Bipedalism and Obstetrics – an Exercise in Darwinian Evoluti

1. Bipedalism and Obstetrics – an Exercise in Darwinian Evolutionary Medicine. Prof. Y Muscat Baron MD FRCOG, FRCPI, PhD

2. 1. Tectonic plate movements changing the African Rainforest to a Savannah 2. Theories of Bipedalism 3. Paradox of Human Birth: Contracted Human Pelvis vs Enlarged Neonatal brain 4. Solution – Relative Prematurity 5. Obstetric Complications of extremes of gestation- Prematurity and Postmaturity

3. 45,000,000 years ago Africa was covered by rainforest

4. 30,000,000 million years ago the “island” India moved towards Eurasia

5. 10,000,000 million years ago “island” India crashed into Eurasia causing the Himalayas

6. 10,000,000 million years ago the Himalayascut off the Siberian rains from entering the Indian ocean depriving Africa of rainfall

7. The African Savannah resulted

8. Some of us came down from the trees

9. And some stood up and walked tall ! Lemur Spider Monkey Rh Monkey Pan troclodyte H.sapiens lucens ERECT / BIPEDAL EVOLUTION

10. Bipedalism - Wading Theory

11. Bipedalism - Reproductive Theoryin Primates Hands free or rather Hands on!

12. Provisioning/Carriage Theory

13. Bipedalism - Thermoregulation Theory

14. Bipedalism - Tool Theory

17. Evolution of Birth Bipedal Posture led to Relative Narrowing of Pelvis

18. Primate and Human Pelvis

19. The Obstetric Dilemma • Narrow Pelvis vs Increased Brain size • Neonatal Human brain weighing 400g • Neonatal brain of Pan troclodytes 155g

21. Human and Primate Brains

22. Evolution of Birth Pan troclodytes 2 Hours Labour H. Sapiens 8 Hours Labour A. afarensis

23. Australopitheticus afarensis the first hominid obstetrician

24. The Obstetric Dilemma • Evolutionary Solution = Relative Prematurity • Developmentally Human babies are born 12 months too early • Evolutionary philosophy “Was mich nicht umbringt macht mich starker”, “What doesn’t kill me makes me stronger”. Friedrich Nietzsche

25. Gestational Age of Deliveries

26. Gestational Age of Deliveries

27. Gestational Age of Deliveries

28. Preterm Labour and Perinatal Morbidity

29. Preterm Labour and Perinatal Morbidity • Preterm labour is the most common cause of fetal morbidity and perinatal mortality. • The incidence of preterm labour (under 34 weeks of gestation) in Malta and Gozo between the years 1999 and 2005 is 1.9%1 • Perinatal Mortality Rate in MalteseIslands 1998 – 2005 28.9% (<34weeks)

30. Preterm Labour and Perinatal Morbidity Complications related to prematurity • respiratory distress syndrome, • necrotising enterocolitis and • intraventricular haemorrhage.

31. Costs of Preterm Birth Hospital costs averaged • 25 weeks $202,700 • 36 week $2600 • 38-week $1100 Gilbert et al 2006

32. Maternal factors Low socioeconomic status Nonwhite race Maternal age <=18 or >=40 years Low prepregnancy weight Smoking Substance abuse. Maternal history Previous history of preterm delivery Previous history of a second-trimester abortion Trauma Threatened miscarriage Uterine volume increased Uterine factors Uterine anomalies Infection Risk Factors for Preterm Labour

33. PERCENTAGE • delivery at less than 32 weeks of gestation (11.4 % vs. 19.6 %; RR, 0.58, 95 % CI, 0.37 to 0.91. Meis et al 2004

34. Preterm delivery was noted in 2.8% in the progesterone group and 18.6% in the placebo group De Fonseca et al 2003

35. p = 0.25 NS No teratogenic effects noted. Over 7,000,000 pregnancies treated with Dydrogesterone.

36. Post-Dates Baby

37. Post-term Labour • Post-term labour also puts the mother’s life at risk. • Around the globe, some 500,000 maternal deaths occur annually due to obstructed labour, the majority due to cephalo-pelvic disproportion. WHO 2010

38. “ You are carved in the palm of my hand. You will never be forgotten” Isaiah 49:15 SANDS MEMORIAL