PERINATAL AN D NEONATAL MORTALITY RATES AND
CAUSES OF DEATH AT M ARM ARA UNIVERSITY HOSPITAL
İ p e k A k m a n , M . D . * / G o n c a İm ir , M .D .* * / E ren Ö z e k , M .D .* N e j a t C e y h a n , M .D .* * * S u b - d e p a r t m e n t o f n e o n a t o lo g y , D e p a r t m e n t o f P e d ia tr ic s , S c h o o l o f M e d ic in e , M a r m a r a U n iv e r s ity , is t a n b u l, T u rk e y . ' * D e p a r t m e n t o f O b s t e t r ic s a n d G y n e c o lo g y , S c h o o l o f M e d ic in e , M a r m a r a U n iv e r s ity , I s t a n b u l, T u rk e y . ABSTRACT
Objective: The aim of our study was to establish
the stillbirth, early and late neonatal mortality and perinatal mortality rates at Marmara University Hospital and to compare the rates with those of other countries.
Methods: We evaluated the mothers who gave
birth at Marmara University Hospital and their infants prospectively for two years from January 1998 to January 2000. The causes of perinatal deaths were grouped according to the modified Wigglesworth Classification. Maternal risk factors were ascertained.
Results: The stillbirth rate was 15.1%, early and
late neonatal mortality rates were 3.8 % and 2.8% respectively, and the perinatal mortality rate was 18.8% in our hospital. The mean gestational age of the neonates who died perinatally in the perinatal period was 26.8±1.2 weeks. In this group, 68% of the mothers did not receive any antenatal care. Sixty percent of their mothers were primipar and 40% were multipar. The most common cause of death was hypoxia during the intrauterine period and preterm labor and delivery. The total number of deliveries in our hospital was 1060 in two years and 19% of the mothers had high risk pregnancy. The average
number of preterm delivery was 37 (7.9% of all deliveries) per year of which 13 (2.5%) had a birth weight of less than 1500 grams.
Conclusion: The perinatal mortality rate at our
hospital (18.8 %) is lower than that of the world (53 %) but higher than the rate of the developed countries (10 %). The perinatal mortality rates of the other hospitals in Turkey are between 11.9- 108 %. Systematic antenatal care should be applied all around the country, high risk pregnancies should be managed at the tertiary care hospitals with intensive care units and the number of neonatal intensive care unit beds should be increased.
K e y W o rd s : Perinatal mortality rate, Neonatal mortality rate, Antenatal care.
IN T R O D U C T IO N
It is important to determine the perinatal mortality rate and causes of death in order to develop the national and regional health policy. The perinatal and neonatal mortality rates are good indicators of the level of practice of obstetric medicine and neonatology (1). The aim of our study was to establish the stillbirth, early and late neonatal
Correspondance to: Eren Özek, M. D. - Sub-department o f Neonatology, Department o f Pediatrics, Marmara University Hospital, Tophanelioğlu Cad. 81190 Altunizade, istanbul, Turkey,
e.mail address: mozek(g)türk.net
(Accepted 27 May, 2001) Marmara Medical Journal 2001 ;14(3):169-172
İpek Akman, et at
mortality and perinatal mortality rate at Marmara University Hospital and to compare the rates with those of other countries.
M A T E R IA L S A N D M E T H O D S
We evaluated the mothers who gave birth at Marmara University Hospital and their infants prospectively for two years from January 1998 to January 2000. Stillbirth was defined as the infants born at a gestational age of more than 22 weeks and birth weight of more than 500 grams but did not have a heart rate or respiratory effort and did not respond to resuscitation (2). Live birth was defined as infants who had a birth weight of 500 grams and had a heart beat and respiration at birth. Death in 7 days after birth was defined as early neonatal death, death between 8 and 28 days after birth was defined as late neonatal death. Perinatal mortality rate was calculated as the ratio of stillbirths and early neonatal deaths to the total number of births (2). The causes of perinatal deaths were grouped according to the modified Wigglesworth Classification (Table I) (1, 2). Maternal risk factors were ascertained. Late neonatal mortality rate was established by calling the mothers of all the infants who gave birth in our hospital to determine infants' status at 28 days of age.
T a b l e I.: M odified W igglesw orth classification (1,2)
Group 1: Deahts before the onset of labor Group 2: Lethal congenital malformation Group 3: Complications of preterm delivery
- Hyalen membrane disease - Intraventricular hemorrhage
- Nonspecific infections of premature infants Group 4: Deaths from hypoxia during labor and delivery Group 5: Some special causes*
Group 6: All Infections of term infants and specific infections of premature infants
Group 7: Unknown causes and miscellaneous causes of deaths
* Special causes: Blood type isoimmunizations, congenital metabolic diseases, transfusion syndrome, hydrops fetalis due to a variety of causes other than malformations, diseases of term infants as RDS and NEC, tumors.
