Maternal and Perinatal Outcome During Expectant Management of Severe Pre-Eclampsia Between 24 and 34?Weeks of Gestation

Objective

To determine the maternal and perinatal outcome after expectant management of severe pre-eclampsia between 24 and 34 weeks of gestation.

Method

The maternal and fetal status was monitored by an intensive, non-invasive method among 94 women with severe pre-eclampsia between 24 and 34 weeks of gestation who were scheduled for expectant management in the OICU at a tertiary care center. Pregnancy prolongation and maternal and perinatal morbidity and mortality were analyzed by the Student ‘t’ test and the Mann–Whitney U test.

Results

The days of pregnancy prolongation and perinatal mortality were significantly higher among those managed at <30 weeks. Increasing gestational age correlated with a reduction of RDS. Maternal morbidities were significantly higher among those managed at <28 weeks. But, there was no maternal mortality.

Conclusion

Expectant management of severe pre-eclampsia at 30–34 weeks in a tertiary care center of a developing country is associated with good perinatal outcome and risk reduction for the mother.     

Obstetric Behavior and Pregnancy Outcome in Overweight and Obese Women

Objective

To perform analyses of maternal and fetal complications in overweight and obese women.

Methods

Eighty-seven women with singleton pregnancies with BMI > 25–29.9 kg/m² and 83 women with singleton pregnancies with BMI > 30 kg/m² were studied for maternal and fetal complications at Nehru Hospital, B.R.D. Medical College, Gorakhpur during June 2007–October 2008. Forty-five women with BMI 20–24.9 kg/m² were selected to serve as control.

Results

Compared with women with normal BMI, the outcomes which were more common in overweight and obese women were gestation hypertension (p < 0.05); pre-eclampsia (p < 0.001); preterm delivery (p < 0.05); induction of labor (p < 0.05); instrumental vaginal delivery (p > 0.05); cesarean section (p < 0.01); increased operative time (p < 0.01); still births (p < 0.05); early neonatal deaths (p < 0.05); Apgar score < 7 at 5 min (p < 0.05); and admission to NICU (p < 0.001). No significant differences were noted among groups regarding hypoglycemia hyperbilirubinemia and respiratory distress.

Conclusion

Overweight and obesity are definite risk factors for adverse pregnancy outcomes. This may be due to altered metabolic state in obesity.     

Vaginal Misoprostol vs Vaginal Misoprostol With Estradiol for Labor Induction: A Prospective Double Blind Study

Objective

To compare the safety and effectiveness of vaginal misoprostol with combined vaginal misoprostol and estradiol for induction of labor in unfavorable cervix.

Method

A prospective study was carried out from Jan 2008 to Jul 2008 on total of 90 women with unfavorable cervix (Bishop’s score was <5) and gestation >36 weeks with clinical indication for induction of labor. They were randomly assigned to receive either vaginal misoprostol 25 μg alone or vaginal misoprostol 25 μg with vaginal estradiol 50 μg. Misoprostol alone was repeated every 3 h in both groups till ripening of cervix (Bishop’s score was = 8) and establishment of active labor.

Results

Main indications were post dated pregnancies (period of gestation >41 weeks) and pregnancy induced hypertension. Age, parity and mode of delivery were not significantly different. No significant difference was found in pre induction Bishop’s score, fetal outcome and maternal complications. However, doses of misoprostol required for cervical ripening (p = 0.017), time required for cervical ripening (p = 0.042), time required for starting of active labor (p = 0.017) and time required for delivery in vaginal delivery cases (p = 0.047) were found significantly less in combined estradiol and misoprostol group.

Conclusion

Estradiol acts synergistically with misoprostol vaginally and significantly hastens the process of cervical ripening, initiation of active labor and vaginal delivery.     

Effect of single embryo transfer on the risk of preterm birth associated with in vitro fertilization

Purpose

To determine whether elective single embryo transfer (eSET) reduces the risk of preterm delivery associated with in vitro fertilization (IVF).

Methods

This is an observational study of 3125 eSET cycles performed from 2008 to 2009 and reported to the Society for Assisted Reproductive Technology (SART) database. Preterm delivery rates were compared to the overall preterm delivery rate among all patients undergoing IVF over the same time period.

Results

The 3125 eSET cycles resulted in 1507 live births (live birth rate 48.2 %) Among these deliveries were 27 twins (1.8 %) and one set of triplets (0.07 %). The overall preterm delivery rate (20–37 weeks gestation) following eSET was 17.6 % (269/1527). This is significantly greater than the preterm birth rate for all patients undergoing IVF over the same time period (12 %, P < 0.001).

