Mokhtar Awang

A clinical evaluation of bleeding patterns, adverse effects, and satisfaction with the subdermal etonogestrel implant among postpartum and non-postpartum users

The etonogestrel implant (Implanon; Merck Sharp and Dohme, Kenilworth, NJ, USA) is an effective contraceptive with a good safety profile for up to 3 years [1]. However, its adverse effects include irregular vaginal bleeding (affecting 68.0% of users), weight gain (20.7%), acne (15.3%), breast pain (9.1%), and headache (8.5%) [2]. To provide further information about contraception options for women in the postpartum period, the aim of the present study was to investigate the bleeding patterns and adverse effects reported by women who underwent Implanon insertion within 8 weeks of delivery and compare them with those experienced by non-postpartum women. A prospective study was undertaken at Hospital Tengku Ampuan Afzan, Pahang, Malaysia, between July 1, 2010, and June 30, 2012. Women attending the postnatal clinic or family planning/gynecology clinic who met WHO medical eligibility criteria 1 and 2 (no medical restriction for use of contraception or advantages of using contraception outweigh the risks) [3] were enrolled. Nulliparous women and women who had last delivered 8 weeks to 6 months previously were excluded. The institutional ethical committee approved the study and informed consent was obtained from participants. Participants were divided into two groups. Women in the postpartum group had delivered up to 8 weeks previously and underwent Implanon insertion 4–8 weeks after delivery. Women in the non-postpartum group had last delivered at least 6 months previously and underwent Implanon insertion between day 1 and day 5 of menses. Baseline body weight was recorded for each participant. Follow-up visits were scheduled at 3 and 6 months. Bleeding patterns were categorized using the WHO 90-day reference period [4]. Non-menstrual adverse effects and satisfaction were recorded at 6 months. Data were analyzed using SPSS version 20.0 (IBM, Armonk, NY, USA). The Student t test and Fisher exact test were used to compare variables. P < 0.05 was considered statistically significant. A total of 110 women were included in the study, 60 in the postpartum group and 50 in the non-postpartum group. There were no differences in bleeding patterns between the groups at 3 months (Table 1). However, at 6 months, amenorrhea was significantly more common in the postpartum group than in the non-postpartum group (P = 0.005), and infrequent bleeding was more common in the non-postpartum group (P = 0.024) (Table 1). With regard to non-menstrual adverse effects, headache and acne were significantly more common in the non-postpartum group than in the postpartum group (P = 0.001 and P = 0.040, respectively) (Table 1). There were no significant differences for other adverse effects. Weight gain was the most frequent adverse effect, but there was no significant difference between groups (Table 1). Most users from both groups were satisfied with Implanon, with no difference in terms of satisfaction between groups ( Table 1). This finding implies that most women who experienced adverse effects were able to tolerate them. In conclusion, the present study has shown that bleeding patterns and non-menstrual adverse effects can differ according to timing of Implanon insertion after delivery. However, despite menstrual irregularities and other adverse effects, Implanon was well accepted in both groups.

W316 EFFECT OF INTRAPARTUM PETHIDINE ON THE NEONATAL OUTCOME: IS IT DURATION RELATED?

Objectives: To study the effect of pethidine on the intrapartum fetal heart rate (FHR) pattern and to assess the neonatal outcome with regards to the interval between pethidine administration to delivery of the fetus. Materials: 73 healthy women intrapartum from labour suite hospital Tengku Ampuan Afzan, Kuantan, Malaysia Methods: This is a prospective observational study done on 73 healthy consented women with singleton pregnancy at term . All fetus were normal, vertex presentation with reactive FHR tracing before pethidine administration. FHR recording were performed for 40 minutes prior to and one hour post pethidine. Cervical dilatation of all patients ≤ 4 cm at time of pethidine administration. Intramuscular pethidine 1mg/kg was given as an intrapartum analgesia. The study sample was divided into two groups, first group delivered within 4 hours and second group delivered more than 4 hours after the pethidine administration. The data were analysed by SSPS 17.0. Results: the mean age of the recruited patients is 28.15 ± 6.15 years and mean gestational age of 39.14 ± 1.094 weeks. The mean duration from pethidine administration to delivery is 296.48 ± 173.65 minutes (4 hours and 56 minutes). Four (5.5%) cases had suspicious CTG 1 hour post pethidine, 1 with absence of acceleration for 45 minutes and 3 cases with early deceleration lasted for 60 to 90 minutes. Out of 73 patients, 38 babies delivered within 4 hours and 35 delivered after 4 hours of pethidine. All neonates delivered with good Apgar Score (AS), 8 at 1 minute and 9 at 5 minute except 1 with AS of 5 at 1 min and 7 at 5 min which delivered more than 4 hours after pethidine. Sixteen (21.9%) cases were admitted to the Neonatal Intensive Care Unit (NICU). Eleven (68.75%) cases were admitted due to neonatal sedation from the delivery group less than 4 hours after pethidine. Five (31.25%) cases from the delivery group more than 4 hours, 4 cases with a diagnosis of transient tachypnea of newborn and 1 secondary to meconium aspiration syndrome (MAS). All discharge to mother after 24 hours, non required ventilation apart from the one with MAS which required ventilation for one day and longer admission. Despite of the higher number of those require admission in the less than 4 hours group, it was not statistically significant with P value of 7.44. Conclusions: Pethidine can be used as an intrapartum analgesia which is safe, easily available without major effect on fetal heart rate pattern and neonatal outcome even if given in advance stage of labour.

W026 MATERNAL OUTCOME OF PRENATALLY DIAGNOSED LETHAL FETAL ANOMALIES: A YEAR REVIEW

Objectives: To determine maternal morbidities in relation to prenatal diagnosis of lethal fetal anomalies and termination of pregnancy (TOP). Materials: Twenty five patients with prenatal diagnosis of lethal fetal anomalies in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. Methods: This was a retrospective review in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia in the year of 2011. All patients diagnosed prenatally to carry lethal fetal anomalies was reviewed. Data regarding maternal morbidities and outcome was collected from patients’ case note in the hospital record office. Analysis was done by using SPSS version 17.0. Results: Twenty five pregnant patients were diagnosed with lethal fetal anomalies via ultrasound with or without genetic study. The patients’ mean age was 29.9±6.3 years old. The mean gestational age at diagnosis of lethal fetal anomalies and at TOP or delivery were 26.5±7.4 and 28.7±7.8 weeks respectively. The lethal fetal anomalies included fetuses with multiple structural abnormalities (40%), anencephaly or severe encephalocele (32%), non-immune hydrops fetalis (16%) and syndromic fetuses (12%) i.e. Pentalogy of Cantrell and Edward’s syndrome. Seven (28%) patients had early counseling and TOP at the gestation of <22 weeks. Beyond 22 weeks gestation, 8 (32%) patients had TOP and 10 (40%) patients had spontaneous delivery. Twenty (80%) patients delivered or aborted vaginally, 3 (12%) patients with assisted breech delivery, and 2 (8%) patients with abdominal delivery. The abdominal deliveries were for transverse lie in labour and emergency hysterotomy for failed induction complicated by hysterectomy due to intraoperative finding of ruptured uterus. Overall, the associated adverse events included abnormal lie during delivery (16%), symptomatic polyhydramnios requiring amnioreduction (16%), post-partum haemorrhage (12%), retained placenta (12%), blood transfusion (8%), uterine rupture (4%) and endometritis (4%). Mean duration of hospital stay was 6.6±3.7 days. Conclusions: Prenatal diagnosis and TOP at an early gestation may reduce maternal morbidities and improve the outcome