tmp5BF6 TMP

Abstracts
DOI: 10.1111/1471-0528.13383
www.bjog.org
E-Posters
Obstetric medicine (EP13)
EP13.01
Corticosteroids for antenatal fetal lung maturation
in the pregnant diabetic population: approaches in
care across Scotland
Santangeli, L; Aedla, N
Conclusion There is no standard practice or guidance in Scotland
based on national guidance. Trusts have different policies

depending on their service provision. We will develop a guideline
for the department based on current evidence and audit it after a
6 month period.
Wishaw General Hospital, Lanarkshire, Scotland, United Kingdom

Introduction Diabetic pregnancies are at higher risk of preterm
delivery. Treatment with antenatal corticosteroids reduces

neonatal mortality and morbidity associated with prematurity,
within the first 48 hours of life. Guidelines by the Royal College
of Obstetricians and Gynaecologist state, antenatal steroids should
be administered to women who are in suspected spontaneous or
planned preterm birth up to 34+6 weeks. The National Institute of
Clinical Excellence (NICE) recommends diabetic women on
insulin receiving corticosteroids for fetal lung maturation, should
receive additional insulin in accordance with locally agreed
protocols. Traditionally such women have received insulin sliding
scales during the treatment period. Some units are now
continuing women on their subcutaneous insulin with increments
to their insulin doses. To date there is no consensus on how these
women should be managed in the West of Scotland. We therefore
surveyed all the Scottish maternity units, investigating the
different approaches in care with regards to steroid use in diabetic
women, with the aim of formulating a guideline.
Methods An email was sent to all the relevant Obstetricians in
Scottish Consultant-led maternity units within. We received
departmental guidelines, policies and general free text information
on the use of corticosteroids in their pregnant diabetic population
on Insulin. Information collected included the type and frequency
of steroids, outpatient or inpatient management and type of
insulin adjustments done.
Results Nine of the 14 units responded. Two units had no policy.
Five units managed women as inpatients, with 4 of these
exclusively treating women with insulin sliding scales. Four units
managed patients initially on an outpatient basis, with increments
made to their usual insulin regime. The additional increments
made to current insulin doses varied between 4050%. One unit
conformed to NICE guidance, increasing insulin doses by 25% on
day 1, followed by 40% on day 2. Those managed as outpatients
were admitted and observed for ketoacidosis after the initial
24 hours. With regards to the corticosteroid used, 4 units
administered intramuscular (IM) betamethasone in two divided
doses of 12 mg 24 hours apart, whereas the remainder
administered the above or IM dexamethasone in four divided
doses of 6 mg 12 hours apart to complete four doses.
252
EP13.02
Thalassaemia trait: neglected cause of anaemia
during pregnancy
Agampodi, SB1; Agampodi, TC1; Chathurani, U1;

Mendic, V2
1
Department of Community Medicine, Faculty of Medicine and Allied

Sciences, Rajarata University of Sri Lanka; 2Department of Pathlogy,
Faculty of Medicine and Allied Sciences, Rajarata University of Sri
Lanka, Sri Lanka
Introduction Iron deficiency is reported as the commonest cause
of anaemia during pregnancy. Universal programme on iron

supplementation after the 12 weeks of gestation is introduced to
prevent iron deficiency anaemia. In countries where the disease
profile is changing and anaemia is decreasing, there might be
other important causes of anaemia. Our objective was to describe
the probable cause of anaemia during pregnancy in rural Sri
Lanka to develop more specific public health guidelines on
antenatal care.
Methods This study was conducted in Anuradhapura district in
the North Central province of Sri Lanka. A community based cross
sectional study was conducted using WHO 30 cluster sampling
with increased precision among all pregnant women residing in
Anuradhapura. Of the selected study sample serum heamoglobin
levels were determined using metheamoglobin method. British
Committee of Standards in Haematology guidelines (BCSH
guidelines) published in 2011 were used to determine anaemia cut
off values; i.e. 11 mg/dL in the first trimester and 10.5 mg/dL in
second and third trimester. For those who were having anaemia,
red cell indices were obtained. Probable causes of anaemia were
assigned after evaluating the red cell indices.
Results Of the 990 pregnant women tested, 89 (9%) were having
Hb levels below the cut off levels. The prevalence of anaemia in
first, second and third trimester was 7.6%, 10.1% and 8.9%
respectively. Only a single woman (1.11% of anaemic mothers)
had severe anaemia. Blood counts and red cell indices were
available for 41 anaemic women. Of them, 10 (24.4%) showed
features of iron deficiency anaemia/ early iron deficiency. Another
seven (17.1%) had the features of thalassaemia trait and iron
2015 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2015 RCOG
E-Posters: Obstetric medicine
deficiency. Classical features of thalassaemia trait were observed in

two patients. Another three were showing mixed anaemia features.
Conclusion Although further studies are needed with confirmatory
tests for thalassaemia trait, this study provides early evidence on
the importance of investigating even mild anaemia in this setting.
This may be a missed opportunity to diagnose thalassaemia trait
among women living in rural areas where screening is not routinely
available. It is worthwhile to perform at least a full blood count
with red cell indices in all pregnant women with anaemia to
identify the possible cases of thalassaemia trait.
EP13.03
Vitamin D deficiency in pregnancy why should
we care?
pregnancy for detection and treatment of severe vitamin D

deficiencies. Randomised trials are needed to evaluate the role of
vitamin D supplementation in pregnancy, the most effective and
safe dosage, and supplementation regimen.
EP13.04
Placental angiogenic factor expression in preeclampsia and fetal growth restriction using
quantitative (digital image analysis) and semiquantitative methods
Alahakoon, TI1,2; Trudinger, BJ1,2; Zhang, WI2;

Lee, VW1,3
1
Riaz Medical Centre Sharjah, United Arab Emirates
University of Sydney at Westmead Hospital, Westmead, Australia;

Department of Maternal Fetal Medicine, Westmead Hospital,
Westmead, Australia; 3Renal Medicine, Westmead Hospital,
Westmead, Australia
Introduction Vitamin D deficiency, during pregnancy is associated
Introduction Angiogenic factors VEGF and PlGF as well as their
with multiple adverse health outcomes in mothers, neonates and

children. It has been associated with an increased risk of preeclampsia, gestational diabetes mellitus, preterm birth, small-forgestational-age infants, hypocalcaemic seizures in neonates,
neonatal rickets or osteopenia and immune dysfunction. There is
high prevalence of vitamin D deficiency in Middle East due to
pigmented or covered skin and obesity despite of high level of
sunshine. The aim of this study was to estimate the prevalence of
vitamin D deficiency among Arab pregnant women and to assess
the efficacy of treatment with vitamin D.
Methods A prospective observational study was carried out on
600 pregnant Arab women of Middle East origin attending
antenatal clinic of Riaz Medical Centre Sharjah UAE, from
January 2013 to November 2013. Serum 25-hydroxyvitamin D
maternal was measured in nmol/L by radioimmunoassay at the
first antenatal visit. Women with vitamin D deficiency were
subsequently supplemented and vitamin D status was rechecked at
term.
Results 75% (95% CI 72.578.5%) of women were found to be
severe vitamin D deficient (25(OH)D <25 nmol/L), 15% (95% CI
12.917.3%) were vitamin D insufficient (25(OH)D <2550 nmol/
L), and 10% were with normal vitamin D levels (50 nmol/L) at
first antenatal visit. Insufficient group was started on a daily dose
of 1000 IU vitamin D and severely deficient group was started on
20 000 IU/week for 6 weeks and then on a maintenance dose of
1000 IU daily. Both groups showed significant improvement in
vitamin D concentrations as measured by 25-hydroxyvitamin D
levels, at term.
Conclusion At this time, there is insufficient evidence to support
a recommendation for routine screening of pregnant women for
vitamin D deficiency. In spite of taking multivitamins containing
vitamin D; vitamin D deficiency is highly prevalent among
pregnant women of Middle Eastern origin. The adequacy of the
current vitamin D dietary recommendations, to reach an optimal
vitamin D status during pregnancy, has been questioned. A
targeted screening strategy is clearly needed in hypocalcaemic or
symptomatic woman with bone pain, gastrointestinal disease in
receptors Flt-1 and KDR play a major role in the angiogenesis of

the placenta. Aberrations in the expression of these factors may
lead to pregnancy complications. The aims were the localisation,
quantification and comparison of VEGF, PlGF, Flt-1 and KDR in
the placentas of normal pregnancy and pregnancy complications
of PE, IUGR and PE+IUGR.
Methods A prospective cross-sectional casecontrol study was
conducted. A total of 30 pregnant women between 2440 weeks
of gestation, were recruited and classified into four clinical groups.
Representative placental samples from each group were
immunohistochemically stained for VEGF, PlGF, Flt-1 and KDR.
Analysis was performed using semi-quantitative methods and
digital image analysis in identifying staining characteristics in the
placenta.
Results A decreased number of placental villi were noted in both
PE and IUGR as compared to the normal term placenta. The
cumulative effects of PE and IUGR appear to lead to a more
significant loss of villous architecture than either condition alone.
VEGF, Flt-1, and PlGF were mainly expressed in the
syncytiotrophoblast layer of the placenta, while KDR expression
was found in the endothelial layer. The findings of our study
show that overall VEGF and Flt-1 were strongly expressed and did
not show any conclusive difference in the expression between
normal placenta, pre-eclamptic placentas or IUGR pregnancies.
One of the most important findings in the present study is that
PlGF and KDR are significantly reduced in expression in the
placentas from pregnancies complicated by IUGR compared to
normal and pre-eclamptic pregnancies. A moderate correlation
was seen between the average score for manual reading and the
score generated by the automated digital image analysis, across all
study subjects in the moderate to strong VEGF intensity levels.
Conclusion The results of our study suggest that changes in VEGF
and Flt-1 expression may be a consequence rather than the cause
of placental vascular disease and pre-eclampsia. The lack of PlGF
and KDR may be a main cause for the development of
intrauterine fetal growth restriction and may explain the loss of
vasculature and villous architecture in IUGR. We have also shown
Ahmad, S
253
that automated digital image analysis software such as Aperio

positive pixel algorithm could be successfully used as an
alternative method to the manual reading of placental
immunohistochemical staining.
EP13.06
Frequency, knowledge and practice of tobacco
smoking in pregnant women at outpatient
department of a tertiary care hospital
Ambreen, G
EP13.05
Dietary assessment methods in pregnancy: a
systematic review of literature
Al Wattar, BH1; Mylrea-Lowndes, B2; Moore, A1;

Thangaratinam, S1
1
Womens Health Research Unit, Barts and the London School of

Medicine, Queen Mary University London, London, United Kingdom;
2
Northwick Park Hospital, Imperial College School of Medicine,
London, United Kingdom
Introduction There strong evidence to support the effect of
dietary and lifestyle interventions in reducing maternal gestational

weight gain and improve outcomes for both mother and baby.
Implementing dietary and lifestyle interventions requires the use
of appropriate assessment methods to capture the level of
patients compliance as well as recording the changes in nutrients
intake. In pregnancy, assessing diet is further complicated due to
the large intra-individual variations and assessment methods
needed to demonstrate high validity and reliability. The field of
dietary assessment methods in pregnancy is poorly studied and
more evidence is needed to suggest the best dietary tool for use in
a pregnant population.
Methods We have performed a systematic review of the literature
following the PRISMA guidelines including all randomised
controlled trials that introduced a dietary intervention in a
pregnant population. A search strategy was developed using an
agreed methodology. Multiple electronic databases were searched
as well as manual examination of reference lists. Quality
assessment was performed to assess risk of bias for all included
studies. Study clinical characteristics and findings were extracted
in duplicate by independent reviewers using a predesigned and
piloted data extraction form.
Results 19 563 potentially relevant citations were identified from
the major electronic databases. Full titles and abstracts were
examined and 16 studies met our inclusion criteria. Quality
assessment was performed demonstrating an overall medium risk
of bias. The majority of trials were conducted in the USA and
Australia (4 studies each). One study included a dietary
intervention involving both counselling and provision of
supplements. All other included studies introduced a counselling
only dietary intervention. Of the 16 studies that included dietary
interventions, only 9 included a dietary assessment tool. The most
common dietary assessment tool was 24 hour recall (n = 3/16)
followed by 3 day food diaries (n = 2/16). Validation of the
dietary assessment tool was performed only in 3 studies.
Conclusion Diet interventions in pregnancy have a promising role
in improving both maternal and fetal health outcomes. Assessing
dietary changes in pregnancy is essential to assess patients
compliance. Developing more robust dietary assessment tools in
pregnancy is needed.
254
Department of Gynaecology and Obstetrics, Liaquat University of

Medical and Health Sciences, Jamshoro, Pakistan
Introduction Tobacco consumption is major preventable cause of
disease and death worldwide. Pakistan is among 15 countries with

high tobacco consumption in the world. Pregnant woman are an
important population for tobacco prevention efforts because its
use causes serious risk to fetal and maternal health. Keeping in
view this background current study was carried out in antenatal
OPD of tertiary care hospital, with the objective to describe the
knowledge and practice of tobacco smoking in pregnant women.
Methods This study was carried out at Liaquat University
Hospital Hyderabad, Sindh, Pakistan, from 1 December 2013 to
January 2014. All pregnant ladies visited the outpatient
Department of Obstetrics and Gynaecology for antenatal care with
an age range 1846 years were enrolled for study. Semi-structured
questionnaire consisting various items used to explore the range
of knowledge and practice of pregnant women as far as tobacco
smoking is concerned. Data was analysed using SPSS version 16.0.
Results A total of 350 pregnant women were included in this
study. Frequency of tobacco smoking was 60.57% (212). 179
(51.14%) women were also using smokeless tobacco along with
smoking. Only 42 (12%) knew hazards of tobacco consumption.
Knowledge was high in 27 (7.71%) patients. Peer pressure was the
reason for commencement of smoking in 234 (66.85%) of women
and depression in 60 (17.14%).
Conclusion Tobacco consumption is a major health problem in
pregnant woman. Obstetricians should promote smoking cessation
during pregnancy using evidence based methods.
EP13.07
Management of women who present with reduced
fetal movement
Balasandrum, S; Ajjawi, S; Moolchan, J;

Al-Baghdadi, O; Bainton, T; Donkor, P
Princess Alexandra Hospital, Harlow, Essex, United Kingdom
Introduction Maternal perception of fetal movement is an early
sign of fetal life. RCOG guideline reports that 55% of women

experiencing stillbirth perceived a reduction in fetal movements
before diagnosis. The initial goal of antenatal fetal surveillance in
reduced fetal movements (RFM) is to exclude fetal death. No
randomised controlled trials were found assessing the
management of RFM. Recurrent RFM has a potential association
with poor perinatal outcome. The aim of this study is to audit the
management of women presenting with a history of RFM at the
Princess Alexandra Hospital (Harlow, UK), and to compare with
the recommended local trust protocol.
Methods A prospective audit on those who had single or

recurrent episodes of RFM from May 2014 to August 2014 was
carried out. A special pro forma was used to collect data on a
total 37 women presenting with a history of RFM (only 27
women delivered so far).
Results The reported average age was 35(range 1840) and their
average BMI was 28.3. Of the total 37 women, 15 (41%) were
primigravida and 22 (59%) were multigravida. Among the 37, 20
(54%) presented with first episode of RFM, and 17 (46%) of them
reported with recurrent RFM. There was only 1 multiple
pregnancy out of 37. All patients (100%) were seen and initially
assessed by the midwives. The average gestational age at
presentation was 34 weeks. No risk factors were noted in 9 of
them. Among the 17 presenting for recurrent RFM, 3 of them
were referred for ultrasound (U/S), and 3 of them were referred
to the consultant in the antenatal clinic (ANC). Of the total 27
women, 18 had vaginal birth (both spontaneous and induction of
labour), 4 had emergency caesarean sections, and 5 had elective
caesarean sections. We had good neonatal outcomes on 25 of
them (93%); only 2 babies had SCBU admission for meconium
aspiration and prematurity.
Conclusion No fetal deaths were noted. No women were found
with key risk factors for RFM. In terms of assessment, we were
fully compliant with departmental guideline. However, in terms of
management, 14 (82%) women with recurrent RFM were not
appropriately referred for U/S and ANC for further assessment
and counselling. The majority 18/27 (67%) delivered by vaginal
birth and overall neonatal outcome was good. Possible
improvements include appropriate referral to ANC, offering U/S
and enhancing the counselling for women with recurrent RFM.
EP13.08
Induction of labour for hypertensive disorders in
pregnancy outcomes
MaLachlan, M; Baraka, M; Mortimer, J;

Balasandrum, S; Bainton, T; Al-Baghdadi, O
Princess Alexandra Hospital (PAH), Harlow, Essex, United Kingdom
Introduction Hypertensive disorders in pregnancy are a major
cause of maternal, fetal, and neonatal morbidity and mortality in

both developing and developed countries. Hypertension
complicates up to 15% of pregnancies and accounts for about a
quarter of all antenatal admissions in the UK. Guidance from
NICE provides a framework for management of these conditions,
including timing of delivery. The aim was to compare the
management and timing of delivery by IOL of women presenting
to the maternity unit with hypertensive disorders in pregnancy
with the recommended management as outlined by NICE. To
look at the outcome of IOL and to determine if this has an
impact on the CS rate.
Methods A prospective audit of IOL was carried out at PAH
from May 2013 to November 2013. 65 (21%) women with raised
BP in pregnancy were induced. Of these, 23 sets of case notes
were reviewed.
Results Of the 23 women audited, 18 (78%) were primi-gravid
and 5 (22%) were parous women. Average age was 27 years

(range 1840) and their avarage BMI 30 (range 2043). 14 (61%)
were regarded low risk at booking, while 9 (39%) were considered
high risk due to underlying comorbidities. Eight (35%) had preeclampsia, 15 (64%) had PIH. PIH in this cohort was graded
(NICE) as mild in 13 (57%) women, moderate in 9 (39%), and
severe in 1 (4%) woman. 57% had no proteinuria and there PET
bloods were normal, only four women had raised urate. 15 (65%)
women had normal fetal USS assessments for growth and liquor,
while 8 (35%) had no USS performed. Clinically, 61% of women
were asymptomatic, while 8 (35%) presented with headaches and
1 (4%) presented with flashing lights. 6 (26%) of these women
were managed for hypertensive disorders of pregnancy as
outpatients, 3 (13%) as inpatients, and 14 (61%) received both
inpatient and outpatient care. Only 11(48%) of women received
antihypertensive medications. At the time of IOL, 18 (78%)
women were induced between 3740 weeks gestation, and
>40 weeks for 5 (22%). No women were induced at <37 weeks
gestation. Of the 23 women, 9 (40%) had NVD, 7 (30%) had
assisted vaginal deliveries, and 7 (30%) were delivered by
caesarean section. Average baby birthweight 3.545 kg. 21 (91%) of
babies had normal Apgar score, only two needed resuscitation.
Conclusion At PAH, the overall management of women with
hypertensive disorders in pregnancy is in keeping with NICE
recommendations. IOL does increase the CS. Efforts should be
made to delay IOL by monitoring and effective use of medications
to control BP.
EP13.09
The outcomes of induction of labour for reduced
fetal movements at a UK district general hospital
Bainton, T; Baraka, M; Mortimer, J; MaLachlan,

M; Al-Baghdadi, O
Introduction Maternal perception of fetal movements, although
subjective, is a commonly used method to assess fetal wellbeing.

Perception of fetal movement is one of the first signs of fetal life.
A reduction, or absence, of fetal movements is a potentially
important clinical sign as there is a demonstrable association
between reduced fetal movements (RFM) and poor perinatal
outcome, including fetal death. There are, however, no
randomised controlled trials addressing the management of RFM,
which can be variable. An audit of women who had IOL for RFM
was therefore performed. To compare the management and
timing of delivery with the recommended management as
outlined in the RCOG, Green-top Guideline 57, February 2011.
Methods A prospective audit of IOL cases for RFM was carried
out at a UK district general hospital (4500 per annum) over a 6month period. A data collection sheet was completed examining a
wide range of demographics. A total of 49 (16%) women had IOL
for RFM and a random sample of 24 (49%) case notes were
reviewed.
255
Results Of the 24 women, average age was 27.5 years (range 22
34), 17 (71%) primi-gravid and 7 parous women, were included.

Their average BMI was 26. 20 (83%) women were assessed as low
risk and 21 (88%) women had no previous obstetric history.
There was no documentation of risk factors for IUFD/SFD or of
reduced fundal-height measurement at presentation. All women
were not medicated and with no history of drugs misuse, 8% were
smoker only. All had normal anomaly-scan results. On
presentation 62% of cases were >37 weeks gestation, duration of
symptoms varied from 1-day (50%), 2-day (29%), and 3-day
(4%). IOL was carried out either following the first presentation
(71%), second (21%), or following multiple presentations (13%).
92% of cases presented with RFM alone. All women had
cardiotocography performed, 92% of which were reassuring and
8% suspicious. Ultrasound assessment was carried out in 50% of
cases. Normal vaginal delivery occurred in 46% of cases, 33%
were delivered by caesarean (CS), and 21% by instrumental
delivery. The average birthweight was 3.473 kg. All babies had
satisfactory Apgars, no resuscitation or neonatal admissions were
recorded.
Conclusion A high proportion of women were offered IOL at
their first presentation with RFM in the presence of a reassuring
CTG and no other risk factors documented. The CS rate was
noted to be above average and efforts should be made to reduce
or delay IOL by further monitoring and effective use of day
assessment unit.
EP13.10
Audit of current practices of induction of labour at
a UK district general hospital
Bainton, T; Mortimer, J; Jeffrey, M; Al-Baghdadi, O

Introduction Induction of labour (IOL) is common practice,
affecting around 20% of pregnancies in the UK. IOL has a

significant impact on the birth experience, and is associated with
higher rates assisted delivery than spontaneous labour. It also
places strain on antenatal and labour wards. It is therefore
important to perform regular auditing of this process. Current
practice of IOL was examined for compliance against trust and
national standards as well as to assess the indications; process; and
outcome of IOL, including caesarean (CS) rate.
Methods A prospective audit was carried out at Princess
Alexandra Hospital (PAH). Data on all women admitted for IOL
were collected over a 6-month period from MayNovember 2013,
incomplete data was collected retrospectively. A special data
collection sheet was used. The processes of IOL was tested against
the PAH trust protocol and NICE clinical guideline.
Results A total of 479 women underwent IOL during the audit
period (24% of total deliveries) cases with incomplete data were
excluded, leaving 310. Mean maternal age was 38 years and mean
gestation was 39 weeks. The most common indications for IOL
were prolonged pregnancy (17%), pregnancy induced
hypertension (PIH) (15%), and reduced fetal movements (RFM)
(11%). IOL varied by gestation, <37 weeks (8%), 3740 weeks
256
(58%) and >40 weeks (34%). The most common indications at

<37 weeks were prolonged rupture of membranes (42%) and
multiple gestation (17%); 3740 weeks PIH (18%) and RFM
(17%); and >40 weeks prolonged pregnancy (52%) followed by
PIH (14%) and RFM (12%). Excluding PIH and RFM indications
that may have been avoidable (18%) included: macrosomia (4%);
VBAC (4%); and social reasons (3%). 4% of IOL cases were for
unrelated maternal medical history or fetal conditions and were
deemed unnecessary. The most common mode of delivery was
normal vaginal delivery (63%), followed by CS (24%), and
instrumental (13%). Indications for CS included failed induction
(11%), failure to progress (52%), fetal distress (18%), and sepsis
(3%).
Conclusion The guidelines suggest that commonly cited reasons:
macrosomia and VBAC are not appropriate indications for IOL.
IOL <37 weeks should only be considered if there is significant
maternal or fetal compromise. IOL at maternal request, although
not generally valid, should be considered when there are
compelling psychological or social reasons together with a
favourable cervix only. Commonly cited indications: macrosomia
and VBAC are not appropriate alone. Information regarding risk
and timing of IOL can be useful when counselling and consenting
women.
EP13.11
Systemic microvasculature changes in preeclampsia and hypertension in pregnancy: in vivo
assessment
Bakhtiari, A1; Peyman, M2; Zahari, M2; Noor

Azmi Bin, MA1,2; Binti Omar, SZ1
1
Department Obstetrics and Gynaecology, University of Malaya, Kuala

Lumpur, Malaysia; 2University of Malaya Eye Research Centre, Kuala
Lumpur, Malaysia
Introduction The main objective of this study is to correlate the
retinal vessels caliber with severity of hypertension in pregnancy.

Methods A total of 37 patients including 1 normal pregnancy (14
cases), 11 patients with diagnosis of pre-eclampsia and 12 patients

with PIH were recruited in this study. Blood samples were drawn
to measure complete blood count, uric acid. The proteinuria
status of participants was assessed with 24 hour urine analysis.
Fundus photography was carried out at the time of diagnosis.
Using image analysis software, measurements summarised as the
central retinal artery equivalent (CRAE) and central retinal vein
equivalent (CRVE).
Results The average age of women was 27.6 7.8 years.
Arteriolar diameter in patients with pre-eclampsia
(136.44 14.24 lm) was significantly less than arteriolar
diameter in patients with PIH (155.37 20.11 lm) [Mann
Whitney test, P = 0.03]. Compared to healthy pregnant controls
(174.25 15.31 lm), women with pre-eclampsia and PIH had a
lower arteriolar diameter (P < 0.05). No significant difference was
found between venular diameters among three groups (Kruskal
Wallis test, P > 0.05). No significant difference was found between
mean arterial blood pressure in patients with pre-eclampsia
(108.95 15.24 mmHg) and PIH (106.46 13.48 mmHg)

[MannWhitney test, P = 0.5]. A significant reverse correlation
was noted between serum levels of uric acid and retinal arteriolar
diameter in patients with high blood pressure [Spearmans
q = 0.8, P = 0.001].
Conclusion Significant retinal arteriolar vasoconstriction in
patients with pre-eclampsia compared with patients with PIH in
absence of significant difference in mean arterial blood pressure
might be due to endothelial cell dysfunction and subsequent
substance alteration that may induce vasoconstriction in retinal
and systemic arterioles. Increased uric acid level is a key clinical
feature of pre-eclampsia and higher levels correlate with
significant maternal and fetal morbidity and mortality. Presence of
significant reverse correlation between uric acid levels with
arteriolar diameter may provide a non-invasive tool to monitor
the disease progress or other organs status and may predict
consequent morbidity and mortality. Lack of significant difference
in mean of venular diameter is in contrast with the role of the
venous system in the pathogenesis of pre-eclampsia that
previously hypothesised.
EP13.12
Validation and use of a triglyceride meter in
pregnancy
Barrett, HL1,2,3; Dekker Nitert, M1,3; DEmden,

M3,4; McIntyre, HD3,5; Callaway, LK2,3
1
UQ Centre for Clinical Research, University of Queensland, Herston,

Queensland, Australia; 2Obstetric Medicine, Royal Brisbane and
Womens Hospital, Herston, Queensland, Australia; 3School of
Medicine, University of Queensland, St Lucia, Queensland, Australia;
4
Endocrinology, Royal Brisbane and Womens Hospital, Herston,
Queensland, Australia; 5Mater Medical Research Institute, Queensland,
Australia
Introduction Elevated maternal triglycerides have been associated
with adverse pregnancy outcomes including an increased risk of

pre-eclampsia and macrosomia. A triglyceride meter would allow
examination of maternal postprandial triglycerides.
Methods A non-fasting venous and capillary (using the Roche
Accutrend Plus meter) triglyceride measurements were taken in
40 participants at a mean of 36 weeks gestation. Following this
validation phase, the meter was trialled for home triglyceride
monitoring: 4 times a day (fasting and 2 hours post each meal)
for 6 days in 12 women. These women were all more than
36 weeks gestation.
Results Venous and capillary methods were highly correlated
(r = 0.89, P < 0.0001), and the distributions were similar (mean
difference 0.01 mmol/L (SD 0.47), t = 0.18, P = 0.86). Passing
Bablok equation was: y = 0.01 + 0.98x (95% CI intercept 0.51
to 0.38; 95% CI for the slope 0.851.15). The estimated bias was
0.01 mmol/L (95% CI 0.93 to 0.91). To date, 12 women have
trialed the meter at home. Median triglycerides were: fasting
2.89 mmol/L (95% CI 2.773.46), postprandial 3.39 mmol/L
(3.273.70).
Conclusion This study demonstrated the triglyceride meter
provides results correlated strongly with the reference method
with low bias when used in late pregnancy. In home use, median
maternal triglycerides did vary greatly over the day. Further
exploration of the practicalities of the use of this meter is needed
prior to embarking on a larger scale trial.
EP13.13
Villitis of unknown aetiology in uncomplicated
gestational diabetes mellitus
Basu, A; Sivanna, S; Antony, M; Charles, A; Oost,

E; Jape, K
South Metro Area Health Servies, Princess Margaret Hospital, Perth,
Western Australia
Introduction Villitis of unknown etiology (VUE) is a histological
diagnosis of chronic placental inflammation reached after

excluding trans-placental infections. It is characterised by CD-8
predominant T-cell mediated immune response with focal nonuniform lympho-histiocytic villitis. VUE can affect between 5
15% of third trimester placentae. The condition is asymptomatic
but is believed to represent maternal immune response to fetopaternal antigens. VUE is commoner in Caucasian population.
High body mass index (BMI), symmetrical growth restriction,
idiopathic prematurity (second and third trimesters) and
autoimmune/ alloimmune diseases are associated with VUE. It
occurs more often in multigravida and is directly related to the
severity of gestational hypertension and perinatal asphyxia. VUE
has also been noted in the smaller of discordant dizygotic twin
pregnancies. The recurrence rate of VUE is 20%.
Case A 30-year-old nulliparous Caucasian woman was diagnosed
with gestational diabetes mellitus (GDM) with a World Health
Organisation (WHO) oral glucose tolerance test at 28 weeks of
gestation using the RANZCOG criteria (fasting >5.4 mmol/L;
2 hour postprandial >7.9 mmol/L). Euglycaemia was achieved
with maternal nutrition therapy. Unexplained early morning
hypoglycaemia was noted from 34 week onwards in an
appropriate for date fetus. Elective induction of labour (IOL) with
prostaglandin (PGE2) was undertaken at 38+3 weeks of gestation.
An emergency caesarean section was done following unexplained
recurrent late decelerations on cardiotocograph following the first
dose (2 mg) of PGE2 that resolved with tocolysis using 250 lg of
Terbutaline. Cord pH and base excess were normal. The woman
has not been pregnant since. The placenta was sent for histology
which showed significant diffuse villitis with vascular changes,
sclerosis and increased perivillous fibrin deposition. No viral
inclusions were identified and cytotrophoblast, syncitiotrophoblast
and fetal vessels were normal.
Conclusion GDM is consequent to relative insulin resistance due
to placental endocrine function. Decline in placental function
from unrelated VUE may cause unexpected resolution of GDM
from less synthesis and secretion of placental hormones in the
index pregnancy. This should trigger the need for earlier delivery
as was done in this case. Surveillance has been recommended in
future pregnancies for satisfactory outcomes.
257
EP13.14
Sublingual misoprostol versus oxitocin infusion to
reduce blood loss in caesarean section
Begum, T; Yeasmin, S; Chakma, S

Chattagram Maa O Shishu Hospital Medical College, Chittagong,
Bangladesh
Introduction Postpartum haemorrhage is one of the important
cause of maternal mortality and morbidity in the world. Blood

loss occurs more in caesarean section than in vaginal delivery.
Reduction in blood loss at caesarean section is beneficial to
maternal health. Different delivery unit use oxitocin to minimise
this blood loss but sublingual misoprostol nowadays is considered
as a more effective alternative to traditional oxitocin. The
objective of this study is to compare the effectiveness of
sublingual misoprostol, administered immediately after delivery,
with IV oxitocin infusion in prevention of uterine atony and
reducing blood loss at caesarean section.
Methods One hundred women with singleton term pregnancy
undergoing caesarean section under spinal anaesthesia were
included in this study. They were randomly allocated to receive
either misoprostol 400 micrograms sublingually or IV infusion of
20 unit oxitocin in 100 mL of dextrose saline soon after delivery
by caesarean section. Main outcome measures were more blood
loss, change in haemoglobin level, need for additional oxitocin
drug and drug related side effects.
Result The mean blood loss was estimated significantly lower in
misoprostol group in comparison to oxitocin group (900 mL
versus 1000 mL, P = 0.004). There was a need for ergometrine
therapy 15% and 20% after use of misoprostol and oxitocin
respectively (P = 0.65). The incidence of side effects of such as
pyrexia, shivering and metallic test were significantly higher in
misoprostol group compared to oxitocin group.
Conclusion Sublingual misoprostol appears to be as high as effective
as IV oxitocin in reducing blood loss during caesarean section.
EP13.15
An audit on rising rates of labour induction at
tertiary care centre over last 6 months
Bhutia, K1; Tagore, S2; Yeo, SH2

1
Division of Obstetrics and Gynaecology, KK Womens and Childrens

Hospital, Singapore; 2Department of Maternal Fetal Medicine, KK
Womens and Childrens Hospital, Singapore
Introduction The incidence of induction of labour is rising over
recent decades all over world especially in developed countries.

We have observed the similar increasing trend of labour induction
in our centre from 1825% over the last 6 months. The aim was
to review indications, success rate, maternal and neonatal
outcome of induction of labour.
Methods Retrospective review of all pregnant women with
singleton pregnancy who underwent prostaglandin E2 induction
of labour for the month of November 2013 at KK Womens and
Childrens Hospital, Singapore. The main outcome measures were
the indication of labour induction, success rate and rate of
258
caesarean section. The secondary outcomes were maternal

outcome like postpartum haemorrhages, perineal trauma, retained
placenta and neonatal outcome like low Apgar score and neonatal
intensive care unit admission.
Results A total of 199 (22.60%) pregnant women with singleton
pregnancy underwent prostaglandin induction of labour for the
month of November 2013. The main indications were postdates
(40 weeks) and low AFI (<5). The success rate of labour
induction was >99% (197/199). A total of 36 (18%) patients
underwent caesarean section, main indication being failure to
progress in 47.2%. None of patient had postpartum haemorrhage,
vaginal or cervical laceration, retained placenta. Low Apgar score
of 4 at 1 min and 5 at 5 min noted in one baby and was
admitted at neonatal intensive care unit for 2 days.
Conclusion Rising trend in labour induction rate of 2124% in
our hospital is consistent with those reported in other developed
countries (2225%). Success rate was >99% irrespective of the
indication of induction. Although no increase in adverse maternal
or perinatal outcome was observed in relation to prostaglandininduced labour, this study is too underpowered to exclude an
increased risk.
EP13.16
Cervical pregnancy in a haemodynamically unstable
patient case report
Boton Reyes, J
Campbelltown Hospital, Campbeltown, New South Wales, Australia
Introduction Cervical pregnancy is a rare and life threatening
form of ectopic pregnancy in which the pregnancy implants in the

lining of the endocervical canal. It accounts for <1 percent of
ectopic pregnancies. Incidence of cervical pregnancy varies
between 1:1000 and 1:18 000 pregnancies. However, it may be
more common in pregnancies achieved through assisted
reproductive technologies. The most common symptoms is
vaginal bleeding, which is often profuse and painless. Women are
at high risk of severe haemorrhage, which may lead to
hysterectomy. The clinical diagnosis of cervical pregnancy is based
upon findings on transvaginal ultrasound. Sonographic criteria
includes: no evidence of intrauterine pregnancy, hourglass shape
of uterus with cervical ballooning, presence of gestational sac or
placenta within the cervix and closed internal os. Incomplete
miscarriage is the main differential diagnose.
Case A 29-year-old female, gravida 1, Para 0, was admitted to the
Emergency Department, complaining of 4 days of heavy vagina
bleeding associated with moderate amount of clots. Blood results
prior to admission were b-hCG 9285 IU/L and Hb 115 g/L. She
had an ultrasound which confirmed a cervical ectopic pregnancy.
During her physical and gynaecological examination patient was
tachycardic, hypotensive and afebrile. Abdominal palpation
showed a vague lower abdominal tenderness with no signs of
guarding. Pelvic examination was normal, except of moderate
bleeding and blood clot. Haemoglobin was significantly reduced
to 88 g/L, with all other blood and coagulation parameters
normal. Patient underwent an urgent suction evacuation, uterine
curettage and insertion of intrauterine balloon due to a significant

1.5 L vaginal bleeding. She had a transfusion of three units of red
cells and admission to the ward. Intrauterine balloon was
removed with no complications and patient was discharge 2 days
later. Continuous monitoring of her blood level of b-hCG was
done. From initial 1598 IU/L b-hCG started after surgical
procedure decreasing to the 3 IU/L on the 22th day.
Discussion The most effective treatment of cervical pregnancy is
still unclear. Dilation and evacuation is a conservative surgical
option. The main complication is a high incidence of severe
haemorrhage. This case highlights the importance of an early
ultrasound and the need for high clinical suspicion.
EP13.17
Low birthweight may no longer be a surrogate
marker for social deprivation in pregnancy
Brook, A
Royal Devon and Exeter NHS Foundation Trust, Exeter, United
Kingdom
Introduction Socioeconomic deprivation in pregnancy is
associated with suboptimal pregnancy outcomes. It has been

traditionally considered that low birthweight is one surrogate of a
socially bereft pregnancy. However, the epidemic of obesity in the
Western world and the link between obesity and social
deprivation may have altered this association.
Methods Data was extracted from a contemporaneous historical
record of 3240 deliveries at the Royal Devon and Exeter Hospital,
UK, which was collated during the Millennium year. Data was
available on age, maternal BMI at booking, prepregnant BMI,
birthweight and smoking status in pregnancy. Geographical data
was converted to yield standardised national deprivation markers
known as Index of Multiple Deprivation (IMD) score and rank
for the period of interest. We hypothesised that higher birthweight
might actually be associated with these indices of social
deprivation.
Results The mean booking BMI in this cohort was 24.71 ( SD
5.0) and the mean prepregnancy BMI 23.83 ( SD 4.8). The
mean child birthweight was 3372 g ( SD 618). IMD was
correlated negatively with maternal age at booking (R = 0.240;
P < 0.001). Smoking was associated with an increase in IMD
score (R = 0.114; P < 0.001). Neither prepregnancy BMI or
pregnant BMI were associated with IMD. IMD had an effect on
child birthweight but with only weak linearity of association
(R = 0.72; P < 0.001) and when controlled for smoking status,
this effect became non-significant. As expected, both prepregnancy
and pregnant BMI were positive predictors of child birthweight
(R = 0.161 and R = 0.128; P < 0.001 respectively).
Conclusion Child birthweight did not associate with IMD as an
indicator of social deprivation in this cohort as predicted. Whilst
maternal BMI positively predicts child BMI, this association
occurred irrespective of markers of social disadvantage. The way
in which socioeconomic impoverish impacts on pregnancy may
have shifted away from the more traditionally defined stereotype
of lower child birthweight. Further robust epidemiological study
would be desirable.
EP13.18
Maternal adiposity is associated with lower
maternal vitamin B12 and folate in pregnancy
Knight, B1; Shields, B1; Brook, A1; Yajnik, C2;

Hattersley, AT3
1
Research Innovation Learning Development (RILD) Centre, Royal
Devon and Exeter Hospital, University of Exeter, United Kingdom;
2
Diabetes Unit, KEM Hospital and Research Centre, Pune, India;
3
Xxxxx
Introduction Vitamin B12 and folate are essential micronutrients,
which support the increased metabolic demands of pregnancy.