Conclusions

Elective single embryo transfer does not reduce the risk of preterm delivery associated with in vitro fertilization (IVF).     

Successful Pregnancy Outcome Following Conservative Management of Morbidly Adherent Placenta

Objective

To determine the prevalence and impact of placental malaria on maternal and fetal outcome.

Design

Cross sectional observational.

Setting

The Department of Obstetrics of Government NSCB Medical College Hospital, Jabalpur (Madhya Pradesh).

Population

Five hundred parturient women with fever or history of fever during the present pregnancy.

Method(s)

Subjects were tested for peripheral and placental malaria by thick and thin smear examination. Maternal and perinatal outcome correlated with malaria results.

Results(s)

The mean age of the studied subjects was 24.5 ± 2.6 years, 60.6 % were primigravida, 87.2 % had unsatisfactory antenatal care. 89.2 % were not using effective malaria prevention measures. Peripheral smear positivity for malaria was detected in 1.8 % subjects and placental malaria positivity in 2.2 % subjects. The mean Hb was lower in malaric subjects (χ² = 14.47, p < 0.05). Maternal mortality and prematurity was significantly higher in malaria +ve subjects (p < 0.001). The mean birth weight in malaria +ve subjects was significantly less (p < 0.001). Poor 5 min APGAR (p < 0.0001) and perinatal mortality (p < 0.05) was significantly more common in malaria +ve subjects.

Conclusion(s)

Malaria, particularly placental infestation with malarial parasites significantly increases maternal and perinatal morbidity and mortality.     

Effect of Body Mass Index on Pregnancy Outcomes in Nulliparous Women Delivering Singleton Babies: Observational Study

Objective

To find out the effect of increasing body mass index (BMI) on pregnancy outcomes in nulliparous women delivering singleton babies.

Method

This was a hospital-based observation study, based on 300 nulliparous women delivering singleton babies in June 2009—Sept. 2010. Women were categorized into three groups. Underweight (BMI < 20 kg/m²), normal (BMI 20–24.9 kg/m²), overweight (BMI 25–29.9 kg/m²), and obese (BMI > 30 kg/m²) obstetric and perinatal outcomes were compared by univariate and multivariate analysis.

Results

Maximum patients who underwent LSCS were having BMI > 30 kg/m² [OR 9.558 (95 % CI 5.82–17.27)]. As compared to women of normal BMI (20–24.9 kg/m²), morbidly obese women faced the higher risk of PIH [OR 8.045 (95 % CI 3.875–16.781)]. Obese women were more likely to have post partum hemorrhage [OR 5.11 (95 % CI 1.76–14.79)] compared with women of normal BMI. Birth weight <2,500 g was more common in women with BMI < 25 kg/m² (21.21 %), while highest incidence of birth weight >4,000 g (14.29 %) is seen in women of the obese group.

Conclusions

Increasing BMI is associated with increased incidence of cesarean delivery, PIH, post partum hemorrhage, and macrosomic babies.     

A Study on Tubal Recanalization

Objectives

To study the various factors affecting the success rate of tubal recanalization and the reasons for failure of the procedure.

Methods

A retrospective study was conducted during 2000–2007 @ KIMS, Hubli.

Results

Of the 25 subjects who underwent tubal recanalization, 44 % of women conceived and they were >35 years of age. Laparoscopically sterilized patients had better chances of conception (50 %) following reversal than those who were sterilized by Pomeroy’s method (30 %). With post-reversal tubal length of >4 cm, pregnancy rate was 50 %. Isthumus–Isthumus and Isthumus–Ampullary anastomosis have 50 % success rates.

Conclusion

Tubal recanalization by microsurgical technique is one of the methods to solve infertility after sterilization.     

Trends in Maternal Mortality and Impact of Janani Suraksha Yojana (JSY) on Maternal Mortality Ratio in a Tertiary Referral Hospital

Objective

To analyse the impact of Janani Suraksha Yojana (JSY) on Maternal Mortality Ratio (MMR).

Design

Retrospective analysis of maternal mortality.

Methods

Analysis of all maternal deaths between January 2001 and December 2009.

Results and Discussion

The total number of deliveries has been steadily rising from 1,685 in 2001 to 3,957 in 2009. The MMR doubled from 1,500/100,000 live births in 2001 to 3,000/100,000 live births in 2006, then declined to 2,464/100,000 live births in 2009. Implementation of the various maternity benefit schemes has had no significant impact on the profile of dying mothers—admission-to-death interval. Deaths due to anemia and eclampsia have significantly increased (P < 0.05), whereas due to sepsis (P < 0.001) and hemorrhage (P < 0.05), deaths have significantly decreased. Almost 96 % of dying subjects received inadequate antenatal care. However, significantly less number (P < 0.001) of women are delivering at home.