RESULTS
The total number of deliveries in our hospital was 1060 in two years and 19% of these mothers had risk factors such as preeclampsia, placenta abnormalities or chronic maternal diseases.The average number of preterm deliveries was 37 (7.9% of all deliveries) per year of which 13 (2.5%) infants had a birth weight of less than 1500 grams. The congenital malformation prevalence in our hospital was 9% which included infants with congenital heart disease (2), cleft lip and palate (2), spina bifida (3), anancephaly (1), and one infant with multiple anomaly (hydrocephaly and multicystic renal disease). Two mothers had termination of pregnancy at 18 and 20 weeks of gestation because of congenital malformation (hydrocephaly and spina bifida) and congenital CMV infection respectively.
Stillbirth rate was 15.1 %, early and late neonatal mortality rates were 3.8 % and 2.8 % respectively, perinatal mortality rate was 18.8 % in our hospital. The mean gestational age of neonates who died perinatally in the perinatal period was 26.8±1.2 weeks. In this group 68% of mothers did not receive antenatal care. Sixty percent of their mothers were primipar and 40% were multipar. The causes of death of infants are shown in Table II. Most commonly, deaths occurred before the onset of labor. (52.2% of all deaths). Preterm delivery complications were the second most common cause of death. The mean birth weight of infants who died after preterm delivery was 800±150 grams (645-950 grams).
T a b l e II.: C auses of deaths according to the cla ssification of m odified W ig glesw orth classification.
Cause of death Number (n) %
Group 1 12 52.2 Group 2 1 4.3 Group 3 5 21.7 Group 4 4 17.5 Group 5 0 0 Group 6 1 4.3 Group 7 0 0
The total number of deliveries = 1060 (in 1998-1999) Stillbirth rate = 15.1 % (n= 16)
Early neonatal mortality rate = 3.8 % (n= 4) Late neonatal mortality rate = 2.8 % (n= 3) Perinatal mortality rate = 18.8 % (n= 20)
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>. Hauptman J. Anderson JW, cl al Oriistat a lipase inhibitor, 1« »eight maintenance aha conventional dieting; a I v swdv Am I Clin Sutr. 1 J99.69: 1108-16 2)Ouertiohni irSuppI S SI? 2J 3)(>avid*m MH. Hauputun f, tixSobmo M, et al Wright control and mk factor reduction in .ibese m^s treated fcr 2 wan sh* orimat MMA. IW; Ml 23 Randomised placebo controlled tnal of oriistat 1« »eight lorn and prevenoiin.ilweight regain ¡nobew patients lancet 1998, 352: 167 WWan C^Br<«m|I Ena C., c. al. Effis obesity: a 6-month dose-ranging study Eur I Clin Pharmacol 1998; 54:123-32 6)IVSunyer >X Medical Hazards of obesity. Ann Intern Med 1993.1191 /pt2 . 655 660
R Mode of action of orimat. Int 1 Obesity. 1997; 235 +2 4W8Rrflm L, Rissancn A. Andersen T, et al Efficacy and tolerability of oriistat io the treaiment of Roche Müstahzarları Sanayi A.Ş.
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O B E Z İT E N İN U Z U N SÜ RELİ T E D A V İS İN D E E N D İK E D İR 34KİLO
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s a ğ l ı k l ı b i r y a ş a m i ç i n s i z l e r l e b i r l i k t e . . .
