Perinatal Journal 2011;19(1):35-50 e-Adress: http://www.perinataljournal.com/20110191009 doi:10.2399/prn.11.0191009

The Conclusion Report of 13th National Perinatology Congress

Ayfle Kafkasl›1, Alper Tanr›verdi2, Yeflim Baytur3, Özlem Pata3, Ertan Adal›3, Hakan Camuzcuo¤lu3, Arif Güngören3, ‹lker Ar›kan3

1Head of the Congress, 13th National Perinatology Congress, ‹stanbul Türkiye 2Congress Secretary, 13th National Perinatology Congress, ‹stanbul Türkiye 3Congress Reporter, 13th National Perinatology Congress, ‹stanbul Türkiye

The Conclusion Report of 13th The subject of “Fetal Postmortem Examination National Perinatology Congress and Chromosomal Analysis of Material” 13th National Perinatology Congress was held was presented by Dr. Gülay Ceylaner. According in ‹stanbul Military Museum and Culture Site in to the results of this presentation, postmortem between 13th and 16th April, 2011. examination should be performed on congenital anomalies, intrauterine growth retardation, non- Before the congress, 3 pre-congress courses immune hydrops fetalis, fetal-neonatal death histo- were held on 13th April, 2011. ry of unknown etiology or in with unknown death reason or maser (high frequency 1. Perinatal Genetic and Postmortem of chromosomal disorder). Findings should cer- Diagnosis Course tainly be recorded during examination, pho- In the first session, Assoc. Prof. Serdar Ceylaner tographs and X-ray should be taken and skin biop- made a presentation about “Basic Genetics and sy should be done. evaluation is really an Management of Genetic Diseases for the Clinician” easy and convenient examination method. and he explained that chromosomal analysis indi- In the presentation of “Fetal Autopsy: The cations are recurrent gestational losses, intrauterine Influence on Perinatal Mortality”, Prof. Dr. Erdener death, of unknown etiology, neonatal Özer emphasized the importance of perinatal death, congenital malformations, suspicious genital autopsy and stated that perinatal autopsy is essen- structure, mental-motor retardation, growth retar- tial for verifying the results of fetal maturity and dation, primary amenorrhea and some secondary diagnostic processes, reviewing clinical approach- amenorrhoea. He also suggested performing chro- es and establishing national perinatal death statis- mosomal analysis if chromosomal disorder was tics. found in previous children, one of the spouses has balanced chromosomal disorder, fetal anomaly is Dr. Nefle Karada¤ specified in her presentation detected in ultrasonographic follow-ups, if there “: The Importance of Pathological are high risk rates in triple screen test and com- Examination” that evaluating placenta provides bined tests, history of recurrent gestational loss, important information in terms of care and health history of intrauterine and postnatal death of of mother and baby during and after delivery as unknown etiology, and if mosaicism is detected in well as creating medicolegal support in terms of CVS sample during chromosomal analysis study. physician when compared to unexpected fetal or

Correspondence: Yeflim Baytur, Celal Bayar Üniversitesi T›p Fakültesi, Kad›n Hastal›klar› ve Do¤um Anabilim Dal›, Manisa, Türkiye e-mail: [email protected] 36 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

maternal results and she emphasized that evaluat- patient’s history and to check some systems more ing placenta is an inseparable part of autopsies for carefully accordingly and he emphasized the fetal and neonatal deaths. importance of systematic evaluation and the use of a check list. It was underlined that at least 20 min- utes should be spared for examination and he sug- 2. Perinatal Ultrasonography Course gested the importance of carrying on physician Assoc. Prof. Yeflim Baytur talked on “Normal training and technical competency of the device. Sonographic Findings in Early ” and He also indicated that anomalies could be missed emphasized the importance of determining gesta- even in the best clinics; skeletal system and KVS tional age, viability and chorionicity within first defects were those mostly missed, and CNS and three months. She stated that yolk sac had to be GUS anomalies were those easily detected. He also observed at 5th week and fetal heart beat had to remarked following topics: be observed when the sac reached 25 mm. She emphasized that some of fetal anomalies such as a. The evaluation of fetal biometry, placenta anencephaly and omphalocele can be detected and fluid, and the systematic and she also said that fetal anatomy should be paid screening of fetal anatomy should be per- attention. She indicated that week 14 should be formed. waited for heart screening and that anencephaly, b. If necessary, Doppler ultrasonography omphalocele and Dandy-Walker can not be diag- should be included. nosed before 11th week. c. During systematic evaluation of the anatomy, “Fetal Anatomical Examination in 11-14 Weeks orbitas on face, lips, nasopalatine, fetal pro- Gestation” was presented by Prof. Dr. Yakup Erata. file, extremities, 4 cardiac chambers, major By the developed technique and the perinatology vessel outlets, 3 vessel images, falx cerebri being a sub-branch, it was begun to do anatomical on central nervous system, ventricular sys- evaluation in earlier weeks and therefore ultra- tem, posterior fossa, choroids plexuses, sonographic imaging became important. stomach, bladder, diaphragm and kidneys “Fetal Chromosomal Anomaly Markers in 11-14 should be checked. Weeks Gestation” was explained by Prof. Dr. d. Indications such as heart anomaly of Down Turgay fiener. He stated that the major anomalies syndrome, duodenal atresia that may be among sonographic identifiers that may cause seen at 2nd trimester should be paid atten- chromosomal anomalies were anatomical defects tion. such as omphalocele, megacystitis, holoprosen- In the same session, Prof. Dr. Lütfü Öndero¤lu cephaly, and that the tests such as NT measure- emphasized in his presentation “Which Fetal ment, nasal bone, ductus venosus, and tricuspid Anomalies Should Not Be Overlooked in the regurgitation should be used for screening purpos- Second Trimester?” that there is confusion about es. Though it is known that chromosomal anomaly who should perform the ultrasonographic evalua- risk increases as maternal age increases, it was tion due to the increase in medicolegal events and remarked by him that it is possible to decrease stated that there is 60% chance to detect in ultra- invasive tests performed and to increase Down sonography and expectation of patient should not Syndrome diagnoses detected by various screening be raised. He expressed that all those normally to strategies. The importance of training was empha- be checked between 18th and 22nd weeks could sized and it was also stated that it should certainly be possibly found in all books and internet, and be certified for effective use of screening tests. everybody who got ultrasonography training can On the session of second trimester, Prof. Dr. perform standard and detailed ultrasonography. Alper Tanr›verdi made a speech about “Fetal He noted that regular care of devices, reporting Anatomical Examination in the Second Trimester”. and image recording should be provided, and It was stated that the examination was done from obese patients should be registered. He stated that the point of fetal anatomy during ultrasonography 83% of lethal anomalies were detected; however, evaluation and it was important to question we can detect 54% of lethal anomalies such as Perinatal Journal 2011;19(1):35-50 37