Previous studies of pregnant women in India describe an
association of maternal adiposity with vitamin B12 deficiency in a
population where nutrient deficiency is common. We explored
whether the same associations exist in a non-diabetic Caucasian
pregnant cohort.
Methods We utilised the Exeter Family Study of Child Health
(EFSOCH) dataset, an extensively characterised UK pregnancy
cohort (n = 995) for which routine anthropometric and
biochemical measurements are available. Vitamin B12 and folate
were measured at 28 weeks ( 5 days) by microbiological assay at
the KEM Hospital, Pune, India. Data was available on 28 week
maternal body mass index (BMI), sum of skinfold thickness
(SSFT), insulin resistance (IR) and triglycerides in addition to
pregnancy and lifestyle factors. Maternal aspartate transaminase
(AST) and alanine aminotransferase (ALT) activity were also
measured at 28 weeks. Descriptive statistics are median and
interquartile range (IQR) and non-normally distributed values
were log transformed for correlation and multivariate regression
analysis.
Results There was a negative association of BMI (26.9 IQR 5.52)
with both vitamin B12 (201 pg/L IQR 104) and folate (13.8 nmol/
L IQR 14; R = 0.271 and 0.150; P < 0.00 respectively). For
vitamin B12 this observation extended to other adiposity
surrogates such as maternal SSFT (52.3 IQR 26.7; R = 0.269;
P < 0.00), IR (0.125 IQR 0.01; R = 0.234; P < 0.00) and
triglycerides (2.00 IQR 0.91; R = 0.217; P < 0.00). 198 mothers
(20%) had vitamin B12 < 150 pmol/L indicating true vitamin B12
deficiency and these women had significantly higher BMI (29.3
versus 26.6; MannWhitney P < 0.00). Multivariate regression
analysis controlling for age, parity, vitamin supplementation,
vegetarianism, social class and haemodilution revealed that for
every one unit increase in BMI, there was a corresponding
decrease of 0.4% in vitamin B12 and 0.3% in folate (P < 0.00 for
both). Vitamin B12 correlated positively with both AST and ALT
independent of IR (R = 0.283 and 0.235 respectively; P < 0.00). A
similar relationship was observed between folate, AST and ALT
(R = 0.224 and 0.169 respectively; P < 0.00).
Conclusion Maternal adiposity was associated with both lower
vitamin B12 and folate in this Western pregnancy cohort. These
findings are important for understanding the effect of adipose in
pregnancy on the circulating maternal micronutrient reservoir.
The positive associations of vitamin B12 and folate with liver
transaminases warrant further study as they are not explained
259
simply by insulin resistance but alternatively could indicate altered

micronutrient turnover or hepatic storage in these pregnancies.
EP13.19
Weighing in pregnancy study (WIP): a randomised
controlled trial of the effect of routine weighing to
reduce excessive antenatal weight gain
Brownfoot, FC1; Davey, M2; Kornman, L1

1
Department of Obstetrics and Gynaecology, Royal Womens Hospital,

University of Melbourne, Parkville, Victoria, Australia; 2Judith Lumley
Centre, Faculty of Health Sciences, La Trobe University, Victoria,
Australia
Introduction Overweight and obesity have reached epidemic
proportions and are now the most common risk factor in

obstetric medicine. Excessive weight gain in pregnancy is also
increasing and is an independent risk factor for poor pregnancy
outcomes. Despite numerous trials focusing on diet and exercise
interventions results have been modest at best with most showing
no effect. Regular weighing in the nonpregnant population has
been found to reduce weight gain. Therefore we assessed whether
weighing patients at each antenatal visit compared to routine care
reduced excessive pregnancy weight gain and maintained weight
gain within the Institute of Medicine (IOM) recommendations.
Methods A randomised controlled trial of 782 women at a
tertiary obstetric hospital in Melbourne, Australia between 2010
and 2012 was conducted. Patients in the intervention group
(N = 386) were weighed at most antenatal visits and counselled
by their obstetric provider in clinic while those receiving routine
care (N = 396) were weighed at their booking visit and at
36 weeks gestation. The primary outcome was gestational weight
gain between groups and weight gain within the Institute of
Medicine (IOM) recommendations. Secondary outcomes included
maternal or neonatal morbidity.
Results Primary outcome data was available for 326 women in
the intervention group and 288 women in the control group.
There was no significant difference in weight gain between the
intervention group (0.54 kg/week) compared to the control group
(0.53 kg/week), P value 0.63. There was a similar proportion of
patients gaining weight above the IOM recommendations in both
groups at 75% of patients receiving intervention and 71% of
controls. This was consistent across each BMI category with no
statistical significance found. Alarmingly when patients were
weighed 5 times they gained significantly more weight than
recommended by the IOM. There were no significant differences
in secondary outcomes between the two groups.
Conclusion Routine antenatal weighing is not effective at reducing
excessive weight gain and maintaining weight within the IOM
guidelines. Frequent antenatal weighing may be harmful and lead
to an increase in weight gain.
260
EP13.20
Sulfasalazine reduces the toxins of pre-eclampsia
soluble Flt1 and soluble endoglin and quenches
endothelial dysfunction in primary human tissues:
a novel potential therapeutic
Brownfoot, FC; Tong, S; Hannan, N; Hastie, R;

Cannon, P; Kaituu-Lino, TJ
University of Melbourne, Heidelberg, Australia
Introduction Pre-eclampsia is a serious complication of pregnancy
responsible for 60 000 maternal deaths annually and many more

fetal and neonatal deaths. It is caused by the placental release of
sFlt-1 into the maternal bloodstream, leading to endothelial
dysfunction and multisystem organ injury. The current treatment
is delivery, which leads to significant morbidity and mortality
associated with prematurity if this disease occurs early in
pregnancy. Therefore a therapeutic able to quench or stabilise the
disease process would be a major advance. Sulfasalazine is an antiinflammatory and immune modulating drug. Its mode of action
has remained elusive, however recent evidence suggests it induces
potent antioxidant enzyme heme-oxygenase1 (HO1) via nuclear
erythroid-2-related factor 2 (Nrf2). Given its anti-oxidant capacity
and that it is safe in pregnancy, we examined the potential for
sulfasalazine as a novel therapeutic for pre-eclampsia. In
particular, we examined its ability to quench anti-angiogenic
factors sFlt1 and soluble endoglin (sEng) and reverse endothelial
dysfunction in vitro.
Methods Increasing doses of sulfasalazine were administered to
primary human umbilical vein endothelial cells (HUVECs) and
sFlt1 and sEng release assessed. To induce endothelial dysfunction,
HUVECs were treated with TNFa and the effect of sulfasalazine
on monocyte adhesion determined. Finally the effect of
sulfasalazine on HUVEC migration and proliferation was assessed.
Results Excitingly, we observed a significant dose dependent
reduction in both sFlt1 and sEng release. Importantly, mRNA
expression of newly described human and placental specific
variant sFlt1-e15a mRNA was significantly decreased, as was
MMP14 mRNA expression (MMP14 is the protease that produces
sEng). As expected, sulfasalazine also significantly increased
mRNA expression of HO-1. Treatment of HUVECs with TNFa
induced significant upregulation of VCAM which was potently
reversed by sulfasalazine, indicating its ability to quench
endothelial dysfunction. Furthermore, sulfalsazine significantly
reduced monocyte adhesion to HUVECs treated with TNFa, again
supporting its anti-inflammatory properties. Finally we
demonstrated that sulfasalazine could reverse the negative effects
of sFlt1 on VEGF-stimulated HUVEC migration, and enhance
HUVEC proliferation.
Conclusion Sulfasalazine is a novel agent, safe in pregnancy that
significantly quenches sFlt1 and sEng release from human
endothelial cells. In addition, it significantly reduces endothelial
dysfunction and enhances endothelial cell migration and
proliferation. This provides strong evidence to suggest that
sulfasalazine may be able to quench the endothelial dysfunction of
pre-eclampsia and could be a novel effective treatment for preeclampsia.
EP13.21
Human leukocyte antigen E (HLA-E) expression on
intrauterine growth restriction
Cahyadi, BT; Sulistyowati, S

Fetomaternal Division, Department of Obstetric and Gynaecology,
Faculty of Medicine, Sebelas Maret university/Dr Moewardi General
Hospital Surakarta, Indonesia
Introduction Intrauterine growth restriction (IUGR) is an
important perinatal syndrome that poses several serious shortand long-term effects and is thought to result from a poorly
perfused placenta and may reflect an abnormal maternal immune
reaction to the hemiallogenic fetus. HLA-E, a major
histocompatibility tissue-specific antigen expressed in extravillous
trophoblast cells (fetal-derived), may protect trophoblasts from
maternalfetal immune intolerance and allow these cells to invade
the uterus. This research aimed to analyse HLA-E expression on
the IUGR trophoblast and normal pregnancy
Methods An analytical observational study and cross sectional
approach were performed at the Departement of Obstetric and
Gynaecology Dr. Moewardi Hospital Surakarta from June to
August 2014. Trophoblast specimens were obtained from 15
women with IUGR and 15 normal controls. These sepecimens
were screened by immunohistochemistry for HLA-E. The data
were analysed by using t-test.
Results There was a significant difference in HLA-E expression
between women with IUGR (18.39 4.94) and those with
normal pregnancies (60.08 18.53; P = 0.000).
Conclusion The HLA-E expression was significantly higher in
normal pregnancy than in IUGR group.
computerised clinical information system for controls, who were

an equal number of women delivering on or nearest the same day
as the index cardiac case, controlling for maternal age
( 5 years), parity and mode of delivery. Additional information
collected on cardiac subjects included WHO Class and
recommended and actual duration of pushing.
Results A total of 48 cases were identified in each group, with 18
spontaneous births, 24 ventouse and 6 forceps. There were no
significant differences in maternal age or mode of delivery
between the two groups. Epidural use was 42/48 (88%) in cases
and 26/48 (54%) in controls. The mean recommended maximum
duration of pushing in cardiac cases was 85, 33, 16 and 0 min in
WHO classes IIV respectively. The actual pushing time exceeded
that recommended in 1/7 (14%), 8/31 (26%), 6/9 and none (1
case) in WHO classes IIV respectively. The mean extra pushing
time was 19 min (class 1, one case), 23 and 10 min respectively.
The lack of compliance with recommendations meant that there
was no significant difference in the overall duration of the second
stage between cases and controls (66.5 SD 49 versus 64 SD 54
respectively). However, there were no reported significant cardiac
events as a result of pushing.
Conclusion Recommendations for elective assisted delivery to
shorten the second stage in women with cardiac disease and
epidural anaesthesia may not be necessary. We plan a prospective
study to test the hypothesis that expectant management based on
maternal condition at the time is safe.
EP13.23
Vitamin D levels in pregnant women with preexisting diabetes or gestational diabetes mellitus in
far north Queensland
Cheng, H1; De Costa, C1; McLean, A2
EP13.22
Management of the second stage of labour in
women with underlying cardiac disease: time for a
change?
School of Medicine and Dentistry, James Cook University, Cairns,

Queensland, Australia; 2Cairns Base Hospital, Cairns, Queensland,
Australia
Cauldwell, M; Steer, P
Introduction Several large previous studies indicated that a
Academic Department of Obstetrics and Gynaecology, Chelsea and

Westminster Hospital, London, United Kingdom
substantial proportion of pregnant women living in southern parts

of Australia are vitamin D [25(OH)D] insufficient or deficient,
and suggested universal 25(OH)D screening may be appropriate
for these populations. Suboptimal 25(OH)D levels have been
linked to several pregnancy complications. Pregnancies with preexisting type 2 diabetes mellitus (T2DM)/gestational diabetes
mellitus (GDM) are associated with suboptimal 25(OH)D levels,
and low 25(OH)D status is associated with poor glycaemic
control. Suboptimal 25(OH)D levels appear to be much less
common in northern Australia, however the 25(OH)D status of
pregnant women with T2DM/GDM has not been well studied in
the north. This study determined the 25(OH)D levels in pregnant
women who live in Far North Queensland (FNQ) with T2DM or
GDM. The associations between maternal 25(OH)D level and
HbA1c, BMI at booking and the occurrence of labour
complications were also evaluated.
Methods A prospective study was conducted, which consecutively
recruited 101 pregnant women who attended antenatal care in the
Introduction All pregnant women with heart disease should have
a clear and individualised plan of care to include recommended

pain relief and mode of delivery. It has been traditional to limit
the duration of pushing and early use of elective instrumental
delivery in the second stage of labour in order to avoid/reduce
repeated Valsalva manoeuvres which may impair cardiac function,
and to reduce the overall length of the second stage to minimise
maternal fatigue.
Methods A retrospective cohort study of nulliparous women with
singleton pregnancies and known heart disease and a vaginal
delivery at >35 weeks gestation managed at the Chelsea and
Westminster Hospital between 2011 and 2014. Data on year of
maternal birth, gestational age at delivery, analgesia, duration of
the second stage and birthweight was collected from a detailed
case note review of cardiac subjects, and via the routine
261
Cairns Base Hospital from April to November 2012. All

participants had a diagnosis of pre-existing T2DM or developed
GDM, were at least in their second trimester at the time of
recruitment, and did not use any form of 25(OH)D
supplementation during the course of the pregnancy. A P < 0.05
indicates statistical significance.
Results A mean 25(OH)D concentration of 110.3 nmol/L was
recorded; in non-indigenous and indigenous subjects means were
114.9 and 98.0 nmol/L. Six percent of subjects were 25(OH)D
deficient, 12% insufficient and 81% sufficient. The average 25
(OH)D level in this cohort with diabetes is similar to that of nondiabetic pregnant women in FNQ (P = 0.292), but significantly
higher than those in the southern states regardless of diabetic
status (six studies from four states were compared, all P < 0.001).
Spearman correlation showed low 25(OH)D levels are correlated
with higher HbA1c values (P = 0.012, correlation coefficient
0.253), but not associated with high BMI (P = 0.812, correlation
coefficient 0.025). Fishers exact test indicated the occurrence of
labour complications (P = 1.000) appeared not significantly
associated with antenatal 25(OH)D levels.
Conclusion The study contributes to the ongoing debate around
the need for universal antenatal 25(OH)D screening in Australia.
The possible implementation of such proposed screen appears
immature at this stage, as the efficacy of the screen requires
further justification by RCTs and the supplementation guidelines
specific for pregnancy are still lacking.
epidural sited for labour analgesia. She was delivered by a

caesarean section in view of failed instrumental delivery and
discharged home uneventfully. She was readmitted after 48 hours,
with a history of faecal and urinary incontinence. She also
complained of neuropathic pain involving her left side,
predominantly the left buttock and lower limb. An anaesthetic
and neurology opinion was sought. An MRI of the cervical/
thoracic and lumbosacral spine suggested no abnormality. An
MRI of the brain suggested an acute demyelinating process
(possible multiple sclerosis), as there were several small
hyperintense lesions in the periventricular and subcortical white
matter. A lumbar puncture showed the presence of oligoclonal
bands, which confirmed the diagnosis of MS.
Conclusion MS is difficult to diagnose and the diagnosis may
often be missed, delayed and incorrect. In pregnancy further
difficulties are posed with making the diagnosis and treatment of
relapses. It would be invaluable to accurately determine the
women at risk for postpartum disease activity. The more one
understands how pregnancy and the rapid postpartum changes
affect MS, the more insight one may gain into disease
pathogenesis and optimal management, including development of
new treatment strategies.
EP13.24
Unusual case of multiple sclerosis (MS) in
pregnancy
Chua, YD1; Chan, YH2; Chua, J1; Tan, EK1;

Biswas, A1; Chong, YS1; Chi, C1
Rehman, R; Chodankar, R
Heatherwood and Wexham Park NHS Foundation Trust, United
Kingdom
EP13.25
Development of a prediction model for vaginal
birth after caesarean section in a multi-racial Asian
population
1
National University Hospital, National University Health System,
Singapore; 2Yong Loo Lin School of Medicine, National University of
Singapore, Singapore
Introduction Previous caesarean section is one of the most

Introduction MS is thought to affect more than 2.3 million
people worldwide and 1 in 1000 people in Western countries. It is

more prevalent in women of childbearing age than in any other
group. Aetio-pathogenesis remains obscure, however factors
including gender, genetics, age, geography, immune mediation
and ethnic background have a role to play. MS is not known to
impact pregnancy in an adverse manner in fact the rate of relapse
has been thought to decrease during pregnancy and increase in
the postpartum period (3040%), but the studies have been small,
and some have reached different conclusions.
Case A 31-year-old primigravida was booked at Wexham Park
Hospital at 25/40 weeks. She was being cared for by a specialist
midwifery led unit (Crystal Team) as she had a history of
depression and a borderline personality disorder. Her medical
history also included Crohns disease in remission and polycystic
ovaries. She had an uneventful antenatal period. She presented to
the obstetric unit at 41/40 weeks in active labour with a history of
ruptured membranes. She suggested a history of a fall on her back
3/7 days ago and 1 episode of faecal incontinence. Limited
neurological assessment suggested she had normal anal tone and
perianal sensation. Labour was augmented with and she had an
262
common indications for caesarean section, accounting for about

50% of the caesarean deliveries performed in our unit.
Counselling on the mode of delivery for women with previous
caesarean section is essential. A successful vaginal birth after
caesarean section (VBAC) is associated with fewer complications,
shorter recovery, and higher maternal satisfaction compared to a
caesarean section. However, an unsuccessful attempt of VBAC is
associated with a greater risk of major complications and lower
maternal satisfaction. Appropriate counselling on the decision for
VBAC should encompass not only the risks and benefits of both
options but also the probability for success with an attempted
vaginal delivery. There are a number of proposed prediction
models for success in achieving VBAC but none has been
developed specifically for the Asian population. The aim of the
study was to develop a model that predicts the outcome of an
attempted VBAC, specifically for a multi-racial Asian population,
for use in personalised decision-making on the pursuit for VBAC.
Methods This was a retrospective cohort study of women with a
history of one caesarean section and a singleton cephalic
pregnancy, with no contraindications for trial of VBAC, who
delivered at term. Potential predictors for attempted VBAC that
were available in the antepartum period were selected based on

clinical reasoning and reported variables associated with successful
VBAC. Data were extracted from electronic medical records. A
risk score model using odds ratios as the weighted score for each
variable was developed. The discriminative performance of the
prediction model evaluated as the area under the receiver
operating characteristic curve (AUC) was calculated.
Results During the study period 184 (38%) of the 485 women
with a history of one caesarean section and term singleton
cephalic pregnancy attempted VBAC. Of these, 115 (63%)
achieved VBAC. The predictors selected were: ethnicity, maternal
age, indication for primary caesarean section, previous vaginal
delivery and maternal pre-pregnancy body mass index. The risk
score ranged from 0 to 10. When using a threshold of score 4, the
positive and negative predictive values were 86% and 59%,
respectively, with a sensitivity of 75% and specificity of 75%. The
AUC was 0.785 (95% CI 0.7030.867) indicating a good
discriminative ability.
Conclusion A prediction model for VBAC has been developed
specifically for Asian population which can serve as a valuable
counselling tool for Asian women on the decision to pursue
VBAC.
EP13.26
Bettering antenatal and postnatal risk assessment
for venous thromboembolism a quality
improvement approach
Cunningham, Y; MacDonald, H; Coutts, S
Finally, the case note audit is planned to be repeated in early 2015

to assess the overall impact of the changes.
Results The initial audit showed that all high risk women
(previous personal history of VTE or thrombophilia) requiring
extended postnatal thromboprophylaxis were correctly identified
and appropriate treatment commenced. However, only 66.6% of
women (2 out of 3) who had had a previous personal history of
VTE and 20% of women (1 out of 5) with three or more risk
factors were identified and commenced on thromboprophylaxis
antenatally. Our PDSA run chart has shown improvement from
an initial 0% of women being formally risk assessed on admission
to hospital in the antenatal period and has continued to show
virtually 100% of women being accurately risk assessed
postnatally. We hope that the results of our followup audit will
confirm these findings.
Conclusion Using MCQIC methodology, we have successfully
increased the number of women being correctly risk assessed for
VTE antenatally and on admission to hospital. We have also
maintained a high level of women being identified as requiring
postnatal thromboprophylaxis.
EP13.27
A successful pregnancy outcome after surgical
decompression of type 1 ArnoldChiari
malformation
IP, P; Dann, P; Pankaja, S; OMahony, F

University Hospital of North Staffordshire NHS Trust, Newcastleunder-Lyme, England
St Johns Hospital, Livingston, West Lothian, United Kingdom

Introduction Type 1 ArnoldChiari malformation (ACM) usually
Introduction Venous thromboembolism (VTE) remains an
important cause of maternal mortality and morbidity, despite

recent advances. The Maternity and Children Quality
Improvement Collaborative (MCQIC) is part of the Scottish
Patient Safety Programme and aims to improve the quality and
safety of maternity healthcare. One aim is to ensure that all
women are risk assessed for VTE at the time of booking, during
any hospital admission, including labour, and following delivery.
Our aim was to increase the numbers of women being accurately
risk assessed and commenced on appropriate thromboprophylaxis.
Methods An initial retrospective audit was performed, looking at
all deliveries during a 1 month period, and assessing whether they
had been appropriately risk assessed antenatally, started on
thromboprophylaxis if required during pregnancy and given
postnatal thromboprophylaxis if needed. As local guidelines at the
time were in need of updating, the RCOG Greentop Guideline
Reducing the Risk of Thrombosis and Embolism during
Pregnancy and the Puerperium was used as our gold standard.
Following this, MCQIC methodology was used to initiate a plan/
do/see/act (PDSA) cycle introducing a formal risk assessment
form for all antenatal admissions. A monthly run chart was
produced, showing the changes in results over time. New
departmental guidelines will be produced following the
introduction of the updated RCOG Greentop guidelines and
introduced to all staff through a number of learning sessions.
presents in adulthood and consists of a downward displacement

of the cerebellar tonsils through the foramen magnum.
Case A 25-year-old woman presented with a 5-month history of
headache associated with blurred vision, tinnitus and sickness.
Imaging recognised the need for surgical intervention, but whilst
awaiting for surgery she fell pregnant. Considering the risks of
neurological deterioration, the woman underwent surgical
decompression of type 1 ACM at 15 weeks gestation. She
subsequently presented with progressively worsening headaches
during late pregnancy from 35 weeks. The obstetric plan was
initially induction of labour at term but since the onset of
worsening symptoms, this date was brought forward to
39+1 weeks gestation. She proceeded to have a normal delivery
with no neonatal complications and an uneventful puerperium
followed. Since the delivery, the patient reported fewer symptoms,
showed no signs of neurological deficit and a repeat MRI showed
good relief of neural compression.
Conclusion This case illustrates how judicious selection of the
appropriate mode of delivery of women following surgically
corrected ACM and a multidisciplinary approach is critical in the
successful management of the antepartum and labour.
263
EP13.28
Management of placenta accreta using prophylactic
balloon catheter occlusion of internal iliac arteries:
a case series
Smyth, C1; Dann, P1; Wells, D2; OMahony, F1

1
Department of Obstetrics and Gynaecology; 2Department of

Radiology, University Hospital of North Staffordshire, Newcastle Road,
Stoke-on-Trent, Staffordshire
Introduction Current Green-top Guidelines from the Royal
College of Obstetricians and Gynaecologists in the UK on placenta

praevia accreta focus specifically on the planned management of
these cases, with particular attention to a dedicated MDT. At our
hospital we implemented our dedicated MDT in 2014. Our aim of
this case series was to review our MDT process, results and
evaluate our service of providing elective caesarean section in
obstetric cases complicated by suspected placenta accreta using
balloon catheter occlusion of the internal iliac arteries in the
interventional radiology suite.
Methods A retrospective study of 8 cases of suspected placenta
accreta at University Hospital of North Staffordshire, from 2006
to 2014 with planned delivery in the interventional radiology
suite using balloon catheter occlusion of the internal iliac arteries
to provide haemostasis and reduce the associated maternal
mortality and morbidity associated with major obstetric
haemorrhage.
Results A total of seven cases were delivered in the interventional
radiology suite, one case was delivered as an emergency in the
obstetric theatre and interventional radiology was not used. Six
patients had a diagnosis of placenta percreta at the time of surgery.
No fetal or maternal mortalities were recorded in this group. Eight
healthy babies were born of the eight mothers. All patients had a
history of minimum one previous caesarean section, with some
women having a more complicated abdominal/pelvic past surgical
history. Estimated average blood loss was 2000 mL (range 500
4000 mL). A total of six women retained their uterus and two
patients required emergency hysterectomies due to massive
haemorrhaging. No major postoperative complications were noted
among the eight cases. One patient returned 2 years later for a
hysterectomy due to chronic pelvic pain.
Conclusion Our results are very encouraging and we believe the
use of balloon catheter occlusion reduced the rate of
intraoperative haemorrhage in our cases. Having dedicated units
that are familiar with dealing with such high risk complicated
obstetric cases will no doubt improve patient outcome, develop
centres of excellence in the field and provide excellent experience
and exposure for training obstetricians.
EP13.29
Maternal sepsis have you considered dengue?
Dashraath, P; Chi, C; Tan, EK; Biswas, A

Department of Obstetrics and Gynaecology, National University
Hospital, Singapore
Introduction Dengue is hyperendemic in the Republic of
Singapore and imperils an estimated 2.5 billion individuals in
264
tropical nations every year. Pregnant women are believed to be

particularly vulnerable to arthropod-borne diseases as a result of
greater exhaled carbon dioxide concentrations and increased basal
body temperature. Dengue infection in pregnancy is tenuous; it is
known to provoke preterm labour, feto-maternal haemorrhage
and may result in vertical transmission. Generally, the clinical
presentation of these patients is similar to the non-pregnant
population and comprises pyrexia, myalgia, leucopenia and
thrombocytopenia and may progress to hypovolemic shock.
Herein, we describe the atypical presentation of a woman with
severe dengue in the second trimester of pregnancy.
Case A 37-year-old multigravida presented at 26 weeks gestation
in fulminant septic shock with pyrexia and bilateral flank
tenderness necessitating dual inotropes for haemodynamic
resuscitation. The provisional diagnosis of urosepsis secondary to
acute pyelonephritis was quelled when blood and urine cultures
remained sterile and the patient failed to improve despite
appropriate antibiotic therapy. A diagnosis of acute dengue was
established when ELISA for NS-1 antigen returned positive and
PCR on maternal serum confirmed infection with dengue virus
type-1. Unusually however, there was neither leucopenia nor
thrombocytopenia throughout her clinical course, which
ordinarily comprises one of the hallmarks of this disease. The
patient was provided with supportive care and made a full
recovery 5 days following admission without any compromise to
the pregnancy.
Conclusion The clinical presentation of dengue in pregnancy may
be atypical and confound diagnosis. A high index of suspicion is
necessary and it behooves consideration in the differential
diagnosis of pregnant women presenting with pyrexia during
epidemics in endemic regions.
EP13.30
The availability of, and healthcare providers
involved with, post-viability termination of
pregnancy in Canada
Hull, D1; Davies, G2; Armour, C3

1
Division of Medical Genetics, Kingston General Hospital, Kingston,
Canada; 2Division of Maternal-Fetal Medicine, Queens University,
Kingston, Canada; 3Clinical Genetics Unit, Childrens Hospital of
Eastern Ontario, Ottawa, Canada
Introduction Late diagnosis of fetal congenital and genetic
abnormalities poses medical and ethical challenges to pregnancy

management options. This survey aims to assess the definition of
fetal viability and the availability, and healthcare providers
involved in the decision making, around post-viability termination
of pregnancy across Canada.
Methods A 26 item Survey Monkey survey was distributed to
members of the Canadian Association of Genetic Counsellors, the
College of Medical Geneticists and the Society for Maternal-Fetal
Medicine between December 2012 and March 2013. Inclusion
criteria were being a healthcare professional and providing direct
counselling or management of prenatal patients in Canada. The
Health Sciences Research Ethics Board at Queens University
approved this study.
Results There was a 19% response rate (123/646). All Canadian
provinces except Prince Edward Island were represented. None of

the three Canadian territories was represented. The reason for lack
of representation from these geographic areas is likely related to
no, or very low, access to any termination of pregnancy services,
elective or otherwise. 82% of the respondents were either genetic
counsellors (53/123) or maternalfetal medicine specialists (48/
123), 15% (18/123) were geneticists, 2% (3/123) were nurse
counsellors and one was a general obstetrician. Fetal viability was
defined as 24 weeks gestation by 67%, 23 weeks by 20% and
22 weeks by 5%, the remainder of respondents used no clear
definition or were unsure of the definition at their centre. 89% of
respondents worked at a tertiary care/university affiliated centre
(109/123), and 80% offer post-viability termination (98/123). 93%
(83/89) reported their centre does not have an established upper
gestational age limit. 92% of respondents (85/92) reported that
maternalfetal medicine is always involved in the decision
making process. Other healthcare professionals reported as
sometimes or always involved included geneticists (94%),
appropriate specialist (i.e. neurology) (91%), neonatology (86%),
obstetrics (79%), genetic counselling (77%) and medical ethics
(69%). The most commonly selected answer for the involvement
of spiritual care was sometimes (39%; 30/76). 60% (52/87) said
that patients are not required to attend psychological assessment
or counselling prior to post-viability termination of pregnancy.
Conclusion In Canada, there is a high level of consistency in the
definition of fetal viability and the types of healthcare provider
involved in the decision making around post-viability termination
of pregnancy. However, there remain some areas of the country
with poor access to post-viability termination of pregnancy,
requiring significant travel and expense.
EP13.31
Decision making around, and indications for,
post-viability termination of pregnancy in Canada
Hull, D1; Davies, G2; Armour, C3

1
Division of Medical Genetics, Kingston General Hospital, Kingston,
Canada; 2Division of Maternal-Fetal Medicine, Queens University,
Kingston, Canada; 3Clinical Genetics Unit, Childrens Hospital of
Eastern Ontario, Ottawa, Canada
Introduction This survey aims to assess the indications for/
decision making process around post-viability termination of

pregnancy for fetal genetic and congenital abnormalities at centres
across Canada.
Methods A 26 item Survey Monkey survey was distributed to
members of the Canadian Association of Genetic Counsellors, the
College of Medical Geneticists and the Society for Maternal-Fetal
Medicine between December 2012 and March 2013. Inclusion
criteria were being a healthcare professional and providing direct
counselling or management of prenatal patients. The Health Sciences
Research Ethics Board at Queens University approved this study.
Results 123 eligible healthcare providers responded to our survey.
Information regarding the rate of response, definition of fetal
viability and types of healthcare providers has been presented in a
separate abstract. Most post-viability termination of pregnancy is
offered on a case by case basis (48%). In 28% of cases the

decision to offer is at the discretion of a review board. In only 5%
of cases is the decision to offer made by a single physician.
Examples of diagnoses that would always or sometimes lead to
offering post-viability termination of pregnancy are: trisomy 18 or
13 (100%), thanatophoric dwarfism (88%), hypoplastic left heart
(63%) and fetal infection, e.g. cytomegalovirus (51%). Examples
of diagnoses that would rarely or never lead to offering postviability termination of pregnancy are: minor isolated congenital
anomaly (cleft lip) (93%), adult onset condition with reduced
penetrance (BRCA1/2) (79%), conditions with mild intellectual
handicap (75%), possible childhood cancer syndrome (familial
adenomatous polyposis) (68%), adult condition with 100%
penetrance (Huntington disease) (63%) and chromosomal
abnormalities of uncertain pathogenicity (55%). Most other
responses were unsure. Opinion in pregnancies affected by Down
syndrome was polarised. 37% always or sometimes offer and
62% rarely or never offer post-viability termination of
pregnancy. 90% (77/86) of respondents reported that perinatal
hospice is offered as an alternative to post-viability termination of
pregnancy.
Conclusion In Canada, post-viability termination is commonly
offered for lethal/severe diagnoses but not for conditions that are
less severe, more treatable, or severe but adult onset. There is no
consensus when a fetus is affected with Down syndrome.
EP13.32
Maternal satisfaction with rooming-in to reduce
neonatal abstinence syndrome
Davies, G1; Newman, A2; Newton, L3; Holmes,

B3; Macdonald, J4; Connelly, R5; McKnight, S5;
Dow, K5
1
Department of Obstetrics and Gynaecology, Queens University,

Kingston, Canada; 2Department of Family Medicine, Queens
University, Kingston, Canada; 3Kingston General Hospital, Kingston,
Canada; 4Kingston Community Health Centres, Kingston, Canada;
5
Department of Paediatrics, Queens University, Kingston, Canada
Introduction In the last 10 years, the province of Ontario,
Canada, has seen a 5 fold increase in the number of infants

admitted to neonatal intensive care units (NICU) with a diagnosis
of neonatal abstinence syndrome (NAS). A rooming-in policy for
newborns of opioid dependent women was introduced at our
tertiary care hospital in 2013. Neonates were not admitted to the
NICU unless oral morphine therapy was required. This policy
change demonstrated a significant reduction in the need for
newborn oral morphine therapy and length of hospital stay.
Mothers were questioned about their satisfaction with the
rooming-in programme.
Methods Otherwise healthy term opioid exposed neonates were
placed in a private room with their mothers until discharge.
Neonates who had severe NAS were transferred to the NICU for
oral morphine therapy. Once a stable dose of morphine was
achieved, the neonates were returned to room-in with their
mothers. After discharge of the neonate, mothers were asked to
265
complete a 13 question quantitative survey about their experience

with rooming-in. Questions were scored out of 5.
Results 14 of 21 mothers completed the questionnaire. Mothers
rated the overall rooming-in experience highly (4.6 0.5). They
felt the rooming-in process had been well explained at their
antenatal visits (4.7 0.6) and were well prepared to care for the
opioid dependent newborn while rooming-in (4.8 0.4).
Although mothers felt that caregivers were approachable and
accessible (4.7 0.5), they felt significantly less supported by the
nursing staff (3.8 1.1) than the social workers (4.6 0.7,
P = 0.03) and doctors (4.9 0.3, P = 0.001). All five mothers
who had a previous opioid dependent newborn that had been
directly admitted to the NICU felt the rooming-in experience was
superior (5). All mothers would recommend the rooming-in
programme to other opioid dependent pregnant women. At an
average of 2.5 months, 85.7% of mothers were still breast feeding.
Conclusion Opioid dependent mothers were highly satisfied with
a programme that allowed them to room-in with their newborns
at risk for NAS. They felt well educated about the programme and
were prepared to care for their newborns. They felt very
supported by the physicians and social workers who had been part
of their care team both antenatally and postpartum, but less so by
the postpartum nursing staff. This may be due to less comfort by
the nursing team with this novel programme, which could be
improved with further education.
7 days unless treatment was required. Neonates requiring

admission to the NICU for other reasons were excluded. Trained
nursing personnel administered regular Finnegan testing to all the
newborns. Newborns who were rooming-in and developed severe
NAS were transferred to the NICU for initiation of oral morphine
therapy and, when on a stable dose, were transferred back to
room-in with their mothers until discharge. Mothers did not
receive ongoing nursing care after the usual postpartum stay (1
2 days).
Results There were 24 infants admitted directly to the NICU
prior to, and 21 infants who started rooming-in with their
mothers after, the policy change. The need for oral morphine
therapy was significantly less in the rooming-in cohort (3/21,
14.3% versus 20/24, 83.3%, P < 0.0001). The length of stay was
also significantly less in the rooming-in cohort (7.9 7.8 versus
24.8 15.6 days, P = 0.0001).
Conclusion Rooming-in for newborns of opioid dependent
mothers reduces the need for neonatal oral morphine therapy and
length of stay.
EP13.34
Management of anaemia in pregnancy: experience
from a Sri Lankan tertiary hospital unit
Palihawadana, T; Dias, T; Motha, C; Thulya, SD;

Herath, R; Wijesinghe, PS
EP13.33
Rooming-in to reduce neonatal abstinence
syndrome
Davies, G1; Newman, A2; Newton, L3; Holmes,

B3; Macdonald, J4; Connelly, R5; McKnight, S5;
Dow, K5
1
Department of Obstetrics and Gynaecology, Queens University,

Kingston, Canada; 2Department of Family Medicine, Queens
University, Kingston, Canada; 3Kingston General Hospital, Kingston,
Canada; 4Kingston Community Health Centres, Kingston, Canada;
5
Department of Paediatrics, Queens University, Kingston, Canada
Introduction Neonatal abstinence syndrome (NAS) is a common
consequence for the newborns of opioid dependent women. In the

last 10 years, due to increasing illicit and prescription use of
opioids, the province of Ontario, Canada has seen a 5 fold
increase in the number of infants admitted to neonatal intensive
care units (NICU) with a diagnosis of NAS. Currently, there are
32 NICU beds per day being used to treat NAS newborns.
Neonatal intensive care units are high light, high noise stimulating
environments. We propose that newborns rooming-in with their
mothers, and the associated increase in motherinfant bonding
and decrease in negative stimulation, will reduce the need for
neonatal oral morphine therapy and the length of stay.
Methods The need for neonatal oral morphine therapy for severe
NAS and length of stay were evaluated for 1 year before and after
a policy change stopping the routine admission of term opioid
dependent newborns to the NICU. After the policy change, these
infants were placed in a private room with their mothers for 5
266
University Obstetric Unit, North Colombo Teaching Hospital,

University of Kelaniya, Sri Lanka
Introduction Higher rates of pregnancy complications have been
reported among anaemic pregnant women. Universal iron

supplementation during pregnancy is recommended in countries
where iron deficiency anaemia (IDA) prevalence rates are high. Sri
Lanka also carries out a policy of such supplementation. The
effectiveness of such programmes in different settings is variable.
A retrospective analysis of the effectiveness of our current policy
on prevention and treatment of anaemia was done for programme
evaluation.
Methods The North Colombo Obstetric Database (NORCOD)
was used retrospectively to analyse the data between March and
August 2014, at the university obstetric unit of the North
Colombo Teaching Hospital, Sri Lanka. All singleton pregnancies
without medical comorbidities were included in the analysis.
Those who did not have haemoglobin (Hb) recording in the first
trimester or in the third trimester were excluded at the data
cleaning stage. An Hb level of <11 g/dL and a level of <10.5 g/dL
were considered as anaemia in first and third trimesters
respectively. The prevalence of anaemia at booking, and the Hb
status in the third trimester were assessed.
Results A total of 1340 singleton pregnancies were included in the
analysis and 74 were excluded from the analysis due to incomplete
data. 28.9% (n = 366) were found to be anaemic at booking while
63.9% (n = 809) were with a normal Hb and 7.1% (n = 91) were
with an Hb of >13 g/dL. In the third trimester the prevalence of
anaemia was 11.5% (n = 146) while 64.7% (n = 820) were with
normal Hb and 23.6% (n = 300) were with an Hb of >13 g/dL.
Among the anaemic women at booking, 22% (n = 81) persisted

to be anaemic in the third trimester while 65% (n = 238) became
normal and 12.8% (n = 47) developed a higher Hb level. Among
those with a high Hb at booking only 1% became anaemic by
third trimester while 40.6% persisted to have a high Hb level.
Conclusion The prevalence of anaemia in this population was of
moderate severity (>20% but <40%) as defined by the WHO.
Major shortcoming in our practice is that we were unable to
successfully treat nearly quarter of women who present with
anaemia at booking, thus highlighting sub-optimal treatment.
Furthermore, a policy of universal supplementation seems to over
treat women with a high Hb at booking. Therefore, a more
individualised supplementation and treatment policy should be
encouraged in routine clinical practice.
family history increases the risk of GDM by nearly 8 fold. Abnormal

PPBS results in early part of pregnancy, in women who later develop
GDM suggest the presence of abnormal glucose homeostasis in this
group even at early stages of pregnancy. This has the potential for
developing in to a test of early detection of GDM in pregnancy.
EP13.36
A retrospective analysis of the prevalence of heart
disease in pregnancy a Sri Lankan experience
Motha, C; Palihawadana, T; Dias, T; Thulya, SD;

Godage, T
Introduction With improvement in obstetric care, the burden due
EP13.35
Diabetes mellitus in pregnancy a Sri Lankan
experience
Dias, T; Palihawadana, T; Motha, C; Thulya, SD

Introduction Diabetes mellitus in pregnancy carries high perinatal
morbidity/mortality and maternal morbidity. Only a proportion of

women would have pre-existing diabetes mellitus with the majority
developing gestational diabetes (GDM). The burden of diabetes in
pregnancy is expected to increase in Sri Lanka as obesity is high
among pregnant population. Aims of this study were to look at the
prevalence, risk factors and complications of diabetes in pregnancy.
Methods The North Colombo Obstetric database (NORCOD),
which records pregnancy data of all women delivering at the
university obstetric unit of the North Colombo Teaching hospital,
Ragama, Sri Lanka, was used for retrospectively analysis. 1830
deliveries between March and August 2014 were included. Those
with incomplete data were excluded. Details regard to prevalence,
associated risk factors and complications were identified.
Results Diabetes mellitus complicated 130 (7.1%) pregnancies.
This consisted of 26 with pre-existing disease and 104 with GDM.
A positive family history in first degree relative (OR 7.87, 95% CI
5.0812.1), and a BMI of >23 kg/m2 (OR 2.68 95% CI 1.754.11)
were associated with development of GDM. The mean (SD) age
was significantly higher among women who developed GDM
compared to those did not (32.1 (4.76) versus 28.7 years (4.7),
P = 0.03 respectively). The mean (SD) postprandial blood sugar
(PPBS) estimate done in the first half of the pregnancy was
significantly higher among women who developed GDM later in
pregnancy compared to those who did not (120 (39.2) versus
95 mg/dL (14.6), P < 0.0001 respectively). Hypertensive disorders
of pregnancy was significantly associated with diabetes in
pregnancy (OR 2.39 95% CI 1.493.83) and a birthweight of
>3 kg at term (OR 1.63 95% CI 1.112.40).
Conclusion Diabetes mellitus complicates a significant number of
pregnancies. Pre-existing diabetes constitutes one fifth of these
pregnancies, highlighting the importance of provision of
preconception care to women contemplating pregnancy. A positive
to direct causes of maternal mortality has declined bringing

medical conditions to the forefront. Heart disease in pregnancy
remains a major cause of maternal morbidity and mortality in Sri
Lanka. In the absence of a robust pre-conception care programme,
many women with pre-existing heart disease embark on pregnancy
unaware of the underlying abnormalities. This study was aimed at
describing the proportion of women with heart disease, the type of
heart disease and the time of detection in this population.
Methods The North Colombo Obstetric database (NORCOD)
records data for all women who deliver at the university obstetric
unit of the North Colombo Teaching hospital, Ragama, Sri Lanka.
Details of women delivered between March and August 2014 were
used in a retrospective analysis. Data on booking screening, and
pregnancy care with regard to heart disease were analysed.
Results A total of 1830 pregnancies were included. Fifty (2.7%)
were complicated with heart disease. 15 (0.8%) patients were
known to have pre-existing heart disease at the time of booking.
They included 10 with congenital heart disease (treated ASD in 3,
untreated ASD in 1, untreated VSD in 1, ligated PDA in 1 and
mitral valve disease in 4) and 5 acquired heart disease due to
rheumatic heart disease. A cardiac murmur on auscultation was
detected in 61 women (3.3%) at their booking screening. 26
(42.6%) of them were found to have an underlying cardiac lesion.
The commonest lesion was isolated mitral valve prolapse (n = 11),
followed by mitral regurgitation associated with mitral valve
prolapse (MVP) in 10, tricuspid regurgitation (TR) in 3, and one
each of ASD and VSD. Nine others were found to have underlying
cardiac lesion at assessment during pregnancy, in the absence of
any abnormality at booking. These included 6 with MVP, 2 with
mitral regurgitation (MR) with MVP, and one with MR.
Conclusion A significant proportion of women with cardiac
abnormalities (70%) were detected during pregnancy. This
highlights the importance of pre-conception care with screening
in this population. While booking screen was able to identify a
majority of patients, some were detected only during subsequent
assessment. Clinical vigilance throughout pregnancy facilitates
such detection.
267
EP13.37
Spinal tuberculosis in pregnancy, a rare clinical
presentation
Douliotis, I; Athanasias, P; Sherriff, E

