445 OBSTETRICAL OUTCOMES ASSOCIATED WITH LAPAROSCOPIC-ASSISTED ABDOM-INAL CERCLAGE: AN OBSERVATIONAL STUDY W WHITTLE (F)1, L GLAUDE2,J THOMAS2, L ALLEN2, S KEATING3, R WINDRIM1, 1Mount Sinai Hospital, Ob-stetrics and Gynecology; Division of Maternal Fetal Medicine, Toronto, On-tario, Canada, 2Mount Sinai Hospital, Obstetrics and Gynecology, Toronto,Ontario, Canada, 3Mount Siani Hospital, Pathology and Laboratory Medi-cine, Toronto, Ontario, Canada

OBJECTIVE: Abdominal cerclage is utilized as a management strategy forthe true incompetent cervix with previous failed vaginal cerclage; recently thelaparoscopic approach to abdominal cerclage placement has been introduced.

STUDY DESIGN: The objective of this observational study was to determinethe obstetrical outcome associated with laparoscopic-assisted abdominalcerclage.

RESULTS: 10 cerclages were placed pre-pregnancy and the remaining 17cerclages were placed in the first trimester of the index pregnancy. 3 cases wereconverted from laparoscopy to laparotomy due to technical difficulties; noother surgical complications were reported. 30 pregnancies have occurred with27 extending beyond the first trimester. 1 pregnancy is currently ongoing. 67%(18/27) of pregnancies were delivered at O32w gestation (mean 36.5w; range32-39w) due to either idiopathic preterm labor or elective term delivery; noperinatal deaths or longterm neonatal complications were reported. 8 preg-nancies (30%) were delivered at !32w with a mean gestational age of 24w(range 17-29w); 4 pregnancies were delivered previablilty (!24w) and 1 neo-natal death occurred following delivery at 25w. 6 pregnancies were deliveredsecondary to clinical chorioamnionitis; placental pathology revealed severechorioamnionitis in each case with no evidence of other pathologies includingischemic-thrombotic damage. 5 of these cases presented as a cerclage failurewith a short/dilated cervix and underwent rescue vaginal cerclage; all 6 caseswere delivered within 2w of presentation regardless of management. 2pregnancies were delivered secondary to idiopathic preterm labor; placentalpathology revealed acute abruption in 1 case. The timing of the cerclageplacement did not influence obstetrical outcome.

CONCLUSION: The laparoscopic assisted abdominal cerclage is associatedwith w70% successful pregnancy outcome. However, the incompetent cervixappears to encompass a spectrum of disease for which, in the extremecircumstance, an abdominal cerclage may not prevent the cervical failurethat leads to preterm birth.

S130 SMFM Abstracts

443 CERCLAGE UTILIZATION IN THE NEW MILLENNIUM: COMPARISON OF A COMMU-NITY AND UNIVERSITY HOSPITAL DANIEL STEWART1, MILDRED RAMIREZ1,MARK TURRENTINE2, 1University of Texas Health Science Center at Houston,Department of Obstetrics, Gynecology and Reproductive Sciences, Houston,Texas, 2Kelsey-Seybold Clinic, Department of Obstetrics & Gynecology,Houston, Texas

OBJECTIVE: Despite frequent utilization of cerclage, randomized prospec-tive trials have shown no overall significant reduction in the risk of pregnancyloss. No data is available regarding current clinical practices of obstetrician’sindications for cerclage placement. The purpose of this study was to comparethe indications of cerclage between a community and university hospital.

STUDY DESIGN: A retrospective review of cerclage utilization from 1/1/2000 through 12/31/ 2001 was performed at two obstetrical centers. One acommunity hospital (CH) with no obstetrical residents and private physicians.The other is associated with a university-based obstetrics and gynecologyresidency program. Both have level III nurseries and maternal-fetal-medicinephysicians on staff. Data was analyzed using two-by-two tables, significancewas considered if p ! .05.

RESULTS: 387 cerclages (2.4% of deliveries) were placed at the CH com-pared to the 19 (0.3% of deliveries) at the university hospital (UH), p !. 05.No significant (NS) difference was noted in the number of cerclages placed by aMFM physician at the CH (40.6%) versus (vs) the UH (68.4%). The CHpatients were older (31 vs 27 years), more likely to be Caucasian (53.7% vs21.1%), and have private insurance (95.9% vs 42.1%), p!0.5. NS differencewas seen in the median gravidity (3 vs 4) or the number of nulligravid receivinga cercalge (13.4% vs 0%). A significant difference for cerclage indication wasnoted in women with R two 2nd trimester losses of which 57.9% (n=11) wereperformed at UH compared to 24.8% (n=96) at the CH, p ! .05.) NSdifference was seen between the CH vs. UH for previous cerclage 23.5%(n=91) vs. 26.3% (n=5); short cervix 13.7% (n=53) vs. 0%; history of LEEPor cone 17.6% (n=68) vs 5.3% (n=1); or multiple gestations 11.4% (n=44)vs 10.5% (n=2).

