Maternal and perinatal outcome of pregnancies after the age of 45.

OBJECTIVE: To describe the maternal and perinatal outcome of pregnancies in women aged 45 years or more at the time of delivery and to compare them with pregnancies in women aged between 20 and 29 years. METHODS: A retrospective review of hospital deliveries after 28 weeks gestation was performed at the Princess Badeea Teaching Hospital in North Jordan for patients delivered between 1st April 1994 and 31st December 1997. We compared the maternal and perinatal outcome of pregnancies in women aged of 45 years or more (study group, n = 114) with women aged between 20-29 years (control group, n = 121) delivered at the same hospital during the same period. RESULTS: The incidence of pregnant women aged 45 years or more was 3.3 per 1,000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45 to 46 years old. Gravidity and parity was significantly higher in the study group (p < 0.0001), also antenatal and medical complications as pre-eclampsia and diabetes mellitus were higher in the study group. Caesarean section rate, incidences of placental abruption and placenta previa were more common in older patients compared with young patients (32.4 vs 10.7%, 6.1 vs 0.8% and 4.4 vs 1.6%, respectively). There were no differences in the incidences of neonatal deaths, lethal malformations and fetal weight between the 2 groups. CONCLUSION: Women aged 45 years or more at delivery may expect a good pregnancy outcome but should expect a higher incidences of placental abruption, placenta previa, preeclampsia and caesarean delivery.

Emergency peripartum hysterectomy at the Princess Badeea Teaching Hospital in north Jordan.

OBJECTIVE: To study the prevalence, indications and outcome of emergency peripartum hysterectomy in women delivered at the Princess Badeea Teaching Hospital in North Jordan. METHOD: This is a retrospective study of all cases of emergency peripartum hysterectomy performed between 1st of January 1994 and 31 August 1998. RESULTS: During the study period there were a total of 21 emergency peripartum hysterectomy were performed. The overall incidence was 0.5/1,000 deliveries. The mean age of patients was 34.7 +/- 3.9 years, the median parity was 6 and the mean gestational age was 36.9 +/- 2.01 weeks. There were 19 cases of caesarean hysterectomy. The leading indication for caesarean section was previous caesarean section (89.5%), placenta previa alone (10.5%). It should be noted that 7 cases with previous caesarean section also had placenta previa (41.2%). The main indications for emergency hysterectomy were, abnormally adherent placenta was the leading indication (38.1%), followed by rupture uterus (33.3%), haemorrhage and uterine atony occurred in 14.3% of cases each, maternal complications occurred in 42.9% of cases postoperatively. There were 4 cases of stillbirths and 2 cases of neonatal deaths. CONCLUSION: Peripartum hysterectomy remains a necessary procedure for life saving during abdominal and vaginal deliveries. The procedure itself is usually associated considerable perioperative morbidity. Obstetricians should identify patients at risk and anticipate the procedure and complications.

Placenta previa: effect of age, gravidity, parity and previous caesarean section.

OBJECTIVE: To study the effect of maternal age, gravidity, parity, previous abortion and previous caesarean section on placenta previa. METHODS: We reviewed records of 95 women with placenta previa and compared with 190 women delivered during the same period, all delivering between 16 April 1994 and 15 May 1997. We compared maternal age, parity, gravidity, previous abortion, and previous caesarean section. RESULTS: Placenta previa is higher among women gravida > 4 (p < 0.002), para > 3 (p < 0.01) and previous caesarean section (p < 0.02). There is no increase in the incidence of placenta previa with increasing maternal age and previous abortion. CONCLUSION: The risk of placenta previa is increased with higher gravidity, higher parity, previous lower segment caesarean section, while increasing maternal age and previous abortion had no significant effect.

Meconium-stained amniotic fluid in term pregnancies-a clinical view.

The objective of this study was to explore details of the clinical relationship between meconium-stained amniotic fluid (MSAF) in labour, abnormal fetal heart pattern and meconium aspiration (MA). This was a prospective study carried out in Princess Badeea Teaching hospital during a 6-month period from March to September 1997. During the study period 344 (8.5%) of the deliveries had MSAF (344 women). Continuous fetal heart monitoring was routinely used and 36 women with MSAF (10.5%) needed to be delivered by caesarean section because of fetal distress (diagnosed by abnormal fetal heart pattern) in early labour, compared with 0.95% in those with clear amniotic fluid (CAF), (P <0.00001). Many infants in the MSAF group had a low Apgar score and required ventilation at birth. Nineteen infants (5.5%) developed MA, three of whom (15.8%) died. We conclude that there is an association between MSAF, abnormal fetal heart pattern in labour and a low Apgar score and that it should be considered a high risk situation. MA a problem that occurs with particulate meconium was significantly related to abnormal fetal heart pattern and longer length of labour.

