Evaluation of pregnant women with scarred uterus in a low resource setting

AIM: Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided. METHODS: An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted. RESULTS: A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively). CONCLUSIONS: Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple.     

瘢痕子宫孕妇孕中晚期引产的方法探讨

目的 探讨瘢痕子宫孕妇孕中晚期引产的适宜方法.方法 选择2002年9月-2009年6月在首都医科大学附属北京妇产医院因医疗指征于孕中晚期引产的瘢痕子宫孕妇共90例,引产指征为胎儿畸形、严重妊娠并发症、胎死宫内.其中,孕中期72例,孕晚期18例;距离前次子宫手术的间隔时间<2年20例,≥2年70例.肝功能正常者服用米非司酮,并行利凡诺过敏试验,阴性者首选利凡诺羊膜腔注射引产法;试验阳性、羊水过少、孕周过小、利凡诺羊膜腔注射困难或注射失败者采用卡前列甲酯(卡孕栓)引产法.共有54例孕妇采用利凡诺引产(利凡诺组),36例孕妇采用卡孕栓引产(卡孕栓组).(1)记录两组孕妇入院时情况,包括年龄、孕周、孕次、产次;(2)前次导致子宫瘢痕的手术种类、手术方法、有无并发症、前次手术间隔时间;(3)此次妊娠的引产方法,并记录孕妇用药至宫缩发动的时间,用药至胎儿娩出的时间;(4)产后出血量,胎盘滞留率,引产成功率,有无子宫破裂及行全子宫切除术等情况.结果 (1)利凡诺组与卡孕栓组孕妇的年龄、孕次、产次、距前次子宫手术间隔时间比较,差异均无统计学意义(P>0.05).但两组孕妇的引产孕周比较,差异有统计学意义(P<0.01).(2)两组孕妇引产的成功率及产后出血量比较,差异无统计学意义(P>0.05),但卡孕栓组孕妇引产用药后宫缩发动的时间及分娩时间明显短于利凡诺组,两组比较,差异有统计学意义(P<0.01);卡孕栓组孕妇24 h内分娩率达到94%(34/36),明显高于利凡诺组的13%(7/54),两组分别比较,差异均有统计学意义(P<0.01).(3)卡孕栓组孕妇胎盘滞留率(31%,11/35)明显高于利凡诺组(10%,5/52);而利凡诺组胎盘胎膜残留率(54%,28/52)明显高于卡孕栓组(34%,12/35),两组分别比较,差异均有统计学意义(P<0.01).但两组孕妇总的产时并发症发生率比较,差异无统计学意义(P>0.05).不良事件发生与前次子宫手术间隔时间的关系分析显示,<2年的孕妇在胎盘滞留、胎盘胎膜残留、胎盘早剥、子宫破裂、产后出血的发生率分别与≥2年的孕妇比较,差异均无统计学意义(P>0.05).(4)卡孕栓组孕妇中有1例发生子宫破裂,利凡诺组孕妇中有1例宫缩发动1 h后发生胎盘早剥.结论 对瘢痕子宫孕妇于孕中晚期应用利凡诺羊膜腔注射引产和卡孕栓阴道用药引产均是可行的,但需在充分的术前准备及严密监护下进行,以警惕子宫破裂的发生.     

Routine induction of labour with extra-amniotic prostaglandin E2 in a viscous gel.

Prostaglandin E2, 350 microgram dispersed in a viscous gel, tylose, was introduced into the extra-amniotic space as a single dose in 285 patients to induce labour. With a favourable cervix, 82 per cent of multiparae and 50 per cent of primiparae were successfully induced. With unfavourable induction features, the success rates were 48 per cent and 24 per cent respectively. In the remaining patients, all but four were successfully delivered when intravenous oxytocin was also used. The method was safe, simple and inexpensive and had many advantages for patients and nursing staff.     

Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: a systematic review

BACKGROUND: Misoprostol is a commonly used prostaglandin to induce labour. A potential risk of induction, however, is caesarean delivery, especially in women with an unfavourable cervix. OBJECTIVES: To evaluate the use of misoprostol, compared with prostaglandin E2 (PgE2), for labour induction in women at term with an unfavourable cervix and intact membranes. SEARCH STRATEGY: PubMed, Medline, EMBASE and the Cochrane Library were searched for articles published in any language from January 1987 to December 2005, using the keywords 'misoprostol', 'labour/labor' and 'induction'. SELECTION CRITERIA: We identified randomised trials of women at term (> or =37 weeks of gestation) with intact membranes and unfavourable cervix, undergoing labour induction with misoprostol, orally, vaginally, sublingually or buccally, compared with PgE2 vaginally or intracervically. DATA COLLECTION AND ANALYSIS: Caesarean delivery was the primary outcome, with tachysystole and hyperstimulation as secondary outcomes. The primary analysis compared any misoprostol with any PgE2 for all women, with a subgroup analysis for nulliparous women. Secondary analyses compared different routes and doses of misoprostol (oral or vaginal and 25 microgram or >25 microgram) and PgE2 (intracervical or vaginal). Relative risks (RR) and 95% confidence intervals (CI) were calculated using random effects models.Main results Fourteen of 611 articles identified met the criteria for systematic review, with three providing information for nulliparous women. There was no difference in the risk of caesarean delivery between misoprostol and PgE2 groups (RR = 0.99, 95% CI = 0.83-1.17). Any misoprostol was associated with higher risks of tachysystole and hyperstimulation compared with any PgE2 (RR = 1.86, 95% CI = 1.01-3.43 and RR = 3.71, 95% CI = 2.00-6.88, respectively). There was a higher rate of vaginal delivery within 24 hours among all vaginal deliveries with any misoprostol compared with any PgE2 (RR = 1.14, 95% CI = 1.00-1.31), and among all deliveries, a lower rate of oxytocin use (RR = 0.71, 95% CI = 0.60-0.85) but a trend towards increased meconium staining was observed (RR = 1.22, 95% CI = 0.96-1.55). The use of misoprostol at starting dosages >25 microgram had similar findings to the primary analysis. Studies of lower misoprostol dosing (starting dose of 25 microgram) did not show any differences in the outcomes of interest, but the sample size of this secondary analysis was small (304 women, 155 receiving misoprostol). AUTHOR'S CONCLUSIONS: Although misoprostol in women at term with an unfavourable cervix and intact membranes was more effective than PgE2 in achieving vaginal delivery within 24 hours, misoprostol does not reduce the rate of caesarean delivery either in all women or in the subgroup of nulliparous women, and it increases the rates of tachysystole and hyperstimulation. Further studies of misoprostol using a starting dose of 25 microgram may be warranted.     

Pregnancy outcome in women with heart disease undergoing induction of labour

OBJECTIVE: To examine the safety and outcome of induction of labour in women with heart disease. DESIGN: Prospective single-centre comparative study. SETTING: Major university-based medical centre. POPULATION/SAMPLE: One hundred and twenty-one pregnant women with heart disease. METHODS: The sample included all women with acquired or congenital heart disease who attended our High-Risk Pregnancy Outpatient Clinic from 1995 to 2001. The files were reviewed for baseline data, cardiac and obstetric history, course of pregnancy and induction of labour and outcome of pregnancy. Findings were compared between women who underwent induction of labour and those who did not. Forty-seven healthy women in whom labour was induced for obstetric reasons served as controls. MAIN OUTCOME MEASURES: Pregnancy outcome. RESULTS: Of the 121 women with heart disease, 47 (39%) underwent induction of labour. There was no difference in the caesarean delivery rate after induction of labour between the women with heart disease (21%) and the healthy controls (19%). Although the women with heart disease had a higher rate of maternal and neonatal complications than controls (17%vs 2%, P= 0.015), within the study group, there was no difference in complication rate between the patients who did and did not undergo induction of labour. CONCLUSION: Induction of labour is a relatively safe procedure in women with cardiac disease. It is not associated with a higher rate of caesarean delivery than in healthy women undergoing induction of labour for obstetric indications, or with more maternal and neonatal complications than in women with a milder form of cardiac disease and spontaneous labour.     

Different labour behaviours following induction, using oxytocin and prostaglandin F2 alpha (Enzaprost) (author's transl)

The authors studied the characteristics of labour induced by means of prostaglandin (Enzaprost F). The results were compared to spontaneous childbirths and to labour induced by means of oxytocin. Increased basal tension of the uterus and higher amplitude of uterine contractions were recorded from the prostaglandin group. Contractions were also analysed for variations in shape. Deformation in response to oxytocin was found to be almost identical to that following prostaglandin. Atypical contractions were found to occur more often in women in whom labour was induced for risk to the foetus and in primiparae, though the number of third-type contractions was lower in such cases. The point is made that betamimetics may be very helpful in getting to grips with incoordinate uterine activity. They were found to stop irregular uterine activity, and re-induction then will be accompanied by regular rhythmicity of labour.     

