Context: Transverse lie at term may have adverse consequences on both the mother and the foetus.Evaluating transverse lie at term by ultrasonography may reduce these adverse consequences andimprove both the maternal and fetal outcome.Objectives: To determine predisposing factors to persistent transverse lie at term using abdominalultrasonography and the outcome of such pregnancies.Study- Design, Setting and Subjects: This was a cross-sectional study of pregnant women at term withpersistent transverse lie referred to the Ultrasound Unit of the Federal Medical Centre, Lokoja, Nigeria.Results: Out of a total of 1296 scanned during the evaluation period, 42 (3.2%) had transverse lie atterm. Five (11.9%) patients were primigravida and 37 (88.1%) multipara. No predisposing factors wereseen on ultrasound in 25 women (59.5%). Placenta praevia was diagnosed in 11 (26.2%), lower segmentfibroid in 5 (11.9%) and pelvic kidney in 1 (2.4%). Thirty nine patients (92.1%) were delivered bycaesarean section (CS). Three (7.1%) spontaneously converted to longitudinal lie [1 Breech and 2Cephalic]. All 3 were delivered per vaginam. There were no maternal deaths but there were 2 stillbirths.Conclusion: Majority of the patients had no predisposing factor seen on ultrasound and were largelymultiparous women. Placenta praevia was the commonest predisposing factor found atultrasonography. Caesarean section rate was very high, largely due to the fact that external cephalicversion (ECV), which has been advocated as an alternative mode of delivery of infants lying transverselyat term, is not currently practised in our centre.Key Words: Transverse Lie, Malpresentation, Ultrasound, Caesarean Sectio