hypoplastic heart and 90% of renal agenesia, but gestational week. He indicated that intervillous lethal musculoskeletal anomalies can be missed. blood flow can be measured by 3D and it can be He pointed out that the actual problem is in babies utilized in hypoxic cases. He also gave information with serious morbidity and chance of living. He about placental anomalies. It was talked about pla- expressed that neural tube defects, hydrocephaly, cental tumors, chorioangioma and placental complex heart abnormalities, abdominal anterior infarcts. Though placental calcifications are accept- wall defects, diaphragmatic hernia, small intestine ed as physiological, it was asked to pay attention obstructions and bladder extrophies should be that they may be the indication of infections at detected (and also they can be missed). early pregnancy. It was stated that there may be Assoc. Prof. Dr. Ebru Tar›m presented the hyperechoic image at 0th-48th hours in ablatio pla- “Anomalies that can be detected during late preg- centae, isoechoic image at 3rd-7th days, hypoe- choic image at 1st-2nd weeks and anechoic image nancy period” and she stated that anomaly can after 2nd week. It was emphasized that umbilical become apparent at 3rd trimester (diaphragmatic vessels blocks servical channel at , it is hernia) though it exists at 2nd trimester since frequent at velamentous insertion, and membrane anomaly appears lately and there is a pause in the rupture and abnormal bleeding may occur if not development of anatomical structure (micro- diagnosed. It was underlined that inferior uterine cephalia). It was said that normal anatomic devel- segment is formed at 28th week at placenta prae- opment continues during pregnancy and some via diagnosis and therefore it should not be diag- anomalies such as central nervous system anom- nosed before this week. It was expressed that alies may arise late. It was emphasized that cere- sonoluscent areas behind placenta disappeared in bellar vermis, ventriculomegaly, and more placenta adhesion abnormalities, there were pla- echogen view around ventricle at intracranial hem- cental lacunas including turbulence and colored orrhages should be paid attention during third and power Doppler may help the diagnosis. It was trimester. She indicated that transvaginal ultra- clarified that Hyrtl anostomoses are important and sonography can be used in uncertain cases in SSS that single umbilical artery may be related with anomalies and that MR can be performed in chromosomal anomalies and gestational complica- breech delivered babies. It was said that SSS tions. tumors and neuronal migration anomalies such as Prof. Dr. Cihat fien presented the topic of lissencephaly may appear lately. She mentioned “Sonography as a Contributory Tool in Multiple about findings developed related to CMV infection Pregnancy”. It was stated that dichorionic twins and explained that coarctation of aorta, pulmonary can be followed up as singles and it is wrong to stenosis, achondroplasia from skeletal dysplasia, perform unnecessary elective cesarean. It was ovarian cysts, sacrococcygeal teratoma, intestinal mentioned that Down syndrome risk calculation is atresia, vesicoureteric reflux and multicystic dys- different in twins compared to single plastic kidney may be diagnosed lately. She and it was also said that it is not appropriate to use emphasized that only biometry check is not suffi- biochemical tests. Checking for nuchal translucen- cient on third trimester but also the anatomy cy and nasal bone is appropriate and risk will be should be evaluated in terms of these anomalies. calculated for each fetus while these risks will vary The topic of “Sonography of the Placenta and according to chorionicity. It was stated that taking its Adnexa” was narrated by Prof. Dr. As›m Kurjak. one sample in monochorionics if invasive process He expressed that placentation can be detected will be performed; however, it may have rarely dif- beginning from early gestational weeks by ferent genetic structures in postzygotic abnormali- Doppler ultrasonography and that 3D Doppler is ties. Since preeclampsia risk increases in multiples, more advantageous than 2D Doppler. He stated uterine artery PI should be checked in first that placental vessels can be imaged by “placental trimester as well as measuring blood pressure. In vascular biopsy” and that spiral arteries and pla- this way, heavy preeclampsia that occurs before cental vascular tree can be imaged by 3D, and 3D 32nd week can be diagnosed at a rate of 90%. indices may change according to the parity and risk increases to 6% from 3% and early 38 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

labor risk decreases to 10% from 20% if Ultrasonographic diagnosis criteria are pre-placen- reduction is performed in triple pregnancies. It tal accumulation under chorionic layers, gel-like should be decided together with the family. movement of chorionic layer by fetal activity, Reduction is not performed in monochorionics, retroplacental accumulation, marginal hematoma, but cord coagulation should be performed. If there sub-chorionic hematoma, heterogen increased pla- is any case requiring termination, it should be cental thickness and intra-amniotic hematoma. done at the earliest period. There is a clinical classification of placental In this course, after speakers presented their decollement and it gets intensified from 0 to 3. presentations, examples about normal fetal anato- Management of decollement in placenta includes my in point-of-care training were given by Ebru appropriate maternal monitorization, fetal status Tar›m, Özlem Pata, Yeflim Baytur, and Mertihan indication, performing differential diagnosis, trans- Kurto¤lu and information was given about fetal fusion of proper blood and blood products, and obstructive uropathy, neural tube defect and termination of pregnancy at a suitable time. increased NT on 3 patients at 1st, 2nd and 3rd Coagulation tests should be performed and urine trimesters. outgoing should be kept under control. If patient is stable during management, she can deliver. If 3. The Course of Obstetric Emergencies there is , then cesarean should be con- sidered. It should be remembered that maternal It was expressed that the real reason of early and fetal complications increase in decollement period bleedings can not be frequently deter- placenta. mined, but the most important one is the differ- ence between and abortus and Can we prevent decollement placenta? a good history, vaginal examination, hemogram It should be prevented to drink alcohol and follow-ups and ultrasonography gain importance smoke during pregnancy, antenatal controls in that case. should be performed, pregnants with hypertension It was said that vaginal 70-90% success was should follow treatment recommendations and obtained by misoprostol applications (600-800 folic acid should be taken. microgram/day) in abortuses. Following opinions Hypertension at Pregnancy was discussed on were shared about : Placenta prae- the first session on 14th April, 2011. via is a spectrum. Those with obstetric bleeding risk should be determined by ultrasonography at Prof. Dr. R›za Madazl› emphasized in his pre- 20th-23rd weeks. Lifestyle should not be changed sentation “Etiology and Staging of Preeclampsia” if cervical length is normal and placental covering that preeclampsia is a unique formation of human is below 15 mm at 20th-23rd weeks. Placenta prae- placenta and it is the cost of evolution. He said that via–vasa praevia, placenta accrete–cesarean under- it causes 50,000 maternal deaths in the world. He gone–maternal age, IVF/ICSI pregnancy are asso- talked about its common endothelial damage in ciated with each other. Normal delivery can be the etiology caused by insufficient trophoblastic performed under close follow up by placental tip invasion. He expressed that the classification at delivery – internal os <1.2 cm. should be changed as early (<34 week) and late (>34 week). He highlighted that early preeclamp- Placental decollement is seen generally at 3rd trimester. In most of the cases, fetal distress accom- sia is caused by placentation anomaly which have panies and its frequency is 0.3-1.6%. The diagnosis serious risk on mother and fetus, and late is clinical at ablation placentae. It is confirmed by preeclampsia is caused by overreaction of mother showing postnatal retroplacental hematoma. for pregnancy. Clinical findings vary according to the decollement Assoc. Prof. Arif Güngören said in his presen- level and bleeding amount. Placenta praevia, dys- tation “Preeclampsia Prediction by tocia and rupture should be eliminated at differen- Ultrasonography” that there is resistance increase tial diagnosis. Hemorrhage may not be observed in in uterine artery of preeclampsia patients against decollement cases ultrasonographically. current and that early diastolic notch may develop; Perinatal Journal 2011;19(1):35-50 39