A l t s o l u n u m y o l u i n f e k s i y o n l a r ı B a k t e r i y e l m e n e n j i t Ü r i n e r s i s t e m i n f e k s i y o n l a r ı D e r i v e y u m u ş a k d o k u i n f e k s i y o n l a r ı K e m i k v e e k l e m i n f e k s i y o n l a r ı I n t r a a b d o m i n a l i n f e k s i y o n l a r m C e r r a h i p r o f i l a k s i Seftriakson (disodyum)
Bileşim: Seftriakson. Özellikleri: Seftriakson geniş spektrumlu, Gram(-) ve Gram (+) bakterilerin büyük kısmına bakterisıd etkili, uzun yarılanma ömürlü 3 jenerasyon sefalosporindir Endikasyonlar: Duyarlı patojenlerin neden olduğu abdomen, kemik-eklem-cilt ve yumuşak doku, ürogenital sistem, solunum sistem i infeksiyonları, immün yetmezliklerde gelişen infeksiyonlar, sepsıs, menenjit, cerrahi profilaksi Doz ve Uygulama: Genel olarak 24 saatte bir 1-2 g (yeni doğanlar: 20-50 mg/kg/gün) maksimum 4 g/gün, tek dozda parenteral olarak uygulanır Kontrendikasyonlar. Sefalosporın duyarlılığı. Uyanlar: Penisilinler ile çapraz alerjik reaksiyon görülebilir Kesin endikasyon olmadıkça gebelikte kullanılmamalıdır Yan Etkiler: Genellikle iyi tolere edilir Geçici yan etkilere rastlanabilir. Ticari Şekiller: Parenteral uygulama için 0.5 g İM, 0 5 g IV, 1 g İM, 1 g IV flakon Reçete ile satılır Şubat 2001/KDV Dahil Per Sat Fi.: 0 5 g IM-IV 5.374 000 T L , 1 g IM-IV 9 .4 14.000 TL. Daha detaylı bilgi firmamızdan temin edilebilir ® "Tescilli Marka'
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GE Medical Systems - Marmara Üniversitesi İşbirliğiyle
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Teşhis/Tedavi Merkezi
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C efatin*
Sefuroksim (aksetil)Bileşimi: Sefuroksim aksetil. Özellikleri: Cefatin geniş spektrumlu, bakterisid etkili, beta-laktamazlara dayanıklı oral sefalosporindir. Endikasyonları: Duyarlı patojenlerin neden olduğu solunum yolları, ürogenital sistem, cilt ve yumuşak doku infeksiyonlan. Doz ve Uygulama: Genel olarak günde 2 kez 2 5 0 mg uygulanır. Doz 250-1000 mg/gün arasında değişebilir. Çocuklarda genel olarak günde 2 kez 1 2 5 mg (2 kez 5 mm'lik 1 ölçek). Kontrendlkasyonları: Sefaiosporin duyarlılığı. Uyanlar: Penisilinler ile çapraz alerjik reaksiyon görülebilir. Kesin endikasyon olmadıkça gebelikte kullanılmamalıdır. Yan Etkiler: Genellikle iyi tolere edilir. Geçici yan etkilere rastlanılabilir. Ticari
Şekiller: 10 adet 125 mg veya 250 mg oral tablet. Süspansiyon 50 mİ granül şişede. Reçete ile satılır. Şubat 2001/KDV Dahil Per. Sat. Fİ.: 125 mg tb. 7.680.000 TL. 250 mg tb 14 109.000 TL. Süspansiyon 10.499.000 TL. Daha detaylı bilgi firmamızdan temin edilebilir ® 'Tescilli Marka'
ACADEMIC HOSPITAL
Altunizade Nuhkuyusu Cad. No: 88 Üsküdar Tel.: (0.216) 341 28 41
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M ARM ARA Ü N İVER SİTESİ T IP FA KÜ LTESİ VA K FI
Academic Hospital
Altunizade Nuhkuyusu Cad. No: 88 Üsküdar Tel.: (0.216) 492 47 50 Fax: (0.216) 492 47 62
Depresif Sendromlar ve Sosyal Fobi Tedavisinde
< R o c h e >
RUR®RIX'
moklobemid
B ile ş im i: M oklobem id Ö z e llik le ri, e tk ile r i: M oklobem id. A tipi m onoam inooksidaz e n zim inin reversibl inhibitörüdür. Ruhsal durum u düzeltici ve psikom otor aktıviteyi artırıcı e tkisinin bir sonucu olarak AU R O R IX dısforı. bitkinlik yaşam isteğinin kaybolm ası ve dikkati yoğunlaştırm a yeteneğinin zayıflam ası g ibi sem ptom ların giderilm esinde etkili olur. AU R O R IX sedasyona neden olm az. AU R O R IX uyanıklık durum unu bozm az ve iyi to lere e dilir Karaciğer ya da kalbe toksık bir etkisi gözlenm em iştir E n d ik a s y o n la rı: D epresif sendrom lar ve sosyal fobi ted a visin d e S ta n d a rt D oz: D epresıf sendrom lar: D epresyonun şiddetine göre günde 300 600m g ıkı veya üçe bölünerek verilir Sosyal fobi: Ö nerilen doz. ıkı doza bölünerek verilen 600m g/gun dür U y a rıla r: AU R O R IX ilaca karşı aşırı duyarlılığın bilindiği hallerde ve yeterli klinik deneyim olm am asından dolayı