Maternal and perinatal outcome of eclampsia over a decade at a tertiary hospital in Kuwait.

AIMS: To determine maternal and perinatal outcome of eclampsia patients over a decade. METHODS: Analysis of case records of all eclampsia cases from January 2005 to December 2014. RESULTS: There were 30 cases of eclampsia. The most significant risk factors for developing pre-eclampsia are unbooked cases (97%), nulliparity, young age, marriage ≤4 months, history of pre-eclampsia in previous pregnancy, remarriage, preexisting diabetes mellitus, interval between pregnancies ≥10 years, positive family history. The incidence of eclampsia was 0.05%, antepartum eclampsia 15 (50%), intrapartum 6 (20%) and postpartum 9 (30%) with no maternal deaths, and 1 perinatal death. Perinatal mortality was 33.3/1000. 22 (73%) patients received magnesium sulphate (MgSO4) and 8 patients (27%) received Diazepam, of which 1 had recurrence of convulsions. All 15 antepartum cases were delivered by cesarean section as were 2 intrapartum. 13 (43%) of women delivered vaginally. Only 6 (20%) patients were of low socio-economic status and were primary school educated. Severe maternal complications occurred in 8 (27%), with abruptio placentae being the most common 3 (38%). CONCLUSIONS: Incidence of eclampsia was low, with no maternal deaths. MgSO4 was found to be highly effective. Lack of antenatal care is a major risk factor.

Induction of labor in grand multiparous women with previous cesarean delivery: how safe is this?

OBJECTIVE: To compare the outcome of induced and spontaneous labor in grand multiparous women with one previous lower segment cesarean section (CS), so that the safety of labor induction could be assessed. METHODS: In 102 women (study group), labor was induced and the outcome was compared with 280 women (control group) who went into spontaneous labor. All 382 women were grand multiparous and had one previous CS. RESULTS: There were no significant difference in oxytocin augmentation, CS, scar dehiscence, fetal birth weight or apgar scores between groups. There was one neonatal death, two still births, one early neonatal death and one congenital malformation in the study group and this was not significant. There was no significant difference in vaginal birth in the study (80.9%) and the control group (83.8%). CONCLUSION: In this moderate-sized study, induction of labor may be a safe option in grand multiparous women, if there is no absolute induction for repeating CS.

Motor-vehicle injury in pregnancy and subsequent feto-maternal outcomes: of grave concern.

OBJECTIVES: (1) To evaluate maternal and fetal outcome after motor-vehicle injury during pregnancy. (2) To determine if there was prenatal care provider counseling for seat belt use. METHODS: Retrospective chart analysis of materno-fetal outcome following motor vehicle injury in 728 pregnant women between 2009 and 2012. Women attending antenatal clinics over these years were asked if they were counseled regarding correct seat belt use by prenatal health care providers during their antenatal visits. RESULTS: In these pregnant women, 80 (11%) sustained minor injuries/sprains. 648 women (89%) had severe adverse materno-fetal pregnancy outcomes. Important causes being: (1) placental abruption 58.8%; (2) preterm labor (40%); and (3) uterine rupture (1.6%). There were 100 (13.7%) maternal and 78 (10.7%) fetal deaths. 91 (12.5%) perimortem cesarean deliveries were performed and 74 (81%) fetus survived, as did 31 women. Prenatal care provider counseling for seat belt use occurred in 44.8% of prenatal visit. Only 125 (21%) were using seat belt during the accident. CONCLUSION: Important causes of adverse pregnancy outcome were: abruptio placenta, preterm labor and uterine rupture. There were 100 maternal and 78 fetal deaths with 97 preterm births. Counseling occurred in 44.8% of women. Those using seat belts during the accidents sustained minor injuries.

Is membrane sweeping beneficial at the initiation of labor induction?

