards for maternity services that can be applied to the developed countries as well as to the developing countries of the world, it is particularly prudent for us to reevaluate the need for routine procedures that may complicate rather than simplify maternity care. Our goal should be for all patients to enjoy quality maternity care supported by appropriate technology. Many discussions about technology fail to assessthe cost of such care both to the individual hospital and to society. Nowhere is this more obvious than in the area of neonatal intensive care. The costs of neonatal intensive care are not standard throughout the world but are expensive by any criteria. In France, for example the generally quoted rate is 6000F per day. In the United States the cost is a minimum of $1000 per day [4]. I am now going to share with you some information drawn from the experience in dealing with multiple pregnancy, because twins, triplets and higher order births provide a good background for any discussion of one of the most pressing worldwide problems in perinatal medicine, the management of preterm labor and the low birth weight neonate. In one recent analysis performed by members of my department, a total of 36 days
Uncomplicated
Pregnancy
/-----AIntravenous Fluids \/I Anxiety Discomfort
Fetal Monitoring Inactivity
\ Pain \ Analgesia Anesthesia Slowed
Questionable Electronic Fetal Monitor Tracing
Labor
Pitkin
I Amniotomy
HyGrstimulation I Fetal Heart Rate Changes Cesarean
Section
Fig. 1. The cascade effect. Use of benign interventions resulting in the need for additional technologies.
8
of neonatal intensive care were required per 1000 live births of singletons at a cost of $36 000 [4]. This same study estimated that a total of 44 158 neonatal intensive care days would be required per 1000 live births of twins, at a cost of 4 168 000. This represents more than a lOO-fold difference. The costs for higher order multiple births are even greater. The higher the number of fetuses, the lower the gestational age at delivery, the lower the birth weight, and the longer the length of stay in the hospital. Now, I should like to present to you the case of an unusual premature birth in Chicago that illustrates both medical and ethical issues that we must face as one of the horizons in perinatal medicine. The patient was 36 years old and this was her only pregnancy following therapy for infertility. Ultrasound revealed a triplet pregnancy with monozygotic twins and a singleton. Because of the likelihood of poor outcome, the twin pregnancy was reduced with an intracardiac injection of potassium chloride into each twin at 10 weeks of gestation, The pregnancy continued as a single pregnancy but late in the second trimester the patient developed severe pre-eclampsia. The pregnancy was terminated by cesarean section at 26 weeks and six days with the delivery of a growth retarded, 280 g female. This infant required assisted ventilation for 61 days and was discharged home from the neonatal intensive care nursery on the 120th day of life with a weight of 1900 gm. The hospital bill for intensive care was approximately $150 000 [5]. This is probably the smallest infant ever to survive. She is now 2 years old and still small for her age. This case stresses not only the expense of neonatal intensive care but also raises the contemporary question regarding the role of selective reduction of multifetal pregnancy. The selective fetal reduction procedure was originally reported in 1988 and has been proposed as an answer to the epidemic of iatrogenic higher order multiple pregnancies that have occurred since the introduction of assisted reproductive technology. In selective reduction, injections of potassium chloride are administered using ultrasound guidance to one or more fetuses in higher order multiple pregnancies. Treated fetuses are resorbed and the pregnancy continues as a lower order gestation. The rationale behind the therapy is to increase the likelihood of survival of a smaller number of fetuses. It appears to be realistic therapy until we are able to control the number of pregnancies from the various assisted reproductive technologies and eliminate the large number of higher order multiples. As of this year, there have been only about 200 published cases with a 90% success rate. By success I mean that the reduction was successful and the pregnancy continued. Only careful clinical research will tell us if selective fetal reduction is the appropriate method for improving perinatal survival in multiple gestation. The medical and ethical issues raised by this procedure present an important modern-day challenge in the field of perinatal medicine. Enhanced international communication
Perinatal medicine is an international specialty and enhanced international communication is essential if progress is to be made and if information is to be transmitted to the largest possible clinical audience, particularly in the developing
9
countries of the world. The rapid transfer of clinical information is important if we are to enhance, on a worldwide basis, the quality of care within our discipline: Such communication is achieved through congresses such as this First International Congress of Perinatal Medicine, but also through written material. One of the goals of FIG0 for the next decade is to enhance international communication in obstetrics and gynecology through the FIGG publications and the International Journal of Gynecology and Obstetrics.