but he also added that Doppler of uterine artery Carpenter Causton values are mostly used at has a limited value for predicting preeclampsia, 100 g OGTT. FBG, 1st, 2nd and 3rd hour threshold IUGR and perinatal death. He expressed that its values are accepted as 95, 180, 155, and 140 decrease in uterine artery Pulsatility Index alone or respectively. together with notching will be successful for pre- 75 g GTT threshold values were decreased after dicting preeclampsia. It was said that there is 90% the results of HAPO study were taken and FBG, 1st sensitivity when 1st Trimester PI and PP-13 are hour and 2nd hour values were determined as 92, used together. He emphasized that it is more valu- 180 and 153 respectively. able to use biochemical markers and USG identi- FBG should be checked at first examination in fiers together. all pregnants and FBG should be below 92 mg/dL. In “Hellp Syndrome: Practical Management”, In diabetic pregnants, maternal and fetal complica- the speaker Sanjay Gupte said that the situation tions increase. If blood glucose is above 200 develops 70% before delivery. He talked about mg/dL in pregnant with nausea and vomit, we endothelial damage caused by cytokines secreted should remember diabetic ketoacidosis. by maternal cell immunity as a reaction against Management of diabetes should begin in precon- pregnancy. He stated that the early diagnosis of ceptional period. If there is type-1 diabetes and the syndrome may give the best chance to mother patient currently uses any cholesterol lowering and delivery should be performed when the situa- drug and ACE inhibitors, they should be not be tion arises, no matter what happens. He highlight- used and it should be begun to use Ca channel ed that nausea or vomit developing at the second blockers and folic acid. half of pregnancy would cause a high level of sus- picion. He expressed that the state will regress Renal function tests should be asked for within 48 hours in most of the cases, and it can be patients with Type-1 DM before pregnancy, eye waited for steroid for 48 hours by stabilizing cases ground examination should be performed and developed between 7th and 32nd weeks. He said consultancy should be given in terms of maternal- that high dose of steroid use is not suggested in fetal risks. syndrome treatment and it does not change out- Congenital malformation risks should be told to comes and also said that thrombocyte suspension case who applies for bad glycemic control at first should not be given when thrombocyte count is trimester, and tight glycemic control should be over 50,000. He emphasized that aggressive treat- provided as not being hypoglycemic. During 20th- ment should be performed in order to save the life 24th weeks at second trimester, it should be sug- of patient. gested to do detailed ultrasonography and fetal “” was discussed in the echo in terms of fetal anomalies. next session. Gestational diabetes is a diabetes At final trimester, patient should be called for type which begins during pregnancy or appears weekly controls and NST and Biophysical Scoring during pregnancy for the first time. 90% of diabetes should be done twice in a week if necessary. observed during pregnancy is gestational diabetes Complications are lesser in gestational DM, but and its incidence is about 5-10%. careful follow-up should not be forgotten. It Even light hyperglycaemia affects progno- should be paid attention to hypertension and sis. Therefore, GD should be checked at pregnan- preeclampsia. In these cases, it is not necessary to cy. The screening can be performed as two-phased check urine routinely for ketone but it can be (50 g OGTT – 100 OGTT) or one-phased (75 checked for diet control. It is suggested to do first OGTT). trimester test at 11th-14th weeks, detailed ultra- At 75 g GTT, FBG (fasting blood glucose) sonography and fetal echo at 18th-22nd weeks, threshold value is 95 mg/dL, while 1st hour thresh- ultrasonography once at every four weeks after old is used as 180 mg/dL and 2nd hour threshold 28th week and delivery as not exceeding 40th is used as 155 mg/dL. week. 40 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

In diabetic pregnants, rate decreases in early pregnancy of those who exer- above 4,000 g is 30%. Shoulder dystocia possibili- cise. It should not be forgotten that nutrition and ty decreases by delivery induction without causing exercise are one of the most important steps for cesarean risk to increase if pulmonary maturation following up diabetic pregnant and preventing is full at 38th-39th weeks in those who were treat- gestational DM. ed by insulin. Classical recommendation is cesare- an above 4,500 gram. ACOG, on the other hand, Treatment Modals in Gestational suggests cesarean above 4,000 gram. Diabetes It should be avoided to do long-acting insulin Planned diet, proper exercise, insulin, oral during labor. Fluid should be given by using neu- hypoglycemic agents are used in treatment. tralized insulin inside glucose solutions. Desired targets are not reached by diet in 40% of In patients with gestational diabetes, Type-2 cases with gestational diabetes. Desired target diabetes risk increases at long-term. Therefore, 75 blood glucose levels are given Table 1. g GGT should be done after postpartum 6th-12th weeks. The purpose in treatment is to provide glycemic control as urine ketone is negative, HbA1C is normal and there is no glycemia. Nutrition at Pregnancy and Diabetes Abdominal circumference is proportional with Nutrition and exercise are both first step in ges- postprandial blood glucose, so macrosomia is tational DM treatment and are important factors directly related with postprandial blood glucose. among other treatments. The purpose is to keep blood glucose levels normal and to prevent At what doses should insulin be used? macrovascular diseases. Nutrition should be per- NPH – short-rapid-acting (insulin 50% - NPH sonal and appropriate to nutrition style of that per- 50%) insuline can be used 1-2 times as insulin son. There is no extra energy need at first pump. Analog insulins are lispro or aspart-ins trimester; however, 300 calories of extra energy is pregnancy category B and are rapid-acting. needed on 2nd and 3rd trimesters. When calculat- Pregnancy category of long-acting insuline analogs ing calorie need, 30 cal/kg energy according to is C, therefore it is stopped during pregnancy and pre-pregnancy weight should be calculated and NPH insulin is used. Pregnants generally do not 50% of it should be carbohydrate while the other want this treatment due to oral hypoglycemic half should be protein and fat. If BMI is higher agents, using injection for insulin, difficulty for than 30, energy can be calculated as 25 cal/kg and carbohydrate amount can be decreased to 40% if adaptation to treatment and hypoglycemia risk, necessary. Nutrition should include 3 main meals prejudice and concern about future, and appetite and 2-4 refreshments. and weight increase. Therefore, oral hypoglycemic agents were brought to the agenda. In GDM, gly- Physical activity-exercise directly affects glu- burid can be used and given 1 hour before meal. cose level over insulin, and it increases insulin sen- It can be used as 1x1 and 2x1. In order to prevent sitivity. Exercises such as swimming, bike moves high FBG, it can be given before going to bed. and chair exercises are suggested; however, tiring Insulin-like effects can be observed if glycemic exercises such as step should be avoided. Daily exercises for 20-30 minutes are effective, and GD control can be provided when daily glyburid dose is below 10 mg; however, risks are higher if more than 10 mg is needed. Table 1. Target blood glucose levels. It is advantageous that metformin breaks insulin resistance, decreases hepatic glucose Plasma Capillary release and does not cause weight gain. Its disad- FBG 70-106 60-95 vantages are that it passes close to the total 1st Hour 100-155 90-140 transplacentally and generally it is not sufficient 2nd Hour 90-130 80.120 alone. It is not suggested to use for these reasons. Perinatal Journal 2011;19(1):35-50 41