CONCLUSION: Cerclage is commonly performed (1/40 deliveries) in acommunity hospital as compared to a univeristy hospital. Randomizedcontrolled trials are needed to optimize utilization of cerclage and minimizepotential over-utilization of this procedure.

444 THE MFMU CESAREAN REGISTRY: VBAC SUCCESS AND COMPLICATION RATESFOLLOWING ONE PREVIOUS CESAREAN FOR MULTIFETAL GESTATIONMICHAEL VARNER1, 1for the NICHD MFMU Network, Bethesda, Maryland

OBJECTIVE: To determine the success and complication rates of womenattempting a trial of labor (TOL) following one previous cesarean delivery(CD) for a multifetal gestation.

STUDY DESIGN: This is a secondary analysis of a four-year prospectiveobservational study (1999-2002) of all women with prior CD undergoing aTOL at 19 centers. Women with viable singleton pregnancies and one priorlow transverse CD for twins or triplets were compared with those having aprior CD in a single gestation. Labor outcomes and perinatal complicationswere compared. A p-value !0.05 was considered significant.

RESULTS: Of 1,119 women with a prior CD for multifetal gestation,646 women underwent a TOL (623 prior twins, 23 prior triplets). Comparedwith women who had one prior CD in a singleton pregnancy (N = 16,263),study women were more likely to have had at least one previous vaginaldelivery (62.3% vs 49.2%, p!0.0001) and were more likely to have asuccessful TOL in the current pregnancy (85.1% vs 73.4%, p!0.0001). Studypatients had no increased risk of atony, endometritis, uterine rupture or anyother peripartum complications. Study patients who had a failed TOL wereless likely to have had a previous vaginal delivery (35.8% vs 67.0%, p!0.0001)or a vaginal delivery after their prior CD (15.1% vs 37.5%, p!0.0001) butwere not different in any demographic or peripartum findings than those studypatients who had a successful vaginal delivery.

CONCLUSION: Women with one previous CD for a multifetal gestationhave a high likelihood of a successful TOL in subsequent pregnancies and arenot at increased risk for peripartum complications.

446 ISCHEMIC-THROMBOTIC PLACENTAL PATHOLOGY AND ACUTE CHORIOAMNIONI-TIS ARE ASSOCIATED WITH RESCUE CERCLAGE FAILURE W WHITTLE (F)1,S KEATING2, S ALSUNNARI1, R WINDRIM1, N OKUN1, J KINGDOM1, 1Mount SinaiHospital, Division of Maternal Fetal Medicine, Toronto, Ontario, Canada,2Mount Sinai Hospital, Dep’t of Pathology and Laboratory Medine, Toronto,Ontario, Canada

OBJECTIVE: Reduced cervical length in the second trimester is a risk factorfor preterm birth and is traditionally attributed to cervical incompetence.Despite a lack of convincing evidence, rescue cerclage is commonly performedfor a short/dilated cervix.

STUDY DESIGN: The objective of this retrospective case-control study wasto determine the placental pathologies associated with rescue cerclage failuredefined as either (1) delivery at !24w prior to fetal viability or (2) delivery at!32w, a period of increased neonatal morbidity/mortality. Placentae wereclassified histologically as normal, chorioamnionitis and/or ischemic-throm-botic lesions (villous infarction, increased peri-villous fibrin, decidual vascu-lopathy, syncytial knots).

RESULTS: Ischemic-thrombotic lesions were observed in 15 of the cases(n=51) compared to 4 of the controls (n=51) {p ! 0.001}. Acute chorioam-nionitis was observed in 63% of cases; no controls demonstrated histiologicevidience of infection. 14% of cases demonstrated both ischemic-thromboticlesions and acute chorioamnionitis; there was no evidence of combinedpathology in the controls. Overall, 47% of cerclage pregnancies ended at!24w and 76% ended by !32w. Ischemic-thrombotic lesions were identifiedin 28% and 32% of pregnancies ending at !24w and !32w respectively; 93%of pregnancies with ischemic-thrombotic lesions ended at !32w. Acutechorioamnionitis complicated 68% of deliveries at !24w and 66% ofdeliveries !32w respectively; 94% of pregnancies with acute chorioamnionitisended at !32w. Of the 7 cases extending O32w, 2 placentae demonstratedacute chorioamnionitis, 1 placenta demonstrated ischemic-thrombotic lesionsand 4 placentae had normal histology.

CONCLUSION: Thus, ischemic-thrombotic placental lesions and acutechorioamnionitis are the leading associations of the short/dilated cervixpresenting in the second trimester; rescue cerclage may not prolong gestationO24w or decrease the risk of neonatal morbidity/mortality. Pre-operativescreening for both pathologies may select for whom the rescue cerclage wouldprove successful.