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Table of Content - Volume 15 Issue 1 - July 2020
Assessment of fetal and maternal outcome between 40 to 42 weeks and beyond 42 weeks of gestation
Khushboo Yasmin1, Ranu Singh Kushwaha2*, K Jha3, Asha Jha4
1Junior Residents2, Junior Residents, 3Professor and Unit Head, 4Professor and HOD, Department of Gynecology, Darbhanga Medical College and Hospital. Bihar, INDIA. Email: dr.ranu2010@gmail.com
Abstract Background: This study was to assess the fetal and maternal outcome between 40 to 42 weeks and beyond 42 weeks. Prolongation of pregnancy has been the cause of concern for the clinicians and the parturients alike. The pregnancies continuing beyond expected period of confinement. ‘postdate’, have been found to be associated with various adverse feto-maternal outcomes. Methods: This study was a Prospective, Analytical. Hospital bases study. Was carried out at Darbhanga Medical College and Hospital, Bihar. The study period was twelve months from July 2018 to June 2019. The study population included 402 obstetric cases with Gestational age between 40 to 42 week and beyond 42 weeks who were admitted in Darbhanga Medical College and Hospital, comparison was done for feto-maternal outcomes in between the control group and also between the two groups of postdated pregnancy one is post-dated but term another is post-dated which is truly post-term. Results: Amongst them ninety nine eases (56.6%) were admitted with gestational age of (40 to 42) weeks and seventy six cases (4.1.4%) weeks period of gestation. Majority of patients in postdate group were nulliparous and more than half of them were between the age group of 19-24years. Most of the patients had spontaneouson set of labour. Induction had to be done in most cases with pregnancy beyond 42 weeks. Conclusion: Adverse maternal like caesarean section, instrumental delivery, postpartum haemorrhage and perineal injury was found to higher in postdate group. These were more seen in mother’s beyond 42 weeks period of gestation than 40 weeks to 42nd weeks. However, a larger scale study is recommended to study the accurate pregnancy outcome. Key Word: Induction of labour, Maternal and fetal complications, Postdate.
INTRODUCTION Normal duration of pregnancy has been defined by World Health Organization (WHO) and International Federation of Gynecologists and Obstetricians (FIGO) to be lasting between 259 to 294 days of pregnancy from the last menstrual period1. Pregnancy that has extended to or beyond 42 weeks of gestation (294 days, or estimated date of delivery [EDD]+14 days) is referred to as post term pregnancy2. Other terms that ore used interchangeably arc postdate, prolonged pregnancy or Post-maturity etc. Prolonged pregnancy (i.e. pregnancy beyond expected date of delivery) has always been a matter of anxiety and concern for the pregnant woman and the Obstetricians The delirious effect of pregnancy continuing beyond expected date of delivery was suspected first by Ballantyne in as early as beginning of last century3. Recently, studies have shown that obesity and ethnicity also have some role to play in this condition4. The incidence of prolonged pregnancy varies from 4% to 14% in different Studies conducted in various continents.[5] Similar study conducted in Nepal over a period of 3 years from 2005 to 2008 by R Marahatta et al. have found that around 4.6% of pregnancies reach post term period6. Studies conducted in European countries like Sweden7 and Russia8 were 7.6% and 3.1% respectively. Incidence various in these studies possibly due the methods employed to estimate the expected date of delivery (EDO). If early ultrasound scan (USG) along with LMP is used to estimate gestational age then the incidence of ‘true’ prolonged pregnancy is decreased by a factor of 50% than when calculated by LMP (last menstrual period) alone.9 Moreover, it has been postulated that biological variations like delay in ovulation can result in erroneous over-estimation of gestation age, even though the LMP is known accurately.10 Recent, ACOG guidelines however suggests that, if the difference between EDD calculated by these two methods is more than ± 7days upto 20weeks, + 14 days upto 20-30weeks and ± 21 days beyond 30 weeks, then dating by USG should be preferred2.
METHODS This study was a Prospective, Analytical. Hospital bases study. Was carried out at Darbhanga Medical College and Hospital, Bihar. The study period was twelve months from Nov 2015 to Nov 2016. The study population included 402 obstetric cases with Gestational age between 40 to 42 week and beyond 42 weeks who were admitted in Darbhanga Medical College and Hospital,comparison was done for feto-maternal outcomes in between the control group and also between the two groups of post dated pregnancy one is post-dated but term another is post-dated which is truly post-term.. various variables noted were Age, parity, H/O postdate, onset of labour, mode of delivery, intrapartum complications, fetal weight, Apgar score at 1 and 5 minute, colour of the liquor, admission in NICU, and neonatal death. All pregnant women with gestational age of (> 40 week and > 42 week) admitted for delivery were enrolled in the study. Data was collected on a structured proforma from the hospital admission record and was checked from the emergency room. The cases fulfilling the inclusion criteria were selected for the study. The cases were followed in the ANC ward, 1st stage room, the labour room, O.T., NICU and as well as postnatal ward. They were grouped according to their period of gestation and mode of delivery - Vaginal or instrumental or Cesarean Section. Any Intrapartum complications and maternal and fetal outcome were tabulated. Control group was taken as completed 37 weeks till 40 weeks with comparable parity either primi and multigravida. The control group was taken immediately after each study case matching with parity. Rates and proportion were calculated accordingly with the help of the statistician and the final analysis was done using the appropriate method. These findings were then presented in tables, graphs diagrams. P value was considered significant if p < 0.05 SPSS software was used for calculation and tabulation of data. The final results were discussed and the conclusion was derived. The recommendation was then made. Ethical committee approval was taken from Institutional ethical committee.
