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Oral Concurrent Session 3 www.AJOG.orgThursday, February 10, 2011 • 1:15 pm – 3:30 pm • Continental 6-9, Hilton San Francisco

CLINICAL OBSTETRICS

Abstracts 27 – 35

Moderators: Donna Johnson, MD; Dan O’Keeffe, MD

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27 17 alpha-hydroxyprogesterone caproate inomen with previous preterm delivery: does arevious term delivery influence effectiveness?

John R. Barton1, Lucy A. Barton2, Niki Istwan3,Debbie Rhea3, Cheryl Desch3, Baha Sibai4

1Central Baptist Hospital, Lexington, KY, 2College of Charleston, Charleston,SC, 3Alere Health, Atlanta, GA, 4University of Cincinnati, Cincinnati, OHOBJECTIVE: To determine whether 17 alpha-hydroxyprogesterone ca-

roate (17P) is equally effective when given to women with a history ofpontaneous preterm delivery with or without a concomitant termelivery.

STUDY DESIGN: Women enrolled in an outpatient 17P administrationprogram with singleton gestations and a history of spontaneous pre-term delivery initiating 17P at �25 weeks were studied. Maternalcharacteristics and the rates of recurrent spontaneous preterm deliv-ery were compared for women with �1 spontaneous preterm deliverywith and without history of at least one prior term delivery. Outcomeswere compared using Chi square and logistic regression analysis.RESULTS: A total of 5102 had 1 previous spontaneous preterm deliverynd 2217 had �1 spontaneous preterm delivery. In women with onlyprior spontaneous preterm delivery, those with a history of a termelivery had significantly lower rates of recurrent spontaneous pre-erm delivery at �35 and �32 weeks compared to those without suchhistory. In contrast, no such differences were found in those womenith �1 prior spontaneous preterm delivery (Table, SPTD � spon-

aneous preterm delivery, RSPTD � recurrent spontaneous pretermelivery). Logistic model results adjusting for confounding factorsith recurrent spontaneous preterm delivery �37 week as dependentariable for 1 prior spontaneous preterm delivery revealed a history ofrior term birth remained significantly associated with lower rate ofecurrent spontaneous preterm delivery (p�0.009); a marginal asso-iation was found for those with �1 prior spontaneous preterm de-ivery (p�0.057).

CONCLUSIONS: In patients receiving 17P because of a history of 1 priorpontaneous preterm delivery, a previous term delivery confers a re-uction in risk for recurrent preterm delivery at �37, �35 and �32eeks’ gestation, however such reduction in risk is not evident for

hose patients with history of �1 prior spontaneous preterm delivery.

Previous Term

1 Prior SPTD >1 Prior SPTD

Yes No Yes No

of patients 1579 3523 729 1488...........................................................................................................................................................................................................

GA at 17P start (wk) 18.8 � 2.4 18.7 � 2.4 19.0 � 2.5 18.9 � 2.5...........................................................................................................................................................................................................

Total injections 17P 15.9 � 4.3 15.9 � 4.3 14.9 � 4.8 15.1 � 4.7...........................................................................................................................................................................................................

RSPTD �37 wk (%) 23.9 27.5* 33.5 28.9*...........................................................................................................................................................................................................

RSPTD �35 wk (%) 8.4 11.2** 16.2 17.5...........................................................................................................................................................................................................

RSPTD �32 wk (%) 3.9 5.2*** 7.5 7.9...........................................................................................................................................................................................................

* �p�0.05, ** �p�0.005, *** �p�0.05

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28 Obstetric outcomes and maternal satisfaction usingatient controlled epidural analgesia in nulliparous women

Michael Haydon1, David Larson1, Enrique Reed1, Vineethrivastava1, Christine Preslicka1, Michael Nageotte1

1Long Beach Memorial Medical Center, Long Beach, CAOBJECTIVE: Patient-controlled epidural analgesia (PCEA) has beenhown to reduce local anesthetic use during labor. It is unclear ifbstetric outcomes and maternal satisfaction are improved with these of PCEA. Our aim was to compare obstetric outcomes and ma-

ernal satisfaction in nulliparous women in spontaneous labor usingCEA vs continuous epidural infusion (CEI).