St Heliers University Hospital, London, United Kingdom
Introduction Tuberculosis is very uncommon in pregnancy in the
UK with an incidence of 4.2:100 000 maternities. The vast

majority of cases involve women of ethic minorities. Most
obstetricians will be unfamiliar with this rare disease and a high
level of suspicion should be maintained to allow prompt
treatment.
Case We present a case of a primi-gravida of Asian background
who presented in the second trimester with neurological
symptomatology of increasing severity. Main complaint was
difficulty walking, instability and pelvic pain. Subsequent clinical
examination and imaging confirmed a diagnosis of spinal
tuberculosis. The patient was started on standard anti-tuberculosis
treatment regime, recovered well and subsequently gave birth to a
healthy infant at term.
Conclusion This case highlights that a very uncommon disease
like tuberculosis can manifest with very common or vague
symptoms. A high level of suspicion is very important especially if
a woman comes from an ethnic background where the prevalence
of the disease is high. Seeking advice from relevant specialities is
recommended as it could lead to a faster diagnosis. Tuberculosis
is treatable and the benefits of treatment outweigh the risks in
pregnancy, but if the diagnosis is delayed permanent damage
could ensue (in our case neurological). In this case prompt
multidisciplinary management allowed for a positive outcome for
both the mother and the baby.
EP13.38
Benign intracranial hypertension in pregnancy
literature review
Dutta, D1; Ofinran, O2

1
Derby Royal Hospital, Derby, United Kingdom; 2Xxxxx
Introduction The history, diagnosis, and therapy of benign
intracranial hypertension (BIH) (pseudotumour cerebri) in

pregnant women are reviewed. Theories of pathogenesis are
considered, the clinical presentation is described, prognosis and
significant diagnostic and therapeutic challenges are explored.
Methods An extensive literature review of BIH in pregnancy and
similar conditions was performed. The history and rationale for
the diagnosis and challenges in pregnancy with respect to medical
and surgical approaches to treatment are reviewed. Available
prognosis and outcomes in both pregnant and nonpregnant
population are compared and presented.
Results BIH is a diagnosis of exclusion. Multiple factors
contribute to the causes of intracranial hypertension which must
be identified or excluded. The clinical presentation most often
includes headache and papilloedema, but many other findings
have been described. The most important goal of therapy is to
prevent or arrest progressive visual loss. Medical therapies include
268
alleviation of associated systemic disease, avoidance of some

contributory medications, provision of carbonic anhydrase
inhibitors and weight loss. Surgical therapies include
lumboperitoneal shunting, ventriculoperitoneal shunting, and
optic nerve sheath fenestration. The proper management of BIH
can lead to normal pregnancy, and decisions regarding the mode
of delivery, anaesthesia, and analgesia should be based only on
obstetric concerns and the visual outcome is the same as for
nonpregnant patients with BIH. Regional anaesthesia is safe to
offer as pain relief to labouring women with BIH. On the basis of
the advantages and disadvantages of the different modalities of
treatment a logical treatment algorithm has been suggested.
Conclusion IIH remains an enigmatic diagnosis of exclusion.
There is no difference in the presentation, prognosis and
treatment offered to pregnant and non pregnant women. However
prompt diagnosis and thorough evaluation and treatment are
crucial for preventing visual loss and improving associated
symptoms both in pregnant and non-pregnant population.
EP13.39
Atypical presentation of HELLP syndrome
Edmonds, H; Fernando, M
Lismore Base Hospital O&G Department, Lismore, New South Wales,
Australia
Introduction Haemolytic anaemia, elevated liver enzymes, low
platelets (HELLP) syndrome is a life-threatening complication of

pregnancy, and a major cause of obstetric morbidity and mortality
world-wide. It is commonly preceeded by hypertension and
proteinuria (pre-eclampsia). HELLP syndrome is a type of
thrombotic microangiopathy (TMA), a spectrum of disorders in
which microvascular endothelial damage, platelet dysfunction,
complement dysregulation and haemolysis occurs. Despite
advances in obstetrics, the pathogenesis of HELLP syndrome is
still not known. In addition, not all women have a preceding
history of pre-eclampsia or the classical risk factors of HELLP
syndrome. For these women, HELLP syndrome may go
unrecognised leading to adverse outcomes. We present a case of
atypical HELLP syndrome.
Case An otherwise well 20-year-old primigravid presented with a
spontaneously conceived MCDA twin pregnancy. During her
pregnancy she had regular antenatal visits with normal
examinations, urine and serology results. She also had regular
growth scans. Between weeks 32 and 36 twin 1 began to show
symmetrical growth restriction, with inadequate interval weight
gain, but normal umbilical Dopplers. As such, she was booked for
an elective LSCS at 37+4. She was given steroids and had an FBC
and Group and Hold (G&H) collected 2 days prior to the LSCS.
During surgery the patient had increased capillary oozing but
haemostasis was achieved satisfactorily. Live twins were delivered
and transferred to special care nursery. Three hours after surgery
TH was still oozing from her wound and became
haemodynamically compromised. She was taken back to theatre.
There was no active bleeding; however, large clots were evacuated
from under the subcutaneous tissue and rectus sheath.
Investigations done at that point revealed a creatinine of 200, and

elevated PT/INR. She was transferred to the ICU and required
multiple transfusions of blood products. Haematology and renal
teams were involved and a retrospective analysis of the G&H she
had 48 hours earlier revealed microangiopathic haemolyis,
elevated LFTs, and elevated creatinine levels. TH was diagnosed
with atypical HELLP syndrome. She developed DIC, acute kidney
impairment, a large abdominal wall haematoma, a bowel pseudoobstruction and sepsis. Despite these complications, she recovered
well and was discharged home 3 weeks later.
Conclusion HELLP syndrome is a major cause of obstetric
morbidity and mortality worldwide, however, the pathogenesis
remains poorly understood, especially in women who present
atypically. This makes predicting adverse outcome difficult. Further
research is required to better understand the role of platelet
dysfunction and complement dysregulation in HELLP syndrome.
required in this subgroup. If NRT is going to be considered, short

acting delivery systems should be used. It may prove to be both
ethically and financially beneficial to consider direct financial
incentives or counselling offered under GP management plans in
shared care arrangements rather than government sponsored NRT
with little or no behavioural counselling. Doctors should be wary
of evidence (including government directives), which is
inadvertently tainted by pharmaceutical company bias and may
lead to patient harm. As professionals we have a duty to our
patients to carefully examine the research ourselves. Finally, NRT
should only be used if the patients are fully informed of the risks
of NRT to the fetus and informed consent obtained.
EP13.40
Review of smoking cessation in pregnancy
English, N1,2; Rao, J1,3
EP13.41
Acute fatty liver in pregnancy with hepato-renal
syndrome, coagulopathy, haemorrhage, diabetes
insipidus and acute pancreatitis
Tamworth Base Hospital, Tamworth, New South Wales, Australia;

School of Medical Science, Griffith University, Gold Coast Campus,
Queensland, Australia
1
Department of Obstetrics and Gynaecology, Joondalup Health
Campus, Western Australia, Australia; 2Department of Obstetrics and
Gynaecology, King Edward Memorial Hospital, Perth, Western
Australia, Australia; 3Faculty of Medicine, University of New South
Wales, Sydney, New South Wales, Australia
Introduction Smoking during pregnancy is harmful to the health
Introduction Obstetric hepatobiliary disorders are varied and
of both the mother and the unborn child and is one of the most
prevalent but preventable causes of infant death and illness.
Historically chemicals such as carbon monoxide were considered
the most dangerous components of cigarette smoke. More
recently, increasing recognition of direct nicotine toxicity to the
fetus has generated concerns regarding the safety and efficacy of
nicotine replacement therapy (NRT).
Methods Critical literature review with particular attention being
paid to positive trial and publication bias and the addition of
population studies. A range of methodologies was used, with
varying quality, making meta-analysis of findings inappropriate.
Results 92 studies and literature reviews were included. Review
and re-examination of research in this review informs
recommendations for alternative, safe and effective interventions
to reduce smoking in pregnant women.
Conclusion Nicotine is directly harmful to the developing infant,
in both animal models and prospective human studies. The most
successful form of smoking cessation in the general population is
cold turkey sudden smoking cessation. Studies of NRT products
in pregnancy suggests that nicotine replacement in pregnant
women does not work as well as it does in the general population
and had no significant advantage over counselling and behavioural
support in smoking cessation. In the largest trial, women had a
similar quit rate to those who had used a placebo (a patch
without nicotine) by the end of their pregnancy. While nicotine
replacement has not been shown to decrease IUGR, counselling
and behavioural support reduce the incidence of low birthweight
and preterm births. In women who exhibit signs of severe
addiction, the chances of smoking cessation are reduced. College
guidelines suggest that pharmacological intervention may be
clinical presentation frequently overlaps. One of the rarer forms is

acute fatty liver in pregnancy (AFLP), which occurs in 1:20 000
deliveries. AFLP causes a substantial morbidity with a case fatality
rate of 1.8%. Pathologically, it is characterised by microvesicular
fatty infiltration of the hepatocytes. AFLP can be complicated by
coagulopathy, haemorrhage, hepato-renal syndrome, pancreatitis,
hypoglycaemia and diabetes insipidus. Prompt delivery and
supportive therapy remains the mainstream management. We
report a patient who manifested all the complications of AFLP
after delivery and recovered with supportive measures.
+5
Case A 32-year-old primip presented at 34 weeks of gestation
with jaundice, abdominal pain, vomiting, blood pressure of 136/
94 mmHg, non-proteinuria, hyperbilirubinaemia (47 lmol/L),
elevated liver enzymes (GGT = 143 U/L and ALT = 49 U/L),
normal platelet counts, normal coagulation profile and
asymptomatic for pre-eclampsia. She was diagnosed with obstetric
cholestasis 5 days earlier, with a fasting bile acid of 39 lmol/L.
Lower section caesarean section was performed and a live infant
was delivered. The patient was transferred to ICU for blood
pressure stabilisation which normalised within 24 hours. Renal
impairment persisted for 48 hours with polyuria, hyponatremia
and a peak serum creatinine of 185 lmol/L. The liver enzymes
remained elevated and the serum bilirubin level peaked at
141 lmol/L. She was hypoalbuminemic (20 g/L), requiring human
albumin infusion. The liver function took 21 days to normalise.
She was persistently hypoglycaemia for 5 days requiring 10%
dextrose infusion. She became coagulopathic from the first
postoperative day (INR = 1.6, serum fibrinogen = 0.9 g/L) and
required repeated infusion of cryoprecipitate and fresh frozen
plasma over 9 days for normalisation. A CT scan due to
Endean, C1; Ahmed, R1; Apen, K1; Massa, H2

1
2
269
abdominal distension showed intra-abdominal and sub-rectus

haemorrhage. There was also fatty infiltration of the liver, ascites,
ileus and peri-pancreatic oedema. The haemoglobin dropped to
66 g/L but the platelet count never dropped below 120 000.
Serum lipase reached a peak of 2800 IU/L; white cell counts and
CRP were elevated, and her temperature spiked to 39C, requiring
broad spectrum antibiotics for a working diagnosis of acute
pancreatitis. Blood culture and ascitic tap microbiology were
negative. Patient stabilised with supportive management.
Conclusion This patients diagnosis changed from obstetric
cholestasis to AFLP with a differential of HELLP syndrome within
5 days. Icterus, hypoglycaemia, normal platelet count and absence
of haemolysis/pre-eclampsia symptoms led to the diagnosis of
AFLP. Early diagnosis, prompt delivery and supportive therapy
saved this patient.
EP13.42
Multi-valvular infective endocarditis in pregnancy
presenting with septic pulmonary emboli
English, N1,2; Weston, P2
surgical intervention not indicated. Blood cultures were positive

for methicillin sensitive Staphylococcus aureus and bacteraemia
persisted for 4 weeks. The patient was treated with a regime of IV
flucloxacillin and rifampicin for 6 weeks and made a good clinical
recovery. She will require ongoing cardiology input and is at high
risk for recurrence.
Conclusion This patient presented in acute respiratory distress
from extensive septic emboli. Infective endocarditis secondary to
IVDU is associated with right-sided vegetations, pulmonary septic
emboli and usually staphylococcus aureus. In pregnancy the
diagnosis requires a high index of clinical suspicion and early
multidisciplinary management.
EP13.43
The registry of pregnancy and cardiovascular
disease: a global initiative of the EURObservational
Research Programme
Parsonage, W1; Roos-Hesselink, J2; Johnson, M3;

Lust, K1; Fagermo, N1; Hall, R4
Department of Obstetrics and Gynaecology, King Edward Memorial

Hospital, Western Australia, Australia; 2Department of Obstetrics and
Gynaecology, Joondalup Health Campus, Western Australia, Australia
Royal Brisbane and Womens Hospital, Herston, Australia; 2Erasmus

Medical Centre, Rotterdam, The Netherlands; 3Imperial College School
of Medicine, London, United Kingdom; 4Norwich Medical School,
Norwich, United Kingdom
Introduction Infective endocarditis in pregnancy is a rare and life
Introduction The Registry of Pregnancy and Cardiovascular
threatening condition with an incidence of 0.006% and a maternal

mortality of 1530%. Intravenous drug use is becoming a more
common risk factor among pregnant women and now accounts
for up to 14% of cases.
Case A 32-year-old gravida three, para two presented with
dyspnoea and chest pain at 36 weeks gestation. She was
tachycardic, tachypnoeic and had oxygen saturation of 87% on
room air. She had a history of previous intravenous drug use
(IVDU) and hepatitis C but had denied any drug use while
pregnant. Her antenatal care had been uncomplicated and she
reported being well up to 3 days prior to presentation. Her
laboratory tests suggested an infective picture with elevated CRP
and leucocytosis. She had normal liver and renal function but was
noted to be thrombocytopenic 75 x10-9/L and hyponatraemic
128 mmol/L. Urine toxicology screen was positive for
methamphetamines and opioids. On examination she had bilateral
pitting oedema to mid thigh level. An urgent CT PA was
performed demonstrating multiple cavitating pulmonary lesions
suspicious for septic emboli. In the presence of maternal clinical
deterioration and fetal distress, she underwent an emergency
caesarean section after which she was transferred to the High
Dependency Unit. She was treated with intravenous antibiotics
with a working diagnosis of infective endocarditis and severe
pneumonia. A transoesophageal echocardiogram identified
multiple large cardiac valve vegetations and an aortic root abscess.
The largest vegetation was 4 cm on the tricuspid valve with
secondary vegetations on the sub valvular apparatus and the right
outflow tract causing severe tricuspid regurgitation. The aortic
valve vegetation had an associated root abscess but preserved
function. Overall systolic function was not affected and immediate
disease (ROPAC) is a global initiative of the European Society of

Cardiology that aims to better define the materno-fetal risks
associated with the presence of maternal structural heart disease
during pregnancy and the puerperium.
Methods ROPAC was established in 2007. Investigational centres
are encouraged to prospectively recruit consecutive patients with
structural heart disease diagnosed during pregnancy or the
puerperium. Demographic data, clinical details and materno-fetal
outcomes are recorded using an online case report form. For the
purpose of this report maternal outcomes are reported to 7 days
following the end of pregnancy.
Results Two thousand nine hundred and sixty six completed
pregnancies from patients attending 77 centres in 50 countries
have been included. The majority (55%) of patients have
congenital heart disease. Seventy-eight percent of patients had
conditions known to be associated with increased risk of maternofetal morbidity and mortality (World Health Organization class
IIIV). Maternal mortality during and up to 7 days postpartum
was 0.4%. Twenty-five percent of patients required hospitalisation
(excluding confinement) during pregnancy with the majority due
to cardiac issues and worsening heart failure as the most common
reason. Delivery was by caesarean section in 41% of cases.
Miscarriage or fetal mortality occurred in 4.3% of cases.
Conclusion ROPAC is the largest registry concerning the impact
of maternal heart disease. The registry confirms that heart disease
is associated with considerable maternal mortality and morbidity.
Prosthetic heart valves, cardiomyopathy and anticoagulant use all
appear to be significant risk factors. Adverse fetal and neonatal
outcomes are also significantly influenced by the presence of
maternal heart disease. The registry will significantly advance the
270
understanding of this challenging area of practice that will help to

better inform patients and clinicians regarding the risk and
management of pregnancy associated with heart disease.
EP13.44
Rheumatic heart disease in pregnancy: a
prospective New Zealand cohort
Farquhar, C1; McLintock, C2; Mahony, F2; Sadler,

L2; on behalf of AMOSS Investigators; Sullivan,
E3; Jackson Pulver, L4; Carapetis, J5; Walsh, W6;
Peek, M7; Kruske, S8; on behalf of PMMRC
members; Belgrave, S9; Crengle, S10; Eddy, A11;
McIver, G1; Meeks, M12; Penlington, L13
1
University of Auckland, New Zealand; 2Womens Health, Auckland

City Hospital Auckland, New Zealand; 3Faculty of Health, University
of Technology Sydney; 4Indigenous Health Unit, UNSW Medicine,
University of New South Wales; 5Telethon Kids Institute, Perth, West
Australia; 6University of New South Wales and Prince of Wales
Hospital; 7Sydney Medical School Nepean, University of Sydney;
8
Maternal and Child Health Institute for Urban Indigenous Health,
Queensland, Australia; 9Waitemata DHB, New Zealand; 10Waitemata
and Southern DHBs, New Zealand; 11Counties Manukau DHB, New
Zealand; 12Canterbury DHB, New Zealand; 13Sands, New Zealand
Introduction Rheumatic heart disease (RHD) is a rare disease in
most developed countries but is prevalent in New Zealand as well

as in many developing countries. Maori and Pacific Island peoples
in New Zealand have among the highest documented rates of
RHD in the world. Knowledge of the impact of RHD on women
in pregnancy is based on studies of severe RHD in non-pregnant
adults. The increased cardiac demands of pregnancy can worsen
clinical symptoms in women with known RHD and unmask
undiagnosed RHD. The RHD in pregnancy is one of the
conditions being studied within the Australasian Maternity
Outcomes Surveillance System (AMOSS), a bi-national
surveillance and research system of rare and severe obstetric
conditions.
Methods Systematic identification of every pregnant woman with
RHD presenting at maternity units in New Zealand between
October 2012 and December 2014 has been facilitated by Perinatal
and Maternal Mortality Review Committee (PMMRC) local
coordinators, obstetricians and cardiologists. The AMOSS RHD in
Pregnancy coordinator has visited sites across New Zealand to
collect data into the online AMOSS database. Interim analysis of
New Zealand data has occurred using simple descriptive statistics.
Results Since October 2012 there have been 122 pregnancies
identified in 113 women with RHD, 95% of who are Maori or
Pacific. Almost all cases (98%) are located in the North Island of
New Zealand, with 66% located in the Greater Auckland region.
Serious RHD disease (severe regurgitation or stenosis, heart
failure, or current or historical surgical repair) was present in 25%
of the women. Echocardiographs have been done in 71% of index
pregnancies. We have identified that the first episodes of RF or
recurrence occurred in 22% of these women as adults (over
20 years of age). Twenty percent were identified for the first time
with RHD as an adult.
Conclusion AMOSS-RHD is providing an evidence base to inform
improvements in clinical care for pregnant women with RHD and

their babies. This evidence is based on patterns of health risk,
diagnosis, course, management and pregnancy outcomes. Research
findings will inform approaches to care of pregnant women with
RHD internationally.
EP13.45
The pregnancy outcomes of chronic kidney disease
female with lupus nephritis
Fauziah, J1; Azreen, A2; Shukri, M1; Johan, SR1;

Farliza, SN2
1
Department of Obstetrics and Gynaecology, School Of Medical
Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia;
2
Chronic Kidney Disease Resource Centre, School of Medical Sciences,
Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
Introduction Females with chronic kidney disease are commonly
associated with increased morbidity and mortality especially

during their pregnancy. Uncontrolled hypertension with severe
pre-eclampsia and acute kidney injury are common examples of
pregnancy related complications. Systemic lupus erythematosus
(SLE) is common among female in their reproductive age, and
recognised as the common cause of chronic kidney disease
especially in Asian population. The associated chronic medical
problems also contribute to their low fertility and poor maternal
and fetal outcomes. There has been limited information regarding
the SLE mothers and their pregnancy outcomes.
Methods We retrospectively reviewed clinical records of 26 biopsy
proven lupus nephritis mothers, between year 2000 to 2013. Social
demographics, parity, delivery details such as birthweight, time
and mode of delivery, Apgar scores, and medications prescribed
were collected.
Results From January 2000 to December 2013, total of 26 biopsy
proven lupus nephritis mothers with the mean age of last parity
31.04 5.26 years had delivered. Their mean parity was
2.15 1.52, and the mean birthweight was 2.48 0.74 kg. The
time of deliveries was between 37.5 3.33 weeks. 18 mothers
(69.2%) underwent spontaneous vaginal deliveries, while 7
(26.9%) underwent emergency lower segment caesarean sections
and 1 (3.8%) underwent instrumental deliveries (forceps delivery).
From 26 babies delivered, only 25 were included for Apgar
scoring calculation, with the median Apgar score 9.0, one baby
was undetermined as the birthweight around 700 g. Only 10
patients (34.5%) were on oral corticosteroids, 7 (70%) were on
minimum dose of 5 mg per day prednisolone, while other three
with 25 mg per day (10%), 30 mg per day (10%) and 60 mg per
day (10%) respectively. Seven mothers (26.92%) were hypertensive
with majority of them on methyldopa (85.7%). Three patients
(42.8%) required single antihypertensive drugs (labetalol or
methyldopa), 2 mothers (28.5%) required two antihypertensive
drugs (methyldopa and nifedipine), while another 2 (28.5%)
needed 3 antihypertensive regimes (methyldopa, nifedipine and
labetalol or prazosin). There was no documented acute kidney
injury in any of the studied subjects.
271
Conclusion Lupus nephritis pregnancies have reasonable fetal and
maternal outcomes. There was no documented acute kidney

injury, fetal loss and flaring of SLE during their pregnancies.
EP13.47
How big is too big? Perinatal outcomes of fetal
macrosomia
Franks, Z; Hettiarachchi, P; Math, V

EP13.46
Gestational-age-specific amniotic fluid indices in
normal Filipino pregnancies
Faustino, KM; Manahan, MRP

Makati Medical Centre, Makati, Philippines
Introduction A correlation between amniotic fluid volume and
gestational age has been established but differences in

environment and race are factors that may influence this
correlation. The objectives of this retrospective study are (1) to
obtain gestational-age-specific amniotic fluid indices (AFI) in a
Filipino population and compare with studies involving
Taiwanese, Chinese, Vietnamese, and North American subjects to
determine if there are significant differences; (2) to construct a
table of values and plot predicted percentiles of AFI per
gestational age.
Methods Data were gathered from 3500 Filipinos with singleton
uncomplicated pregnancies between 24 and 41 weeks age of
gestation who underwent sonography at the OB-GYN Ultrasound
Section of a tertiary institution from January 2001 to December
2005. Examinations were performed using a linear array
transducer on B-mode. The AFIs were measured using the fourquadrant technique: the vertical diameter of the largest pocket of
fluid in each quadrant was added. The AFIs obtained were
stratified by gestational age. The mean and median for each
completed week were calculated, then compared with other
populations. SAS software was used for statistical analyses.
Quadratic regression analysis of mean AFIs was used to predict
the 3rd, 5th, 10th, 50th, 90th, 95th, and 97th percentiles of AFI
per gestational age.
Results The mean AFI of our subjects peaked at 14.86 cm at
28 weeks then gradually declined until 41 weeks. Comparing the
Filipino with Taiwanese and Vietnamese populations, majority of
the mean AFIs per gestational age have significant differences.
Thirteen of the 18 weekly mean AFIs in the Filipino-Taiwanese
comparison, and 11 of 14 in the Filipino-Vietnamese comparison
were statistically different. The North Americans had a slightly
higher AFI than Filipinos, with an average difference of 0.64 cm.
The Chinese had a markedly lower AFI, with an average difference
of 3.59 cm. Quadratic regression of the mean gestational-agespecific AFIs was used to obtain a best-fit line to plot predicted
values for the 3rd, 5th, 50th, 95th and 97th percentiles. These
lines provide a better estimation of the periodic changes in AFI.
Conclusion The authors recommend usage of the predicted values
obtained in this study as reference AFI values for Filipino patients.
There are significant differences in values across populations,
increasing the value of a race- and gestational-age-specific
reference.
272
Gold Coast University Hospital, Gold Coast, Queensland, Australia

Introduction Fetal macrosomia is considered a birthweight greater
than 4000 g regardless of gestational age. Precise estimation of

fetal weight is not easy antenatally. The incidence of fetal
macrosomia is increasing and is associated with significant
perinatal mortality and morbidity. For this reason understanding
the risk factors and adverse events associated with fetal
macrosomia is important. Obstetricians are reluctant to deliver
suspected macrosomic babies vaginally despite a paucity of
evidence to contradict the safety of the vaginal route and
limitations of technology in estimating fetal weight accurately.
This study provides a retrospective descriptive analysis of
maternal, antenatal, intrapartum and infant factors relating to
macrosomia.
Methods A retrospective analysis was conducted on all babies
born at the Gold Coast University Hospital over a 3-year period.
Birth records were reviewed to determine subjects to be included
for analysis. The electronic medical records were reviewed for
both mother and infant separately.
Results In the analysis conducted approximately 50% of women
did not have an identifiable risk factor for fetal macrosomia. We
were able to diagnose approximately 25% of large for gestational
age (LGA) babies using clinical exam alone, however when
ultrasound was performed there was significant improvement in
detection of large for gestational age babies. The shoulder dystocia
rate at delivery was not proportional to birthweight. Only a very
small proportion of the population had adverse events including
erbs palsy or hypoxic events following birth. Of the infants
included in the study approximately 50% were detected to be
macrosomic in the antenatal period, however there was a high
success rate of vaginal births.
Conclusion A significant portion of the population who had
adverse outcomes was born to mothers without known risk
factors. Careful antenatal assessment is required as routine
antenatal examination only detected approximately 25% of LGA
babies. Despite the limitations of ultrasound in the third trimester
should a future role be considered? The neonatal outcomes were
very good in women where fetal macrosomia was not diagnosed,
would these results change our practice when considering mode of
delivery.
EP13.48
Maternal and perinatal outcome in pregnant
women with leukaemia: a systematic review of
literature
Gupta, SN1; Shrestha, S2; Kumari, S3; Rijal, P4

1

Pathology; 3Department of Family Medicine and Emergency Medicine;
4
Department of Obstetrics and Gynaecology, B.P. Koirala Institute of
Health Scienecs, Dharan, Nepal
Introduction The haematological malignancies are rare entities.
The incidence of leukaemia as 1 in 75 000 deliveries limits the

design and implementation of large prospective studies. The
purpose of this study is to describe maternal and perinatal
outcome of pregnant women with diagnosis of acute or chronic
leukaemia and to evaluate the limited existing data to draw useful
conclusion in order to help during essential prenatal counseling.
Methods We reviewed the published literatures from year 1995
2012 which were searched from PubMed and Google scholar
using the relevant and similar terms including all heading and
subheadings. The principal terms used were: hematological
malignancy, leukemia, perinatal outcome, chemotherapy, and
pregnancy. We systematically analysed the maternal and perinatal
outcomes.
Results Eighteen published literature including case reports were
selected for analysis in view of similarity and relevant content.
The literature included 604 pregnant women who underwent
treatment during pregnancy. 72.3% of the women had acute
leukaemias (AML/ALL) and remaining had CML. Majority of
acute leukaemia had poorer outcome with evidence of
spontaneous or therapeutic termination of pregnancy, congenital
fetal malformation, prematurity, low birthweight and intrauterine
growth retardation whereas chronic leukaemia in pregnancy had
favourable result. Many of patients disease went in remission but
some patient died due to complication of leukaemia.
Conclusion Majority of the pregnant women presented with
leukaemia had features of acute leukaemia and must be
considered for early treatment. Maternal and perinatal morbidity
is high in pregnancies complicated with acute leukaemia even in
treated patients where as pregnancy with chronic leukaemia had
quite satisfactory outcome.
high risk of lethal pulmonary hypoplasia, chronic pulmonary

morbidity, fetal limb contractures. Unlike in the other part of the
world, termination of pregnancy is not legally permitted in Sri
Lanka for this circumstance.
Case A 31-year-old mother at her second pregnancy with
diagnosed di chorionic di amniotic twin pregnancy. She delivered
her first baby by normal vaginal delivery 10 years back. This
pregnancy is a planned pregnancy with the spontaneous
conception. She had the booking visit at the period of gestation of
10 weeks and underwent basic investigations. Those results were
found to be normal. She had her dating scan at the period of
gestation of 12 weeks. She was offered shared care with a tertiary
care hospital, DSHW and field clinic. She had mild spotting
episodes at 12 and 14 weeks and treated as threatened miscarriage.
She developed pre viable PPROM at 19 weeks of gestation and
this was confirmed by sterile speculum examination. Patient
treated in the ward for a period of 4 weeks and investigated with
full blood count, C reactive protein, high vaginal swap culture and
ABST and serial ultra sound scans. She was treated with the usual
prophylactic antibiotic erythromycin for 10 days. The antibiotic
was changed according to the ABST. There is no evidence of
chorio amnionitis in her stay. She was discharged from the ward
and followed up in the ante natal clinic. She got admitted to the
ward at the gestation of 28 weeks and 6 days with the labour
pain. Dexamethazone and magnesium sulphate give for the fetal
protection. She delivered her twin babies vaginally with the weight
of 1.175 kg and 1.260 kg and both were active and alive at the
time of delivery. Babies were taken to neonatal ICU due to
prematurity. Both babies are doing well at the moment awaiting
discharge from the hospital. Still no complications mentioned
above identified in these babies.
Conclusion Previable PPROM can be managed with serial
monitoring and appropriate treatment. Prolongation of the
pregnancy may helpful to achieve the viability of the fetus.
EP13.50
Abstract sample for original research/systematic
reviews Obstetric Medicine
Haack, MC1; Walsh, SO2; Chin, K3; Sherran, T3

1
Mid Cheshire NHS Foundation Trust, Crewe, United Kingdom;

North Staffordshire NHS Foundation Trust, Stoke on Trent, United
Kingdom; 3Mid Staffordshire NHS Foundation Trust, Stafford, United
Kingdom
2
EP13.49
Previable preterm prelabour rupture of membrane
in a twin mother, a success story from Sri Lanka
1
Guruparam, K ; Ratnasiri, UP ; Gamage, R ;

Jayawardenn, GRMUGP1; Gamaathige, N1;
Lambiyas, LY1
1
De Soysa Hospital for Women, Colombo; 2Castle Street Hospital for
Women, Colombo, Sri Lanka
Introduction Preterm prelabour rupture of membrane defined as
rupture of amniotic membrane before 37 weeks of gestation.

When the rupture of membrane occurs before 2324 weeks it is
categorised as previable preterm rupture of membranes. There is a
Introduction Women suffering from chronic inflammatory
conditions such as rheumatoid arthritis, ankelosyding spondlylitis

and systemic lupus erythematosus face an ethical dilemma when
found/desire to be pregnant. Current guidelines by the Royal
College of Obstetrics and Gynaecology (RCOG) state that all
Disease-modifying Anti-rheumatic Drugs (DMARDs) are to be
discontinued 612 months prior to conception and stopped at
once when found pregnant. Due to the ethical implications there
is limited evidence available, therefore worldwide only a few case
studies have been published to demonstrate the potential risks/
side effects associated with DMARDs.
273
Methods A retrospective case analysis of 14 women found to be

on biological agents during the first trimester of pregnancy.
Maternal and fetal well-being parameters were analysed. A
systemic literature review was carried out and outcomes were
compared.
Results We found 14 live births all with normal Apgar scores and
average birthweights with no fetal abnormalities. There is a slight
tendency for earlier gestational age and expected birthweights.
Conclusion Overall the case series reveals no maternal/fetal
complications associated with the use of biological agents during
the 1st trimester of pregnancy. We strongly recommend national
joint care between the medical and obstetric profession to ensure
optimal care for maternal and fetal wellbeing. There is a need to
emphasis early on preconception counselling, structured advice on
choice of contraception and a universally accessible data base of
retrospective case reviews.
O2 sat 60%, H1N1 screening negative, woman was critically ill,

tachypnoec and tacycardiac with O2 sat 88%. Further interferone
and Ribavirin were added to on mechanical ventilation and
decided to conduct delivery of baby to take off obstetric burden.
Day 5 the women underwent emergency LSCS with outcome of
alive baby female, Apgars (6 /1, 8/5), weight 2240 g. Day 6,
remains critically ill, on day 8 women deteriorated with h/o
MERS-CoV pneumonia, respiratory failure septic shock, on nor
epinpephrine, women kept on deteriorating, had respiratory
failure. The women deceased after failed resuscitation.
Conclusion Pregnant mothers are high risk group for MERS
complications due to change in immune response and fetal effects
of a severe respiratory syndrome.
EP13.51
MERS-CoV in pregnancy
Haran, C1; Ganeshananthan, S2
Habib, Z; Asghar, F; El Masry, K; El Reddy, M;

Ravi, M
1
Royal Brisbane and Womens Hospital, Queensland, Australia; 2Logan
Hospital, Queensland, Australia
Introduction Good syndrome is an exceptionally rare condition
Mafraq Hospital, Abu Dhabi, United Arab Emirates

Introduction MERS-CoV syndrome is a severe viral illness first
reported in Saudi Arabia in 2012. Presents with fever, cough and

shortness of breath. It can affect lower respiratory, kidney,
intestinal (bowel) and liver cells. Primary reservoir is Bats,
intermediate for transmission to human, modes of transmission
are droplet, direct contact. Patients present with severe
pneumonia and respiratory distress syndrome, acute renal failure.
Incubation period is 7 days.
Case A 32-year-old Jordanian woman G4 P3 at 32 weeks of
gestation, attended ER with h/o lower abdominal pain on
radiating to thigh, associated with fever for 4 days, chills,
headache, dizziness and loss of appetite. Advised admission, she
refused and signed against medical advise. She was admitted after
3 days with high g fever, right sided pleuritic chest pain, dry
cough and breathing difficulty. Her husband and one child were
admitted to other hospital. Temperature 38.3C, Rr 30 br/min BP
95/61 mmHg, o2 sat 95%, bilateral lung consolidation, HCO3:
24.2, sat O2: 94.4. Patient was having respiratory alkalosis with
severe hypoxemia with increased A-a gradient. CT chest: diffuse
areas of consolidation in both lungs more in the bases, and
excluded pulmonary embolism. D2 post admission temp 37.5 c,
pulse 115 bpm, respiratory rate 24 c/m, BP 100/50 mmHg, o2 sat
95%, CTG showing baseline tachycardia, impression bilateral
pneumonia. Started on IV antibiotics and LMWH. Day 3 post
admission was distressed, RR >35, so2 89% on 5 litre O2, BP
stable, Pulse rate 135/min. Started on legeonella, mycoplasma and
influenza workup, the womans condition became worse despite
standard antimicrobial therapy and she had to be transferred to
the ICU for assisted respiration. With impression of respiratory
failure, at day 3 testing for H1N1 and novel coronavirus done and
was started on Oseltamivit, received steroid injection for fetal lung
maturity and growth USS was uneventful, EFBWT 2300 gm, day 4
274
EP13.52
Incidental finding of panhypogammaglobulinemia
in pregnancy an extremely rare condition
characterised by a combination of B and T cell immunodeficiency

and the presence of a thymoma. As a result of their
immunodeficiency patients are susceptible to bacterial infection
with encapsulated organisms as well as opportunistic viral and
fungal infections. The presence of such a condition during
pregnancy presents a unique challenge for treating clinicians as
there are very few published cases regarding thymoma related
immunodeficiency in pregnancy with only one other case noted.
We report a case of Good syndrome presenting as
panhypogammablobulinaemia in the third trimester as part of
routine screening bloods.
1
Case A 22-year-old woman, G2P0 presented at a 31 weeks of
gestation with an abnormal group and antibody test found
incidentally during routine 28 week blood testing. She reported
no past medical history apart from medication controlled
gestational diabetes and denied any family history of autoimmune
diseases. She was subsequently diagnosed with
panhypogammaglobulinemia. After consultation with an
immunologist, a number of investigations were undertaken
(including blood tests, MRI and obstetric ultrasound), all of
which were negative, except for the MRI which showed a possible
small thymoma. All fetal ultrasounds were unremarkable. Given
the importance of transplacental immunoglobulin (Ig) transfer in
the third trimester and the concern of serious infection during
pregnancy, she has was commenced on intravenous
immunoglobulin (IVIg). After a loading dose of IVIg (0.6 mg/kg)
and a subsequent dose (0.4 mg/kg) her Ig level was 10 g/L. She
was administered a third dose and it was decided that her Ig
levels be monitored weekly and IVIg only administered should her
levels drop below 7. Since her Ig levels dropped to 6.9 g/L at
375 weeks of gestation, she received another dose (0.4 mg/kg). She
underwent a normal delivery at 391 weeks and after delivery the
infants Ig levels were monitored and found to be progressing as
expected of a normal child. A postpartum CT scan confirmed the

diagnosis of a thymoma which was surgically removed and
histologically confirmed as a thymoma. The patient recovered well
from the procedure and has had no long term side effects.
Conclusion This case demonstrates the importance of
investigating abnormalities found in routine blood tests taken
during pregnancy. Although there are few cases published
regarding Good syndrome and indeed
panhypogammaglobulinaemia in pregnancy, currently, IVIg
therapy is the mainstay in order to optimise fetal and neonatal
outcome.
Conclusion Through the findings of this Australian first study it is
hoped that antenatal screening for anxiety, depression and related

difficulties will become mandatory in the NSW private hospital
sector. It will thus form best practice and be considered as routine
as all other forms of screening that occur during pregnancy.
EP13.54
Idiopathic thrombocytopenic purpura diagnosed in
pregnancy: a case report and review of
management
Huang, EY1; Tan, LK2

EP13.53
Screening for perinatal anxiety and depression: an
Australian private hospital first
Hickinbotham, R1; Kohloff, J2; Trumper, R3;

Schadel, S4; Thompson, K4; Gidget Research
Group5
1
North Shore Private Hospital, St Leonards, Australia; 2Karitane,
Sydney, Australia; 3Newcastle University, Newcastle, Australia;
4
University of Sydney, Sydney, Australia; 5Gidget Foundation, North
Sydney, Australia
Introduction Given the well-documented prevalence and negative
impacts of perinatal mood disorders, the importance of early

identification and intervention is clear. Many public hospitals in
Australia have integrated universal screening for depression,
anxiety and assessments of psychosocial risks into routine
perinatal care, but such processes do not exist in the private
sector. With a significant proportion of Australian women
choosing the private model of obstetric care, many miss out on
the support and treatment that they require at this important
time. The Emotional Wellbeing Programme is a depression and
anxiety screening and psychosocial assessment programme
implemented at North Shore Private Hospital in Sydney, NSW.
Methods Ethics approval was obtained through the National
Ethics Application process. The programme is delivered by a team
of midwives and a Social Worker who work in close collaboration
with treating obstetricians. Women are invited in for a screening
interview with trained midwives that consist of a questionnaire
designed to capture relevant demographic data and explore the
various risk factors that have been shown to put a pregnant
women at risk of perinatal anxiety, depression and other related
disorders. It also includes and Edinburgh Post Natal Depression
Score. If a problem is identified the patients primary care giver is
alerted and the patient is referred for individualised care and
follow-up. After completing the questionnaire the patient is asked
to evaluate their overall experience.
Results We have collected data on over 1000 women. A multivariant analysis will be performed on the quantitative data and the
results presented at the World Congress in 2015. Qualitative
feedback from the patients has been very positive, highlighting the
benefits felt after meeting with a midwife to discuss and reflect on
their pregnancy, their mental health and other concerning issues.
1
Division of Obstetrics and Gynaecology, KK Womens and Childrens
Hospital, Singapore; 2Department of Obstetrics and Gynaecology,
Singapore General Hospital, Singapore
Introduction Idiopathic thrombocytopenic purpura (ITP) is an
uncommon, but important cause of thrombocytopenia in

pregnancy. It is a diagnosis of exclusion and management should
be based on a multidisciplinary care approach. ITP is
characterised by moderate to severe thrombocytopenia commonly
diagnosed in the first or early second trimester of pregnancy. The
severity of thrombocytopenia has adverse implications on both
maternal and fetal well-being. This report is based on a case seen
and managed in our institution and aims to discuss the various
causes of thrombocytopenia and its implications in pregnancy as
well as management of ITP in pregnancy based on current
evidence and guidelines.
Case We report a case of ITP diagnosed in pregnancy. The
patient was a 29-year-old primigravida who was transferred at
21 weeks gestation from a private healthcare institution for
thrombocytopenia detected on routine clinical testing.
Collaboration between the obstetrician and haematologist in our
case was important to provide a smooth antenatal journey to
ensure good maternal and fetal outcomes.
Conclusion Thrombocytopenia complicates 10% of all pregnancies
and fortunately, the majority of cases are benign and gestationrelated. There are however, other causes which can potentially
increase both maternal and fetal morbidity and mortality. When
thrombocytopenia is diagnosed, a systematic approach is required
to ascertain the cause. Gestational thrombocytopenia or ITP can
only be diagnosed if other causes are excluded. Gestational
thrombocytopenia is mild and does not have adverse effects on
the mother or fetus, does not require treatment and usually
resolves after delivery. On the other hand, ITP is associated with
moderate to severe thrombocytopenia which increases the risks of
maternal haemorrhage as well as fetal thrombocytopenia and
potentially, fetal intracranial haemorrhage. Treatment is needed in
ITP and is no different from non-pregnant individuals, except for
non-conventional drugs such as cytotoxics or thrombopoietic
agents. Peripartum management involves optimising platelet
counts for delivery and procedures such as epidural analgesia.
Well-controlled ITP with adequate platelet counts is not a
contraindication to vaginal delivery and caesarean section should
only be performed based on maternal indications only. There is
also no strong association between maternal ITP and the
275
development of intracranial haemorrhage in the newborn, making

predictability of haemorrhage difficult. It is thus recommended to
monitor the infant with serial platelet counts and assessing for
intracranial bleeding postpartum. Treatment should be instituted
if the platelet counts are low or if the infant is symptomatic.
EP13.56
Placentae of preterm and idiopathic growth
restricted pregnancies: correlation with cervical
cytology and HPV detection
Devenish, C1; Samaranayaka, A2; Clow, W1;

