- Email: [email protected]
Dating of pregnancy using last menstrual period, crown-rump length, or second-trimester ultrasound biometry: results from the faster trial
S134 SMFM Abstracts 260
THE EFFECT OF PATIENT CONTINUOUS EPIDURAL ANALGESIA VERSUS INTERMITTENT BOLUS EPIDURAL ANALGESIA ON PROGRESS OF LABOR AND PATIENT SATISFACTION RAED SALIM1, MICHAL LAVEE1, ARNOLD MOSKOVIZ2, ZOHAR NACHUM1, ELIEZER SHALEV3, 1 Ha’Emek Medical Center, Obstetrics and Gynecology, Afula, Israel 2 Ha’Emek Medical Center, Anesthesia, Afula, Israel 3Technion-Israel Institute of Technology, Haifa, Israel OBJECTIVE: To compare effects of patient continuous epidural analgesia (PCEA) containing fentanyl and bupivacaine infusion with top-ups (TU) containing bupivacaine only on the duration of labor and patients’ satisfaction in primiparous women. STUDY DESIGN: Primiparous women who requested epidural analgesia during labor were randomly allocated in a prospective study to receive either a PCEA of 0.125% bupivacaine with 2 lg/mL fentanyl at a rate of 8 mL/hour (group A) or intermittent TU of 0.25% bupivacaine 10 mL on demand (group B). Inclusion criteria were singleton term pregnancies with cervical dilatation less than 5 cm. A comparison was made between the two groups regarding the duration of the active phase and the second stage of labor. Moreover, patients were asked to score their pain using a 10-cm linear scale prior to insertion of the epidural, and hourly thereafter. A sample size of 36 subjects in each group was needed to demonstrate a difference of 60 minutes in duration of labor between the two groups with a probability of 95% and power of 80%. RESULTS: The study groups comprised 83 women. Thirty-nine were randomly assigned to receive PCEA and 44 received TU. Mean gestational age, birth weights, and cervical dilatation at epidural insertion were not different between the groups. Mean duration of active phase was 4.55 hours ( ± 2.7) and 4.49 hours ( ± 2.8) in groups A and B, respectively (P = 0.9). Mean duration of second stage was 1.66 hours ( ± 1) and 1.33 hours ( ± 1) in groups A and B, respectively (P = 0.2). Mode of delivery was not significantly different between the groups. Each technique produced comparable analgesia, achieving equivalent maternal satisfaction, with no apparent complications. CONCLUSION: We provide evidence to support that both techniques are safe with no difference in duration of labor and neonatal outcome. Additionally, each technique produced comparable analgesia, achieving equivalent maternal satisfaction.
261
DATING OF PREGNANCY USING LAST MENSTRUAL PERIOD, CROWNRUMP LENGTH, OR SECOND-TRIMESTER ULTRASOUND BIOMETRY: RESULTS FROM THE FASTER TRIAL RADEK BUKOWSKI1, GEORGE SAADE1, FERGAL D. MALONE2, T. FLINT PORTER3, DAVID A. NYBERG4, CHRISTINE H. COMSTOCK5, GARY D.V. HANKINS1, KEITH EDDLEMAN6, SUSAN GROSS7, LORRAINE DUGOFF8, SABRINA D. CRAIGO9, ILAN E. TIMOR10, STEPHEN R. CARR11, HONOR M. WOLFE12, DANIELLE EMIG13, MARY E. D’ALTON2, 1University of Texas Medical Branch, Department of Obstetrics and Gynecology, Galveston, TX 2Columbia University, Department of Obstetrics and Gynecology, New York, NY 3 University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT 4Swedish Medical Center, Department of Obstetrics and Gynecology, Seattle, WA 5William Beaumont Medical Center, Department of Obstetrics and Gynecology, Royal Oak, MI 6Mount Sinai Medical Center, Department of Obstetrics and Gynecology, New York, NY 7Montefiore Medical Center, Department of Obstetrics and Gynecology, Bronx, NY 8 University of Colorado, Department of Obstetrics and Gynecology, Denver, CO 9Tufts New England Medical Center, Department of Obstetrics and Gynecology, Boston, MA 10New York University Medical Center, Department of Obstetrics and Gynecology, New York, NY 11Women and Infants Hospital, Department of Obstetrics and Gynecology, Providence, RI 12University of North Carolina at Chapel Hill, Department of Obstetrics and Gynecology, Chapel Hill, NC 13DM Stat, Medford, MA OBJECTIVES: To determine the precision of gestational age estimation by last menstrual period (LMP), crown-rump