Conclusions

There is a need to stress the importance of good antenatal care in reducing MMR.     

Labor Induction with 50?μg Vaginal Misoprostol: Can We Reduce Induction-Delivery Intervals Safely?

Objective

To compare the efficacy and safety profile of two methods of labor induction i.e., intracervical dinoprostone gel (0.5 mg 8 h) and misoprostol (50 μg 4 h) for induction of labor in women with a poor Bishop’s score.

Design

Observational study.

Study Period

January 1st, 2009 to December 31st, 2010.

Population

A total of 329 women with unfavorable cervices induced at or near term.

Methods

Two cervical ripening agent study arms were used: dinoprostone gel (193 women) and misoprostol (137 women).

Main Outcome Measures

Induction to delivery interval, cesarean section, incidence of meconium stained liquor, FHR pattern, incidence of uterine hyperstimulation, and neonatal outcomes.

Results

The induction to delivery interval was significantly shorter in the misoprostol group as compared to the dinoprostone group (p < 0.001). There was no difference in cesarean section rates between the two groups (dinoprostone gel 43 %; misoprostol 33 %; p = 0.144). The incidence of non-reassuring fetal heart rate pattern, meconium stained liquor, and uterine hyperstimulation were equivalent in both the groups (p = 0.529; 0.733; and 0.321, respectively). The neonatal outcomes in both the groups were comparable in terms of Apgar scores at birth (p = 0.160) and NICU admissions (p = 0.951).

Conclusions

Labor induction in women with unfavorable cervices results in high caesarean section rates. However, the use of misoprostol significantly reduces the induction to delivery interval, without adversely affecting the caesarean section rates and neonatal outcomes. Hence it may become a cost-effective alternative to dinoprostone gel in resource-poor settings like India.     

Prediction of Preeclampsia by Midtrimester Uterine Artery Doppler Velocimetry in High-Risk and Low-Risk Women

Objective

To observe the role of uterine artery Doppler flow velocimetry at midtrimester in prediction of preeclampsia.

Method

179 women carrying <16 weeks of pregnancy, with singleton fetus and without any fetal anomaly were recruited and were divided in high-risk and low-risk group. Doppler velocimetry of uterine artery was done at 24–26 weeks. Any notch in uterine artery, unilateral or bilateral, or RI > 0.6, was considered abnormal. Women were followed up and development of preeclampsia noted.

Result

Sensitivity and specificity of abnormal uterine artery Doppler study for prediction of preeclampsia were 73.33 and 86.48 % in high-risk and 57.14 and 95.83 % in low-risk group, respectively. Relative risk with 95 % confidence interval was 5.427 (2.272–12.958) in high-risk and 13.65 (5.669–32.865) in low-risk women.

Conclusion

Doppler velocimetry of uterine artery at 24 weeks can be used as a reliable screening test for prediction of preeclampsia in both high-risk and low-risk women.     

Randomized, Placebo-Controlled Trial of Granisetron for Control of Nausea and Vomiting During Cesarean Delivery Under Spinal Anesthesia

Objective(s)

The objective of this study was to evaluate the efficacy and safety of granisetron (5HT₃ receptor antagonist) on the incidence of nausea and vomiting in cesarean deliveries under spinal anesthesia.

Method(s)

In the randomized, double-blind study, 80 parturients received granisetron 40 μg/kg or placebo (n = 40 each) intravenously, immediately after clamping of the fetal umbilical cord. Nausea, vomiting, and adverse events were then observed for 24 h after administration of spinal anesthesia.

Results

A complete response (defined as no postoperative nausea and vomiting) during 0–4 h after administration of spinal anesthesia was achieved in 80 % of patients with granisetron and in 45 % of patients with placebo. The corresponding incidences during (4–24 h) were 82.5 and 55 % (P value <0.05). No difference in adverse events was observed in any of the groups.

Conclusion(s)

Prophylactic use of granisetron is effective for preventing emetic episodes during spinal anesthesia for cesarean delivery.     

Maternal Mortality and Its Causes in a Tertiary Center

Objectives

To study the maternal mortality and the complications leading to maternal death.

Methods

A retrospective study of hospital records and death summaries of all maternal deaths over the period from January 2000 to August 2009 was carried out.