Obstetrics and perinatal outcome of pregnancies after the age of 45.

We set out to describe the maternal and perinatal outcome of pregnancies in women >/= 45 years old at the time of delivery. A retrospective review of hospital deliveries after 28 weeks of pregnancy was performed at the Princess Badeea Teaching Hospital (PBTH) in North Jordan for patients delivered between 1 April 1994 and 31 December 1997. During the study period, there were 114 women aged >/= 45 years at delivery at the PBTH. The incidence was 3.3 per 1000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45-46 years old. Maternal ages were 45 (n =64), 46 (n =29), 47 (n =9), 48 (n =8), 49 (n =2) and 50 (n =2) years. Median gravidity was 10, median parity was seven. Forty-four (38.6%) patients had obstetric complications. The most frequent complication was diabetes mellitus (9.6%), followed by hypertension (4.4%). Caesarean section was performed in 32.5%. There were nine stillbirths and four early neonatal deaths, the perinatal mortality rate was 114/1000 births. We conclude that women >/= 45 years old at delivery have high perinatal mortality rate and we also noted a higher incidence of placental abruption, placenta praevia and caesarean delivery, compared with a younger group of women.

Placental praevia and accreta: an analysis of two-years' experience.

This retrospective review of the case records was designed to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. All women delivered with the diagnosis of placenta praevia at Princess Badeea Teaching Hospital from 1 January 1995 to 31 December 1996 were analysed. There were 18 651 deliveries in the study period. Sixty-five had placenta praevia, 21 of whom had a history of previous caesarean. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%) (P<0.0001). The risk increased as the number of previous caesarean sections increased. We also conclude that there is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections.

Neural tube defects in newborns.

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Ectopic pregnancy in North Jordan.

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Placenta praevia and accreta: analysis of a two-year experience.

OBJECTIVE: Our purpose was to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. METHOD: A retrospective review of the case records of all women delivered with the diagnosis of placenta praevia during the 2-year period from January 1, 1995, to December 31, 1996, at the tertiary referral centre, Princess Badeea Teaching Hospital, in north Jordan. RESULTS: There were 18, 651 deliveries in the study period. 65 (0.35%) had placenta praevia, 21 (32.3%) of whom had a history of previous caesarean section. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%); p < 0.0001). This risk increased as the number of previous caesarean sections increased: 1.78% for one previous section; 2.4% for two, and 2.8% for three or more. The incidence of anterior placenta praevia and placenta accreta was significantly increased in those with previous caesarean scars. In the group without antecedent of caesarean section, accretism risk was 9%, with one section or more 40.8% (p < 0.005). CONCLUSION: There is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections. Patients with an antepartum diagnosis of placenta praevia who have had a previous caesarean section should be considered at high risk of developing placenta praevia and accreta.

PIP: The association between previous cesarean section delivery and subsequent development of placenta praevia and placenta praevia with accreta was investigated in a retrospective review of the records of all women delivered at Princess Badeea Teaching Hospital (Irbid, Jordan) in 1995-96 with a diagnosis of placenta praevia. The 65 women with placenta praevia represented 0.35% of total deliveries during the 2-year study period; 21 of these women (32.3%) had a history of previous cesarean section. The incidence of placenta praevia was significantly greater in women with a history of cesarean section than in those without such a history (1.87% and 0.25%, respectively; p 0.0001). This risk increased with increases in the number of previous surgical deliveries: 1.78% for 1, 2.4% for 2, and 2.8% for 3 or more. The incidence of placenta accreta also was significantly increased in women with previous cesarean section compared to those without a prior surgical delivery (40.8% and 9.0%, respectively; p 0.005).

Retrospective study of outcome on vaginal and abdominal delivery in twin pregnancy in which twin 1 is presenting by the breech.

We retrospectively reviewed the perinatal outcome of twin pregnancies cohere the first baby was presenting by the breech. 21 were delivered vaginally and 37 abdominally. Differences in perinatal outcome, as measured by Apgar score and mortality, were not apparently different.

Effect of mode of delivery on perinatal results in singleton breech presentation weighing >/= 1500 g.

The object of this retrospective study was to evaluate the mode of delivery and perinatal outcome of singleton fetuses with breech presentation weighing >/= 1500 g. Consecutive cases of all singleton pregnancies at the Princess Badeea Teaching Hospital in North Jordan in the years 1994 and 1995 were compared for crude and corrected perinatal mortality and effect of mode of delivery by weight after correction for non-preventable causes. There were no differences in the 1 and 5 minutes Apgar scores and corrected perinatal mortality between those delivered vaginally and abdominally. It is concluded that poor perinatal outcome are primarily related to factors other than breech presentation. The mode of delivery for infants weighing >/= 1500 g does not influence neonatal outcome and therefore caesarean section for breech presentation in this group is not justified.