length (CRL), and composite ultrasound estimate in the second trimester (2T) and evaluate the effect of these estimations on the need for re-dating a pregnancy. STUDY DESIGN: 4557 singleton pregnancies enrolled in the FASTER Trial with reliable LMP, and both first- and second-trimester ultrasound were included. We calculated the differences between actual delivery date (DD) and estimated delivery date by LMP (EDDLMP), crown-rump length (EDDCRL), and second-trimester ultrasound (EDD2T). We also determined the proportion of patients whose EDD would incorrectly be adjusted if only the LMP or 2T dating were available. We calculated the number of patients with a discrepancy between GADLMP and GADCRL below and above 7 days (cutoff determined from a subset of 643 IVF pregnancies) at each value of the discrepancy between GADLMP and GAD2T. RESULTS: DD-EDDLMP, DD-EDDCRL, and DD-EDD2T were significantly different. No significant difference between EDD2T and EDDCRL was observed in a subgroup of 3189 patients with early 2T ultrasounds at 15-20 weeks. Discrepancy between GADLMP and GADCRL was $7 days in 396 (8.7%) patients. The proportion of women whose GADLMP was within 7 days of the GADCRL significantly exceeded those otherwise as long as the difference between GADLMP and GAD2T was < 9 days. When the latter difference was > 9 days, the proportion of women with GADLMP that was $7 days of the GADCRL was significantly greater. CONCLUSION: Estimation of gestational age by CRL was more precise than LMP and 2T ultrasound. There was no significant difference between CRL and 2T estimates performed < 20 weeks. When CRL measurement is not available, gestational age should not be estimated unless the discrepancy between menstrual and 2T ultrasound dating is 9 days or more, as this policy would result in the smallest proportion of incorrect adjustments.
December 2003 Am J Obstet Gynecol 262
ABNORMAL PLACENTATION: WHERE ARE WE NOW? ANALYSIS OF THE LAST TWENTY YEARS SERENA WU1, KATE PICKETT1, JUDITH HIBBARD1, 1University of Chicago, Obstetrics and Gynecology, Chicago, IL OBJECTIVES: (1) To determine if the increased cesarean delivery rate at University of Chicago is paralleled by an increased number of cases of placenta accreta, increta, and percreta. (2) To study the incidence, risk factors, treatment, and outcome of pregnancies complicated by abnormal placentation. STUDY DESIGN: Data were collected from all patients with possible abnormal placentation identified in the delivery case record database; data included ICD-9 codes, operative reports, pathology, and ultrasound database from the period of January 1982 to December 2002. Abnormal placentation was confirmed by histopathologic diagnosis on a hysterectomy specimen and by clinical diagnosis. Predictor variables include prior cesarean delivery, previa, prior uterine surgery, maternal age, gravidity, and parity. Outcome variables include hysterectomy, blood transfusion, return to operating room, and maternal morbidity and mortality. A randomly selected group of controls in the ratio of 4:1 was used to calculate the relative risk (RR) and 95% confidence interval (CI) of placenta accreta after cesarean delivery, as well as risk of accreta in the presence of placenta previa using chi-square and Fisher exact tests. RESULTS: 64,359 total deliveries, 7921 primary cesarean deliveries, 4047 repeat cesarean deliveries. In this cohort of women, 413 abnormal cases were identified, of which 93 had abnormal placentation. Incidence of accreta has risen as the concurrent rate of cesarean birth has increased. Univariate analysis of the risk of accreta with a previous cesarean delivery shows RR 6.4 (4.7-8.8), whereas the risk of accreta with the presence of placenta previa shows RR 6.4 (5.0-8.2). A multivariate analysis taking into consideration prior cesarean birth, previa, number of cesarean births, prior uterine surgery, gravidity, and parity has been undertaken. CONCLUSION: The risk of accreta with a prior cesarean delivery, as well as the risk of previa, is greatly increased. The rise in cesarean births reflects the rise in placenta accreta.
