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267: Does increased BMI affect the accuracy of EFW by ultrasound in twin gestations?
SMFM Abstracts
www.AJOG.org 264
MODE OF DELIVERY AND NEONATAL OUTCOMES IN BREECH SECOND TWINS ADRIAN QUESADA ROJAS1, MATTHEW HOFFMAN1, JENNY BENSON2, ANTHONY SCISCIONE1, 1Christiana Care Health System, Obstetrics and Gynecology, Newark, Delaware, 2Christiana Care Health System, Newark, Delaware OBJECTIVE: We sought to determine whether mode of delivery for a breechpresenting second twin affected neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of women delivering twins at a gestational age ⬎24 weeks at our tertiary care teaching hospital between 1998 and 2003. Two separate analyses were conducted comparing vaginally delivered breech second twins versus:1)Women who had a breech twin at the time of cesarean delivery. 2) All women who under went cesarean delivery regardless of the presentation of the second twin. Twins who had growth discordance ⬎20% or a fetal malformation were excluded. Our primary outcome was a composite morbidity index including fetal death and IVH grade 3 & 4. Secondary outcomes were Apgar score and NICU admission. RESULTS: A total of 230 women were studied,151 delivering by Cesarean and 79 vaginally. Maternal characteristics were similar in the two groups. The first analysis, revealed no statistical differences in the primary outcome variable between the two groups (5.06% for the vaginal and 4.64% for the cesarean, p-value⫽1.0). All secondary outcomes were similar with the exception of the Apgar score at 1 minute (vaginal 7 vs. cesarean 8 -p value ⫽ 0.026). Five minute Apgar scores were not different. In the second analysis, there were no significant differences when the analysis was broadened to include all women who underwent a cesarean delivery regardless of the presentation (312 patients) and compared to those who underwent vaginal breech delivery, comparable results were obtained. CONCLUSION: Mode of delivery did not affect neonatal outcomes in second twins in the breech presentation.
STUDY DESIGN: Using data from NCHS, we determined the numbers of MM, FF and MF twin pairs for the US by year from 1990 to 2001. Birth certificate data were matched on the basis of twin records with the same city, state, year and month of birth, maternal race, maternal age and paternal age. We divided twin pairs into male-male (MM), female-female (FF), and male-female (MF). We determined rates of twin pairs in each sex category from ‘90-‘95 and ‘96-‘01. We used the East Flanders Twin Study of twin sex ratios to modify Weinberg=s rule and mathematically model DZ and monozygotic (MZ) twins. Weinberg=s rule for DZ twin pairs is based on the fact that all unlike sex twins are DZ. Among DZ twin pairs, like sex twin pairs ⫽ unlike sex twin pairs, ie MM ⫹ FF ⫽ MF ⫹ FM. Thus, the total of DZ twins ⫽ 2*(unlike sex twins). Finally, MZ twins ⫽ total twins - DZ twins. We estimated MC twins as 2/3 of MZ twins and TTTS occurs in 10% of MC twins. RESULTS: There were 47,995,361 livebirths between 1990 and 2001 in the US. There were 574,699 twins in ‘90-‘95 and 670,521 in ‘96-‘01 . The birth prevalence of MC twins and TTTS per year is seen in Table 1. CONCLUSION: The number of MC twins/yr. has increased slightly from =90-=95 to =96-‘01 in the US. We estimated that there are an average of 1,166 cases of TTTS/year. This information may prove useful in planning the allocation of the expensive resources required to treat these high risk conditions. MC twin pairs and TTTS by year from 1990 –1995 and 1996 –2001 in the U.S 1990 to 1995
Median
1996 to 2001
MC twin pairs/yr.
TTTS/yr.
MC twin pairs/yr.
TTTS/yr.