Royds, J3; Slatter, T3; Hung, N3
1
EP13.55
Biochemical and clinical outcomes following the
use of micronised progesterone and
dydrogesterone for threatened miscarriage a
randomised controlled trial
Hui, CYY1; Siew, SJY2; Tan, TC1

1
KK Womens and Childrens Hospital, Singapore; 2Duke-NUS

Graduate Medical School, Singapore
Introduction Threatened miscarriage affects 20 to 30% of
pregnancies, although only 25% may lead to a miscarriage. There

is a growing body of evidence to suggest that the downstream
effects of progesterone mediated by progesterone induced blocking
factor (PIBF) are crucial in establishing an adequate immune
response in the early stages of successful pregnancies. Progestogens
have been shown to reduce the rate of miscarriage in women with
threatened miscarriage, but there has not been any study
comparing two of the commonly used progestogens, Micronised
Progesterone (MP) and Dydrogesterone (DYD), for this purpose.
Methods We performed an Institutional Review Board (IRB)
approved randomised controlled trial to compare the miscarriage
rates and the change in serum progesterone and serum PIBF levels
at recruitment and between days 4 and 6 of treatment in pregnant
women (with gestational age between weeks 6 to 10) presenting
with threatened miscarriage at our hospital, who have been
randomised to receive either MP or DYD.
Results There were 41 patients in the MP arm and 42 patients in
the DYD arm. The two groups were comparable in terms of age,
body mass index, gestational age, number of days of bleeding
prior to presentation, number of previous miscarriages and serum
progesterone levels at presentation. There was a significant
increase of 139.3 228.4 nmol/L (P < 0.0001) in serum
progesterone level post MP treatment but no significant increase
post DYD treatment. There were significant rises in serum PIBF
levels for MP and DYD, 1124.5 1070.1 nmol/L (P < 0.0001)
and 80.3 235.7 nmol/L (P = 0.033) respectively. There was no
significant difference in the extent of bleeding post treatment in
the two groups (P = 0.128). The miscarriage rates (20.5% in MP
group and 22% in DYD group) also did not achieve statistical
difference (P = 1.000).
Conclusion Although treatment in both groups led to varying
degrees of change in serum biochemical markers, this in turn did
not lead to a difference in the clinical outcome for the MP and
DYD groups. Evidence from our study currently does not support
one progestogen over the other in reducing the rate of miscarriage
in patients with threatened miscarriage.
276
Womens and Childrens Department, University of Otago Dunedin

School of Medicine, Dunedin, New Zealand; 2Preventive and Social
Medicine Department, University of Otago Dunedin School of
Medicine, Dunedin, New Zealand; 3Pathology Department, University
of Otago Dunedin School of Medicine, Dunedin, New Zealand
Introduction Certain viruses are well known to adversely affect
pregnancy, but scant attention has been paid to HPV. HPV DNA
has been demonstrated in the fetus, amniotic fluid and placenta,
and that it is clinically of some importance is suggested by a
higher incidence in miscarriages. Further, Zuo et al. have linked
cytological abnormalities of the cervix with preterm birth. We
asked whether the immunohistochemical (IHC) detection of HPV
L1 capsid protein in the placenta correlated with previous cervical
cytology results and adverse clinical outcomes.
Methods This was a cross-section study of 120 singleton
placentae prospectively collected for the Otago Placenta Study
comprised 36 preterm, 38 idiopathic fetal growth restricted (FGR)
and 33 normal term pregnancies. The FGR cases were < 5th
personalised growth centile determined by the Gestational
Network Calculator for NZ. Known maternal or fetal medical
conditions were excluded. Ninety of the 120 cases had complete
cytology cervical reports in the 7 years preceding the index
pregnancy. A randomly selected centrally located transmural
section of the placentae was subject to HPV antibody (cloneK1H8,
Dako, Glostop, Denmark) which reacts to a major capsid protein
of HPV-1 in HPV types 6, 11, 16, 18, 31, 33, 42, 51, 52, 56 and
58 was evaluated by two investigators blinded to the clinical
history. Cases were scored positive if either the decidua or villous
trophoblast had positive IHC detection of HPV L1.
Results Overall 64% (77/120) of the cases were positive for HPV
L 1 in the placentae using IHC. Seventy three percent of women
with a positive smear history for HPV (14/19) also had HPV L1
positive decidua, compared to 10% with negative HPV L1 IHC.
This is a statistically significant correlation chi squared (2,
N = 90) = 6.75, P = 0.03. HPV status was trichotomised as
negative, type1, type1+2. RR = 3.31 is for the type1+2 group
relative to negative group. Having HPV L1 positive villi was
statistically correlated with fetal growth restriction (RR 3.31, 95%
CI 1.885.8, P < 0.01), and prematurity (RR 1.26, CI 1.42, 6.07,
P = 0.01).
Conclusion IHC detection of HPV L1 correlates with cervical
HPV cytopathological features. Having HPV L1 in the decidua
was not associated with prematurity or FGR, however, HPV L1
detection in the placental villi correlated with adverse clinical
outcomes. We propose that HPV presence in the placenta
associates with these pregnancy complications. Further
multivariate analyses adjusting for confounding variables are
under way in a larger cohort.
EP13.57
Vaginal warts in pregnancy: two case reports
Siddique, S; Irfan, Y; Muzaffar, S

Hatta Hospital, Hatta, Dubai, United Arab Emirates
Introduction Anogenital warts are the clinical manifestation of
Human Papilloma Virus (HPV) infection, mostly caused by type 6

and 11. Condylomata acuminata (genital warts) are generally
recognised as benign proliferations of the anogenital skin and
mucosa resulting from HPV infection. This is the most common
sexually transmitted infection (STI) in UK and pregnant women
have higher rates of detectable HPV DNA as compared to non
pregnant may be due to altered immunity. During pregnancy the
warts become symptomatic, extensive and fragile and grow rapidly
due to increased vascularity. Risks associated with anogenital
warts in pregnancy are vertical transmission to neonate (1 in 80)
and extensive lesions may cause obstruction of birth canal and
excessive haemorrhage during delivery. Treatment during
pregnancy is challenging due to limited options and extensive
disease. Our two cases of vaginal warts were diagnosed during
labour and suffered with severe bleeding from warts.
Case 1 A 21-year-old primigravida, unbooked, presented at 40+
weeks of gestation with labour pains and rupture of membranes.
Small three to four papular warty lesions were present on
perineum, vaginal introitus and anus was healthy looking. Her Hb
% was 8.1 g/dL. Her first stage progressed well and outlet forceps
delivery with right mediolateral episiotomy was performed due to
prolonged second stage and fetal distress. She had 3 cm lateral
vaginal wall tear. While repairing the vagina and perineum we
noticed 3 cauliflower like warty growths on posterior and lateral
vaginal walls. Vaginal mucosa was fragile and was tearing on
handling and suturing. She lost 1 L of blood and received 2 units
of blood; postnatal recovery was uneventful.
Case 2 A 25-year-old G3P1+1, booked case, presented at 40 weeks
in labour. She was also having multiple vulvovaginal warts; and
starts bleeding before the delivery of head. She lost 1.5 L of blood
and received three units of blood. Her recovery was also
uneventful.
Conclusion Early recognition and treatment of large and extensive
anogenital warts in pregnancy is important to reduce the risk of
haemorrhage and associated complications.
EP13.58
A rare condition pemphigoid gestationis
Jain, N; Amin, T; Elbradawy, M

Department of OBGY, West Wales General Hospital, Carmarthen,
United Kingdom
Introduction Pemphigoid gestationis is a rare autoimmune
blistering disease exclusively seen in pregnancy. Incidence is 1 in

50 000 pregnancies. It is characterised by diffuse pruritic urticarial
plaques with the development of tense vesicles and bullae within
the lesions.
Case A 24-year-old primi presented with itchy fluid filled vesicles
and tense bullae on the abdomen, legs and hands at 37 weeks of
gestation subsided with topical steroid preparations and

antihistaminics. She delivered with the help of forceps at
40 weeks, 4 days. Baby born with good Apgars and had no skin
lesions. She was readmitted again with lesions in periumblical area
of abdomen, legs and hands started getting worse and she
represented in A&E on day 4/7 postnatal. She had multiple,
polymorphic raised vesicles and bullae over the abdomen, upper
and lower limbs with mucosal sparing. Large tense blisters which
increased in size. She had no other medical issues. She was
investigated thoroughly for other autoimmune conditions like
pernicious anaemia and graves disease. She also had her skin
swabs, skin biopsy, ELISA test, indirect and direct
immunoflourence study of the skin sample. The histology of skin
biopsy showed sub epidermal blister with morphological features
of pemphigoid gestationis. The direct immunofluorescence
showed positive linear basement membrane staining for IgG and
C3. She was given intravenous steroids on which she responded
very well.
Conclusion As pemphigoid gestationis is a rare condition, it is
very important to identify early with the multidisciplinary input,
as evidence shows best outcome for mother and baby with early
intervention.
EP13.59
Relapse of peri-partum cardiomyopathy among
mothers during subsequent pregnancies
Jamil, S; Mahmood, N
King Abdul Aziz Medical City for National Guard, Riyadh, Saudi
Arabia
Introduction Peri-partum cardiomyopathy (PPCM) is
characterised by the new onset of heart failure between 1 month

before and 5 months after delivery in previously healthy women.
Partial or complete recovery of cardiac function is reported in
23% to 54% of patients within 6 months. For women with history
of PPCM, the issue of safety in a subsequent pregnancy is a great
concern as subsequent pregnancy is associated with risk of relapse
of heart failure.
Methods We reviewed the charts of 18 women diagnosed to have
PPCM and had subsequent pregnancies between 1 January 2009
and 1 June 2013. Diagnostic and treatment decisions were
determined by the patient and her obstetrician and cardiologist.
Diagnostic criteria for PPCM included: (1) first appearance of
heart failure during the last month of pregnancy or within
5 months postpartum with no previous heart disease and (2)
echocardiographic evidence of systolic heart failure with an LVEF
of >0.45. Relapse of heart failure during a subsequent pregnancy
was identified as an echocardiographic decrease of LVEF to 0.45
or less, with or without symptoms of heart failure.
Results A total of 21 post-PPCM pregnancies were identified in
18 women, with 6 relapses of heart failure (28.5%). Relapse
occurred in 4 (44.4%) of the 9 pregnancies in which the LVEF
was less than 0.50 before the pregnancy, and in 2 (16.6%) of the
12 pregnancies in which the LVEF was 0.50 or more before the
pregnancy. Total of 6 pregnancies had relapse of PPCM. Out of
277
these 6 pregnancies, only 1 (25%) of 4 pregnancies where the

LVEF was less than 0.50 prior to the pregnancy, the mother
recover to her previous level of LVEF postpartum. In comparison
both pregnancies where the LVEF was 0.50 or greater prior to the
pregnancy, all the mothers recovered to their previous level of
LVEF postpartum. There were no significant differences among
the women who relapsed in mean age, mean parity, or treatment
in those who ultimately regained pre-pregnancy LVEF levels
compared with those who did not. Three of these PPCM mothers
had 2 subsequent pregnancies, one of whom experienced heart
failure relapse during the first subsequent pregnancy, but not
during the second.
Discussion Subsequent pregnancies in women with history of
PPCM are associated with a risk for recurrent and persistent
cardiac dysfunction. The risk is substantially higher in patients
with persistent LV dysfunction before subsequent pregnancy.
EP13.60
A case report of peripartum cardiomyopathy in an
asymptomatic female in her third trimester of
pregnancy
Jayawardena, GRMUGP1; Guruparan, K1;

Gamage, RS1; Ratnasiri, UDP2
1
Ward 2, 5, 8 De Zoysa Hospital for Women, Colombo, Sri Lanka;

Ward 9, 10 Castle Street Hospital for Women, Colombo, Sri Lanka
Introduction Peripartum cardiomyopathy (PPCM) is a rare but
serious complication of pregnancy with an incidence of 1: 1300 to

1:4000. Several pathogenic factors are suspected to play a role in
causation including inflammation, infection, genetics,
autoimmune and oxidative stress. Diagnosis is based on the
presence of 1) development of heart failure during the last month
of delivery or within 5 months postpartum 2) absence of
identifiable cause of heart failure 3) absence of recognisable heart
disease prior to the last month of pregnancy 4) left ventricular
dysfunction determined during echocardiography with ejection
fraction is < 45%.
Case A 39-year-old woman admitted to the obstetrics ward due
to a systolic murmur detected at 35 weeks of gestation. It was her
third pregnancy with her first pregnancy ending in a second
trimester miscarriage. Her second pregnancy 3 years prior had no
pregnancy or birth complications. Her current pregnancy was a
singleton pregnancy and she had no history of heart disease and
had no symptoms and sign of pre-eclampsia. She was not on any
medication and had no bad habits. Her investigations showed
signs of neutrophil leucocytosis: WBC 17.5 103/lL with
neutrophils at 11.74 103/lL. However she had no clinical signs of
infection. Liver and renal function assessment remained within
normal limits. Echocardiography showed left ventricular ejection
fraction of 30% with global hypokinesia and Grade 2 mitral
regurgitation. She remained asymptomatic despite the low systolic
function. Her treatment included a loop diuretic and selective b1
receptor blockers. At 37 weeks a planned caesarean section was
performed under general anaesthesia and a male baby weighing
2.1 kg was delivered.
278
Conclusion As the incidence of PPCM is low and symptoms are
non-specific or absent as in this patient. Therefore diagnosis can

often be delayed and may even be missed unless echocardiography
is performed. Thus obstetricians should be aware of PPCM and
consider it when diagnosing patients with incidental findings of
cardiac murmurs to expedite management in a potentially lethal
condition.
EP13.61
Early neonatal attendances to hospital services and
how we deliver postnatal services
Ji, C1; Sadasivan, L1; Abrahamson, E2; Sharma, S2

1
Imperial College School of Medicine, London; 2Chelsea and

Westminster Hospital NHS Foundation Trust, London, United
Kingdom
Introduction In the UK, the length of inpatient postnatal stay has
reduced significantly in the last few decades. Also, routine

professional support in the form of community midwives and
health visitor support has reduced. Evidence of the impact of
reduced length of hospital stay on mothers and the newborns is
contradictory. The effect of reduction in community/home
support is difficult to ascertain due to a large variation in the
delivery of services across geographical localities and very
differing patient demographics. This review was undertaken to
identify ways to optimise the information and support provided
to new parents.
Methods A retrospective review was undertaken of all infants
(<10 days of age), who presented to the paediatric emergency
department of a London teaching hospital during the years 2010
2013. There are approximately 5500 deliveries per annum at the
hospital.
Result During the study period, the hospital acquired full babyfriendly accreditation whilst hospital breast-feeding support team
was re-configured and dedicated staff-hours reduced. There were
686, 770, 729 and 593 emergency attendances of <10 days age
infants for the years 2010, 2011, 2012 and 2013 respectively. The
main primary diagnoses could be categorised into jaundice,
feeding problems and worried-well groups. For the years 2010
2013 respectively, neonatal jaundice represented 48%, 46%, 34%
and 35% of attendances, with approximately 75% infants
discharged after the initial assessment; feeding problems was a
cause for attendance in 28%, 24%, 25% and 20% need for
admission ranged from 24% (n = 44) in 2011 to 43% (n = 50) in
2013; worried-well group increased from 1.7% (n = 12) to 15%
(n = 90), with majority discharged home.
Conclusion Majority of infant (<10 days age) hospital emergency
attendances are for potentially preventable causes and did not
warrant a hospital admission. In seven out of 10 infants, the final
diagnosis was jaundice, feeding problems or worried-well.
Improved community support will help reduce attendance to the
emergency department, which is an inappropriate and potentially
hazardous environment for newborns. Recent UK data shows that
BF-accredited hospitals have an 8% higher breastfeeding rate at
7 days post delivery, when compared to non-accredited hospitals
but this is not sustained at 4 weeks. These findings have led to calls
for more investment in BF initiatives in primary care services. There
is a close relationship between infants with feeding difficulties and
the development or persistence of neonatal jaundice. Introducing
community BF initiatives will also work towards lowering the need
for emergency attendances and hospital admissions.
customised growth chart is a better method of choice as

compared to estimated fetal weight by fundal height.
EP13.63
Acute fatty liver in pregnancy
Kandanuru, V
EP13.62
Accuracy of assessment of fetal weight in obese
women using fundal height or estimated fetal
weight by serial scans on customised growth
charts
Kalar, N1; Kalar, MU1; Verma, K2

1
Scarborough General Hospital, York Teaching Hospitals NHS
Foundation Trust, Scarborough, United Kingdom; 2Department of
Community and Population Health Sciences, University of
Saskatchewan, Canada
Introduction Fetal growth is underestimated in obese women.
Obesity affects the accuracy of ultrasound biometry; it makes

palpation and fundal height measurement even more difficult.
This study was carried out to ascertain the accuracy of assessment
of actual fetal weight in obese women fundal height measurements
or serial scans for estimated fetal weight.
Methods This was a cross sectional study design and purposeful
sampling technique was used. It was carried out from May till
July 2014 at Scarborough General Hospital. Maternity notes from
women with a body mass index (BMI) of more than 31 patients
were collected. The sample size calculation was done by using the
World Health Organization software a = 5%, 1 b= 90,
Po = 0.10, P2 = 0.01, n = 31. Thirty-eight women were identified
with a BMI of greater than 30. Fundal height measurements in
centimeters were plotted on the customised growth charts as were
the estimated fetal weight determined by ultrasound scan(s). The
actual fetal weight after delivery was plotted on the chart and was
compared with serial fundal height measurements and scan
estimation of fetal weight. Inclusion criteria was singleton
pregnancy with women having a BMI more than 30. Exclusion
criteria was multiple pregnancies.
Results One-way ANOVA was run to determine the difference
between estimated fetal weight by scans on customised growth
chart, actual fetal weight at birth and estimated fetal weight by
fundal height. The mean estimated fetal weight on customised
growth chart by serial scans was 3762 g 1.5 SD, the mean
actual fetal weight at birth was 3691 g 1.7 SD and the mean
estimated fetal weight by fundal height was 4479 g 1.3 SD. By
post hoc test there was a non-significant difference between
estimated fetal weight on customised growth chart by serial scan
and actual fetal weight at birth, P = 0.835. There was a statistically
significant difference between actual fetal weight at birth and
estimated fetal weight by fundal height, P = 0.0001.
Conclusion The mean values of estimated fetal weight on
customised growth chart by serial scans were close to the mean
values of actual fetal weight at birth without any statistical
significance. This indicates that estimated fetal weight on
Bankstown-Lidcombe hospital, New South Wales, Australia

Introduction Acute fatty liver of pregnancy (AFLP) is a rare and
dangerous disorder. The incidence is 1 in 13 000 pregnancies. It

may be defined as acute liver failure with reduced hepatic
metabolic capacity in the absence of other causes. It usually
occurs in the third trimester and patients typically present with
vague symptoms of malaise, nausea, vomiting and abdominal
pain. AFLP has a high mortality rate of 18% for the mother and
23% for the fetus. Early diagnosis is difficult, because AFLP shares
features common with cholestasis of pregnancy, pre-eclampsia,
viral hepatitis and HELLP syndrome. The exact mechanism of
fetal-maternal interaction is not known but it is postulated that
there is increased fatty acid infiltration to the maternal circulation
leading to microvesicular steatosis and resultant liver injury. In
severe cases, there is multi-system involvement with acute renal
failure, encephalopathy, gastrointestinal bleeding, pancreatitis and
coagulopathy. Women with severe AFLP can develop preeclampsia with or without jaundice. Treatment is usually prompt
delivery with quick improvement in hepatic dysfunction. The
diagnosis of acute fatty liver of pregnancy can be aided using a
collection of signs and symptoms called the Swansea Criteria. If
six or more of the following criteria are present in the absence of
other causes, acute fatty liver of pregnancy can be made:
vomiting, abdominal pain, polydipsia/polyuria, encephalopathy,
elevated bilirubin >14 lmol/L, hypoglycaemia < 4 mmol/L,
elevated urea >340 lmol/L, leucocytosis >11 9 10/L, ascites or
bright liver on ultrasound scan, elevated transaminases (AST or
ALT) >42 IU/L, elevated ammonia >47 lmol/L, renal impairment;
creatinine >150 lmol/L, coagulopathy; prothrombin time
>14 seconds or APPT >34 seconds, and/or microvesicular steatosis
on liver biopsy. The gold standard for diagnosis is liver biopsy.
+5
Case A 25-year-old primigravida was admitted at 34 weeks of
gestation feeling unwell with ruptured membranes and meconium
stained liquor. She was not contracting and normotensive with no
pre-eclampsia symptoms, however liver function was grossly
abnormal. She underwent an emergency caesarean section and was
transferred to the Intensive Care Unit postoperation. The patient
had a full hepatitis screen which was negative and she was
managed by a multidisciplinary team. She was discharged
clinically well on day 7 with normalising LFTs. Subsequent liver
biopsy confirmed fatty liver.
Conclusion AFLP is rare and life-threatening with variable
presentation. Early diagnosis, prompt delivery and a
multidisciplinary management approach are the keys for good
outcome.
279
EP13.64
Should thyroid profile be part of universal
screening in pregnancy?
Kaushiki, D; Deepa, M
Max Hospital, Gurgaon, India
Introduction Thyroid disorders are common in pregnancy with
reported maternal and fetal adverse outcomes. A prospective study

was conducted on 100 pregnant women to check the prevalence
and associated complications of hypothyroidism in pregnancy.
Methods A prospective study was conducted at a private
antenatal clinic between 16 April 2013 to 1 March 2014 where 100
women who registered for ANC in their first trimester were
checked for FT4, TSH and anti-TPO.The cut off for subclinical
hypothyroidism was 2.5 mIU/L in first trimester.
Results The prevalence of subclinical hypothyroidism was a
staggering 22% with 1% having overt hypothyroidism when ATA
guidelines were followed for reference range of diagnosis of
subclinical hypothyroidism. They were started on levothyroxine.
The one woman with overt hypothyroidism needed dose
increments in all the three trimesters upto a maximum of 150
micrograms daily. She also had a strong family history of
hypothyroidism. 3 of the women in overt group gave a family
history of hypothyroidism. 6 out of 22 in the subclinical group
needed dose increment. One with overt disease had a late onset
gestational hypertension, while in subclinical group 2 had early
pregnancy miscarriage and one had late onset gestational
hypertension. There were no neonatal complications.
Conclusion With such high prevalence of hypothyroidism, serum
TSH should be a part of routine pregnancy screening.
in her third pregnancy. She was referred from private clinic at

33 weeks with blood-stained vomiting and pain. She was found to
have duodenal tumour and biopsy confirmed aggressive neuroendocrine tumour. She was delivered by caesarean section. She
passed away three months later. Fourth case is a 33-year-old
woman in her third pregnancy. She was 15 weeks pregnant and
was referred from local clinic with incidental finding of high white
cell count. A diagnosis of acute lymphoblastic leukaemia was
reached. Patient had termination of pregnancy for definitive
treatment. Our last two cases are for ladies with breast cancers. A
32-year-old woman in her third pregnancy was referred with lump
in breast. She was still breast feeding her 2-year-old child. She was
diagnosed to have ductal carcinoma of breast and had medical
termination of pregnancy at 8 weeks of gestation. This was
followed up by right mastectomy and axillary clearance. The next
woman is 32-year-old woman in her second pregnancy. She was
3 months postnatal, breastfeeding and had history of breast lump
in last pregnancy. A biopsy confirmed the diagnosis of invasive
duct carcinoma. She was found to be 7 weeks pregnant at that
time and had medical termination of pregnancy. She underwent
wide local excision.
Conclusion Timing of delivery and/or decision of terminating
pregnancy are critical decisions for obstetricians to maintain fetal
and maternal wellbeing. A multidisciplinary approach is the key in
management of these cases.
EP13.66
Management of quadruplet pregnancy first in
Brunei Darussalam
Khalil, A; Basheer, S; Soe, NN; Emran, E; Chong,

E; Abdullah, A
EP13.65
Malignancy in pregnancy Brunei experience 2014
Raja Isteri Penguran Anak Saleha Hospital, Bandar Seri Begawan,

Brunei Darussalam
Khalil, A; Abdullah, A; Yakoub, RH; Momin, S;

Maung, K
Introduction Multiple pregnancies and in particular higher order
Raja Isteri Penguran Anak Saleha Hospital, Bandar Seri Begawan,

Brunei Darussalam
Introduction Cancer complicating pregnancy is rare with
incidence of 0.020.1%. Breast cancer, cervical cancer, Hodgkins

disease, malignant melanoma, and leukaemias are the most
frequently diagnosed malignancies in pregnancy.
Cases We present our experience of dealing with six cases of
malignancies in pregnancy in 2014. First case was a 28-year-old
woman presenting with dry cough and dyspnoea. She was referred
to the tertiary centre at 8 weeks with pericardial effusion and
pericarditis. Investigations and pericariotomy diagnosed her with
malignant non-Hodgkin lymphoma B cell type. Her pregnancy
was terminated after thorough counselling and to start her
definitive treatment. Second case was a 29-year-old woman in her
fourth pregnancy. She presented with right breast lump and lump
in neck. An FNAC was inconclusive. Due to worsening symptoms
biopsy was done and confirmed diagnosis of non-Hodgkins
lymphoma. She was induced and delivered at 34 weeks. She had
good response to treatment. Third case was a 30-year-old woman
280
multiple pregnancies are high risk pregnancies with associated

increases in maternal, fetal and neonatal morbidity and mortality.
The incidence has been increasing especially with increase is
assisted conception. The incidence of quadruplet pregnancy is
around 1: 512 010 pregnancies.
Case We present a case of a 29-year-old woman, student, married
for 4 years in her third ongoing pregnancy with history of two
first trimester miscarriages at 6 and 4 weeks respectively. She
received medical treatment for assisted conception in Egypt that
resulted in sextuplet pregnancy, which later reduced to quadruplet
pregnancy. She had regular antenatal visits with ultrasound scan
fortnightly. She received two courses of steroids at 24 and
29 weeks for fetal lung maturity. At 29 weeks she developed preeclampsia and was admitted for feto-maternal surveillance. She
had paediatric counselling and visit to special care baby unit
(SCBU). She had preterm pre-labour rupture of membranes at
31+1 weeks followed by preterm labour. An emergency caesearean
section was carried out with full paediatric intensive care input.
Consultants from obstetrics, paediatrics and anaesthetics attended
delivery. She delivered two male and two female babies weighing
between 945 to 1400 g. The babies were sent to SCBU and are
doing very well. Postanatally, on day 1, patient had cardiac arrest.
She was diagnosed to have postpartum cardiomyopathy which was
managed by a multidisciplinary team (cardiologists, physicians
and obstetricians) first in SICU (surgical intensive care unit) and
later on in CCU (coronary care unit). She was discharged on 20th
post operation day in good health condition with an advice to
follow-up.
Conclusion This case demonstrates how a high risk pregnancy was
managed successfully by a multidisciplinary team work approach.
EP13.67
Retrospective analysis of maternal and neonatal
outcomes following the introduction of metformin
in the treatment of gestational diabetes
Knight, LJ; Page, J; Green, E

Derriford Hospital, Plymouth, United Kingdom
delivered before 37 weeks gestation with no caesarean sections in

this group.
Conclusion Our results with metformin have so far shown
positive fetal and maternal outcomes, fewer caesarean section
deliveries (particularly category I) and neonatal macrosomia. This
analysis shows metformin to be a favourable alternative to insulin
in terms of cost-effectiveness for healthcare service and provision
and maternal acceptability. An interesting extension to this study
will be the comparative incidence of neonatal hypoglycaemia in
the metformin compared with insulin group, the results of which
will be available in due course.
EP13.68
Echocardiography in pregnancy
Lalji, A1,2,3,4; Khiroya, N1,3; Lalji, M4,5; Jayasinghe,

R1,4
1
Gold Coast University Hospital, Gold Coast, Queensland, Australia;

St Vincents Hospital, Melbourne, Victoria, Australia; 3Bond
University, Gold Coast, Queensland, Australia; 4Griffith University,
Gold Coast, Queensland, Australia; 5Princess Alexandra Hospital,
Brisbane, Queensland, Australia
2
Introduction Multiple, ground-breaking studies in the last
10 years have demonstrated the effects of maternal hyperglycaemia

on poor fetal and maternal outcomes during pregnancy and in the
peripartum period. The multi-national Hyperglycaemia and
Pregnancy Outcome (HAPO) study in 2008 demonstrated how
fetal growth can be modified by glucose-lowering therapies, with
diet and lifestyle intervention often being successful. The
Australian Carbohydrate Intolerance Study in Pregnant Women
(ACHOIS) established that treatment of gestational diabetes with
insulin improved pregnancy outcomes. Subsequent research has
demonstrated that treatment with metformin results in similar
outcomes to initial insulin treatment in gestational diabetes.
Metformin was first advocated as a treatment for Gestational
Diabetes by the National Institute for Clinical Excellence (NICE)
in 2008.
Methods Here we report the maternal and neonatal outcomes of
243 women with gestational diabetes managed with insulin-alone
(pre-metformin) and with metformin alone following its
introduction within our unit in 2011. The maternal outcomes
recorded were course of labour onset, gestation and mode of
delivery. Fetal outcomes include the fetal weight, cord gas results,
Apgar scores and whether an admission to Neonatal Intensive
Care (NICU) was needed.
Results Overall there were a higher proportion of women
undergoing caesarean section (CS) in the insulin only group
compared with the metformin group (46% versus 26%). Category
I CS was much lower in the metformin group (<1% versus 20%).
Instrumental deliveries were equivocal; 14% and 11% for insulin
and metformin groups respectively. A higher proportion of
macrosomic babies (>4.5 kg) were noted in the insulin group
(3.6% versus 0%). One of these babies delivered vaginally, the
others by planned CS. There were no NICU admissions and all
had an Apgar score of >9 at 5 min. Admissions to NICU were
equivocal in each group (7%). Of note 62% of these patients
within the insulin group delivered prematurely (<37 weeks) and
50% underwent a category I CS. In the metformin group 50%
Introduction Pregnancy involves a number of physiological
changes including reversible adaptations to the cardiovascular

system. Haemodynamic changes include blood volume expansion,
increased maternal heart rate, preload, cardiac output, ventricular
volumes and left atrial size with an overall decrease in systemic
vascular resistance and systemic blood pressure. Echocardiography
is a useful, safe, accurate and non-invasive technique allowing
clinicians to investigate normal maternal cardiac morphology and
functional changes in pregnancy. Perhaps echocardiography
should be integrated into routine clinical practice to develop a
better understanding of the normal cardiac changes that occur
throughout pregnancy and furthermore to detect abnormal
changes during pregnancy.
Methods A literature review was conducted to assess the changes
that occur in cardiovascular morphology and function during
normal pregnancy as shown on echocardiography. We conducted
searches of Pubmed, Cochrane and Medline for articles published
between 1 January 2000 and 30 October 2013. Studies published
in English were selected for inclusion in this review as were
additional articles identified from bibliographies.
Results The main cardiovascular changes that occur during
normal pregnancy include a decrease in peripheral vascular
resistance and an increase in stroke volume and cardiac output.
This is mainly due to an increase in preload and a decrease in
after-load, resulting in left ventricular remodelling. Cardiac
output, ventricular volumes, Ventricular chamber size and left
atrial size have all been shown to increase as early as in the fifth
week of gestation. Left atrial volume, left ventricular diastolic
volume, left ventricular mass, the right atrium and ventricular
diastolic area also increased throughout pregnancy. LVEF remains
unchanged with a large decrease in longitudinal deformation
during the late stages of pregnancy. The left ventricular wall
281
thickness, left ventricular mass and the diameters of all chambers

increase during pregnancy.
Conclusion To date the range of echocardiography parameters
during normal pregnancy have not been well defined. There are
no current guidelines in relation to the reference ranges of
echocardiography parameters, during normal pregnancy, using
current echocardiography imaging modalities. The lack of clinical
guidelines makes it difficult for clinicians to correctly differentiate
between normal cardiac changes in pregnancy and pathological
changes that may need immediate management. A comprehensive
understanding of normal increase in parameters during pregnancy
is essential to understand and more importantly to detect
abnormal parameters during pregnancy.
as diabetes and hypertensive disorders for stillbirth was low, likely

due to the fetal surveillance that is undertaken is such cases. SGA
was seen in nearly three fourths of cases, but was picked up prior
to the unfortunate event only in a minority. Therefore, more
emphasis should be placed on detection of small babies, which
may be able to improve the final outcome.
EP13.70
Risk assessment for small-for-gestational-age
babies: could it make a difference?
Lia, C; Nirmal, D
Norwich and Norfolk University Hospital (NNUH), Norwich, United
Kingdom
EP13.69
Unexpected stillbirth: can we do more to prevent
them?
Lia, C; Nirmal, D
Norwich and Norfolk University Hospital, Norwich, United Kingdom
Introduction Unexpected stillbirth is a distressing situation for
both parents and clinicians alike. The key question coming to the
mind of any obstetrician met with this situation is Could I have
prevented this? An understanding of the main reasons for
stillbirth would enable us to identify women who are at a risk of
stillbirth. Comorbidities such as diabetes and pregnancy induced
hypertension and post-maturity are known causes for stillbirth
though a majority of cases are unexpected. Growth restriction
often precedes fetal demise and detection of such is an important
aspect of antenatal care. A retrospective data analyses was carried
out to identify main factors associated with stillbirths.
Methods The maternal health records of women who had had a
stillbirth in the year 2013 at the Norwich and Norfolk University
Hospital were reviewed and analysed. The stillbirths above 24
completed weeks of gestation and above or equal to 500 g were
included whilst those with lethal congenital anomalies were
excluded. Pregnancy complications that can predispose them to a
higher risk of stillbirth were recoded.
Results There were 18 stillbirths, among 5917 deliveries that
fulfilled the criteria. Nine of them were receiving consultant led
care for risks identified while nine (50%) were midwifery led care
till the time of the calamitous event. 13 (72%) stillbirths occurred
before 37 weeks of gestation and none were beyond 42 weeks of
gestation. 28% of women were known to have medical
complications in their pregnancy, which included two women
with hypertensive disorders. None of the mothers were diabetic.
One woman had a history of recurrent antepartum haemorrhage
whilst another presented at admission with profuse bleeding. In
13 of the 18 (72%) fetuses the birthweight was <10th centile for
that gestation. However, only one of them was detected prior to
the event. The pickup rate with SFH measurement, using the
customised GROW charts, was therefore only 8%.
Conclusion Unexpected stillbirth rate in this population was
around 2.8 per 1000 births. Half of them occurred in women with
a low risk pregnancy. The contribution of medical disorders such
282
Introduction Suboptimal fetal growth, known as small for
gestational age (SGA), is a risk factor for stillbirths. Nearly 40% of

stillbirth fetuses recorded in the UK would measure small.
However, our ability to detect small babies is limited. While
customised GROW charts provide the best tool for comparison,
clinical examination of symphysio-fundal height measurement
sometimes fails to detect SGA. Since, ultrasound scans for growth
cannot be offered to every woman, new RCOG guidelines
recommend use of a risk assessment tool to identify the at-risk
pregnancies which should be offered closer fetal surveillance. We
performed a retrospective risk assessment on all patients who had
an unexpected stillbirth in 2013, using this RCOG assessment tool
to assess the detection rate.
Methods Medical records of stillbirths that were managed at
NNUH in 2013 were reviewed. 18 were included in the analysis
after excluding those less than 24 completed weeks and/or 500 g
and those with lethal congenital anomalies. The presence of SGA
in this group and our rate of detection were determined. The risk
factors described in the RCOG clinical guideline (Greentop 31)
were noted. We looked at this cohort retrospectively and analysed
if application of the RCOG assessment tool would have identified
SGA babies.
Results SGA was noted in 13 (72%) of the stillbirths. 5 of these
did not have a completed GROW chart despite the fact that this
should be generated with the first scan. SGA was detected in only
2 of the 13 (15%) women prior to the stillbirth. 7 out of 18
women had one or more major risk factors warranting serial scans
and this included 6 of the SGA babies. Another woman, who had
a SGA baby, had 3 minor risk factors warranting UA Doppler
studies. All but one woman had at least one minor risk factor.
Nulliparity, raised BMI and smoking were the common risk
factors seen. A previous SGA baby was noted in 3 women but had
not been flagged antenatally in 2 of them.
Conclusion SGA precedes the majority of our stillbirths but our
ability to detect it is limited. Use of the RCOG recommended risk
assessment tool would have allowed us to offer further fetal
surveillance to 8 of the stillbirths (55%) which could potentially
have detected 7 SGA babies. However, if such interventions would
have prevented the stillbirth is still debatable.
EP13.71
A comparative study between waterbirths and
conventional vaginal deliveries in an obstetricianled unit in Singapore
EP13.72
Analysis of trends of caesarean section by the
Robson Ten Group Classification
Lim, KMX; Tong, PSY; Chong, YS

National University Hospital, Singapore
Department of Obstetrics and Gynaecology, National University

Hospital, Singapore
Introduction In April 2014, the ACOG released a committee
Introduction Caesarean section (CS) rates are rising worldwide.
opinion on waterbirths, citing rare but serious complications

associated with immersion in water during labour and delivery.
On the premise that waterbirths have not been shown any clear
benefit to mother or baby, the ACOG recommended that
immersion in water during delivery be conducted only as part of
a clinical trial. Contrasted by the RCOG recommendation that
water immersion should be made available to labouring women
with uncomplicated pregnancies, the topic of waterbirth remains
controversial. As the pioneering hospital for waterbirths in
Singapore since 2006, the National University Hospital has
conducted 186 waterbirths to date. Unique to our centre is the
fact that these births are led by a consultant obstetrician, in the
setting of continuous intrapartum fetal monitoring, and one-toone midwifery care. To date, no study has been performed in an
Asian population evaluating waterbirth, and most studies have
evaluated water immersion as a form of analgesia during the first
stage of labour. This study aimed to assess if water immersion in
the second stage of labour is associated with increased rates of
adverse maternal and fetal outcomes compared to conventional
vaginal deliveries at our hospital.
Methods A retrospective review of women who delivered
underwater at our centre between 2010 and 2013 was conducted.
Outcomes of interest were estimated blood loss, 3rd or 4th degree
tears, postpartum complications, neonatal Apgars, and admissions
to neonatal intensive care unit. These were compared against a
matched control group of women who had conventional vaginal
deliveries within no more than 1 month of the index case.
Results A total of 236 women were included in the study (118
women in each arm). Mean maternal age was 33.5 years. There
was no significant difference in estimated blood loss (P = 0.99)
and rates of postpartum haemorrhage between groups. There were
no cases of maternal infection, third or fourth degree perineal
tears, or adverse neonatal outcomes in either group. Three cases
of retained placenta were reported in the waterbirth group
(0.03%), but did not reach statistical significance.
Conclusion Waterbirth at our centre does not appear to be
associated with an increased incidence of adverse neonatal and
maternal outcomes, and should continue to be offered to a group
of carefully selected women, in an obstetrician-led setting with
good midwifery support. Room exists for a larger prospective
study evaluating water immersion in the second stage of labour,
as waterbirths continue to be increasingly accepted in Asia.
The Robson Ten Group Classification System (RTGCS) classifies

all CS into 10 groups based on various obstetric factors and
provides a useful framework for auditing CS trends. The aims of
the study were to employ the RTGCS to analyse current trend of
CS rates in 20132014 and compare it to the trends observed in
the previous decade (20002010) in order to identify the main
contributors to the rising CS rates at a tertiary teaching hospital
serving a multiracial Asian population.
Methods The RTGCS was used to classify all women who
delivered over a 1-year period from September 2013 to August
2014 according to parity, any previous caesarean, singleton or
multiple pregnancy, fetal presentation, gestational age and mode/
onset of labour/delivery. Data were obtained from the delivery
suite electronic database. The 1-year data was compared to the
previously published data for 20002010.
Results The overall CS rate continued to rise from 19.9% in 2000
to 29.6% in 2010 and 31.8% in 2014. Group 5 (multiparous
women with previous caesarean and singleton cephalic term
pregnancy) remained the largest contributor, with increasing
share, to the overall CS rate (40.3% of all CS in 20132014 and
27% in 20002010). Group 2 (nulliparous women with singleton
cephalic term pregnancy either induced or caesarean section
before labour) has taken over Group 1 (nulliparous women with
singleton cephalic term pregnancy in spontaneous labour) as the
second largest contributor to the overall CS rate [Group 2
(22.7%) and Group 1 (10.6%) of all CS in 20132014; Group 2
(8.5%) and Group 1 (21.2%) of all CS in 20002010]. Although
the CS rates within each individual RTGCS group have not
increased significantly, the proportions of all deliveries in Group 5
and Group 2 have risen by 2-fold (8.9% to 16.8%) and 3-fold
(4.2% to 15.8%), respectively. The CS rates in these 2 groups
remained high at 76.7% (Group 5) and 45.8% (Group 2).
Conclusion The increase in CS rate is attributed mainly to the
increasing proportion of deliveries in Groups 2 and 5. This
implies that future efforts to curb overall CS rates should focus on
women with previous caesarean and nulliparious women with
singleton cephalic term pregnancy undergoing induction of labour
or caesarean section before labour. The RTGCS serves to highlight
cohorts who are the main contributors to the rising CS rates, thus
enabling targeted interventions aimed to curb this trend.
Lim, LM; Ching, SY; Lim, MY; Biswas, A; Chi, C
283
EP13.73
Pathogenetic aspects of disturbance formation in
the haemostasis system in pregnant women
depending on the fetal gender
EP13.74
Pregnancy in women with artificial heart valves:
outcomes from the registry of pregnancy and
cardiovascular disease (ROPAC)
Botasheva, TL; Linde, VA; Kapustin, EA; Erofeev,

NP; Kaushanskaya, LV
Parsonage, W1; Hall, R2; Johnson, M3; Lust, K1;

