- Email: [email protected]
101: Preterm prelabour rupture of membranes: is home care a safe management?
www.AJOG.org
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
Poster Session I
100 Evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy in a protocol of severe PPH management
99 Comparison of management for pregnant women with Delta Storage Pool Deficiency during labor and delivery: a pilot study
Charles Bui1, Enora Laas1, Thomas Popowski1, Patrick Rozenberg1
Chao Li1, Lanissa Pappas2 1
University of Toledo and University of Iowa Hospitals and Clinics, OB/GYN, Iowa City, IA, 2The Toledo Hospital, Ob/Gyn, Toledo, OH
1
Poissy Saint-Germain Hospital, Obstetrics and Gynecology, Poissy, France
OBJECTIVE: To compare different management of pregnant women with
Delta Storage Pool Deficiency (␦-SPD)during labor and delivery . STUDY DESIGN: In platelet ␦-granules, small molecules such as ADP, ATP, and serotonin are concentrated. These molecules play an important role in hemostasis. On the floor of labor and delivery, different managements, including hemorrhaging prophylaxis, whether applying epidural and spinal anesthesia were provided to patients in labor with ␦-SPD by different providers. There is no study so far to compare the outcome of different management. In last 5 years, about 30 patients with ␦-SPD were delivered. After chart review, 25 were recruited in this study. The 25 patients all had clear documented diagnosis. Patients’ age, race, gravity, parity, gestational age, pregnancy complications, blood loss, anesthesia, delivery mode and neonatal outcomes were all documented. Different managements and complications were compared. Statistic method: Student T test. Interventional factors applied before regional anesthesia and delivery included platelet transfusion, DDAVP, DDAVP plus Amicar or no intervention. RESULTS: 1. Different interventional factors applied before anesthesia. No complications developed in all the regional anesthesia applied. 2. Different interventional factors applied before spontaneous vaginal delivery in multiparity patients. No difference in estimated blood loss (EBL) was detected. 3. Different interventional factors applied before cesarean section. No difference in EBL was detected. CONCLUSION: With limited data, SPD is not a major bleeding disorder for labor patients. Safety profiles of different managements are all acceptable. It seems DDAVP plus Amicar is an effective treatment during c-section. But further studies with higher power need to be carried out to draw definitive conclusion.
OBJECTIVE: Postpartum hemorrhage (PPH) is among the most com-
mon causes of pregnancy-related death. When uterotonic drugs fail, second-line therapies including artery ligations, compressive uterine sutures or arterial embolization may be performed. Recently, intrauterine balloon tamponade has been proposed as a second-line procedure. Our objective was to study the evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy to our protocol of severe PPH management. STUDY DESIGN: We carried out a before and after cohort study in Poissy Saint-Germain Hospital. We compared the outcomes of all patients delivered vaginally with a PPH unresponsive to sulprostone during two equal periods. Medical management of PPH was similar during the 2 periods. However, from September 2006 to March 2008, if bleeding was still not controlled in spite of an infusion of sulprostone, an invasive procedure was at once performed. From April 2008 to December 2010, the intrauterine balloon tamponade was attempted in order to avoid an invasive procedure. RESULTS: The general and obstetrical characteristics of the patients delivered vaginally with a PPH unresponsive to Sulprostone were similar between the 2 periods. Among these, 13.4% (26/194) and 16.0% (35/218, p⫽0.45) required a second-line therapy during the first and the second period, respectively. During the second period, the Bakri balloon was used in 31 patients delivered vaginally with a success rate of 84% (26/31). The rates of arterial embolizations and conservative surgical procedures (artery ligations, compressive uterine sutures) were significantly reduced in the second period (8.2% vs 2.3%, p⫽0.006 ; OR 0.26, 95% CI 0.09-0.72 and 5.1% vs 1.4%, p⫽0.029 ; OR 0.26, 95% CI 0.07-0.95, respectively). No differences were observed in the rate of hysterectomy between the 2 periods. CONCLUSION: In the setting of intractable hemorrhage, balloon tamponade may avoid the need for embolization or conservative surgical procedure with their related risk.