STUDY DESIGN: We conducted a double-masked trial in which 270nulliparous women were randomized to one of three groups. Initially,an intrathecal dose of 2 mg bupivicaine/20mcg fentanyl was givenfollowed by maintenance epidural infusion 0.1% bupivicaine/2mcg/ml fentanyl. Group 1 CEI background only (10 mls/hr); Group 2CEI�PCEA(CEI at 10 ml/hr plus PCEA 10 ml, 20 min lockout; Group3 PCEA only (PCEA 10 ml, 20 min lockout). PCEA bolus button wasgiven to each subject and the pump acknowledged the request regard-less of group assignment. The primary outcome was dosage of localanesthetic used. Secondary outcomes include obstetric outcomes andmaternal satisfaction.RESULTS: Total mg bupivicaine used was less in the PCEA only groupompared to CEI; group 1 (74.9 � 36 mg), group 2 (95.9 � 52 mg),roup 3 (52.8 � 42 mg) p�.001. No differences were seen in total time

of labor; group 1 (8.4 hr), group 2 (7.9 hr), group 3 (8.0 hr) or cesareandelivery; group 1 (26/87), group 2 (23/84), and group 3 (22/85). Num-ber of instrumented vaginal deliveries was slightly higher in subjectswith a continuous background infusion; group 1 (8/87), group 2 (8/84), group 3 (3/85). Neither lower extremity strength or urge to pushwere affected by method of epidural. Pain with pushing, however, wasworse in PCEA only. Median satisfaction scores were similar; 0 (best)-100(worst); group 1: 0 (0-100), group 2: 0 (0-100), group 3: 0 (0-100).CONCLUSIONS: PCEA results in less anesthetic used and maternal sat-sfaction remains high without a continuous infusion. Cesarean de-ivery and time of labor are unaffected by using PCEA alone. Thereas a trend toward reduction in instrumented vaginal deliveries in theCEA only group.

29 Neonatal morbidities in a multicenterandomized trial of ultrasound-indicatederclage for shortened cervical length (CL)

John Owen1, Jeff Szychowski1, for theaginal Ultrasound Consortium2

1University of Alabama at Birmingham, Birmingham, AL, 2MulticenterOBJECTIVE: To estimate the effect of ultrasound-indicated cerclage on

eonatal (NN) morbidities.STUDY DESIGN: Planned secondary analysis of the NICHD-sponsored

ulticenter cerclage trial. Women with �1 prior spontaneous pre-erm birth 17-33 wks underwent serial CL measurements and ran-omized to cerclage or no cerclage for CL�25 mm between 16-226/7

wks. The primary outcome was a composite, any of: severe RDS,chronic lung disease, confirmed sepsis, NEC, or grades 3-4 IVH. Sinceperinatal death was previously reported it was excluded from morbid-ity assessment. Outcomes were compared by intent to treat.RESULTS: Of 302 maternal-fetal dyads randomized, 300 cases had suf-

cient NN information for analysis; 38 experienced a perinatal death

ent to JANUARY 2011 American Journal of Obstetrics & Gynecology S17

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Oral Concurrent Session 3 Clinical Obstetrics www.AJOG.org

(13, cerclage; 25, no-cerclage, p�0.046). Of the 262 survivors, themean birth GA for the cerclage group, 36.2, was similar to the no-cerclage group, 35.7 (p�0.3), and 87 were admitted to the NICU. Theremaining 175 went to a continuing care nursery, and none experi-enced any components of the NN composite. Of those admitted toNICU, the mean birth GA for the cerclage and no-cerclage groupswere 32.3 and 31.5 wks respectively (p�0.35). Rates of compositemorbidity, NICU admission and components of the composite mor-bidity are shown in the Table.CONCLUSIONS: Ultrasound-indicated cerclage for CL�25 mm was as-sociated with a null effect on NN composite morbidity in survivinginfants.

Outcome (N�262) Cerclage (52%) No-cerclage (48%) p

Composite Morbidity 13 (10%) 15 (12%) 0.57..........................................................................................................................................................................................

Severe RDS 10 (7%) 10 (8%) 0.89..........................................................................................................................................................................................

Chronic lung Disease 7 (5%) 6 (5%) 0.86..........................................................................................................................................................................................

Sepsis 4 (3%) 8 (6%) 0.20..........................................................................................................................................................................................

NEC 1 (1%) 1 (1%) 1.00..........................................................................................................................................................................................

Grades 3-4 IVH 0 (0) 1 (1%) 0.48..........................................................................................................................................................................................

NICU admission 34% 33% 0.76..........................................................................................................................................................................................

Mean NICU Stay (days) 31.7 (35.4) 37.1 (31.9) 0.46..........................................................................................................................................................................................

30 New thresholds for significant intratwinrowth discordance: results of the prospectiveulticenter ESPRiT study

Fionnuala Breathnach1, Fionnuala McAuliffe2, Fiona Manning1,tephen Carroll3, Fergal Malone1, Michael Geary4, Seanaly5, John Higgins6, James Dornan7, John J Morrison8,erard Burke9, Shane Higgins10, Patrick Dicker1

1Royal College of Surgeons in Ireland, Dublin, 2UCD School of Medicine andMedical Science, National Maternity Hospital, Holles St, Dublin, 3National

aternity Hospital, Dublin, 4Rotunda Hospital, Dublin, 5Coombe Womenand Infants University Hospital, Dublin, 6Cork University MaternityHospital, Cork, 7Royal Victoria Maternity Hospital, Belfast, 8University

ollege Hospital Galway, Galway, 9Graduate Entry Medical School,niversity of Limerick, Limerick, 10Our Lady of Lourdes Hospital, Drogheda

OBJECTIVE: To determine the level of intratwin birthweight (BW) dis-ordance at which perinatal mortality and severe morbidity increasen monochorionic and dichorionic twin pregnancy.