11,650
1,165
11,848
1,185
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.278 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.280 265
PERINATAL OUTCOME OF TRIPLETS FOLLOWING VAGINAL VS. CESAREAN DELIVERY: IS PLANNED VAGINAL DELIVERY STILL A VIABLE OPTION? RONIT MACHTINGER1, EYAL SIVAN2, AYALA MAAYAN3, JACOB KUINT3, EYAL SCHIFF4, 1Sheba Medical Center & Tel Aviv university, Herzelia, Israel, 2Sheba Medical Center, Ob&Gyn, Israel, 3 Sheba Medical Center, Israel, 4Sheba medical Center, Tel Aviv University, Obstetrics and Gynecology, Ramat-Gan, Israel OBJECTIVE: To compare the maternal and perinatal outcome of triplet pregnancies delivered by cesarean section with those delivered vaginally and to assess whether a vaginal delivery of triplets is still acceptable among women who are interested in further multiplied births. STUDY DESIGN: A retrospective analysis of 73 triplet pregnancies delivered at ⬎28 week between 1996 and 2005 in a single tertiary center. Twenty six sets of triplets planned for a trial of labor were compared with 47 women with triplet gestations who delivered by elective cesarean section. The vaginally intended and cesarean delivered groups were carefully matched for gestational age at delivery and year of delivery. Neonatal outcomes parameters included Apgar scores, mortality, and rates of RDS, BPD, ROP, NEC, IVH and sepsis. Maternal parameters that were checked included short term post-partum complication rates and hospitalization length. RESULTS: Mean gestational age was 33.1⫹2.9 and 33.4⫹2.6 weeks for the vaginal and cesarean groups respectively (NS). Twenty-three women (88.4%) of the vaginally-intended group had a successful vaginal delivery of all three newborns. Data was analysed based on the intension to treat principle. Neonatal complications were not different between the groups Maternal hospitalization length was significantly shorter, following vaginal delivery (4.6⫹4.0 days vs. 6.0⫹2.4, p⫽0.02). Maternal complication rate did not differ between the groups. Logistic regression revealed that neonatal and perinatal complications were influenced only by gestational age at delivery and not by delivery mode. CONCLUSION: We believe that using strict and planned protocol for vaginal delivery with staff experienced in managing vaginal deliveries of multiple gestation is safe. A vaginal delivery of triplets is advantageous especially in women who are interested in further multi-order births, in order to avoid VBAC or repeat cesarean complications. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.279
267
DOES INCREASED BMI AFFECT THE ACCURACY OF EFW BY ULTRASOUND IN TWIN GESTATIONS? MANISHA GANDHI1, LAUREN FERRARA1, VICTORIA BELOGOLOVKIN1, ERIN MOSHIER2, ANDREI REBARBER1, 1Mount Sinai School of Medicine, New York, New York, 2Mount Sinai School of Medicine, Department of Community and Preventive Medicine, New York, New York OBJECTIVE: To determine if increasing BMI decreases the accuracy of ultrasound estimations of fetal weights in twin gestations. STUDY DESIGN: A retrospective chart review was conducted. 361 charts of patients with twin gestations were reviewed of which 194 patients had a growth US within 6 days of delivery and were included in the analysis. RESULTS: Ultrasound overestimated birth weight in twin A by 56.46 ⫹/229.07g (p⫽0.0007) and in twin B by 123.75 ⫹/- 255.05g (p⬍0.0001). There is a significant increasing trend in mean absolute % errors with increasing BMI in both twins. There was no effect of the day of measurement on the mean differences. CONCLUSION: Our retrospective analysis of 194 twins showed that ultrasound continues to be a fairly accurate method of estimating fetal weight with only a 56g difference in twin A and 124g difference in twin B which are clinically acceptable differences. There is evidence that increasing BMI decreases the accuracy for both twins. Still, despite the decrease in accuracy, there is only a mean difference of 60g in twin A and 120g in twin B for patients with morbid obesity which indicates that although accuracy may decrease, the difference in EFW remains clinically acceptable. Does BMI Affect Accuracy of EFW in Twin A BMI Category
N
⬍25 25-29.9 30-34.9 ⬎34.9 Test for Linear Trend
25 87 54 28
Mean Differences (g)
Mean Absolute % Errors
31.44 59.21 61.76 60.04 P-value 0.6965
6.04 7.63 9.42 8.55 P-value 0.0797*
Does BMI Affect Accuracy of EFW in Twin B 266
TWIN TO TWIN TRANSFUSION SYNDROME (TTTS) IN THE U. S. FROM 1990 TO 2001 JAMES EGAN1, PETER BENN2, LILLIAN KAMINSKY3, LUCYBETH NIEVES1, JAY BOLNICK1, ADAM BORGIDA4, 1University of Connecticut, Obstetrics and Gynecology, Farmington, Connecticut, 2University of Connecticut, Pediatrics and Genetics, Farmington, Connecticut, 3University of Medicine and Dentistry of New Jersey, Obstetrics and Gynecology, New Brunswick, New Jersey, 4Hartford Hospital, Hartford, Connecticut OBJECTIVE: TTTS occurs in monochorionic (MC) twins and often requires intensive and costly treatment with serial amnioreductions and/or laser photocoagulation of placental vessels. We determined the birth prevalence of MC twins and TTTS in the US from 1990-1995 and 1996-2001.