Unsucessful labour induction in women with unfavourable cervical scores: predictors and management

BACKGROUND: Misoprostol fails to induce labour in 5-20% of women at term. AIM: To analyse possible predictors of unsuccessful induction with 50 microg vaginal misoprostol and effectiveness and the safety of intracervical Foley catheter application in induction failures. METHODS: An observational study was conducted on 1030 women with singleton, live fetuses, vertex presentation, > 34 weeks of gestation and Bishop score < 5. Induction of labour with 50 microg vaginal misoprostol repeated every 6 h was attempted. Women without regular uterine contractions and cervical changes at the end of 24 h were considered to be unsuccessful, and a transcervical Foley balloon catheter was placed and inflated with 50 mL saline. Possible predictors of induction failures were analysed via logistic regression analysis. Neonatal outcomes and vaginal delivery achieved after Foley catheter were also determined. RESULTS: Induction was successful in 918 cases (89.1%) and Foley catheter was placed in 112 (10.8%) women. Increasing gestational age in weeks (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.68-0.88) and increasing Bishop score (OR 0.73, 95% CI 0.60-0.90) decreased the risk of failed induction. Failure rates were 16% (27/169) in post-term nulliparous women with Bishop score 相似文献   

Induction of labour with prostaglandin E2 vaginal gel in women with one previous caesarean section

ObjectiveTo study the outcome of induction of labour with prostaglandin E2 (PGE2) vaginal gel in those with one previous caesarean section.DesignOne year prospective comparative study.SettingA tertiary care Armed Forces Hospital, Muscat.PopulationForty-six women with one previous caesarean section (CS) underwent PGE2 vaginal gel induction (study group). Hundred women with previous CS had gone into spontaneous onset of labour (control group).Main outcome measuresPrimary outcome measures are mode of delivery and uterine rupture. Others are neonatal outcome, indications for caesarean section, and complications like, postpartum haemorrhage and infectious morbidity.ResultsOverall rate of vaginal delivery after caesarean section (VBAC) was 65.21% and 79% in the study and control groups, respectively. There were 7 cases of neonatal intensive care unit (NICU) admissions (7%) in the control group; however, none in the study group. Caesarean section done for foetal distress was 5/16 CS in the study group (31.25%) and 10/21 CS in the control group (47.61%). There were no cases of uterine rupture in both control and study groups.ConclusionInduction of labour with prostaglandin E2 vaginal gel in women with one previous caesarean section does not significantly increase the risk of caesarean section rate or ruptured uterus and does not adversely affect immediate neonatal outcome.     

Biochemical and haematological changes during the induction of labour at term with oxytocin, prostaglandin E-2 and prostaglandin F-2alpha.

A total of 75 patients had labour induced near term using intravenous oxytocin, prostaglandin E-2 or prostaglandin F-2alpha. Biochemical and haematological investigations were performed to assess hepatic, renal and adrenocortical function and changes in platelet adhesiveness. In doses which were similarly effective in inducing labour, both prostaglandins were without the water-retaining effect of oxytocin. Adrenocortical stimulation was greatest with oxytocin. No difference between these agents was observed for the other measurements made.     

The routine use of oral prostaglandin E2 in induction of labour.

Oral PGE2 when combined with amniotomy was found to be safe and also an effective agent for induction of labour at term even when intensive monitoring is not possible for all patients as is the case in the University Department in Kandang Kerbau Hosital which has 9000 deliveries per year. It was found to be most useful in patients with a pelvic score of 5 and above and especially in multigravidae. It obviates the discomform and difficulties in maintaining an intravenous infusion.     

Indications and results of labour induction in nulliparous women: An interview among obstetricians,residents and clinical midwives

Objective

To investigate which clinical factors are important in management decisions that clinicians make in the process of labour induction, and which clinical factors they estimate as predictive of labour outcome after induction.

Study design

A written interview was conducted among obstetricians, residents and clinical midwives in five teaching hospitals in the south of the Netherlands. Sixteen fictive vignettes were constructed of pregnant nulliparous women who were candidates for induction of labour. The vignettes differed on eight clinical variables: maternal age, BMI, gestational age, indication for induction (maternal request vs mild pre-eclampsia), dilation, position, consistency and effacement of the cervix. For each case presentation, the inclination to induce labour was calculated for the three groups, and their estimates of the probability of a spontaneous vaginal delivery or a caesarean delivery were analyzed.

Results

Of the 80 questionnaires sent, 60 (75%) were completed. Mild pre-eclampsia and post-term pregnancy were the most important clinical factors for the decision to induce or not in all three groups. Gestational age, effacement and dilation of the cervix were considered as the most important predictors of labour outcome after induction.

Conclusions

In this interview, obstetricians, residents and clinical midwives based their decision-making whether or not to induce labour predominantly on medical indications. Outcome of labour after induction was estimated to depend on gestational age and cervical status at the start of induction.