Fagermo, N1; Roos-Hesselink, J4
Rostov Scientific Research Institute of Obstetrics and Paediatrics,

Rostov-on-Don, Russia
Introduction The study of disturbances in the coagulation system
of pregnant women remains relevant because of their pathogenetic

involvement during placental insufficiency formation, fetal
growth inhibition, gestos is of the second half of pregnancy, etc.
The fetal gender is a genetically determined factor, which
influences the character of gestation course and the outcome of
labour; however, peculiarities of womens coagulation system
depending on the fetal gender have not been studied yet.
Methods With the aim of studying peculiarities of the
haemostasis system we examined 360 women over the time of the
1st, 2nd and 3rd trimesters of physiological pregnancy: there were
187 pregnant women with male fetuses and 173 pregnant women
with female fetuses. Thrombin time, prothrombin time,
prothrombin index, international normalised ratio and activated
partial thromboplastin time were estimated; soluble fibrin
monomer complexes, fibrinogen, clotting time, D-dimer level,
platelet count and hematocrit volume were determined.
Results Regardless of the duration of gestation, some components
of the haemostasis system were very active in mothers of boys.
This activity manifested itself in the statistically significant higher
values of D-dimer in the 2nd and 3rd trimesters (by 32.9% and
48.5% correspondingly), prothrombin time in the 1st, 2nd and
3rd trimesters (by 10.2%, 2.8% and 8.8% correspondingly) and
platelets in the 3rd trimester (by 6.6%). According to the results
of the correlation analysis (medium strong correlations and strong
correlations r > 0.6; r > 0.8) it was revealed that in mothers of
male fetuses the interconnections between the indices of
prothrombin and thrombin time, the level of fibrinogen became
stronger, while in mothers of girls the inverse relationship was
determined. During the estimation of parameters of the fetal
biophysical profile it appeared that the indices were better (812
points) mainly in mothers of girls (92%) as compared with
mothers of boys (83%). It was registered that the most favourable
outcomes of labour and normal state of newly born babies were
1.8 times more often in mothers of girls, while mothers of boys
had birth difficulty in a larger number of cases (44%).
Conclusion The higher activity and the integration of vascularthrombocytic and plasmatic components of the haemostasis
system increasing over time in the mothers of boys makes it
possible to consider the male fetal gender as an additional risk
factor of dysfunctional disturbance appearance in the coagulation
system in the 2nd and 3rd trimesters of pregnancy.
284
Royal Brisbane and Womens Hospital, Herston, Australia; 2Norwich

Medical School, Norwich, United Kingdom; 3Imperial College School
of Medicine, London, United Kingdom; 4Erasmus Medical Centre,
Rotterdam, The Netherlands
Introduction The Registry of Pregnancy and Cardiovascular
Disease (ROPAC) is a global initiative of the European Society of

Cardiology and is the largest registry of its kind. The registry aims
to better define the maternal-fetal risks associated with the
presence of maternal structural heart disease.
Methods ROPAC was established in 2007. Investigational centres
are encouraged to prospectively recruit consecutive patients with
structural heart disease diagnosed during pregnancy or the
puerperium. Demographic data, clinical details and materno-fetal
outcomes are recorded using an online case report form. For the
purpose of this report the cohort includes all patients with
artificial heart valves (both bioprosthetic and mechanical) and
includes maternal outcomes up to 7 days following the end of
pregnancy.
Results Two-thousand nine-hundred and sixty-six completed
pregnancies from patients attending 77 centres in 50 countries
were considered. Three hundred and forty-six pregnancies
occurred in patients with an artificial heart valve (212 mechanical
and 134 bioprosthetic). Maternal mortality was increased in
patients with artificial heart valves (1.4% mechanical, 1.5%
bioprosthetic compared to 0.2% of other pregnancies). Mechanical
heart valves were associated with an increased risk of thrombotic
events (6.1%), haemorrhagic events (23%), miscarriage (15.6%)
and fetal mortality (2.8%) all of which were significantly higher
(P < 0.05) than in patients without artificial valves. The rate of
live birth was also significantly (P < 0.001) lower in patients with
mechanical, but not bioprosthetic, heart valves when compared to
patients without artificial valves. There was considerable variability
in the anticoagulant regimen used in the management of patients
with mechanical heart valves.
Conclusion Artificial heart valves are associated substantial
materno-fetal morbidity and mortality. These risks are
significantly increased in the presence of a mechanical heart valve
and are likely to be partly related to the need for therapeutic
anticoagulation in this situation. ROPAC is the largest registry
concerning the effects of maternal heart disease and the data
relating to the management of artificial heart valves should help
to improve risk stratification and inform management of the
complex patient cohort.
EP13.75
A retrospective analysis of the peri-partum
management of therapeutic anticoagulation in
pregnant women with venous thromboembolism
and mechanical heart valves
1
2,3
Allen, J ; Petrie, S ; Callaway, L ; Barrett, H

Fagermo, N2; Wolski, P2; Lust, K2
2,3
EP13.76
Pregnancy outcome in women with heart disease
a single centre joint obstetric-medicine/cardiac
multidisciplinary service experience
Lust, K1; Lamanna, A2; Kimble, R3; Fagermo, N1;

Parsonage, W2
1
Prince Charles Hospital, Brisbane, Queensland; Royal Brisbane and

Womens Hospital, Brisbane, Queensland; 3University of Queensland,
Brisbane, Queensland
Department of Obstetric Medicine, Royal Brisbane and Womens

Hospital, Australia; 2Department of Cardiology, Royal Brisbane and
Womens Hospital, Australia; 3Maternity Services, Royal Brisbane and
Womens Hospital, Australia
Introduction An increasing number of women require therapeutic
Introduction In Australia cardiac disease is the single most
anticoagulation during their pregnancy and the immediate postpartum. There is little clinical data in the literature to guide the
management of therapeutic anticoagulation during this period.
We proceeded to audit the choice, management and
complications of therapeutic anticoagulation in the peri- and
postpartum periods at a tertiary obstetric medicine centre.
Methods A retrospective chart review of pregnancy women over a
5 year period (20072011) who required therapeutic
anticoagulation for a venous thromboembolic event (VTE) or a
mechanical heart valve (MHV) during their delivery and/or in the
2 weeks postpartum.
Results 45 patients were identified who required anticoagulation
in the peri-partum or 2 weeks immediately postpartum. The
majority of these patients required anticoagulation for VTE,
although three patients had MHV. 32 women required therapeutic
anticoagulation at the time of delivery, with 23 patients converted
to intravenous unfractionated heparin (UFH) from low-molecular
weight heparin (LMWH) at the time of delivery. 30 women were
initially given IV UFH post-delivery, whilst the remainder were
started on LMWH. 26.6% of women who were therapeutically
anticoagulated over the peri-partum and immediate postpartum
period developed a clinically significant haemorrhagic
complication. 13 women had a postpartum thrombosis; only two
of these were anticoagulated prior to delivery.
Conclusion In our cohort, there was a high incidence of
haemorrhage with a low risk of thrombosis. We have reported a
higher risk of haemorrhage than previous studies. Possible reasons
for this are the inclusion of prophylactic anticoagulation and
unclear follow-up times in previous studies; and a more liberal
definition of major haemorrhage in our review. The risk of
recurrent thrombosis is very low, in line with previously published
data. Current cardiac and obstetric guidelines are not prescriptive
in the peri and postpartum management of anticoagulation, and,
although there are new fixed dose regimens published in the
literature these are yet to be validated with larger trials. We
believe that further research is required in this area.
common cause of maternal deaths accounting for 15% of all

maternal deaths in Australia. We describe the experience of a
multidisciplinary obstetric-cardiology clinic at a single tertiary
hospital established to address the lack of a strategic approach to
cardiac disease in pregnancy.
Methods A retrospective review was undertaken on women
referred to the obstetric-cardiology service between April 2008 and
June 2014 (74 months) at the Royal Brisbane and Womens
Hospital.
Results Data is available at the time of the abstract on 138
pregnancies in 131 women until June 2012. Average age of women
at birth 28.5 6 years. 4 women were primiparous, average
gravidity 2.2 1.5 and parity 0.9 1.2. Congenital heart diseases
were the most common reason for referral 45%, followed by
arrhythmia 17%, cardiomyopathy14%, acquired valvular disease
13% and coronary disease 5%. There were no maternal deaths.
There were 36 antepartum hospital admissions for cardiac
indications in 28 confinements. The most common indications for
admission were arrhythmia 42%, heart failure 44%, and acute
coronary ischaemia 8%. 77% of women have cardiac pathologies
greater than WHO risk category 1 which is predictive of maternal
cardiac complications during pregnancy. Of the 138 confinements
there were 140 live births and one stillbirth. Caesarean sections were
performed in 46%, 7 cases for cardiac indications. Mean gestation at
delivery 38 weeks. The most common obstetric complications of the
confinements were postpartum haemorrhage 17%, premature
rupture of membranes 14%, intra-uterine growth restriction
(IUGR) 7%, threatened premature labour 4%. Neonatal
complications occurred in 21% of confinements, the most common
being prematurity 19% followed by low birthweight 13%, small for
gestation 6% and hyaline membrane disease 5%. Data will be
updated for the additional patients from June 2012June 2014.
Conclusion Congenital heart diseases represent the single most
common indication for referral as more women with congenital
heart disease reach childbearing age. Maternal cardiac
complications and hospitalisation are common. Neonatal risk is
also increased, mostly due to prematurity and associated
complications. IUGR and low birthweight were common, possible
contributing factors will be explored.
285
EP13.77
Renal tubular acidosis in pregnancy presenting as
facial spasm: a case report
Macalintal, J; Tan, E
Department of Obstetrics and Gynaecology, St Lukes Medical Centre,
E. Rodriguez Sr. Avenue, Quezon City, Philippines
Introduction Renal tubular acidosis (RTA) refers to a group of
disorders in which metabolic acidosis develops because of defects

in the ability of the renal tubules to perform the normal functions
required to maintain acidbase balance. It is rarely encountered in
pregnancy, and when it does, it is expected to be worse than in
the general population. Undiagnosed cases of maternal systemic
acidosis have multiple adverse pregnancy outcomes such as
recurrent pregnancy loss, gestational hypertension, fetal distress;
and abnormalities in fetal growth and development.
Case We report a case of a 31-year-old gravida 1 para 0 who
presented at 34 weeks age of gestation with facial spasm and
preterm labour. Work-up showed persistent hypokalemia despite
potassium supplementation. Further investigation was done and
the patient was subsequently diagnosed as a case of distal renal
tubular acidosis. She was then managed accordingly, eventually
entered labour and delivered to a healthy infant, with no
complications noted.
Conclusion Persistent hypokalemia despite adequate medical
management should prompt further search for possible etiologies.
Our patient followed a meticulous diagnostic evaluation, and was
eventually diagnosed with distal RTA. Possible adverse maternal
and fetal effects were cited, which may have been inevitable had
the diagnosis not been made.
EP13.78
Anticoagulation in pregnancy after mechanical
mitral valve replacement
Mahmood, N; Jamil, S
King Abdul Aziz Medical City for National Guard, Riyadh, Saudi
Arabia
Introduction Management of pregnancy in women who had
mechanical heart valve replacements is one of difficult challenges

that clinicians caring for pregnant women face. Therapeutic
anticoagulation has to be continued throughout pregnancy to
reduce the risk of thromboembolic complications. The prevalence
of rheumatic heart disease is high in Saudi Arabia and also the
parity rate is high as well.
Methods We performed retrospective chart review on 37
pregnancies in 26 women who had previous mechanical mitral
valve replacement. Low molecular weight heparin (LMWH) was
continued for the entire duration in 8 pregnancies and monitored
by anti-factor Xa assay. In the rest of 29 pregnancies anticoagulation was continued with heparin in first 12 weeks then
switched to warfarin for up to 48 hours before delivery where it
was switched back to heparin for 24 hours after a delivery.
Pregnancy outcome including feto-maternal mortality and
morbidity and prosthetic valve related complications were assessed.
286
Results Overall, there were 25 live births (67.5%), 1 stillbirths
(2.7%), 10 miscarriages (27%) and 1 neonatal death after preterm

delivery (2.7%)). There were more live births among patients
administered heparin after a diagnosis of pregnancy and later
changed to warfarin than among those administered low
molecular weight heparin throughout the pregnancy. Late
postpartum haemorrhage occurred in 1 patient who was on
LMWH throughout the pregnancy. No embolic complication or
valve dysfunction was observed in any women on warfarin while
one patient developed valve thrombosis in LMWH.
Discussion Warfarin use from the second trimester in
combination anticoagulation regimens has no added risk of an
adverse perinatal outcome when compared to LMWH use
throughout the pregnancy. The use of LMWH for long duration
may lead to thrombotic complications for the mechanical valves.
EP13.79
Thrombotic complications of enoxaparin use in
patients with mechanical heart valves during
pregnancy
Maindiratta, B; Paul, K; Barclay, M

Liverpool Hospital, New South Wales, Australia
Introduction Managing anticoagulation for women with
prosthetic heart valves during pregnancy can be complex and

problematic. Warfarin throughout pregnancy; enoxaparin in 1st
and 3rd trimester with warfarin during 2nd trimester; and
enoxaparin with low dose aspirin throughout pregnancy are the
most widely used regimens, but each presents some risk to mother
or fetus. We are discussing 2 such cases where patients with
mechanical heart valves on enoxaparin had thrombotic
complications during pregnancy.
Cases A 35-year-old primigravida with a past history of ASD
repair and mechanical mitral valve replacement due to MV
prolapse had an IVF pregnancy and was changed from warfarin to
enoxaparin pre-pregnancy. Factor Xa levels were not checked. At
5 weeks of gestation, the patient developed acute pulmonary
edema secondary to valve thrombosis. She underwent
thrombectomy and was on heparin infusion while in hospital.
Valve thrombosis recurred a month later and hence she
underwent MV replacement with bioprosthesis considering her
prothrombotic state. She then was on aspirin and metoprolol
during pregnancy and had an emergency caesarean section for
failure to progress at term. A 28-year-old primigravida, with past
history of rheumatic heart disease and patent ductus arteriosus
had a mechanical mitral valve replacement and pacemaker
insertion for complete heart block post surgery. She was switched
from warfarin to enoxaparin at 23 weeks of gestation. She then
went on to develop an ischaemic left leg due to an embolus for
which she had an embolectomy. She then developed compartment
syndrome and had a fasciotomy. During her hospital stay she was
on heparin infusion. She then had another thrombus in her limb
and repeat embolectomy. After long discussions with the patient
by the obstetrics team she agreed to have warfarin by which time
she was close to 14 weeks gestation. Four days after starting
warfarin she developed vaginal bleeding and ended up having a

miscarriage.
Conclusion The choice of anticoagulant for women with
mechanical heart valves during pregnancy is difficult. It has to be
a balance between maternal and fetal risks. Women should be
counselled adequately prior to pregnancy to be able to make an
informed decision as to which anticoagulant regimen is most
acceptable to them. Warfarin has well documented but rare
teratogenic effects on the fetus but yields the lowest risk of
thrombosis; whereas enoxaparin has minimal fetal risks but has a
higher chance of maternal thrombotic complications. Use of a
multidisciplinary team to coordinate care from pre-pregnancy
through to the postpartum period is optimal.
EP13.80
Gestational diabetes: can women managed with
dietary advice and metformin only be considered
low risk and, if so, can they be managed in the
community?
Mustafa, R1; Mammen, C2; Bhatnagar, D3

1
Royal Oldham Hospital, Oldham, United Kingdom; 2Women and
Childrens Unit, Royal Oldham Hospital, Oldham, United Kingdom;
3
Diabetes Centre, Royal Oldham Hospital, Oldham, United Kingdom
Introduction Glucose intolerance with onset or first recognition
during pregnancy is known as gestational diabetes. The combined

obstetrics and diabetes clinic at Royal Oldham Hospital is
currently experiencing a high number of referrals. Average
number of patients in 1 day can be between 50 and 60 and some
women wait longer than 3 hours for their appointments. We
propose that women treated with dietary advice and metformin
only should be considered as low risk, and those with insulin
included in their management should be considered to be high
risk. The aim of this study is to redesign the flow of women
through the gestational diabetes services, with dedicated care for
high risk women under consultant based secondary care, and
community based care for low risk women. This will reduce
waiting times and will allow community staff to be trained in the
management of low risk women with gestational diabetes.
Methods A retrospective cohort study of all women who had
been seen in the diabetes in pregnancy clinic between January
2012 and August 2013 were analysed to look at how they were
managed and what complications, if any, occurred through their
pregnancies. This will allow us to look for any correlation between
low and high risk patients and complications that occurred in
both groups, and determine if these differences are statistically
significant.
Results Of the 312 women included in the study, 81 were given
dietary advice only, 107 had dietary advice plus metformin, 97
were given dietary advice, metformin and insulin and 27 were
given dietary advice plus insulin. We found that there was no
significant difference when using a 95% confidence interval in the
number of emergency caesarean sections performed
(P = 0.076544), prematurity (P = 0.585476), shoulder dystocia
(P = 0.112649) and perinatal deaths (P = 0.390783) between those
who were managed with dietary advice and dietary advice plus
metformin, and those managed with dietary advice, metformin
and insulin and dietary advice plus insulin.
Conclusion We conclude that women who have been managed
with dietary advice and metformin only can be considered lower
risk than those who have insulin included in their management.
As women managed with insulin are at no higher risk of
developing complications associated with gestational diabetes, we
propose that management of those managed with dietary advice
and metformin only could be managed by specialist midwives and
primary care practitioners, with the appropriate training, in the
community setting.
EP13.81
Preventing post-caesarean infection: a systematic
review to establish recommended practice
Martin, E1; Beckmann, M2; Graves, N1

1
Australian Centre for Health Services Innovation, Queensland
University of Technology, Brisbane, Queensland, Australia; 2Mater
Health Services, Brisbane, Queensland, Australia
Introduction There is currently no guideline on the most effective
strategies to prevent surgical site infection (SSI) following

caesarean section. There is little agreement across existing clinical
guidelines for strategies such as skin asepsis, surgical technique
and even administration of antibiotic prophylaxis. In addition,
systematic reviews and meta-analysis have produced inconsistent
results that sometimes conflict with clinical guidelines. In 2012,
14% of Queensland mothers reported that their caesarean wound
became infected, and nationally the infection rate is estimated to
be 9%. For the mother, an infection results in pain and delay in
returning to normal function and may compromise bonding with
baby and establishment of breastfeeding, during an already
challenging time. Consequences of SSI for the health service can
be additional use of staff time, pharmaceutical and health
supplies, and increased length of stay or readmission to hospital,
potentially forgoing a hospital bed for another patient. This study
aimed to identify the most effective strategies to prevent postcaesarean SSI in order to establish recommended practice for
Australian hospitals.
Methods A systematic review of literature reviews and metaanalyses published from 2004 to 2014 was conducted. Seven
databases were searched using the terms caesarean AND
infection or endometritis. Existing systematic reviews and metaanalyses were examined and then updated by extending the search
periods. Studies were assessed for quality and effectiveness data
was extracted and compared.
Results After screening the titles and abstracts, 49 studies were
included in the systematic review. These systematic reviews and
meta-analyses examined the effectiveness of 45 individual infection
prevention strategies for reducing post-caesarean SSI. Important
strategies appropriate for both emergency and elective caesarean
section included administering antibiotic prophylaxis pre-incision,
vaginal cleansing, no pubic hair removal from 4 weeks before
estimated date of delivery, and adopting a patient safety checklist.
287
Conclusion The results of this systematic review will be compared
to strategies Australian Obstetricians and Diplomates are currently

employing, enabling gaps in clinical practice to be identified. The
cost-effectiveness of moving from current practice to a goldstandard infection prevention approach will also be evaluated.
Post-caesarean infection is an avoidable complication that is
under-reported through hospital surveillance systems. Identifying
key infection prevention strategies and updating Australias
clinical guidelines will contribute to improving practice and
reducing infections following caesarean section.
EP13.82
Incidence and risk factors for surgical site
infections following caesarean section in
Queensland
Martin, E1; Beckmann, M2; Graves, N1
closer to 9% as has been observed by research in the UK. As high

body mass index is a significant risk factor for infection, which
correlates with other international research findings, infection
prevention strategies need to target these women. Health services
should also discuss the feasibility of including caesarean section in
regular surgical site infection monitoring and surveillance.
Understanding infection rates that incorporate post-discharge
infection will assist in the evaluation of infection control efforts in
obstetric practice.
EP13.83
Pheochromocytoma recurrence in pregnancy:
challenge in management of peripartum
hypertension
Pandian, R; Mathur, M
KK Womens and Childrens Hospital, Singapore
Australian Centre for Health Services Innovation, Queensland

University of Technology, Brisbane, Queensland, Australia; 2Mater
Health Services, Brisbane, Queensland, Australia
Introduction It is difficult and resource-intensive for hospitals to
capture post-discharge infections. Knowing the post-discharge

infection rate is important as 95% of infections following
caesarean section are identified and treated in an outpatient
setting and a 30-day readmission rate will underestimate the
burden of this complication on women and health services. This
study estimated post-caesarean surgical site infection rates and key
risk factors using self-reported data sourced from the 2012 Having
a Baby in Queensland survey.
Methods The survey was sent to 19 958 women recruited through
the Queensland Registry of Births, Deaths and Marriages
3 months following birth. Women were eligible to participate if
they gave birth in Queensland between October 2011 and January
2012. Data for women who had a caesarean birth was sought for
this study. The primary outcome was self-reported wound
infections, and data on risk factors for infection such as prepregnancy body mass index. Data was analysed using chi-squared
tests for differences between two proportions, examining
prevalence and key risk factors for infection.
Results Responses from 1971 women who had a caesarean section
were available for analysis. The self-reported incidence of wound
infection following caesarean section was 14.3%. More overweight
and obese women (17%) reported a caesarean wound infection
compared to women with a healthy body mass index (11.7%) and
this difference was significant (P < 0.001). Women who delivered
their baby in a public hospital were significantly more likely to
report that their caesarean wound became infected than those
who delivered in a private hospital (16.7% compared to 11.9%,
P < 0.01). No significant differences in the infection rate were
found for emergency or elective caesarean, whether labour had
commenced or remoteness of hospital facility.
Conclusion This study gives an indication of the caesarean section
surgical site infection rate in Queensland that includes postdischarge infections. Patients are more likely to over-report
infections following surgery and therefore the true rate may be
288
Introduction Pheochromocytoma is a rare cause of hypertension
in pregnancy with incidence of less than 0.2 per 10 000

pregnancies and if unrecognised can cause potentially devastating
consequences for both mother and fetus. The sign and symptoms
are mainly related to increase in catecholamine secretions, which
can lead to adverse effect on cardiovascular and cerebrovascular
system. The aim is to report a case of recurrent
pheochromocytoma during pregnancy and its management
including the literature review. Even recurrent cases should be
meticulously handled by team management anticipating the risk
of hypertensive crisis which can cause adverse effect on mother
and fetus.
Case A 30-year-old woman was admitted for prostin induction of
labour. With regards to her past history, 4 years back she was
diagnosed by endocrinologist as pheochromocytoma and
underwent laparoscopic right adrenalectomy. Histology confirmed
the complete excision of phaechromocytoma without any
malignant features. Her postoperative period was uneventful.
Following that she had 2 spontaneous uncomplicated miscarriages
and one normal uncomplicated delivery, which was well managed
by multidisplinary team. In the current pregnancy, she was
booked at 11 weeks. Magnetic resonance imaging showed soft
tissue focus in the right adrenal bed, which may be either a postsurgical scar or recurrent tissue. Multidisplinary involvement
helped in adequate control of her blood pressure and urine
metanephrine were monitored throughout pregnancy but was
noted to be persistently high. She was on aspirin up to 34 weeks
and her pregnancy progressed well without any complication.
Regarding the mode of delivery, endocrinologist opinion was that
she can be allowed to have normal delivery as her soft tissue foci
were very small. However, patient opted emergency caesarean
section as she does not want to take the risk of hypertensive crisis
during labour. She was given peri-partum phenoxybenzamine and
magnesium sulphate intra operatively. The blood pressure
fluctuated before the caesarean. The lower uterine segment was
very vascular and caesarean section was bit challenging.
Intraoperatively her blood pressure dropped and intravenous
ephedrine was given. Patient was kept in intensive care unit for
1 day and magnesium sulphate was continued for 24 hours. Her

intra-operative and postoperative period was well managed by
senior multidisciplinary team.
Conclusion Early antenatal care with correct medical therapy and
careful management of recurrent cases with close follow-up is
absolutely essential. Awareness regarding the risk of hypertensive
crisis during delivery and effective management by
multidisciplinary team is pivotal for successful maternal and fetal
outcome.
postnatal care, the neonatal heel stick may not be a reliable test of
stress response within a routine hospital setting.
EP13.85
Influenza vaccination in pregnancy after the 2009
pandemic: experience in a Melbourne teaching
hospital 2010 to 2014
McCarthy, EA1,2; Tapper, L2; Pollock, WE2,3;

Sommerville, M2
EP13.84
Can neonatal stress reactivity be reliably measured
in the context of routine care? Salivary cortisol and
the neonatal heel stick
Matusiak, K1; Barrett, HL1,2,3; Dekker Nitert, M1,3;

Callaway, LK1,2
1
School of Medicine, University of Queensland, Herston, Queensland,
Australia; 2Royal Brisbane and Womens Hospital, Herston,
Queensland, Australia; 3UQ Centre for Clinical Research, University of
Queensland, Herston, Queensland, Australia
Introduction Cortisol levels reflect hypothalamic-pituitary-adrenal
axis function, including response to acute stressors. Salivary

cortisol concentration is well correlated with serum concentrations,
and therefore offers a non-invasive method for measuring stress
response. Salivary cortisol has previously been described as a useful
method for evaluating neonatal and infant stress reactivity. The
salivary cortisol level has been shown to rise significantly from
baseline 20 to 30 min following the neonatal heel stick. After
consulting the literature and piloting collection technique, the
following method was used as part of a study evaluating neonatal
stress response following preconception weight loss.
Methods Activities 4 hours prior to, and between saliva samples
are recorded. This includes potential stressors such as pediatrician
checks and immunisations as well as calming activities such as
feeding or sleeping. The data collection did not interfere with
these activities. A trained blood collector performs the Neonatal
Screening card between 48 and 72 hours of life. Saliva is collected
using the Salimetrics Infant Swab lightly dipped in citric acid
crystals to stimulate saliva flow. A 5-min sample is taken by
holding the swab next to the buccal mucosa of the babys mouth.
The baseline sample is taken before the heel stick and the second
sample is taken 30 min following the heel stick. The saliva
samples are frozen after collection. Nineteen subjects were batch
analysed using the Salimetrics ELISA kit.
Results There was not a significant change in salivary cortisol
level from baseline (median = 15.76 nmol/L, IQR 12.562) to postheel stick (median = 16.756 nmol/L, IQR 18.388) P = 0.804.
Approximately half of the subjects had a reduction in salivary
cortisol levels following heel stick. There was pronounced
variability in the feeding and handling of neonates in the period
before and during sampling. Not all neonates were observed to
have a negative response (cry) to the stressor.
Conclusion Due to the variability in behavioural response to heel
stick as well as the numerous potential confounding stressors of
1
University of Melbourne, Department of Obstetrics and Gynaecology,
Victoria, Australia; 2Mercy Hospital for Women, Heidelberg, Victoria,
Australia; 3La Trobe University, Melbourne, Australia
Introduction Expectant and new mothers, fetuses and young
babies are particularly vulnerable to severe illness and death due

to influenza virus. Conversely, influenza vaccine during pregnancy
protects against respiratory illness for pregnant women and babies
under 6 months and protects against stillbirth and poor fetal
growth. Despite systematic, longstanding information about
influenza vaccination safety and efficacy, pregnant women are not
universally vaccinated. Recognised obstacles to vaccination include
low priority of vaccination compared with other aspects of
antenatal care; maternity providers being unfamiliar in the role of
vaccinator; lack of awareness of vulnerability of pregnant women,
fetuses and babies to influenza infection and its consequences;
under-confidence about vaccine effectiveness; over-concern about
vaccine hazards.
Methods We interviewed all new mothers for 14 days each July
as inpatients using a tool based on the Centres for Disease
Control (CDC) Pregnancy Risk Assessment Monitoring System
(PRAMS). We asked women if they recalled receiving influenza
vaccination while pregnant, their opinions about influenza
vaccination and enabling and obstructing factors.
Results The interview tool was well accepted with completion by
>92% of new mothers. Vaccination rates increased over the 5 year
period: 30%, 40%, 36%, 54% and 51% for 2010, 2011, 2012, 2013
and 2014, chi-square trend P < 0.01. Pregnant women increasingly
seek out influenza vaccine. Whereas 8.8% of vaccinated women
recalled seeking vaccination in 2010 to 2013, the proportion of
vaccinated women who remember asking for vaccination was 42%
in 2014. Obstructing factors persist. Around (50.7%) of nonvaccinated women did not recall influenza vaccination being
mentioned by midwives or doctors and this did not change over
time. We observed non-significant trends to lower vaccination
rates among women born overseas and/or women using
interpreters compared with Australian born and/or English
speaking women.
Conclusion Pregnant women and maternity professionals are
beginning to incorporate influenza vaccination into routine
pregnancy care but there is scope for improvement. We
propose further research into text message reminders to build
on patient initiatives, assist busy maternity providers and be
sufficiently comprehensible for women with basic English
literacy.
289
enjoyed a welcomed decline following the introduction of the

1995 RCOG guideline on thromboprophylaxis after caesarean
section. The 2009 revised guideline risk stratifies women into low,
intermediate and high risk and advises 6 weeks of postpartum
subcutaneous LMWH in those with three or more risk factors.
This audit aimed to understand the rate of compliance of
postpartum subcutaneous LMWH in women high risk of
thrombembolic events and reasons for early cessation.
Methods The audit was performed during September 2014 at St
Georges Healthcare NHS Trust. Patients who delivered at St
Georges Healthcare NHS Trust during July 2014 and discharged
with 6 weeks of subcutaneous LMWH were included. 75 women
were identified and contacted via telephone. Answers to
predefined questions about compliance, timing of
commencement cessation, reasons for noncompliance and
suggestions for improving patient experience were obtained. The
participant was asked to give a score out of ten for the quality of
the education received regarding LMWH thromboprophylaxis.
Results 42 women agreed to take part in the telephone survey.
Only 50% (21/42) of participants confirmed completion of the
6 weeks of LMWH. The main reasons for noncompliance were
poor explanation, forgetfulness, and time management. The mean
score for explanation from those compliant was 7.6/10, compared
with 5.9/10 in the noncompliant group.
Conclusion This audit demonstrated a low compliance in women
at high risk of thromboembolic events and suggests that the
quality of patient education received may play a role. We believe
these low compliance rates are not isolated to our population and
recommend all units review local compliance rates and invest in
patient education if required.
pregnant women. The genital tract microbiota during late

pregnancy was investigated to compare the vaginal and intraamniotic populations of individuals, as well as between
individuals.
Methods Vaginal and intra-amniotic swabs were obtained from
90 women at the moment of delivery by caesarean section.
Participants were administered a questionnaire including
demographic and pregnancy data. DNA was extracted from the
swabs, and the identity of the taxa present was determined by
ultrafast sequencing of the V3V5 regions of the 16S rDNA gene of
samples. Species diversity and richness, and Shannons diversity
analyses were performed on the sequence data of each woman.
SIMPER analysis showed the contribution of each species to the
vaginal and intra-amniotic microbiomes. PERMANOVA and
PERDISP analyses showed that the vaginal and intra-amniotic
microbiomes classify into two different groups,
Results More than 420 and 830 different taxa were identified in
the vagina and intra-amniotic space of these women, respectively.
Generally, there were more different taxa in the intra-amniotic
space than in the vagina. The average number of species, species
richness, and the Shannon index of diversity were significantly
higher in the intra-amniotic space than in the vagina. For most
women, the intra-amniotic microbiota was significantly more
diverse than the vaginal microbiota. Many more taxa contributed
to the intra-amniotic microbiome than to the vaginal
microbiome; the latter was usually dominated by one or two
Lactobacillus spp. Metric multidimensional scaling showed distinct
groupings for the vaginal and intra-amniotic microflora.
Conclusion At variance with commonly held assumptions, the
analyses identified in the intra-amniotic cavity of the women in
the study rich and diverse bacterial populations that were
significantly different to the vaginal populations. Importantly, the
populations of both loci had different compositions; the results
suggested that the intra-amniotic microbial profile remains quite
stable independently of the variability of the vaginal microbial
profile. The outcomes of this study have potentially important
implications for the management of urogenital infections during
pregnancy.
EP13.87
The female genital tract microbiome at delivery
EP13.88
Fetal monitoring in labour in obese mothers
Mendz, GL1; Quinlivan, JA2; Kaakoush, NO3
Everden, C; Kirkpatrick, A; Modarres, M
Frimley Park NHS Trust, Surrey, United Kingdom
EP13.86
Low postpartum thromboprophylaxis compliance
rates in women at high risk of VTE
McLaren, JS; Stevenson, H; Pretti, M; Hughes, P

St Georges Healthcare NHS Trust, London, United Kingdom
Introduction Maternal deaths from thromboembolism have
University of Notre Dame Australia, Sydney, New South Wales,

Australia; 2University of Notre Dame Australia, Western Australia,
Australia; 3University of New South Wales, Sydney, New South Wales,
Australia
Introduction Important advances in the knowledge of the
microbiota that inhabit humans, but the microbial populations of

the genital tract of pregnant women in health and disease remain
to be elucidated. Recent studies of the vaginal and intra-amniotic
microflora in different groups of pregnant women have yielded a
considerable amount of information on the bacterial communities
of the urogenital female tract in health and disease. However, only
a limited number of comparisons have been performed between
the vaginal and intra-amniotic microbiomes of individual
290
Introduction Obesity in pregnancy is associated with a number of
adverse outcomes. In addition to the maternal risk factors, the

fetus is at increased risk of stillbirth and neonatal death. Despite
this our current guidelines fail to make any definite
recommendations on the mode of monitoring that should be
utilised in labour. This is important as poor monitoring in labour
compounds the already present risk of neonatal morbidity and
mortality. Our study was designed to look at the care received by
obese pregnant women in our department, specifically looking at
different modes of fetal monitoring utilised in labour and the
outcomes for these babies.
Methods We carried out a retrospective study, looking at the

intrapartum care received by mothers with a BMI of >30 in
OctoberNovember 2013, at Frimley Park Hospital, a general
district hospital in the UK. We identified 55 women who met our
criteria. We looked closely at their antenatal care, fetal surveillance
in labour, mode of delivery and fetal outcomes including Apgar
scores and admissions to Special Care Baby Unit (SCBU).
Results 78% of our population had a BMI between 3035, 18%
between 3540 and 4% had a BMI above 40. In terms of
monitoring, 69% of women were initially commenced on
intermittent auscultation as a form of fetal monitoring. This
changed through labour so that by the end of labour 65% were
receiving continuous fetal monitoring in the form of a fetal scalp
electrode or CTG. The most common reason for this was
abnormal intermittent auscultation. In the presence of continuous
fetal monitoring there was persistent loss of contact in 27% of
cases, resulting in the use of a fetal scalp control in 17% of the
population. 10% of babies had Apgars less than 7 at birth and 5%
required admission to SCBU. This being just below the target of
6% set by the maternity dashboard.
Conclusion Obesity in pregnancy is a great challenge to achieving
safe care in obstetrics and one aspect of this is problems with fetal
heart monitoring in labour. Our study suggests that we require
stricter guidelines for encouraging accurate fetal heart monitoring
in labour as babies of obese mothers are at risk of fetal distress
and low Apgars. By instigating adequate, accurate continuous
monitoring from the beginning of labour we may be able to avoid
or reduce harm to these babies by picking up signs of distress
earlier and addressing them in a more timely fashion.
EP13.89
Urine dipstick is not helpful in screening pregnant
women for proteinuria
Moisey, D1,2
1
Maternal-Fetal Assessment Unit, King Edward Memorial Hospital,

Subiaco, Western Australia, Australia; 2Emergency Department,
Rockhampton Base Hospital, Rockhampton, Queensland, Australia
Pre-eclampsia is described with the triad of hypertension, oedema

and proteinuria. Screening for this condition is a routine part of
the assessment of patients presenting to the Maternal-Fetal
Assessment Unit of our hospital. This unit delivers care to
patients presenting for unplanned and urgent outpatient care. The
reliability of urine dipstick testing for proteinuria was unknown.
The test characteristics of urine dipstick in screening for
proteinuria were assessed in a retrospective manner in our tertiary
referral centre. Cases were tested against a gold standard of urineserum protein-creatinine ratio (PCR) that serves as the diagnostic
standard for significant proteinuria in our facility. All PCR tests
completed were identified by a laboratory database query. A chart
review of the Maternal-Fetal Assessment Unit (MFAU) standard
documentation pro forma was reviewed to identify urine dipstick
findings. A total of 531 tests for PCR were completed between 18
November 2012 to 31 December 2012. Of these 247 were ordered
from the MFAU and had the urine dipstick findings documented.
The urine dipstick was positive (+1) when the PCR was positive
(30 mg/mmol) in 34 cases (true positive); positive dipstick with
negative PCR in 45 cases (false positive); negative dipstick with
positive PCR in 30 cases (false negative) and negative dipstick
with negative PCR in 138 cases (true negative). This corresponded
to a sensitivity of 53% (95% CI 4066%), specificity of 75% (95%
CI 6981%), a positive likelihood ratio of 2.16 (95% CI 1.53.0)
and a negative likelihood ratio of 0.62 (95% CI 0.50.8). A
positive dipstick protein finding may serve to increase the
likelihood of significant positive urine protein findings. Negative
urine dipstick for protein however is no more accurate than the
flip of a coin. In our population of pregnant patients presenting
for outpatient evaluation urine dipstick screening for proteinuria
is not useful. A more sensitive test for example PCR should be
used to screen for proteinuria in pregnant patients in the
outpatient setting.
EP13.90
Caesarean section delivery: lowering the incidence.
A prospective observational study of 1182
deliveries
Monaghan, C; Goodall, H; Roberts, R

Ulster Hospital, Dundonald, Belfast, Northern Ireland
Introduction The rise in caesarean section rate locally and further
afield has caused much concern. Various reasons for this trend
have been suggested. We proposed that by assessing current
practice in our unit we could identify possible ways of reducing
the caesarean delivery rate in the future.
Methods Prospective observational study, over a 1-year period, of
all patients undergoing either caesarean section or instrumental
delivery in theatre, in the Ulster Hospital, Dundonald.
Results Information was obtained on 1018 caesarean sections and
164 successful instrumental deliveries. The caesarean section rate
for the allocated study period was 24.7%. 514 of the caesarean
deliveries were elective and 504 were emergency procedures. The
most common indication for elective caesarean was previous
caesarean section (278 deliveries). Breech was the second most
common indication (85 women). 38 primigravidae requested an
elective caesarean delivery. The most frequent reason for failed
vaginal birth after caesarean (VBAC) was failed induction. 32% of
emergency caesareans for abnormal CTG had abnormal umbilical
cord pHs. A consultant was present at 91% of trials of
instrumental delivery in theatre, including all 9 failed instrumental
deliveries. There was no increase in maternal or neonatal adverse
outcome with the use of rotational forceps compared with
vacuum or non-rotational forceps.
Conclusion Our figures suggest that the most important factors
for limiting the caesarean section rate are reducing non-essential
caesarean sections in first pregnancies and elective caesarean
sections in subsequent pregnancy due to maternal request because
of one previous caesarean section. Appropriate debriefing should
reduce maternal anxiety and promote VBAC. A dedicated External
Cephalic Version (ECV) clinic should reduce the number of
caesarean deliveries for breech presentation. The high percentage
291
of successful trials of instrumental delivery is likely to be related

to a high consultant presence. Continued use of rotational forceps
in experienced hands does not confer any additional maternal or
neonatal risk.
EP13.91
PPROM, incidence, mode of delivery, maternal and
perinatal outcomes an Al Rahba Hospital
experience
Munawar, F; Nambiar, R; Jangalgi, R; Jamil, S;

Israell, I; Moul, K; Boma, N; Ali, B
Al Rahba Hospital, Abu Dhabi, United Arab Emirates
Introduction The objective was to study incidence, mode of
delivery, maternal and perinatal outcome of women delivering at

Al Rahba Hospital after presenting with PPROM between 24 to 34
and 34.1 to 37 weeks.
Methods A retrospective analysis of files of patients who delivered
at Al Rahba Hospital, presenting with PPROL between gestational
age of 24 to 34 weeks, and 34.1 to 37 weeks of gestational age in
2013 was done. All PPROM patients admitted received IV
antibiotics for 48 hours followed by oral antibiotics for 10 days
and had baseline investigation done. The mode of delivery,
incidence of choriomaniocitis and perinatal outcome
(prematurity, fetal distress, neonatal sepsis, pulmonary hypoplasia
was studied)
Results Total deliveries 1897. Number of PPROM 76 (4%).
GA > 34, 44. GA > 3437, 32. Mode of delivery: SVD, 46; elective
CS, 12; emergency CS, 18. Maternal mortality 0. Maternal
morbidity 4. Chorioamnionitis 4 (5.2%). Fetal mortality 1,
neonatal death. Fetal morbidity 16. Neonatal sepsis 2. Fetal
distress/cord compression 14.
Conclusion Our data is comparable with the international
literature for the incidence of PPROM, mode of delivery, maternal
and perinatal outcomes.
EP13.92
The difference of HLA-E expression in intrauterine
fetal death (IUFD) with normal pregnancy
Nugroho, MA; Sulistyowati, S

Obstetric and Ginecologic Sebelas Maret University, Indonesia
Introduction Intrauterine fetal death (IUFD) is death of fetus in
uterine with >500 g weight or death of fetus in uterine within