Mode of delivery and perinatal results of the breech first twin.

To evaluate the safety of vaginal delivery for breech first twin we reviewed retrospectively and compared the perinatal outcome of breech first twin: 42 delivered vaginally and 87 delivered abdominally. Vaginal delivery was allowed under the same criteria for singleton breech presentation. Both groups had similar maternal and neonatal characteristics. Intergroup differences in perinatal outcome, as measured by Apgar score, and mortality cases, were not significant. Our results showed that vaginal delivery is a safe mode of delivery and this route is not associated with higher mortality and morbidity.

Is the second-born twin at high risk?

We set out to compare the outcome of the second born twin with that of the first twin to determine if any differences could be improved. We reviewed retrospectively twin deliveries from 15 April 1994 to 14 April 1996. We excluded from analysis twins weighing < 500 g, where either twin had lethal malformation, and where either twin was dead before the onset of labour. After these exclusions 246 twin pairs remained in the study. We compared perinatal mortality, and 5 minutes Apgar scores for both twins. Perinatal mortality was similar for both twins as was the 5 minutes Apgar scores. Twins < 1500 g appear at special risk. The mode of delivery has no influence on the perinatal outcome of both twins. It is concluded that the second born twin may not be at increased risk of complications compared with the first born twin. Caesarean delivery will not improve this outcome.

Great grand multiparity: is it a risk?

We wished to compare antenatal and intrapartum complications among women delivering for the 10th or subsequent time and to compare them with women of lower parity (para 2-5). The records of 154 women of great grand parity (para >/= 10) were reviewed and compared with 308 women (para 2-5) delivered during the same period. Antepartum as well as intrapartum complications were compared. All the women delivered between 16 April 1994 and 15 January 1995. Great grand multiparous women were, not surprisingly, older. The incidence of diabetes millitus, chronic hypertension, preterm labour are similar to those with low parity while they have higher incidence of pre-eclampsia (7.1% vs. 2.6%) and intrauterine fetal death (5.2 vs. 1.3%) P < 0.04. There were no differences in the incidence of placental abruption, placenta previa, malpresentation and postpartum haemorrhage between the two groups. Great grand multipara had a higher incidence of macrosomia (7% vs. 2%) and operative delivery (20.6% vs. 11.4%) P < 0.02. Great grand multiparous woman are at some increased risk of having severe pre-eclampsia, intrauterine fetal death macrosomia and subsequently operative delivery with its associated risk of maternal mortality and morbidity.

The predictive value of the sperm-cervical mucus interaction test on the outcome of in vitro fertilization and ovulation induction combined with intrauterine insemination.

We investigated the effect of the sperm-cervical mucus penetration tests (SPT) on the fertilization rate (FR) and pregnancy rate (PR) in patients treated with either in vitro fertilization (IVF) or ovulation induction combined with intrauterine insemination (OI + IUI). Infertile couples where the women had normal ovarian function and a normal pelvis at laparoscopy and her partner had normal seminology who had failed at least 2 SPTs were treated with either IVF or OI + IUI. These patients were compared with similar couples in whom SPTs were satisfactory (SPT/ve). Group A (SPT+ve) consisted of 46 patients who underwent 78 treatment cycles of IVF and Group B (SPT-ve) comprised 31 patients who underwent 35 IVF cycles. Group C (SPT/ve) consisted of 39 patients who underwent 84 treatment cycles with OI + IUI, and Group D (SPT-ve) consisted of 15 patients who underwent 37 cycles with the same treatment. In patients treated with IVF, the FR and PR per embryo transfer were 77.0% and 20.0% respectively in Group A, and 64.0% and 22.6% respectively in Group B. The difference in FRs was statistically significant (p > 0.001) but there was no difference in the PRs. In patients treated with OI + IUI, the PR per cycle were 22.0% in Group C and 16.2% in Group D. These results indicate that SPT failure was associated with a lower FR in IVF but this did not affect the PRs. Similarly there was no difference in PRs following OI + IUI.

Preterm singleton breech in North Jordan: vaginal versus abdominal delivery.

The safety of vaginal birth for singleton preterm breech has not often been addressed before. We retrospectively compared the perinatal outcome of two groups of preterm breech delivery. Sixty-six patients delivered vaginally and 32 delivered abdominally between 26 and 36 completed weeks. Vaginal delivery was allowed under the same protocol for singleton breech delivery at term. Both groups had similar maternal characteristics. Intergroup differences in early neonatal outcome, as measured by Apgar score, were not significant. Intrapartum and early neonatal deaths in vaginal and cesarean delivery were compared. There was no significant difference in intrapartum death and early neonatal mortality between those who delivered vaginally and those who delivered by cesarean section (16.6 vs. 15.6%). So even with optimum neonatal care facilities, cesarean section does not offer any advantage over vaginal delivery in a developing country. This study does not advocate the routine use of cesarean section for delivering preterm breech fetuses.