An important example of a FIG0 publication that has the potential for significant international impact, is the FIG0 Manual of Human Reproduction, which is now in its second edition and is currently available with teaching slides. These publications will soon be available in French, in addition to English and eventually, possibly in Spanish. Another example, of course, is the International Journal of Gynecology and Obstetrics for which I have served as the editor for the past several years. This year we are publishing, in addition to the FIG0 committee reports, the ‘Technical Bulletins,’ and the ‘Committee Opinions,’ of the American College of Obstetricians and Gynecologists and for the first time this information will be available to the full international community on a timely basis. Improving perinatal outcome through improving maternal nutrition In the areas of the world where socioeconomic conditions are poor, pregnant women often suffer the most. Clearly, improving maternal nutrition will improve perinatal outcome. This should be a social as well as a medical goal for the next decade. Members of my department have published several papers in relation to maternal nutrition. I shall again draw on multiple pregnancy for my example because the problems seen in twin pregnancies are a magnification of problems we see in singleton pregnancy, particularly in relation to preterm labor and low birth weight infants. In normal pregnancy there is a strong relationship between maternal pregravid weight, gestational weight gain and birth weight. This has been shown in several published studies [6-121. With regard to twins, recent research indicates that a weight gain of 35-40 [13- 151 pounds and specifically, a gain of 24 pounds by 24 weeks, results in the highest birth weight for gestational age. Figure 2 shows the actual birth weight distributions for 1985 United States twin and singleton live births. It also shows a theoretical distribution of twin birth weights based on a shift in birth weight distribution by 500 g. Therefore, if enhanced maternal nutrition could add 500 g to the birth weight of twins, this would result in 50% of newborn twins having birth weights in the optimal range of 2500-3000 g. The proportion of birth weights of twins above 3000 g would remain the same but the percentage of birth weights below 2500 g would be reduced by more than half and consequently, so would perinatal mortality and morbidity. In addition, the length of neonatal intensive care stay would probably be sharply reduced and so would the associated costs. While this analysis may be oversimplified, it does raise the possibility that a dramatic reduction in perinatal mortality and morbidity could theoretically be accomplished without the introduction of any new technology but simply by an improvement in
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E 40 8
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TheoryTwins
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3,000
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4,600
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Birthweight Categories (grams) * adapted
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Fig. 2. Actual percent distribution of twin versus singleton birthweights (adapted from Vital Statistics of the US, 1985) and theoretical distribution of twin birthweights.
maternal nutrition and, of course, good prenatal care. If prospective studies confirm the concept that early pregnancy weight gain results in higher birth weights in twins these findings may be applicable to singleton pregnancies as well. Safe motberbood On a worldwide basis, one of the great challenges to the specialty of perinatal medicine is safe motherhood. FIGG is committed to working toward the three goals of: (1) Safe motherhood, (2) A safe and healthy birth, and (3) A healthy infancy for all newborns. To achieve these goals, it is imperative that we work toward improving reproductive health for women worldwide. This includes not only the social goal of elevating the status of women in society but improving health care services in family planning and in maternity care. The World Health Organization (WHO) has established the goal of ‘Health for all by the year 2000. While this may be ambitious, it should be focal point for medical and political efforts in the decade of the 1990s. There is an urgent need to educate the medical profession and the general public in the value of safe motherhood. This is the term used by Dr Halfdan Mahler, the former Director General of WHO, in his address to a world congress in Nairobi in February 1987 [17]. Maternal mortality varies enormously between the industrializ-
11
ed nations and the developing countries of the world. For industrialized nations the risk of death averages 30 per 100 000 live births. In contrast, there are 450 maternal deaths per 100 000 live births in developing countries. The comparative risk of such death in a developing country can be as high as 200 times that in an industrialized nation. The number of pregnancies and deliveries also determines a woman’s lifetime risk of maternal death [18]. In Africa, this may be as high 1 in 21 while in northern Europe it may be as low as 1 in 10 000. If you look at international maternal mortality statistics another way, we can make the dramatic statement that each year 500 000 women die in childbirth from complications of pregnancy, problems during delivery, or unsafe abortion 1181. The real tragedy of modem obstetrics is that the majority of these deaths are preventable. If all women had access to adequate prenatal monitoring and intrapartum care, as well as postpartum family planning, many of these problems would solve themselves. In many instances the difficulties are more social than medical. For example, in one study in Tanzania it was found that 63% of the women who died had no means of transport and lived more than 10 km from the hospital and 37% lived more than 30 km away [19]. In another study, from India, 70% of pregnant women with serious complications came to the hospital by public bus [19]. A study in rural China showed that half of the maternal deaths were due to hemorrhage in areas where adequate blood replacement was unavailable [19]. Universally available family planning to prevent unwanted pregnancies, aid in family limitation and assistance in birth spacing would make a significant impact on reducing reproductive mortality. This is particularly true in Latin America, where it is estimated that as many as 50% of the maternal deaths may be secondary to unsafe abortion [ 191. In this regard, in many developed nations, we now have a situation where the number deaths of reproductive age women attributed to contraceptive use and procedures exceeds the number of maternal deaths. This paradoxical situation arises because the number of women using contraceptives is far greater than the number of women who are pregnant. The reverse, however, is the situation in developing countries, where mortality due to contraception is insignificant in comparison to maternal mortality. I stated earlier that 500 000 women die each year in childbirth. Looked at on an individual basis, one woman dies each minute of every hour of every day of the year from pregnancy, complications of pregnancy, or unsafe abortion. All but 6000 of these deaths take place in developing countries. For many years women of all societies sought measures to ensure safe motherhood and safe delivery. Not far from here is the Meiji-Jingu shrine, established in 1920 in memory of Emperor Meiji and his consort Empress Shoken. At the shrine it is possible for women to purchase a charm in the hope for a safe delivery. This is the goal of our patients and so it should become the goal of modern perinatal medicine. Four elements of the WHO/FIG0 program for safe motherhood and safe delivery are: (1) Adequate primary health care, including family planning for all women everywhere. (2) Comprehensive prenatal care, adequate nutrition and referral of high risk patients to appropriate centers.
