PREDICTORS FOR SUCCESSFUL LABOUR INDUCTION WITH PGE2 IN PRIMIGRAVIDA

Afnan mesfer al-otiabi 1 and Farzana Rizwan arain 2 . 1. Assistant lecture,Taif medical college,Taif university ,KSA. 2. M.B.B.S, M.C.P.S, F.C.P.S,Professor of obstetrics & gynecology,Obstetrics & gynecology department, Taif medical college, Taif university .KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 20 June 2019 Final Accepted: 22 July 2019 Published: August 2019


Patients and Methods:-
This retrospective study was, conducted at KAASH Hospital, Taif KSA. After the approval of local ethics committee. The Medical and Nursing Records of 401 Nulliparous Parturient who received PGE2 Gel for induction of labor conducted at KAASH Hospital from January 2015 to December 2015 were retrospectively reviewed.

Inclusion criteria:
all Nulliparous women at any maternal age, any gestational age, singleton, viable, cephalic presentation, who were not in established labor and with medical or obstetrics indications for labor induction including (the post term ≥ 41 week, decrease fetal movement, IUGR, Oligohydramnios, PROM, diabetes, hypertension and mild/moderate PET).were included in study .
Exclusion criteria Multiple pregnancies, IUFD and non-vertex presentation were excluded from the study.
These women were placed on the hospital protocol in which the initial dose of PGE2 GEL administered is 0.5 to 1 mg and the dosing intervals range between 6 to 8 hours. If cervical ripening (dilatation ≥ 3cms) or active labor did not occur, repeated doses were given to a maximum of 4 mg, no more than 4 mg was permitted.
If cervical dilatation ≥ 3 cm, patient started to have continuous fetal cardiac tracing in the labor ward then Oxytocin was administered intravenously by a standardized incremental infusion protocol to a maximum of 20mU/min. until the patient progresses and delivered vaginally, which considered and recorded also successful induction.

Data Collection and Analysis:
Data was collected from medical records, to assess the effect of each factor on the outcome of the induction process, statistical presentation and analysis of the different data was conducted, using the mean, standard deviation, and student t-test.
Comparison between NSVD's Ventouse and LSCS deliveries in regards to membrane state which shows slightly increase in the incidence of NSVD's 104 women (73%) with SROM over intact membrane 166 women (63.8%). In contrast LSCS was significantly increased with intact membrane compared with SROM as was, 48 women (18.5%) and 13 women (9.2%) respectively which statistically significant (P-Value 0.039) while ventouse delivery show no difference (Table 5, Figure 7).

Discussion:-
This study had a major finding; NSVD's rate increased with advanced maternal age but not statistically significant, our findings are similar to the repeated issues encountered in the overall literature regarding maternal age and the risk of caesarean delivery. Two retrospective cohort studies reported an increase in caesarean delivery in women over the age 35 as compared to women younger than 35 years old.
We found that rate of LSCS had been increased with advanced maternal age but not statistically significant, this finding shows the trending issue in the overall literature regarding maternal age and the risk of caesarean delivery.
As two retrospective cohort studies reported an increase in caesarean delivery in women over the age of 35 as compared to women younger than 35 years old.
Another prospective cohort study by Tan and colleagues was conducted in Malaysia between January 2003 and August 2004. This study included 152 women who had an induction of labor. In this cohort, there was no significant Difference in caesarean delivery rates between women who were less than 35 years (24.0 percent) compared with women who were greater than or equal to 35 years (19 percent) of age (20). In another prospective study conducted between 1974 and 1981, Orhue and colleagues examined 1,775 women who had induction of labor in Nigeria and found that maternal age greater than 35 years was not associated with increased caesarean delivery (21). These observational studies presented conflicting data to support maternal age as a predictor of caesarean delivery. Thus, the direction of effect could not be adequately determined based on the literature reviewed and the evidence was rated as insufficient.
The connection may reflect a definite biological difference seen between old and young women. For example, older women are susceptible to experience obstetric complications such as, gestational hypertension, preeclampsia and gestational diabetes. Nevertheless, old maternal age has been reported to have a dysfunctional myometrium, which in return leads to a higher incidence of failure in labour (22,23).
Our study reports lower rate of LSCS with term pregnancy (37 -41 weeks) and a higher rate of LSCS with preterm and post a term group which was statistically significant. These findings are generally consisted with four cohort studies examined gestational age at delivery as a predictor of caesarean delivery in women who underwent induction of labor compared to spontaneous labor. Overall, there was a trend of increasing frequency of caesarean delivery with increasing gestational age. 1171 Another large retrospective cohort study of 6,985 women , conducted in Canada, observed that caesarean frequency increased from 18.5 percent when delivery occurred between 39 and 40 weeks gestation to 23.9 percent at 41 weeks gestation, and was as high 44.6 percent when delivery occurred during 42 weeks and beyond (28) Similarly, another cohort study reported women who delivered at 40 weeks or less also had a caesarean frequency (18.9 percent) lower than of women who delivered at greater than 40 weeks (27.4 percent) (20).
In another study emphasizing on gestational age and induction of labor, it was found that there was non-significant decrease in the rate of caesarean delivery in patients having their labour induced. OR 0.92; 95 percent CI 0.76 -1.12). Meanwhile, in the same group of study, women < 41 week of gestation there was a reduction in rate of caesarean in the elective induction setting (OR 0.58 percent CI 0.34 -0.99), which was statistically significant finding (29).
We had found in our study constant slightly increased rate of LSCS as fetal weight was increased with obvious increase when fetal weight reaches more than 4 kg which was not statistically significant. It was reported in four cohort studies that examined gestational age at delivery, the continuous fetal growth progression in return, increase the chance of cephalon-pelvic disproportion with increased gestational age. These findings have been demonstrated in term pregnancies in a study of labouring women (30).
The effect of SROM was statistically highly significantly as vaginal delivery rate increased and LSCS rate decreased with women who had ruptured membrane when compared with women who had intact membrane before induction labour started.
There was statistically highly significant lower rate of vaginal deliveries compared with higher rate of ventouse deliveries with epidural analgesia, but not affecting the rate of LSCS. Which correlated with a Cochrane review published in 2005 showed that epidural analgesia was associated with an increased risk of instrumental vaginal birth (pooled RR 1.38, 95% CI 1.24 -1.53) compared with deliveries with non-epidural analgesia or no analgesia (31).
A land mark study by Wong et al. (32) published in 2005 provided evidence that epidural analgesia does not cause increased rate in LSCS rate in nulliparous women. We noticed higher vaginal deliveries with the use of lower dose of prostin of less than 1 mg, compared with higher rate of LSCS with the use of higher doses of prostin which was statistically highly significant.

Conclusion:-
It has been concluded from the study that young age, low BMI, low fetal weight, increase gestational age and SROM prior induction can be considered as good predictors for successful induction of labour in PG's.