Maternal antenatal profile and immediate neonatal outcome in VLBW and ELBW babies
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《美国医学杂志》
1 Department of Pediatrics, All India Institute of Medical Science, New Delhi, India
2 Department of Obst. and Gynce, All India Institute of Medical Science, New Delhi, India
Abstract
Objective. To evaluate the antenatal profile of the mother and the immediate neonatal morbidity and mortality till discharge. Methods. The study was a retrospective analysis of 92 patients of preterm labour who delivered babies weighing < 1500 gms at 26 weeks to 34 weeks of gestation. The maternal demographic profile, causes of preterm labour, treatment profile and delivery outcome were recorded. Similarly, the immediate neonatal morbidity and mortality were recorded in our case file. Both these data of maternal and neonatal profile were pooled and analysed. Results. A total of 92 mothers in preterm labour at 26 to 34 weeks were admitted and subsequently delivered 70 VLBW babies (<1500 gms) and 36 ELBW babies (<1000 gms) including 8 pairs of twins and 3 triplets pregnancies. Majority of the patients (93.4%) were booked. Amongst the various high risk factors for preterm labour, anaemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and pervious history of preterm labour (18.4%) were common associations. Calcium channel blocker (Depin) tocolysis was effective in postponing labour from 48 hours to more than 2 weeks. The cesarean section rate was very high (67.3%) in our study. The commoner neonatal complications in both VLBW and ELBW babies were RDS, neonatal jaundice and sepsis. Features of IUGR were seen in both the groups (22.8% in VLBW and 22.2% in ELBW babies). The neonatal mortality rate till discharge was 15.7% in VLBW group and 33.3% in ELBW group. The morality rate was highest in 26 to 30 weeks gestation babies and in babies weighing <800 gms. Conclusion. Antenatal profile of preterm labour in our series showed a number of high risk factors. The identification of common high risk factors is important for appropriate prenatal care. A better neonatal survival rate was possible due to timely intervention, appropriate management and NICU care facility available in our tertiary care centre.
Keywords: Antenatal profile; Preterm labour; VLBW, ELBW
Preterm birth is one of the major clinical problems in obstetrics and neonatology as it is associated with perinatal mortality, serious neonatal morbidity and in some cases childhood disability. It is reported that 60-80% of all neonatal mortality and morbidity is due to preterm birth.[1] During the last two decades the survival for premature infants has significantly increased due to advancement in perinatal and neonatal treatment expertise and improvement in the care of high-risk mother. The survival rate of lower birth weight infant is reported to have increased from 10% to 50-60%.[2],[3] The survivors of preterm birth especially when born at <34 weeks of gestation require to remain in newborn intensive care unit (NICU). They need to spend time in NICU till close to term to allow for sufficient multi-organ maturation resulting in prolonged hospital stay for both mother and infant. Therefore, the consequence of preterm birth often continue beyond the neonatal period and can lead to significant direct and indirect costs that have to be borne by parents and society. Hence, a better understanding of maternal antenatal factors contributing to preterm birth and need for improvement of perinatal care are necessary to increase the neonatal survival.
Here we present this retrospective study of maternal antenatal profile and immediate neonatal outcome of very low birth weight (<1500 gm) and extremely low birth weight (<1000 gm) babies.
Material and Methods
This retrospective study was conducted in our unit III of department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi for a period of 4 years from January 2001 to January 2005. This centre is the apex tertiary centre, caters to mainly high-risk pregnant mothers from all over the country and is equipped to handle any complication of labor. The NICU is well equipped for mechanical ventilation, surfactant treatment, parenteral nutrition and has all the facilities to handle preterm babies. All pregnant mothers with documented preterm labour from 26 weeks to 34 weeks period of gestation were admitted in the hospital and then followed up till delivery. The neonates of these mothers who delivered at or before 34 weeks were followed up till the mother was discharged along with the baby from the hospital. The detailed case record of the mother and daily baby record entered by our residents were reviewed. The maternal details like demographic profile, antenatal profile, medical complications during pregnancy, antepartum hemorrhage, definite cause of preterm labour if any, treatment profile, intranatal care and delivery outcome were collected. Similarly, detailed neonatal records entered in the maternal records were collected and analyzed. The neonatal profile of VLBW (<1500 gm) and ELBW (<1000 gm) babies like gestational age, asphyxia requiring ventilitary support, surfactant treatment, culture proven sepsis, jaundice, retinopathy of prematurity, stay in NICU and total hospital stay were recorded.