Treatment Manual trol. Also, calcium channel blockers and oxytocin • If FBG is higher than 95 or 1st hour postpran- receptor antagonists should be preferred. dial blood glucose is over 140, then insulin Gestational period is closely related with blood should be used. If FBG is 95–110 mg/dl, and glucose level. Since antenatal steroid is applied, 1st hour is 110–150, then treatment should be insulin infusion is the best effective method in initiated by NPH as 0.3-0.4 unit/kg. blood glucose management. • If FBG is 110mg/dl, and 1st hour is over 200, In “Multiple Pregnancies” session, Prof. Dr. then treatment should be initiated by 0.7 Murat Yayla gave information about unit/kg insulin. “Epidemiology of Twin Pregnancies in Turkey”. • Individual capillary blood glucose should be The incidence of multiple pregnancy increased checked for 4-7 times daily in 3 days in a week. after 1980. The major reason is the improvements in reproductive medicine. Its incidence at first peri- ods of pregnancies is indicated as 6-12%. The rate Preterm Labor Management in is observed as 2-3% in deliveries. (The increase of Diabetic Pregnant abortus risk?). The incidence is over 30% in HT Iatrogenic preterm labor is frequently seen pregnancies. is suggested at ver- especially in diabetes. Diabetes-caused IUGR, tex presentations in twin pregnancies while cesare- macrosomia or bad can cause an is suggested non-vertex presentations. Maternal early labor requirement. Also bad maternal blood mortality increases approximately 3 times. It is glucose control, noncontrollable HT caused by required to do chorionicity determination by ultra- vascular complications may require delivery to be sonography at early period. It is suggested to do performed early. If blood glucose is high, then follow-up in perinatology clinics for pregnancies preterm labor risk is high, too. Preterm labor risk more than two and . Routine in those with good glycemic control is similar with cervical sonography should be performed at 22nd- a normal pregnant. 24th weeks and follow-ups of pregnants who have Fetal hyperinsulinism antagonizes early labor risk should be suggested doing at peri- effect and Type-2 alveolus cell development is natology clinics. Less number of embryo transfer delayed. Surfactant is decreased and newborn made by the new law decreased multiple preg- tachypnea occurs. In cases where pregnancy will nancy rates 4 times; however, it did not change be terminated before 38 weeks and 7 days, pul- pregnancy rates. It should be remembered that monary maturation should be known for sure. perinatal mortality and morbidity will increase in Tests used in pulmonary maturation are L/S, PG, multiple pregnancies. and Lamellar Body (37 thousand / microliter) Assoc. Prof. Okan Özkaya then talked about counts. Sometimes can be RDS though it is “Management in Preterm Twins”. mature according to L/S test. Therefore, PG should More than 50% of twin pregnancies give birth also be checked. before 37th gestational week. Short cervix and fFn Tocolytic agents + antenatal steroid are used in screening by ultrasonography is useful for deter- preterm labor management. There are some risks mining preterm labor. There is no effective method about antenatal steroid use, because maternal for preventing preterm labor. Contrarily, prophy- hyperglycemia may be observed. This also may lactic circlage may increase preterm labor. cause fetal hyperglycemia and increases fetal Hospitalization, bed rest and prophylactic proges- insulin. Fetal hyperinsulinemia delays pulmonary terone are not effective. The purpose in acute maturation. Checking hourly capillary blood glu- preterm labor treatment is to perform antenatal cose and doing insulin infusion in diabetic preg- steroid application and to gain time for referring nant to whom steroid is applied are proper appropriate center. approaches. The last session of the day was “Turkish- Beta agonist can be given as a tocolytic agent Georgian Joint Meeting”. In this meeting, to diabetic pregnant who has good glycemic con- “Cesarean on Demand” was presented by Assoc. 42 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

Prof. Mekin Sezik. He emphasized that the defini- receive physical and emotional support regularly tion of cesarean on demand is quite difficult. He from an educated health employee, walking and stated that the situation is complicated if it is moving freedom should be provided for her; rou- patient who demands cesarean as it may not be a tine lithotomy should not be insisted and healthy decision. It should be discussed whether position preferred by her should be provided; patient demands cesarean as her health is deterio- induction rate should be decreased ≤10% and epi- rated or it is possible that we call it as cesarean out siotomy rate should be decreased ≤20% (target is of indication. ≤5%). Unless required, it is not encouraged to use Who determines cesarean indications? Should analgesic and anesthetic materials. physician be determiner traditionally with his Consequently, it was stated it could not be knowledge and experience or should there be expected to see a decrease in increasing cesarean instructions and regulations about it? In fact, there rates without leaving male-dominated medical dis- are many factors affecting indication determining course and interiorizing the privilege of “giving process (ministry, SSI, societies, physician, NGOs birth” by women which is peculiar to women. etc.). Consequently, both patient-physician relation Dr. Nana Gvetadze spoke about decreases and technician role is given to physician. “Homotoxicological Therapy of Chronic Feto- As a reflection, “increase in cesarean rates” Placental Insufficiency and Fetal Growth becomes an intricate situation caused by the com- Retardation”. In this session, it was mentioned bination of some “interrupted” social practices and about the use of homotoxic drugs in gestational value judgments through global-scaled excessive complications. The most important reasons for medicalization and mechanization in obstetric choosing homotoxicology in fetal medicine are practice. that they do not have embryotoxic and teratogenic Solution offers are not as easy as thought, they effects, they do not cause allergy and do not have should cover the change of some complicated any contraindications, they are more effective in social value judgments. In fact, women are in the treatment of chronic diseases and they are advan- focus of the debate; however, everyone except tageous in terms of costs. These preparates are obtained by mixing various dilutions of certain nat- women participates to the debate. ural herbs. They can be used in especially growth What can be done to decrease cesarean rates? retardation and placental insufficiency in terms of First of all, transparency should be provided. fetal medicine. Pregnant should be informed clearly about how On 15 April 2011, the second day of the con- pregnant will be prepared for labor, where labor gress, the first session was “High-Risk will be performed, who will make do labor, and Pregnancies”. The topic “From Pregnancy to the who will also be there. Neonatal Period” was presented by Prof. Dr. Another topic emphasized by the speaker is if Kalbiye Yalaz. By findings at early period of high- cesarean rates can be decreased. Support to labor risk pregnancies, it is not always possible to detect by someone else except health personnel and peo- neurologic problems such as cerebral palsy and ple close to pregnant decreased cesarean rates mental retardation that will appear on advanced about 2.5%. There should not be any places like ages. Babies who are delivered on time and have pain room of delivery room in hospitals since such no risk factor (cerebral palsy 60%-70%) may have places insulate and alienate pregnant. Lithotomy neurological problems in the future. Intrauterine or position and routine should be ques- low body weight during delivery according to ges- tioned. Importance should be attached to patient tational age, small head circumference, intrauterine privacy. movement shortage, low heart beats during preg- The Ministry of Health established mother- nancy, hypoglycemia during intrauterine and natal friend hospital criteria. According to this, a close period, placenta dysfunction, and retardation at person chosen by candidate mother should stay development steps are most important preliminary with her during delivery; candidate mother should findings of cerebral palsy and mental retardation. Perinatal Journal 2011;19(1):35-50 43