OBJECTIVE: To determine whether cervical membrane sweeping during labor induction is beneficial. METHODS: Outcomes of labor after induction in pregnant women at term were compared in a randomized trial. Women were assigned to having their membranes "swept" or "not swept" at the initiation of labor induction. RESULTS: We recruited a total of 870 women of which 70 were excluded. There were 400 nullipara (Group A) [198 "swept", 202 "not swept"] and 400 multiparas (Group B) (201 "swept" and 199 "not swept"]. Among group A who received intravaginal prostaglandin (PG) E2, those who had simultaneous sweeping had significantly shorter mean induction-labor interval (12.9 ± 1.3 versus 16.2 ± 1.1 hours, p = 0.046), lower mean dose of oxytocin (6.6 ± 0.6 versus 10.11 ± 1.4 mU/minute, p = 0.01), and increased normal delivery rates (vaginal delivery 82.8% versus 58.6%, p = 0.01). Sweeping also had a favorable effect on nulliparas who had ARM and received oxytocin alone (mean induction-labor interval 5.9 ± 2.9 versus 10.9 ± 2.6 hours p = 0.04, mean maximum dose of oxytocin 9.8 ± 1.1 versus 15.2 ± 1.1 mU/min, p = 0.01). These results were restricted to women with unfavorable cervix in Group A those who had membrane sweeping. CONCLUSION: Membrane sweeping, has beneficial effects on labor and delivery, which is limited to nulliparas with unfavorable cervix requiring PGE2 or Oxytocin alone.

Maternal and neonatal outcome in triplet, quadruplet and quintuplet gestations following ART: a 11-year study.

OBJECTIVES: To review the maternal and fetal outcome of triplet, quadruplet and quintuplet gestations following ART, which were managed at a hospital over 11 years. STUDY DESIGN: Retrospective chart review of 150 triplet, 27 quadruplet, and 6 quintuplet pregnancies between January 2001 and December 2011. 25 women aged 50-56 years with triplet pregnancies, were excluded due to lack of data. No prophylactic interventions were used. RESULTS: 300 triplets, 108 quadruplets, and 30 quintuplets were born. The mean maternal age was 30.2 years (SD 4.2 years). Mean gestational age delivery was 32.2 weeks (SD 4.2 weeks). Maternal complications included preterm labor 114 (86 %), prematurity 115 (87 %), anemia 44 (33 %) gestational diabetes 35 (27 %), preeclampsia 33 (25 %), post partum hemorrhage 13 (10 %). Preterm labor was diagnosed in 84 (84 %) triplets, 32 (97 %) of quadru- and quintuplet pregnancies (P > 0.05). Prematurity and preterm labor were major determinants. Of the 438 fetuses born there were 57 (13 %) still births, 77 (18 %) neonatal deaths. 32 (7 %) were early neonatal deaths, 45 (10 %) late neonatal deaths. The majority died due to extreme low birth weight. 75 (17 %) neonates had low apgar score of <7 at 5 min. 22 (5 %) infants had congenital anomalies. Severe respiratory distress syndrome, perinatal asphyxia, very early preterm delivery and perinatal mortality were higher in quadru- and quintuplets (P < 0.05). CONCLUSION: Preterm labor and preterm prematurity were the commonest complications. Neonatal mortality and morbidity was significantly increased in quadru- and quintuplets. Prophylactic interventions were not used in an attempt to prevent preterm labor.

A 26-year review of emergency peripartum hysterectomy in a tertiary teaching hospital in Kuwait - years 1983-2011.

OBJECTIVE: To identify the risk factors and study the incidence, indications and complications of emergency peripartum hysterectomy (EPH). MATERIALS AND METHODS: This was a retrospective case-control study. The cases consisted of all women who underwent EPH between January 1983 and January 2011. Two controls per case were randomly selected from the remaining deliveries by using a random number table. Case records were retrieved from the medical records. RESULTS: Among 150,993 deliveries, there were 59 EPHs (cases), giving a rate of 0.390 per 1,000. Of the 59 cases, only 56 were analysed because 3 files were unavailable. These women were older (mean age 36 ± 5.7 vs. 22 ± 5.3 years, p < 0.01) and had delivered more than 1 child (p = 0.02). Thirty-seven (66%) cases had had previous caesarean sections (CSs) and the number of CSs in this group was greater than in the controls (21%, p < 0.01). More index cases had a history of atonic postpartum haemorrhage (46 vs. 4%, p < 0.001) and placenta praevia (34 vs. 4%, p < 0.01). More cases than controls were delivered by CS (73 vs. 29%; p = 0.003). The leading indications for EPH were haemorrhage due to uterine atony and placenta praevia. Independent risk factors were older age, multiparity, history of one or more CSs and placenta praevia. There were 2 maternal deaths from coagulopathy following massive obstetric haemorrhage. The main complications of EPH were febrile morbidity: 12 (21%), wound infection: 8 (14%) and bladder or ureteric injury: 8 (14%). CONCLUSIONS: CSs, especially repeat CSs in women with placenta praevia and persistent uterine atony, significantly increased the risks of peripartum hysterectomy.

