Pregnancy loss in the third-timester in patients with sickle cell trait: Is it time for a...
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279 SAFETY AND EFFICACY OF MISOPROSTOL FOR SECOND-TRIMESTER PREGNANCY TERMINATION: EFFECT OF PRIOR CESAREAN SECTION LARA FRIEL 1 , MEREDITH ROCHON 1 , CYNTHIA GYAMFI 1 , ADAM JACOBS 1 , 1 Mount Sinai School of Medicine, Obstetrics, Gynecology, and Reproductive Science, New York, New York OBJECTIVE: To assess the safety and efficacy of misoprostol for second- trimester pregnancy termination in patients with a prior cesarean section using a meta-analysis of published studies. STUDY DESIGN: Studies were identified using a medline search from 1966- 2004, limited to english language and human subjects. Keywords included: misoprostol, second-trimester, termination, abortion, cesarean or cesarean section, and uterine rupture. Prospective studies using misoprostol as the sole induction agent for second-trimester medical termination were included if data regarding patient’s prior obstetrical history and termination outcomes could be obtained from the authors. Primary safety outcomes include uterine rupture, maternal death, need for laparotomy, or blood transfusion. Primary efficacy outcomes include time to delivery and cumulative dose of misoprostol. RESULTS: Eight studies were identified with these inclusion criteria for a total of 878 subjects, 98 (12.6%) of which had a history of a previous cesarean section (Prev C/S). When compared with women who had not had a previous cesarean section (No C/S), those in the Prev C/S group were significantly older (33.3 vs. 28.3 yrs, P ! .001). There was no difference in gestational age at time of procedure (19.4 vs. 19.0 wks, range 13-28 weeks). Mean time to delivery as well as mean total dose of misoprostol were higher in the Prev C/S group (1282 vs. 957 min, P ! .001 and 1635 vs. 1152 mg, P ! .001, respectively). There were no uterine ruptures or maternal deaths in either group. One patient in the Prev C/S group required hysterectomy and a blood transfusion secondary to intractable postpartum hemorrhage; this patient had histologically confirmed placenta accreta. CONCLUSION: Misoprostol is safe and effective for induction between 13 and 28 weeks in patients with a history of previous cesarean section. 280 SPONTANEOUS VERSION WITH PRETERM PREMATURE RUPTURE OF MEMBRANES LINDA FONSECA 1 , MANJU MONGA 2 , 1 University of Texas Health Science Center at Houston, Obstetrics, Gynecology and Reproductive Sciences, Houston, Texas, 2 University of Texas Health Science Center at Houston, Houston, Texas OBJECTIVE: The rate of non-cephalic presentation at delivery decreases with gestational age (25% at 28 weeks, 7% at 32 weeks and 3% at term). The rate of spontaneous version from non-cephalic presentation following preterm pre- mature rupture of membranes (PPROM) is not well documented. Our objective was to determine the rate of spontaneous version following PPROM. STUDY DESIGN: Medical charts of women hospitalized over a four year period with PPROM at a tertiary care hospital were reviewed. All women with singleton gestation between 24-34 weeks gestation were included. Fetal pre- sentation, gestational age at PPROM, gestational age on admission, and fetal presentation at delivery were recorded. Other data obtained from the medical chart included age, race, parity, admission amniotic fluid index (AFI), gestational age at delivery, indication for delivery, and delivery route. De- scriptive statistics and Fisher exact test were used for analysis. RESULTS: 65 patients met the inclusion criteria during this study period. Median maternal age was 28 (range, 17-45). Median parity was 1 (range, 0-6). The population was 40% African-American, 35.4% Hispanic, 21.5% Caucasian, and 3.1% other. Mean gestational age at admission was 29.5 G 3.4 weeks. By ultrasound on admission, 48 had cephalic presentation, 16 were breech, and one was transverse lie. Mean AFI on admission was 5.1 G 4.8 cm. Mean gestational age at delivery was 30 G 3.2 weeks and mean birth weight was 1675 G 568 g. Indication for delivery included labor (58.5%), induction >34 weeks (15.4%), chorioamnionitis (12.3%), abnormal fetal heart rate (10.8%), and abruption (3.1%). Spontaneous version from cephalic presentation at admission to non- cephalic presentation at delivery occurred in 1 pregnancy (2.2%). Spontaneous version from non-cephalic presentation at admission to cephalic presentation at delivery occurred in 3 pregnancies (17.6%, P = .05). Among women with non- cephalic presentation at delivery (n = 15), 73.3% had a cesarean section. CONCLUSION: Spontaneous version, particularly from cephalic to non- cephalic presentation, is unlikely following PPROM. 