101 Preterm prelabour rupture of membranes: is home care a safe management? Charles Garabedian1, Camille Bocquet1, Betty Rousselle2, Sara Balagny2, Nadia Tillouche3, Philippe Deruelle4 1 CHRU de Lille, Obstetrics, Lille, France, 2CHRU de Lille, hopidom, Lille, France, 3CH de Valenciennes, Obstetrics, Valenciennes, France, 4EA 4489, Universite de Lille 2, Obstetrics, Lille, France
OBJECTIVE: Premature prelabour rupture of membrane is associated with an increased risk for both the mother and the fetus. Expectant management is usually advised under hospital supervision. Home care is associated with reduced cost. However, its safety in PPROM management has not yet been established. Our objective was to assess neonatal and maternal outcome in pregnancies complicated by PPROM comparing to either home care or in-hospital management. STUDY DESIGN: Retrospective study in two tertiary centers over a twoyear period between January 2009 and December 2010. We included all singleton pregnancies with a history of PPROM which occured between 24 and 35 weeks of gestation. We compared women with PPROM and a home care after a short period of observation in center 1 (Group 1; n⫽ 32), and women with PPROM and in-hospital management in center 2 (Group 2; n ⫽ 42). We studied gestational age at delivery, pregnancy complications, mode of delivery and neonatal outcome. RESULTS: Demographic characteristics were similar at onset of PPROM between the two groups. Women in group 1 delivered later than in group 2 (234.8 ⫹/⫺ 19.54 days vs 224.6 ⫹/⫺ 22.02 days; p⫽0.04). There was no difference between the groups in pregnancy Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S59
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
complications including chorioamnionitis, delivery issue and neonatal outcome. The length of stay in neonatal intensive care unit was higher in group 2 compared to group 1 (n⫽43.51 ⫹/⫺ 2.67 fdays or group 2 vs. n⫽24.21 ⫹/⫺ 2.72 days for group 1; p⫽0.0003). CONCLUSION: In conclusion, home care appears to be a safe option for women with PPROM between 24 and 35 weeks with stable condition. These preliminary findings suggest performing a randomized control trial with a higher number of women, including further data such as assessment of maternal satisfaction and cost analysis.
102 Prior term birth decreases the risk of preterm delivery in a subsequent twin pregnancy Clara Ward1, Sanae Nakagawa1, Yvonne W. Cheng1 1 University of California, San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA
OBJECTIVE: To determine if prior term birth alters the risk of preterm delivery in patients with twin gestations. STUDY DESIGN: We used the 2008 United States Natality Live Birth dataset to examine the risk of preterm births among twin gestations. All twin births between 24 weeks 0 days and 36 weeks 6 days gestational age were included. Women were categorized into: nulliparas, multiparas without a history of preterm delivery, and multiparas with a history of preterm delivery. Risk of preterm birth was compared using chi-square test and multivariable logistic regression to control for potential confounding factors. RESULTS: 19,383 nulliparous and 39,288 multiparous women were included in the study. Of the multiparous women, 4413 (11%) had a history of a prior preterm delivery. The risk of preterm delivery was increased among multiparous women with prior preterm deliveries compared to their counterparts. Multiparous women with a history of a prior term birth had a decreased risk of delivery less than 34 weeks compared to both nulliparas and those with a prior preterm birth (Table 1). CONCLUSION: A prior term delivery confers a decreased risk of preterm birth less than 34 weeks in a subsequent twin gestation compared to nulliparous women and women with a prior preterm birth. This information can be used to guide surveillance protocols and counsel patients.