20 weeks gestational or more. Incident of IUFD in Indonesia
according to SDKI (Survei Demografi dan Kesehatan Indonesia),
survey in 2012 is 32 divide by 1000 life birth and in Surakarta is
5.3 divide by 1000 life birth. Human leukocyte antigen-E (HLA-E)
have an important thing in semialogenic immune tolerance of
mother. HLA-E that enough in trophoblast cause no imunolgy
respon of mother, so pregnancy will be in normal. This
experiment will explain about difference of HLA-E expression in
IUFD between normal gestational. The aim of this experiement is
292
to prove about difference of HLA-E expression in IUFD between

normal gestational.
Methods Rhe experiment will be held in Dr Moewardi General
Hospital Surakarta that is analytic observasional experiment with
croos sectional study approachment. Independent variable: HLA-E
expression, dependent variable IUFD and normal gestational.
Total sample is 32, consist of 16 IUD sampel and 16 normal
gestational. The technic to take sampel is purposive random
sampling, data analysis with t test independent, using SPSS versi
17.00 for windows.
Result The result is average of HLA-E expression in IUFD group
57.06 32.04, while average of HLA-E expression in normal
gestation group 17.32 6.69, with centre point is 39.73. Statistis
test using independent t test with confidence rate 95%, P = 0.008
(P < 0.05), can be concluded that there is significant difference
HLA-E expression between IUFD and normal gestational in
statistic.
Conclusion There is significant HLA-E expression between IFD
and normal gestational in statistic.
EP13.93
Maternal outcomes in acute fatty liver of
pregnancy in a tertiary-care referral institute in
North India
Nuthalapati, S1; Suri, V1; Chawla, YK2; Das, A3;

Sharma, S1
1

Hepatology; 3Department of Histopathology, PGIMER, Chandigarh,
India
Introduction Acute fatty liver of pregnancy (AFLP) is a rare entity
mostly occurring in the late trimester of pregnancy. Furthermore,

clinical presentation often simulates fulminant viral hepatitis. The
aim of this study was to assess the demographic profile and the
maternal outcomes in women with AFLP.
Methods A retrospective observational study of 32 patients with
the diagnosis of AFLP was conducted in the Department of
Obstetrics and Gynaecology, PGIMER, Chandigarh from January
2007 to December 2012. The women diagnosed with AFLP based
on the Swansea criteria were reviewed for the clinical presentation,
laboratory parameters and their clinical course. The maternal
complications and mortality rates were recorded.
Results The mean age of the women was 24.8 3.4 years and
mean gestational age at presentation was 34.4 2.9 weeks.
Twenty four (75.0%) women were nulliparous and 8 (25.0%)
were multiparous. The mean gestational age at delivery was
34.7 2.5 weeks. Twenty two women (68.8%) had presented
after 34 weeks gestation, 8 (25%) between 28 34 weeks and 2
(6.3%) women before 28 weeks of gestation. Jaundice [mean
serum bilirubin 12.9 5.6 mg/dL] was the most common clinical
presentation seen in 30 (93.8%) women. Mean serum
transaminase levels being aspartate transaminase
(AST) = 354 553 IU/L, alanine transaminase
(ALT) = 360 542 IU/L. Pre-eclampsia was noted in 11 (34.4%)
patients. Only 13 (40.6%) women had ultrasound imaging
suggestive of fatty liver changes. Coagulopathy was observed in all

women (100%) with a mean prothrombin time of
34 20 seconds [range 16120 seconds]. Other maternal
complications included encephalopathy 23 (71.9%),
hypoglycaemia 29 (90.6%), acute renal failure 29 (90.6%), postpartum haemorrhage (28.6%) and sepsis (59.4%). ICU admission
was needed in 25 (78.1%) with 22 women (68.8%) requiring
mechanical ventilation. Seven (24.1%) women required dialysis for
renal shutdown. Twenty-six (92.8%) women were delivered
vaginally and two (7%) by lower segment caesarean section. Three
women died undelivered while one was taken against medical
advice by her relatives. Maternal mortality rate observed in
present study was 53.4%.
Conclusion AFLP has high incidence of maternal mortality
(53.4%). Meticulous approach and high index of suspicion is
needed in establishing the diagnosis. Management in tertiary care
settings with multidisciplinary team involving obstetricians,
hepatologists, and intensive care specialists would help improve
the outcome.
risk of bias. Women who received an antenatal dietary and

lifestyle intervention were less likely to experience maternal
hypertension (2 studies; 243 women; risk ratio 0.34; 95% CI 0.13,
0.91) and gestational weight gain above Institute of Medicine
(IOM) guidelines (3 studies, 389 women; risk ratio 0.71, 95% CI
0.560.88). There were no statistically significant differences in
total weight gain during pregnancy, caesarean section,
birthweight greater than 4 kg, gestational diabetes, postpartum
return to pre-pregnancy weight and postpartum weight loss.
Conclusion The provision of antenatal dietary and lifestyle
intervention for women commencing pregnancy with a normal
BMI, results in women being less likely to experience gestational
weight gain above the current IOM recommendations and less
likely to develop hypertension. This review was limited by sample
size, lack of power to detect changes in clinical outcomes with few
studies contributing data for women with a normal BMI. Further
well design randomised controlled trials are required to determine
the effect of antenatal interventions on this group of women and
on important maternal and infant outcomes.
EP13.94
Systematic review of antenatal dietary and lifestyle
interventions in women with normal body mass
index
EP13.95
Obesity and gestational diabetes mellitus: the
compound effect
OBrien, CM1,2; Grivell, RM1,2; Dodd, JM1,2

1
Womens and Babies Division, Womens and Childrens Hospital,

North Adelaide, South Australia, Australia; 2Discipline of Obstetrics
and Gynaecology, School of Paediatrics and Reproductive Health,
Robinson Research Institute, University of Adelaide, Australia
Introduction Efforts to prevent excessive gestational weight gain
and fetal macrosomia are important in the reduction of obstetric

related complications, postpartum weight retention and in the
prevention of childhood obesity. Whilst many intervention studies
have focused on women with high body mass index (BMI),
women who commence pregnancy with a normal BMI are at
highest risk of excessive gestational weight gain, which is linked to
postpartum weight retention, higher birthweight and later obesity
for the child. This systematic review aimed to assess the effect of
dietary and lifestyle interventions in pregnancy for women with
normal BMI on maternal and infant outcomes.
Methods We searched PubMed and Medline in September 2014
using the following free text search terms: pregnancy, gestational
weight gain, postpartum weight retention, dietary intervention,
lifestyle intervention and randomised controlled trials. The
inclusion criteria included all published, unpublished and ongoing
randomised controlled trials recruiting women with normal BMI
categories, comparing dietary and lifestyle intervention with
standard antenatal care.
Results Our search strategy identified 42 abstracts for
consideration, of which 16 full-text manuscripts were reviewed.
Eleven randomised controlled trials were eligible for inclusion in
the review, involving a total of 2467 pregnant women. Four
studies reported clinical data for 723 women with a normal BMI.
The included studies were of good quality with low to moderate
Thukral, SK; Bowden, SJ; Page, L; Dixit, A;

Cotzias, C; Kaushal, R
West Middlesex University Hospital, London, United Kingdom
Introduction The incidence of obesity is rising rapidly and has
significant implications for maternal and fetal health. Obesity is a

risk factor for the development of gestational diabetes mellitus
(GDM) and both GDM and obesity are significant risk factors for
subsequent Type 2 diabetes mellitus (T2DM). Obesity guidelines
(CG43) by the National Institute for Clinical Excellence (NICE)
recommend that patients with a body mass index (BMI) 35 kg/
m2 with comorbidities that could be improved by weight loss
should be referred for consideration of bariatric surgery.
Methods A retrospective data analysis of all women with a BMI
35 kg/m2 who booked into the antenatal service at a London
District General Hospital between January and December 2012
inclusive and had live births, was conducted.
Results There were 194 obese women (BMI 35) of which 28 had
GDM. Of the 164 without GDM (NGDM) 14 did not have a
glucose screen at 28 weeks and may have had undiagnosed GDM.
GDM patients trended towards being heavier (107.3 kg/40.5 kg/
m2) than NGDM (104.9 kg/39.2 kg/m2). GDM patients delivered
significantly earlier than NGDM (38+1 versus 39+1 weeks,
P = 0.0005) and were significantly more likely to have caesarean
sections (46% versus 31%, P = 0.0003). During labour, GDM
patients trended towards greater blood loss (729 versus 612 mL).
There was a higher incidence of admission to the Special Care
Baby Unit (SCBU) amongst GDM patients (14% versus 9%)
although due to the small sample size this did not achieve
statistical significance (P = 0.337).
Conclusion Both obesity and GDM negatively impact upon
maternal health, delivery and fetal wellbeing. Our data supports this
293
and highlights that the combination of obesity and GDM have a

dangerous compound effect. We wish to reinforce
recommendations of systematic practices to ensure that all obese
patients are screened for GDM. Obese women with GDM are an
extremely high-risk group for the development of multiple health
problems including T2DM and high obstetric risk in further
pregnancies. There is an urgent need for early identification of obese
women in maternity care who are eligible for bariatric surgery
referral postpartum. Bariatric surgery in this group is likely to be
cost-effective when compared to the lifetime costs of complicated
obstetric deliveries, SCBU admissions, diabetes care and
management of diabetic complications. It may also prevent and/or
delay the onset of obesity and diabetes in the offspring of these
women.
this has not, to date, influenced the total PTB rate for WMUH.
The data suggest that increasing numbers of risk factors increases
the likelihood of PTB. These data will be used to streamline
referral pathways to the PTC and also to implement appropriate
cervical length screening in a timely fashion.
EP13.97
Management of multiple sclerosis in pregnancy in
university hospitals in Leicester (UHL): a service
evaluation
Shahin, M1; Venkitaraman, U2; Patel, P1

1
University Hospitals Leicester (UHL), Leicester Royal Infirmary;

University Hospital Leicester (UHL), Leicester General Hospital,
United Kingdom
2
EP13.96
The impact of a prematurity clinic
Introduction Multiple sclerosis (MS) is an inflammatory
Tailor, V; Page, L; Girling, J

West Middlesex University Hospital (WMUH), London
Introduction Preterm birth (PTB), less than 37 weeks of gestation
has significant impact on neonatal mortality and morbidity;

associated annual healthcare costs in UK equal those of smoking
related ill-health. WMUH is a busy district general hospital in
west London serving a multiethnic community. In December 2010
a multidisciplinary antenatal prematurity clinic (PTC) was
established to care for women at high risk of PTB aiming to
improve pregnancy outcome. An audit was carried out to assess
the impact of the clinic for women reviewed between January
2011 and December 2013.
Methods Using the prospectively completed clinic database, 389
women referred antenatally to the clinic were identified. Using the
hospital electronic systems further information was obtained from
patient letters, investigation results and delivery outcome data.
Patient demographics were and their risk factors for PTB
established with cervical length screening [CL] results.
Results Outcome data for 14 women were not available as they had
moved away from the district, leaving 375 women. For this period,
WMUH PTB rate was 6.2%; for this high risk cohort it was 17.2%,
and for those who delivered at 32 36 weeks, the rate changed
from 13.9% 2011, 14% 2012 to 8.1% 2013. The three most common
reasons for PTC referral included previous history of PTB >28/40
(44%), previous cervical excision (33%), and previous 2nd trimester
loss (22%); 10 women were referred following finding of very short
CL/bulging membranes; 7 women were referred inappropriately. 16
women had elective history indicated cerclage; 319 women had
CL < 24 weeks, of whom 10 [3%] had ultrasound-indicated
cerclage; 12 had emergency cerclage with respective rates of term
delivery 80%, 56% and 33%. The number of additional risk factors
(uterine abnormality, BMI, extremes of maternal age, smoking,
drug use, domestic violence) influenced a womans chance of
reaching term for 1, 2, 3 and 4 risk factors, the rate of term
delivery was 85.5%, 72.55, 75.9% and 62.5% respectively.
Conclusion Early data suggest a positive impact on PTB, with a
fall in the PTB rate for high risk women presenting to the clinic;
294
demyelinating disorder of the CNS most likely secondary to

autoimmune responses causing destruction of the myelin sheath
surrounding axons. It is approximately 3 times more common in
women with an onset age typically between 2040 years with a
prevalence in the UK between 100140/100 000 of the
population. Therefore, large proportions of those suffering with
MS are women of child bearing age. Large scale studies, such as
the pregnancy in multiple sclerosis study (PRIMS), has shown
that women suffering with MS are at an increased risk of
delivering babies which are small for gestational age and having
higher rates of operative deliveries. However, there are no
maternity guidelines in place at UHL for pregnant women
suffering from MS. The aim of our study was to evaluate
services provided to pregnant women with MS and compare our
practice to the best available evidence.
Methods Area of care provided for MS sufferers of child bearing
age was split into 3 categories: preconception counselling,
antenatal and intrapartum care and postnatal counselling. Twentytwo case notes of women between the ages 2542 years who have
MS and were pregnant between 2004 and 2013 were identified of
which a total of 29 pregnancies were studied.
Results Our results revealed that only 1 woman had preconception care; 3 cases were booked as low risk under midwifery
care; the remainder had their antenatal care either in maternal
medicine clinics or general obstetric clinics with no neurology
input for 17 women. Associated medical disorders were identified
in 47.2%; the majority (37%) suffering from depression. Obstetric
complications occurred in 17%, mainly in the form of IUGR
(6.8%). Antepartum anaesthetic referral was arranged for one
patient only, with bladder care and advice mentioned in 9 case
notes. Most of the patients (58%) had spontaneous vaginal
delivery with the rate of instrumental delivery (21%) higher than
nonMS sufferers.
Conclusion This service evaluation helped to identify great
discrepancies and inconsistencies in the care provided to this
vulnerable group of pregnant women. Therefore, we designed a
multidisciplinary local guideline as well as patient information
leaflet for the care of MS pregnant women, in order to overcome
these inconsistencies and discrepancies.
EP13.98
Gastric pacemaker malfunction in pregnancy
Patil, P; Demitry, A
Luton and Dunstable University Hospital NHS Trust, Luton, United
Kingdom
Introduction 38-year-old, Caucasian, G4 P3, previous 3 caesarean
sections, type 1 DM, had gastric pacemaker fitted for severe

gastroparesis in 2012.
Case Booked at 8 weeks gestation. At 26 weeks gestation she
sustained an electrical shock causing her pacemaker to stop. She
had the pacemaker reprogrammed but was ineffective initially. She
had excessive vomiting, dysuria, left renal angle tenderness and
uterine contractions every 23 min. She became dehydrated,
ketotic and was diagnosed with diabetic ketoacidosis,
pyelonephritis and threatened preterm labour. We managed her
on labour by the medical and obstetric teams using antiemetics,
sliding scale, IV antibiotics. Steroids and tocolytics were
administered for threatened preterm labour. The following day,
she developed abdominal distension, dyspnoea, and tachycardia
and low oxygen saturation. Blood test results showed only raised
haematocrit and low haemoglobin. Her blood glucose levels were
brought under control after a Diabetologist review. Urine culture
grew E. coli. Renal ultrasound showed dilated renal calyces and
evidence of recurrent urinary tract infections. After a Urology
review, she was commenced on prophylactic low-dose antibiotics.
Acute bowel obstruction was suspected. Hence, a nasogastric tube
was inserted, surgical review arranged and patient admitted to
HDU. Obstetric ultrasound scan showed a normally grown fetus
with polyhydramnios. Over the next few days, she started making
improvement, aided by resumption of her pacemaker
functionality, and was discharged on day 7. She was readmitted at
29 weeks with threatened preterm labour, fetal fibronectin test
was positive. Uterine contractions continued with no cervical
changes requiring strong analgesia. In view of her history of 3
previous caesarean sections and persistent uterine contractions,
she underwent an emergency caesarean section at 29 weeks and
4 days gestation. Before and after the operation, her pacemaker
was switched off, and then, back on by a specialist technician.
Bipolar diathermy had to be avoided, as had the potential to
damage the device. A live male infant was delivered in a good
condition. Possible scenarios for delivery were pre-planned and
well documented in patients hospital notes.
Conclusion Gastro paresis is a chronic disorder in which there is
a delayed gastric emptying in the absence of any mechanical
obstruction. Gastro electrical stimulation is an option for treating
chronic, intractable nausea and vomiting secondary to gastro
paresis. Key efficacy outcomes are reduced symptoms, reduced
need for nutritional support, and less hospital admissions. Key to
successful management of this case was the MDT management
and pre-planning of possible delivery scenarios.
EP13.99
A clinical audit of the indications for use of
magnesium sulphate in the management of severe
pre-eclampsia at the Royal Brisbane and Womens
Hospital (RBWH)
Phillips-Yelland, J; Barrett, H; Callaway, LK;

Fagermo, ND; Wolski, P; Lust, KM
Royal Brisbane and Womens Hospital, Brisbane, Queensland,
Australia
Introduction The use of magnesium sulphate (MgSO4) in pre-
eclampsia (PET) is well established. There has been little

assessment of PET incidence and documented indications of
MgSO4 use in the developed world. The aim was to review the
incidence of PET and eclampsia and indications for the use of
MgSO4 in the management of severe PET in an Australian tertiary
hospital and determine if this is in keeping with existing
management guidelines.
Methods A retrospective chart review of 154 cases clinically coded
with a diagnosis of hypertensive disorders in pregnancy at the
Royal Brisbane and Womens Hospital (RBWH) in a 6-month
period between 1 July 2012 and 31 December 2013 was
conducted. Correct diagnosis of PET, indications documented for
MgSO4 use and the treatment regime used were examined. The
data was compared with the Statewide Queensland (SQ) Maternal
and Neonatal Clinical Guidelines and the Society of Obstetric
Medicine Australia and New Zealand (SOMANZ) clinical
guidelines for PET management.
Results Of the 154 cases, 24 did not meet inclusion criteria and
one chart was lost. One hundred and twenty-nine charts were
reviewed. Forty-nine (37.9%) patients were diagnosed with
pregnancy-induced hypertension (PIH). Eighty (62.1%) patients
were diagnosed with PET with 44 (55% of total PET) of these
reaching severe PET criteria. One patient was transferred for ICU
care following an eclamptic seizure at another facility with no
other cases of eclampsia diagnosed during the study period.
Twenty (45.4%) of the severe PET patients received MgSO4. Of
those receiving MgSO4, a total of 19 (95%) patients received the
drug as per guidelines for its use; 16 (80%) in accordance with
both SQ and SOMANZ guidelines and an additional three
patients using SOMANZ guidelines alone. A further 24 severe preeclampsia patients who did not receive MgSO4, also reached
criteria where at least one guideline recommended that MgSO4
could be commenced. Of those receiving MgSO4, 16 received the
drug as per SOMANZ guidelines for administration and four
received a regime which did not adhere to guidelines for either
duration or dose.
Conclusion This study determined that patients prescribed MgSO4
at RBWH generally received the drug as per accepted guidelines.
It also suggests that we are under utilising the drug if we were to
strictly adhere to local and Australia-wide guidelines for its use. It
was noted, however, that there were no eclamptic seizures
occurring in patients who did not receive prophylactic MgSO4.
This research will assist with management guidelines for use of
MgSO4 at RBWH.
295
EP13.100
The north metropolitan Perth gestational diabetes
cohort: The IADPSG diagnostic criteria for
gestational diabetes mellitus identify a group of
women with higher rates of persisting glucose
intolerance and type 2 diabetes mellitus
Quinlivan, J
1,2,3
; Lam, D ; Petersen, R
Department of Obstetrics and Gynaecology, Joondalup Health

Campus, Joondalup, Western Australia, Australia; 2Institute for Health
Research, University of Notre Dame Australia, Fremantle, Western
Australia, Australia; 3Womens and Childrens Health Research
Institute, Womens and Childrens Hospital, Adelaide, South Australia,
Australia; 4Womens and Newborns Division, Womens and
Childrens Hospital, Adelaide, South Australia, Australia
EP13.101
Australian Fathers Study: how does hyperemesis
in pregnancy impact upon expectant fathers?
Sartori, J1,2; Coall, D1,3; Petersen, R1,4;

Quinlivan, J2,5
1
School of Medical Sciences, Edith Cowan University, Joondalup,

Western Australia, Australia; 2Department of Obstetrics and
Gynaecology, Joondalup Health Campus, Joondalup, Western
Australia, Australia; 3School of Psychiatry and Clinical Neurosciences,
University of Western Australia, Crawley, Western Australia, Australia;
4
Division of Women and Infants Health, Womens and Childrens
Hospital, North Adelaide, South Australia, Australia; 5Institute of
Health Research, University of Notre Dame Australia, Fremantle,
Western Australia, Australia
Introduction There is limited research on expectant fathers
Introduction Women diagnosed with gestational diabetes mellitus
(GDM) have an increased risk for developing glucose intolerance

(GI) and type 2 diabetes mellitus (DM2). The impact of the
change in the diagnostic criteria for GDM from ADIPS 1991
criteria to IADPSG 2010 is unknown. The aim was to determine
the impact on the diagnosis of GI and DM2 in the first postnatal
year.
Methods Women with a diagnosis of GDM who delivered from 1
July 2010 to 30 June 2014 at Joondalup Health Campus, Western
Australia, were followed via a hospital-based service, or their
general practitioner. Women underwent a postnatal 75 g oral
glucose tolerance test. Women had been diagnosed with GDM
according to ADIPS criteria until 31 December 2011 and by the
IADPSG criteria thereafter. The incidence of GI and DM2 was
audited.
Results Data from 349 women with GDM were available for
audit. Of these, 127 were diagnosed using ADIPS and 222 using
IADPSG criteria. The rate of GI and GM2 was significantly higher
in women diagnosed using the IADPSG criteria (ADIPS 14%
versus IADPSG 23%; P = 0.047; OR 1.81, 95% CI 1.003.25). In
multivariate analysis, factors associated with GI and GM2 were
need for medication in pregnancy (metformin/insulin) and obesity
(P < 0.05).
Conclusion The IADPSG criteria identify a group of women at
increased risk for GI and GM2 within the first postnatal year. In
multivariate analysis need for medication and obesity were
significantly associated with subsequent development of GI and
GM2.
understanding of the physical impact of early pregnancy nausea

and vomiting upon their partner despite the significant associated
female morbidity. We report on expectant fathers awareness and
understanding of the impact of pregnancy-induced nausea and
vomiting in their partners pregnancy.
Methods Observational study of 300 expectant fathers enrolled
within the larger Australian Fathers Study. Institutional ethics
approval and consent were obtained. Fathers were recruited from
antenatal clinics and community settings. Researchers administered
demographic, attitudinal and perception questionnaires. Fathers
were specifically asked if they were aware of nausea and vomiting,
or morning sickness, in their partner during the first half of
pregnancy. If they were aware of this problem, they were asked to
comment upon the impact in their lives.
Results Expectant fathers were similar in demographics to those
of the wider Australian community of expectant fathers. Overall,
18% (N = 54) were not aware if their partner suffered from the
condition and 16% (N = 48) stated their partner did not
experience the condition. The remaining 64% (N = 192) stated
they were aware their partner had the condition. Of these, 35%
(N = 67) said the problem was mild, 48% (N = 92) moderate and
17% (N = 33) severe. In qualitative comments, four themes
emerged: disruption on work, feelings of frustration and
helplessness, concern over depression in their partner and a sense
of being manipulated.
Conclusion Nausea and vomiting in early pregnancy impacts
upon the expectant father and may create both positive and
negative influences in the couples relationship.
EP13.102
Maternal critical care and high dependency care in
obstetric patients
Raglan, O1; Lawson, K2; Meher, S1; Akmal, S1

1
Queen Charlottes and Chelsea Hospital, Imperial College NHS Trust,
London, United Kingdom; 2St Marys Hospital, Imperial College NHS
Trust, London, United Kingdom
Introduction As the complexity of management of high-risk
pregnant women increases, the need for expert maternal critical
296
care, high dependency units (HDU) and models of care that are
standardised and delivered comparably at national level has
become increasingly important. Maternal mortality has been
analysed by the Confidential Enquiries and there is still a
significant number of deaths associated with suboptimal care. The
National Institute for Health and Care Excellence (NICE)
guidelines align with those of RCOG for women who become
critically ill during pregnancy/postpartum; each woman should
have access to the same standard of care for both pregnancyrelated and critical care needs, delivered by professionals with
equal levels of competence irrespective of whether these are
provided in a maternity/general critical care setting. Maternity
HDUs provide Level 2 (single organ failure support) and Level 3
care (multi-organ failure support).
Methods Data was collected from all admissions to HDU (level 2/
3 care) over a 4-month period at two hospital sites (Queen
Charlottes and Chelsea Hospital (QCCH) and St Marys Hospital
(SMH), Imperial College, London). A prospective audit was
carried out to assess indication for admission, level of care
required and management of critically ill obstetric patients.
Results Data was collected for forty-three women (median age
32 years (range 2146 years), median BMI 26). The median
neonatal birthweight was 2512 g and 2990 g at QCCH and SMH,
respectively with a total of 5 babies requiring admission to the
Special Care Baby Unit. Postpartum haemorrhage was the single
most common reason for admission to HDU, followed by
requirement of invasive monitoring (arterial/central line). Rate of
admission for management of sepsis was 24% (QCCH) and 12%
(SMH). Time from admission onto HDU to Consultant review
was 75 min (QCCH) and 282 min (SMH). The average stay in
HDU was 37 hours (QCCH, range 584 hours) and 49 hours
(SMH, range 7144 hours).
Conclusion We were able to evidence appropriate and timely
review by a senior obstetrician at time of HDU admission and
decision to step-down from HDU care. We identified reasons for
HDU admission as well as multidisciplinary team input into
critical steps in patient management. We need further audit and
research evaluating safety, effectiveness, healthcare outcomes and
patient experience for women requiring critical care during
pregnancy and in the postpartum period.
Case report A 43-years-old woman, gravida five, para 3 was
referred to our tertiary care centre on an emergency basis

following a failed attempt of surgical termination of pregnancy at
just under 22 weeks of gestation. The patient had an earlier failed
attempt of termination of pregnancy at 6 weeks gestation that was
carried out following a transvaginal ultrasound scan confirming
intra-uterine gestation. The patient carried on with the pregnancy
until it was decided with her local unit to repeat the attempt of
surgical termination at 21 weeks and 6 days gestation. The latter
attempt was complicated by bleeding but no actual products of
conception were seen. On admission to our tertiary unit the
patient had significant drop in her haemoglobin not explained by
the amount of vaginal bleeding witnessed. A fetal heart was
initially identified in the emergency room. Uterine trauma and or
intra abdominal bleeding was suspected and the patient
underwent emergency laparotomy. A left broad ligament
pregnancy of approximately 22 weeks gestation was found on
surgical exploration. No sign of fetal life noted during the
laparotomy itself. The uterus appeared relatively small with two
sites of perforation that were repaired surgically at the time. The
left broad ligament gestation was managed by surgical excision.
The patient recovered well afterwards and was subsequently
discharged home. Histology confirmed left broad ligament
pregnancy.
Conclusion To our knowledge this is the first report of a left
broad ligament advanced pregnancy at nearly 22 weeks gestation.
The diagnosis was not made or suspected antenatally. It is also
not clear entirely how the pregnancy implanted and continued
growing until nearly 22 weeks gestation. Whether it would have
continued for longer if the patient did not have the second
attempt at termination at 21 weeks and 6 days gestation is
unclear. Diagnostic challenges to be highlighted in the case report.
EP13.104
Rectal mucinous adenocarcinoma in pregnancy
Ramirez, AK; Limson, MJ; Manahan, MRP

Makati Medical Centre, Makati City, Philippines
Introduction Colorectal cancer (CRC) during pregnancy is a rare
EP13.103
A case of left broad ligament ectopic pregnancy
diagnosed at 21 weeks and 6 days gestation
diagnostic challenges?
Ramdas, A; Harris, P; Soltan, A

Liverpool Womens Health NHS Trust, Liverpool, United Kingdom
Introduction Abdominal pregnancy represents about 1% of all
ectopic pregnancies and is usually defined as a pregnancy located

within the peritoneal cavity outside the fallopian tubes but not in
the broad ligament. It is associated with a seven fold increase in
risk of mortality compared to tubal ectopic pregnancy. We here
report a case of advanced left broad ligament pregnancy diagnosed
intraoperatively at 22 weeks of gestation.
and challenging event occurring in 0.002% or 1 in 13 000

pregnancies. CRC presents a diagnostic and therapeutic challenge
because its symptoms are attributed to the usual manifestations of
pregnancy resulting to its delayed diagnosis and progression to an
advanced stage. There are no standardised guidelines for its
management. The aims of treatment are early therapy for the
mother and delivery of the baby at the earliest time possible while
simultaneously balancing maternal and fetal risks.
Case A 29-year-old G2 P1 (1001) 2526 weeks gestation
presented with rectal bleeding. Haematochezia started a year ago
during her first pregnancy that was attributed to haemorrhoids.
Symptoms progressed now associated with anal pain and cybalous
stools. On rectal examination, there was a 4 cm non-tender mass
on the right lateral and posterior rectum. Colonoscopy showed a
highly friable fungating mass occupying 7080% of the rectal
lumen, 45 cm from the anal verge. MRI showed a 3 9 8 cm
297
posterior mid-low rectal mass with peri-rectal fat infiltration and

23 cm pre-sacral lymphadenopathies probably neoplastic. Biopsy
revealed Rectal Mucinous Adenocarcinoma Stage III. A
multidisciplinary management was planned involving
Perinatology, Medical Oncology, Colorectal Surgery, Radiation
Oncology, Neonatology and Bioethics Committee. Due to the
advanced stage of the disease, immediate treatment was ideal with
chemoradiation followed by surgery. However, since radiation
therapy was hazardous to the fetus and the pregnancy was remote
from term barring early delivery, the team decided on
neoadjuvant chemotherapy to control tumour spread while
bringing the pregnancy close to term. Two cycles of a 2-week
course of oral Capecitabine (Xeloda) 2500 mg daily in 2 divided
doses was administered. Biweekly fetal surveillance was done. At
3132 weeks gestation, antenatal corticosteroids and magnesium
sulfate for neuroprotection was given. The cervix was primed
using evening primrose. After 2 days, induction of labour was
started using oxytocin drip. On the 3rd induction day, she
delivered vaginally to a live male, 35 weeks paediatric age,
appropriate for gestational age, Apgar 9,9. No malformations
noted. Chemoradiation followed by surgery was planned post
delivery.
Conclusion When colorectal cancer is diagnosed during
pregnancy, optimum outcomes can be achieved with a rapid
multidisciplinary approach. Early delivery of a viable infant
allowing for the earliest treatment of the patients cancer can be
done at a gestational age of 32 weeks. Meanwhile, chemotherapy
during the 2nd and 3rd trimesters to delay cancer progression
showed no adverse fetal effects.
EP13.105
Employment: a protective factor against antenatal
depression in a rural setting with high incidence of
self-harm and suicide?
Ranasinghe, ORJC1; Agampodi, SB2; Herath,

HMJN1; Premadasa, J1; Thilakaratne, YGRKK1
1
Teaching Hospital Anuradhapura, Sri Lanka; Department of

Community Medicine, Faculty of Medicine and Allied Sciences,
Saliyapura, Sri Lanka
Introduction Anuradhapura district has the highest incidence of
suicide in Sri Lanka and Sri Lanka is having 4th highest incidence
of suicide globally. Suicide was reported as one of the commonest
cause of death during pregnancy and postpartum period in
Anuradhapura. For prevention of suicide, early detection of
antenatal depression and identification of related factors is
essential. Our aim was to determine the prevalence and risk
factors associated with antenatal depression.
Methods Consecutive pregnant women with more than 36 weeks
of period of amenorrhea and admitted to two antenatal units of
Teaching Hospital Anuradhapura, Sri Lanka for delivery over a
period of 2 weeks were included in the study. Basic demographic
data were collected and validated Sinhalese translation of
Edinburgh Postpartum Depression Scale (EPDS) was administered
on admission to antenatal ward. Previously validated cut off value
298
of 9 was used to screen for antenatal depression. We used chi

square for trends to explore the association between selected
factors and antenatal depression.
Results Total of 151 pregnant women were included in this
analysis. Gestational age of 75.5% of the sample was between 39
to 40 weeks. Mean age of the study sample was 27 (SD 5.8) years.
Study sample included 60 (40%) primiparous women. Of the total
sample, only 19 (12.7%) were reported as currently employed.
EPDS scores of the study sample ranged from 019 with a median
of 5 (interquartile range 37). Of the women tested, 27 (17.9%)
had EPDS score >9. None of the employed women had EPDS
score >9 compared to 27 (20.6%) housewives with high EPDS
scores (P = 0.029). Prevalence of EPDS score >9 among women in
their first or second pregnancy was 15.9% compared to others
(25%). Of the 14 teenage pregnant women, 5 (35.7%) had high
EPDS score compared to others (16.1%). However, these
observations were not statistically significant. Six (4.0%) pregnant
women had suicidal ideation (EPDS question 10). Suicidal
ideation was significantly higher among teenage pregnant women
(21.4%) compared to others (2.2%) (chi square = 12.32,
P < 0.001). None of the employed women had suicidal ideation
(0%) in this study sample.
Conclusion Employment seems to have a protective effect against
antenatal depression in this study sample. Further suicidal
ideation was significantly higher among teenage pregnant women.
More focused studies with this specific objective are needed to
identify unemployment as a risk factor.
EP13.106
The use of intravenous ferric carboxylase within
obstetric anaemia
Baker, D; Rajasri, A; Ravandreen, K

Royal Cornwall Hospital, Truro, Cornwall, United Kingdom
Introduction Anaemia in the obstetric population is most often
due to iron deficiency, with a prevalence of 38%. Our hospital

uses ferric carboxymaltose as a parenteral iron treatment in
obstetric anaemia. Ferric carboxymaltose has been shown to
provide a reliable rise in haemoglobin in a shorter period of time
when compared to oral ferrous sulphate. Autologous blood
transfusions carry significant risks to patients and we use
intravenous iron as a method of avoiding transfusions. Our
hospital policy is to transfuse at a haemoglobin less than 70 g/L
or less than 80 g/L if symptomatic. The aim was to assess our use
of ferric carboxylase in our obstetric population and its effect on
haemoglobin level and autologous blood transfusion rate.
Methods Results from 119 patients who received intravenous iron
during an 8 month period were collected, including: pre and post
haemoglobin level, any autologous blood transfusions and whether
patients were ante or postnatal. The average rise in haemoglobin
was calculated along with any transfusions that were avoided.
Results A total of 119 women received intravenous ferric
carboxymaltose within an 8 month period in our hospital; of
these 19 were antenatal and 100 postnatal. The mean haemoglobin
concentration pre administration was 81.9 g/L and post
administration 105.5 g/L, a rise of 23.6 g/L. An average dose of

400 mg was used. Of our studied population 10.9% of women
also required autologous blood transfusion. 22 units were
transfused to 13 of our women. There were five women who met
the hospital criteria for blood transfusion and these were avoided
with the use of ferric carboxylase.
Conclusion The use of intravenous ferric carboxymaltose has the
advantages of providing a faster and more effective rise in
haemoglobin concentrations. Our audit shows that our obstetric
population who received intravenous ferric carboxymaltose
achieved a mean rise in haemoglobin of 23.6 g/L. In addition, five
women avoided blood transfusions with the use of intravenous
iron.
EP13.107
Maternal outcome with hepatitis E in pregnancy
Rizwan, N
Department of Gynaecology and Obstetrics, LUMHS, Pakistan
Introduction Hepatitis in pregnancy presents challenging disease
to the obstetrician.
Methods This study was carried out in department of
Gynaecology and Obstetrics Liaquat University Hospital from

January 2012 to May 2013. All pregnant women with serologically
proven HEV were included in study. All patients having viral
infection other than HEV and cholestasis of pregnancy, preeclampsia etc were excluded. Diagnosis was based on clinical
examination and investigation which included serological tests like
hepatitis E IgM antibodies, viral serological for hepatitis A, B and
C, LFT, CBC. Data were collected regarding age, parity,
gestational age and fetomaternal outcome. All women were
admitted and were followed during pregnancy status, any
complications maternal and fetal morbidity and mortality was
recorded. All patients were managed in collaboration with
physician. Data was analysed on SPSS version 16.0. Quantitative
variables like age, gravidity and gestational age were analysed
using simple descriptive statistics like mean and standard
deviation, qualitative variable such as fetal and maternal outcome
were calculated using frequency and percentages.
Results Twenty-seven patients were admitted during the study
period with hepatitis E infection. Most were primigravidas 19
(70.37%). Mean age of women was 34.8 years. Most of the
women presented in third trimester (66.6%). All these women
were serologically proven hepatitis E while 03 were HbsAg
positive. Mode of delivery was vaginal in 23 (85.18%). Labour was
spontaneous in 18 (66.66%) and it was induced in 9 (33.33%)
patients with prostaglandin E2. Hepatic encephalopathy were
found in 6 (22.2%), DIC in 2 (7.40), PPH 4 (14.81), APH 2
(7.40%). Maternal death was recorded in 6 (22.22%) patients.
Regarding perinatal outcome 19 (70.3%) babies were born alive.
Nine (33.33%) were premature. Intrauterine death was found in 8
(29.62%).
Conclusion Acute viral hepatitis E has a high mortality in
pregnancy, termination of pregnancy improves the outcome.
EP13.108
Antenatal prediction of caesarean section delivery
Robson, DE1; Braniff, KM2; Gunnarsson, RK1,3,4

1
School of Medicine and Dentistry, James Cook University, Australia;

Obstetrics and Gynaecology, Mackay Base Hospital, Queensland,
Australia; 3Research and Development Unit, Primary Health Care and
Dental Care, Southern Alvsborg

County, Region Vastra G
otaland,
Sweden; 4Department of Public Health and Community Medicine,
Institute of Medicine, Sahlgrenska Academy, University of
Gothenburg, Sweden
2
Introduction The rates of caesarean section delivery in the
developed world are increasing. The increased rates of caesarean

section delivery are often attributed to the social and cultural
changes of the 21st century, yet the World Health Organization
argues that caesarean section rates should be no higher than 10
15%. Many developed countries such as Australia and the USA
have rates well above 30%, yet other developed countries such as
Sweden maintain modest rates of 17.3%. The variations between
countries has not been thoroughly explained by current research
which has sought to examine determinants and risk factors for
caesarean section delivery. Few studies further established this
research to form a prediction model for caesarean section delivery.
A prediction model that can be applied in an antenatal setting
could arguably improve antenatal education and assessment of
potential determinants for caesarean section delivery. This study
aimed to investigate current determinants for caesarean section
delivery in Australia and establish an antepartum prediction
model for both nulliparous and multiparous women.
Methods A retrospective study examining data from 20102012
obtained from the Queensland Perinatal Data Collection, Health
Statistics Centre. A total of 182 684 women were included in this
study. Both multiparous and nulliparous women were analysed.
Individual determinants were analysed against likelihood of
caesarean section delivery, using bivariate and multivariate logistic
regressions. Factors examined included maternal age, BMI,
Indigenous or Torres Strait Islander ethnicity, smoking, assisted
conception, maternal origin of birth, marital status, parity,
delivery at private versus public hospital, type of antenatal care,
amniocentesis, maternal comorbidities and last birth method.
Results While all determinants showed predictive accuracy, the
nulliparous model proved to have poor internal validity. However,
a useful antepartum prediction model was established for
multiparous women. This model could accurately predict the
majority of caesarean section delivery, with area under curve
being 0.892.
Conclusion A user-friendly prediction model for caesarean section
delivery can be used by clinicians to identify women with a high
risk for caesarean section delivery earlier. For some of these
identified women it might be relevant to discuss their attitude
towards and preference of different forms of delivery. The
information can also be used by policy makers to identify groups
of patients where caesarean section delivery seems to be higher
than expected.
299
EP13.109
Successful pregnancy outcome after treatment for
primary lung cancer
1
Robson, S ; Englund, M ; Burke, W ; Brazenor,

S1; Leong, D1; Rezo, A1; Tharion, J1
1
Australian National University Medical School, Garran, Australian

Capital Territory, Australia; 2Gosford Hospital/Central Coast Local
Health District Gosford, New South Wales, Australia
Introduction The incidence of primary lung cancer in young
women in Australia is extremely low, with an age-specific

incidence of 0.7 per 100 000. The coexistence of primary lung
cancer and pregnancy is rare but might be expected to increase
with increased rates of smoking in young women, increased
maternal age during pregnancy, and the increasing incidence of
lung cancer worldwide. The only previous case report of successful
pregnancy after treatment for primary lung cancer is of a 25-yearold woman who underwent right middle lobectomy for welldifferentiated papillary adenocarcinoma followed by adjuvant
radiotherapy. Five years after treatment, she conceived and
delivered a healthy child.
Case An asymptomatic 29-year-old non-smoking woman was
found to have a 42 mm lobulated mass in the left lower lobe of
the lung on imaging. Left pneumonectomy was performed,
confirming a non-small cell lung cancer of adenocarcinoma
subtype, stage of 3A. Following successful resection she received
adjuvant chemotherapy with cisplatin and vinorelbine, followed by
radiotherapy. A naturally conceived pregnancy was achieved at age
32 years. On review at 16 weeks she was comfortable at rest, with
an SaO2 on room air was 98% and clinical signs consistent with a
left pneumonectomy, but no clinical features of right heart strain
or pulmonary hypertension. Her lung function was as follows
(predicted values in brackets): FEV1 1.18L (2.43L), FVC 2.00L
(3.41L), RV 0.45L (1.48L), TLC 2.46L (4.81L). She achieved 80%
of her predicted 6-min walk distance but desaturated from 98% to
86%. Echocardiography was technically difficult but did not show
evidence of pulmonary hypertension. Obstetric progress was
normal, with no maternal or fetal complications. The baby was
delivered by elective caesarean section at 36 weeks of gestation.
The patient made an unremarkable postnatal recovery and the
baby, a boy weighing 2.57 kg (just above the 25th centile for
gestation) was delivered in good condition, with unremarkable
subsequent infant development to 6 months.
Conclusion Lung cancer in women of reproductive age is
extremely uncommon, with only eleven other cases reported in
the literature. When the diagnosis is made during pregnancy, the
prognosis is uniformly poor. In the only 2 reported cases of
primary lung cancer diagnosed and treated curatively several years
prior to the pregnancy, and for pregnancies following
pneumonectomy for benign disease, the outlook for the mother
and baby is favourable.
300
EP13.110
Recurrence of placental spectrum disorders
Lee, V1,2; Ryan, J2; Brown, MA3,4; Pettit, F3,4;

