A Comparative study of the Pregnancy Outcome with Induction at 40 Weeks and Beyond 40 Weeks of Gestational Age

BACKGROUND: Human Birth is a gift from God, and He has empowered the obstetricians, the duty of delivering a good, healthy well fetus to make a strong backbone of our country and healthy future generation. India being the second largest population country next to China, in the world, has implemented national family welfare program in a very large scale and now the acceptance rate of nuclear family norm has gained increased popularity in India. So each and every pregnancy is important, and every baby is precious baby. The definition of prolonged pregnancy according to international guidelines is 42 completed weeks or more than that from the first date of the last menstrual period. Prolonged pregnancy always causes anxiety and distress for parents, their families, and also the obstetricians. The main reason quoted for this is the risk of late IUD. Despite many trials and studies, there is still no consensus and clear decision regarding the most appropriate management of this difficult situation. Accurate estimation of gestational age and expected date of delivery is important for successful outcome of pregnancy. Herein this study we compare the pregnancy outcome of those intervened at forty weeks of gestation and those beyond forty weeks and thereby we are arriving at an optimum period for intervention in these pregnancies. We split them into two groups- group A- Induction of pregnancy beyond 40 weeks and group B- Induction of pregnancy at 40 weeks. AIM OF THE STUDY: To compare the pregnancy outcome with induction at 40 weeks and beyond 40 weeks of gestational age. OBJECTIVES: 1. To analyse and evaluate the optimum period of intervention in pregnancies without compromising the Fetomaternal outcome. 2. To evaluate the maternal and perinatal outcome when induction of labour is done at 40 weeks of gestation. 3. To evaluate the maternal and perinatal outcome when induction of labour is done beyond 40 weeks of gestation. MATERIALS AND METHODS: After Institutional ethical committee approval and informed written consent, patient will be selected for the study based on inclusion and exclusion criteria. Patient will be observed over a period of one year. A prospective observational study will be started comprising 2 groups- control group pregnant women at 40 weeks gestation and study group - pregnant women beyond 40 weeks of gestational age. ❖ Gestational Age was based on the Mother’s statement of first day of last menstrual period. Then clinical examination, NST and ultrasound examination were carried out. Fetal presentation, position, maturity and amount of liquor assessed. The estimated baby weight assessed, and bimaul examination done to know the Bishop’s Cervical Score. ❖ The study group consisted of 50 women with beyond 40 weeks of gestational age all of them were booked elsewhere and admitted through casualty. They were unaware of the significance of prolonged pregnancy due to either illiteracy or lack of easy approach to the health system. They had induction either by prostaglandin E2 gel or foley according to cervix status. Active management of labour done, by amniotomy and oxytocin. Colour of liquor noted, and Amnio infusion given if it is meconium stained using normal saline at room temperature. The mode of delivery decided accordingly and neonate inspected for evidence of postmaturity syndrome, macrosomia, IUGR. ❖ The control group consisted of 50 women picked up from antenatal op at 40 completed gestational weeks and induction attempted immediately. They all underwent NST and ultrasound examination and induction was followed by Active management of labour. The colour of liquor, Baby’s condition at birth (baby weight, baby apgar), labour and outcome studied. Maternal outcome in form of mode of delivery (vaginal delivery, instrumental (or) operative vaginal delivery and caesarean section) evaluated in both these groups. Neonatal / Perinatal outcome evaluated which comprised of Meconium staining at labour of Amniotic fluid (MSAF), Meconium Aspiration Syndrome (MAS), Macrosomia, Intra Uterine Growth Restriction, apgar score and Neonatal Intensive care unit (NICU) admission rate. RESULTS: The study population consisted of 100 women of which 50 women who had regular cycles and admitted on their expected date of delivery at 40 weeks and 50 women were they had crossed the expected date of delivery. ❖ Of these 50 women had crossed the gestation beyond 40 weeks but less than 41 weeks and 50 women had completed 40 weeks of gestation. There were 80 Primigravida. Previous History of overdue pregnancy that has gone beyond dates – 12%. ❖ In the control group in whom the gestation age corresponded to 40 weeks, women enrolled were 50. Of the various modes of induction, 78 % induced with Foley followed by PGE2 gel, 22 % induced with misoprostol. ❖ 54 % had natural delivery. Vacuum delivery constituted 10% and so total operative vaginal delivery for those who delivered in this group was 64% caesarean in the 40 weeks group 36%. ❖ In the study group in whom the gestation age crossed 40 weeks but less than 41 weeks, women enrolled were 50. Of the various modes of induction, 84% foley induction followed by PGE1 gel, and 16 % induced by misoprostol. Overall meconium staining in this group = 10 (20%) . 80% had natural delivery and 14% went for caesarean section and 6% were delivered by operative vaginal delivery (vacuum delivery .Perinatal outcome in control group is Apgar score AT 5 MIN < 7 is 5 (10%), NICU Admission Rate is 8 (16%), Mortality rate is nil. Perinatal outcome in study group is Apgar score AT 5 MIN < 7 is 3 (6%), NICU Admission Rate is 12 (24%), Mortality rate is nil. CONCLUSION: Whenever a pregnant women crosses her expected date of confinement, the patient becomes anxious, and the obstetrician keeps the finger crossed. From the study conducted, we get the inference that the caesarean section rate is reduced from 36% to 14%, when the labour is induced beyond 40 weeks of expected date of confinement. Also, the instrumental delivery rate is low (6%) in the study group compared to the control group (10 %). ❖ Eventhough the meconium staining of liquor is higher in the study group (20% vs 6%), NICU admission and perinatal mortality is comparatively not significant in both Study group and control group. ❖ So, the induction of labour optimally in otherwise uncomplicated pregnancies, beyond 40weeks is associated with no adverse effect on maternal and perinatal outcome