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A Comparative Study Between Tramadol and Pethidine as a Form of Labour Analgesia

Anahita Pandole, Ranjit Akolekar, Nagendra Sardeshpande, Shailesh Kore, VR Ambiye

The perinatal outcome of 329 very low birth weight preterm babies born at LT Memorial General Hospital, Sion, Mumbai was studied in terms of morbidity and mortality and their mode of delivery. The babies were divided into two groups. Two hundred forty five babies had been delivered vaginally and were categorized to group ‘A’ was 33.46% as compared to 47.61% in Group ‘B’. The mortality rate in group A was 18.36% while that of group ‘B’ was 21.42%. The antenatal status of patients, presentations of foetuses and indications of aesarean sections were also studied. Results of our study showed that babies weighing 1.25 to 1.5 kg had a more favourable perinatal outcome than those weighing < 1.25 kg. The mode of delivery did not significantly affect the perinatal outcome in terms of morbidity and mortality.
Over the years, there has been a dramatic improvement in the management of preterm birth and its sequelae. Preterm babies of less than 1 kg were considered unsalvageable in the past. However, the advent of antenatal steroids, excellent and vastly improved neonatal intensive care unit facilities has offered a ray of hope to such preterm babies. According
to the WHO working group, preterm labour is one occurring before 37 completed weeks of gestation from the first day of last menstrual period. Low birth weight babies are defined as those weighing less than 2.5 kg, while very low birth weight babies are those weighing less than 1.5 kg and extremely low birth weight babies weighing < 1 kg.1
A retrospective study was carried out at LTMG Hospital, a tertiary referral centre at Mumbai. The
study evaluated patients over a time period of one year from Jan 2001 to Dec. 2001. A total number of 6391 deliveries were conducted at LTMGH during this period. Out of these 865 were preterm births. We studied 329 babies who had very low birth weight. The mode of delivery of these babies were taken into account. They were divided into two groups based on this. Group ‘A’ included 245 patients who had delivered vaginally and Group ‘B’ included 84 patients who had ndergone lower segment caesarean section.
Antenatal status of these patients was studied. One hundred forty four patients were antenatally registered, 168 patients were unregistered, this group included referred patients and those who had less than 3 antenatal visits.
Presentation of the foetus along with the common indications of LSCS were also evaluated and morbidity and mortality of the two groups was compared.

Mode of delivery of the patients is shown in Table 1. Two hundred forty five patients had delivered vaginally out of which 3 were instrumental deliveries.
Of the 329 patients, 202 had a cephalic presentation, 116 patients had breech presentation while 11 had a transverse lie.

The main indications of caesarean section are shown in Table 2. Commonest ones are abruptio placentae and reduced uteroplacental blood fiow. Other indications included PIH, malpresentations, placenta previa.

Morbidity rate was compared between the two groups as shown in Table 3.

Level of care required for the babies was used as a parameter for this comparison. Ninety babies from group A and 28 babies from group B required management in premature unit. Almost 25 babies (33.6%) from group B required admission in neonatal intensive care unit for critical management. Causes of perinatal mortality are enumerated in Table 4.

Morbidity and mortality rate in relation to mode
of delivery is shown in Table 5.

On evaluating the salvage rate of babies depending on the birth weight but irrespective of mode of delivery it was found that, salvage rate was better in the babies weighing 1251-1500 gms as shown in Table 6.
There are few studies on the epidemiology of preterm labour. It is often not possible to establish precisely the aetiology of preterm labour in almost 30% of the patients. This continues to remain an area of active investigation. However, a poor past reproductive performance must alert the obstetrician about the possibility of preterm labour. The mainstay of management of these high risk patients involves tocolysis, antibiotics, glucocorticoids, phenobarbitone and good neonatal intensive backup. Labour and delivery may be a severe insult to the preterm infant. This has led to suggestions that
caesarean section should be used to deliver infants under 1500 gms irrespective of their presentation.2 However, this continues to remain a controversial subject and there is no solid evidence that caesarean section is better way of delivering very small babies although this is a suggestive proposition.3 Though our study series was small, the perinatal outcome was not infiuenced by the mode of delivery but was directly related to the birth weight of the babies. The outcome was better in the birth weight ranging from 1251 to 1500 gms.
A review of literature also shows that the active phase of labour rather than delivery is the most important factor related to the occurrence of intracranial bleeding in very low birth weight preterm infants.4
An imminent preterm delivery is best managed at a tertiary institute with a good neonatal back up. Primary strategies should include early antenatal registration and identifying high risk pregnancies. Secondarily, adequate individuals with liberal early hospitalisation policies probably could help us improving long term morbidity and mortality of preterm babies.
V Fletcher, Lancet, 2003; 361 : 1577-78. Though our study group was small, we found that the mode of delivery whether LSCS or vaginal does not directly infiuence the perinatal outcome of very low birth weight babies. In conclusion, for every preterm baby, a balanced, rationalized decision regarding the mode of delivery with intensive neonatal care is crucial in improving perinatal outcome.
We thank Dr ME Yeolekar, Dean, LT Municipal Medical College and LT Memorial General Hospital for permitting us to
use hospital data for publication.
1. DeWayne M Pursley, John P Coherty. Identifying the high - risk newborn and evaluating gestational age, prematurity,
postmaturity, large for gestational age and small for gestational age infants. Manual of Neonatology; 3, 40.

2. Philip AGS, Allan WC. Does caesarean section project against intraventricular haemorrhage in preterm infants?
J Perinatal 1991; 11 : 3-9.

3. Arias F, Tomich P. Etiology and outcome of low birth weight and preterm infants. Obstet Gynecol 1982; 60 : 277.

4. Anderson CD, Bade HS, Siba BM, et al. The relationship


This agent is the first of a class of binding-fusion-entry inhibitors to receive regulatory approval.
The recommended adult dose of enfuvirtide is 90 mg subcutaneously, twice daily. The elimination half-life averages 3-8 hours, which supports this dosing interval.
Enfuvirtide’s safety and efficacy have been established in two pivotal studies of the same design.
The addition of enfuvirtide to a new optimised regimen of antiretroviral agents has been convincingly shown to improve virological and immunological responses in patients who are highly experienced with previous treatment.

Courtney V Fletcher, Lancet, 2003; 361 : 1577-78.

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