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O780 Feracrylum as a hemostatic agent in obstetric procedures
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Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
O777 Debriefing (post natal birth review) following emergency operative delivery – Does this influence future pregnancy and delivery? M. Ramalingam, K. Patrick. NHS Forth valley Aims: Operative deliveries accounts for 30% of all deliveries in British maternity units. This can be associated with psychological morbidity. The aims of our study were to 1. find out if all women had adequate explanation before the procedure, 2. review their birthing experience, 3. evaluate how this has influenced their thoughts about future delivery, 4. identify the importance of postnatal birth review. Methods: A survey was conducted among women who underwent emergency operative childbirth from 2007 to 2008. A standardised questionnaire was used. 100 women were included. Results: In 89% of the patients the procedure was explained beforehand. 39% found their experience traumatic; 40% of the women said this experience has influenced their thoughts about future pregnancy and delivery; 60% would still try for natural labour; 22% would prefer a caesarean section and 18% would deter from having further children. A birth review was carried out by a doctor in 75% of patients with good satisfactory rate. Of the women who did not receive a birth review a majority of them wanted one. 96% thought that a birth review would influence their thoughts about future delivery. Conclusions: The survey shows operative delivery has a greater impact on the women’s view on future pregnancy and labour. Women undergoing operative delivery would appreciate a postnatal birth review. This review could possibly help in bringing down the number of patients requesting a caesarean section in future pregnancies. O778 Sildenafil citrate improves fetal outcomes in a L-NAME induced pre-eclamptic rat model S. Ramesar1 , I. Mackraj1 , P. Gathiram2 , J. Moodley3 . 1 University of KwaZulu-Natal, Department of Physiology and Physiological Chemistry, 2 University of KwaZulu-Natal, Department of Family Medicine, 3 University of KwaZulu-Natal, Women’s Health and HIV Research Group, Dept of O & G Objectives: This study aimed to investigate the effects of Sildenafil Citrate on various fetal and physiological parameters, including fetal mortality, number of pups, placental weights and microalbuminuria, in an L-NAME pre-eclampsia induced rat model. Methods: Pre-eclampsia was induced by L-NAME (0.3 g/l, drinking water) on day 1 of the experiment. The experimental group received Sildenafil Citrate (10 mg/kg, s.c.) daily commencing on day 2. Animals were sacrificed on day 20, at which time a laparotomy was performed and the various fetal parameters measured. On days 0 and 20 blood pressure measurements were recorded non-invasively and urinalysis was conducted in 24 hr urine samples. Results: The results show that subcutaneous injections of Sildenafil Citrate decrease fetal mortality and increase birth and placental weights in an L-NAME pre-eclampsia induced rat model. Sildenafil Citrate administration does not ameliorate hypertension but decreases proteinuria. Conclusion: We speculate that Sildenafil Citrate by potentiating the effects of nitric oxide in vivo improves uterine artery blood flow and thus improving fetal outcomes. Source of funding: National Research Foundation (NRF) of South Africa. Pfizer Laboratories, United Kingdom – Sildenafil Citrate (UK92480–10).