Davis, G1,2; Henry, A1,2,5
1
School of Womens and Childrens Health, UNSW Medicine,

Australia; 2Womens and Childrens Health, St George Hospital,
Kogarah, Sydney, Australia; 3St George Clinical School, UNSW
Medicine, Australia; 4Department of Renal Medicine, St George
Hospital, Kogarah, Sydney, Australia; 5Australian Centre for Perinatal
Science, UNSW Medicine, Australia
Introduction Hypertensive disorders of pregnancy (HDP),
particularly pre-eclampsia, and intrauterine growth restriction

(IUGR), are both important causes of perinatal mortality and
morbidity. Abnormal placentation underlies both disorders, and
clinically they overlap, with IUGR a recognised fetal manifestation
of pre-eclampsia that in some cases precedes hypertension. We
aimed in this study to identify cases of placental spectrum
disorder (PSD) (IUGR and HDP), and to examine the
relationship between, and relative recurrence risks of, PSD
components.
Methods Databases at our metropolitan Sydney hospital (St
George Hospital) were used to identify women with both 1) index
pregnancy (IP) complicated by HDP, birthweight <10th centile for
gestation and gender (SGA), or mixed HDP/SGA during the study
period (20072013), and 2) subsequent pregnancy (SP)
>20 weeks gestation at St George Hospital.
Results There were 360 IP with PSD: 252 (70%) were HDP, 74
(21%) SGA, and 34 (9%) mixed HDP + SGA. Most cases were
nulliparous (79%), 56% were born in Australia and 26% in Asia,
and 98% were singleton pregnancies. Average maternal age was
31 years and mean BMI 26 (BMI 26.8 in HDP only versus 22.3 in
SGA only, P < 0.001). Most delivered at term (average gestation
37.7 weeks, NS between PSD groups), with average birthweight
3.3 kg, 2.3 kg, and 2.4 kg respectively for HDP, SGA and mixed
groups (P < 0.001). In the SP, there was a 50% chance of
recurrent PSD. Risk of recurrence differed by index pathology:
54% of HDP had a PSD recurrence, 32% of SGA, and 62% of
HDP + SGA (P = 0.002). When HDP complicated the IP, the SP
was complicated by HDP 49%, SGA 1.6%, HDP+SGA 3.2%. SGA
in the IP was associated with 32% recurrence of SGA, and no
HDP or mixed PSD. Mixed PSD in the IP recurred as HDP 44%,
12% SGA, 6% HDP+SGA. SP birthweight increased by average
259 g (3.4 kg, 2.5 kg, 1.9 kg, and 3.4 kg in HDP, SGA, mixed and
uncomplicated SP groups), however the 10 cases with mixed
HDP+SGA as their recurrent PSD were phenotypically more
severe than IP mixed cases, with birthweight 1.9 kg and gestation
at birth 35.5 weeks.
Conclusion Recurrence of PSD is common. The most common
form of PSD in our cohort was HDP, both initially and in
recurrence. When the original PSD was isolated SGA recurrence
risk was lower (32%) than for HDP (54%) or HDP+SGA (62%),
and any recurrent PSD was also SGA, suggesting a different
placental pathophysiology to cases involving HDP.
EP13.111
Can we manage diet controlled GDM in the
community? Outcomes and experience from the
Royal London Hospital 20112013
1
EP13.112
Chorioangioma of placenta resulting in
polyhydramnios and preterm labour
1
Sacco, A ; Lu, R ; Sanghi, A ; Thangaratinam, S ;

Huda, MSB2
Ackgoz, A1; Sahin, O2; Cakmak, B3; Aydn, B1;

Kolomuc, T1; Uludag, S1
1
Department of Womens Health; Department of Diabetes and

Metabolism, Royal London Hospital, Barts Health NHS Trust London,
United Kingdom
Istanbul University Cerrahpasa Medical Faculty Obs&Gyn

Department, Istanbul, Turkey; 2Kanuni Training and Research
Hospital, Trabzon, Turkey; 3Sanlurfa Maternity Hospital, Sanlurfa,
Turkey
Introduction In England and Wales it is estimated that 25% of
Introduction Chorioangioma is the most frequent benign, vascular
pregnancies are complicated by diabetes, and of these 87.5% have

gestational diabetes mellitus (GDM). The Royal London Hospital
is a tertiary maternity unit with a high prevalence of GDM of
between 11.513.0% of pregnancies. This is due mainly to a high
risk local population with large numbers of women from
Bangladeshi and south Asian communities. Since 2003, women
with GDM requiring lifestyle modification only have been
managed in the community by midwives and local general
practitioners (GPs), and not in the hospital setting. Our aim was
to retrospectively assess outcomes for this cohort to ensure that
community-based care was safe and effective.
Methods All women who had a positive 75 g glucose tolerance
test (GTT) (fasting >5.8 mmol/L (104 mg/dL), and/or 2 hours
>7.8 mmol/L (140 mg/dL)) were referred to a one stop midwife
and dietitian led clinic for education and blood glucose
monitoring training. Women used a target range of pre-meal
capillary blood glucose readings (CBG) 3.55.8 mmo/L (63
104 mg/dL) and 2 hours post-meal <7.0 mmol/L (126 mg/dL).
CBG testing was carried out twice daily, and if two readings were
above target, they were referred to the hospital based service for
further management. Electronic case records were analysed.
Results Over two non-consecutive years (2011 and 2013), records
of 761 patients with GDM were examined. Six hundred and
twenty-eight (82.5%) women were managed with lifestyle alone
and we report the demographics and outcomes for this cohort.
The induction rate was 14.9% and caesarean section rate was
30.6%. Fetal macrosomia, defined as birthweight over 4000 g,
occurred in 41 cases (6.5%). Delivery prior to 37 weeks gestation
occurred in 49 cases (7.8%). There was one case of shoulder
dystocia (0.16%), no cases of neonatal hypoglycaemia and 47
(7.5%) admissions to the neonatal intensive care unit. There were
two cases of intrauterine death (0.32%), one due to placental
abruption and one due to multiple congenital abnormalities in a
consanguineous couple. These outcomes compare favourably to
the published literature in GDM.
Conclusion We found that in general, women with low risk
diabetes managed in the community had good outcomes and a
low level of complications. As the incidence of gestational diabetes
is rising, and pressure on hospital services increases, we propose
that community-based management for women not requiring
medication is safe and comparable to hospital-based care.
tumour of placenta. Although the reported incidence of

nonclinical chorioangiomas on pathologic examination is 1%, in
clinical variants it is approximately 1:9000. We report a case of
24 weeks pregnancy with a placental mass near cord insertion
resulting in polyhydramnios and preterm labour. Chorioangioma
is a vascular tumour of placenta associated complications with
amniotic fluid disorders and preterm delivery.
Case A 26-year-old pregnant at 24th week was referred to our
clinic with rapidly increasing preterm pains. Sonographic
examination revealed a single fetus, normal growth, no fetal
anomalies with polyhydramnios. Amniotic fluid index was 32.1
centimeters. In posterior wall of placenta 6 9 5 9 4.5 cm
echogenic mass with no evidence of placental abruptio was
detected. Tocolytics were administered. After 3 days of
administration hospital, uterine contractions were regular, the
uterus was distended with increasing amniotic fluid (amniotic
fluid index was 43.4 cm). Cervical dilatation was 5 cm with 60%
effacement. A baby was born with Apgar scores 3 and 5 at 1 and
5 min respectively. The weight of her was 980 g. There was a large
placenta, blood vessels of umbilical cord were normal but
hypoechoic mass within the placenta was seen near the cord
insertion. The histopathological diagnosis of the mass was
angiomatous chorioangioma. Patient was discharged home
uneventfully following delivery
Conclusion Most chorioangiomas are small and primarily
asymptomatic. The larger tumours have more chance of
developing maternal and fetal complications such as
polyhydramnios, premature labour, hydrops fetalis, intrauterine
growth restriction, fetal haemolytic anemia, thrombocytopenia,
pre-eclampsia, abruption and maternal coagulopathy depending
on the size and location of tumour. Among these complications,
the correlation of the tumour with polyhydramnios and preterm
labour were significant in our case. The most important thing in
these cases is optimising fetal outcome with ultrasound and
doppler and being aware of complications associated with
chorioangioma.
301
EP13.113
Evidence-based patient blood management
guidelines for obstetric and maternity patients
Savoia, H1; Roberts, J2; Abeypala, W3; Challis, D4;

Clarke, M5; Earnshaw, L6; Farmer, S7; French, C8;
McLintock, C9; Permezel, M10; Pollock, W11;
Rowlands, S12; Thomson, A13; Whitby, C14
1
Royal Australian and New Zealand College of Obstetricians and
Gynaecologists; 2National Blood Authority; 3Australian and New
Zealand College of Anaesthetists; 4Royal Australian and New Zealand
College of Obstetricians and Gynaecologists and Perinatal Society of
Australia and New Zealand; 5Independent Indigenous representative;
6
National Blood Authority; 7Independent Patient Blood Management
Consultant; 8Australian and New Zealand Intensive Care Society;
9
Australasian Society of Thrombosis and Haemostasis and Society of
Obstetric Medicine of Australia and New Zealand; 10Royal Australian
and New Zealand College of Obstetricians and Gynaecologists;
11
Australian College of Midwives; 12Royal Australian and New Zealand
College of Obstetricians and Gynaecologists and Perinatal Society of
Australia and New Zealand; 13Australian and New Zealand Society of
Blood Transfusion; 14Independent Consumer representative
Introduction The National Blood Authority, Australia, is
managing a comprehensive review and update of the 2001

National Health and Medical Research Council/Australasian
Society of Blood Transfusion (NHMRC/ASBT) Clinical Practice
Guidelines on the Use of Blood Components. Six evidence-based
Patient Blood Management (PBM) Modules will replace the 2001
Guideline. The modules are being developed by clinical experts for
specific populations: Critical Bleeding/Massive Transfusion (2011),
Perioperative (2012), Medical (2012), Critical Care (2013),
Obstetric and Maternity (2014) and Paediatric/Neonatal
populations. PBM minimises the need for transfusion by
improving red cell mass, conserving the patients own blood and
improving tolerance of anaemia. This abstract presents the
findings of Module 5 Obstetrics and Maternity.
Methods A Clinical/Consumer Reference Group (CRG) with
experts from clinical colleges and societies was established for each
Module. The CRG defined the scope of the questions for
systematic review for Module 5. These questions included: the
effect of red cell and other blood component transfusion on
patient outcomes, the effect of non-transfusion measures on
haemoglobin, and the effect of non-obstetric strategies to
minimise maternal blood loss on transfusion and clinical
outcomes. The CRG used the NHMRC guideline development
process to develop the research protocol, conduct the systematic
reviews and generate evidence-based recommendations. Practice
Points were developed when the evidence was insufficient to
generate an evidence based recommendation. Expert Opinion
Points based on CRG consensus were developed when a
systematic review was not undertaken. An evidence-based
implementation strategy has been developed to support uptake of
the Modules. Module 5: Obstetrics and Maternity was submitted
to NHMRC in September 2014 for approval.
Results The first four Modules have been approved by NHMRC.
Over 175 000 copies have been either ordered (>75 000) or
downloaded (>100 000) across 81 countries. The implementation
302
strategy has included the development of multiple Blood Safe

eLearning courses, multiple tools and the concurrent development
of a Blood Standard for Health Services. Blood usage has decreased
significantly. Module 5 received an Appraisal of Guidelines for
Research and Evaluation (AGREE) II methodological assessment
rating of 6/7 from two independent assessors. The Module contains
four evidence-based Recommendations, 33 Practice Points and 18
Expert Opinion Points.
Conclusion If blood components are likely to be indicated,
transfusion should not be a default decision. Instead, the decision
on whether to transfuse should carefully consider the specific
patient circumstances, preferences, and the full range of available
therapies, balancing the evidence for efficacy and improved
clinical outcome against the potential risks.
EP13.114
The need for an enhanced recovery programme: a
pre-implementation audit
Whitehouse, K; Saxena, S
Health Education North East, United Kingdom
Introduction Enhanced recovery has been improving patient
experiences in a range of surgical specialties for a number of

years; reducing length of stay, improving patient satisfaction and
increasing patient throughput. Enhanced recovery for the
management of elective caesarean sections is becoming
increasingly common and has shown similar benefits. The Royal
Victoria Infirmary (RVI), Newcastle upon Tyne, is a busy tertiary
obstetric centre with approximately 8500 deliveries per annum. An
enhanced recovery programme will soon be rolled out to improve
the service provided for elective caesarean sections. A preimplementation audit was undertaken to highlight areas of care
that need to be improved by this programme.
Methods A prospective audit was carried out over a 1 month
period. Data was collected for all elective caesarean sections
performed during this time. Information recorded included the
duration of fasting preoperatively, time to resumption of diet
postoperatively and time to postoperative mobilisation and
discharge.
Results In June 2014 audit data was collected for each of the 70
elective caesarean sections performed at the RVI. This data was
complete for 56 cases. Preoperatively patients were fasted for on
average 6 hours for water and 13.4 hours for food. Postoperatively
patients waited 2.3 hours before drinking and 5.8 hours before
eating. Women waited 19.4 hours before getting out of bed and
39.5 hours before discharge home.
Conclusion Patient care will be improved in a number of areas by
the introduction of an enhanced recovery programme. Reducing
fasting times both pre and postoperatively will help to reduce the
physiological stresses of surgery, hence improving patients
outcomes. Early mobilisation is important post caesarean section;
it improves a womans experience in enabling her to care for her
newborn with greater ease but medically, mobilisation reduces the
risk of developing VTE (venous thrombo-embolism). Currently
women are waiting on average 19.4 hours before getting out of
bed. As part of the proposed enhanced recovery programme this

time will be reduced significantly. Enhanced recovery programmes
have been shown to reduce the length of inpatient stay. Reducing
the stay from 39.5 hours will improve a womans overall
experience as well as reducing complications associated with
prolonged hospital stays. Following the implementation of the
enhanced recovery programme at the RVI, this audit will be
repeated in order to confirm these proposed improvements.
EP13.115
Why assisted vaginal deliveries fail: a casecontrol
study in a tertiary hospital
Shamsa, A1; Raviraj, P2; Bai, J3; Babazadeh, M3;

Gyaneshwar, R3
1
Clinical Womens and Newborn Health, Westmead Hospital, Sydney,

New South Wales, Australia; 2Department of Obstetrics and
Gynaecology, Blacktown Hospital, Sydney, New South Wales,
Australia; 3Department of Obstetrics and Gynaecology, Liverpool
Hospital, Sydney, New South Wales, Australia
Introduction Although assisted vaginal deliveries (AVD) have
been reported relatively safe by some authors, they carry their

own attendant risk to the mother and the neonate. Difficult and
failed instrumental deliveries result in even greater adverse
neonatal outcomes, thus avoiding these interventions when failure
is likely, is an important management strategy. Overall failure
rates of vacuum and forceps-assisted delivery vary in different care
settings, ranging from 1% to 30% depending on other influential
factors. The aim of this study is to identify the predictive factors
for failed operative vaginal delivery and in order to inform
clinicians about the potential risks.
Methods This is a retrospective review of assisted vaginal
deliveries preformed in Liverpool Hospital, a tertiary health
facility in south western New South Wales. The electronic medical
records were used to identify subjects in 3 year period, 2007
2010. Failure of operative vaginal delivery is defined as failing the
first attempt of delivering a baby assisted by vacuum or forceps.
Multiple pregnancies were excluded from the study. We
hypothesised a priori that the duration of labour, birthweight,
primiparity, training level of the care provider and supervision by
a senior obstetrician are factors with potential factors to predict
the likelihood of a successful instrumental delivery.
Results During the 3-year period, a total of 545 vacuum-assisted
deliveries and 166 forceps-assisted deliveries were attempted
including trial of instrument in operating theatre. Vacuum
extraction failed in 64 patients (11.7%) while the failure rate for
forceps lift out was 7.3%. Duration of second stage of labour, fetal
presentation and station, number of pulls with instrument and
detachments of vacuum cup and being a public patient are factors
significantly associated with failure of AVD (P < 0.5). Failed
instrumental deliveries led to significantly higher estimated blood
loss. A number of factors including duration of first stage of
labour, having an epidural block as the method of analgesia, total
time of instrument application and timing of delivery, classified in
different working shifts were almost significant (P < 0.1).
Conclusion Our results confirm other studies showing higher rate
of failed vacuum deliveries compared to forceps and similar

incidence of failed AVD. Fetal birthweight, parity, seniority of the
operator and presence of supervision did not affect the success of
attempted instrumental deliveries.
EP13.116
Induction of labour in women with previous one
caesarean section; mifepristone versus transcervical
Folleys catheter. A randomised controlled trial
Sharma, C; Soni, A; Thakur, S; Verma, S

Dr Rajendra Prasad Government Medical College, Kangra at Tanda,
H.P., India
Introduction Caesarean section (CS) rates are increasing
worldwide leading to an increase in pregnant women with

previous CS. With limited options available, induction of labour
is a challenge in pregnant women with previous CS. Hence, search
for an ideal agent for induction of labour in these women is need
of the hour. So we investigated the role of single dose
mifepristone (400 mg) orally for induction of labour in post
dated women with previous one CS and compared it with
transcervical Folleys catheter.
Methods In this prospective randomised controlled trial,
induction of labour was done in post dated (gestation 40 weeks
5 days) pregnant women with previous one low segment CS.
Women in group 1 received 400 mg of mifepristone orally and
those in group 2 were inserted with transcervical Folleys catheter.
All the women were reassessed 24 and 48 hours later.
Spontaneous onset of labour after first manoeuvre was recorded.
If at any time (24 or 48 hours) bishop score was more than 6;
amniotomy was done, followed by oxytocin infusion. If still after
48 hours, bishop score was less than 6 induction of labour was
done with oxytocin infusion. The primary outcome of the study
was spontaneous onset of labour. Secondary outcomes were
cervical ripening (24 or 48 hours), vaginal delivery, CS, need of
oxytocin and proportion of women with scar dehiscence/rupture
in two groups.
Results From June 2012 to September 2014, we enrolled 107
women. Out of these, 57 received oral tab mifepristone (400 mg)
and 50 were inserted with trans-cervical Folleys catheter.
Spontaneous onset of the labour after first manoeuvre was
statistically significantly more in group 1 as compared to group 2
(37/57 versus 13/50 respectively; P = 0.0001). More women in
group 2 required oxytocin for labour induction as compared to
group 1 (39/50 versus 24/57 respectively; P = 0.0007). Scar
dehiscence/rupture was seen more commonly in group 2 (9/50
versus 3/57), this difference approached significance (P = 0.062)
There was no statistically significant difference in normal delivery
or CS in either group (P = 0.242 and 0.331 respectively). Women
in group 2 had better cervical ripening after 24 hours (P = 0.000)
but not after 48 hours (P = 0.098).
Conclusion Oral mifepritone (400 mg) is a better option for
induction of labour in post dated pregnant women with previous
one CS, as compared to transcervical Folleys catheter.
303
EP13.117
Case report: twin IVF pregnancy with severe
pre-eclampsia with peripartum cardiomyopathy
Sharma, S; Singh, NN; Meetei, LT; Terhase, N;

Sapkota, A
Department of Obstetrics and Gynaecology, Regional Institute of
Medical Science, Imphal Manipur, India
Introduction Peripartum cardiomyopathy a type of dilated
cardiomyopathy of unknown origin, seen from last month of

pregnancy to 5 months after delivery, with incidence <0.1% and
with high morbidity and mortality rates as high as 5%32%. In
this case presentation we review peripartum cardiomyopathy and
present guideline for practice.
Case A 48-year-old primigravida, twin pregnancy following IVF
conception, 33 weeks 6 days gestation, with high BP, difficulty in
breathing, swelling of the lower limbs and pain abdomen on and
off. With no previous significant medical history of heart disease.
USG for fetal wellbeing was normal but other investigation shows
deranged liver enzymes, TSH- 11.97 lIU/mL (on thyronorm
25 lg OD) and urine routine examination shows proteinuria 3+.
Patient was managed conservatively for 3 days with
antihypertensive drugs and betamethasone injection. She
developed acute respiratory distress at 34 weeks 3 days, for which
she was shifted to ICU under mechanical ventilation as her Spo2
dropped down to 40% with oxygen. Decision for termination was
taken at 34 weeks 3 days in ICU and she underwent caesarean
section. Two female babies weighing 1.9 and 2 kg respectively
with normal Apgar score were delivered. PPH develop
intraoperatively secured with B lynch suture. She developed acute
respiratory distress again on 6th postoperative day, managed
conservatively, with echocardiogram showing signs of
cardiomyopathy (ejection fraction 43%, end-diastolic dimension
2.7 cm/m2). Follow-up examination at 6 months showed a stable
cardiomyopathy, with well controlled hypertension on cardiac
medication.
Conclusion To achieve successful pregnancy outcome, a clear
understanding of haemodynamic adaptation that occur in
pregnancy, meticulous maternal and fetal surveillance for risk
factor and complications throughout the antepartum,
intrapartum, and postpartum period as well as a multidisciplinary
approach is essential. Physician should be familiar with
peripartum cardiomyopathy and therefore consider it when
diagnosing dyspenic patients to expedite medical treatment for a
potentially lethal condition.
(45.5%) and children made up to 2.0 million (6.06%). 90% of

HIV positive children acquired the virus from their mother. The
risk of transmission of virus from mother to baby is about 15
30%. The aim of this study was to see the fetomaternal outcome
of pregnancy in the HIV positive mother.
Methods Prospective study was carried out from July 2006 to
June 2008 in RIMS, Imphal. The study was further continued up
to September 2014. 50 HIV infected women (cases) were
compared with 150 (controls). Statistical analysis was done using
chi square test with epi info version 6 software. P < 0.5 was taken
as significant. The patients in the study group were followed
regularly for progress and complications during the pregnancy
period. CD4 cell count was done for all the cases with CD4 < 250
were given ART. Mothers were administered oral Nevirapine with
the onset of labour. Term newborns were administered weight
adjusted dose of Nevirapine drops at birth. Birth parameters of
newborn recorded and followed for HIV seroconversion at
18 months.
Results Out of 142 577 patients, attending the antenatal clinic,
110 088 (77.21%) were counselled and 96 007 (86.58%) were
tested between July 2006 and September 2014. 502 patients were
found to be HIV positive with the prevelance of 0.52%. The
overall antepartum complications were 68% in cases versus 33%
in control. Anaemia and preterm labour were significantly more
in study group, P = 0.0001 and P = 0.02 respectively. The mean
gestational age at birth was shorter in study group (37.33 2.32
versus 38.13 1.43). Mean birthweight was found slightly lower
(3.08 0.454 kg versus 3.19 0.491 kg). Vertical transmission at
18 month of age was found to be very low (5%).
Conclusion Prevalence of HIV infection among pregnant women
in Manipur is high. HIV infected women had higher incidence of
adverse pregnancy outcome than uninfected controls. The course
of HIV infection seems to be unaffected by pregnancy as there
was no incidence of disease progression to AIDS defining disease
though CD4 cell count of less than 250 was found in 48% of
cases. ART, elective caesarean and replacement feeding were found
to be associated with lower rate of mother to child transmission.
EP13.119
Investigating TSH and parturition
Sheehan, P1,2; Stevenson, J2

1
Department of Obstetrics and Gynaecology, University of Melbourne,
Australia; 2Pregnancy Research Centre, RWH, Melbourne, Australia
Introduction Preterm birth, the delivery of a baby before
EP13.118
Fetomaternal outcome in HIV infected women
Sharma, S; Singh, LR; Sapkota, A

Department of Obstetrics and Gynaecology, Regional Institute of
Medical Science, Imphal Manipur, India
Introduction An estimated 33.0 million people in the world are
living with HIV out of which women account for 15.45 million
304
37 weeks completed gestation is associated with high rates of

neonatal mortality and morbidity including long-term disabilities.
Epidemiological studies have provided some evidence that thyroid
autoimmunity is a risk factor for preterm birth. Hypothyroidism
is reasonably common in women of reproductive age. In a recent
meta-analysis, the authors identified five studies including a total
of 12 566 women. The OR for preterm birth with thyroid
antibodies was 2.07 (95% CI 1.17 to 3.68; P = 0.01). Similarly,
women with subclinical hypothyroidism have been found to have
an increased risk of preterm birth in a recent systematic review
(OR 1.9, 95% CI 1.13.5). One possible mechanism is through the

action of thyroid stimulating hormone (TSH). The TSH receptor
(TSHR) is an integral membrane protein coupled to the Gs
protein in common with prostaglandins D2 and I2 and b
adrenergic receptors. The presence of TSHR in human myometrial
cells has not previously been investigated.
Methods In this study we investigated the association between
TSH and gestation at delivery in pregnant women attending the
Royal Womens Hospital. We also investigated the expression of
TSHR mRNA and protein in myometrial samples obtained from
women at caesarean section with or without labour (n = 10) by
real time RT-PCR and western blot and examined the effect of
raised TSH on myometrial explants in culture.
Results An audit of 347 TFT results in 180 patients shows a
significant association between gestation at delivery and TSH
taken only in the second trimester in patients not on thyroxine
(r2 = 0.2, P = 0.04). There was no association with TSH in the
first trimester or in patients on thyroxine supplementation. Realtime RT-PCR showed a decrease in TSHR expression in
myometrial samples with labour (P = 0.0009). A similar decrease
was seen in TSHR protein, confirmed by western blot. TSHR was
identified by immunohistochemistry in both myometrium and
placenta. TSHR mRNA expression in the placenta was unchanged
with labour. In myometrial cells maintained in culture, incubation
with increasing concentrations of TSH resulted in significantly
increased TSHR expression.
Conclusion TSHR is expressed in reproductive tract tissues such
as placenta and myometrium and decreases signficantly in labour.
Treatment with thyroxine removes the association between TSH
and gestational age at birth.
EP13.120
Antenatal corticosteroids in the septic antenate
to give or not to give?
Shukralla, H
King Edward Memorial Hospital, Perth, Western Australia, Australia
Introduction The benefit of a course of antenatal corticosteroids
(ACS) in pregnant women at risk of preterm birth is well

established. Most women requiring corticosteroids tolerate the
drug well with only transient side effects, but real concern about
the immunosuppressive action of steroid administration exists in
the pregnant woman suffering systemic infection.
Case A 37-year-old G1P0 presented at 29+4 weeks of pregnancy
with abdominal pain, vomiting and diarrhoea of 1 day duration.
A diagnosis of appendicitis was made and the patient was
admitted for appendectomy. Nifedipine tocolysis was given but
ACS were withheld due to concern regarding the
immunosuppressive effect. At laparotomy the patient was found
to have an acute necrotising ruptured appendix with purulent
peritonitis. Postoperatively the patient remained stable, and did
not receive ACS during her admission. The patient went on to
deliver a 3.5 kg baby by spontaneous vaginal delivery at term.
Conclusion 1% of pregnant women will require surgery for nonobstetric indications. Surgery and anaesthesia can be complicated
due to the physiological changes seen in pregnancy and surgery in

pregnant patients is associated with an increased risk of preterm
birth. This case serves as a reminder that no consensus exists to
answer the question as to whether prophylactic steroids should be
given in septic antenates requiring surgery, and that decision
making should be tailored to the specific case.
EP13.121
The effect of hyoscine butylbromide on labour as a
labour accelerant and labour analgesic: a double
blind randomised controlled clinical trial
Singh, R; Das, V; Singh, U; Sujata, D

Department of Obstetrics and Gynaecology, King Georges Medical
University, Lucknow, India
Introduction The progression of labour depends on cervical
effacement and dilatation. The principle of active management of

labour was introduced to shorten the duration of labour while
achieving a low rate of caesarean delivery. Cervical dilatation can
be facilitated by mechanical, pharmacological and non
pharmacological methods. Cervix is widely supplied by autonomic
nerves, which may play a role in cervical dilatation. Hyoscine
butylbromide (HBB) acts by inhibiting cholinergic transmission in
the abdominal and pelvic parasympathetic ganglia thereby
relieving spasm in smooth muscles of gastrointestinal,
genitourinary tracts and cervico-uterine plexus. It acts as a cervical
spasmolytic agent. Being parasympatholytic, HBB has also been
tried for labour analgesia. The study was undertaken to observe
the effects of 40 mg intramuscular HBB on labour as a labour
analgesic and accelerant.
Methods The study was a randomised double blind controlled
trial. Two hundred twenty primigravid term pregnant women in
spontaneous labour received 2 mL of either HBB (40 mg) or
placebo (distilled water) intramuscularly once the women entered
the active phase of labour. Women were subjected to pain
quantification by using the verbal numeric 010 rating scale
(NRS) at the point of recruitment and 2 hourly for 6 hours
following drug or placebo administration. Since the exact time of
full dilatation of cervix was difficult to determine, delivery was
taken as the end point. The primary outcome was the injection
delivery interval and percentage change in pain. The secondary
outcomes were blood loss at delivery, mode of delivery and Apgar
scores for the neonates. The study protocol was approved by the
ethics committee.
Results A total of 245 women were eligible and consented for the
study. However 25 were excluded due to inappropriate selection,
thus 220 women eventually yielded data for analysis. Of these 110
women received placebo and 110 received HBB. The two groups
were comparable in age and gestational age. The mean injection
delivery interval (minutes SD) in placebo group was
significantly higher as compared to HBB group (312.0 76.6
versus 119.2 38.3; P = 0.001). The percentage change in pain
scores from baseline in the HBB group was 40.4% while it was
20.9% in the placebo group. This was statistically significant
(P = 0.001). The neonatal outcome and mode of delivery was
305
comparable in two groups. No adverse maternal effects were

observed.
Conclusion HBB is effective as a labour analgesic and labour
accelerant. Its use is not associated with any apparent adverse
maternal or neonatal outcomes.
EP13.122
Evaluation of adverse effects of hyperglycaemia on
pregnancies in the maternity unit of Mafraq
Hospital
Srivastava, S; Masry, K; Asghar, F; Ravi, M;

Khouri, K
Mafraq Hospital, Abu Dhabi, United Arab Emirates
Introduction Gestational diabetes (GDM) is an emerging health
problem (29% pregnancies). It is associated with high fetal,

neonatal and maternal morbidity. Increased risk of mother to
develop type 2 diabetes in first 5 years after delivery. The aim of
our study was to retrospectively analyse the outcomes of women
with gestational diabetes in our hospital and comparing our
management with the international standards and identifying
areas of improvement.
Methods Retrospective analysis of patients diagnosed as
gestational diabetes based on 75 g OGTT test was done during
12 month period from April 2012 to March 2013 in Mafraq
Hospital. IADPSG (International Association for Diabetes in
Pregnancy Study Group) values were used. The following data
were collected: ethnicity; BMI; final treatment given for GDM
management; gestation at delivery; mode of delivery; maternal
complication and neonatal admissions; fetal weight and
complications. Comparisons were made between outcomes of
pregnancy in women treated by diet alone and that on insulin and
also it was determined if treatment of diabetes reduced the
neonatal and perinatal complications.
Results During this period there were 2400 deliveries. 272
patients were identified to have GDM. Maternal: 112 patients had
BMI >30 and only 40 patients had BMI < 25. The rest were
between BMI 2530. 186 were diet controlled, 12 were metformin
controlled and 68 were insulin controlled. 9 had polyhydramnios.
45 delivered after 40 weeks. 39 induction of labour. Fetus: 15
babies were preterm. 192 babies were less than 3.5 kg. 60 babies
were 3.54 kg and 20 were >4 kg. 166 delivered normally. 106
had elective or emergency caesarean section. 21 babies had NICU
admission, 6 had shoulder dystocia, 1 had Bells palsy, 1 case of
intrauterine fetal death.
Conclusion Gestational diabetes is more common in multigravida,
older age group and patients with higher BMI. In our study the
incidence of GDM was 11.3% of which 70% were diet controlled
25% were insulin controlled and 5% were metformin controlled.
14% needed induction of labour due to GDM. 15% reached past
40 weeks clearly they needed delivery by 40 weeks so need for
closer follow-up and patient education. 2% had shoulder dystocia
and 7.7% needed NICU admission. Thus confirming risk of fetal
macrosomia, high neonatal morbidity in gestational diabetes and
need for proper antenatal care.
306
EP13.123
The characteristics and outcomes of women
requiring pharmacotherapy under the 2013
Australasian Diabetes in Pregnancy Society
Consensus Guidelines: comparing suggested
treatment targets and current practice in a north
Queensland cohort
Stitz, L; Kevat, D; Caddaye, S; McLean, A

Cairns Hospital, Cairns, Queensland, Australia
Introduction The 2013 Australasian Diabetes in Pregnancy Society
(ADIPS) Consensus Guidelines for the testing and diagnosis of

gestational diabetes mellitus (GDM) in Australia have proposed a
change in the self-monitoring blood glucose targets to levels of 5.0
fasting and 6.7 at mmol/L at 2 hours post prandially. The targets
proposed are lower than previously used in the north Queensland
region (fasting 5.5, 2 hour fasting 7.0 mmol/L), and therefore
result in a new group of women with milder hyperglycaemia who
will need commencement on pharmacotherapy such as insulin
during pregnancy.
Methods A prospective cohort study was undertaken at Cairns
Hospital comparing women with GDM as diagnosed on a 75 g
oral glucose tolerance test (diagnostic thresholds 5.5 mmol/L,
2 hour 8 mmol/L) who were managed with diet and lifestyle
measures (D), those managed with insulin as per current
guidelines (C), and those who are currently managed with diet
but would need to commence insulin under these new guidelines
(N). 308 women with GDM were enrolled in the study (group D
n = 119, group C n = 141, group N n = 48). Maternal and
neonatal outcomes were analysed. Microsoft Excel 2013 was used
to analyse results using ANOVA and chi square tests.
Results Comparing the group with milder hyperglycaemia who
would be treated under new treatment targets (N), with the
outcomes of group treated with insulin under current practice (C)
there was no statistical difference in birthweight, Apgar scores, or
rates of shoulder dystocia, perineal tear or postpartum
haemorrhage. Neonatal hypoglycaemia rates were lower in Group
N than in Group C or Group D which was diet controlled.
Gestation at birth for Group N was 39 weeks; 1 week longer than
that for Group C (P < 0.05).
Conclusion In our regional cohort from north Queensland, there
was no difference in outcomes between the group of women with
milder hyperglycaemia who would require treatment under
treatment targets under new guidelines, and the outcomes of the
women of currently receiving pharmacotherapy at higher levels of
hyperglycaemia. Intervening to treat milder hyperglycaemia in our
cohort would be unlikely to improve maternal or fetal outcomes.
Adopting new treatment targets would likely result in more
women delivering earlier at 38 weeks due to our current
institutional practice of delivering women on insulin at this
gestation. Further research including interventional studies are
required to elucidate the risks and benefits of treating mild
hyperglycaemia in pregnancy.
EP13.124
Evaluating obstetric medicine practice at Milton
Keynes hospital against good medical practice
guide of General Medical Council, United Kingdom
EP13.125
Obstetric and perinatal outcomes in women with
type 1 and type 2 diabetes mellitus
Jindal, S; Stock, A; Neale, E
Tambimuttu, E1; Lott, A2; McIntyre, D1; Kumar, S1
Milton Keynes Hospital NHS Foundation Trust, United Kingdom
Mater Mothers Hospital, Brisbane, Queensland, Australia; 2Royal

Brisbane and Womens Hospital, Brisbane, Queensland, Australia
Introduction The General Medical Councils (GMC) document
Introduction Pregestational diabetes mellitus can influence
Good Medical Practice (GMP) describes what standard is expected

of all doctors registered with them in order to maintain their
licence to practise.
Methods We undertook a qualitative assessment of obstetric
medicine practice at Milton Keynes Hospital against the four
domains of GMP. Domain 1: Knowledge, skills and performance.
The services are consultants led. All clinical staff make the care of
patients their first concern, are competent, keep their knowledge
and skills up-to-date by engaging in ongoing training, audit,
appraisals and revalidation. Good care is provided, with robust
governance systems in place. Domain 2: Safety and quality.
Concerns are raised in line with workplace policy in order to
promote a safe culture, e.g. all reported incidents are investigated.
Learning from incidents helps the Trust to provide safer
environment for patients, staff and visitors. Standards of practice
are audited regularly for quality assurance, e.g. in Milton Keynes
4.6% women need care under Obstetric Medicine network.
Multidisciplinary team reviews, combined clinics and performance
audits are the best possible options to ensure safer pregnancy and
safer childbirth (conclusion of audit in March 2014). Domain 3:
Communication, partnership and teamwork. All relevant
information is shared in a timely manner with colleagues involved
in a patients care. All team members work in partnership within
the multidisciplinary teams, e.g. please suggest plan for 15 weeks
woman presenting with Sjogrens syndrome (painful parotids),
ST6 Maternal Medicine; She needs bloods including ANA, anti
Ro, anti La, dsDNA, C3, C4, anticardiolipin Ab and treatment for
symptomatic parotids, Rheumatologist; If anti Ro, anti La
positive, please arrange fetal echocardiography, regular fetal
surveillance including Doppler assessment and recording weekly
fetal heart rate count because of risk of sudden heart block in
fetus, Consultant Obstetrician. Domain 4: Maintaining trust.
Patient confidentiality and trust is maintained according to the
principles of information governance and duty of candour as
quoted by the Chief Executive officer on hospital website:
Another recommendation in the Francis Report is the duty of
candour. This means that all staff need to be open and honest
about their concerns and for clinicians and managers to listen
and act on them.
Conclusion We have demonstrated that our Obstetric Medicine
practice aligns with the principles and values set in all the four
domains of GMCs Good Medical Practice.
obstetric and perinatal outcomes particularly if glycaemic control

is poor during pregnancy. Major complications include congenital
anomalies, macrosomia, pre-eclampsia and shoulder dystocia. The
aim of this study was to compare outcomes between women with
type 1 and type 2 diabetes mellitus delivering at a major
Australian tertiary centre.
Methods This is a retrospective cohort study of women with type
1 or type 2 diabetes delivering at the Mater Mothers Hospital in
Brisbane between January 2007 and November 2013. Medical
records were reviewed to obtain obstetric and perinatal outcomes.
Results A total of 458 pregnancies were identified. Women with
type 2 diabetes were older (33.80 versus 30.03 years old;
P < 0.001), had a higher BMI (32.42 versus 25.61; P < 0.001),
higher parity (3 versus 2, P < 0.001) and were more likely to be
smoking at booking (17% versus 11.6%; P = 0.096). In contrast
those with type 1 diabetes were more likely to have babies with
higher birthweights compared to those with type 2 diabetes
(3353.98 g versus 3156.38 g; P = 0.009) and more likely to deliver
a macrosomic baby (4 kg) (80.5% versus 86.7%; P = 0.061).
Women with type 2 diabetes were less likely to have an
episiotomy (4% versus 17%; P = 0.025) and more likely to have a
spontaneous vaginal delivery (51% versus 49%, P < 0.001). The
rates of emergency caesarean section were also higher in women
with type 1 diabetes (45.4% versus 33.9%, P = 0.015). Those with
type 2 diabetes were more likely to deliver at term (>37 weeks)
(72.1% versus 56.3; P < 0.001). Neonatal outcomes were worse in
women with type 1 diabetes mellitus with babies more likely to
require resuscitation (66.2% versus 50.9%; P < 0.001), have
respiratory distress (20.5% versus 11.5%; P = 0.013),
hypoglycaemia (9.2% versus 4.8%, P = 0.055) and require NICU
admission (24.2% versus 14.5%; P = 0.009).
Conclusion The results from this study suggest that the obstetric
and perinatal outcomes for women with pre-existing type 1
diabetes are worse compared to women with type 2 diabetes. The
reasons for this are not entirely clear but may be a reflection of
the difficulty of glycaemic control and a higher incidence of both
micro and macro-vascular complications. Further research is
under way to investigate these findings.
307
EP13.126
Role of metformin and insulin in epigenetic
regulation of IGF axis in women with gestational
diabetes
Nawathe, A1,2; Savvidou, M2; Christian, M3;

Johnson, M1,2; Terzidou, V1,2
1
Imperial College London; 2Chelsea and Westminster Hospital;