RESULTS Table 1: Incidence of prelabour rupture of membrane (PROM) based on gestational age
Table 2: Incidence of aetiology between gestational age28+0-36+6weeks and 37+0-41+6weeks.
Table 3: Incidence of booked and unbooked case
Table 4: Mode of delivery
Table 5. Incidence of chorioamnionitis between gestational age 28+0-36+6 weeks and 37+0-41+6 weeks
Table 6: Comparison of Neonatal outcomes in early preterm PROM on Aggressive vs Conservative management
Table 7: Comparison of Neonatal outcomes in late preterm PROM on Aggressive vs Conservative management
Table 8: Comparison of neonatal morbidities between women with (study group), and without prelabour rupture of membranes (control)
DISCUSSION The management of postdated pregnancy is highly debatable. The two managementoptions advocated are expectant management with antepartum fetal surveillance and induction of labour. Again, the timing of induction of labour is difficult to determine and is based on institutional practice. My study was conducted to determine the optimum time of effecting delivery in prolonged pregnancies to improve feto- maternal outcome. Table 1. shows the incidence of term prelabour rupture of membrane was 6.62%, late preterm prelabour rupture of membrane was 2.8% and early preterm prelabour rupture of membrane was 1.1%. To know the incidence of etiological factors, we divide the study cases in two groups. First group includes preterm PROM (28wks-36wks 6days) and term PROM (37wks-41wks 6days). Aetiological factors are divided into two groups infective and noninfective. For study of infective causes, we took sample from amniotic fluid and from high vaginal swab for cultures. The finding of organism obtained from amniotic fluid culture were corroborated to that of vaginal swab cultures. Study revealed that infective cause is more evident in preterm PROM than term PROM. Table 3. shows, out of 402 cases in the study group, 62 cases were booked and 340 cases were unbooked. In the control group out of 402 ,86 were booked and 316 were unbooked. From the above table it was also observed that majority of women in the both group were unbooked. The incidence of unbooked cases were higher among cases than control (84.58 % vs 78.61%). Table 4. shows that the maximum number of PROM women underwent vaginal deliveries (53.5%). 32.8% women underwent operative deliveries (forceps and caesarean section). Forceps deliveries were indicated in 10 cases of PROM. It was undertaken for fetal distress in second stage of labour. Other indications were non progress of presenting part and/or maternal distress in second stage of labour. Caesarean section was indicated in chorioamnionitis, fetal distress, malpresentation and failure of induction of labour. Study conductcd in Southern India by Bhat AR et al. found that significant increase in rate of instrumental delivery and cesarean delivery was seen beyond 40 weeks of gestation. Rate of cesarean delivery increased from 8.4% at 39 weeks to 14.9%at 40+6 weeks and 20% at 41+6 weeks.11 Ohel G et al. from Israel in the retrospective analysis of 2776 pregnancies have found that incidence of emergency cesarean section, mainly due to fetal distress and failure of progression of labour was seen in 11-42 weeks pregnancies. Statistically significant increase in rate of instrumental vaginal delivery, meconium in liquor, and macrosomia was seen in post date group.12 The study of liquor amnii shows the higher number of women with features of chorioamnionitis in PROM were below 37weeks of gestational age. The finding of Microorganism obtained from amniotic fluid were corroborated to that of vaginal swab cultures. So, it suggests that chorioamnionitis is due to ascending infection. Table 6. shows that neonatal morbidity and mortality are lower with conservative compared to aggressive management. Because this was an observational study the morbidity and mortality of aggressively managed, babies was high because of the indication of termination of pregnancy. Table 7. shows that neonatal morbidity and mortality are lower with conservative compared to aggressive management. Marahatta et al. have found 5.6% babies born in posttenn period had birth weight more than 4000 grams. Cheng YW et al. in gestation wise analysis have noted that the risk of fetal weight more than 4000 grams increases from 39 weeks onwards. The risk was 7.88% at 39 weeks which increased to 12.64 at 40 weeks and two and half fold increased (19.23%) at 41 weeks. Similarly increase in risk of birth weight of more than 4500grams was 0.92 at 39 weeks and increased to 1.63 at 40 weeks and 3.09 at 41 weeks.13 The odds ratio of having macrosomic baby was 1.63 at 40 weeks, which increased to 3.43 at 41 weeks and at 42 weeks it doubled to 7.0414. Macrosomia and meconium staining was found to be a marker for neonatal complications in the study Caughey AB et al.14. Neonatal complications resulted from asphyxia, admission to NICU, septicaemia, conjunctivitis, pneumonia, skin infection. In study cases out of 402 cases 19 babies developed such complication in the neonatal period. Where is in control group only 11babies developed such complications.
CONCLUSION Adverse maternal like caesarean section, instrumental delivery, postpartum haemorrhage and perineal injury was found to higher in postdate group. These were more seen in mother’s beyond 42 weeks period of gestation than 40 weeks to 42nd weeks. However, a larger scale study is recommended to study the accurate pregnancy outcome.
REFERENCES
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