263
NEONATAL MORTALITY IN THE PRESENCE OF ANTENATAL HIGHRISK CONDITIONS: THE IMPACT OF MODE OF DELIVERY DIMITRIOS MASTROGIANNIS1, CANDE V. ANANTH2, CHARLES P. MIRABILE1, DAVID ROUSSO1, ANTHONY M. VINTZILEOS3, 1Good Samaritan Hospital, Department of Maternal Fetal Medicine, West Islip, NY 2UMDNJ–Robert Wood Johnson Medical School/Robert Wood Johnson University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ 3UMDNJ– Robert Wood Johnson Medical School/Robert Wood Johnson University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ OBJECTIVE: To quantify impact of mode of delivery on the risk of neonatal mortality in presence of antenatal high-risk conditions. STUDY DESIGN: The U.S. linked birth/infant death data sets (89-91 & 9500) were utilized to examine risk of neonatal mortality in relation to various antenatal high-risk conditions. Analysis was restricted to non-anomalous singleton pregnancies, delivering at > 24 weeks (n = 31,413,046). Risk of neonatal death for pregnancies at high risk (complicated by small-forgestational age [SGA], chronic hypertension [CHTN], gestational hypertension [PIH], diabetes [DM], and premature rupture of membranes [PROM]) delivered vaginally (non-instrumental) or by cesarean were compared. Relative risks (RR) and 95% confidence intervals (CI) for gestational agespecific neonatal mortality in relation to cesarean delivery (with vaginal delivery as the reference) were derived from multivariable logistic regression models for each high-risk condition, after adjusting for several confounders. RESULTS: Among the 31.4 million pregnancies examined, at least one high-risk condition was present in 17%. In pregnancies complicated by SGA fetuses, PIH, & PROM, cesarean delivery, at early gestation, was associated with lower relative risk of neonatal mortality as compared to vaginal birth. This pattern was reversed at later gestational age (Table). CONCLUSION: At early gestational age, compared to vaginal delivery, cesarean delivery appears to confer lower risk of neonatal death in some highrisk conditions. Association (RR & 95% CI) between mode of delivery and neonatal mortality 24-27 wks SGA CHTN PIH DM PROM No cx
0.5 0.5 0.5 1.0 0.7 0.7
(0.3-0.7) (0.2,1.1) (0.3,0.9) (0.5,1.9) (0.5,0.8) (0.6,0.8)
28-31 wks 0.5 1.6 0.8 0.7 1.0 1.2
(0.4,0.7) (0.5,4.5) (0.5,1.4) (0.2,1.9) (0.7,1.4) (0.9,1.6)
32-33 wks 0.7 0.4 0.5 1.2 1.3 1.9
(0.4,1.1) (0.0,4.6) (0.2,1.2) (0.3,5.2) (0.7,2.4) (1.3,2.7)
34-36 wks 0.9 1.4 0.8 1.6 1.7 1.8
(0.7,1.3) (0.3,6.0) (0.4,1.7) (0.8,3.4) (1.0,2.8) (1.4,2.3)
37-41 wks 1.2 1.4 1.1 1.9
(1.0,1.5) (0.5,3.7) (0.8,1.7) (1.2,2.9) — 1.5 (1.3,1.7)
THE EFFECT OF PATIENT CONTINUOUS EPIDURAL ANALGESIA VERSUS INTERMITTENT BOLUS EPIDURAL ANALGESIA ON PROGRESS OF LABOR AND PATIENT SATISFACTION RAED SALIM1, MICHAL LAVEE1, ARNOLD MOSKOVIZ2, ZOHAR NACHUM1, ELIEZER SHALEV3, 1 Ha’Emek Medical Center, Obstetrics and Gynecology, Afula, Israel 2 Ha’Emek Medical Center, Anesthesia, Afula, Israel 3Technion-Israel Institute of Technology, Haifa, Israel OBJECTIVE: To compare effects of patient continuous epidural analgesia (PCEA) containing fentanyl and bupivacaine infusion with top-ups (TU) containing bupivacaine only on the duration of labor and patients’ satisfaction in primiparous women. STUDY DESIGN: Primiparous women who requested epidural analgesia during labor were randomly allocated in a prospective study to receive either a PCEA of 0.125% bupivacaine with 2 lg/mL fentanyl at a rate of 8 mL/hour (group A) or intermittent TU of 0.25% bupivacaine 10 mL on demand (group B). Inclusion