BMI Category
N
⬍25 25-29.9 30-34.9 ⬎34.9 Test for Linear Trend
25 87 54 28
Mean Differences (g)
Mean Absolute % Errors
72.32 136.29 129.63 119.39 P-value 0.6685
6.70 10.59 11.35 12.32 P-value 0.0225*
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.281
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S85
www.AJOG.org 264
MODE OF DELIVERY AND NEONATAL OUTCOMES IN BREECH SECOND TWINS ADRIAN QUESADA ROJAS1, MATTHEW HOFFMAN1, JENNY BENSON2, ANTHONY SCISCIONE1, 1Christiana Care Health System, Obstetrics and Gynecology, Newark, Delaware, 2Christiana Care Health System, Newark, Delaware OBJECTIVE: We sought to determine whether mode of delivery for a breechpresenting second twin affected neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of women delivering twins at a gestational age ⬎24 weeks at our tertiary care teaching hospital between 1998 and 2003. Two separate analyses were conducted comparing vaginally delivered breech second twins versus:1)Women who had a breech twin at the time of cesarean delivery. 2) All women who under went cesarean delivery regardless of the presentation of the second twin. Twins who had growth discordance ⬎20% or a fetal malformation were excluded. Our primary outcome was a composite morbidity index including fetal death and IVH grade 3 & 4. Secondary outcomes were Apgar score and NICU admission. RESULTS: A total of 230 women were studied,151 delivering by Cesarean and 79 vaginally. Maternal characteristics were similar in the two groups. The first analysis, revealed no statistical differences in the primary outcome variable between the two groups (5.06% for the vaginal and 4.64% for the cesarean, p-value⫽1.0). All secondary outcomes were similar with the exception of the Apgar score at 1 minute (vaginal 7 vs. cesarean 8 -p value ⫽ 0.026). Five minute Apgar scores were not different. In the second analysis, there were no significant differences when the analysis was broadened to include all women who underwent a cesarean delivery regardless of the presentation (312 patients) and compared to those who underwent vaginal breech delivery, comparable results were obtained. CONCLUSION: Mode of delivery did not affect neonatal outcomes in second twins in the breech presentation.
STUDY DESIGN: Using data from NCHS, we determined the numbers of MM, FF and MF twin pairs for the US by year from 1990 to 2001. Birth certificate data were matched on the basis of twin records with the same city, state, year and month of birth, maternal race, maternal age and paternal age. We divided twin pairs into male-male (MM), female-female (FF), and male-female (MF). We determined rates of twin pairs in each sex category from ‘90-‘95 and ‘96-‘01. We used the East Flanders Twin Study of twin sex ratios to modify Weinberg=s rule and mathematically model DZ and monozygotic (MZ) twins. Weinberg=s rule for DZ twin pairs is based on the fact that all unlike sex twins are DZ. Among DZ twin pairs, like sex twin pairs ⫽ unlike sex twin pairs, ie MM ⫹ FF ⫽ MF ⫹ FM. Thus, the total of DZ twins ⫽ 2*(unlike sex twins). Finally, MZ twins ⫽ total twins - DZ twins. We estimated MC twins as 2/3 of MZ twins and TTTS occurs in 10% of MC twins. RESULTS: There were 47,995,361 livebirths between 1990 and 2001 in the US. There were 574,699 twins in ‘90-‘95 and 670,521 in ‘96-‘01 . The birth prevalence of MC twins and TTTS per year is seen in Table 1. CONCLUSION: The number of MC twins/yr. has increased slightly from =90-=95 to =96-‘01 in the US. We estimated that there are an average of 1,166 cases of TTTS/year. This information may prove useful in planning the allocation of the expensive resources required to treat these high risk conditions. MC twin pairs and TTTS by year from 1990 –1995 and 1996 –2001 in the U.S 1990 to 1995
Median
1996 to 2001
MC twin pairs/yr.
TTTS/yr.
MC twin pairs/yr.
TTTS/yr.