Results
A total number of 92 mothers with preterm labour between 26 weeks and 34 weeks who subsequently delivered at or before 34 weeks and their babies weighing upto 1500 gm were included in the study. Eighty-six patients were booked and 6 patients were unbooked. In our study, out of 92 patients, 63 were primigravida and 29 were mutligravida. The age of the patient ranged from 17 to 37 years with a mean of 26.2 years. There were 11 patients in the teenage group. In a majority of patients (n - 52) the family income was >Rs. 10,000 per month, in 29 patients it was >Rs. 7,000 but 28 to 30 weeks of gestation, 37 patients between >30 weeks to 32 weeks and 15 patients presented at >32 to 34 weeks of gestation. There was associated preterm premature rupture of membranes in 14 patients.
Amongst various maternal risk factors anemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and previous history of preterm delivery (15.2%) were common associations followed by UTI with pyelonephritis (13%), Rh-isoimmunisation (13%), multiple pregnancy (11.9%) heart disease (10.8%), uncontrolled diabetes (9.7%) and antepartum hemorrhage (9.7%). Other less common risk factors seen in our patients were history of first trimester bleeding, history of one or two second trimester spontaneous or induced abortion, intrauterine infection, malnutrition, smoking, congenital malformation of uterus, previous myomectomy, stress and alcohol intake. In 22 (23.9%) cases no obvious cause or risk factor was found. Out of the 92 patients admitted, medical and surgical treatment could be given in 52 patients and the rest of the patients (n-40) delivered within 18 hours after admission. In all 52 patients calcium channel blocker (Depin with a loading dose of 30 mg followed by 10 mg 4 - 8 hrly) were given. The number of patients and the time duration for which pregnancy could be prolonged by Depin tocolysis is given in table1. Two doses of betamethasone (12.5 mg each) 24 hours apart could be given in 40 patients and one dose of betamethasone (12.5 mg) could be given to another 12 patients who delivered within 24 hours.
Labor was induced at 32 to 34 weeks of gestation in 11 cases due to severe PIH and eclampsia. . The fetal indication for premature induction was poor biophysical profile (Manning score = 4) in 5 cases and IUGR with oligohydramnios in 3 cases. There were 30 patients who delivered vaginally, out of which liberal episiotomy was made in 25 cases and 5 cases were delivered without episiotomy. Sixty-two patients were delivered by cesarean section and the commonest indications for cesarean section (CS) was failure of medical treatment with depin tocolysis and extreme prematurity followed by fetal distress in 10 cases. Other indications of CS were breech presentation in 7 cases, severe pre-eclampsia in 5 cases, eclampsia in 3 cases and severe IUGR in 3 cases. The total number of deliveries in each weight and gestational age groups and corresponding mortality are given in table2.
The mean gestational age in ELBW group and VLBW group was 28.9 ± 1.1 weeks and 32 ± 1.8 weeks respectively. In the ELBW group 12 babies (33.3%) died where birth weight was ranging from < 800 gms to 926 gms. In the VLBW group 11 babies (15.7%) who died were weighing < 1200 gms at birth. The overall mortality rate was found to be significantly higher in boys (26.7%) than the girls (16%). All the babies who survived in both VLBW and ELBW group were admitted in NICU for supportive treatment. There were 30 (83.3%) babies in ELBW group and 28 (40%) babies in VLBW group who needed ventilitary support. Intratracheal surfactant treatment was given by the pediatrician in 4 babies in ELBW and 6 babies in VLBWgroup. Intratracheal surfactant could not be given when required in the rest of the babies due to financial reason. The various conditions recorded in our case sheets of both ELBW and VLBW neonates till discharge are given in table3.
The common complications seen in both the groups were neonatal jaundice (47.2% in ELBW and 24.2% in VLBW babies) and RDS (38.8% in ELBW and 17.1% in VLBW babies). The incidence of RDS was found to be lower (6 out of 40) where 2 doses of betamethasone could be given. The other common complications found in both the groups were culture proven sepsis, birth asphyxia and retinopathy of prematurity. The association of IUGR was similar in both the groups (22.2% in ELBW vs 22.8% in VLBW).