103 Maternal super-obesity: does gestational weight gain matter? Dalia Wenckus1, Weihua Gao2, Judith Hibbard1, Michelle Kominiarek1 1
University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, IL, University of Illinois at Chicago, School of Public Health, Chicago, IL
2
OBJECTIVE: To compare maternal and neonatal outcomes in superobese women who do not gain weight within the recommended guidelines. STUDY DESIGN: The Consortium on Safe Labor abstracted labor and delivery information from electronic medical records in 19 hospitals
S60
www.AJOG.org
across the US. Maternal and neonatal outcomes were analyzed from liveborn singletons, ⱖ37 wks from women with BMI ⱖ 50(n⫽1237) stratified into 4 gestational weight gain(GWG) groups: 5-9 kg (referent group, n⫽165), 9 kg(n⫽876) with Chi-square and t-tests. Multiple logistic regression analysis was performed for each of the outcomes, adjusting for important confounders. RESULTS: Prior cesarean (39% referent, 19% GWG9kg, p9kg, p0.60) among the GWG groups. Less blood loss (546 vs 653 mL, p9kg and referent group (3556g vs 3460g, p9kg, p⬍0.02) but the LGA difference was not significant after adjusting for confounders. There was no difference in SGA when comparing GWG⬍0kg vs referent group (OR 0.34 CI 0.042-2.748) or when comparing GWG 0-4.9kg vs referent group (OR 1.02 CI 0.383-2.716). CONCLUSION: Even though 71% of super-obese women exceeded the Institute of Medicine GWG recommendations, this did not translate to worse maternal or neonatal outcomes. Lower GWG or weight loss did not increase SGA infants, however the outcome occurrences were small and a larger sample size is needed.
104 Maternal super-obesity: intended mode of delivery and outcomes Dalia Wenckus1, Weihua Gao2, Michelle Kominiarek1, Judith Hibbard1 1
University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, IL, University of Illinois at Chicago, School of Public Health, Chicago, IL
2
OBJECTIVE: To compare maternal and neonatal outcomes in superobese women having a pre-labor cesarean delivery (PLC) vs a trial of labor (TOL), as well as to compare factors that impact the actual mode of delivery. STUDY DESIGN: The Consortium on Safe Labor abstracted labor and delivery information from electronic medical records in 19 hospitals across the US. Liveborn singletons, ⱖ37 wks from women with BMI ⱖ50 were analyzed. Maternal and neonatal outcomes were compared between women who had a PLC(n⫽496) and women who had a TOL(n⫽1130). Analysis was performed using chi-square and t-tests. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated. RESULTS: Differences in age (29.5 vs 27.2 yrs), prior cesarean (70% vs 7%), pre-existing diabetes (12% vs 6%), gestational diabetes (11% vs 7%), and gestational hypertension/pre-eclampsia spectrum (10% vs 17%) were noted between PLC and TOL groups, p⬍0.01 for all comparisons. In the TOL group, there were 63% inductions, 59% vaginal deliveries, 15 shoulder dystocias, and 1 neonatal death. Estimated blood loss (811 vs 541 mL p⬍0.001) and chorioamnionitis (0.6% vs 4% p⬍0.003) were different in the PLC vs TOL group before and after adjustment. There was no difference in blood transfusions. Differences were noted in birthweight (3625g vs 3470g, p ⬍0.001), macrosomia (OR 3.9 CI 2.33-6.59), LGA (OR 2.7 CI 2.02-3.46), SGA (OR 0.41 CI 0.198-0.834), and NICU admission (OR 1.6 CI 1.19-2.18) for PLC vs TOL, though the latter two did not remain significant after adjustment. Prior cesarean (4% vs 41%, OR 0.07 CI 0.047-0.103), and diabetes-any type (11% vs 19%, OR 0.5 CI 0.37-0.68) were associated with actual vaginal vs cesarean delivery, and remained significant after adjusting for age, race, prior cesarean, diabetes, and gestational hypertension/pre-eclampsia spectrum. CONCLUSION: Women with a BMI ⱖ50 and PLC were older and more likely to have a prior cesarean, diabetes, and larger infants compared to TOL. Women undergoing TOL did not have worse perinatal outcomes compared to PLC, and realized reasonable success at vaginal delivery.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
Poster Session I
100 Evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy in a protocol of severe PPH management
