Tribute to a great obstetrician: in memory of Ingemar Ingemarsson (2014)

Ingemar Ingemarsson grew up in a rural area in Småland in the southern part of Sweden. He studied at and graduated from the Medical Faculty at Lund University and started his career in obstetrics and gynecology in 1972 at the University Hospital in Lund. He defended his PhD thesis in 1975, was appointed consultant and later became Head of the Department and Professor in Obstetrics at Lund University. In 1997 the Royal College of Obstetricians and Gynaecologists (London, UK) acknowledged Ingemar Ingemarsson's contributions to our specialty and honored him with the Fellow ad eundum award; one of seven Swedish obstetricians and gynecologists to be given that honor. In 1972, when Professor Lars Philip Bengtsson was head of the Department of Obstetrics and Gynecology in Lund, one of the first cardiotocographs in Sweden was placed in the labor ward there, as a research instrument under the care of Ingemar Ingemarsson. This instrument became an important part of his future remarkable clinical and academic achievements. Ingemar Ingemarsson's PhD thesis included studies, performed together with the pharmacologist Karl-Erik Andersson, on the inhibition of myometrial activity during human pregnancy by using the β-adrenoceptor stimulator drug terbutaline 1. Their results were unique, as before the β-adrenoceptor era infusion of alcohol had been one of the few therapies that could be tried to stop preterm labor. Under the leadership of Ingemar Ingemarsson the 1970s became the golden era of modern Swedish obstetrics. The partogram became a vital part of active management of labor. Fetal monitoring was practiced continuously or intermittently with the use of cardiotocography. Fetal scalp blood sampling with on-the-spot analysis of pH was used to confirm or refute threatening asphyxia. Since the 1960s, vacuum extraction had been the preferred method for instrumental delivery, but Ingemar Ingemarsson re-introduced the practice of performing outlet forceps delivery using the small Wrigley forceps. Special guidelines were also developed to achieve safe vaginal breech delivery taking into consideration fetal weight, biparietal diameter, position of the fetal head, pelvic dimensions from obstetric pelvimetry, and then emphasizing the need for a good progress of the labor 2. A dramatic reduction in perinatal mortality was seen from 15/1000 in 1973 to 6–7/1000 in the 1980s, whereas the frequency of cesarean section at his department was still kept around 8% with an induction rate below 10% for many years. Studies on and management protocols for preterm and term pre-labor rupture of membranes 3, preterm delivery 4-7, delivery of twins, external cephalic version, post-term pregnancy 8 and shoulder dystocia, were discussed, taught, published and implemented in clinical practice. The importance of having a senior consultant available in the labor ward to improve safety and quality of care was demonstrated by Ingemar Ingemarsson personally. He had his small office with the legendary manually organized cardiotocogram archive just inside the entrance door to the labor ward. The archive worked as a living textbook for systematic analysis of fetal heart rate traces and became the source for numerous publications on intrapartum fetal heart rate patterns 9-12. Within seconds, his hands, expertise and experience were available to midwives and junior doctors, or to perform any obstetric surgical or manual procedure. In the late 1980s Ingemar Ingemarsson was appointed visiting professor at the National University of Singapore. Together with his wife Eva and two of their sons, they spent 3 years in Singapore. At first, he worked at the busy Kandang Kerbau Hospital with 24 000 annual deliveries and later at the newly built National University Hospital. Here, Ingemar Ingemarsson could discuss the mysteries of preterm labor and other obstetric issues with, among others, the head of the Department of Obstetrics and Gynecology, Professor S. Shan Ratnam. He started a close collaboration with a number of his Singapore colleagues, which provided the impetus for international clinical obstetric research. During Ingemar Ingemarsson's working period in Singapore some 26 clinical studies were published in international scientific journals, a remarkable achievement demonstrating his energy and capacity. The admission cardiotocogram practice, which he established after research in Singapore, soon became the norm for Swedish obstetric practice 13, 14. He took the initiative to establish a fruitful and long-lasting collaboration between Lund University and the National University of Singapore. In the footsteps of Ingemar Ingemarsson, another seven obstetricians were welcomed at the obstetrics and gynecology department in the National University Hospital in Singapore for longer or shorter periods. They forged research collaborations resulting in numerous further scientific publications. Between 