Discussion
Preterm delivery is defined as delivery before 37 weeks gestation or before 259 days according to world health organisation.[4] Preterm deliveries of babies weighing less than 1500 gms (VLBW) and particularly less than 1000 gms (ELBW) are of major concern because of maximum perinatal morbidity and mortality found in this group.[5],[6],[7],[8] The retrospective analysis of maternal antenatal profile in our study represent the various high risk factors responsible for preterm deliveries of VLBW and ELBW babies. Anemia during pregnancy was found to be the commonest association in preterm labour in our study and it was present in 32.6% of cases. In another similar study it was found that 65% of patient of preterm labour had anemia.[5] Culture proven bacterial vaginosis by high vaginal swab culture was found in 26.1% of cases in our series and was the second commonest cause of preterm labor. This is found to be one of the common cause of preterm labor in other studies and like in our study anerobic organisms were found to be the commonest[9],[10]. Similar to other studies, we found gestational hypertension, previous preterm delivery; multiple pregnancy and heart disease were other common associations with preterm labour.[5],[11],[12] There is a strong association between preterm labor and antepartum hemorrhage reported in various studies.[11],[12],[13] In one study, Harger et al found vaginal bleeding in any trimester as an important marker of preterm premature rupture of fetal membrane.[13] It was proposed that abruptio placente may account for both the vaginal bleeding and uterine irritability and intrauterine pressure. We found in our series 18.5% patient had first trimester and third trimester bleeding. History of previous preterm birth is the most important predictor of the likelihood of preterm delivery in the multiparous women.[14],[15] In our study out of 29 multiparous women 14 patients (48.2%) had previous history of preterm delivery. This finding was consistent with previous studies.[15],[16] It has been also reported that with a history of one or more spontaneous abortion the risk of preterm birth increases.[13],[17],[18] The risk of preterm delivery also found to be increased with history of induced abortion.[19] In our study, we could find more than one spontaneous abortion in the second trimester in 10 patients. Another common association in preterm delivery in our study was heart disease. We noted heart disease as the only factor in 10 patients. Similar to earlier studies,[5], [20] we observed malnutrition (in 7 cases), smoking (in 7 cases) and stress (domestic violence in 4 cases) associated with preterm labor. Though different modes of medical and surgical intervention were tried to postpone delivery in various studies, we found tocolysis by calcium channel blocker (Depin) effective in postponing labor from 48 hours to more than 2 weeks. The incidence of LSCS was very high (67.3%) in our series as the common indications were extreme prematurity where medical or surgical treatment failed. This is similar to earlier observation[21].
The outcome of both ELBW and VLBW babies depends on many factors like optimization of neonatal care, better knowledge of the pathophysiology of the premature infant, advent of exogenous surfactant therapy and neonatal intensive care unit to handle sick infants. The survival rate in VLBW group was 84.2% and this was better than the survival rate in ELBW group (69.2%). There is a wide variability in survival rate as reported in different centres[5],[21],[22]. This is due to difference in patient population, antenatal care, intranatal care, aggressive neonatal care and availability of NICU facilities. In our series, the survival rate was better in both VLBW and ELBW group compared to other studies in Indian set up[5],[21]. Most of the death occurred within 7 days after delivery in contrast to other studies[5],[23], where half the deaths took place within 72 hours. In our series, survival rate was better in girls than boys. Similar gender difference favoring girls with improved survival was seen in another study[24]. This is in contrast to one study[5] which showed better survival rate in boys. The survival rate (50%) at < 28 weeks increased to (82.6%) at more than 28 weeks gestation in our series. It was also found that the birth weight was higher in the survival group. These were similar to earlier studies[2],[5],[16]. The expected neonatal complications were observed in both ELBW and VLBW group in our study. The incidence of RDS (38.8% in ELBW group and 17.1% in VLBW group) and neonatal jaundice (47.2% in ELBW and 24.2% in VLBW group) were comparable to earlier study[5]. There were almost similar incidence of IUGR in VLBW (22.8%) and ELBW (22.2%) babies. The IUGR babies in the VLBW group survived better as they had matured organs and better tolerated to withstand the transition from intrauterine to extrauterine life. These findings were similar to other study.