Prof. Dr. Neslihan Tekin explained the topic of proper method on chosen cases may help to “Prevention and Management of Perinatal reduce hypoxic encephalopathy cases. Asphyxia”. Perinatal asphyxia may develop at First speech on “Postpartum Bleedings” was intrauterine period, during labor, during delivery done by Assoc. Prof. Dr. Umut Dilek with the pre- or at early postnatal period. Recognizing risky sentation of “PP Bleeding and Risk Factors”. The cases and eliminating risk factors, referring risky speaker made the definition of PP Bleeding as the patients to perinatal centers, providing sufficient bleeding more than 500 ml in vaginal deliveries antenatal care, training health personnel to enable and more than 1,000 ml in cesarean deliveries. He them to evaluate and resuscitate newborns, and stated that it is first reason of maternal deaths in establishing a safe transport for risky pregnants Turkey, it has a rate of 4-6% and about 125-140 and sick newborns are basic approaches to pre- women die every year in the world for that reason. vent perinatal asphyxia. Fetal heart rate, fetal He expressed that its most frequent reason is ato- blood flow rate and similar tests are important to nia (70-90%) and that it is preventable clinical sit- determine proper delivery time by evaluating fetus uation with 50% chance. He talked about 4 T fac- condition. Hypothermia treatment applied as cool- tors in the etiology of PP Bleeding (Toe 70%, ing head circumference or whole body of a baby Tissue 10%, Trauma 20%, and Thrombin 1%). He about 3-4 °C who born as asphyxiating is accept- indicated that extended 3rd phase, preeclampsia, ed as the latest treatment method since it decreas- episiotomy, PP bleeding history, multiple pregnan- es the rate of a series of metabolic event (which cy, arrest of descent, delivery induction, and oper- will lead to secondary neuron death), decreases ative deliveries are risk factors. He emphasized mortality and affects neurological prognosis posi- that clinics mostly overlook and diagnosis is tively. delayed. “Induction and Management of Labor” was pre- “Clinic and Hypovolemic Shocks in PP sented by Assoc. Prof. Dr. N. Ömer Kandemir. Bleeding” was presented by Assoc. Prof. Dr. Today, obstetrics is an art in which it is required to Selahattin Kumru and he classified the shock use knowledge, skill and technology together. It under 4 topics: 1- 15% (900 ml) loss of blood (no was begun to use in 1960s for labor symptom), 2- 20-25% (1,200-1,500 ml) loss of induction and using prostaglandins marked a new blood (tachycardia, tachypnea, orthostatic era beginning from the mid-80s. Mechanical servi- changes), 3- 30-35% (1,800-2,100 ml) loss of blood cal dilatation is among invasive methods used on (hypotension, distinctive tachycardia, cold moist stubborn cases and it is generally used together skin), 4- 40% (>2,400 ml) loss of blood (oliguria- with prostaglandins and oxytocin. anuria, no peripheral pulse). He expressed that Assoc. Prof. Dr. Serdar Yalvaç talked about active management type in which loss of blood “Fetal Hypoxia at Labor”. Nowadays, due to will diminish should be a routine approach by giv- medicolegal issues caused by perinatal asphyxia, ing uterotonics at third phase of delivery, remov- obstetricians and gynecologists feel themselves ing placenta by clamping cord. Consequently, life under pressure when they are doing their jobs. In can be saved by recognizing risky cases, deter- order to detect hypoxia on time, intrauterine mining bleeding amount, managing third phase growth retardation, hypertension, postterm preg- actively and with a good team work. nancies, reduce in baby movements, breech pre- Assoc. Prof. Dr. Ahmet Yal›nkaya made a sentation, decrease in and infections speech on “Medical and Surgical Approaches in PP are those to be paid attention in the first place. Bleeding”. He stated that early breast-feeding, nip- Ultrasonographic evaluation, Doppler, cord blood ple massage, uterine massage and bimanual uter- examination, Non-stress test, counting baby move- ine compression are medical treatments in PP ments are major methods used for predicting bleeding. He indicated that anti-shock treatment asphyxia. Although none of classical-modern fol- should be performed by doing blood and blood low-up methods leads to certain diagnosis for pre- product transfusion. He also mentioned that tam- dicting antepartum/intrapartum asphyxia, using ponade, compression suture techniques, artery lig- 44 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

ations and artery embolization are among the “Fetal Heart Scanning” was presented by Prof. options as surgical techniques. He expressed that Dr. Cihat fien. The speaker began his speech by 0.05% is required and he suggested emphasizing the incidence rate of fetal cardiac doing it to save life. He stated that success rates of anomalies among the society and he stated that these methods are about 80-90%. As result, he cardiac malformations constitute a major part of emphasized that treatment should be done aggres- neonatal deaths. It would be possible to keep sively and effectively. many newborns alive by doing fetal echo evalua- “: Preventive Measures of tion especially risky patients and performing deliv- ” was presented by Prof. Dr. Özgür ery in senior centers due to existing pathology. He Deren. The speaker stated that uterotonic agents expressed that checking only four chambers when should be administered rapidly in postpartum screening fetal heart cause us to miss much patho- bleeding and that the biggest problems are DIC logical stuff, but it would be possible to catch (disseminated intravascular coagulation) and many existing pathologies by checking especially myocardial ischemia developed due to delay. He major vessel outlets. Therefore, it was emphasized specified that oxytocin should be preferred rather that gynecologists should certainly check major than oral misoprostol. vessel outlets when screening fetal heart and it was In “Screening Tests” session, the presentation said that it would be useful for physicians to attend on “First Trimester Screening on Aneuploidies” courses held for their trainings related with this was made by Giovanni Monni. In the beginning of topic. the presentation, Dr. Monni emphasized that many Assoc. Prof. Dr. Ertan Adal› talked about “New scannings (gestational diabetes, preeclampsia risk, Approaches for Screening of Gestational Diabetes”. preterm labor risk etc.) together with chromosomal The concept of Gestational diabetes mellitus anomalies should be performed at first trimester. (GDM) is used for defining abnormal glucose tol- Fetal biometry (CRL, microcephaly etc.), function- erance which is either first noticed during preg- al evaluation (decreased or increased heart beat, nancy or appeared at various levels. However, the increased UA PI, pulsatility in umbilical vein), soft number of patients increases who previously have markers (choroid plexus, caliectasis, echogenic diabetes during pregnancy but not diagnosed yet focus, hyperechogenic intestine etc.) and other due to type-2 diabetes frequency throughout the markers which are popular these days (nasal bone, world. These patients have different risks than facial angle, ductal current, tricuspid regurgitation, those of whom diabetes begin with pregnancy. mitral gap etc.) can be evaluated in the ultra- Therefore, IADPSG (International Association of sonography used in the first trimester aneuploidy Study Groups) offered a screening. change in this terminology in 2010. According to The importance of detecting chromosomal this, diabetes diagnosed during pregnancy is clas- anomaly especially in nuchal translucence mea- sified into two groups as “gestational” and “overt- surement was emphasized and advantages and dis- preexisting diabetes”. advantages of semi-automatic NT measurement of late years were mentioned. In this terminology, overt diabetes diagnosis should be established at first prenatal visit for Finally, it was stated at the end of this session women from risk group. Accordingly, if diagnosis that scanning only maternal age does not have any of FBG is ≥126 mg/dl or of hemoglobin is ≥ 6.5% meaning; scanning first trimester is more effective or randomly checked blood glucose is found as ≥ than second trimester; consecutive scanning may work in patients with intermediate risk; step-wise mg/dl (later on, it should be confirmed by FBG scanning would be more useful in patients with and hemoglobin A1C levels), then pregnant is low risk; additional markers would decrease the diagnosed as overt diabetes. requirement for second trimester scanning, contin- According to the new terminology, gestational gent scanning performed by checking nasal bone- diabetes mellitus is diagnosed when FBG is ≥92 tricuspid regurgitation-ductus venosus current mg/dl but <126 mg/dl at first prenatal visit or high would contribute to obtain best results. abnormal values (FBG ≥ 92, 1st hour; ≥ 180, 2nd Perinatal Journal 2011;19(1):35-50 45

