A Dissertation on COMPARISON OF MIFEPRISTONE WITH FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY Dissertation submitted to THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY CHENNAI-600032 With partial fulfillment of the requirements for the award of M.S.DEGREE IN OBSTETRICS AND GYNAECOLOGY (BRANCH VI) Reg No:221716303 COIMBATORE MEDICAL COLLEGE, COIMBATORE MAY 2020 DECLARATION I Dr. DHIVYA.M. solemnly declare that the dissertation entitled “ COMPARISON OF MIFEPRISTONE WITH FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY” is a bonafide work done by me at Coimbatore Medical College Hospital during the year Jan 2018 to Dec 2018 under the supervision of Dr.RMANONMANI, M.D,D.G.O, Professor& Head of Department, Department of Obstetrics and Gynaecology, Coimbatore Medical College & Hospital. The dissertation is submitted to Dr.MGR Medical University towards partial fulfillment of requirement for the award of MS degree Obstetrics and Gynaecology. PLACE: Dr. DHIVYA.M DATE: CERTIFICATE This is to certify that the dissertation entitled “COMPARISON OF MIFEPRISTONE WITH FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY”is a bonafide original work done by Dr.DHIVYA.M.Post graduate student in the Department of OBSTETRICS AND GYNAECOLOGY , Coimbatore Medical College Hospital, Coimbatore under the guidance of Dr.R.MANONMANI (M.D,D.G.O), Professor and HOD of Department, Department of OBSTETRICS AND GYNAECOLOGY, Coimbatore Medical College Hospital, Coimbatore in partial fulfillment of the regulations for the Tamilnadu DR.M.G.R Medical University, Chennai towards the award of M.S., degree (Branch VI) in Obstetrics and Gynaecology. Date : GUIDE Dr.N.GEETHA, M.D.OG, Professor, Department of Obstetrics and Gynaecology, Coimbatore Medical College & Hospital. Date : Dr.R.MANONMANI, M.D,D.G.O, Professor & HOD, Department of Obsterics and Gynaecology, Coimbatore Medical College & Hospital. Date : Dr.B.ASOKAN, M.S., Mch., Dean, Coimbatore Medical College & Hospital, Coimbatore. COPYRIGHT Declaration by the Candidate I hereby declare that The Tamilnadu DR.M.G.R Medical University, Chennai shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/research purpose. PLACE: COIMBATORE Dr. DHIVYA.M DATE: PLAGIARISM CERTIFICATE This is to certify that this dissertation work titled "COMPARISON OF MIFEPRISTONE WITH FOLEY’S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY" of the candidate Dr.DHIVYA.M with registration number for the award of M.S.OBSTETRICS AND GYNAECOLOGY IN THE BRANCH VI. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and results shows 6 percentage of plagiarism in the dissertation. Signature of the Guide ACKNOWLEDGEMENT I solicit my humble thanks to the Dean Dr.B.Asokan, M.S., Mch.,Coimbatore Medical College Hospital, for allowing me to conduct the study in this hospital. I would like to express my gratitude and indebtness to our Prof and HOD, Dr.R.MANONMANI,M.D,D.G.O, Department of Obstertrics and Gynaecology for her motivation and support. I am also immensely thankful to my guide Prof. Dr.N.GEETHA,M.D,OG. Professor, Department of Obstetrics and Gynaecology for her invaluable guidance, motivation and help throughout the study. I express my earnest gratitude to all Professors, Department of Obstetrics and Gynaecology Dr. K.Murugalakshmi, M.D,D.G.O, Dr.Mohanasundari M.D,OG,Dr.P.Thilagavathy M.D,OG, without their help and guidance this work would not have been possible. I thank all my Assistant professors who helped me to accomplish my study. I owe a lot to my parents, my spouse Dr. D.Senthil kumar and other family members who have always been my pillar of support in all stages of my life. I thank my seniors and my fellow post graduate colleagues who have been of immense help throughout the study period. I am very grateful to all patients for their co-operation and participation in the study. CONTENTS SL.NO TITLES PAGE NO 1 INTRODUCTION 1 2 AIMS AND OBJECTIVES 3 3 4 REVIEW OF LITERATURE 4 THEORETICAL BACKGROUND 8 5 MATERIALS AND METHODS 63 6 OBSERVATION AND RESULTS 66 7 DISCUSSION 79 8 SUMMARY 81 9 CONCLUSION 83 10 BIBLIOGRAPHY 84 ANNEXURES 11 98 LIST OF TABLES SL.NO TABLES PAGE NO 1 Modified Bishop’s score 33 2 Distribution of Study Participants 66 3 Mean Age of the study group 68 4 Association of Parity with type of induction 69 Association between mode of delivery and 5 71 type of induction Association between induction –delivery 6 73 interval and type of induction Association between the neonatal outcome and 7 75 type of income Association between induction type and 8 77 incidence of PPH LIST OF CHARTS SL.No CHARTS PAGE No 1 Flow chart for management of post dated pregnancy 31 2 Distribution of study participants 67 3 Distribution of mean age of the study group 68 4 Association between parity and type of induction 70 Association between mode of delivery