[2],[5] In all 40 mothers who could receive 2 doses of betamethosone the incidence of HMD in babies were much less (6 out of 40). This findings was similar to previous study[5]. All 10 babies (4 babies in ELBW group and 6 babies in VLBW group) who received surfactant survived though 2 babies in the ELBW group developed RDS inspite of surfactant. These 2 babies had birth weight less than 800 gms. Limited use of surfactant in our series was due to cost factor. Major causes of mortality in our series in both the groups were RDS, pulmonary hemorrhage, intracerebral hemorrhage (ICH) and sepsis similar to earlier studies. We observed culture proven sepsis in 28.2% babies and maternal sepsis in the form of bacterial vaginosis was present in 32.2% of mothers. This was comparable to other studies where incidence of sepsis ranged from 20-30%[5],[9]. In our study there were 30 (83.3%) babies in ELBW group and 28 (40%) babies in VLBW group who needed ventilitary support immediately or in subsequent days in NICU. This clearly reflects that NICU ventilitary support facility is one of the major contributory factors for neonatal survival in both the groups. Similar to other studies we found birth asphyxia, patent ductus arteriosus, intra ventricular hemorrhage and retinopathy of prematurity (ROP).[3],[5],[25] as other complications in both ELBW and VLBW groups. The mean duration of total hospital stay was less in our series compared to other study in Indian set up.[5],[21] In our series, the comparatively less hospital stay was due to effective management in NICU and earlier handing over of babies to mothers in the ward.
Conclusion
We found anemia during pregnancy, maternal sepsis, previous history of preterm deliveries, multiple pregnancies, antepartum hemorrhage and previous history of abortion were common associations with preterm delivery. Some of these risk factors may be remediable if adequate antenatal care and timely medical intervention is done. The better neonatal survival rate and lesser complications in our series compared to earlier studies in India were possible due to timely antenatal intervention at tertiary care level, provision of good NICU facilities and available surfactant treatment in some of the babies.
References
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2. Brothwood M, worke D, Gamsu H, Cooper D. Mortality, mobidity, growth and development of babies weighing 501 - 1001 grams and 1001 - 1500 grams at birth. Acta Pediatr Scand 1988; 77 : 10-18.
3. Rogowsk JA, Horbar, J.D. Staiger D.O. Indirect vs direct hospital quality indicators for very low birth weight infants. JAMA 2004; 291 (2) : 202-209.
4. World Health Organization. The prevention of perinatal mortality and morbidity. Geneva, Switzerland WHO Technical report series report 457: 1970.
5. Sehgal A, Telang S, Passah S M, Jyothi M C Maternal and neonatal profile and immediate outcome in ELBW babies. Pediatrics 2003; 40 : 991-995.
6. Horbar JD, Badger GJ, Carpenter JH, Fauoroff AA, Kilpatrick S, Lacorte M, Phibbs R et al. Trends in mortality and morbidity for very low birth weight babies, 1991-1999. Pediatric 2002; 110 : 143-151.
7. Kaiser JR, Tiford JM, Simpson PM, Salhal WA, Rosenfeld CR Hospital survival of very low birth weight neonates from 1977 to 2000. J Perinatol 2004; 24 (6): 343-350.
8. Saigal S., Rosenboum P, Stoskopf B, Sinefair JC. Out come in infants 501-1000 gm birth weight delivered to the residents of the MC Masters health region. J Pediatric 1989; 105 : 969-976.
9. Pastore LM, King TS, Dawson IJ, Hollifeld A, Thorp JM Jr. Prospective validation of a perinatal bacterial vaginosis screening risk score. J Perinatol 2004; 24: 735-742.
10. Hiller SL, Nugent RP, Eschenliach DA, Krohn RS, Gibbs RS, Martin DH et al. Association of bacterial vaginosis and preterm delivery of a low birth weight infant. N Engl J Med 1995; 333: 1737-1742.
11. Assessment of risk factors for preterm birth - ACOG practice bulletin American College of Obstetrics and Gynaecologist. Obstet Gynaecol 2001; 98: 709-716.
12. Karmar MS. Determinants of low birth weight - Methodological assessment and meta analysis. Bull WHO 1987; 65: 663-667.