281 TWINS: ARE THERE DIFFERENCES IN MATERNAL OUTCOME BETWEEN ASSISTED REPRODUCTIVE TECHNOLOGY VERSUS SPONTANEOUS GESTATIONS? HARISH SEHDEV 1 , NILS STENMAN 1 , SORAYA ABBASI 1 , JACK LUDMIR 2 , 1 Pennsylvania Hospital, University of Pennsylvania Health System, Obstetrics and Gynecology, Philadelphia, Pennsylvania, 2 Pennslyvania Hospital, University of Pennsylvania Health System, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: To determine if there are differences in maternal outcomes between twin pregnancies conceived by assisted reproductive techniques (ART) and those that are conceived spontaneously. STUDY DESIGN: Retrospective chart review of all twins delivered over 24 weeks gestational age in one tertiary care center over a 5 year period. Charts were reviewed for maternal demographics, method of conception, and ante- partum and delivery outcomes. Statistical analysis was done by Student’s t test, c 2 , and ANOVA. RESULTS: A total of 478 twin gestations were analyzed. Group A (ART) consisted of 117 twin gestations, and Group B (spontaneous conceptions) consisted of 359 twin gestations. The average gestational age at delivery and birthweight were not statistically different for the 2 groups respectively (33.7 weeks and 2127.9 g vs 34.2 weeks and 2120.4 g). Maternal outcomes are described on the table. CONCLUSION: Maternal outcome in twin gestations conceived through ART was similar to that of spontaneously conceived twin gestations. Maternal outcomes Group A Goup B P value Maternal age 34.9 G 5.0 29.1 G 6.0 .01 Nulliparity 79.5% 58.4% .01 Caucasian 85% 43% .01 PIH 12.9% 10.2% .4 C/Section 72.8% 55.6% .01 PPROM 17.6% 16.5% .76 Chorio 4.0% 3.1% .29 Del !32 wk 21% 18.1% .18 282 PREGNANCY LOSS IN THE THIRD-TIMESTER IN PATIENTS WITH SICKLE CELL TRAIT: IS IT TIME FOR A REAPPRAISAL? MICHELLE TAYLOR 1 , JOSEPHINE WYATT-ASHMEAD 2 , JULIE CUSHMAN 1 , JAMES BOFILL 1 , RICK MARTIN 1 , JOHN MORRISON 1 , 1 University of Mississippi Medical Center, Obstetrics & Gynecology, Jackson, Mississippi, 2 University of Mississippi Medical Center, Pathology, Jackson, California OBJECTIVE: To determine obstetric outcome and pathology correlates in pregnant women with sickle cell trait. STUDY DESIGN: Over 18 months, the placentas of 131 pregnancies with sickle cell trait (confirmed by hemoglobin electrophoreses) were sent for pathologic examination in this prospective case series investigation. Obstetric and perinatal/ early neonatal information was gathered on each pregnancy. RESULTS: The pregnant women, all African American, had an average age of 23.9 years (range 15-40). The average gestational age at delivery was 30.1 weeks (range 14.9-40.8). The majority of pregnancies were singleton (123) with eight twin gestations. Of these 131 gestations, 16% had documented hypertension. Only 10.6% had recognizable clinical IUGR. Meconium histiocytosis was noted in 92%. Acute ascending amniotic fluid infection was noted in 50%. All placentas had massive sickling in the intervillous space but, unexpectedly, sickling was also evident in the decidual vessels (especially venous channels). Infarctions in the placental body were noted in 12% and pale/bland infarcts in the decidua were noted in at least 90%. Retroplacental hemorrhage was noted in 9%. but this finding correlated with only four of the IUFD’s (infarction) and one (retroplacental hemorrhage) respectively. There were 11 third-trimester perinatal deaths (8%) due to retroplacental hemorrhage, placental infarction, and acute ascending amniotic fluid infection. All of the babies autopsied had asymmetric growth retardation (brain weight/liver weight ratio >4/1). CONCLUSION: Sickling in the decidual vessels and poor placental perfusion may play a role in pregnancy loss after the first trimester in excess of what has previously been reported. A cohort control study comparing such women to women with normal hemoglobin appears to be in order. SMFM Abstracts S85
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Transcript of Pregnancy loss in the third-timester in patients with sickle cell trait: Is it time for a...