O779 Examining the impact of abortion legalisation on women’s health in post legalisation era in Nepal A. Rana1 , N. Pradhan2 , P. Mahesh2 , J. Henderson3 . 1 Tribhuvan University Teaching Hospital, 2 Crehpa, 3 Reproductive Health Research & Policy; Univ of California San Francisco Aim: To find out trends of unsafe abortion practice and the number of abortion complication treated at Tribhuvan University Teaching Hospital before and after abortion legalisation. Methods: This study assesses the trend in abortion complications treated at a large Teaching Hospital in Kathmandu. Inpatients’ medical charts were retrospectively abstracted for all women admitted to the hospital with symptoms, medical complications or death from abortion during 2002–07. About 5,000 medical charts were checked for eligibility and 557 charts related to abortion were analyzed. The characteristics of patients presenting with different levels of severity are compared using chi-squared tests and Anova. A log-linear poisson regression model was used to test for a significant trend in the proportion of severe cases relative to all cases. Results: Results show that, out of total abortion related cases admitted in TUTH, 26% (110 out of 421 cases) were related to induced abortion. A quarter of women (28.5%) having high severity indices and about two thirds of the women having medium severity (63.2%). High severity cases were more likely to be observed among women who were older (mean age 27.5 years) and multiparity (≥2 children) that had ever used contraception (48%). Fever, tachycardia, painful/cramping abdomen, sepsis/septicemia, septic shock, perforated uterus were the associated morbidity. Those women who had confirmed induced abortion were more likely to have high severity. About 85% of the women had received antibiotics followed by MVA (39.2%), blood transfusion (15.9%); surgical repair (3.1%) respectively. In addition, about 2% of the cases had to be treated in Intensive Care Unit. Conclusion: Although there was no declining trend in the number of illegally performed abortion, a marked reduction in severity of the complication has been noted that has given positive impact of abortion legalization in Nepal. O780 Feracrylum as a hemostatic agent in obstetric procedures S. Rao Patri Aim and Objectives: In order to obtain hemostasis in different circumstances following vaginal delivery, caesarean section or missed abortion, feracrylum has been tried when other conventional methods have failed to obtain the desired hemostasis. Materials and Methods: Place of study – Valluvanad & Aswini hospitals, Ottapalam Kerala, India. In all over 80 pts. have been studied in the last five years with the usage of feracrylum, instilled topically. Feracrylum is a water soluble mixture of incomplete ferrous salt of polyacrylic acid which acts with proteins in blood especially albumin forming a poly complex which converts soluble fibrinogen into insoluble fibrin which then forms a coagulum. This coagulum arrests bleeding & oozing from highly vascularised tissues. Among the eighty patients studied there were pts with atonic P.P.H. (30), traumatic P.P.H. (35), casarean hysterectomies (5), missed abortions (5) and secondary P.P.H. (5). In all these pts the conventional methods like uterine massage where ever appropriate, administration of inj. Oxytocin, inj. Methylergometrine, p/r insertion of misoprostal & i.m administration of carboprost have been used. It is only as a last resort that feracrylum has been used topically when hemorrhage could not be controlled with the above measures.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
Results: The outcome with regard to control of hemorrhage has been excellent except in two cases, where the hemorrhage could not be controlled. The 2 cases were: A. A pt with sec. P.P.H (following casarean) who had to undergo internal iliac art. ligation. As the bleeding could not be controlled using feracrylum. B. Another pt was a primi with a massive primary atonic P.P.H. (couvelaire uterus) who did not respond to conservative management including feracrylum and had to be taken up for emergency subtotal hysterectomy. Both the above pts could be saved and had uneventful recovery. There were no deaths in the above eighty pts. Conclusion: Feracrylum has decreased the need of multiple blood tranfusions and helped in decreasing maternal morbidity and even mortality. Hence feracrylum should be tried before one considers a surgical option to control P.P.H. O781 Is there any association between the body mass index and cervical intraepithelial neoplasia? S. Raouf, P. Gupta, S. Papaioannou. Heart of England NHS Foundation, Birmingham. B9–5SS, UK Background: The relationship between obesity and cervical cancer remains uncertain despite some observational studies reporting an increased prevalence of cervical cancer in obese women. Research to the effect of obesity on cervical intraepithelial neoplasia (CIN) is nonexistent. Objectives: To investigate association between BMI and histologically confirmed CIN. Materials and Methods: A prospective observation study conducted in a dedicated colposcopy clinic.180 women attending their first visit to the colposcopy clinic during 6 months period (February 07-July 07) were included. Data on age, smoking, height, weight and BMI were collected. The reasons of referral to colposcopy clinic, the initial cervical liquid base cytology results and final histological diagnosis based on cervical biopsy or loop excisions were analysed and statistical tests were used to find out whether there are any effect of patient BMI on their cervical histological abnormalities. Analysis of variance and covariance were performed to examine the relationship between BMI and severity of CIN. Main outcome measures: Relationship between BMI and severity of cervical intraepithelial abnormalities. Results: The mean age of the study group was 37 years (range 22–66 years). The mean BMI was 26.7 kg/m2 (range 16.1–50.5 kg/m2 ). Sixty seven (37.2%) women were smokers. In total 79 women were diagnosed with CIN (CIN I 11.1%, CIN II 8.9%, CIN III 23.9%). The mean BMI in women diagnosed with normal histology was (mean± SD) 26.27±5.77, CIN 1 29.45±7.94, CIN 2 27.18±6.17and CIN 3 26.43±54.2. Data were log transformed for analysis. There was no relationship between BMI and severity of CIN (p = 0.24). This was true even after adjustment for smoking and age (Confidence interval for average adjusted BMI were Normal histology 24.3–27, CIN I 25.9–31.6, CIN II 24.1–30.1, CIN III 24.4–28.1). Conclusions: This study shows that obesity does not influence the severity of cervical intraepithelial neoplasia. O782 Adolescent pregnancy in Upper Egypt: Incentives and implications S. Rasheed1 , A. Abd el Monem1 , H. Hamed2 , A. Ait Alla1 , E. Sayed2 , H. Salem2 , M. Abd el Hkalek1 . 1 Sogah University Hospital, 2 Assiut University Hospital Objectives: To define the background and to evaluate the maternal, foetal and neonatal outcomes of teenager pregnancy amongst upper Egyptian women. Design: Cross-sectional study.