Aboyeji, AP

Jimoh, KO

Okoyomo, AA

Oyinloye, OI

English

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118Evaluation of Transverse Lie at Term by Ultrasonography1 2 3 1Olalekan I Oyinloye , Alexander A Okoyomo , Abiodun P Aboyeji  and Kamaldeen O Jimoh1 3Departments of Radiology, and Obstetrics & Gynaecology, University of Ilorin Teaching Hospital, Ilorin, 2Nigeria and Department of Obstetrics and Gynaecology, Federal Medical Centre Lokoja Nigeria.AbstractContext:  Transverse lie at term may have adverse consequences on both the mother and the foetus. Evaluating transverse lie at term by ultrasonography may reduce these adverse consequences and improve both the maternal and fetal outcome.Objectives: To determine predisposing factors to persistent transverse lie at term using abdominal ultrasonography and the outcome of such pregnancies.Study- Design, Setting and Subjects: This was a cross-sectional study of pregnant women at term with persistent transverse lie referred to the Ultrasound Unit of the Federal Medical Centre, Lokoja, Nigeria.Results: Out of a total of 1296  scanned during the evaluation period, 42 (3.2%) had transverse lie at term. Five (11.9%) patients were primigravida and 37 (88.1%) multipara. No predisposing factors were seen on ultrasound in 25 women (59.5%). Placenta praevia was diagnosed in 11 (26.2%), lower segment fibroid in 5 (11.9%) and pelvic kidney in 1 (2.4%). Thirty nine patients (92.1%) were delivered by caesarean section (CS). Three (7.1%) spontaneously converted to longitudinal lie [1 Breech and 2 Cephalic]. All 3 were delivered per vaginam. There were no maternal deaths but there were 2 stillbirths. Conclusion:  Majority of the patients had no predisposing factor seen on ultrasound and were largely multiparous women. Placenta praevia was the commonest predisposing factor found at ultrasonography. Caesarean section rate was very high, largely due to the fact that external cephalic version (ECV), which has been advocated as an alternative mode of delivery of infants lying transversely at term, is not currently practised in our centre.Key Words: Transverse Lie, Malpresentation, Ultrasound, Caesarean SectionIntroduction Polyhydramnios intrauterine synechiae, pelvic The fetal “lie” indicates the orientation of the contraction, uterine malformation, pelvic 2,4,5,6. fetal spine relative to that of the mother. The kidneys and other pelvic masses Many cases normal lie is longitudinal which by itself does not are however, known not to manifest any of these 7indicate whether the presentation is cephalic or predisposing factors .1breech . The fetus is in a transverse lie when its longitudinal axis is perpendicular to the maternal Persistent transverse lie at term constitutes a 2.spine management dilemma for obstetricians  between expectant management, external A transverse lie can occur in two configurations. cephalic version followed by induction of labour 4The curvature of the fetal spine could be and elective caesarean section . There is oriented  upwards and the fetal small parts consensus that a careful search for potentially present at the cervix.(also called back-up or dangerous or compromising aetiology is dorso-superior); or the curvature of the fetal indicated in cases of transverse lie. This is spine could be facing downwards, such that the important so that a safe mode of delivery can be foetal shoulders presents at the cervix (also 2called the back-down or dorso-inferior) .The reported incidence of transverse lie at term 2-4is between 1 in 300 and  500 pregnancies . Factors known to predispose to transverse lie, are multiparity, placenta praevia, Trop J Obstet Gynaecol, 26 (2), October 2009.                                                                                               ISSN 0189 5178Correspondence: Dr. O I Oyinloye, Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, Nigeria. E-mail: oyinbuk2001@yahoo.com1201191determined .  Ultrasound examination is useful where referral cases and the remaining 20 to exclude major fetal malformation, pelvic (47.6%) patients consisted of 14 booked patients masses and abnormal placentation. This study in the hospital and 6 unbooked cases. Sixteen aims to determine predisposing factors to patients (38.1%) had their head oriented to the persistent transverse lie at term using abdominal left iliac fossa, while 26(61.9%) patients had their ultrasonography and the findings at delivery. head oriented to the right iliac fossa. The mean age of patients in this study was 29.4yrs ± 5.9yrs, Materials and Methods while the mean gestational age of pregnancy was A cross-sectional study carried out from October 38.18 ±1.16wks.The mean gravid experience was 2002 to august 2004 at Federal medical centre, 4.2 with a mode of 4 and median of 4. Lokoja,Nigeria. All patients referred to the ultrasound unit of the hospital at term for Ultrasound findings in this study are summarised ultrasonography were recruited for the study. A in table 1.Five (11.9%) patients were Siemens SL machine 3.5Mhz probe linear primigravidae and 37(88.1%) multiparae, with machine was used. Patients laid in the supine 12(28.6%) in this group been grandmultiparae position and the entire abdomen scanned. (Greater than 5 deliveries). Twenty five (59.5%) The full-bladder technique was not used women had no associated predisposing factors routinely except in some cases of suspected seen on ultrasound, while 17(40.5%) women had placenta praevia, or lower segment masses. A positive findings. Placenta praevia was fetus was said to be in transverse lie when its diagnosed in 11(26.2%), lower segment fibroids longitudinal axis is perpendicular to the maternal in 5(11.9%), and pelvic kidney in 1(2.4%). In the spine. The direction of the fetal head with primigravidae predisposing factors were seen in respect to the maternal abdomen was noted, i.e. 4 out of 5patients(80%),while in the multiparous towards the right or left iliac fossa. patient predisposing factors were found in 13 out of 37 patients(35.1%). Six (14.3%) patients had In cases with fetal transverse lie, possible previous history of CS in this study. Thirty-nine etiological factors like placenta praevia and (92.8%) out of 42 patients had CS. Emergency CS lower uterine segment masses were carefully was done in 30 patients(76.9%), while elective CS sought. The location and sizes of associated was done in 9 Patients(23.1%).Three(7.14%) pelvic masses were noted.  