279 SAFETY AND EFFICACY OF MISOPROSTOL FOR SECOND-TRIMESTER PREGNANCYTERMINATION: EFFECT OF PRIOR CESAREAN SECTION LARA FRIEL1, MEREDITHROCHON1, CYNTHIA GYAMFI1, ADAM JACOBS1, 1Mount Sinai School of Medicine,Obstetrics, Gynecology, and Reproductive Science, New York, New York
OBJECTIVE: To assess the safety and efficacy of misoprostol for second-trimester pregnancy termination in patients with a prior cesarean section usinga meta-analysis of published studies.
STUDY DESIGN: Studies were identified using a medline search from 1966-2004, limited to english language and human subjects. Keywords included:misoprostol, second-trimester, termination, abortion, cesarean or cesareansection, and uterine rupture. Prospective studies using misoprostol as the soleinduction agent for second-trimester medical termination were included if dataregarding patient’s prior obstetrical history and termination outcomes could beobtained from the authors. Primary safety outcomes include uterine rupture,maternal death, need for laparotomy, or blood transfusion. Primary efficacyoutcomes include time to delivery and cumulative dose of misoprostol.
RESULTS: Eight studies were identified with these inclusion criteria for a totalof 878 subjects, 98 (12.6%) of which had a history of a previous cesarean section(Prev C/S). When compared with women who had not had a previous cesareansection (No C/S), those in the Prev C/S group were significantly older (33.3 vs.28.3 yrs, P ! .001). There was no difference in gestational age at time ofprocedure (19.4 vs. 19.0 wks, range 13-28 weeks). Mean time to delivery as wellas mean total dose of misoprostol were higher in the Prev C/S group (1282 vs.957 min, P ! .001 and 1635 vs. 1152 mg, P ! .001, respectively). There were nouterine ruptures or maternal deaths in either group. One patient in the Prev C/Sgroup required hysterectomy and a blood transfusion secondary to intractablepostpartum hemorrhage; this patient had histologically confirmed placentaaccreta.
CONCLUSION: Misoprostol is safe and effective for induction between 13 and28 weeks in patients with a history of previous cesarean section.
280 SPONTANEOUS VERSION WITH PRETERM PREMATURE RUPTURE OF MEMBRANESLINDA FONSECA1, MANJU MONGA2, 1University of Texas Health Science Center atHouston, Obstetrics, Gynecology and Reproductive Sciences, Houston, Texas,2University of Texas Health Science Center at Houston, Houston, Texas
OBJECTIVE: The rate of non-cephalic presentation at delivery decreases withgestational age (25% at 28 weeks, 7% at 32 weeks and 3% at term). The rate ofspontaneous version from non-cephalic presentation following preterm pre-mature rupture of membranes (PPROM) is not well documented. Our objectivewas to determine the rate of spontaneous version following PPROM.
STUDY DESIGN: Medical charts of women hospitalized over a four yearperiod with PPROM at a tertiary care hospital were reviewed. All women withsingleton gestation between 24-34 weeks gestation were included. Fetal pre-sentation, gestational age at PPROM, gestational age on admission, and fetalpresentation at delivery were recorded. Other data obtained from the medicalchart included age, race, parity, admission amniotic fluid index (AFI),gestational age at delivery, indication for delivery, and delivery route. De-scriptive statistics and Fisher exact test were used for analysis.
RESULTS: 65 patients met the inclusion criteria during this study period.Median maternal age was 28 (range, 17-45). Median parity was 1 (range, 0-6).The population was 40% African-American, 35.4% Hispanic, 21.5% Caucasian,and 3.1% other. Mean gestational age at admission was 29.5 G 3.4 weeks. Byultrasound on admission, 48 had cephalic presentation, 16 were breech, and onewas transverse lie. Mean AFI on admission was 5.1 G 4.8 cm. Mean gestationalage at delivery was 30 G 3.2 weeks and mean birth weight was 1675 G 568 g.Indication for delivery included labor (58.5%), induction >34 weeks (15.4%),chorioamnionitis (12.3%), abnormal fetal heart rate (10.8%), and abruption(3.1%). Spontaneous version from cephalic presentation at admission to non-cephalic presentation at delivery occurred in 1 pregnancy (2.2%). Spontaneousversion from non-cephalic presentation at admission to cephalic presentation atdelivery occurred in 3 pregnancies (17.6%, P = .05). Among women with non-cephalic presentation at delivery (n = 15), 73.3% had a cesarean section.