99 Comparison of management for pregnant women with Delta Storage Pool Deficiency during labor and delivery: a pilot study
Charles Bui1, Enora Laas1, Thomas Popowski1, Patrick Rozenberg1
Chao Li1, Lanissa Pappas2 1
University of Toledo and University of Iowa Hospitals and Clinics, OB/GYN, Iowa City, IA, 2The Toledo Hospital, Ob/Gyn, Toledo, OH
1
Poissy Saint-Germain Hospital, Obstetrics and Gynecology, Poissy, France
OBJECTIVE: To compare different management of pregnant women with
Delta Storage Pool Deficiency (␦-SPD)during labor and delivery . STUDY DESIGN: In platelet ␦-granules, small molecules such as ADP, ATP, and serotonin are concentrated. These molecules play an important role in hemostasis. On the floor of labor and delivery, different managements, including hemorrhaging prophylaxis, whether applying epidural and spinal anesthesia were provided to patients in labor with ␦-SPD by different providers. There is no study so far to compare the outcome of different management. In last 5 years, about 30 patients with ␦-SPD were delivered. After chart review, 25 were recruited in this study. The 25 patients all had clear documented diagnosis. Patients’ age, race, gravity, parity, gestational age, pregnancy complications, blood loss, anesthesia, delivery mode and neonatal outcomes were all documented. Different managements and complications were compared. Statistic method: Student T test. Interventional factors applied before regional anesthesia and delivery included platelet transfusion, DDAVP, DDAVP plus Amicar or no intervention. RESULTS: 1. Different interventional factors applied before anesthesia. No complications developed in all the regional anesthesia applied. 2. Different interventional factors applied before spontaneous vaginal delivery in multiparity patients. No difference in estimated blood loss (EBL) was detected. 3. Different interventional factors applied before cesarean section. No difference in EBL was detected. CONCLUSION: With limited data, SPD is not a major bleeding disorder for labor patients. Safety profiles of different managements are all acceptable. It seems DDAVP plus Amicar is an effective treatment during c-section. But further studies with higher power need to be carried out to draw definitive conclusion.
OBJECTIVE: Postpartum hemorrhage (PPH) is among the most com-
mon causes of pregnancy-related death. When uterotonic drugs fail, second-line therapies including artery ligations, compressive uterine sutures or arterial embolization may be performed. Recently, intrauterine balloon tamponade has been proposed as a second-line procedure. Our objective was to study the evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy to our protocol of severe PPH management. STUDY DESIGN: We carried out a before and after cohort study in Poissy Saint-Germain Hospital. We compared the outcomes of all patients delivered vaginally with a PPH unresponsive to sulprostone during two equal periods. Medical management of PPH was similar during the 2 periods. However, from September 2006 to March 2008, if bleeding was still not controlled in spite of an infusion of sulprostone, an invasive procedure was at once performed. From April 2008 to December 2010, the intrauterine balloon tamponade was attempted in order to avoid an invasive procedure. RESULTS: The general and obstetrical characteristics of the patients delivered vaginally with a PPH unresponsive to Sulprostone were similar between the 2 periods. Among these, 13.4% (26/194) and 16.0% (35/218, p⫽0.45) required a second-line therapy during the first and the second period, respectively. During the second period, the Bakri balloon was used in 31 patients delivered vaginally with a success rate of 84% (26/31). The rates of arterial embolizations and conservative surgical procedures (artery ligations, compressive uterine sutures) were significantly reduced in the second period (8.2% vs 2.3%, p⫽0.006 ; OR 0.26, 95% CI 0.09-0.72 and 5.1% vs 1.4%, p⫽0.029 ; OR 0.26, 95% CI 0.07-0.95, respectively). No differences were observed in the rate of hysterectomy between the 2 periods. CONCLUSION: In the setting of intractable hemorrhage, balloon tamponade may avoid the need for embolization or conservative surgical procedure with their related risk.