Is the second-born twin at high risk?

OBJECTIVE: To compare the outcome of the second-born twin with that of the first twin and to find out whether there were any differences and the reason for such differences, if any, and how to improve those differences. METHOD: We retrospectively reviewed twin deliveries from the 15th of April, 1994 to the 14th of April, 1996. Excluded were twins weighing < 500 gm, either twin with a lethal malformation, and either twin who died before the onset of labour. After this exclusion 246 twin pairs remained in the study. We compared perinatal mortality and 5-minute Apgar scores for both twins. RESULTS: Perinatal mortality was similar for both twins as well as 5-minute Apgar scores. The twins < 1500 gm appeared at special risk. The mode of delivery had no influence on the perinatal outcome of either twin. CONCLUSIONS: The second-born twin may not be at increased risk of complications compared with the first-born twin and caesarean delivery may not improve this outcome.

Breech delivery at term: do the perinatal results justify a trial of labour?

This is a retrospective study conducted at Princess Badee'a Teaching Hospital in North Jordan to compare neonatal loss and morbidity in term singleton breech infants delivered either vaginally or by caesarean section. In this study, all singleton term breech presentation at 37 completed weeks' gestation were reviewed. Three hundred and eight singleton term babies, presenting by the breech were studied. Intrapartum deaths, neonatal deaths and Apgar scores in vaginal and caesarean delivery were compared. After exclusion of infants with lethal congenital malformations and antenatal stillbirths, the incidence of intrapartum and neonatal deaths associated with vaginal births was 3.5% compared with 1.3% in infants born abdominally. The number of low Apgar scores were similar in both groups. We concluded that caesarean section for term singleton breech presentation is associated with good neonatal outcome and this may influence the decision of obstetricians about the mode of delivery.

Great grand multiparity: is it a risk?

OBJECTIVE: To compare antenatal and intrapartum complications incidence among women delivering for the 10th time or more and to compare this with those of low parity (para 2-5). METHODS: The records of (154) women of great grand multipara (para > 10) were reviewed and compared with (308) women (para 2-5) delivered during the same period. Antepartum as well as intrapartum complications were compared, all occurring between 16 April 1994 and 15 January 1995. RESULTS: Great grand multiparous women are older. The incidence of diabetes mellitus, chronic hypertension and preterm labor are similar to those with low parity, while they have higher incidences of pre-eclampsia (7.1% vs. 2.69%) and intrauterine fetal death (5.2 vs. 1.3%) P < 0.025. There were no differences in the incidences of placental abruption, placenta previa, malpresentation, postpartum hemorrhage and operative delivery between the two groups. Great grand multipara also have a higher incidence of macrosomia (12% vs. 12%) P < 0.0001. CONCLUSION: Great grand multiparous woman are at increased risk of having pre-eclampsia, intrauterine fetal death and macrosomia.

The effect of sperm-mucus interaction test on the outcome of in vitro fertilization and ovulation induction combined with intrauterin insemination.

OBJECTIVE: To investigate the effect of sperm mucus penetration tests (SPT) on the fertilization rate (FR) and pregnancy rate (PR) in patients treated with either in vitro fertilization (IVF) or ovulation induction combined with intrauterine insemination (OI + IUI). METHODS: Retrospective analysis of a regional Infertility Unit database. Infertile couples where the women had normal ovarian function and a normal pelvis at laparoscopy and her partner had normal seminology who had failed at least two SPTs who were treated with either IVF or OI + IUI. These patients were compared with similar couples in whom SPTs were satisfactory (SPT + ve). Group A (SPT + ve) consisted of 46 patients who underwent 78 treatment cycles of IVF and Group B (SPT - ve) comprised 31 patients who underwent 35 IVF cycles. Group C (SPT + ve) consisted of 39 patients who underwent 84 treatment cycles with OI + IUI, and Group D (SPT - ve) consisted of 15 patients who underwent 37 cycles with the same treatment. RESULTS: In patients treated with IVF, the FR and PR per embryo transfer were 77.0% and 20.0%, respectively in Group A, and 64.0% and 22.6%, respectively in Group B. The differences in FRs were statistically significant (p < 0.001) but there was no difference in the PRs. In patients treated with OI + IUI, the PR per cycle were 22.0% in Group C and 16.2% in Group D. CONCLUSION: The results indicate that SPT failure was associated with a lower FR in IVF but this did not affect the PRs. Similarly there was no difference in PRs following OI + IUI.