hour ≥153) high by 75 g one phased test at 24th- of head, taking hand to head, eye, face and ear. 28th gestational weeks. ADA 2011 also adopts this KANET score system has been developed for scor- approach. However, ACOG 2001 recommenda- ing these moves in antenatal period. He, however, tions offer to do scanning on all pregnants by two emphasized that more studies are required to eval- phased test (first 50 g GCT, then 100 g OGTT to uate normal levels for evaluating brain functions. abnormal ones). He said that positions of hand fingers and thumb In the Manual of Diabetes Mellitus and standing apart can be determined by intrauterine Diagnosis, Treatment and Follow-up its 4D ultrasonography when evaluating brain func- Complications published by The Society of tions at neonatal period by Amiel-Tisson. Endocrinology and Metabolism of Turkey in 2009, Prof. Dr. Turgay fiener made a speech about it is asked to do risk evaluation (GDM history, obe- “Ultrasonographic evaluation of placenta, umbili- sity, glycosuria, DM in first degree relative) at first cal cord and membranes”. He spoke of placental prenatal visit for GDM screening and to do screen- anomalies. Placenta circumvallate is membrane ing at next trimester if risk is negative. The manu- twisting onto placenta and may be confused with al recommended doing screening (50 g GCT) to all adhesion and tapes. Placenta succentriata may pregnants at their 24th-28th gestational weeks. cause complication since accessory lobe stays Another issue to emphasize is that there is no behind after placenta is removed. This is why it is consensus in the world on performing diagnosis important to evaluate by ultrasonography and to and screening of gestational diabetes. The conclu- know it at delivery. Battledore (Racket) placenta is sion obtained from HAPO study is to apply 75 g more in twins and insertion is more marginal. one-phased screening and diagnosis test by using Placenta membranacea is thinner than normal pla- new diagnostic criteria. However, professional centa and it covers whole . Vessel structures organizations should decide based on their local also may be less. Chorioangiomas are tumors risk factors. which have high vascular content and may cause In the “Ultrasonography” session, Thomas intrauterine hydrops, growth retardation and Everett made a speech about “New Studies about death. Doppler helps diagnosis. Lipomas are the Preeclampsia”. He expressed that preeclampsia structures which are more hypoechoic and do not can not be treated efficiently though it is an impor- include Doppler signal, and they do not have tant health problem and that treatment approaches effect on prognosis very much. Placental cysts do are very old. He emphasized that preeclampsia is not affect obstetric approach. Placental lacunas not only hypertension. He mentioned about stud- (ponds) are the structures which need more atten- ies performed with newly developed drugs such as tion clinically. They have motion inside. “Digoxin binding antibody fragments, relaxin, Thrombosed infarct areas seem hyperechogenic. sildenafil, recombinant active protein C”. Placenta praevia and vasa praevia can be defined In the same session, Prof. Dr. As›m Kurjak pre- by using Doppler and vaginal ultrasonography. We sented “The 4d Assessment of Fetal Brain Function may meet placenta Rh incompatibility in in Preeclampsia”. He expressed that cerebral palsy infections. The thickness is above 4 cm. He also mostly (80%) develops related with intrauterine mentioned about evaluating molar pregnancies reasons, but its diagnoses appear at a later period and membranes. after delivery and that the cerebral palsy risk is Prof. Dr. Yakup Erata talked about “Perinatal higher in multiple pregnancies. He stated that eval- Doppler”. He stated that Doppler can be used in uating moves of fetus at intrauterine period pro- preeclampsia and IUGR prediction by using it as a vides benefit in evaluating fetal brain functions. uterine artery screening test and that fetal Doppler There are six different facial expressions that can be used in order to evaluate fetuses with should be analyzed in ultrasonography: blinking, IUGR. He said that preeclampsia may be predicted yawning, lip sucking, sticking tongue out, grimac- by applying uterine artery Doppler on high risk ing and swallowing. Head and head moves to be group and it would not be useful on low risk evaluated are retroflexion, rotation and anteflexion group. He expressed that it is not necessary to 46 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

apply Doppler on all pregnants and it should be performed. Evaluation at 12th week will give us an used only in cases such as preeclampsia and IUGR. idea about follow-up frequency at next period. He explained that the non-existence of diastole Uterine artery evaluation should be performed at end blood flow in umbilical artery is normal, high-risk group; if there is bilateral notch and resis- because diastole end blood flow is formed after tance increase, then preeclampsia risk is high. 15th week and it increases as pregnancy proceeds Cervix measurement should be done twice in a while PI decreases. Depending on the MCA brain week at 14th-18th week and 18th-22nd week in protective effect, diastole blood flow increases high risk cases, and at 20th-22nd week in low risk under hypoxia case, and cerebro-umbilical rate cases. Mud-like structure around cervix orifice may goes below 1.08 accordingly. In such case, the be related with preterm labor. When cervix is con- decision of giving birth can be given depending on tracted, preterm labor prevention strategies descendant aorta blood flow. If arterial Doppler change. may be used. If cervix is diagnoses are corrupted, then venous Doppler below 20 mm, tocolysis indication may occur. should be performed. If ductus venosus diagnoses Circlage use should be discussed. are corrupted, then delivery should be performed. Prof. Dr. Serdar Ural mentioned about “Short There is adverse flow which does not exist in duc- Cervix: Diagnosis and Management” as the second tus in inferior vena cava, and being deepening is speaker. The most important one among risk fac- the diagnosis of hypoxia. Pulsation in umbilical tors for preterm labor is the contraction of cervix. vein is the worst diagnosis which appears lately. Contraction in cervix is important especially Assoc. Prof. Dr. Yeflim Baytur made a presen- between 16th and 24th weeks. When cervix is tation entitled as “IUGR on Single Fetus in Twins: taken as 3 cm, labor rate increases four times while Diagnosis Management”. sIUGR in twins is a rare it increases 6 times when it is taken as 25 mm. but significant problem. Management in DC is not Cervical length evaluation should be done by so different than singles. It should be acted accord- transvaginal ultrasonography. If cervix is shorter ing to the classification made depending on UA than 25 mm and there is no history of preterm diagnoses in MC twins, and delivery should be labor more than one, close follow-up can be rec- performed at 34th week in fetuses with normal UA ommended; but if there are two pregnancy losses diagnoses. In Type-2 and Type-3 MC sIUGR, the or more, then circlage can be suggested. Steroid management varies according to family request, can be applied after 24th week to short cervix if frequency of weight difference and gestational there are preterm labors more than two. This is the week. Cord occlusion should be considered in bad standard approach in the USA. It was reported that prognoses that are diagnosed early. pregnancy might be elongated 15% when circlage On the third day of the congress (16th April, is done if short cervix limit is taken as 15 mm. The 2011), first session was “IUGR and Preterm Labor”. most important value of cervical length measure- The first speaker Prof. Dr. Lütfü Öndero¤lu pre- ment is negative predictive value. When it is used sented “IUGR and Preterm Labor: Antenatal together with the , unnecessary Strategies”. Gestational complications expected interventions would be prevented. In the recent antenatally should be detected early, preventive studies, using vaginal progesterone gel beginning processes should be performed, and maternal and from 24th week when short cervix is between 10 fetal health should be considered together. When and 20 mm decreased the rate of delivery before doing this, all health personnel should work 33rd week about 45%. As a result of evaluating together and the awareness of families should be benefits of progesterone use together with other raised. The most frequent reasons for losing baby studies, it seems that it can be suggested to apply are preterm labor, IUGR and preeclampsia. Instead alone or with other treatments to groups which of traditional monthly approach, screening tests at had losses at second trimester, had only short 11th-14th week, anatomy and uterine artery, cervix cervix or had preterm labor history. Cervix mea- evaluation by ultrasonography at 20th-22nd week, surement can also be suggested in terms of and growth follow-up at 32nd week should be decreasing health expenses. Perinatal Journal 2011;19(1):35-50 47