101 Preterm prelabour rupture of membranes: is home care a safe management? Charles Garabedian1, Camille Bocquet1, Betty Rousselle2, Sara Balagny2, Nadia Tillouche3, Philippe Deruelle4 1 CHRU de Lille, Obstetrics, Lille, France, 2CHRU de Lille, hopidom, Lille, France, 3CH de Valenciennes, Obstetrics, Valenciennes, France, 4EA 4489, Universite de Lille 2, Obstetrics, Lille, France
OBJECTIVE: Premature prelabour rupture of membrane is associated with an increased risk for both the mother and the fetus. Expectant management is usually advised under hospital supervision. Home care is associated with reduced cost. However, its safety in PPROM management has not yet been established. Our objective was to assess neonatal and maternal outcome in pregnancies complicated by PPROM comparing to either home care or in-hospital management. STUDY DESIGN: Retrospective study in two tertiary centers over a twoyear period between January 2009 and December 2010. We included all singleton pregnancies with a history of PPROM which occured between 24 and 35 weeks of gestation. We compared women with PPROM and a home care after a short period of observation in center 1 (Group 1; n⫽ 32), and women with PPROM and in-hospital management in center 2 (Group 2; n ⫽ 42). We studied gestational age at delivery, pregnancy complications, mode of delivery and neonatal outcome. RESULTS: Demographic characteristics were similar at onset of PPROM between the two groups. Women in group 1 delivered later than in group 2 (234.8 ⫹/⫺ 19.54 days vs 224.6 ⫹/⫺ 22.02 days; p⫽0.04). There was no difference between the groups in pregnancy Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S59
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
complications including chorioamnionitis, delivery issue and neonatal outcome. The length of stay in neonatal intensive care unit was higher in group 2 compared to group 1 (n⫽43.51 ⫹/⫺ 2.67 fdays or group 2 vs. n⫽24.21 ⫹/⫺ 2.72 days for group 1; p⫽0.0003). CONCLUSION: In conclusion, home care appears to be a safe option for women with PPROM between 24 and 35 weeks with stable condition. These preliminary findings suggest performing a randomized control trial with a higher number of women, including further data such as assessment of maternal satisfaction and cost analysis.
102 Prior term birth decreases the risk of preterm delivery in a subsequent twin pregnancy Clara Ward1, Sanae Nakagawa1, Yvonne W. Cheng1 1 University of California, San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA
OBJECTIVE: To determine if prior term birth alters the risk of preterm delivery in patients with twin gestations. STUDY DESIGN: We used the 2008 United States Natality Live Birth dataset to examine the risk of preterm births among twin gestations. All twin births between 24 weeks 0 days and 36 weeks 6 days gestational age were included. Women were categorized into: nulliparas, multiparas without a history of preterm delivery, and multiparas with a history of preterm delivery. Risk of preterm birth was compared using chi-square test and multivariable logistic regression to control for potential confounding factors. RESULTS: 19,383 nulliparous and 39,288 multiparous women were included in the study. Of the multiparous women, 4413 (11%) had a history of a prior preterm delivery. The risk of preterm delivery was increased among multiparous women with prior preterm deliveries compared to their counterparts. Multiparous women with a history of a prior term birth had a decreased risk of delivery less than 34 weeks compared to both nulliparas and those with a prior preterm birth (Table 1). CONCLUSION: A prior term delivery confers a decreased risk of preterm birth less than 34 weeks in a subsequent twin gestation compared to nulliparous women and women with a prior preterm birth. This information can be used to guide surveillance protocols and counsel patients.