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Settings: Assiut and Sohag University hospitals, Egypt. Patients and Methods: During a 2-years study period, all primigavida women <30 years of age attending the emergency sectors of both hospitals have been recruited. The patients have been divided into 2 groups; the study group (2153) who were ≤19 years at the time of pregnancy and the control group (3162) who aged 19–30 years. The maternal, foetal and neonatal outcomes have been compared between the 2 groups. Patients of the study group have been asked to fill a questioner in order to identify the incentives and backgrounds of adolescent pregnancy. Results: About 94% of the patients do not consider themselves young at the age of the 1st pregnancy. More than half of the patients have got married seeking for motherhood. The average age at marriage was 17.8±0.9 years. The vast majority (84%) of the patients were of the low socioeconomic class and most of them (62%) were educated up to the post-preparatory school level. The risk of preeclmpsia, eclampsia, premature rupture of membranes, preterm labor was significantly higher amongst teenager pregnant women. Most of these complications (46%) were confined to patients aged ≤16 years. After that age, the rate of complications decreases and become steadily comparable to the control group. C.S. was significantly higher in the study group than the control group (45% versus 23%). Cephalo-pelvic disproportion and dysfunctional labor were the most frequent indications of C.S. Conclusions: Seeking for motherhood is the main incentive behind adolescent pregnancy in Upper Egypt. Adolescent pregnancy increases the risk of preeclmpsia, eclampsia, premature rupture of membranes, preterm labor and C.S. The risk of these complications is limited mainly to patients aged ≤16 years. Pregnancy after the age of 16 years seems save and does not increase the rate of complications. O783 Outcome of pregnancy in patients with liver cirrhosis S. Rasheed1 , I. Hasan2 , O. Arafa3 . 1 Ob./Gyn. Department, 2 Pediatrics, 3 Internal medicine, Sohag Faculty of Medicine Objectives: To evaluate the maternal and fetal outcomes in patients with liver cirrhosis and to determine the impact of pregnancy on the hepatic disease process. Design: A cross sectional study. Setting: Sohag University hospital, Egypt. Patients and Methods: Fifty one pregnant women with liver cirrhosis. They were followed throughout pregnancy both clinically and laboratory to detect manifestations of hepatic decompensation and to detect any obstetric complication. Results: 18% of patients developed hepatic decompensation during pregnancy; of which 88% have occurred during the last 4 weeks of pregnancy. Only 2% of this decompensation has occurred before 32 weeks of gestation. 60% of patients developed obstetric complications. Preterm labor, HELLP syndrome, preeclmpsia and atonic postpartum haemorrhage increase significantly in patients with liver cirrhosis. The vast majority (88%) of these complications have occurred after 36 weeks of pregnancy. 30% of fetuses developed intra-uterine growth retardation and 15% died intrauterine mainly in patients who developed hepatic decompensation. The maternal mortality rate was 8% and all were the result of hepatic coma occurring during labor. Conclusions: The risk of hepatic decompensation increases significantly during the last 4 weeks of pregnancy. Preterm labor, HELLP, pre-eclampsia and atonic post-partum haemoorhage increase significantly in decompensated patients. Hepatic coma occurring during labour is the leading cause of maternal death. Termination of pregnancy at 36 weeks of gestation can decrease the maternal morbidity and mortality.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
O777 Debriefing (post natal birth review) following emergency operative delivery – Does this influence future pregnancy and delivery? M. Ramalingam, K. Patrick. NHS Forth valley Aims: Operative deliveries accounts for 30% of all deliveries in British maternity units. This can be associated with psychological morbidity. The aims of our study were to 1. find out if all women had adequate explanation before the procedure, 2. review their birthing experience, 3. evaluate how this has influenced their thoughts about future delivery, 4. identify the importance of postnatal birth review. Methods: A survey was conducted among women who underwent emergency operative childbirth from 2007 to 2008. A standardised questionnaire was used. 100 women were included. Results: In 89% of the patients the procedure was explained beforehand. 39% found their experience traumatic; 40% of the women said this experience has influenced their thoughts about future pregnancy and delivery; 60% would still try for natural labour; 22% would prefer a caesarean section and 18% would deter from having further children. A birth review was carried out by a doctor in 75% of patients with good satisfactory rate. Of the women who did not receive a birth review a majority of them wanted one. 96% thought that a birth review would influence their thoughts about future delivery. Conclusions: The survey shows operative delivery has a greater impact on the women’s view on future pregnancy and labour. Women undergoing operative delivery would appreciate a postnatal birth review. This review could possibly help in bringing down the number of patients requesting a caesarean section in future pregnancies. O778 Sildenafil citrate improves fetal outcomes in a L-NAME induced pre-eclamptic rat model S. Ramesar1 , I. Mackraj1 , P. Gathiram2 , J. Moodley3 . 1 University of KwaZulu-Natal, Department of Physiology and Physiological Chemistry, 2 University of KwaZulu-Natal, Department of Family Medicine, 3 University of KwaZulu-Natal, Women’s Health and HIV Research Group, Dept of O & G Objectives: This study aimed to investigate the effects of Sildenafil Citrate on various fetal and physiological parameters, including fetal mortality, number of pups, placental weights and microalbuminuria, in an L-NAME pre-eclampsia induced rat model. Methods: Pre-eclampsia was induced by L-NAME (0.3 g/l, drinking water) on day 1 of the experiment. The experimental group received Sildenafil Citrate (10 mg/kg, s.c.) daily commencing on day 2. Animals were sacrificed on day 20, at which time a laparotomy was performed and the various fetal parameters measured. On days 0 and 20 blood pressure measurements were recorded non-invasively and urinalysis was conducted in 24 hr urine samples. Results: The results show that subcutaneous injections of Sildenafil Citrate decrease fetal mortality and increase birth and placental weights in an L-NAME pre-eclampsia induced rat model. Sildenafil Citrate administration does not ameliorate hypertension but decreases proteinuria. Conclusion: We speculate that Sildenafil Citrate by potentiating the effects of nitric oxide in vivo improves uterine artery blood flow and thus improving fetal outcomes. Source of funding: National Research Foundation (NRF) of South Africa. Pfizer Laboratories, United Kingdom – Sildenafil Citrate (UK92480–10).