All other relevant pat ients  spontaneous ly  converted to  data were also collected from patient case files longitudinal lie, 1 breech and 2 cephalic including history of previous surgeries. Data was presentations. No maternal deaths were analysed using statistical package for social recorded; however, there were 2 stillbirths.sciences. (SPSS).Discussion Results Transverse lie persisting to term has been A total of 42 patients out of 1296 had transverse associated with serious complications to both lie at 37weeks and above, giving an incidence of the mother and foetus during labour, hence a 3.2% in this study. Twenty- two (52.4%) women cause of concern for pregnant women and their 5, 6carers .Detection of transverse and lie and expectant management were adopted only 1 out associated etiologies like placenta praevia by of 11nullipara had spontaneous version to ultrasonography can substantially reduce longitudinal lie before onset of labour while the 12complications to both the mother and foetuses, corresponding figure was 34% in multipara . 8. by determining a safe mode of delivery In this These findings gives further support to the study, the largest group of patients 25(59.5%) aforementioned statement that transverse lie in had no predisposing factor seen on ultrasound. a primigravida implies likelihood of underlying Multigravidae constituted 24 out of the 25 pathology. Therefore, careful search for causes patients (96%) in this group, with 12(28.6%) of transverse lie especially in a primigravida is 4been grand-multiparous patients. Women in important in obstetrics management .ththeir 4  gravid experience constituted the largest number (nine) and the mean gravid experience Placenta praevia was the commonest finding was 4.2.This observation is not surprising as the predisposing to transverse lie constituting commonest predisposing aetiology to transverse 11(26.2%) patients. Out of this number 10 lie has been attributed to laxity of the abdominal patients (90.1%) were multigravidae and 1 2 patient (9.1%) primigravidae. Fried et al in a musculature from multiparity .study in which foetuses discovered to be in transverse lie by ultrasonography at 20 weeks The possible mechanism attributable to this is a were followed up, found placenta praevia in pendulous abdomen which allows the uterus to 35.7% of cases of transverse lie persisting to fall forwards deflecting the long axis of the foetus 13away from the axis of the birth canal into a term  .From the above facts therefore, we would transverse lie. Women with greater than four suggest a careful localisation of the placenta deliveries, have a ten fold incidence of transverse when transverse lie is encountered during 2 antenatal ultrasonography. A relatively high lie compared to nullipara . Grand-multiparity has incidence of placenta praevia was also noted in almost disappeared in the western countries due 9 those with previous history of caesarean section, to advancement of family planning .However, in with 3(50%) out of 6 patients with such histories a developing country like Nigeria, a significant having placenta praevia. Multiparity and proportion of women in the child bearing group previous caesarean section has been implicated category are grand-multiparae. Ogedengbe et al among possible predisposing factors to placenta estimated the incidence of grand-multiparity in 1410 praevia . Lagos Nigeria to be 4.11 , while Ozumba et al in Lower segment fibroids were discovered in 5 Enugu Nigeria,estimated the incidence to be as 10 patients (11.9%). Uterine fibroid is the high as11% in that region of the country .They commonest benign tumour of the female both observed an increased incidence of genitial tract. It can cause malposition of the abnormal lie and malpresentation in grand-10,11 foetus and obstructed labour, especially if the multiparous patients . 15size is large .   Ultrasound assessment in this study revealed Management of transverse lie at term is between associated predisposing factors in 17 expectant management, CS and ECV followed by patients(40.5%). 4 were primigravidae,which 2induction of labour .In our centre, the mode of constituted 80% of the total number of delivery of patients presenting with persistent primigravidae, while 13 were multigravidae transverse lie, at term is by CS. Thirty-nine constituting  35.1%of the total number in this (92.8%) out of 42 patients had CS. Emergency CS group. Transverse lie is relatively rare in a was done in majority of the cases (76.9%), while primigravidae and its presence suggests the elective CS was performed in (23.1%) of cases. likelihood of underlying pathology, some like The emergency CS rate was quite high since cephalo-pelvic disproportion , pelvic bony majority of the patients were diagnosed to be in abnormalities  and uterine malforfmation may transverse lie at term gestation. Most of the not even be apparent during routine antenatal 4. patients were referred cases on account of visits.  In a comparative study by Edwards and antepartum haemorrhage and clinical suspicion Nicholson of ECV and expectant management, if Trop J Obstet Gynaecol, 26 (2), October 2009.                                                                                               ISSN 0189 5178 Trop J Obstet Gynaecol, 26 (2), October 2009.                                                                                               