Shock Index in the Prediction of Adverse Maternal Outcome.

INTRODUCTION: WHO states that obstetric hemorrhage, hypertensive disorders of pregnancy and sepsis account for approximately 50% of maternal deaths worldwide. All these conditions are associated with changes in vital signs including blood pressure (BP) and heart rate (HR). Shock index (SI) is the ratio of HR to systolic BP. AIMS AND OBJECTIVES: To evaluate role of shock index as an early indicator of adverse maternal outcomes and to determine the threshold points of SI for five adverse maternal outcomes. METHODOLOGY: This was a prospective observational study on 1004 consecutively enrolled subjects presenting in labor. Vital signs and Shock Index were recorded. SI thresholds were analyzed with respect to obstetric complications and adverse outcomes. Parametric tests such as Chi-square, comparison of proportions, comparison of mean and ROC curve analysis were applied on the data. RESULTS: The mean SI value in the vaginal delivery group was 1.02 ± 0.26 and it was 0.95 ± 0.033 in the caesarean delivery group. The values of SI ((Mean and SD) for ICU admission were (1.23 (± 0.35)), for (MODS) it was (1.47 (± 0.84)), for blood transfusion > 4 units it was (1.15 (± 0.41)), for surgical intervention it was (1.58 (± 0.51)) and for maternal death (1.39 (± 0.85)). SI ≥ 1.4, had sensitivity 26.82% (21.09-33.19); specificity 100%(99.53-100), PPV was 100% and NPV was 82.96%(81.8-84.06)with an AUC of 0.8 (0.78-0.83) on ROC analysis. In subjects with PIH/eclampsia, SI was lower and in patients with severe anemia, SI was higher. CONCLUSION: SI performed well as a screening tool in the prediction of adverse maternal outcomes. SI ≥ 0.9 was significantly associated with maternal adverse outcomes: ICU admission, MODS, surgical intervention, blood transfusion and death. The study proposes an SI cut-off of 0.9 for referral and a cut-off of 1.1 for intervention in a tertiary care hospital. Patients with PIH/eclampsia tend to have lower mean SI values as compared to the rest of the study population, suggesting that SI may not be a reliable indicator in patients with PIH/eclampsia.

Comparison of Efficacy and Safety of Intravenous Labetalol Versus Hydralazine for Management of Severe Hypertension in Pregnancy.

BACKGROUND: There is no consensus about the better intravenous drug between Hydralazine and Labetalol to control hypertension in cases of severe hypertension in pregnancy. Both drugs have their own advantages and disadvantages. METHODS: This is a prospective randomized controlled trial comparing the efficacy and safety of intravenous Labetalol versus Hydralazine for management of severe hypertension in pregnancy. A total of 152 eligible subjects were randomised in two groups consisting 76 subjects each by envelope method. Both the groups were comparable with respect to systolic, diastolic and mean arterial blood pressure at admission. One group received Labetalol and the other Hydralazine. The number of drug doses, the time taken to achieve target blood pressure and side-effects were noted. RESULTS: With a single dose, Labetalol (81.5%) was able to achieve target blood pressure in a significantly higher number of cases as compared to Hydralazine (69.5%). Labetalol could help in achieving the target blood pressure faster than Hydralazine. The incidence of maternal adverse effects was comparable between the groups. Fetal outcome was comparable in both groups. CONCLUSION: Hydralazine and Labetalol both were found to be equally efficacious in reducing blood pressure in cases of severe hypertension in pregnancy. Labetalol achieved the target blood pressure faster than Hydralazine. The adverse effects of both the drugs were comparable.

Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems.

BACKGROUND: Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient's preexisting demographic and clinical factors. OBJECTIVE: To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC. METHODS: Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria. RESULTS: A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%. CONCLUSION: Both prediction models, the FLAMM and the "close to delivery" nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

Comparison of Cervical Length Measured by Transvaginal Ultrasonography and Bishop Score in Predicting Response to Labor Induction.

Background: This study aims to compare the value of the Bishop score and cervical length measurement by transvaginal ultrasonography in predicting active labor within 6 h, induction-to-delivery interval, and the duration of active labor and to estimate the most useful cutoff points for the two methods. Methods: This is a prospective comparative study of Bishop score and cervical length measured by transvaginal sonography on 62 nulliparous subjects who underwent induction of labor. Results: The Bishop score of the subjects ranged from two to seven (2-7). The mean Bishop in this study population was 4.37 + 1.23. The mean cervical length in this study was 25.59 + 6.07. Bishop score was highly significant (P value < 0.0001) in predicting active phase of labor as compared to cervical length (P = 0.004). The best cutoff value for Bishop score to predict induction of labor within 6 h was more than 4 with sensitivity of 69% and specificity of 79%. Similarly, best cutoff value for cervical length to predict induction of labor within 6 h was less than or equal to 25 mm with sensitivity of 51% and specificity of 70%. Bishop score was more significant (P = 0.001) in predicting induction-to-delivery interval within 12 h as compared to cervical length (P = 0.01). Conclusion: The Bishop score was superior in predicting the response to induction as compared to the cervical length measured by transvaginal ultrasonography.