criteria were singleton term pregnancies with cervical dilatation less than 5 cm. A comparison was made between the two groups regarding the duration of the active phase and the second stage of labor. Moreover, patients were asked to score their pain using a 10-cm linear scale prior to insertion of the epidural, and hourly thereafter. A sample size of 36 subjects in each group was needed to demonstrate a difference of 60 minutes in duration of labor between the two groups with a probability of 95% and power of 80%. RESULTS: The study groups comprised 83 women. Thirty-nine were randomly assigned to receive PCEA and 44 received TU. Mean gestational age, birth weights, and cervical dilatation at epidural insertion were not different between the groups. Mean duration of active phase was 4.55 hours ( ± 2.7) and 4.49 hours ( ± 2.8) in groups A and B, respectively (P = 0.9). Mean duration of second stage was 1.66 hours ( ± 1) and 1.33 hours ( ± 1) in groups A and B, respectively (P = 0.2). Mode of delivery was not significantly different between the groups. Each technique produced comparable analgesia, achieving equivalent maternal satisfaction, with no apparent complications. CONCLUSION: We provide evidence to support that both techniques are safe with no difference in duration of labor and neonatal outcome. Additionally, each technique produced comparable analgesia, achieving equivalent maternal satisfaction.
261
DATING OF PREGNANCY USING LAST MENSTRUAL PERIOD, CROWNRUMP LENGTH, OR SECOND-TRIMESTER ULTRASOUND BIOMETRY: RESULTS FROM THE FASTER TRIAL RADEK BUKOWSKI1, GEORGE SAADE1, FERGAL D. MALONE2, T. FLINT PORTER3, DAVID A. NYBERG4, CHRISTINE H. COMSTOCK5, GARY D.V. HANKINS1, KEITH EDDLEMAN6, SUSAN GROSS7, LORRAINE DUGOFF8, SABRINA D. CRAIGO9, ILAN E. TIMOR10, STEPHEN R. CARR11, HONOR M. WOLFE12, DANIELLE EMIG13, MARY E. D’ALTON2, 1University of Texas Medical Branch, Department of Obstetrics and Gynecology, Galveston, TX 2Columbia University, Department of Obstetrics and Gynecology, New York, NY 3 University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT 4Swedish Medical Center, Department of Obstetrics and Gynecology, Seattle, WA 5William Beaumont Medical Center, Department of Obstetrics and Gynecology, Royal Oak, MI 6Mount Sinai Medical Center, Department of Obstetrics and Gynecology, New York, NY 7Montefiore Medical Center, Department of Obstetrics and Gynecology, Bronx, NY 8 University of Colorado, Department of Obstetrics and Gynecology, Denver, CO 9Tufts New England Medical Center, Department of Obstetrics and Gynecology, Boston, MA 10New York University Medical Center, Department of Obstetrics and Gynecology, New York, NY 11Women and Infants Hospital, Department of Obstetrics and Gynecology, Providence, RI 12University of North Carolina at Chapel Hill, Department of Obstetrics and Gynecology, Chapel Hill, NC 13DM Stat, Medford, MA OBJECTIVES: To determine the precision of gestational age estimation by last menstrual period (LMP), crown-rump length (CRL), and composite ultrasound estimate in the second trimester (2T) and evaluate the effect of these estimations on the need for re-dating a pregnancy. STUDY DESIGN: 4557 singleton pregnancies enrolled in the FASTER Trial with reliable LMP, and both first- and second-trimester ultrasound were included. We calculated the differences between actual delivery date (DD) and estimated delivery date by LMP (EDDLMP), crown-rump length (EDDCRL), and second-trimester ultrasound (EDD2T). We also determined the proportion of patients whose EDD would incorrectly