1973 and 2007, Ingemar Ingemarsson published 150 scientific articles, book chapters and abstracts and was invited to lecture in all continents. His scientific contributions were published in 36 different medical journals. He published 27 times in AOGS, the first article in 1975 1. The last, about eclampsia in Scandinavia, was published in 2006 15. He had publications in the British and American obstetrics and gynecology journals, in the major perinatology publications and in the world's most prestigious journals like the Lancet, British Medical Journal and Life Science. Having invented the use of intravenous terbutaline for acute tocolysis in order to reduce fetal asphyxia 16, he investigated the effects of different drugs such as pindolol 17, methyldopa, isradipine 18, and nifedipine 19 on maternal and fetal hemodynamics. He studied fetal acid–base balance in labor 20, 21 and different aspects of the use of oxytocin to induce or augment labor 22. In this work at Lund University, Ingemar Ingemarsson was, over the years, the tutor for several young obstetricians and he acted as co-tutor and mentor to many of his colleagues, also for their PhD work. He and his wife Eva wrote the classical textbook in Swedish – Fetal surveillance with cardiotocography – in 1987. The book was extensively revised in 2005 and the latest edition was published in 2012 23. Ingemar Ingermarsson's close international links were illustrated by the team of advisors for this book, including ourselves (S. Arulkumaran, Singapore, S. Montan, Sweden) and notable researchers in the field (such as R.H. Paul and B.S. Schifrin in the USA, and D.M.F. Gibb, J.A.D. Spencer and P.J. Steer in the UK), who produced guidelines for the interpretation of antepartum and intrapartum cardiotocography in a pocket version, which was first published in 1992 (sponsored by Hewlett Packard). The guideline was later revised in Swedish and an updated version of the cardiotocography guideline was launched in 2011. Ingemar Ingemarsson was a generous person. Collaboration was one of his key messages. He fully understood the importance of obstetricians working closely together with midwives and neonatologists and to pay each and every one of them, including the patients, his full attention and respect. He was the perfect role model for so many of us who had the pleasure to work closely under his supervision. Many of these younger colleagues later held prestigious academic positions in obstetrics in Sweden and abroad. He arranged courses for Swedish obstetricians and midwives in Singapore and taught widely in the Nordic countries. He lectured several times in Buenos Aires, giving him the possibility to practice the tango. A special international contribution was when Ingemar Ingemarsson in 2004 lectured as keynote speaker at the Indo-Swedish travelling seminar, visiting major cities in India. At the Department of Obstetrics and Gynecology in Lund he held annual or biannual courses for doctors and midwives in fetal surveillance and interpretation of the cardiotocogram. Over the years he held 40 courses with some 50–60 delegates at each course, which means that in total there were more than 2000 obstetricians and midwives who had attended his lectures. For many years he organized advanced courses in obstetrics in London and Cambridge together with British obstetricians. He was an eminent teacher, presenting different obstetric cases and key messages with clinical wisdom and dignity, keeping his audience in a magic grip. If concentration dropped he could switch to one of his many humorous short stories and then carry on with the next case. He fully understood the core soul of practising obstetrics. He taught how to emotionally handle grief in relation to an unexpected intrauterine death. He could share the happiness and relief with parents and midwives after a successful outcome following a difficult labor and delivery. His valedictory symposium was celebrated in 2004. Through his last professional years and after his retirement he was an expert advisor for the Swedish National Board of Health and Welfare concerning obstetric malpractice and litigation cases. Ingemar found a contrast from the busy labor ward in nature. Together with his wife Eva he built their recreational summerhouse in the northern part of Öland, an island in the Baltic Sea, and summer was his favorite season of the year. He was very proud of his greenhouse tomatoes. Together with Eva he picked buckets of blueberries and lingonberries. They were unbeatable in finding the tiny funnel chanterelles. One beautiful summer day, in July 2013. Ingemar Ingemarsson at the age of 74 suddenly passed away. The mood of Ingemar on that particular day was expressed in his diary written on the same morning “Lovely morning, almost calm”. His warm energetic personality together with his clinical and academic excellence has influenced obstetric care in Scandinavia and around the world. The memory of his legendary career will last.