11,650
1,165
11,848
1,185
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.278 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.280 265
PERINATAL OUTCOME OF TRIPLETS FOLLOWING VAGINAL VS. CESAREAN DELIVERY: IS PLANNED VAGINAL DELIVERY STILL A VIABLE OPTION? RONIT MACHTINGER1, EYAL SIVAN2, AYALA MAAYAN3, JACOB KUINT3, EYAL SCHIFF4, 1Sheba Medical Center & Tel Aviv university, Herzelia, Israel, 2Sheba Medical Center, Ob&Gyn, Israel, 3 Sheba Medical Center, Israel, 4Sheba medical Center, Tel Aviv University, Obstetrics and Gynecology, Ramat-Gan, Israel OBJECTIVE: To compare the maternal and perinatal outcome of triplet pregnancies delivered by cesarean section with those delivered vaginally and to assess whether a vaginal delivery of triplets is still acceptable among women who are interested in further multiplied births. STUDY DESIGN: A retrospective analysis of 73 triplet pregnancies delivered at ⬎28 week between 1996 and 2005 in a single tertiary center. Twenty six sets of triplets planned for a trial of labor were compared with 47 women with triplet gestations who delivered by elective cesarean section. The vaginally intended and cesarean delivered groups were carefully matched for gestational age at delivery and year of delivery. Neonatal outcomes parameters included Apgar scores, mortality, and rates of RDS, BPD, ROP, NEC, IVH and sepsis. Maternal parameters that were checked included short term post-partum complication rates and hospitalization length. RESULTS: Mean gestational age was 33.1⫹2.9 and 33.4⫹2.6 weeks for the vaginal and cesarean groups respectively (NS). Twenty-three women (88.4%) of the vaginally-intended group had a successful vaginal delivery of all three newborns. Data was analysed based on the intension to treat principle. Neonatal complications were not different between the groups Maternal hospitalization length was significantly shorter, following vaginal delivery (4.6⫹4.0 days vs. 6.0⫹2.4, p⫽0.02). Maternal complication rate did not differ between the groups. Logistic regression revealed that neonatal and perinatal complications were influenced only by gestational age at delivery and not by delivery mode. CONCLUSION: We believe that using strict and planned protocol for vaginal delivery with staff experienced in managing vaginal deliveries of multiple gestation is safe. A vaginal delivery of triplets is advantageous especially in women who are interested in further multi-order births, in order to avoid VBAC or repeat cesarean complications. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.279
267
DOES INCREASED BMI AFFECT THE ACCURACY OF EFW BY ULTRASOUND IN TWIN GESTATIONS? MANISHA GANDHI1, LAUREN FERRARA1, VICTORIA BELOGOLOVKIN1, ERIN MOSHIER2, ANDREI REBARBER1, 1Mount Sinai School of Medicine, New York, New York, 2Mount Sinai School of Medicine, Department of Community and Preventive Medicine, New York, New York OBJECTIVE: To determine if increasing BMI decreases the accuracy of ultrasound estimations of fetal weights in twin gestations. STUDY DESIGN: A retrospective chart review was conducted. 361 charts of patients with twin gestations were reviewed of which 194 patients had a growth US within 6 days of delivery and were included in the analysis. RESULTS: Ultrasound overestimated birth weight in twin A by 56.46 ⫹/229.07g (p⫽0.0007) and in twin B by 123.75 ⫹/- 255.05g (p⬍0.0001). There is a significant increasing trend in mean absolute % errors with increasing BMI in both twins. There was no effect of the day of measurement on the mean differences. CONCLUSION: Our retrospective analysis of 194 twins showed that ultrasound continues to be a fairly accurate method of estimating fetal weight with only a 56g difference in twin A and 124g difference in twin B which are clinically acceptable differences. There is evidence that increasing BMI decreases the accuracy for both twins. Still, despite the decrease in accuracy, there is only a mean difference of 60g in twin A and 120g in twin B for patients with morbid obesity which indicates that although accuracy may decrease, the difference in EFW remains clinically acceptable. Does BMI Affect Accuracy of EFW in Twin A BMI Category
N
⬍25 25-29.9 30-34.9 ⬎34.9 Test for Linear Trend
25 87 54 28
Mean Differences (g)
Mean Absolute % Errors
31.44 59.21 61.76 60.04 P-value 0.6965
6.04 7.63 9.42 8.55 P-value 0.0797*
Does BMI Affect Accuracy of EFW in Twin B 266
TWIN TO TWIN TRANSFUSION SYNDROME (TTTS) IN THE U. S. FROM 1990 TO 2001 JAMES EGAN1, PETER BENN2, LILLIAN KAMINSKY3, LUCYBETH NIEVES1, JAY BOLNICK1, ADAM BORGIDA4, 1University of Connecticut, Obstetrics and Gynecology, Farmington, Connecticut, 2University of Connecticut, Pediatrics and Genetics, Farmington, Connecticut, 3University of Medicine and Dentistry of New Jersey, Obstetrics and Gynecology, New Brunswick, New Jersey, 4Hartford Hospital, Hartford, Connecticut OBJECTIVE: TTTS occurs in monochorionic (MC) twins and often requires intensive and costly treatment with serial amnioreductions and/or laser photocoagulation of placental vessels. We determined the birth prevalence of MC twins and TTTS in the US from 1990-1995 and 1996-2001.
BMI Category
N
⬍25 25-29.9 30-34.9 ⬎34.9 Test for Linear Trend
25 87 54 28
Mean Differences (g)
Mean Absolute % Errors
72.32 136.29 129.63 119.39 P-value 0.6685
6.70 10.59 11.35 12.32 P-value 0.0225*
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.281
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S85