be adjusted if only the LMP or 2T dating were available. We calculated the number of patients with a discrepancy between GADLMP and GADCRL below and above 7 days (cutoff determined from a subset of 643 IVF pregnancies) at each value of the discrepancy between GADLMP and GAD2T. RESULTS: DD-EDDLMP, DD-EDDCRL, and DD-EDD2T were significantly different. No significant difference between EDD2T and EDDCRL was observed in a subgroup of 3189 patients with early 2T ultrasounds at 15-20 weeks. Discrepancy between GADLMP and GADCRL was $7 days in 396 (8.7%) patients. The proportion of women whose GADLMP was within 7 days of the GADCRL significantly exceeded those otherwise as long as the difference between GADLMP and GAD2T was < 9 days. When the latter difference was > 9 days, the proportion of women with GADLMP that was $7 days of the GADCRL was significantly greater. CONCLUSION: Estimation of gestational age by CRL was more precise than LMP and 2T ultrasound. There was no significant difference between CRL and 2T estimates performed < 20 weeks. When CRL measurement is not available, gestational age should not be estimated unless the discrepancy between menstrual and 2T ultrasound dating is 9 days or more, as this policy would result in the smallest proportion of incorrect adjustments.
December 2003 Am J Obstet Gynecol 262
ABNORMAL PLACENTATION: WHERE ARE WE NOW? ANALYSIS OF THE LAST TWENTY YEARS SERENA WU1, KATE PICKETT1, JUDITH HIBBARD1, 1University of Chicago, Obstetrics and Gynecology, Chicago, IL OBJECTIVES: (1) To determine if the increased cesarean delivery rate at University of Chicago is paralleled by an increased number of cases of placenta accreta, increta, and percreta. (2) To study the incidence, risk factors, treatment, and outcome of pregnancies complicated by abnormal placentation. STUDY DESIGN: Data were collected from all patients with possible abnormal placentation identified in the delivery case record database; data included ICD-9 codes, operative reports, pathology, and ultrasound database from the period of January 1982 to December 2002. Abnormal placentation was confirmed by histopathologic diagnosis on a hysterectomy specimen and by clinical diagnosis. Predictor variables include prior cesarean delivery, previa, prior uterine surgery, maternal age, gravidity, and parity. Outcome variables include hysterectomy, blood transfusion, return to operating room, and maternal morbidity and mortality. A randomly selected group of controls in the ratio of 4:1 was used to calculate the relative risk (RR) and 95% confidence interval (CI) of placenta accreta after cesarean delivery, as well as risk of accreta in the presence of placenta previa using chi-square and Fisher exact tests. RESULTS: 64,359 total deliveries, 7921 primary cesarean deliveries, 4047 repeat cesarean deliveries. In this cohort of women, 413 abnormal cases were identified, of which 93 had abnormal placentation. Incidence of accreta has risen as the concurrent rate of cesarean birth has increased. Univariate analysis of the risk of accreta with a previous cesarean delivery shows RR 6.4 (4.7-8.8), whereas the risk of accreta with the presence of placenta previa shows RR 6.4 (5.0-8.2). A multivariate analysis taking into consideration prior cesarean birth, previa, number of cesarean births, prior uterine surgery, gravidity, and parity has been undertaken. CONCLUSION: The risk of accreta with a prior cesarean delivery, as well as the risk of previa, is greatly increased. The rise in cesarean births reflects the rise in placenta accreta.