STUDY DESIGN: This prospective multicenter study included 1028 un-selected twin pairs recruited over a 2-year period in one country. Allparticipants underwent 2-weekly intensive sonographic surveillanceby a team of highly-trained sonographers, from 24 weeks’ gestation,with surveillance of monochorionic (MC) twins 2-weekly from 16weeks. All perinatal outcomes were entered onto a central consoli-dated database. Analysis using Cox proportional hazards was con-ducted to compare perinatal mortality and a composite measure ofperinatal morbidity (respiratory distress syndrome/ hypoxic ischemicencephalopathy/ periventricular leukomalacia /necrotising enteroco-litis/ sepsis) at different degrees of birthweight discordance, with ad-justment for chorionicity and gestational age at delivery.RESULTS: Complete study data was available for 1001 women. Cho-ionicity was assigned as mono-or dichorionic (DC) in 19% (192/001) and 81% (809/1001) of pregnancies, respectively. Pre-viabilityingle or dual fetal demise was identified in 24 pairs, such that peri-atal outcome was recorded for 100% (977) patients who continued

he study with both fetuses alive beyond 24 weeks’ gestation. MeanW discordance was 13.2% (range 0.1% to 53%) and 11.4% (range% to 58%) for MC and DC twin pairs, respectively. Adjusting forestational age at delivery, perinatal mortality, individual and com-osite perinatal morbidity were all seen to increase in association with

ntratwin birthweight discordance in excess of 14% for monochori-nic pairs (Hazard ratio�2.04, p�0.006) and 17% for dichorionic

airs (Hazard ratio�2.08, p �0.0001).

S18 American Journal of Obstetrics & Gynecology Supplement to JANUARY 20

CONCLUSIONS: The degree of intratwin birthweight discordance whicherves as an independent predictor of perinatal mortality or severe

orbidity is 14% for monochorionic pairs and 17% for dichorionicwins. This threshold for significant discordance is considerably lowerhan that defined by retrospective series as pathologic.

Figure 1: Kaplan-Meier morbidity-free survival curves

31 Effects of a shoulder dystocia managementrotocol on the incidence of brachial plexus injury

Steven R. Inglis1, Nikolaus Feier1, Jyothi Chetiyaar1,argaret Naylor1, Melanie Sumersille1,elly Cervellione1, Mladen Predanic1

1Jamaica Hospital Medical Center, New York, NYOBJECTIVE: To determine whether implementation of a Shoulder Dys-ocia (SD) management protocol (Code D) reduces the incidence ofbstetric brachial plexus injury (OBPI).

STUDY DESIGN: After implementation of mandatory Shoulder Dysto-ia training to all labor and delivery staff, the incidence of OBPI wasompared between pre-training (no Code D) (August 2003 to August006; n � 83) and post-training (Code D) (September 2006 to Sep-ember 2008; n � 54) periods, in deliveries complicated by SDn�number of cases of Shoulder Dystocia). SD management tech-iques and incidence of OBPI were compared using both univariatend multivariate analyses.

RESULTS: There were 6,192 and 3,240 deliveries in the study groupsuring pre-training and post-training periods, respectively. There wassignificant overall reduction of incidence of OBPI from 0.4% (25/

192) before Code D to 0.19% (6/3240) after Code D implementationp�0.02). As well, the rate of OBPI during SD dropped from 30%25/83) to 11% (6/54) with Code D (p�0.01). There was a significantecrease in maternal BMI (p�0.01) and fetal weight (p�0.02) and an

ncrease in the rate of Shoulder Dystocia (p�0.05 reaching statisticalignificance) in Code D group. This suggests that due to a heightenedwareness of Shoulder Dystocia the diagnosis is made more frequentlynd more quickly after Shoulder Dystocia Training. There was signif-cant decrease (p�0.05) in the use of McRobert’s Maneuver and in-rease in lateral position (p�0.05) with Code D. There is no signifi-ant difference in gestational age at delivery, number of induced andugmented labors and epidural anesthesia in both the groups. As an-icipated, the head to body delivery time increased from 1.51minSD�1.37) to 2min (SD�1.34) in Code D group. After regressionnalysis, only Code D remained associated with reduction of OBPIp�0.04).

CONCLUSIONS: A SD management protocol for maternity staff appearso increase awareness of Shoulder Dystocia. More importantly, it re-uces the overall incidence of OBPI in our patients and also reduceshe incidence of OBPI in births complicated by SD.

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