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MALPRESENTATION--INCIDENCE AND CAUSES.

BACKGROUND

Malpresentation is defined as when the presenting part of foetus is other than normal vertex of foetal head. It includes breech, face, brow, shoulder, compound and cord presentations. In vast majority of deliveries near term, the foetus presents by the head with the best fit into the lower pelvis. More than 95% of foetuses at term present in labour by the vertex. In modern obstetrics, the incidence of malpresentations has fallen due to reducing parity. Among malpresentations, breech presentation is the most common followed by transverse lie with shoulder presentation and face presentation, others like brow, compound and cord presentations are less common. Congenital anomalies and perinatal mortality are increased with malpresentations.

MATERIALS AND METHODS

A retrospective study of malpresentation was conducted in Obstetrics and Gynaecology Department for a period of 5 years from 1st January 2012 to 31st December 2016 at MGMMCH, Jamshedpur, Jharkhand. There were 28,431 deliveries conducted with 1099 malpresentations with an incidence of 3.87%. Different variables such as parity, booked-unbooked case, maternal risk factors, type of malpresentation, mode of delivery, foetal anomalies associated with malpresentation were analysed and reviewed to see its association with maternal and perinatal outcome. All history sheets, labour room records and operative record were scrutinised and relevant information was extracted.

RESULTS

Total numbers of deliveries conducted in Obstetrics and Gynaecology Department for a period of 5 years from 1st January 2012 to 31st December 2016 at MGMMCH, Jamshedpur, Jharkhand were 28,431. Out of these 1099 (3.87%) patients presented with malpresentation. Breech presentation is the commonest 811 (73.79%), transverse lie with shoulder presentation are 170 (15.47%), face presentation are 64 (5.82%), compound presentations are 23 (2.09%), cord presentations are 20 (1.82%) and brow presentation are 11 (1.00%).

The incidence of total malpresentations is 3.87% among 28,431 deliveries conducted.

Commonest malpresentation was breech (2.85%) followed by transverse lie (0.60%), face presentation (0.23%), compound presentation (0.08%), cord presentation (0.07%) and brow presentation (0.04%).

Majority of the cases (62.97%) in our study were not booked in the hospital for antenatal care.

Most of the foetal malpresentations (45.38%) occurred in primi para followed by 26.92% in para 2.

In the present study breech was the most common malpresentation, 334 (41.18%) cases were delivered by vaginal route. Among them 29.22% had assisted breech delivery, 11.96% had spontaneous breech delivery. Majority of breech presentations (58.82%) were delivered by caesarean section.

In the present study prematurity was the aetiological factor, accounting to 7.92% of the cases, 25.93% accounted to multiparity, 2.47% presented with uterine anomalies and 4.64% contracted pelvis, 3.10% presented with disorders of amniotic fluid volume and 1.09% cases had placenta previa and 6.39% accounting to twins.

Majority of about 1065 cases had no anomalies associated with malpresentation. In the present study, 34 cases with malpresentations delivered anomalous babies. Among them 10 babies had hydrocephalus, 7 were born with congenital talipes equino varus, 11 were anencephaly babies and 6 were gastroschisis.

In the present study, 15.37% babies were still birth associated with malpresentation, neonatal death was seen in 7.10%.

DISCUSSION

Identification of malpresentations and their aetiological factors is of vital importance to reduce perinatal morbidity and mortality. In the present study, 1099 cases of malpresentations were identified among 28,431 deliveries in MGMMCH Jamshedpur, Jharkhand. According to 11th edition of Munro Kerr's operative obstetrics, incidence of breech at term is 3%-4%, face presentation is 1 in 500 i.e. 0.2%, brow is 1 in 1000 i.e. 0.1%, transverse lie is 1 in 500 births i.e. 0.2%. [1] In the present study 2.85% accounted to breech presentation, 0.60% of cases were transverse lie, 0.23% were face presentation, brow accounted to 0.04% of the cases, 0.08% were compound presentation and 0.07% were cord presentation. This was similar to study conducted by Noor et al. [2]

In this study, 62.97% were unbooked cases, which was similar to other studies. Vijayalakshmi et al reported 65 were unbooked cases [3] and Noor et al reported 276 unbooked cases. [2] In the present study, 45.38% occurred in primigravidae. Noor et al showed 25.17% of the cases were in primigravidae and Vijayalakshmi et al reported 75% of the cases were in multipara.