and type of 5 72 induction Association between duration of delivery and 6 74 induction type Association between neonatal outcome and induction 7 76 type Association between induction type and incidence of 8 78 PPH LIST OF FIGURES SL.NO FIGURE PAGE NO Formation Of Physiological And Pathological 1 12 Retraction Ring 2 Image showing Mechanism of Labour 14 3 FRIEDMAN’S curve for labour monitoring 16 4 Image showing Bag of membranes formation 17 5 Bearing down efforts and fetal expulsion 20 6 Placental seperation 22 7 Sweeping of membranes 35 8 Amniotomy 37 9 Synthesis of Prostaglandins 41 10 Mechanism of action of PGE2 43 11 Intracervical application of PGE2 44 12 Chemical structure of Mifepristone 46 13 Three dimensional image of Mifepristone 47 Mechanism of action of Mifepristone 48 14 15 Image of Foley’s catheter 52 Image showing cervical dilatation and 16 55 effacement 17 Image of a double balloon catheter 57 18 Insertion of double balloon catheter 58 19 Picture of Laminaria tent 59 20 Insertion of Laminaria tent 61 LIST OF ABBREVIATIONS ACOG American College of Obstetrics and Gynaecology ANC Antenatal clinic ARM Artificial rupture of membranes BMI Body Mass Index C/S Caeserean section CPD Cephalo-pelvic disproportion FIGO International Federation of Obstetrics and Gynaecology PGs Prostaglandins PGE1 Misoprostol PGE2 Dinoprostone RU 486 Mifepristone RCOG Royal College of Obstetricians and Gynaecologists WHO World Health Organization MLCK Myosin Light Chain Kinase LIST OF NOMENCLATURE Expected date of delivery(EDD)- 280 days or 40 completed weeks from the last menstrual period. Post-maturity: Post-maturity or Post-maturity Syndrome (PMS) can only be diagnosed after delivery and is defined as a post-dated pregnancy accompanied with any combination of the following newborn assessments a. No Lanugo ( fine body hair ) b. Long Nails c. Abundant Hair On Head d. Calcified Fetal Skull e. Hanging Or Wrinkled Skin, With The Appearance Of Weight Loss f. Dehydrated g. Alert Face h. Peeling Skin i. Little or No Vernix j. Oligohydramnios k. Meconium or bile staining of skin and long, thin growth retarded body with long thin limbs. Induction of labor: Artificial initiation of contractions in a pregnant woman who is not in labor to help her achieve a vaginal birth within 24 to 48 hours. Successful induction: A vaginal delivery within 24 to 48 hours of induction of labor. Elective induction: Induction of labor in the absence of acceptable fetal or maternal indications. Cervical ripening: Use of pharmacological or other methods to soften, efface, or dilate the cervix to increase the likelihood of a vaginal delivery. Tachysystole: More than 5 uterine contractions in 10 minute period averaged over 30 minutes. This is further subdivided into two categories, one with and one without fetal heart rate changes. Hypertonus: Excessive uterine contractions lasting more than 120 seconds without fetal heart rate changes. Hyperstimulation: Excessive uterine contractions (tachysystole or hypertonus) as a result of induction of labor with nonreassuring fetal heart rate changes Amniotomy: Artificial rupture of the membranes to initiate or speed up labor. Failed induction: Failure to achieve regular uterine contractions (every 3 minutes) after one cycle of completion of cervical ripening consisting of a) Insertion of three intracervical PGE2 gel (3gm) at 6-hourly intervals, and 12-24 hours of oxytocin administration after rupture of membranes, if feasible, or b) One PGE2 pessary (10 mg) within 24 hours. ABSTRACT TITLE: COMPARISON OF MIFEPRISTONE WITH FOLEY’S CATHETER FOR INDUCTION OF LABOR IN POST DATED PREGNANCY. BACKGROUND AND OBJECTIVES: Induction of labor is artificial initiation of uterine contractions before spontaneous onset of labor or after the period of viability of the fetus. Induction of labour is indicated when complications of pregnancy may have a negative impact on the health of the mother, fetus, or both. Induction of labour is therapeutic option when the benefits of the delivery outweigh the risks of continuing the pregnancy. Routine antenatal ultrasound for confirmation of EDD has been shown to reduce induction rates for post dated pregnancies after correction of dates. Prolonged pregnancy is known to be associated with significantly increased risks of perinatal and maternal complications. Induction of labour is planned for many indications.In this study induction of labour done for post dated pregnancies was taken into account.The purpose of this study is to compare the efficacy of mifepristone with foley’s catheter for induction of labour in post dated pregnancies.The drug have been chosen for the above study based on cost factor,safety profile and the results shown by previous studies.This will be of very use in future management of post dated pregnant woman planned for induction of labor.