O779 Examining the impact of abortion legalisation on women’s health in post legalisation era in Nepal A. Rana1 , N. Pradhan2 , P. Mahesh2 , J. Henderson3 . 1 Tribhuvan University Teaching Hospital, 2 Crehpa, 3 Reproductive Health Research & Policy; Univ of California San Francisco Aim: To find out trends of unsafe abortion practice and the number of abortion complication treated at Tribhuvan University Teaching Hospital before and after abortion legalisation. Methods: This study assesses the trend in abortion complications treated at a large Teaching Hospital in Kathmandu. Inpatients’ medical charts were retrospectively abstracted for all women admitted to the hospital with symptoms, medical complications or death from abortion during 2002–07. About 5,000 medical charts were checked for eligibility and 557 charts related to abortion were analyzed. The characteristics of patients presenting with different levels of severity are compared using chi-squared tests and Anova. A log-linear poisson regression model was used to test for a significant trend in the proportion of severe cases relative to all cases. Results: Results show that, out of total abortion related cases admitted in TUTH, 26% (110 out of 421 cases) were related to induced abortion. A quarter of women (28.5%) having high severity indices and about two thirds of the women having medium severity (63.2%). High severity cases were more likely to be observed among women who were older (mean age 27.5 years) and multiparity (≥2 children) that had ever used contraception (48%). Fever, tachycardia, painful/cramping abdomen, sepsis/septicemia, septic shock, perforated uterus were the associated morbidity. Those women who had confirmed induced abortion were more likely to have high severity. About 85% of the women had received antibiotics followed by MVA (39.2%), blood transfusion (15.9%); surgical repair (3.1%) respectively. In addition, about 2% of the cases had to be treated in Intensive Care Unit. Conclusion: Although there was no declining trend in the number of illegally performed abortion, a marked reduction in severity of the complication has been noted that has given positive impact of abortion legalization in Nepal. O780 Feracrylum as a hemostatic agent in obstetric procedures S. Rao Patri Aim and Objectives: In order to obtain hemostasis in different circumstances following vaginal delivery, caesarean section or missed abortion, feracrylum has been tried when other conventional methods have failed to obtain the desired hemostasis. Materials and Methods: Place of study – Valluvanad & Aswini hospitals, Ottapalam Kerala, India. In all over 80 pts. have been studied in the last five years with the usage of feracrylum, instilled topically. Feracrylum is a water soluble mixture of incomplete ferrous salt of polyacrylic acid which acts with proteins in blood especially albumin forming a poly complex which converts soluble fibrinogen into insoluble fibrin which then forms a coagulum. This coagulum arrests bleeding & oozing from highly vascularised tissues. Among the eighty patients studied there were pts with atonic P.P.H. (30), traumatic P.P.H. (35), casarean hysterectomies (5), missed abortions (5) and secondary P.P.H. (5). In all these pts the conventional methods like uterine massage where ever appropriate, administration of inj. Oxytocin, inj. Methylergometrine, p/r insertion of misoprostal & i.m administration of carboprost have been used. It is only as a last resort that feracrylum has been used topically when hemorrhage could not be controlled with the above measures.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