Trends in maternal mortality over 29 years in a Kuwait Tertiary Teaching Hospital: signs of progress?

UNLABELLED: This study aims at (1) Assessing trends in maternal mortality in kuwait (2) Define strategies for prevention. METHODS: Retrospective analysis of maternal deaths that occurred among, 55,979 live births at a tertiary hospital, between 1980 and 2009. RESULTS: There were 14 maternal deaths, and 55,979 live births, giving a maternal mortality rate of 25 per 100,000 live birth. In terms of decades maternal mortality declined from 54.8 in 1980-90 to 28.4 in 1990-2000 and continued to decline to 12.2 in 2000-2009. Thromboembolism (28.6%), Obstetric haemorrhage (21.5%) and Eclampsia (14.3%) were the leading causes of direct deaths. Cardiac disease is the most common cause of indirect deaths (14.3%) followed by H1N1 pneumonia 7.1%. Eclampsia contributed to 40% of deaths, only in the 1980s. Thromboembolism caused 28.6% of deaths, 50% of which were in the last 9 years. Indirect deaths from cardiomyopathies (66.7%) gained prominence in the 1990s. No deaths from puerperal sepsis were reported after the 1980s (14.3%). CONCLUSIONS: Maternal mortality rates are decreasing significantly (p<0.01) at our institution over the last 29 years. Obstetric haemorrhage and thromboembolism remain important causes of maternal mortality. Substandard care was identified in 70% of Direct and 55% of indirect deaths.

Female circumcision: obstetrical and psychological sequelae continues unabated in the 21st century.

OBJECTIVES: To assess the incidence of female circumcision/female genital cutting (FGC) among pregnant women and describe the obstetrical and psychological sequelae of female circumcision. METHOD: Four thousand eight hundred pregnant women over a 4-year period were assessed for female circumcision. Odd ration (OR) and 95% confidence interval (CI) were calculated to measure association between female circumcision, maternal morbidity, and birth outcome. Variables included prolonged maternal hospitalization, low birth weight, prolonged labor, obstructed labor, cesarean section, and fetal outcome. Assessment measures to determine cognitive and emotional effects included the Mini international Neuro-psychiatric interview and Rey memory test. RESULTS: The prevalence of female circumcision was 38%; women who were circumcised were more likely have extended hospital stay. There was a positive association between such women and prolonged labor, cesarean section, post-partum hemorrhage, early neonatal death, and hepatitis C infection. Psychiatric sequelae included: 80% continued to have flashbacks to the FGC event; 58% had a psychiatric disorder (affective disorder); 38% had other anxiety disorders, and 30% had post-traumatic stress disorder. CONCLUSION: Female circumcision is associated with adverse materno-fetal outcome and psychiatric sequelae. Many will need psychiatric as well as gynecological care.

Uterine rupture and subsequent pregnancy outcome--how safe is it? A 25-year study.