13. Harger JH, Hsing AW, Tuomala RE, Gibbs RS, Mead PB, Eschenbach DA et al. Risk Factors for preterm premature rupture of fetal membrane - A multicetnre case control study. Am J Obstet Gynaecol 1990; 163: 130-137.
14. Steer PJ. Premature labour. Arch Dis Child 1991; 66: 1167-1170.
15. Muller Heubach E, Guzick DS. Evaluation of risk scoring in a preterm birth prevention study of indigent patients. Am J Obstet Gynaecol 1989; 160: 829-837.
16. Youssef A, Eissa AI, Hassan S. Ba'Aqeel. Risk factors for spontaneous preterm birth in a Saudi Population. European J Obstet & Gynaecol and Reprod Biolo 1994; 57: 19-24.
17. De Haas I, Harlow BL, Cramer DW, Frigoletoo FD. Spontaneous preterm birth : A case control study. Am J Obstet Gynaecol 1991; 165 : 1290-1296.
18. Carr Hill RA, Hall MH. The repetition of spontaneous labour. Br J Obstet Gynaecol 1985; 92: 921-928.
19. Ancel PV, Lelong N, Papiernik E, Saurel Cubizolles MJ, Kaminski M. History of induced abortion as a risk factor for preterm birth: results of European survey. Human Reprod 2004; 19(3); 734-740.
20. Moutquin J M. Classification and heterogeneity of preterm birth. Br J Obstet Gynaecol 2003; 110 : 30-33.
21. Das C, Das CS. Morbidity and mortality pattern in level II neonatal care unit in Silchar (
Abstract) Annual conference of National Neonatology Forum Guwahati NNF 2001: 72.
22. Shankaran S, Fanaroff AA Wright LL, Stevenson DL, Donovan FF, Ehrenkranz RA et al. Risk factors for early death among extremely low birth weight infants. Am J Obstet Gynaecol 2002; 186 (4) : 796-802.
23. Sehgal A, Roy MS, Dubey NK, Jyothi MC. Factors contributing to mortality in newborns delivered outside and referred to a teaching hospital. Indian Pediatr 2000; 46 : 335-337.
24. Lipin TR, Jackson C, Benett FC, outcome of infants weighing less than 800 grams at birth. Pediatric 1995; 96 : 479-483.
25. Nair MC, Ganesh A, Mitra S, Ganguly SS. Retinopathy of prematurity in VLBW and extreme LBW babies. Indian J Pediatr 2003; 70(4) : 303-306.(Roy KK, Baruah Jinee, Kum)
2 Department of Obst. and Gynce, All India Institute of Medical Science, New Delhi, India
Abstract
Objective. To evaluate the antenatal profile of the mother and the immediate neonatal morbidity and mortality till discharge. Methods. The study was a retrospective analysis of 92 patients of preterm labour who delivered babies weighing < 1500 gms at 26 weeks to 34 weeks of gestation. The maternal demographic profile, causes of preterm labour, treatment profile and delivery outcome were recorded. Similarly, the immediate neonatal morbidity and mortality were recorded in our case file. Both these data of maternal and neonatal profile were pooled and analysed. Results. A total of 92 mothers in preterm labour at 26 to 34 weeks were admitted and subsequently delivered 70 VLBW babies (<1500 gms) and 36 ELBW babies (<1000 gms) including 8 pairs of twins and 3 triplets pregnancies. Majority of the patients (93.4%) were booked. Amongst the various high risk factors for preterm labour, anaemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and pervious history of preterm labour (18.4%) were common associations. Calcium channel blocker (Depin) tocolysis was effective in postponing labour from 48 hours to more than 2 weeks. The cesarean section rate was very high (67.3%) in our study. The commoner neonatal complications in both VLBW and ELBW babies were RDS, neonatal jaundice and sepsis. Features of IUGR were seen in both the groups (22.8% in VLBW and 22.2% in ELBW babies). The neonatal mortality rate till discharge was 15.7% in VLBW group and 33.3% in ELBW group. The morality rate was highest in 26 to 30 weeks gestation babies and in babies weighing <800 gms. Conclusion. Antenatal profile of preterm labour in our series showed a number of high risk factors. The identification of common high risk factors is important for appropriate prenatal care. A better neonatal survival rate was possible due to timely intervention, appropriate management and NICU care facility available in our tertiary care centre.