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(3) The assistance of trained delivery personnel for all women in childbirth, at home and in hospitals. (4) For women in high risk and for women in dire emergencies of pregnancy, childbirth, and puerperium, effective access to the essential elements of comprehensive quality obstetric care. A component of safe motherhood is safe birth and a healthy infancy. A painting by Girard David in the National Gallery of Scotland, painted in the sixteenth century, shows St. Nicholas giving thanks for his safe birth. A safe birth is the beginning of a healthy infancy. Closing remarks As we work toward the pursuit of neonatal excellence for the next century we must remember the expectations of our patients. I believe that in all countries, all cultures and all societies, patients want and deserve quality maternity services delivered in a compassionate manner. As we get increasingly specialized we run the risk of providing fragmented and sometimes impersonal care. Sir William Ossler made the following statement early in this century and the words remain a caution for us today: The extraordinary development of modern science may be her undoing. Specialism, now a necessity, has fragmented the specialists themselves in a way that makes the outlook hazardous. Obviously there are many other important horizons in perinatal medicine than the four I focused on today and it would be inappropriate not to recognize the other challenges in this exciting area of obstetrics. These include: Preterm labor and postdate pregnancy AIDS Substance abuse Prenatal genetic diagnosis Fetal therapy IUGR Early pregnancy loss Computer assisted care It is always worth restating that the goal of modern obstetrics is a healthy mother and a healthy baby. References 1 FIG0 Study Group on The Assessment of New Technology (1992): Recommendations on the Use of Ultrasound and Doppler Technology in Clinical Obstetrics and Gynecology. Elba island, Italy April 1991. Int. J. Gyn. Obstet., 37 (2), 221-227. 2 American College of Obstetricians and Gynecologists (1989): Newsletter 32:4, 1989. 3 Davis, L. and Riedmann, G. (1991): Recommendations for the management of low risk obstetric patients. Int. J. Gyn. Ob., 35 (2), 107. 4 Keith, L.G., Papiernik, E. and Luke, B. (1992): The costs of multiple pregnancy. Int. J. Gyn. Ob., 36 (Z), 109-l 14. 5 Muraskas, J.K., Carlson, N.J., Halsey, C., Frederiksen, M.C. and Sabbagha, R.E. (1991): Survival of a 280 g infant. New Eng. J. Med., 324 (22), 1598-1599.
13 6 Abrams, B.F. and Laros, R.K. (1986): Prepregnancy weight, weight gain and birth weight. Am. J. Obstet. Gynecol., 154, 503-509. Brown, J.E., Berdan, K.W., Splett, P. and Robinson, M. (1986): Prenatal weight gains related to the birth of healthy-sized infants born to low-income women. J. Am. Diet. Assoc., 86, 1679-1683. 8 Luke, B., Dickinson, C. and Petrie, R.H. (1981): Intrauterine growth: Correlations of maternal nutritional status and rate of gestational weight gain. Eur. J. Obstet. Gynecol., 12, 113- 121. 9 Seidman, D.S., Ever-Hadani, P. and Gale, R. (1989): The effect of maternal weight gain in pregnancy on birth weight. Obstet. Gynecol., 74, 240-246. 10 Taffel, S. (1986): Maternal weight gain and the outcome of pregnancy, United States, 1980. Vital and Health Statistics, Series 21, No 44. Hyattsville, MD, National Center for Health Statistics. 11 Eastman, N.J. and Jackson, E. (1968): Weight relationships in pregnancy: The bearing of maternal weight gain and pre-pregnancy weight on birth weight in full term pregnancies. Obstet. Gynecol. SW., 23, 1003-1025. 12 Niswander, K.R. and Jackson, E. (1974): Physical characteristics of the gravida and their association with birth weight and perinatal death. Am. J. Obstet. Gynecol., 119, 306-313. 13 Brown, J.E. and Schloesser, P.T. (1990): Prepregnancy weight status, prenatal weight gain and the outcome of term twin gestations. Am. J. Obstet. Gynecol., 162, 182-186. 14 Pederson, A.L., Worthington-Roberts, B. and Hickok, D.E., (1989): Weight gain patterns during twin gestation. J. Am. Diet. Assoc., 89, 642-646. 15 Institute of Medicine/National Academy of Sciences (1990): Nutrition During Pregnancy. Washington DC: National Academy Press. 16 Luke, B. and Johnson, T.R.B. (1991): Nutrition and pregnancy: a historical perspective and update. Women’s Health Issues, 1 (4) 177-186. 17 Mahler, H. (1987): Safe motherhood. Remarks made at the World Congress on Safe Motherhood, Nairobi. Geneva, World Health Organization. 18 Fathalla, M. (1991): Reproductive health: a global overview. Annu. N.Y. Acad. Sci., June 28. 19 World Health Organization (1991): Maternal Mortality: A Global Fact Book. Division of Family Health, World Health Organization, Geneva.