Results: The outcome with regard to control of hemorrhage has been excellent except in two cases, where the hemorrhage could not be controlled. The 2 cases were: A. A pt with sec. P.P.H (following casarean) who had to undergo internal iliac art. ligation. As the bleeding could not be controlled using feracrylum. B. Another pt was a primi with a massive primary atonic P.P.H. (couvelaire uterus) who did not respond to conservative management including feracrylum and had to be taken up for emergency subtotal hysterectomy. Both the above pts could be saved and had uneventful recovery. There were no deaths in the above eighty pts. Conclusion: Feracrylum has decreased the need of multiple blood tranfusions and helped in decreasing maternal morbidity and even mortality. Hence feracrylum should be tried before one considers a surgical option to control P.P.H. O781 Is there any association between the body mass index and cervical intraepithelial neoplasia? S. Raouf, P. Gupta, S. Papaioannou. Heart of England NHS Foundation, Birmingham. B9–5SS, UK Background: The relationship between obesity and cervical cancer remains uncertain despite some observational studies reporting an increased prevalence of cervical cancer in obese women. Research to the effect of obesity on cervical intraepithelial neoplasia (CIN) is nonexistent. Objectives: To investigate association between BMI and histologically confirmed CIN. Materials and Methods: A prospective observation study conducted in a dedicated colposcopy clinic.180 women attending their first visit to the colposcopy clinic during 6 months period (February 07-July 07) were included. Data on age, smoking, height, weight and BMI were collected. The reasons of referral to colposcopy clinic, the initial cervical liquid base cytology results and final histological diagnosis based on cervical biopsy or loop excisions were analysed and statistical tests were used to find out whether there are any effect of patient BMI on their cervical histological abnormalities. Analysis of variance and covariance were performed to examine the relationship between BMI and severity of CIN. Main outcome measures: Relationship between BMI and severity of cervical intraepithelial abnormalities. Results: The mean age of the study group was 37 years (range 22–66 years). The mean BMI was 26.7 kg/m2 (range 16.1–50.5 kg/m2 ). Sixty seven (37.2%) women were smokers. In total 79 women were diagnosed with CIN (CIN I 11.1%, CIN II 8.9%, CIN III 23.9%). The mean BMI in women diagnosed with normal histology was (mean± SD) 26.27±5.77, CIN 1 29.45±7.94, CIN 2 27.18±6.17and CIN 3 26.43±54.2. Data were log transformed for analysis. There was no relationship between BMI and severity of CIN (p = 0.24). This was true even after adjustment for smoking and age (Confidence interval for average adjusted BMI were Normal histology 24.3–27, CIN I 25.9–31.6, CIN II 24.1–30.1, CIN III 24.4–28.1). Conclusions: This study shows that obesity does not influence the severity of cervical intraepithelial neoplasia. O782 Adolescent pregnancy in Upper Egypt: Incentives and implications S. Rasheed1 , A. Abd el Monem1 , H. Hamed2 , A. Ait Alla1 , E. Sayed2 , H. Salem2 , M. Abd el Hkalek1 . 1 Sogah University Hospital, 2 Assiut University Hospital Objectives: To define the background and to evaluate the maternal, foetal and neonatal outcomes of teenager pregnancy amongst upper Egyptian women. Design: Cross-sectional study.