çocuklarda kullanılm am alıdır Baskın klinik özelliği aııtasyon olan depresıf hastalarda A U R O R IX bir sedatifle birlikte kullanılm alıdır. Y oğun d ikkat gerektiren e tkinliklerde AU R O R IX perform ans bozukluğuna yol açm az, ancak tedavinin erken dönem indeki tepkilerin şahıstan şahısa değişebileceği göz önünde tutulm alıdır G e b e lik te k u lla n ım : G enel kural olarak kabul edilen gebeliğin erken dönem inde, gerekm edikçe her türlü ilacı kullanm aktan kaçınm a ilkesi göz önünde bulundurulm alıdır İs te n m e ye n e tk ile r: Plaseboya gö re istenm eyen e tkilerin sıklığı % 5'den fazla değildir. Uyku bozukluğu, sersem lik, bulantı ve baş ağrısı arasıra rastlanan etkileridir. E tk ile ş im le r: Sım etıdin m oklobem ıd’ın m etabolizm asını uzatır M oklobem id alkolle etkileşim e girm ez A ş ırı d o z : Aşırı doz tedavisi ö n celikle vital fonksiyonların sürdürülm esini hedeflem elidır T ic a ri ş e k li: 150 mg. 300 mg, 30 a d e t blısterde O cak 2001 K D V D ahil Per Sat Fı 150mg: 14 310 000 TL 3 0 0 m g 22 9 5 7 0 0 0 . TL R e ç e te ile s a tılır . D a h a d e ta y lı b ilg i firm a m ız d a n s a ğ la n a b ilir . ® 'T e s c illi M a rk a " R o c h e M ü s ta h z a rla rı S a n a y i A Ş P .K 1 6 -8 0 6 2 2 L e v e n t-ls ta n b u l. h ttp w w w .ro c h e c o m tr
A Ğ R I V E
E I M F L A M A S Y O İM
T E D A V İ S İ İM D E
Y A K L A Ş I M
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7 y ıllık ç a l ı ş m a l a r d a i s p a t l a n m ı ş 111
G Ü V E İM İ L İ R L İ K
G ü n d e t e k d o z ile h e r h a s t a g r u b u iç in
u y g u n f o r m s e ç e n e ğ i ,
T A B L E T , S U P O Z İ T U A R , A M P U L
Tilcotil
(1). R.C.A. Heintz, seven years worldwide experience, VII Eular Symposium, Istanbul, Turkey 8-11 June 1994.
Bileşimi:Tenoksıkam Özellikleri: Antienflamatuar, analjezik ve antiromatizmal etki gösterir, trombosıt agregasyonunu inhibe eder Endikasyonları: İskelet kas sisteminin ağrılı enflamatuar ve dejeneratif hastalıklarının semptomatik tedavisinde endikedir Doz ve uygulama: Gut artriti dışındaki tüm endikasvonlar için günde tek doz bir tablet, bir flakon veya bir supozituvar. Kontrendikasyonları: İlaca aşırı hassasiyeti olanlar, NSAİD'lerin kullanılmaması gereken durumlar. Yan etkiler: Tilcotil önerilen 20 mg'lık günlük dozlarında genelde çok iyi tolere edilmektedir. Yan etkiler daha çok Gl sistemde meydana gelmektedir. Ticari Şekiller: Tablet, 20 ma, 10 ve 30 adet, supozituvar 20 mg, 10 adet, flakon 20 mg, 1 adet + 2 mİ distile su. Reçete ile satılır. Ekim 2000/KDV Dahil Per. Sat. Fi.: 10 tablet 4.863.000.-TL., 30 tablet 12.083.000 - TL., Ağustos 2000/KDV Dahil Per. Sat. Fi.: Supozituvar 4425.000-TL., Haziran 2000/KDV Dahil Per. Sat. Fi.: Flakon 784.000.-TL. Daha detaylı bilgi firmamızdan temin edilebilir. ® Tesilcilli Marka."
^Roche)>
Beşeri İlaç
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Perinatal and neonatal mortality rates and causes of death at Marmara University Hospital
DISCUSSION
In developing countries, about 50% of Infant deaths occur during the neonatal period and commonly in the first week of life (1-3). Most of the infants die from preventable perinatal problems. Deaths during the perinatal period reflect quality and adequacy of the care given to the mother and the infant during antenatal, intrapartum and early neonatal period.
Perinatal mortality rate can be decreased with optimal antenatal care for maternal problems such as infection, hypertension. Perinatal mortality rate of our hospital (18.8 %) is lower than that of the world (53 %) but higher than the rate of developed countries (10 %) (1-3). The perinatal mortality rates of the other hospitals in Turkey are between 11.9-108 % (Table III) (4). Perinatal mortality is due to unpreventable causes (congenital malformations, inborn errors of metabolism etc.) in developed countries
Table III.: PM R and NM R at the hospitals other than the M arm ara U niversity Hospital in T urkey in 1999 (3).