OBJECTIVES: (a) To review the cases of ruptured uterus over the last 25 years and analyze the causative factors with a view to its prevention (b) To analyze subsequent pregnancy outcome with a view to its safety. METHOD: The case notes were reviewed for all patients with ruptured uterus over a period of 25 years from January 1982 to January 2007. Relevant dates relating to the characteristics of labor, delivery, maternal, perinatal, and subsequent pregnancy outcomes were assessed. RESULTS: The incidence of ruptured uteri was calculated to be 0.03%. Total deliveries included in the study were 152,426. There were 46 cases of ruptured uteri and 44 were available for study. Twenty-two (52%) ruptured uteri occurred in patients with previous caesarean scars, of which 10 occurred in women with previous four or more caesarean sections. In 12 cases (27%), uterine rupture occurred due to oxytocin; PGE2 and oxytocin were used in 3 of these 12 cases. Two (4.5%) ruptures occurred due to non-removal of cervical cerclage during labor. Two (4.5%) primigravidae ruptured their uterus following road traffic accident, resulting in maternal and fetal deaths. Malpresentation in labor resulted in eight (18%) ruptures. Rupture occurred at the fundus in 10 cases and in the lower segment in the remaining 34. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in 20 cases (45%) of which 13 were subtotal and 7 (10%) were total. Of the remaining 24 (55%) patients, 10 had suture repair and in addition 14 patients underwent hypogastric artery ligation. Later, 22/24 (92%) women became pregnant. Twenty (91%) were delivered by planned caesarean section. There were no maternal or fetal complications. The remaining two women had previous classical scar, undetected malpresentation, and sparse antenatal care. Their uteri ruptured spontaneously at 32 and 35 weeks at home. They died intra-operatively due to intractable hemorrhage along with their fetus. CONCLUSION: In the previous caesarean section, the indiscriminate use of oxytocin and malpresentation are the risk factors for uterine rupture. Child birth after uterine rupture is not to be recommended routinely. Most women with a previous uterine rupture with meticulous tertiary level antenatal care had a favorable outcome in subsequent pregnancies.

Adverse outcome of pregnancy following air travel: a myth or a concern?

OBJECTIVE: To assess whether air travel elevates the risk of adverse pregnancy outcomes in essentially healthy women with single non-anomalous fetuses at a gestational age greater than 20 weeks. METHODS: A retrospective analysis of air travel during the current pregnancy and pregnancy outcome was undertaken in 992 women admitted for delivery over a 12-month period. The study group of 546 (55%) women, of whom 57% were primigravidae, travelled at least once during pregnancy, and were compared with a control group of 447 women (45%), of whom 54% were primigravidae, who did not travel by air. RESULTS: The primigravidae in the study group showed an increased risk of preterm birth, and this risk was statistically significant between the gestations of 34 and 37 weeks (adjusted odds ratio 1.5, 95% confidence intervals 1.2, 1.8); this risk remained elevated after adjustment for covariates. These women's pregnancies were appreciably shorter than those of primigravidae who did not fly (36.1 +/- 0.8 vs. 39.2 +/- 2.1 weeks) and their babies had lower birthweights (2684 +/- 481 vs. 3481 +/- 703 g). and were more likely to be admitted to the neonatal intensive care unit. This group of air travellers is unusual for the uncommonly long and frequent duration of air travel, which is not routinely undertaken in most parts of the world. There were no thromboembolic events complicating any pregnancies. CONCLUSIONS: Primigravid women who travel by air appear to be at higher risk for preterm birth. Multicentre large studies are required to confirm or repute these findings.

Unexplained antepartum fetal deaths: what are the determinants?

OBJECTIVE: The objective was to assess fetal, antenatal, and pregnancy determinants of unexplained antepartum fetal death. METHODS: This is a hospital-based cohort study of 34,394 births weighing 500 g or more from January 1995 to December 2002. Unexplained fetal deaths were defined as fetal deaths occurring before labor, without evidence of significant fetal, maternal or placental pathology. RESULTS: Ninety-eight unexplained antepartum fetal deaths accounted for 27.2% of 360 total fetal deaths. Two-thirds of these deaths occurred after 36 weeks' gestation. The following factors are independently associated with unexplained fetal deaths: primiparity (OR 1.74; 95% CI 1.21, 2.86); parity of five or more (OR 1.19; 95% CI 1.26, 3.26); low socioeconomic status (OR 1.22; 95% CI 1.14, 2.86); maternal age 40 years or more (OR 3.62; 95% CI 1.22, 4.52); maternal age of 18 years or less (OR 1.79; 95% CI 0.82, 2.89); maternal prepregnancy weight greater than 70 kg (OR 2.20; 95% CI 1.85, 3.68); fewer than three antenatal visits in women whose fetuses died at 31 weeks or more (OR 1.11; 95% CI 1.08, 2.48); birth weight ratio (defined as ratio of birth weight to mean birth weight for gestational age) between 0.85 and 0.94 (OR 1.77; 95% CI 1.28, 4.18) or over 1.45 (OR 2.92; 95% CI 1.75, 3.21); trimester of first antenatal visit. Previous fetal death, previous abortion, cigarette smoking, fetal sex, low maternal weight, fetal-to-placenta weight, and post date pregnancy were not significantly associated with unexplained fetal deaths. CONCLUSION: Several factors were identified that are associated with an increased risk of unexplained fetal deaths.