CONCLUSION: Spontaneous version, particularly from cephalic to non-cephalic presentation, is unlikely following PPROM.
281 TWINS: ARE THERE DIFFERENCES IN MATERNAL OUTCOME BETWEEN ASSISTEDREPRODUCTIVE TECHNOLOGY VERSUS SPONTANEOUS GESTATIONS? HARISHSEHDEV1, NILS STENMAN1, SORAYA ABBASI1, JACK LUDMIR2, 1PennsylvaniaHospital, University of Pennsylvania Health System, Obstetrics andGynecology, Philadelphia, Pennsylvania, 2Pennslyvania Hospital, University ofPennsylvania Health System, Obstetrics and Gynecology, Philadelphia,Pennsylvania
OBJECTIVE: To determine if there are differences in maternal outcomesbetween twin pregnancies conceived by assisted reproductive techniques (ART)and those that are conceived spontaneously.
STUDY DESIGN: Retrospective chart review of all twins delivered over 24weeks gestational age in one tertiary care center over a 5 year period. Chartswere reviewed for maternal demographics, method of conception, and ante-partum and delivery outcomes. Statistical analysis was done by Student’s t test,c2, and ANOVA.
RESULTS: A total of 478 twin gestations were analyzed. Group A (ART)consisted of 117 twin gestations, and Group B (spontaneous conceptions)consisted of 359 twin gestations. The average gestational age at delivery andbirthweight were not statistically different for the 2 groups respectively (33.7weeks and 2127.9 g vs 34.2 weeks and 2120.4 g). Maternal outcomes aredescribed on the table.
CONCLUSION: Maternal outcome in twin gestations conceived through ARTwas similar to that of spontaneously conceived twin gestations.
Maternal outcomes
Group A Goup B P value
Maternal age 34.9 G 5.0 29.1 G 6.0 .01Nulliparity 79.5% 58.4% .01Caucasian 85% 43% .01PIH 12.9% 10.2% .4C/Section 72.8% 55.6% .01PPROM 17.6% 16.5% .76Chorio 4.0% 3.1% .29Del !32 wk 21% 18.1% .18
SMFM Abstracts S85
282 PREGNANCY LOSS IN THE THIRD-TIMESTER IN PATIENTS WITH SICKLE CELL TRAIT:IS IT TIME FOR A REAPPRAISAL? MICHELLE TAYLOR1, JOSEPHINE WYATT-ASHMEAD2,JULIE CUSHMAN1, JAMES BOFILL1, RICK MARTIN1, JOHN MORRISON1, 1University ofMississippi Medical Center, Obstetrics & Gynecology, Jackson, Mississippi,2University of Mississippi Medical Center, Pathology, Jackson, California
OBJECTIVE: To determine obstetric outcome and pathology correlates inpregnant women with sickle cell trait.
STUDY DESIGN: Over 18 months, the placentas of 131 pregnancies with sicklecell trait (confirmed by hemoglobin electrophoreses) were sent for pathologicexamination in this prospective case series investigation. Obstetric and perinatal/early neonatal information was gathered on each pregnancy.
RESULTS: The pregnant women, all African American, had an average age of23.9 years (range 15-40). The average gestational age at delivery was 30.1 weeks(range 14.9-40.8). The majority of pregnancies were singleton (123) with eighttwin gestations. Of these 131 gestations, 16% had documented hypertension.Only 10.6% had recognizable clinical IUGR. Meconium histiocytosis was notedin 92%. Acute ascending amniotic fluid infection was noted in 50%. Allplacentas had massive sickling in the intervillous space but, unexpectedly,sickling was also evident in the decidual vessels (especially venous channels).Infarctions in the placental body were noted in 12% and pale/bland infarcts inthe decidua were noted in at least 90%. Retroplacental hemorrhage was noted in9%. but this finding correlated with only four of the IUFD’s (infarction) and one(retroplacental hemorrhage) respectively. There were 11 third-trimester perinataldeaths (8%) due to retroplacental hemorrhage, placental infarction, and acuteascending amniotic fluid infection. All of the babies autopsied had asymmetricgrowth retardation (brain weight/liver weight ratio >4/1).
CONCLUSION: Sickling in the decidual vessels and poor placental perfusionmay play a role in pregnancy loss after the first trimester in excess of what haspreviously been reported. A cohort control study comparing such women towomen with normal hemoglobin appears to be in order.