ISSN 0189 5178122121of transverse lie. Other factors include poor routinely done in our centre, this is mainly due to .lack of experience with this technique  Although antenatal attendance by booked patients and routinely when scanning foetuses with unbooked patients presenting for the first time at transverse lie, the direction of the head, i.e. to labour.Seffah et al in a study of transverse lie right or left iliac fossa is recorded to aid the during labour, recorded a high rate of emergency Obstetrician contemplating an external cephalic CS of 92%, with a subsequent high incidence of version. A higher number of patients in this study maternal complications, still births and infants 8requiring hospital admission .He therefore had their head oriented towards the right iliac proffered that that early antenatal detection of fossa, although the significance of this is not predisposing factors by ultrasonography like certain, however a probable reason is that there p l a c e nta  p ra ev i a  co u l d  red u c e  s u c h  is right rotation of the uterus during pregnancy.complications.We would advocate that ECV, followed by Three patients spontaneously converted to stabilisation and induction of labour should be longitudinal lie at 39 weeks. The aforementioned encouraged in our environment. as an 3 patients converted to longitudinal lie and had alternative to CS for patients with transverse lie spontaneous vaginal delivery, despite detection at term, especially in multiparae with no obvious of transverse lie at 37weeks.Possible explanation predisposing factor seen on ultrasonography. proffered for this is that they might be in This would reduce the CS rate in patients with unstable lie, as suggested by Phelan et al who persistent transverse lie at term and its recorded spontaneous conversion rate as high as associated morbidity and can also provide an 83% to longitudinal lie In a study of 29 patients alternative route of delivery for women with  with transverse lie at 37weeks gestation and aversion to surgery particularly in our above, before labour using expectant environment.management. He therefore concluded that close monitoring of these patients till 39wks before Conclusiononset of labour is necessary to forestall surgery The incidence of 3.2% quoted for transverse lie in 6and its associated morbidity . this study is quite high compared to 1 in 300-500 observed in previous studies. This is most External cephalic version(ECV) followed by probably due to the fact that our centre is a stabilisation and induction of labour as been referral centre, and the aforementioned advocated as a safe technique for delivery of incidence in this study may not account for the patients in transverse lie at term in which there total number of transverse lie detected at term in are no predisposing etiology.It can reduce our environment. Placenta praevia was the 6,16. commonest finding on ultrasound as a associated morbidity with CS  In a study of ECV predisposing factor to transverse lie in our as an alternative to CS for labouring patients with environment. The mode of delivery of patients transverse lie after sonographic confirmation, a was essentially by CS, majority being emergency vaginal delivery rate of 50% was achieved, CS. However, ECV should be encouraged, thereby reducing caesarean section rate by 16. especially in patients with aversion to surgery 50%   Similarly, Devandra studied ECV as a and who have no obvious predisposing factors to technique for delivery of foetuses in transverse transverse lie that can prevent successful lie, in women 36 weeks and above, by version, since it can reduce significantly CS rate obstetricians with limited experience with ECV. and its associated morbidity in patients with Successful version was achieved in 45% of the persistent transverse lie at term.patients, with vaginal delivery achieved in 83% of 17those with successful version .  ECV is not References Eitan-Paldi. The grand-multipara  is it a problem. 1. Seeds JW, Walsh M. Malpresentation in Int J Gynecol Obstet, 1985;23:321-326obstetrics. In:Steven GG,Jennifer RN,Joe LS (Eds), 10. O g e d e n g b e  O K ,  O g u n m o k u n  A A :  Normal and Problem Pregnancies, 3rd edition, Grandmultiparity in Lagos, Nigeria. Niger Newyork: Churchill Livingstone 1995;469-468. Postgrad Med J. 2003 ;10:216- 219.2. Cunningham FG, Levano JK, Bloom LS, Hauth JC, 11. Ozumba B.C.Igwegbe A.O. The challenges of Gilstrap III LC, Wenstrom KP. Williams Obstetrics, grandmultiparity in Nigerian obstetrics practice. 22nd edition USA. Mcgrawhill companies, 2005; Int J Gynecol Obstet, 1992;37:259-264.511-512. 12. Edward RL, Nicholson HO. The management of 3. Cru ikshank DP,  White  CA.  Obstetr ics  the unstable lie in late pregnancy. J Obstet malpresentation: 20 years experience. Am J Gynecol 1969; 76: 719-720. Obstet Gynecol, 1973;116:1097. 13.  Fried AW, Cloutier M, Woodring JH, Shier RW: 4.  Lau WC, Fung HY, Lau TK, To KF: A benign Sonography of the transverse foetal lie. Am J polypoid adenomyoma: an unusual cause of Roentgen, 142:  421-423. persistent foetal transverse lie. Eur J Obstet 14. Eniola A.O, Bako A.Q. Selo Ojeme B.O. Risk for Gynecol Reprod Biol. 1997; 74:23-25.. placenta previa in Southern Nigeria. East Afr Med 5. Gemer O, Kopmar A, Sassoon E, Segal S.: J. 2002;79:535-538.Neglected transverse lie with uterine rupture. 15. Nel JT, Schaetzing AE: Foetal transverse position Arch Gynecol Obstet. 1993;252:159-60 caused by giant leiomyoma in the lower segment 6. Phelan J.P, Stine L.E, Boucher M, Mueller E, of the uterus. A case report. S Afr Med J. 1985; McCart D, Horenstein J, Clark SL. The non- 68:333-334.labouring transverse lie a management dilemma. 16. Phelan JP, Stine LE, Edwards NB, Clark SL, J Reprod Med 1986; 31:184-186. Horenstein J. The role of external version in the 7.  Corkburn KG, Drake RF.Transverse and oblique lie intrapartum management of the  transverse lie of the foetus. Aust NZ J Obstet Gynecol. 1968; presentation Am J Obstet Gynecol. 1985; 8:211. 151:724-6.8. Seffah JD Maternal and perinatal mortality and 17. Devendra K: Introducing routine external morbidity associated with transverse lie. Int J cephalic version for the management of the Gynecol Obstet, 1999; 65:11-15.   malpresenting fetus near term. Med J Malaysia. 9. Kanfuchs,bezalel-Alik-Peretz,Rami Marcovici, 2002; 57:454-459.Trop J Obstet Gynaecol, 26 (2), October 2009.                                                                                               ISSN 0189 5178 Trop J Obstet Gynaecol, 26 (2), October 2009.                                                                                               ISSN 0189 5178

Evaluation of Transverse Lie at Term by Ultrasonography

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Evaluation of Transverse Lie at Term by Ultrasonography

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