103 Maternal super-obesity: does gestational weight gain matter? Dalia Wenckus1, Weihua Gao2, Judith Hibbard1, Michelle Kominiarek1 1
University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, IL, University of Illinois at Chicago, School of Public Health, Chicago, IL
2
OBJECTIVE: To compare maternal and neonatal outcomes in superobese women who do not gain weight within the recommended guidelines. STUDY DESIGN: The Consortium on Safe Labor abstracted labor and delivery information from electronic medical records in 19 hospitals
S60
www.AJOG.org
across the US. Maternal and neonatal outcomes were analyzed from liveborn singletons, ⱖ37 wks from women with BMI ⱖ 50(n⫽1237) stratified into 4 gestational weight gain(GWG) groups: 5-9 kg (referent group, n⫽165), 9 kg(n⫽876) with Chi-square and t-tests. Multiple logistic regression analysis was performed for each of the outcomes, adjusting for important confounders. RESULTS: Prior cesarean (39% referent, 19% GWG9kg, p9kg, p0.60) among the GWG groups. Less blood loss (546 vs 653 mL, p9kg and referent group (3556g vs 3460g, p9kg, p⬍0.02) but the LGA difference was not significant after adjusting for confounders. There was no difference in SGA when comparing GWG⬍0kg vs referent group (OR 0.34 CI 0.042-2.748) or when comparing GWG 0-4.9kg vs referent group (OR 1.02 CI 0.383-2.716). CONCLUSION: Even though 71% of super-obese women exceeded the Institute of Medicine GWG recommendations, this did not translate to worse maternal or neonatal outcomes. Lower GWG or weight loss did not increase SGA infants, however the outcome occurrences were small and a larger sample size is needed.
104 Maternal super-obesity: intended mode of delivery and outcomes Dalia Wenckus1, Weihua Gao2, Michelle Kominiarek1, Judith Hibbard1 1
University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, IL, University of Illinois at Chicago, School of Public Health, Chicago, IL
2
OBJECTIVE: To compare maternal and neonatal outcomes in superobese women having a pre-labor cesarean delivery (PLC) vs a trial of labor (TOL), as well as to compare factors that impact the actual mode of delivery. STUDY DESIGN: The Consortium on Safe Labor abstracted labor and delivery information from electronic medical records in 19 hospitals across the US. Liveborn singletons, ⱖ37 wks from women with BMI ⱖ50 were analyzed. Maternal and neonatal outcomes were compared between women who had a PLC(n⫽496) and women who had a TOL(n⫽1130). Analysis was performed using chi-square and t-tests. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated. RESULTS: Differences in age (29.5 vs 27.2 yrs), prior cesarean (70% vs 7%), pre-existing diabetes (12% vs 6%), gestational diabetes (11% vs 7%), and gestational hypertension/pre-eclampsia spectrum (10% vs 17%) were noted between PLC and TOL groups, p⬍0.01 for all comparisons. In the TOL group, there were 63% inductions, 59% vaginal deliveries, 15 shoulder dystocias, and 1 neonatal death. Estimated blood loss (811 vs 541 mL p⬍0.001) and chorioamnionitis (0.6% vs 4% p⬍0.003) were different in the PLC vs TOL group before and after adjustment. There was no difference in blood transfusions. Differences were noted in birthweight (3625g vs 3470g, p ⬍0.001), macrosomia (OR 3.9 CI 2.33-6.59), LGA (OR 2.7 CI 2.02-3.46), SGA (OR 0.41 CI 0.198-0.834), and NICU admission (OR 1.6 CI 1.19-2.18) for PLC vs TOL, though the latter two did not remain significant after adjustment. Prior cesarean (4% vs 41%, OR 0.07 CI 0.047-0.103), and diabetes-any type (11% vs 19%, OR 0.5 CI 0.37-0.68) were associated with actual vaginal vs cesarean delivery, and remained significant after adjusting for age, race, prior cesarean, diabetes, and gestational hypertension/pre-eclampsia spectrum. CONCLUSION: Women with a BMI ⱖ50 and PLC were older and more likely to have a prior cesarean, diabetes, and larger infants compared to TOL. Women undergoing TOL did not have worse perinatal outcomes compared to PLC, and realized reasonable success at vaginal delivery.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012