In the present study breech was the most common malpresentation, 334 (41.18%) cases were delivered by vaginal route. Among them 29.22% had assisted breech delivery and 11.96% had spontaneous breech delivery. This report was similar to Noor et al who reported assisted breech delivery in 65.4%, spontaneous breech delivery in 20.9% and breech extraction in 5.9%. [2]

In the present study face presentation accounted to 5.82% cases of malpresentation, of which 74.7% were delivered by caesarean section. Benedetti TJ et al reported caesarean section in 50% of the cases. Noor et al reported 33.3% underwent caesarean section. [4]

In the present study, 34 cases with malpresentations delivered anomalous babies. Among them 10 babies had hydrocephalus, 7 were born with congenital talipes equino varus, 11 were anencephaly babies and 6 were gastroschisis. Similar observations were made in other studies. Noor et al reported 8 cases with malpresentations, among them 5 had hydrocephalus, 3 presented with clubfoot, anencephaly and sacrococcygeal teratoma. [2]

In the present study, prematurity was the aetiological factor accounting to 7.92% of the cases, 25.93% accounted to multiparity, 2.47% presented with uterine anomalies and 4.64% contracted pelvis, 3.10% presented with disorders of amniotic fluid volume and 1.09% cases had placenta previa, 6.39% accounting to twins. Similar observations were made in other studies; Vijayalakshmi et al reported multiparity as the most common aetiological factor (75 cases), 10 cases had uterine anomalies, 7 presented with placenta previa, 3 cases had contracted pelvis and 3 had twin gestation and in 2 cases was not known. [3]

In the present study, 15.37% babies were still birth associated with malpresentation and neonatal death was seen in 7.10%.

CONCLUSION

Management of abnormal presentation is a continuing challenge to the obstetrician. Education about diagnosis of malpresentation and identification of aetiological factors should be imparted to health care personnel to enable early referral to higher centres for specialist services. Delivery in malpresentations should be planned at centres which have expertise in conducting vaginal delivery in malpresentations with good intrapartum monitoring and with facilities for caesarean section for better foetomaternal outcome.

REFERENCES

[1] Munro Kerr's operative obstetrics. 11th edn. Elsevier Chapter 9, 14.

[2] Noor S, Faiz NR, Murad S. Malprentation incidence and causes. JPMI 2011;15(1):33-8.

[3] Vijayalakshmi B, Purra P. A clinical stdy of outcome of labour in transverse lie. JEBMH 2015;2(34):5232-9.

[4] Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol 1980;55(2):199-202.

Anjali Srivastava (1), Manjula Srivastava (2), K. M. Preeti (3)

(1) Associate Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.

(2) Assistant Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.

(3) Junior Resident, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.

'Financial or Other Competing Interest': None.

Submission 27-10-2017, Peer Review 20-12-2017, Acceptance 26-12-2017, Published 08-01-2018.

Corresponding Author:

Dr. Manjula Srivastava, Duplex-12, Vasundhara Estate, NH-33, Near Irrigation Colony, Dimna-831018,1SR.

E-mail: manjulasrivastava78@gmail.com

DOI: 10.14260/jemds/2018/55
Table 1. Incidence of Malpresentation

Presentation   No. of Cases   Prevalence
                (n=28431)       (100%)

Vertex            27332         96.13%
Non-Vertex         1099         3.87%

Table 2. Distribution of Malpresentation

Type         No. of Cases   Prevalence
              (n=28431)      (3.87%)

Breech           811          2.85%
Transverse       170          0.60%
Face              64          0.23%
Compound          23          0.08%
Cord              20          0.07%
Brow              11          0.04%

Table 3. Booked-Unbooked Cases

Cases      No. of Cases   Prevalence
             (n=1099)       (100%)

Booked         407          37.03%
Unbooked       692          62.97%

Table 4. Distribution of Cases in Relation to Parity

Parity      No. of Cases    Prevalence
              (n=1029)        (100%)

1                467          45.38%
2                277          26.92%
3                173          16.81%
4                85           08.26%
5 or More        27           02.62%

Table 5. Mode of Delivery in Breech Presentation

Mode of Delivery              No. of Cases   Prevalence
                                (n=811)        (100%)

Spontaneous breech delivery        97          11.96%
Assisted breech delivery          237          29.22%
Caesarean section                 477          58.82%

Table 6. Maternal Risk Factors

Risk Factors            No. of Cases   Prevalence
                          (n=1099)       (100%)

Prematurity                  87          07.92%
Twins                        70          06.39%
Polyhydramnios               06          00.55%
Oligohydramnios              28          02.55%
Placenta previa              12          01.09%
Uterine malformations        27          02.47%
Foetal anomalies             34          03.09%
Multiparity                 285          25.93%
Contracted pelvis            51          04.64%
Unknown causes              499          45.40%

Table 7. Foetal Anomalies associated
with Malpresentation

Foetal Anomaly   No. of Cases (n=1099)

Hydrocephalus             10
Anencephaly               11
Gastroschisis             06
CTEV                      07
No Anomaly               1065

Table 8. Status of Babies associated with Malpresentation

Babies Status   No. (n=1099)   Prevalence
                                 (100%)

Alive               852          77.53%
N.N.D.               78          07.10%
Still Birth         169          15.37%
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Article Details
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Title Annotation:Original Research Article
Author:Srivastava, Anjali; Srivastava, Manjula; Preeti, K.M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jan 8, 2018
Words:1523
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