Keywords: Antenatal profile; Preterm labour; VLBW, ELBW
Preterm birth is one of the major clinical problems in obstetrics and neonatology as it is associated with perinatal mortality, serious neonatal morbidity and in some cases childhood disability. It is reported that 60-80% of all neonatal mortality and morbidity is due to preterm birth.[1] During the last two decades the survival for premature infants has significantly increased due to advancement in perinatal and neonatal treatment expertise and improvement in the care of high-risk mother. The survival rate of lower birth weight infant is reported to have increased from 10% to 50-60%.[2],[3] The survivors of preterm birth especially when born at <34 weeks of gestation require to remain in newborn intensive care unit (NICU). They need to spend time in NICU till close to term to allow for sufficient multi-organ maturation resulting in prolonged hospital stay for both mother and infant. Therefore, the consequence of preterm birth often continue beyond the neonatal period and can lead to significant direct and indirect costs that have to be borne by parents and society. Hence, a better understanding of maternal antenatal factors contributing to preterm birth and need for improvement of perinatal care are necessary to increase the neonatal survival.
Here we present this retrospective study of maternal antenatal profile and immediate neonatal outcome of very low birth weight (<1500 gm) and extremely low birth weight (<1000 gm) babies.
Material and Methods
This retrospective study was conducted in our unit III of department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi for a period of 4 years from January 2001 to January 2005. This centre is the apex tertiary centre, caters to mainly high-risk pregnant mothers from all over the country and is equipped to handle any complication of labor. The NICU is well equipped for mechanical ventilation, surfactant treatment, parenteral nutrition and has all the facilities to handle preterm babies. All pregnant mothers with documented preterm labour from 26 weeks to 34 weeks period of gestation were admitted in the hospital and then followed up till delivery. The neonates of these mothers who delivered at or before 34 weeks were followed up till the mother was discharged along with the baby from the hospital. The detailed case record of the mother and daily baby record entered by our residents were reviewed. The maternal details like demographic profile, antenatal profile, medical complications during pregnancy, antepartum hemorrhage, definite cause of preterm labour if any, treatment profile, intranatal care and delivery outcome were collected. Similarly, detailed neonatal records entered in the maternal records were collected and analyzed. The neonatal profile of VLBW (<1500 gm) and ELBW (<1000 gm) babies like gestational age, asphyxia requiring ventilitary support, surfactant treatment, culture proven sepsis, jaundice, retinopathy of prematurity, stay in NICU and total hospital stay were recorded.
Results
A total number of 92 mothers with preterm labour between 26 weeks and 34 weeks who subsequently delivered at or before 34 weeks and their babies weighing upto 1500 gm were included in the study. Eighty-six patients were booked and 6 patients were unbooked. In our study, out of 92 patients, 63 were primigravida and 29 were mutligravida. The age of the patient ranged from 17 to 37 years with a mean of 26.2 years. There were 11 patients in the teenage group. In a majority of patients (n - 52) the family income was >Rs. 10,000 per month, in 29 patients it was >Rs. 7,000 but 28 to 30 weeks of gestation, 37 patients between >30 weeks to 32 weeks and 15 patients presented at >32 to 34 weeks of gestation. There was associated preterm premature rupture of membranes in 14 patients.
Amongst various maternal risk factors anemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and previous history of preterm delivery (15.2%) were common associations followed by UTI with pyelonephritis (13%), Rh-isoimmunisation (13%), multiple pregnancy (11.9%) heart disease (10.8%), uncontrolled diabetes (9.7%) and antepartum hemorrhage (9.7%). Other less common risk factors seen in our patients were history of first trimester bleeding, history of one or two second trimester spontaneous or induced abortion, intrauterine infection, malnutrition, smoking, congenital malformation of uterus, previous myomectomy, stress and alcohol intake. In 22 (23.9%) cases no obvious cause or risk factor was found. Out of the 92 patients admitted, medical and surgical treatment could be given in 52 patients and the rest of the patients (n-40) delivered within 18 hours after admission. In all 52 patients calcium channel blocker (Depin with a loading dose of 30 mg followed by 10 mg 4 - 8 hrly) were given. The number of patients and the time duration for which pregnancy could be prolonged by Depin tocolysis is given in table1. Two doses of betamethasone (12.5 mg each) 24 hours apart could be given in 40 patients and one dose of betamethasone (12.5 mg) could be given to another 12 patients who delivered within 24 hours.