Birth outcomes in perinatally HIV-infected adolescents and young adults in Manipur, India: a new frontier.

OBJECTIVE: The objective was to study birth outcomes in perinatally HIV infected adolescents and young adults. METHOD: Between January 1997 and January 2001, 30 asymptomatic perinatally HIV-infected primigravid pregnancies (Group A, study group) were identified amongst perinatally HIV-infected adolescents and young adults. They were attending the high-risk antenatal clinic at the Government Hospital, Manipur. Pregnancy and birth outcome were assessed. The control group (Group B) consisted of 28 perinatally infected females with no history of pregnancy. Both groups, of tribal origin, were matched for age < or = 1 of the age of the pregnant females: median age 18 years (range: 16-22 years) and socio-economic class, (lower middle socio-economic class). RESULTS: The median viral load of the pregnant women were 16,383 copies/ml (range 5,251-65,571 copies/ml) and median CD4 count was 220 cells/mm3 (range: 18-980 cells/mm3. Twenty-seven (90%) of the 30 pregnant women received antiretroviral therapy (ARV) consistently during the pregnancy. Among the 30 pregnancies, 4 ended in elective abortion. The remaining 26 women delivered 26 live born infants (of these, one was a preterm delivery (35.2 weeks). There was no IUFD, IUGR, spontaneous miscarriages, or fetal, infant or maternal deaths. CONCLUSION: Pregnancy in perinatally HIV-infected adolescents and young adults, does not appear to be associated with adverse maternal or fetal outcome if retroviral therapy is taken consistently prior and during the pregnancy. Counseling with respect to sexual activities, pregnancy and birth control is mandatory.

Child-bearing beyond age 50: pregnancy outcome in 59 cases "a concern?".

OBJECTIVE: To study maternal and perinatal outcomes in healthy women aged 50 years and older. METHOD: This study was of 59 clinical pregnancies, of which 10 ended in first trimester spontaneous miscarriage (and were excluded from further studies) and 58 live births. This retrospective review of 58 live births in 49 essentially healthy women (mean [SE] age, [52+/-2.5] years; range 50-55 years), with no chronic medical conditions (of which 28 were primigravids). Pregnancy outcomes were ascertained by chart review and telephone follow-up. RESULTS: Of the 58 live births, 41 were singletons, and 7 were twins, and 1 triplet, for which the mean+/-SE gestational age at delivery were 38.1 weeks +/-0.4, 36.2 weeks +/-0.1 and 34.1 weeks respectively. Birth weights (mean +/- SE) were 3,201 g+/-10, 2,252 g+/-4 and 1,998+/-95 g respectively. Mean Apgar score +/- SE at 1 and 5 min were 9.2+/-0.8 and 8.8+/-0.6 respectively. Total cesarean deliveries were 73% (36/49). Of singletons 68% (28) were delivered by cesarean section as were all multiples. The incidence of pre-eclampsia was 30.6%: mild pre-eclampsia 20.4% (10/49), severe pre-eclampsia 10.2% (5/49). Gestational diabetes required insulin in all 19.5% of women. Anemia was noted in 6.5%. CONCLUSIONS: Appropriately screened women, aged 50 years or older, can deliver successfully. During pregnancy, they appear to be at increased risk of pre-eclampsia and gestational diabetes. A significant majority can expect to deliver via cesarean.

Should HEV infected mothers breast feed?

