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DR. SIMPSON is Executive Associate Dean for Academic Affairs, and Professor of Obstetrics and Gynecology and Human and Molecular Genetics, Florida International University College of Medicine, Miami, FL. He is Past President of the Society for Gynecologic
Contemporary OB/GYN Editorial Board member Joe Leigh Simpson, MD, attended and spoke at last month’s FIGO meeting in Malaysia. This is his personal account of the conference highlights.
More than 8,000registrants gathered inKuala Lumpur, Malaysia,November 5 to 10, 2006,for the XVIII FIGO WorldCongress of Gynecologyand Obstetrics. With its110 national membersocieties, FIGO providesa forum for scientificadvances and also hasinstituted many initiativesto improve women’shealth worldwide. All ofthe organization’s effortswere on display at thetriennial meeting.
Paul Van Look, Khalid J. Khan, and Ahmet Metin Gulmezoglu, all of the World Health Organization (WHO), reviewed specific causes of maternal death. Of all maternal deaths, 29% result from hemorrhage, 20% from infection, 19% from preeclampsia/eclampsia, and 12% from unsafe abortion.
Using a WHO worldwide audit (Khan KS, et al. Lancet. 2006;367:1066), Dr. Gulmezoglu reported that hemorrhage was the most common cause of death in both Africa (34%) and Asia (31%). In Latin America and the Caribbean, hypertensive disorders were most prevalent (26%). Abortion deaths were the highest in Latin America and the Caribbean, accounting for as many as one third of maternal deaths in these countries. Of great importance is that the leading cause of anemia in Sub-Saharan Africa is malaria. It accounts for 60% of cases. Malaria is responsible for 10,000 maternal deaths per year, as a result of either preeclampsia or vulnerability to hemorrhage secondary to anemia.
To begin to reduce maternal mortality, FIGO has targeted pilot projects to selected low-income countries (Haiti, Kenya, Kosovo, Pakistan, Peru, Moldova, Nigeria, Geri, Uganda, Ukraine, and Uruguay). In each area, FIGO and the national and local societies collaborate.
Professor Van Look touted marked improvements in some countries, in particular FIGO host Malaysia and other rapidly developing countries in Asia; however, maternal mortality in Africa is disappointingly unchanged, placing in doubt the MDG-5 goal. Dr. Van Look posited that the high rate of maternal mortality is not likely to change unless intermediate causes are addressed. These include low use of contraception, lack of availability of obstetrical surgery (cesarean delivery [CD]), and lack of a skilled birth attendant. CD rates are less than 1% in many low-income countries with high maternal mortality, whereas rates of 5% to 15% are considered necessary to minimize maternal mortality.
Given the high prevalence of postpartum hemorrhage, FIGO has specifically targeted this cause of maternal mortality. Dr. Pisake Lumbegana (Thailand) reviewed encouraging efforts in Asia, applying guidelines that reflect joint recommendations of the International Confederation of Midwives (ICM) and FIGO. Foremost in preventing postpartum hemorrhage is active management of the third stage of labor. Even when a skilled birth attendant is present, as in the United States, active management still reduces blood loss and need for blood transfusion. In developing countries, these measures can be lifesaving.
It is recommended that oxytocin and other uterotonic drugs be administered within 1 minute after birth, along with controlled cord traction and uterine massage. If a skilled birth attendant is not present, controlled cord traction is not recommended, but uterine massage is begun immediately after passage of the placenta. If oxytocin is unavailable or the birth attendant has limited skills, misoprostol is recommended after birth of the baby. The dose is 100 mg orally or sublingually, and should not be repeated. Shivering and pyrexia are common side effects.
FIGO and ICM also have embarked upon teaching home-based lifesaving skills. However, knowledge is still limited in many countries, and the failure to fully implement recommendations of ICM and FIGO is a disappointment. Also discussed were several novel methods to treat postpartum hemorrhage that are not likely to be used in the US. These include devices prefilled with oxytocin for injection in the umbilical cord, methods of uterine tamponade, and nonpneumatic anti-shock garments. Uterine B-Lynch sutures continue to be used, with apparent benefit.
Mitigating deleterious effects of postpartum hemorrhage is an adequate hemoglobin level at delivery, thus aggressive administration of iron is recommended for women who are iron-deficient. In many countries, diagnosis is now based on serum ferritin and transferrin receptor (Tfr) levels. Serum ferritin below 12 μg/L indicates iron deficiency, but the most sensitive measure is serum TfR. Serum TfR concentrations are inversely related to the amount of iron stores. TfR levels become elevated before changes in either serum ferritin or mean corpuscular volume (MCV).