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Settings: Assiut and Sohag University hospitals, Egypt. Patients and Methods: During a 2-years study period, all primigavida women <30 years of age attending the emergency sectors of both hospitals have been recruited. The patients have been divided into 2 groups; the study group (2153) who were ≤19 years at the time of pregnancy and the control group (3162) who aged 19–30 years. The maternal, foetal and neonatal outcomes have been compared between the 2 groups. Patients of the study group have been asked to fill a questioner in order to identify the incentives and backgrounds of adolescent pregnancy. Results: About 94% of the patients do not consider themselves young at the age of the 1st pregnancy. More than half of the patients have got married seeking for motherhood. The average age at marriage was 17.8±0.9 years. The vast majority (84%) of the patients were of the low socioeconomic class and most of them (62%) were educated up to the post-preparatory school level. The risk of preeclmpsia, eclampsia, premature rupture of membranes, preterm labor was significantly higher amongst teenager pregnant women. Most of these complications (46%) were confined to patients aged ≤16 years. After that age, the rate of complications decreases and become steadily comparable to the control group. C.S. was significantly higher in the study group than the control group (45% versus 23%). Cephalo-pelvic disproportion and dysfunctional labor were the most frequent indications of C.S. Conclusions: Seeking for motherhood is the main incentive behind adolescent pregnancy in Upper Egypt. Adolescent pregnancy increases the risk of preeclmpsia, eclampsia, premature rupture of membranes, preterm labor and C.S. The risk of these complications is limited mainly to patients aged ≤16 years. Pregnancy after the age of 16 years seems save and does not increase the rate of complications. O783 Outcome of pregnancy in patients with liver cirrhosis S. Rasheed1 , I. Hasan2 , O. Arafa3 . 1 Ob./Gyn. Department, 2 Pediatrics, 3 Internal medicine, Sohag Faculty of Medicine Objectives: To evaluate the maternal and fetal outcomes in patients with liver cirrhosis and to determine the impact of pregnancy on the hepatic disease process. Design: A cross sectional study. Setting: Sohag University hospital, Egypt. Patients and Methods: Fifty one pregnant women with liver cirrhosis. They were followed throughout pregnancy both clinically and laboratory to detect manifestations of hepatic decompensation and to detect any obstetric complication. Results: 18% of patients developed hepatic decompensation during pregnancy; of which 88% have occurred during the last 4 weeks of pregnancy. Only 2% of this decompensation has occurred before 32 weeks of gestation. 60% of patients developed obstetric complications. Preterm labor, HELLP syndrome, preeclmpsia and atonic postpartum haemorrhage increase significantly in patients with liver cirrhosis. The vast majority (88%) of these complications have occurred after 36 weeks of pregnancy. 30% of fetuses developed intra-uterine growth retardation and 15% died intrauterine mainly in patients who developed hepatic decompensation. The maternal mortality rate was 8% and all were the result of hepatic coma occurring during labor. Conclusions: The risk of hepatic decompensation increases significantly during the last 4 weeks of pregnancy. Preterm labor, HELLP, pre-eclampsia and atonic post-partum haemoorhage increase significantly in decompensated patients. Hepatic coma occurring during labour is the leading cause of maternal death. Termination of pregnancy at 36 weeks of gestation can decrease the maternal morbidity and mortality.