263
NEONATAL MORTALITY IN THE PRESENCE OF ANTENATAL HIGHRISK CONDITIONS: THE IMPACT OF MODE OF DELIVERY DIMITRIOS MASTROGIANNIS1, CANDE V. ANANTH2, CHARLES P. MIRABILE1, DAVID ROUSSO1, ANTHONY M. VINTZILEOS3, 1Good Samaritan Hospital, Department of Maternal Fetal Medicine, West Islip, NY 2UMDNJ–Robert Wood Johnson Medical School/Robert Wood Johnson University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ 3UMDNJ– Robert Wood Johnson Medical School/Robert Wood Johnson University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ OBJECTIVE: To quantify impact of mode of delivery on the risk of neonatal mortality in presence of antenatal high-risk conditions. STUDY DESIGN: The U.S. linked birth/infant death data sets (89-91 & 9500) were utilized to examine risk of neonatal mortality in relation to various antenatal high-risk conditions. Analysis was restricted to non-anomalous singleton pregnancies, delivering at > 24 weeks (n = 31,413,046). Risk of neonatal death for pregnancies at high risk (complicated by small-forgestational age [SGA], chronic hypertension [CHTN], gestational hypertension [PIH], diabetes [DM], and premature rupture of membranes [PROM]) delivered vaginally (non-instrumental) or by cesarean were compared. Relative risks (RR) and 95% confidence intervals (CI) for gestational agespecific neonatal mortality in relation to cesarean delivery (with vaginal delivery as the reference) were derived from multivariable logistic regression models for each high-risk condition, after adjusting for several confounders. RESULTS: Among the 31.4 million pregnancies examined, at least one high-risk condition was present in 17%. In pregnancies complicated by SGA fetuses, PIH, & PROM, cesarean delivery, at early gestation, was associated with lower relative risk of neonatal mortality as compared to vaginal birth. This pattern was reversed at later gestational age (Table). CONCLUSION: At early gestational age, compared to vaginal delivery, cesarean delivery appears to confer lower risk of neonatal death in some highrisk conditions. Association (RR & 95% CI) between mode of delivery and neonatal mortality 24-27 wks SGA CHTN PIH DM PROM No cx
0.5 0.5 0.5 1.0 0.7 0.7
(0.3-0.7) (0.2,1.1) (0.3,0.9) (0.5,1.9) (0.5,0.8) (0.6,0.8)
28-31 wks 0.5 1.6 0.8 0.7 1.0 1.2
(0.4,0.7) (0.5,4.5) (0.5,1.4) (0.2,1.9) (0.7,1.4) (0.9,1.6)
32-33 wks 0.7 0.4 0.5 1.2 1.3 1.9
(0.4,1.1) (0.0,4.6) (0.2,1.2) (0.3,5.2) (0.7,2.4) (1.3,2.7)
34-36 wks 0.9 1.4 0.8 1.6 1.7 1.8
(0.7,1.3) (0.3,6.0) (0.4,1.7) (0.8,3.4) (1.0,2.8) (1.4,2.3)
37-41 wks 1.2 1.4 1.1 1.9
(1.0,1.5) (0.5,3.7) (0.8,1.7) (1.2,2.9) — 1.5 (1.3,1.7)