PMR (%) NMR (%)
Başkent University Hospital 11.9 6.0
Dokuz Eylül University Hospital 19.2 3.2 Hacettepe University Hospital 21.5 6.8 Bakırköy Maternity and Teaching Hospital 23.5 12.7
Ankara University Hospital 24.6 6.9
Zekai Tahir Burak Maternity and
Teaching Hospital 26.9 11.9
Akdeniz University Hospital 297 15.7
Ege University Hospital 30.7 13.5
Zeynep Kamil Maternity and
Teaching Hospital 47.3 32.3
Trakya University Hospital 51.0 30.0
Çukurova University Hospital 58.2 10.9
Selçuk University Hospital 62.0 30.4
Fırat University Hospital 63.0 39.0
19 Mayıs University Hospital 68.0 20.2
Atatürk University Hospital 70.2 16.4
Istanbul University Hospital 70.9 34.6
Osmangazi University Hospital 107.6 56.8
PMR: perinatal mortality rate; NMR: neonatal mortality rate.
whereas preventable causes (infections,
asphyxia, etc.) make up the majority in developing countries. Perinatal mortality can be decreased by reducing the number of inutero or
intrapartum deaths. Antenatal deaths are 52.2 %
of all perinatal deaths in our hospital and this reflects the importance of antenatal care. In our study group, 68% of mothers whose infants died during the perinatal period did not receive antenatal care. It is possible to reduce the total number of high risk pregnancies with a well- organized fetal-maternal assessment program covering the whole region.
Seventy to eighty percent of preterm deliveries can be ascertained before delivery and have a chance of maternal transport to tertiary hospitals (4). The neonatal mortality rate of our country can be reduced by transport of high risk pregnancies to the tertiary centers that have neonatal intensive care units. The decline in perinatal and neonatal mortality rates in the 1980s in U.S.A. is a result of the development of the concept of regionalization (5-7). Preterm delivery and low birthweight are major causes of both neonatal mortality and long term disability (8,9). In our hospital 17.5 % of infants died of hypoxia during preterm labor and delivery. Most of these mothers presented with vaginal bleeding due to placenta previa and ablatio placenta and their infants could not be saved. During the study period 21.7 % of infants who died had birthweights ranging between 645 to 950 grams and died of prematurity. The perinatal mortality rate can be further reduced by using new technological methods in neonatal intensive units. Neonatal mortality has fallen by 36% in the 24-36 weeks of gestation groups amongst Scottish preterm singleton births between 1985 and 1994 (10). This dramatic decline is a good example of the progress in neonatology.
In conclusion, to improve the perinatal and neonatal mortality rate in our country to that of the developed countries, our society should become conscious about family planning and the importance of antenatal care. Systematic antenatal care should be applied all around the country, high risk pregnancies should be managed at the tertiary care hospitals with intensive care units and the number of neonatal intensive care unit beds should be increased.
İpek Akman, et aI
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1 9 9 5 ; 9 6 : 4 1 7 -4 2 3 .
7. P h ib b s CS, B ro n s te in JM , B u x to n E, P h ib b s RH. The e ffe c ts o f p a tie n t v o lu m e a n d le v e l o f ca re a t th e h o s p ita l o f b irth o n n e o n a ta l m o rta lity . JA M A 1 9 9 6 ; 2 7 6 : 1 0 5 4 -1 0 5 9 . 8. The S c o ttis h L o w B irth w e ig h t S tu d y G ro u p .
The S c o ttis h lo w b ir th w e ig h t s tu d y : I. S u rv iv a l, g ro w th , n e u r o m o to r a n d s e n s o ry im p a irm e n t. A rc h D is C h ild 1 9 9 2 ; 6 7 : 6 7 5 - 6 8 1 . 9. M e n a rd MP, L iu QL, H o lg re n EA, S a p p e n fie ld W M .H e o n a ta l m o r t a lit y f o r v e ry lo w b irth w e ig h t d e liv e rie s in S o u th C a ro lin a b y le v e l o f h o s p ita l p e r in a ta l s e rv ic e . A m J O b s te t G y n e c o l 1 9 9 8 ; 1 7 9 : 3 7 4 -3 8 1 . 10. M agow an BA, B a in M, J u s z c z a k E, M c ln n e n y P. H e o n a ta l m o r ta lity a m o n g s t S c o ttis h p re te rm s in g le to n b irth s (1 9 8 5 -1 9 9 4 ). B r J O b s te t G y n a e c o l 1 9 9 8 ; 1 0 5 : 1 0 0 5 -1 0 1 0 . 172