Results

There were a total of 80 maternal deaths out of 88,443 live births giving maternal mortality rate (MMR) of 90.45 per 100,000 live births. Unbooked and late referral accounted for 77.5 % of maternal deaths. The majority of the deaths was in 30–40-year age group and around term. Hemorrhage was the commonest cause of death (52.5 %), followed by sepsis (13.75 %) and pregnancy-induced hypertension including eclampsia (10 %).

Conclusions

Hemorrhage, sepsis, and pregnancy-induced hypertension including eclampsia were found to be the direct major causes of death. Anemia and cardiac disease were other indirect causes of deaths.     

Prediction of PIH by Maternal Serum Beta HCG Levels in the Second Trimester (13–20?Weeks) of Pregnancy

Objective

To test the hypothesis that women with high serum beta-HCG levels in early pregnancy are at higher risk of developing PIH.

Methods

Serum beta-HCG estimation was done by CLIA method in 200 women between 13 and 20 weeks of gestation, selected randomly for this study from July 2008 to Aug 2009. Multiple of median (MOM) was calculated from charts of norms available for that week of pregnancy. They were followed till delivery for development of PIH and pregnancy outcome and results analysed statistically with Chi-square test and Z test.

Results

Out of 200 cases, 178 (89 %) were finally evaluated. Of whom 22 (12.36 %) cases developed PIH. Beta HCG levels were considered raised if the levels were >2MOM.20 (83.33 %) out of 24 cases with beta HCG levels >2MOM developed PIH against 2 (1.2 %) cases out of 154 having beta HCG levels ≤2 MOM (P value <0.001). Also, higher levels of beta HCG are associated with increased severity of PIH (P value <0.01). The sensitivity was 90.91 %, specificity was 97.44 % and positive predictive value was 83.33 %.

Conclusion

The study concluded that the serum beta HCG estimation at mid trimester (13–20 weeks) is a good predictor of PIH and higher levels of beta HCG are associated with increased severity of PIH.     

Sublingual Misoprostol to Reduce Blood Loss at Cesarean Delivery

Objective

This prospective randomized controlled study was carried out with the purpose of assessing the efficacy of sublingual misoprostol in decreasing intraoperative blood loss and the need for additional uterotonic agents at cesarean delivery.

Methods

One hundred seventy-four women undergoing elective or emergency cesarean delivery were assigned randomly to receive either 400 μg misoprostol or placebo sublingually at the time of cord clamping. An intravenous infusion of 20 units of oxytocin was started in all women at the same time. The primary outcome measures were intraoperative blood loss, need for additional uterotonic agents, and perioperative hemoglobin (Hb) fall.

Results

The maternal demographic factors, indications for cesarean delivery, and high-risk factors were similar between the two groups. Mean intraoperative blood loss was significantly less in misoprostol group as compared with placebo group (595 ± 108 vs. 651 ± 118 ml, P = 0.025). Fewer women needed additional uterotonic agents in misoprostol group (22.2 vs. 42.8 %; P = 0.0035; RR 0.52, 95 % CI 0.33–0.82). Perioperative Hb fall was significantly less in misoprostol group (0.87 ± 0.29 vs. 1.01 ± 0.26 g, P = 0.0018).

Conclusion

Sublingual misoprostol decreases intraoperative blood loss and the need for additional uterotonic agents at cesarean delivery.     

Early Teenage Pregnancy: Is it Safe?

Aim

To compare obstetric and perinatal outcomes of early and late teenage pregnancies of Omani nulliparous women with singleton pregnancies cared for and delivered at a tertiary teaching hospital.

Method

In this retrospective study, we reviewed obstetric and perinatal outcomes of early teenage pregnancies (14–16 years), (n = 20) delivered at Sultan Qaboos University Hospital, Muscat, Oman, between 1 July 2006 and 30 June 2013 and compared their outcomes with outcomes of late teenage pregnancies (17–19 years), (n = 287) delivered at the same hospital during same period.

Results

When compared with late teenage pregnant women, early teenagers were found to have no significant differences in prevalence of very preterm delivery <32 weeks (P = 0.62), preterm rupture of membranes (P = > 0.99), and anemia (P = 0.34). When compared to late teenagers, early teenagers had similar cesarean sections rates (P = >0.99), instrumental delivery rates (P = 0.56) and spontaneous vaginal delivery rates (P > 0.99). Both groups had similar birth weights (P = 0.87), low birth weights, (P = 0.55), and very low birth weights babies (P = 0.56 %). Perinatal mortality rate was similar in both groups.

Conclusion

We may conclude that early teenage pregnant Omani women are not at increased risk of obstetric and perinatal complication compared to older teenagers.     