Labor was induced at 32 to 34 weeks of gestation in 11 cases due to severe PIH and eclampsia. . The fetal indication for premature induction was poor biophysical profile (Manning score = 4) in 5 cases and IUGR with oligohydramnios in 3 cases. There were 30 patients who delivered vaginally, out of which liberal episiotomy was made in 25 cases and 5 cases were delivered without episiotomy. Sixty-two patients were delivered by cesarean section and the commonest indications for cesarean section (CS) was failure of medical treatment with depin tocolysis and extreme prematurity followed by fetal distress in 10 cases. Other indications of CS were breech presentation in 7 cases, severe pre-eclampsia in 5 cases, eclampsia in 3 cases and severe IUGR in 3 cases. The total number of deliveries in each weight and gestational age groups and corresponding mortality are given in table2.
The mean gestational age in ELBW group and VLBW group was 28.9 ± 1.1 weeks and 32 ± 1.8 weeks respectively. In the ELBW group 12 babies (33.3%) died where birth weight was ranging from < 800 gms to 926 gms. In the VLBW group 11 babies (15.7%) who died were weighing < 1200 gms at birth. The overall mortality rate was found to be significantly higher in boys (26.7%) than the girls (16%). All the babies who survived in both VLBW and ELBW group were admitted in NICU for supportive treatment. There were 30 (83.3%) babies in ELBW group and 28 (40%) babies in VLBW group who needed ventilitary support. Intratracheal surfactant treatment was given by the pediatrician in 4 babies in ELBW and 6 babies in VLBWgroup. Intratracheal surfactant could not be given when required in the rest of the babies due to financial reason. The various conditions recorded in our case sheets of both ELBW and VLBW neonates till discharge are given in table3.
The common complications seen in both the groups were neonatal jaundice (47.2% in ELBW and 24.2% in VLBW babies) and RDS (38.8% in ELBW and 17.1% in VLBW babies). The incidence of RDS was found to be lower (6 out of 40) where 2 doses of betamethasone could be given. The other common complications found in both the groups were culture proven sepsis, birth asphyxia and retinopathy of prematurity. The association of IUGR was similar in both the groups (22.2% in ELBW vs 22.8% in VLBW).
Discussion
Preterm delivery is defined as delivery before 37 weeks gestation or before 259 days according to world health organisation.[4] Preterm deliveries of babies weighing less than 1500 gms (VLBW) and particularly less than 1000 gms (ELBW) are of major concern because of maximum perinatal morbidity and mortality found in this group.[5],[6],[7],[8] The retrospective analysis of maternal antenatal profile in our study represent the various high risk factors responsible for preterm deliveries of VLBW and ELBW babies. Anemia during pregnancy was found to be the commonest association in preterm labour in our study and it was present in 32.6% of cases. In another similar study it was found that 65% of patient of preterm labour had anemia.[5] Culture proven bacterial vaginosis by high vaginal swab culture was found in 26.1% of cases in our series and was the second commonest cause of preterm labor. This is found to be one of the common cause of preterm labor in other studies and like in our study anerobic organisms were found to be the commonest[9],[10]. Similar to other studies, we found gestational hypertension, previous preterm delivery; multiple pregnancy and heart disease were other common associations with preterm labour.[5],[11],[12] There is a strong association between preterm labor and antepartum hemorrhage reported in various studies.[11],[12],[13] In one study, Harger et al found vaginal bleeding in any trimester as an important marker of preterm premature rupture of fetal membrane.[13] It was proposed that abruptio placente may account for both the vaginal bleeding and uterine irritability and intrauterine pressure. We found in our series 18.5% patient had first trimester and third trimester bleeding. History of previous preterm birth is the most important predictor of the likelihood of preterm delivery in the multiparous women.[14],[15] In our study out of 29 multiparous women 14 patients (48.2%) had previous history of preterm delivery. This finding was consistent with previous studies.[15],[16] It has been also reported that with a history of one or more spontaneous abortion the risk of preterm birth increases.[13],[17],[18] The risk of preterm delivery also found to be increased with history of induced abortion.[19] In our study, we could find more than one spontaneous abortion in the second trimester in 10 patients. Another common association in preterm delivery in our study was heart disease. We noted heart disease as the only factor in 10 patients. Similar to earlier studies,[5], [20] we observed malnutrition (in 7 cases), smoking (in 7 cases) and stress (domestic violence in 4 cases) associated with preterm labor. Though different modes of medical and surgical intervention were tried to postpone delivery in various studies, we found tocolysis by calcium channel blocker (Depin) effective in postponing labor from 48 hours to more than 2 weeks. The incidence of LSCS was very high (67.3%) in our series as the common indications were extreme prematurity where medical or surgical treatment failed. This is similar to earlier observation[21].