OBJECTIVE: The aim of this study was to determine by a prospective study: the presence of anti-hepatitis E virus (HEV) and or HEV RNA in the colostrum of HEV infected mothers; transmission of HEV to infants from their mothers by breast-feeding. METHOD: Ninety-three infected pregnant mothers in the third trimester of pregnancy of which 36 were positive for anti-HEV antibodies and 57 for HEV RNA (index patients) and 90 healthy pregnant mothers (control subjects) were studied. Maternal blood was taken at 7th and 9th of gestation and also within 5 days post-partum, along with colostrum and tested for anti-HEV and HEV RNA. Blood samples were collected from all infants at birth (cord blood) and at 1, 3, and 6 and 9 months of age. RESULTS: There were 12 cesarean sections and eighty full term vaginal deliveries. Anti-HEV antibody and HEV-RNA was present in the colostral samples but in significantly lower levels ( p<0.001) as compared to corresponding maternal levels. Within 2 weeks post-partum, 6 of these 93 index patients, whose infants were anti-HEV antibody and HEV RNA negative at birth, developed acute hepatic disease. These mothers, four of whom delivered by cesarean section, had anti-HEV titers ranging from 1:10,000 to 1:60,000 and HEV RNA ranging from 1.5x10(6) to 2.5x10(4) copies/ml. Due to acute maternal disease their six respective infants were formula fed. Four of these infants were in close maternal contact, frequently kissed and cuddled, and developed symptomatic liver disease by 6-8 weeks of age. Apart from these 6 infants the remaining were exclusively breast-fed for 3.6+/-0.32 months. There was no evidence of HEV infection in the remaining babies. All mother-infant pairs from the control group remained anti-HEV negative throughout this study. CONCLUSION: Although anti-HEV antibody and HEV-RNA are present in the colostrum of HEV infected mothers, breast-feeding appears to be safe for these infants. However this report must be confirmed by others. Transmission of infection may occur postpartum, through close contact of mother-infant pairs, especially in the presence of acute maternal disease.

Severe preeclampsia and the very-low-birth-weight infant. The controversy over delivery mode continues.

OBJECTIVE: To compare the effects of labor induction with those of cesarean delivery without labor on neonatal outcome in pregnancies complicated by severe preeclampsia and delivery of very-low-birth-weight infants. STUDY DESIGN: This retrospective study covered 400 singleton, live-born infants who weighed 750-1,500 g at birth and were delivered because of severe preeclampsia. Outcome in infants delivered by cesarean section without labor was compared with that in infants exposed to labor induction. RESULTS: Of the 400 women with severe preeclampsia who delivered infants between 750 and 1,500 g; 280 (70%) had labor induced, and 120 (30%) delivered without labor. Vaginal delivery was accomplished by 182 (65%) women in the induced group. Apgar scores of < or = 3 at five minutes was more common in the labor-induced group (6% versus 3%, P = .04); however, other neonatal outcomes, including respiratory distress syndrome, ventricular hemorrhage, sepsis, seizures and neonatal death, were similar in the two groups. Data analysis of the induced group did not reveal an association between route of delivery and neonatal outcome. Outcome in both groups was satisfactory at six months. CONCLUSION: Induction of labor in women with severe preeclampsia is not harmful to very-low-birth-weight infants and appears to be a safe mode of delivery.

Course and outcome of pregnancy in 54 persistently HIV-1-seronegative sex workers and their infants.

OBJECTIVE: To determine the course and outcome of pregnancy in 54 persistently HIV-1-seronegative pregnant commercial sex workers (prostitutes). STUDY DESIGN: Five hundred twenty-three initially HIV-1-seronegative prostitutes in Manipur, India, were studied between 1990 and 1999. Two hundred forty (46%) women seroconverted to HIV-1 during the study period. HIV-1 polymerase chain reaction with env, nef and vif gene primers was done on 98 persistently seronegative sex workers, who remained seronegative after three years of follow-up. Fifty-four of these women became pregnant (study group). The course and outcome of pregnancy were studied prospectively in 54 persistently HIV-1-seronegative women and compared with those in matched HIV-1-seronegative women from the general population coming for routine antenatal checkups. RESULTS: In the 54 seronegative women (study group) who became pregnant, there were 52 singleton, term vaginal deliveries and two emergency cesarean sections for fetal distress. All 54 infants had negative viral cultures for HIV-1 at birth. The women remained seronegative throughout pregnancy, as did the control group. All 54 infants were breast-fed and remained well. CONCLUSION: A small proportion of highly exposed individuals may have natural protective immunity to HIV, may be resistant to HIV-1 and may have successful outcomes of pregnancy.