Public health implications of a North American publicly funded in vitro fertilization program; lessons to learn

Purpose

A retrospective study was conducted to determine trends in practice and outcomes that occurred since the implementation of the publicly funded in vitro fertilization (IVF) and single embryo transfer (SET) program in Quebec, in August, 2010.

Methods

Data presented was extracted from an advisory report by the Health and Welfare Commissioner, and from a report by the Ministry of Health and Social Services published in June 2014 and October 2013, respectively. This data is publicly available, and was collected from all six private and three public-assisted reproduction centers in Quebec providing IVF services. Data pertains to all IVF cycles performed from the 2009–2010 to 2012–2013 fiscal years.

Results

SET was performed in 71 % of cycles in 2012. The number of children born from IVF was 1057 in 2009–2010 and 1723 in 2012–2013 (p < 0.0001). Multiple birth rates from IVF were 24 % in 2009–2010 (before the program began) and 9.45 % in 2012–2013 (p < 0.0001). The proportions of IVF babies that were premature, that were the result of multiple births, or that required neonatal intensive care unit admission (NICU) all decreased by 35.5 % (p < 0.0001), 55 % (p < 0.0001), and 37 % (p < 0.0001), respectively, from 2009–2010 to 2012–2013. The cost per NICU admission for an IVF baby increased from $19,990 to $28,418 from 2009–2010 to 2011–2012.

Conclusion

This first North American publicly funded IVF program with a SET policy shows that such a program contributes substantially to number of births. It has also succeeded in increasing access to treatment and decreasing perinatal morbidity by decreasing multiple birth rates from IVF. A substantial increase in global public health care costs occurred as well.     

Impact of elevated peak serum estradiol levels during controlled ovarian hyperstimulation on the birth weight of term singletons from fresh IVF-ET cycles

Purpose

To investigate the impact of elevated serum estradiol (E₂) levels on the day of hCG trigger on the birth weight of term singletons after fresh In Vitro Fertilization (IVF)-Embryo Transfer (ET) cycles.

Methods

Retrospective cohort study of all patients initiating fresh IVF-ET cycles resulting in live births between January 2004 and February 2013. The incidence of low birthweight (LBW) term singletons in patients with E₂ levels on day of hCG trigger above or below the 95 % cutoff for E₂ values in our clinic (3,069.2 pg/mL) was estimated. Multiple gestations and vanishing twin pregnancies were excluded.

Results

Two thousand nine hundred thirty-nine singleton live births were identified for inclusion. One hundred forty seven (5 %) and 2792 (95 %) live singleton births occurred in patients with peak E₂ levels above and below 3,069.2 pg/mL, respectively. The overall incidence of term LBW was 5.4 % in the >3,069.2 pg/mL group compared to 2.4 % in the ≤3,069.2 pg/mL group (P = .038). An E₂ level >3,069.2 pg/mL on the day of hCG administration was associated with increased odds of LBW term singletons (OR = 2.29; 95 % CI = 1.03–5.11). The increased odds remained unchanged when adjusting for maternal age (aOR = 2.29; 95 % CI = 1.02–5.14; P = .037), gestational age at delivery (aOR = 2.04; 95 % CI = 1.22–3.98; P = .025), and day 3 versus blastocyst transfer (aOR = 2.5; 95 % CI = 1.11–5.64; P = .023).

Conclusions

Peak E₂ level >3,069.2 pg/mL is associated with increased odds of LBW term singletons after fresh IVF-ET cycles. Conservative stimulation protocols aiming not to exceed an E₂ level of 3,000 pg/mL may be advantageous for placentation and fetal growth if a fresh transfer is planned.     

Role of 17 α Hydroxy Progesterone Caproate (17OHPC) in the Prevention of Preterm Labor

Objective

To evaluate the role of 17 α hydroxyprogesterone caproate (17OHPC) in the prevention of preterm labor in high risk asymptomatic patients with a history of preterm delivery.

Methods

The study included 96 patients with a singleton pregnancy and having a prior preterm birth. They were divided in 2 groups, group I (treatment group) included 46 asymptomatic patients who were given 17OHPC injections starting from 16–20 weeks till 36 weeks and group II (control group) included 50 patients who did not receive any treatment.

Results

The incidence of preterm delivery was found to be 6.9 %. The median gestational age at delivery was 36 weeks in group I and 33 W5D in controls. 50 % cases in group I and 80 % of controls delivered prematurely in the group with a prior preterm birth between 20–28 weeks.

Conclusion

In patients who had a prior history of a preterm delivery the recurrence of a preterm birth was less in the treated group as compared to controls. The median gestational age at delivery was significantly higher in 17OHPC treated patients with history of earliest prior preterm delivery at 20–28 weeks.