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

Objective: to evaluate the frequency of vaginal birth after induction of labour with vaginal tablet prostaglandin E2 in women with previous one caesarean section

Methods: total 100 pregnant women were selected for the study with singleton, cephalic pregnancy and history of previous one caesarean section at gestational age between 37 to 41 weeks. EFW was less than 3.7kg and Bishop Score was> 5. Cervical ripening was done with PGE2 vaginal tablet Prostin E2 [3mg] after initial CTG. These women were evaluated after 6 hours by Bishop Score. CTG was repeated, if reactive, 2nd dose of PGE2 vaginal tablet was given. If patients went into labour after first or 2nd dose of prostin E2, labour was carefully monitored by close one to one monitoring by vital signs, uterine contractions, FHR monitoring, scar tenderness and Bishop Score. Outcomes measured were frequency of VBAC [vaginal birth after caesarean section], uterine rupture, neonatal outcome and frequency of emergency repeat caesarean section

Results: mean age of pregnant women was 28.06 + 3.45 years. 64 patients delivered vaginally and 36 delivered by emergency repeat caesarean section. Fetal distress was the main reason for emergency repeat caesarean section [ERCS]. There was one case of uterine rupture. Neonatal outcome were measured by Apgar score, admission to nursery and survival rate. One baby died in utero because of uterine rupture and another baby died in nursery on 2nd day of life due to meconium aspiration syndrome. 98 babies were delivered with good Apgar score and survival rate of 98% was found

Conclusion: our study concluded that prostaglandin E2 vaginal tablets are safe for inducing labour in women with previous one caesarean section but it should be administered with caution. Risk of uterine rupture is 1 % in our study

Thyroid disease in pregnancy

Objective: aim of the review is to determine the effect of thyroid dysfunction on the course of pregnancy

Material and Methods: Medline, Embase [from 2000 to 2011] and research articles. There was no language restriction for any of these searches. Studies included were randomized clinical trials, cohort and case control studies

Results: there are few prospective population based cohort studies which study the effect of thyroid dysfunction on fetal development. There was a prospective population based cohort study in china. 1017 women with singleton pregnancy participated in this study. The study showed that clinical hypothyroidism was associated with increased fetal loss, low birth weight, and congenital malformations. The sub clinical hypothyroidism was associated with increased fetal distress, preterm delivery, poor vision development, and neurodevelopment delay. The clinical hyperthyroidism was associated with hearing dysplasia. A systemic review and meta-analysis found a strong association between clinical hypothyroidism and preeclampsia, perinatal mortality and lower IQ in the child. They also found an association between thyroid autoimmunity and unexplained subfertlity, miscarriages, recurrent miscarriages and preterm birth

Conclusion: the management of thyroid disease in pregnancy is important as thyroid function undergo changes which can adversely affect pregnancy and the fetus

Comparison of prostaglandin E2 with misoprostol for induction of labour at term

To evaluate the use of vaginal misoprostol compared with vaginal prostaglandin E2 [PGE2] for labour induction at term. Experimental. Gynae Unit III, Department of Obstetrics and Gynaecology SIMS / Services Hospital Lahore. Patients were randomized to two groups with 100 patients in each group. One group received 50:g of misoprostol vaginally every four hours up till 5 doses, second group was given 3mg PGE2 vaginal tablet every 6hrs up till 3doses. The drug was stopped earlier if active labour started. 96% of patients were successfully induced in misoprostol group verses 84% patients in PGE2 group [P=0.01]. Mean induction delivery interval was significantly short in misoprostol group 13.3 +/- 8.7 hours verses 18.5 +/- 11.3 hours in PGE2 group [P=0.01]. 35% patients in misoprostol group and 40% in PGE2 group [P=0.46] had C/Sections. Increase Meconium staining and fetal heart rate abnormalities was seen in misoprostol group [P=0.03]. 20% of babies in misoprostol group had low APGR Score and needed neonatal intensive care unit admission, as compared to 12% in PGE2 group but failed to show statistical significance [P=0.12]. There was no perinatal death in both groups. Hyper stimulation was seen in only one patient of misoprostol group. Misoprostol is more effective than PGE2 in successfully inducing the patient but it does not reduce C/Section rate. Moreover it is associated with increase chances of fetal distress. Despite being cheaper than PGE2, it cannot be advocated superior to PGE2 in terms of fetomaternal outcome. Further studies with lower doses of misoprostol are recommended

Eclampsia, a major cause of maternal and perinatal morbidity and mortality

Amstract: Eclampsia is a serious obstetric complication, particularly in developing countries

Objectives: The objective of our study was to highlight the high incidence of eclampsia at our institution and to determine the maternal and perinatal morbidity and mortality associated with it. Setting: Lahore General Hospital, Lahore, Period: January, 2001 to December, 2002

Patients and Methods: 136 eclamptic patients among a total of 6173 deliveries during this two year period

Results: The incidence of eclampsia at our institution was 22 per 1000 deliveries or 2.2%. Most of the patients were less than 21 years old [51.4%] and were primigravida [59.6%]. The majority of patients were uneducated [85%] and belonged to the lower socioeconomic class [90%]. 94% were unbooked and only 6% were booked. Most of the patients presented with antepartum eclampsia [63.2%] and were at 28 to 36 weeks of gestation [50%]. 15% were at less than 28 weeks of gestation, while 35% were at more than 36 weeks of gestation. The commonest mode of delivery in eclamptics was spontaneous vaginal delivery [71.6%] followed by lower segment caesarean section in 18.7% and forceps delivery in 9.7%. The mean hospital stay was 8 days. The maternal complications were septicemia [69.85%], pulmonary complications [66.18%], urinary tract infection [41.18%] and cerebrovascular accidents [11.03%]. HELLP syndrome occurred in 2.94 %. There were 11 maternal deaths, the case fatality rate being 8%. The maternal mortality rate among eclamptics was 89.5 per 100,000 live births. The commonest cause of maternal mortality in our series was cerebrovascular accident [54.55%]. Other causes of maternal mortality were pulmonary complications [27.27%] and renal failure [18.18%]. The perinatal mortality rate was 47.77% including 31 stillborns [47.7% of perinatal deaths] and 34 early neonatal deaths [52.3% of perinatal deaths]. The early neonatal mortality rate was 32.38%. The causes of perinatal mortality were prematurity [30.77%], birth asphyxia [33.85%], meconium aspiration syndrome [18.46%] and intrauterine growth retardation [15.38%]

Conclusion: The incidence of eclampsia is very high. The case fatality rate in our series is lower than most developing countries. Eclampsia is associated with significant maternal morbidity and perinatal mortality. The major avoidable contributing factor is lack of antenatal care. Hence, improvement in antenatal care services is required to reduce the incidence of eclampsia as well as the morbidity and mortality associated with it