The outcome of both ELBW and VLBW babies depends on many factors like optimization of neonatal care, better knowledge of the pathophysiology of the premature infant, advent of exogenous surfactant therapy and neonatal intensive care unit to handle sick infants. The survival rate in VLBW group was 84.2% and this was better than the survival rate in ELBW group (69.2%). There is a wide variability in survival rate as reported in different centres[5],[21],[22]. This is due to difference in patient population, antenatal care, intranatal care, aggressive neonatal care and availability of NICU facilities. In our series, the survival rate was better in both VLBW and ELBW group compared to other studies in Indian set up[5],[21]. Most of the death occurred within 7 days after delivery in contrast to other studies[5],[23], where half the deaths took place within 72 hours. In our series, survival rate was better in girls than boys. Similar gender difference favoring girls with improved survival was seen in another study[24]. This is in contrast to one study[5] which showed better survival rate in boys. The survival rate (50%) at < 28 weeks increased to (82.6%) at more than 28 weeks gestation in our series. It was also found that the birth weight was higher in the survival group. These were similar to earlier studies[2],[5],[16]. The expected neonatal complications were observed in both ELBW and VLBW group in our study. The incidence of RDS (38.8% in ELBW group and 17.1% in VLBW group) and neonatal jaundice (47.2% in ELBW and 24.2% in VLBW group) were comparable to earlier study[5]. There were almost similar incidence of IUGR in VLBW (22.8%) and ELBW (22.2%) babies. The IUGR babies in the VLBW group survived better as they had matured organs and better tolerated to withstand the transition from intrauterine to extrauterine life. These findings were similar to other study.[2],[5] In all 40 mothers who could receive 2 doses of betamethosone the incidence of HMD in babies were much less (6 out of 40). This findings was similar to previous study[5]. All 10 babies (4 babies in ELBW group and 6 babies in VLBW group) who received surfactant survived though 2 babies in the ELBW group developed RDS inspite of surfactant. These 2 babies had birth weight less than 800 gms. Limited use of surfactant in our series was due to cost factor. Major causes of mortality in our series in both the groups were RDS, pulmonary hemorrhage, intracerebral hemorrhage (ICH) and sepsis similar to earlier studies. We observed culture proven sepsis in 28.2% babies and maternal sepsis in the form of bacterial vaginosis was present in 32.2% of mothers. This was comparable to other studies where incidence of sepsis ranged from 20-30%[5],[9]. In our study there were 30 (83.3%) babies in ELBW group and 28 (40%) babies in VLBW group who needed ventilitary support immediately or in subsequent days in NICU. This clearly reflects that NICU ventilitary support facility is one of the major contributory factors for neonatal survival in both the groups. Similar to other studies we found birth asphyxia, patent ductus arteriosus, intra ventricular hemorrhage and retinopathy of prematurity (ROP).[3],[5],[25] as other complications in both ELBW and VLBW groups. The mean duration of total hospital stay was less in our series compared to other study in Indian set up.[5],[21] In our series, the comparatively less hospital stay was due to effective management in NICU and earlier handing over of babies to mothers in the ward.
Conclusion
We found anemia during pregnancy, maternal sepsis, previous history of preterm deliveries, multiple pregnancies, antepartum hemorrhage and previous history of abortion were common associations with preterm delivery. Some of these risk factors may be remediable if adequate antenatal care and timely medical intervention is done. The better neonatal survival rate and lesser complications in our series compared to earlier studies in India were possible due to timely antenatal intervention at tertiary care level, provision of good NICU facilities and available surfactant treatment in some of the babies.
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