Jason Gardosi talked about “New Concepts in suppressed in recurrent doses. Steroid endogeny is IUGR Diagnosis”. He stated that most of the deaths increased in IUGR babies, and 11-beta hydroxys- in the womb are related with IUGR and they also teroid dehydrogenase is decreased in placenta. cause neonatal deaths. It was said that cerebral This enzyme is neuroprotective. It has a great role palsy risk increases in term IUGR. Making these in normal development of HPA axis. If this barrier babies intrauterinely with a non-functional placen- is broken as in IUGR, the transformation of corti- ta may increase this risk. It was emphasized that sol into cortisone is decreased and hypertension the physiological parameters affecting birth weight may develop in progressive years. Vasoconstric- such as gender, maternal weight, height and race tion and decreased cardiac output are seen when etc. should be taken into consideration and using antenatal steroid is given to a healthy baby of customized growth cards are important. It was stat- sheep, but vasodilation and increased cardiac out- ed that these cards have not been developed for put are seen when it is given to IUGR fetus. Turkey yet; however, they can be done soon. He Antenatal steroid does not create great effect in said that SGA and IUGR distinction can be done human IUGR and babies with normal umbilical better by customized cards. It was emphasized that artery Doppler; however, in IUGR fetuses with more proper information can be obtained by using AEDF have effects similar to sheep and this may be growth curves in IUGR diagnosis, , dangerous in terms of fetus. 62% of babies with serial ultrasonography measurements and IUGR and AEDF who were applied antenatal Doppler. There is “selection bias” in randomized steroid had progress in Dopper diagnoses within studies about the time for carrying out the labor. 24 hours. It is related with the removal of MCA GRIT study was criticized and it was expressed dilation and disappearance of cerebral protective that patients who had IUGR beginning from 26th effect. Though results are better in cases that have week and patients who had IUGR beginning from diastolic flow returned, acute worsening may 29th week can not be same, also the results of pre- occur at a rate of 40% in these cases. Brains of ferring to wait against delivery are evaluated in the IUGR babies may reach half of their neuronal short period and the long-term status of these development. Steroid use may cause this situation babies are not known. Patients rather in good con- to be worsened much. Re-increase of reduced dition during randomization were chosen but blood flow of IUGR fetus may cause oxidative delivery might be done in patients in bad condi- damage. Consequently, steroid should not be tion. Consequently, it was highlighted that the applied without doing Doppler. If AEDF exists, issue of delivery timing is critical and each patient fetus should be followed up closely for 3 days after should be evaluated separately. steroid application, steroid may damage in worse Alex Vidaeff talked about “Risks and Benefits of cases; should be preferred when Antenatal Therapy Prior Preterm nongenomic effects are less. In light of current IUGR". It was stated that antenatal steroid use information, it can not be forbid to apply steroid decreases RDS about 34% and neonatal death on IUGR fetuses, however it should be paid atten- about 30%. It should be considered well whether tion. the metabolic speed increased by corticosteroid The final speaker of the session was Thomas use on IUGR fetus would be harmful or not, espe- Everett and he made a speech entitled as “Perinatal cially on hypoxic fetuses. There are studies report- Management in Extreme Preterm Labor”. He stated ing that results of steroid use are better in IUGR that preterm labors between 23rd and 27th weeks babies between 25th and 30th weeks as well as are accepted as extreme preterm. He explained reporting useless and also ineffective in short term that deaths related with preterm labor in England in acute IUGR babies. It was shown in some ani- decreased and survival rates in births between 29th mal experiments that genomic effect of steroids and 32nd weeks were close to term births by the increased maturation and its nongenomic effect improvements in newborn care. He mentioned suppressed liver and lung increase. This effect of that cerebral palsy rates were about 50% though is much more compared to survival rates increased in labors before 25th week. betamethasone. Growth and CNS development are He expressed that preterm labors after 32nd week 48 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