University of Warwick, United Kingdom
Introduction The insulin-like growth factors 1 and 2 (IGF1 and
IGF2) are known to play an important role in placental and fetal

growth. We sought to investigate whether the placental expression
and DNA methylation of IGF and their binding proteins (IGFBPs)
is altered in pregnancies affected by gestational diabetes (GDM)
compared to those of uncomplicated singleton pregnancies.
Methods We included 114 pregnant women with singleton
pregnancies; 37 with uncomplicated pregnancies and 61 with
GDM. Placental samples were obtained at delivery and stored at
80C. Laboratory techniques were qPCR, western immunoblot
and DNA methylation in CpGs upstream of transcription start site
(TSS) of IGF1, IGFBP1 and IGFBP2.
Results Compared to controls, IGF1, IGFBP1 and IGFBP2 gene
expression was found to be significantly under-expressed in the
placentae of the GDM group on diet (n = 23) and in those on
metformin (n = 23) but not in those taking insulin (n = 15).
There was no difference in placental IGF2 expression between the
groups. IGF1, IGFBP1 and IGFBP2 genes were found to be
significantly hypermethylated in women on diet only that was not
seen in women on metformin or insulin.
Conclusion Placental expression of IGFs and their binding
proteins differ in pregnancies affected by GDM. Downregulation
of IGF1 expression in GDM on diet and metformin group but not
on insulin may suggest an endocrine role of insulin in
normalising altered IGF1 expression in diabetic placenta.
Significant hypermethylation in women only on diet but not on
metformin or insulin raises the question of role of metformin and
insulin in regulating methylation. Whether these alterations
contribute to neonatal phenotype or accompany other
pathogenetic mechanisms requires further investigation.
EP13.127
Pregnancy in a dialysis patient
Thangamani, D; Mahesh, R
Apollo Firstmed Hospitals, Chennai, Tamilnadu, India
Introduction Pregnancy is uncommon in women on maintenance
dialysis. But with improvement in dialysis technique, pregnancy is

common. Here, we report the successful multidisciplinary
management of pregnant dialysis patient.
Case 26-year-old woman with end stage renal disease on
maintenance dialysis for 2 years presented with pain and
distension of abdomen. Her primary renal pathology is systemic
lupus nephris which was biopsy proven. She did not have any
significant medical or surgical history till she presented with pain
and distension of abdomen. On investigation, her USG revealed
308
she is 20 weeks pregnant. Once pregnancy diagnosed, she was

properly counselled regarding fetal and maternal risks and her
haemodialysis protocol intensified, with increased erythropoeitin
dosages, a generous administration of water-soluble vitamins and
trace elements, and a multidisciplinary clinical management
approach with a very low threshold for hospitalisation. Fetus was
monitored with USG and fetal Doppler to rule out IUGR. Mother
monitored for pre-eclampsia and preterm contractions. She
developed preterm contractions at 34 weeks and delivered girl
baby weighing 2.1 kg by caesarean section in view of fetal distress.
Conclusion Pregnancy in patients with ESRD is rare and remains
especially challenging. Because endocrine abnormalities and sexual
dysfunction decrease fertility, conception rates have been
remarkably low in this patient population. Moreover, when
pregnancy does occur, hypertension, pre-eclampsia, anemia,
intrauterine growth restriction, preterm delivery, stillbirth, and
other complications can decrease the rate of a successful outcome.
However, recent experiences with intensive haemodialysis
managed by a multidisciplinary team are encouraging with respect
to better overall outcomes for mothers and infants.
EP13.128
Sickle cell disease and pregnancy
Thomas-George, R; Rambocas, N
Sangre Grande Regional Hospital, Sangre Grande Trinidad, Trinidad
and Tobago
Introduction Sickle cell disease is very common haematological
disorder in Trinidad and Tobago. The management of obstetric

patients with this condition can at times be very challenging due
to the maternal and fetal risks associated with this condition. We
would like to present the following case.
Case A 22-year-old P1+0 female with known sickle cell disease
presented at 30 weeks of gestation with chest pain and shortness
of breath. Antenatally, her steady state Hb was about 8.0 g/dL. All
antenatal booking bloods were normal and her 20 week anomaly
scan did not show any abnormalities. On admission she was
icteric, febrile and tachycardic. Although her oxygen saturation on
room air was 100%, chest auscultation revealed decreased air
entry in the left lung base with no crepitations or wheeze. The
fetal heart monitoring was normal. A chest X-ray done showed
bilateral lower lobe infiltrates. The diagnosis entertained at this
time was an acute chest syndrome but the need to rule out a
pulmonary embolism. The patient was started on anticoagulation,
broad spectrum antibiotics and chest physiotherapy. A pulmonary
embolism was ruled out by CT angiogram of the chest. The
patient made steady improvements over the next few days.
However on the fifth admission day, she developed a pathological
fetal heart tracing and was counselled on emergency caesarean
section. The patient had a general anaesthetic due to failure of the
spinal. The operation was otherwise uneventful. However
immediately postoperatively, she developed severe respiratory
distress and became hypoxic. She had to be re-intubated and
ventilated. Suctioning of the endotracheal tube revealed purulent
secretions and a repeat chest X-ray showed radiologic worsening
of her chest. Due to the sepsis and the sickling risk, the patient
underwent a partial exchange blood transfusion and was treated
with broad spectrum intravenous antibiotics and intensive chest
physiotherapy. She made steady recovery and was discharged from
intensive care after 5 days.
Conclusion Acute chest syndrome in a pregnant patient with
sickle cell disease has a high morbidity and mortality. In this case,
the patient was treated successfully with intensive care support,
partial exchange transfusion and antibiotics.
clinics. Emerging evidence regarding risks of AEDs and epilepsy in

pregnancy used in combination with patient expectations will
provide guidance on provision of high quality care.
EP13.130
Case report: renal cell carcinoma presenting as
hypertension, abruption and stillbirth in mid
trimester pregnancy
Udayasankar, V; Clark, CE
EP13.129
Service evaluation of the care offered to women
with epilepsy in pregnancy
Department of Obstetrics and Gynaecology, Victoria Hospital, Prince

Albert Parkland Health Region, Australia
Tolliday, A; Wallace, S; Jones, A; Loughna, P
pregnancy. Here we report a patient presenting with hypertension,

placental abruption and stillbirth in mid trimester followed by
postpartum diagnosis of renal cell carcinoma that was missed
antepartum.
Case A 29-year-old primigravida, with a BMI of 22, conceived
with clomid and IUI in a tertiary centre. She had presented with
hypertension in the first and second trimester (152/101 and 134/
99) and early pregnancy US in first trimester showed 17 cm left
sided renal mass and was waiting further evaluation. At 21 weeks
she presented in the ER of a local hospital with sudden onset of
severe abdominal pain and tachycardia, fundus was large for dates
and tender, fetal heart was not heard and obstetrical US
confirmed fetal demise. Blood tests revealed Hb of 5.2 g/dL LDH
of 2662 U/L, creatinine of 54 ummol/L urea of 3.5 mmol/L and D
dimer of 11 570 ug/L consistent with abruption and DIC. She
underwent midline hysterotomy with B Lynch sutures, placental
abruption was confirmed and stillborn baby weighing 190 g with
severe IUGR was delivered. In the postoperative period she had
CT performed that revealed large left renal mass measuring
18 9 13.5 cm. She was referred to the urologist and underwent
open left radical nephrectomy. Histology revealed T2bN0M0
chromophobe type renal cell carcinoma and tests did not reveal
any spread. She is 3 months postpartum and normotensive, BP
118/78 mmHg.
Conclusion Renal mass presenting in pregnancy is rare and even
rarer is renal cell carcinoma presenting as placental abruption and
stillbirth in mid trimester of pregnancy. More commonly they
present as loin mass, pain or haematuria in pregnancy, rarely as
hypertension in pregnancy, though in recent years they are often
detected by US imaging. CT and IVU are not routinely used in
pregnancy due to fetal risks from radiation exposure but MRI and
US can be performed in pregnancy to establish diagnosis.
Recommended treatment of radical nephrectomy for renal mass
has been performed in pregnancies including in the second
trimester with successful obstetric outcomes. The case that we
report had a unique presentation that highlights the importance
of physical examination and of early follow-up of any abnormal
renal mass detected in pregnancy. This could lead to earlier
diagnosis of renal carcinoma that can potentially be treated in
pregnancy to improve maternal and fetal outcomes.
University of Nottingham, United Kingdom

Introduction To evaluate the service of a new Joint Antenatal
Epilepsy Clinic (JAEC) using patient opinions to find areas of

success and areas for improvement, and to involve patients by
using their suggestions to shape the clinic. The JAEC was
established in October 2011 to provide pre-conception and
antenatal care for women with epilepsy. A multidisciplinary team
was formed to facilitate integration of obstetric and neurological
care. It aimed to provide advice and support such as folic acid
supplementation, monitoring of seizures and anti-epileptic drugs
(AEDs), formation of a birth plan and safety advice regarding care
of the baby.
Methods A service evaluation was carried out using a postal
questionnaire sent to 42 patients of the JAEC. A total of 43
women attended since the clinic opened, one woman was
excluded from the sample because it was thought the
questionnaire would cause emotional distress. Results were used
to assess the accomplishment of the clinic aims set up at its
founding. Topics additional to the aims were also explored in the
questionnaire.
Results 15 out of 42 patients responded. Replies identified areas
of success in quality of care (15 women were very satisfied or
satisfied), range of information given and provision of emotional
support (14 women stated it as very important or important to
them). Areas to improve were patient education and increasing
attendance for pre-conception counselling through improved
awareness of the clinic (2 women attended pre-conception, 13
post-conception). Qualitative data revealed that the clinic
alleviated womens fears and empowered them in their ability to
cope with epilepsy: made me feel I can cope with it all now and
that I live life as it happens. Demand for increased awareness of
the clinic was expressed in the suggestions for improvement:
Making relevant referrals to relevant parties in my case (1st
pregnancy) this did not happen. Midwives also did not refer, I self
referred!
Conclusion This study demonstrated the success of a specialised
multidisciplinary clinic for treatment of women with epilepsy
during pregnancy. It is based on small numbers, but is
informative of patient worries and expectations. This may be
valuable in the improvement of existing clinics or creation of new
Introduction Renal cancer can present as hypertension in
309
EP13.131
Prepregnancy management of auto immune
haemolytic anaemia
Vanes, NK; Raman, S; Sinha, A; Ganapathy, R;

Murrin, R
University Hospitals of Coventry and Warwickshire, Coventry, United
Kingdom
Introduction Auto immune haemolytic anaemia occurs when an
individuals antibodies are directed against red blood cells and

cause their lyse. Immunohaematological diagnosis aims to detect
these antibodies. It is a rare condition affecting 1 in 100 000. It is
poorly understood and divided into primary (idiopathetic) and
secondary (e.g. drugs, autoimmune conditions,
lymphoproliferative conditions). Clinical presentation includes
pallor, fatigue and shortness of breath. Prepregnancy counselling
and management help prevent complications during pregnancy.
Case We present a 39-year-old, Para 3 woman who was initially
diagnosed with auto immune haemolytic anaemia at the age of 26
in her first pregnancy. She presented with anaemia and jaundice.
Her Hb was 6.7 and had a reticulocyte count 240 and direct coombs
test was positive. She had a past history of autoimmune thyroiditis
and was on thyroxine. She was commenced on prednisolone 60 mg
along with folic acid 5 mg. She had investigations to rule out other
causes. CT scan and auto antibody screen were negative. She was
continued on steroids on a tapering dose for around 2 years as she
was continuing to have active disease. Other options such as
azathioprine and splenectomy were discussed and she was tapered
off steroids and continued on azathioprine. She was considering
becoming pregnant and, as she was still having relapses, the decision
was made for rituximab to establish a remission before embarking
on pregnancy. She was then weaned off azathioprine and steroids.
She conceived nearly 2 years after rituximab therapy and off all
treatment. Her Hb was 11.6 at the start of pregnancy. She was seen
jointly in the haematology-obstetric clinic and monitored for
anticipated haemolysis and pre-emptively treated with steroids. She
progressed well in the pregnancy and delivered a baby by ventouse
delivery. Future pregnancy counselling was performed and a further
2 pregnancies were achieved.
Conclusion Careful management of autoimmune haemolytic
anaemia can reduce the chances of flare ups during pregnancy.
Joint obstetric and haematological input should be sought.
EP13.132
All that wheezes is not asthma: a cautionary case
study of shortness of breath in pregnancy
Varnier, N1; Chwah, S1; Miller, T1; Henry, A1,2

1
Department of Womens and Childrens Health, St George Hospital,
Kogarah, New South Wales, Australia; 2School of Womens and
Childrens Health, UNSW Medicine, Sydney, Australia
Introduction Shortness of breath (SOB) is a common physiological
pregnancy presentation, secondary to both hormonal and

mechanical effects. Its pathological causes are commonly asthma
exacerbation or infection; rarely exacerbation of known, or new-
310
onset, cardiac pathology. This case is a reminder of its many

diagnostic possibilities.
Case JC, a 39-year old G4P2T1, presented at 34 weeks of
gestation with SOB unrelieved by salbutamol. History included
asthma (prn salbutamol), poly-drug abuse, and 24 pack-years of
smoking. Obstetric history included two term live births, 24-week
stillborn twins, and poor attendance for antenatal care. JC
described 6 weeks of cough (scant clear sputum, no fevers) and
SOB, worse for 2 days. On examination, BP ranged 90/60130/90,
HR 110125, RR 2030, SaO2 95100% RA and T 36.5.
Auscultation showed widespread wheeze, normal heart sounds, no
murmur and pitting oedema to the knees. CTG was normal.
Agitated behaviour (queried secondary to illicit drug use) settled
over 24 hours. There was acute renal failure (ARF) (Creatinine
156, eGFR 32, urate 0.72) with deranged liver function (AST 47,
ALT 94, Alb 27). Urine Protein: Creatinine Ratio was 67. JC was
admitted for asthma exacerbation treatment and investigation of
ARF. Renal function improved with hydration. Respiratory
symptoms initially responded to increased salbutamol, but
deteriorated again and on day 2, bibasal lung crepitations and
cardiac systolic murmur were auscultated. Echocardiogram
showed severe cardiomyopathy (LVEF 20%). Transfer to Coronary
Care for monitoring and management of peripartum
cardiomyopathy (PCCM) occurred; diuretics and 1.2L fluid
restriction were commenced. Labour was induced at 35 weeks of
gestation, with birth of a healthy female infant (BW 2475 g) by
elective assisted vaginal delivery. Cardiac function improved in
subsequent weeks, confirming PCCM.
Conclusion PPCM affects 1 in 25004000 live births. Over 90% of
women regain normal cardiac function postpartum with optimal
medical management. PPCM presents a diagnostic conundrum as
its primary symptoms mimic those of normal pregnancy but also
a number of other, more common conditions. As achieving a
good outcome in PPCM relies on correct diagnosis, it is
important to consider cardiac causes of SOB initially, and vital to
revisit an initial non-cardiac SOB diagnosis if there is no
sustained improvement with treatment. In this case, asthma
history and initial wheeze on examination impeded correct
diagnosis, however the situation was re-evaluated and correct
diagnosis made when the patients SOB deteriorated. Subsequent
multidisciplinary management and birth in an appropriate setting
facilitated the best outcome for both mother and baby.
EP13.133
Coronary artery disease secondary to familial
hypercholesterolaemia: an infrequent cause of
increasingly common pregnancy comorbidity
Varnier, N1; Pettit, F2,3; Rees, D4; Thou, S1;

Henry, A1,3
1
Womens and Childrens Health, St George Hospital, Kogarah, New
South Wales, Australia; 2Renal Department, St George Hospital,
Kogarah, New South Wales, Australia; 3School of Medicine, University
of New South Wales; 4Cardiology Department, St George Hospital,
Kogarah, New South Wales, Australia
Introduction Cardiovascular disease (CVD) is the leading cause of
death in Australia, is responsible for 11% of health expenditure,
and affects 0.24% of pregnancies. The physiological changes

caused by CVD coupled with the stress of pregnancy presents a
significant challenge to management. This case reviews the
multidisciplinary approach required in the management of a
patient with severe effects of familial hypercholesterolaemia.
Case 33-year-old G4P1M2, presented. She has a history of
coronary artery disease (6070% occlusion of two-vessels on CT
angiogram in 2010) and heterozygous familial
hypercholesterolaemia. She suffered multiple xanthoma to her
hands and elbows. Baseline echocardiogram showed an hourglass formation above the aortic root consistent with aortic
xanthoma. Cardiac function was preserved. At the onset of
pregnancy she was taking aspirin and multivitamins only. She
stated initial symptoms of shortness of breath and chest pain on
exertion however no rest pain. She was commenced on
metoprolol with good effect and was recommenced on statin
therapy at 29 weeks given persistently elevated cholesterol
(16.3 mmol/L). These medications were continued at the
completion of her pregnancy. At 36 weeks gestation, she
experienced chest discomfort and exacerbated shortness of breath.
Repeat TTE showed no significant changes in cardiac function.
After multidisciplinary care planning, induction in the High
Dependency Unit was scheduled for 37 weeks. She proceeded to
elective assisted vaginal delivery (Neville-Barnes forceps) of a
healthy female infant (birthweight 2460 g). She recovered well
with no ongoing complications.
Conclusion Whilst this case is an example of a rare condition, the
wider reach of cardiovascular disease (CVD) is impacting an
increasing number of pregnancies. Whilst an ischaemic event in
pregnancy is unlikely, new diagnosis and management of existing
disease is becoming more common. Associated with this is a
commensurate increase in cardiovascular risk factors including
age, smoking status, weight, diabetes diagnosis, pre-existing
hypertension and positive family history. Maternal mortality
following ischaemic events is estimated at 510%, emphasising the
need for a clear management plan for each pregnancy from the
outset. This case involved a multidisciplinary team including
obstetricians, obstetric medicine, cardiology, anaesthetics and
intensive care services. The plan for delivery was individualised
with a view to minimising cardiac stressors and maintaining
haemodynamic stability. This approach provided the basis for safe
term fetal delivery without added maternal complications.
monogenetic disorders with more than 70 000 babies born per

year worldwide. Defective globin chain synthesis results in red
cells with inadequate haemoglobin content. Homozygous bthalassaemia causes severe transfusion-dependent anaemia
requiring more than seven transfusion episodes per year
(thalassaemia major). However, disease severity may vary, causing
a clinical spectrum requiring little or no transfusion (thalassaemia
intermedia). Thalassaemia syndromes in pregnancy carry
significant risks to both mother and baby. Women require
specialist care in a multidisciplinary team setting.
Methods A retrospective study was performed using antenatal
and postnatal records over a 5 year period at the Whittington
Hospital NHS Trust in North London. 9 women with bthalassaemia major and 3 women with thalassaemia intermedia
were identified. A number of maternal characteristics were
recorded as well as pregnancy outcomes and delivery
complications. Adherence to the RCOG Guideline for
Management of Beta Thalassaemia (Green Top Guideline No. 66,
March 2014) was assessed. This guideline was published by our
unit.
Results Almost half of our patients each had insulin-dependent
diabetes mellitus, hypogonadotrophic hypogonadism, vitamin D
deficiency, osteoporosis and had undergone splenectomy. 8 of our
12 women conceived with ovulation induction and there were 2
twin pregnancies. 2 pregnancies were complicated by severe
intrauterine growth retardation requiring induction of labour at
33 weeks gestation. All other birthweight centiles ranged between
40 and 80%. Pre-eclampsia and gestational diabetes, hyperemesis
and urinary tract infection were also noted in 3 cases. 6 women
had a vaginal delivery, 2 had elective caesarean section (CS) whilst
2 had emergency CS. These women received detailed prepregnancy and antenatal counselling and appropriate and timely
maternofetal surveillance from our joint haematology/obstetric
specialist team which included administering folic acid and
antibiotic prophylaxis, conducting regular Doppler and growth
scans and assessing thromboembolic risk. There is room for
improvement in antenatal anaesthetic reviews (4/12) and ensuring
a 24 hour stay in the Recovery Ward in Labour Ward postdelivery (9/12).
Conclusion Thalassaemia pregnancies carry a high risk of
maternofetal complications as demonstrated in our population.
Optimal care requires a multidisciplinary team approach and
reference to the management guidelines.
EP13.134
Pregnancy management and outcomes in
thalassaemia major and intermedia in a north
London population: a retrospective study
EP13.135
BeckwithWiedemann syndrome and pregnancy
Vlachodimitropoulou Koumoutsea, E; Shah, F;

Kyei-Mensah, A
University Hospital South Manchester, Wythenshawe, Manchester,

United Kingdom
Whittington Hospital NHS Trust, London, United Kingdom

Introduction Our objective was to evaluate the management and
outcomes of b- thalassaemia major and intermedia pregnancies

delivered in our hospital between January 2009 and September
2014. Thalassaemia is one of the commonest inherited
Walker, S; Mohanraj, P; Arora, R
Introduction BeckwithWiedemann syndrome (BWS) is a
congenital overgrowth syndrome characterised by pre and postnatal

overgrowth, macroglossia, and omphalocoele. Additional
complications include organomegaly, hypoglycaemia,
hemihypertrophy, genitourinary abnormalities and predisposition
311
to certain tumours. BWS is caused by a loss of imprinting and

regulation at specific sites on chromosome 11. Early diagnosis and
effective management of children with BWS has led to an increased
numbers of affected women reaching reproductive age, however
there remain no documented cases of pregnancy in such patients.
Case We present a primigravida booked under consultant care for
BWS in our unit. She was diagnosed with BWS at birth after
investigation for a large congenital omphalocoele requiring
surgery. In childhood, she was followed up closely by both
geneticist and paediatrician. Early geneticist input assessed the
genetic cause of BWS in this patient to be paternal uniparental
disomy. Therefore, on diagnosis of pregnancy, the risk of the fetus
being affected was deemed as very low. Precautionary serial scan
surveillance and detailed morphology scan were performed and
were unremarkable. The second and third trimester were
complicated by significant haematuria, associated with a drop in
haemoglobin, hydronephrosis and bilateral renal calculi, managed
conservatively under urology inpatient care. She reported
symptoms of pre-syncope on starvation and was found to be
hypoglycaemic on multiple random serum glucose tests. This was
managed with input from a dietician and endocrinologist,
supported with regular blood sugar testing in a joint antenatal
endocrinology clinic. Anaesthetic input was sought in view of
hemihypertrophy of the spine and macroglossia associated with
previous difficult intubation. Labour was induced at 39 weeks due
to recurrent hypoglycaemia. There were no intrapartum or
immediate postpartum concerns. The puerperium was
acomplicated by secondary postpartum haemorrhage on day 16
requiring overnight admission for observation and antibiotics.
Conclusion This is the first documented case of pregnancy in a
patient with BeckwithWiedemann syndrome. Potential serious
issues may coexist or complicate antenatal/intrapartum care in
women with BWS. In managing these women it is important to
involve relevant specialists and pre-empt potential complications.
In this case, renal calculi, haematuria and symptomatic
hypoglycaemia requiring induction of labour complicated this
patients pregnancy. In managing pregnancy of other patients
affected by BeckwithWiedemann syndrome, it may be important
to consider early blood glucose and urine monitoring in order to
identify and pre-emptively manage possible complications.
importance in pregnant and breastfeeding women given the

neurodevelopmental vulnerability of the fetus and child to age
three. Despite this, data on the prevalence of iodine deficiency in
pregnancy is lacking from most countries. In October 2009 the
Mandatory Iodine Fortification for Australia programme was
initiated to address countrywide iodine deficiency. Additionally
national public health campaigns recommended iodine
supplementation of women from the point of pregnancy planning
through to the end of breastfeeding.
Methods We performed a retrospective cohort study of 747
women in the first trimester of pregnancy attending a private
antenatal clinic in Ballarat from November 2005 to July 2013.
Iodine concentrations in urinary samples were used as a
representative for dietary iodine intake. We compared results
between women prior to (Group 1, n = 360) and after (Group 2,
n = 387) the commencement of the iodine fortification
programme. The WHO epidemiological criteria for assessing iodine
nutrition in pregnant women were used for data interpretation.
Results Pregnant women in Group1 demonstrated mild iodine
deficiency with a median urinary iodine concentration (MUIC) of
83 micrograms/L. A significant increase was noted in Group 2 to
a MUIC of 163 micrograms/L (P < 0.0001), corresponding to an
adequate dietary iodine intake. Of concern we noted an increase
in women with excessive dietary iodine from 2% in Group 1 to
6.1% in Group 2 (P < 0.001).
Conclusion This study has confirmed that pregnant women in
West Victoria were iodine deficient. We have demonstrated that
the Australia-wide pubic health campaigns were successful in
increasing the dietary iodine intake in this population. Our study
supports the need to continue to educate women and healthcare
providers of the importance of iodine supplementation from
preconception through to breastfeeding, in iodine deficient
regions. In addition we have raised the need for further studies to
investigate the perinatal impacts of oversupplementation.
EP13.137
Complications of classic EhlersDanlos syndrome in
pregnancy: a rare collagen disorder
Watson, V1; Watson, R2

1
EP13.136
Iodine intake in pregnancy the effects of the
Australia-wide public health campaign in regional
West Victoria
Ward, M1; Monga, D2; Sharma, J3

1
Ballarat Health Services, Victoria, Australia; 2Ballarat Specialist
Womens Health, Victoria, Australia; 3University of Liverpool, United
Kingdom
Introduction Iodine, as a building block for thyroid hormones, is
vital for the normal development and function of the brain and
organ systems. Iodine deficiency is a global health problem,
declared by WHO to be the most common preventable cause of
intellectual impairment. Dietary iodine intake is of particular
312
Logan Hospital, Brisbane, Queensland, Australia; 2North West Private

Hospital, Brisbane, Queensland, Australia
Introduction EhlersDanlos syndrome encompasses a group of
genetic disorders of collagen synthesis with an incidence between

1 in 5000 and 1 in 20 000. Classic EhlersDanlos syndrome (EDS)
results from autosomal dominant gene mutations. Data from rare
case reports indicate mothers are at increased risk of pelvic pain
and instability, cervical incompetence, preterm prelabour rupture
of membranes, uterine rupture, complicated pelvic floor trauma,
poor wound healing and postpartum haemorrhage.
Case A 29-year-old woman was referred to an obstetrician for
prepregnancy counselling regarding her history of classic EDS with
joint hypermobility, recurrent dislocations, hyperextensible skin,
keloid scarring and fatigue. Geneticist review indicated a 1:2
chance of having an affected child. The patient conceived
spontaneously. At 11 weeks gestation she ceased work due to

significant joint discomfort. She declined invasive testing for
prenatal diagnosis of EDS. Increasing gravidity caused a marked
worsening in her symptoms of lower back and pelvic pain. At
29 weeks she was reviewed by a psychiatrist for daily panic attacks
triggered by fear of premature labour, musculoskeletal injury and
worsening pain. At 33 weeks 6 days she presented in preterm
labour. Steroids were administered and a baby boy in good
condition at 2520 g was delivered by uncomplicated caesarean
section. She presented 11 months later, early in her second
pregnancy. In view of the previous pregnancy, she was planned
for early steroid administration, screening of cervical length
during the third trimester and elective caesarean section at
38 weeks. During this pregnancy she again suffered with a severe
exacerbation of back, pelvic and joint pain, and anxiety
symptoms. She was admitted with threatened preterm labour at
25, 26, 28 and 32 weeks of gestation and was treated with
nifedipine and four doses of corticosteroids. She continued to
experience daily painful contractions, debilitating joint pain and
was diagnosed with pubic symphysis diathesis. Due to intractable
pain caesarean section was performed at 34 weeks 0 days and a
baby girl in good condition at 2395 g was delivered. No abnormal
scarring of the caesarean section wound has occurred. The patient
reports partial diminution in the joint pain exacerbated by
pregnancy. Both children (aged 2 and 3) have been diagnosed
with hypermobility EDS.
Conclusion This case demonstrates a propensity for mothers with
classic EhlersDanlos syndrome to experience preterm labour and
debilitating pain related to joint laxity. Close surveillance
(including cervical length), psychosocial support and possibly
early antenatal steroid administration are indicated.
EP13.138
A case of pituitary apoplexy in a pregnant woman
on anticoagulation
Watson, V; Ganeshananthan, S
Logan Hospital, Logan, Queensland, Australia
Introduction Pituitary apoplexy is haemorrhage or impaired
blood supply to the pituitary gland and usually occurs in the

setting of a pituitary tumour. This condition is a rare event in
pregnancy but can be provoked by physiological enlargement of
the pituitary gland. We report on a case of pituitary haemorrhage
in the third trimester of pregnancy in a patient with a previously
undiagnosed pituitary tumour on prophylactic anticoagulation
due to a history of deep vein thrombosis (DVT).
Case A 30-year-old woman presented at 37 weeks 4 days
gestation with the sudden onset of visual disturbance, left upper
limb paraesthesia, vomiting and severe neck and thoracic back
pain. She reported a background of 4 weeks of blurred vision. She
was in her fifth pregnancy and had received steroids in the days
prior in preparation for elective repeat caesarean section. She
sustained a left below knee DVT 15 months earlier following soft
tissue injury and had a strong family history of venous
thromboembolism but negative thrombophilia screen. She had
ceased warfarin at 5 weeks gestation and commenced enoxaparin

40 mg daily. On examination bilateral hemianopia, numbness of
the left upper and lower limbs and dysdiadochokinesis of the left
upper limb were identified. MRI of the head and neck including
angiography and venography revealed enlargement of the pituitary
gland at 12 mm diameter with internal haemorrhage and the
impression of likely pre-existing cyst or adenoma. There was mild
compression of the optic chiasm. The pituitary haemorrhage was
managed conservatively and the patient underwent uneventful
caesarean section 2 days later. All neurological symptoms resolved
except mild blurred vision. Hypocortisolaemia was diagnosed and
cortisone acetate commenced. No other evidence of
hypopituitarism was present at the time of discharge.
Conclusion Pituitary apoplexy is a rare event with potentially
serious neurologic and endocrine consequences. It is often the
first presentation of an undiagnosed pituitary tumour and is more
likely to occur in pregnancy due to enlargement of the pituitary
gland. Symptoms may be varied and this case serves as a reminder
to consider this differential diagnosis for headache, visual
disturbance or symptoms of hypopituitarism in pregnancy.
EP13.139
Myasthenia gravis: new diagnosis in pregnancy
Wijemanne, A; Watt-Coote, I
St Georges Hospital, Tooting, London, United Kingdom
Introduction Myasthenia gravis is an autoimmune disorder of
neuromuscular transmission, characterised by weakness and

fatigability of the skeletal muscles. It has a prevalence of between
1 in 10 000 and 1 in 50 000 and approximately 6570% are
female. It most commonly affects females in their 20s and 30s.
The effect of pregnancy on the course of myasthenia gravis in
pregnancy is unpredictable, with 40% of women having
exacerbations, 30% with no change in clinical status and 30%
experiencing disease remission. The disease is particularly
challenging for two reasons; the clinical state at the beginning of
pregnancy does not predict the course during pregnancy, and the
disease course is not always the same in different pregnancies in
the same woman. Respiratory crises can occur and may be
precipitated by the stress of pregnancy and delivery. The following
case illustrates a new diagnosis of myasthenia gravis in pregnancy,
complicated by multiple respiratory crises.
Case A 36-year-old primigravida presented to her GP at 11/40
gestation with a 5 day history of progressive symmetrical bilateral
weakness of her face and upper limbs, dysarthria and dysphagia.
She had a normal MRI brain in a district general hospital, and
was subsequently transferred to the Medical Admissions Unit of a
tertiary centre. On examination tone, reflexes, and sensation were
normal, but upper limb power was only 3/5 bilaterally. Bilateral
fatigable ptosis was also demonstrated and she had a weak cough.
Blood tests and an arterial blood gas showed normal results. A
differential diagnosis of myasthenia gravis was made and a lung
function test was performed. The FVC was found to be only 27%
of the predicted value, so she was admitted to the Neurology ITU
and commenced on high dose prednisolone and pyridostigmine.
313
A nasogastric tube was inserted and she was found to be Ach

receptor antibody positive. Her vital capacity was closely
monitored. She was transferred between the neurology ward and
neurology ITU several times due to fluctuating vital capacity. She
was eventually commenced on intravenous immunoglobulin and
underwent multiple courses of plasmapheresis. Her care was
jointly managed between the neurology, maternal medicine and
anaesthetic teams. She experienced premature rupture of
membranes and was delivered by caesarean section at 32 weeks.
Conclusion Myasthenia gravis may present for the first time
during pregnancy. The management of such patients is complex
due to the variable disease course, and requires multidisciplinary
care between neurology, obstetric and anaesthetic teams.
positive predictive value 87.88% and negative predictive value

78.38%.
Conclusion These findings suggest that hypocalciuria was
associated with severity of pre-eclampsia and it is a potential
screening test for pre-eclampsia.
EP13.141
Pan-London gestational diabetes survey
Wong, M; Sivarajah, K; Adeyemo, A; Ashokumar,

O
Whittington NHS Trust, London, United Kingdom
Introduction Up to 5% of pregnancies in England and Wales are
EP13.140
Relationship of urinary calcium creatinine ratio and
severity of pre-eclampsia
Win, SH1; Myat, TT2; Nyunt, KK2

1
Central Womens Hospital, Mandalay; 2Department of Obstetrics and
Gynaecology, University of Medicine, Mandalay, Myanmar
Introduction This study was to determine the relationship
between urinary calcium creatinine ratio and severity of preeclampsia and to determine the cut off value of urinary calcium
creatinine ratio in differentiating mild and severe pre-eclampsia
(PE).
Methods This was cross sectional analytical study of 70 pregnant
women (37 with severe pre-eclampsia and 33 with mild preeclampsia). Blood pressure on the day of admission was recorded.
Proteinuria detected by dip strip was confirmed and quantified by
24 hour urinary protein. Only singleton pregnancy of more than
or equal to 28 weeks gestations were enrolled in this study.
Patients with known chronic hypertension, diabetes mellitus,
preexisting renal or vascular disease or urinary tract infection were
excluded. Urinary calcium level, creatinine level and calcium
creatinine ratio was calculated by using spot urine sample on the
day of admission.
Results The two study groups Mild PE and Severe PE were not
paired but the epidemiological characteristics in terms of age,
gravida and gestational periods were comparable (P > 0.05).
Mean SD of urinary calcium in Severe PE group
(1.85 1.15 mmol/L) was significantly lower than that of Mild
PE group (3.17 1.37 mmol/L) (P = 0.000). Mean urinary
creatinine excretion was slightly lower in Severe PE group
(P > 0.05). Mean calcium-creatinine was statistically significant
difference between Mild PE group (0.23 0.11) and Severe PE
group (0.14 0.03) (P = 0.000). Inverse relationship of urinary
calcium excretion and mean arterial pressure was noted and the
association was moderately significant (r = 0.42). Inverse
association was also noted for calcium excretion in mmol/L and
24 hour urinary protein excretion (r = 0.36). Using the receiver
operator curve, a cut-off level of 0.15 (mmol/mmol) for the
calcium to creatinine ratio was chosen for prediction of severity of
pre-eclampsia and area under the curve was 0.9017 (significant).
This cut off value had sensitivity 78.38%, specificity 87.88%,
314
complicated by diabetes, 88% attributable to gestational diabetes

mellitus (GDM). The Hyperglycaemia and Adverse Pregnancy
Outcomes (HAPO) study showed a linear association between
maternal hyperglycaemia and adverse perinatal outcomes such as
macrosomia, shoulder dystocia and stillbirth. However, there is as
yet no gold standard for the diagnosis of GDM or consensus on
thresholds for treatment. Thus, we sought to obtain a snapshot of
current practice in the management of GDM in London.
Methods A questionnaire was sent to units across London in
September 2013 and resent in March 2014. We received responses
from 23 units. The results were analysed with Excel and compared
against guidelines from NICE (2008) and the International
Association of Diabetes and Pregnancy Study Groups (IADPSG),
as well as the recent survey by the National Diabetes in Pregnancy
Network and NHS Diabetes.
Results Only a third of units followed the IADPSG
recommendation for universal screening. In two-thirds of units,
screening was done between 24 and 28 weeks gestation (from
16 weeks in those with previous GDM). Diagnostic criteria ranged
from 5% (IADPSG) to 59% (WHO) with the remainder being
modified WHO (9%) and other (27%), all of which were similar
to the results from the national survey. The majority of clinics
saw 30 or more patients a week (48%). Rapid increase in fetal
abdominal circumference was an indication for early delivery in
just over a third of units and steroids were given in 44% of units
where delivery was by planned caesarean section before 39 weeks.
For diet-controlled GDM, delivery was arranged between 40 and
41 weeks in most units (70%). Postpartum testing was
recommended by all units. This was mainly done in hospital
(61%) with the glucose tolerance test being most popular (57%).
Conclusion Most London units use NICE guidelines to screen for
and diagnose GDM but there remains a lack of uniformity.
Although universal screening as per IADPSG could lead to a 4.5fold increase in GDM diagnoses to 16%, the Australian
Carbohydrate Intolerance Study in Pregnant Women (ACHOIS)
and Maternal-Fetal Medicine Units (MFMU) study have shown
the majority can be managed conservatively. However, there is
still the increased demand on services to consider,
notwithstanding that treatment of borderline GDM may not
necessarily affect outcomes. Therefore, future studies should
compare pregnancy outcomes in units with different strategies in
order to further elucidate the optimal screening and management

of GDM.
EP13.142
Elective caesarean section with an abdominal
neuromodulator in situ
Woon, EV; Sikhar, S

Wishaw General Hospital, NHS Lanarkshire, Scotland, United
Kingdom
Introduction The past decade has shown a dramatic increase in
the use of electric stimulation in the treatment of medically

refractory chronic pain in a variety of situations. Peripheral nerve
field stimulation is a relatively novel idea and we aim to present
the case of a patient who progressed through pregnancy with an
abdominal neuromodulator in situ.
Case A 29-year-old primigravid patient (Rhesus positive, BMI 35)
suffers from nerve damage and chronic pain following an
appendicectomy complicated by peritonitis in 2003. As medical
treatment and multiple corrective surgeries involving specific
abdominal nerves had limited success, an abdominal
neuromodulator was implanted in 2008. She has since undergone
3 further operations to correct the device malfunction which
currently rests in the right subumbilical region. Although presence
of the device was not contraindicated in pregnancy, switching it
off was part of the pre-pregnancy plan because the effect of an

electric field on the fetus is still unknown. Early pregnancy scan
confirmed a viable fetus at 6 weeks. Growth scans at 28, 32, 34,
36 and 38 weeks indicated a healthy fetus. She was reviewed at the
neuromodulator clinic at 24 weeks which showed pressure on the
skin overlying the device but no break. The initial plan was for
spontaneous vaginal delivery (SVD), but as she was encumbered
by symphysio-pubic dysfunction and sciatica during third
trimester, an elective caesarean section was planned at 38 weeks
gestation under spinal anaesthesia. Unipolar diathermy was strictly
contraindicated. An alternative plan for pain management was
also mapped out in case of spontaneous vaginal delivery. The
operation was uncomplicated. A lower uterine segment caesarean
section was performed using a Pfannenstiel incision. The
neuromodulator device and wires were identified and avoided
throughout the operation. The baby was delivered with Apgar
scores of 9 from birth. Postoperatively, the patient did very well
and only required simple opioids for pain relief. On follow-up at
1 week postpartum, the neuromodulator was switched on again
and she is due for further operations to correct the position of the
device.
Conclusion Our case illustrates that with careful planning and
appropriate precautions, peripheral neuromodulator in situ is not
a contraindication to pregnancy and caesarean section. This has
implications in the future with the increasing potential application
of peripheral nerve stimulation to a wide range of common
conditions.
315

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Abstracts

Conclusion There is no standard practice or guidance in Scotland

based on national guidance. Trusts have different policies

Wishaw General Hospital, Lanarkshire, Scotland, United Kingdom

delivery. Treatment with antenatal corticosteroids reduces

Agampodi, SB1; Agampodi, TC1; Chathurani, U1;

Department of Community Medicine, Faculty of Medicine and Allied

of anaemia during pregnancy. Universal programme on iron

E-Posters: Obstetric medicine

deficiency. Classical features of thalassaemia trait were observed in

pregnancy for detection and treatment of severe vitamin D

Alahakoon, TI1,2; Trudinger, BJ1,2; Zhang, WI2;

Riaz Medical Centre Sharjah, United Arab Emirates

University of Sydney at Westmead Hospital, Westmead, Australia;

Introduction Vitamin D deficiency, during pregnancy is associated

Introduction Angiogenic factors VEGF and PlGF as well as their

with multiple adverse health outcomes in mothers, neonates and

receptors Flt-1 and KDR play a major role in the angiogenesis of

E-Posters: Obstetric medicine

that automated digital image analysis software such as Aperio

Al Wattar, BH1; Mylrea-Lowndes, B2; Moore, A1;

Womens Health Research Unit, Barts and the London School of

dietary and lifestyle interventions in reducing maternal gestational

Department of Gynaecology and Obstetrics, Liaquat University of

disease and death worldwide. Pakistan is among 15 countries with

Balasandrum, S; Ajjawi, S; Moolchan, J;

sign of fetal life. RCOG guideline reports that 55% of women

E-Posters: Obstetric medicine

Methods A prospective audit on those who had single or

MaLachlan, M; Baraka, M; Mortimer, J;

cause of maternal, fetal, and neonatal morbidity and mortality in

Results Of the 23 women audited, 18 (78%) were primi-gravid

and 5 (22%) were parous women. Average age was 27 years

Bainton, T; Baraka, M; Mortimer, J; MaLachlan,

subjective, is a commonly used method to assess fetal wellbeing.

E-Posters: Obstetric medicine

Results Of the 24 women, average age was 27.5 years (range 22

34), 17 (71%) primi-gravid and 7 parous women, were included.

Bainton, T; Mortimer, J; Jeffrey, M; Al-Baghdadi, O

affecting around 20% of pregnancies in the UK. IOL has a

(58%) and >40 weeks (34%). The most common indications at

Bakhtiari, A1; Peyman, M2; Zahari, M2; Noor

Department Obstetrics and Gynaecology, University of Malaya, Kuala

retinal vessels caliber with severity of hypertension in pregnancy.

cases), 11 patients with diagnosis of pre-eclampsia and 12 patients

E-Posters: Obstetric medicine

(108.95  15.24 mmHg) and PIH (106.46  13.48 mmHg)

Barrett, HL1,2,3; Dekker Nitert, M1,3; DEmden,

UQ Centre for Clinical Research, University of Queensland, Herston,

with adverse pregnancy outcomes including an increased risk of

Basu, A; Sivanna, S; Antony, M; Charles, A; Oost,

diagnosis of chronic placental inflammation reached after

E-Posters: Obstetric medicine

Begum, T; Yeasmin, S; Chakma, S

cause of maternal mortality and morbidity in the world. Blood

Bhutia, K1; Tagore, S2; Yeo, SH2

Division of Obstetrics and Gynaecology, KK Womens and Childrens

recent decades all over world especially in developed countries.

caesarean section. The secondary outcomes were maternal

form of ectopic pregnancy in which the pregnancy implants in the

E-Posters: Obstetric medicine

curettage and insertion of intrauterine balloon due to a significant

(108.95 15.24 mmHg) and PIH (106.46 13.48 mmHg)