are not a problem in developed countries. It was mortality is 6 times higher. Also other neonatal emphasized that long term handicaps should be complications are higher in multiple pregnancies. taken into consideration while efforts are made to Cerebral palsy rate increases in death of twin of keep fetus alive in labors before 25th week. monochorionic baby in twin pregnancies, TTTS, In the session of “Neonatal Problems”, Prof. Dr. and SGA cases in discordant twins. Especially the Neslihan Tekin made a presentation about monochorionicity is an independent bad prognos- “Prevention and Management of Perinatal tic factor. Studies done to show that selective feto- Asphyxia”. Perinatal asphyxia can be defined as cide decreases cerebral palsy risk are not reliable hypoxia, hypercapnia and acidosis development in due to small sample group. Especially reducing newborn or fetus as a result of insufficient gas embryo number (transferred during ART – assisted exchange. It typically occurs in intrapartum reproductive techniques) to one was found effec- antepartum period. The most significant way to tive for having a living and healthy baby as well as prevent or protect against perinatal asphyxia is to reducing health expenses. It was found that 75% of determine risky cases beforehand, and to refer multiple pregnancies in our country were obtained patients to advanced perinatal centers by using by ART applications. In pregnancies obtained by required dispatch and transport mechanisms. Tests ART, increased antenatal complications are met as used to detect antenatal hypoxia are biophysical well as increased maternal complications. score, modified biophysical score, umbilical artery Consequently, the multiple pregnancies have Doppler, cardiotacography, scalp pH, and NIRS increased risk in terms of neonatal mortality, (near infrared spectroscopy). All organ systems, preterm labor, miscarriage weight, cerebral palsy especially central nervous system, can be affected and neurocognitive disorders. Multiple pregnan- by asphyxia. cies place physical, psychosocial and financial bur- In the efficient management of asphyxia, sub- dens on whole society, especially on mother-father structure should be prepared for required resusci- and children. Our target should always be single tation and stabilization. Various neuroprotective healthy baby. treatment methods are used for decreasing the “Premature baby mortality and morbidity in effect of asphyxia (hypothermia, magnesium, Turkey and World” was presented by Prof. Dr. adenosine, vitamin C and E, indomethacin etc.). Asuman Çoban. Though newborn baby death rates There are some recent promising developments in decelerate, it is still not at a desired level. In the use of prophylactic barbiturate and giving ery- Turkey, we lose 22,000 babies every year before thropoietin. they reach their first age. Most of the newborn Consequently, perinatal asphyxia maintains its deaths occur in low-income countries. 50% of importance in terms of early and late morbidity babies are lost within first 24 hours. The most and mortality. It is important to determine com- important reason for newborn deaths is the pre- pensation potential of fetus by antenatal tests. maturity (low birth weight), it is 13 times higher Supportive treatment is required after successful than those born in risk term. Deaths in preterm resuscitation. First hours are significant for neuro- labors gradually decrease in especially developed protective treatment. Nowadays, the most promis- countries and the most significant reasons are tech- ing results have still been obtained by hypother- nological developments and increase in newborn mia; however, multi-centered studies are needed care opportunities. to obtain the effects of future periods. There may be neurodevelopmental sequelas in “Neonatal problems in multiple pregnancies” preterms and difficulties in rough-thin motor func- was presented by Prof. Dr. Nilgün Kültürsay. Due tion. Also behavioral and emotional problems in to the increase in reproductive techniques espe- them are stated. Eye and hearing problems are cially in recent years, there has been an increase in high according to the terms. Besides, metabolic prematurity due to multiple pregnancies and in disorders such as diabetes are frequently met. . As known, fetal mortality is four In conclusion, it is important to cure prognosis times higher in twins than singles and neonatal in preterm babies. In order to do that, approaches Perinatal Journal 2011;19(1):35-50 49

such as antenatal steroid in preterm labor, antibi- In the last session of the congress, “Medicolegal otics in EMR, K vitamin, neonatal sepsis treatment, Aspects” were spoken. Prof. Dr. Seyfettin Uluda¤ clamping cordon lately, early breast feeding and made a speech about the topic of “What Is surfactant treatment gain importance. Malpractice? What Is A Complication?”. Performing Prof. Dr. Saadet Arsan presented “Very irregular processes, not obeying requirement rule, Premature Births: Substantial Perinatal not performing those which can be done by any- Management for a Healthy Life”. Integrated one or not preventing a preventable complication approach means to manage patients by perinatol- can be deemed as malpractice. Being unable to ogy team, newborn team and follow-up team and predict possible danger can also be deemed as malpractice. In order to accept it as a malpractice, the collective work of these teams. Perinatologic there should be damage due to medical process. part of the approach includes healthy pregnancy Not performing things that should be done before planning, decrease of assisted multiple pregnan- operation, not checking pathological results, not cies, use of antenatal steroid and antibiotics, tocol- performing things that should be done during ysis, intrauterine transport and delivery type. delivery follow-up, forgetting gas compress etc. Neonatological approach includes delivery room can be given as the examples of causing injury and stabilization, oxygen targets, surfactant treatment, death as a result of negligence and recklessness. In respiration support and antibiotic treatment. a complication case, everything which should be Antenatal steroid treatment contributes lung devel- done as a standard is done, but unpredictable opment as well as neurological development. results occur. It is physician’s responsibility to Antibiotic treatment at extended EMR is useful for keep all kinds of medical records. Also informed elongating delivery. Tocolysis is used to gain time consent should be taken. These consents should in antenatal steroid applications and transport. be conformed to ethics and medical rules and In low premature, cesarean is protective at a should include complications. Explaining what low rate; however, patients should be evaluated in screening tests mean and not saying “everything is terms of maternal morbidity. ok” may protect physician. Overlooking presenta- It was found that autologous blood transfusion tion, overlooking preeclampsia by not checking (late clamping of the cord) during delivery did not tension, overlooking fetal asphyxia reasons and cause increase in blood pressure of newborns, not following up normal delivery process carefully increase in urine amount, decrease in transfusion are the examples of malpractices made during need, decrease in oxygen need and increase in the delivery. Malpractice and complication may be risk of polycythemia and hepatitis. Resuscitation together in cases such as fetal macrosomia. Though macrosomia is frequent in shoulder dysto- and stabilization processes are significant in deliv- cia, it also may be in babies with normal weight. It ery room. Providing improper oxygen to prema- is not possible to predict. If physicians feel them- ture babies would do more harm than good. CPAP selves competent in breech presentation, baby applications and non-invasive ventilation use should be about 2,000-3,000 gr, pure breech and rather than mechanical ventilation should be pro- head is in flexion. If there are broken bones in vided as respiratory support. patients with these conditions, then it is complica- Maintaining body temperature, sufficient fluid tion. If first baby in twins is breech, then cesarean replacement, total parenteral nutrition and early should be done. If vacuum and forceps are applied full enteral nutrition can be deemed as supportive unnecessarily, it can be deemed as malpractice; care. injuries in applications performed by proper indi- Consequently, premature babies with low birth cation can be deemed as complication. weights benefit from integrated prenatal approach Nezih Varol presented the speech “Building and non-invasive care applications. In that way, Physicians Strategy in Medicolegal Cases”. The bronchopulmonary dysplasia, necrotising entero- speaker expressed that medicolegal problems gen- colitis and premature retinopathy are decreased erally appear as a result of complaints and patient and the development is positively affected. dissatisfaction. It should be established that who 50 Kafkasl› A et al. The Conclusion Report of 13th National Perinatology Congress

will provide solution and who will meet financial Parties are liable to prove their claims; therefore, liabilities when a problem appears. When patient records should be kept properly. is accepted to hospital, an admittance agreement is Prof. Dr. Alper Tanr›verdi made a speech about done first. As physicians, we have employment “Up-to-date Practice Standards”. He emphasized contract with hospital and also a patient treatment that it should be paid attention that standards have agreement. First of all, health legislation should be to be applicable in everywhere when putting them sufficient. Turkish Criminal Code gives physician forth. He mentioned manuals established by the the right of intervening to patient, therefore, appli- Ministry of Health briefly. The Manual of “Prenatal cations done within standards are complications. Care Management” can be given as an example. Surveyors pay attention whether standards are fol- Tests and examinations specified here should be lowed or not. The frequent legal case examples performed and patient should be referred to an shoulder dystocia, bleedings, prenatal diagnosis, upper step if there is something significant. If and organ injuries. This can be protective if partic- patient is referred to an upper step, it should be ipative treatment is done, in other words informed checked whether she went or not. consent is taken. The basic o health service is to Ultrasonographic examinations are recommended carry out a team work in compliance with laws but they are not compulsory. Also, “Labor and legislations, by using initiative and also Management Guide” can be used as a standard for expecting the same from other service units. labor.