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219: Parental wishes, resuscitation decisions, and prognostic estimates at 22-24 weeks gestation
SMFM Abstracts 218
PREDICTING A SUCCESSFUL INDUCTION OF LABOR: A SECONDARY ANALYSIS OF MISOPROSTOL VAGINAL INSERT TRIAL LEO PEVZNER1, PAMELA RUMNEY2, RITA PETERSEN3, DEBORAH WING1, 1University of California, Irvine, Orange, California, 2 University of California, Irvine, Department of OBGYN, Orange, California, 3 University of California, Irvine, Department of Statistics, Irvine, California OBJECTIVE: To determine and analyze the maternal and pregnancy characteristics that predict a successful induction of labor. STUDY DESIGN: A secondary analysis was performed on the recently collected data from a multi-center, randomized controlled trial comparing the misoprostol vaginal insert (MVI) to Cervidil for induction of labor. RESULTS: 1275 patients had sufficient labor and delivery data for a comparative analysis. Nine hundred seventeen (72%) of the induced patients subsequently had a vaginal delivery. Multiparity (OR 4.64, 95% CI 3.4-6.3, p⬍0.0001), maternal BMI ⬍30 (OR 1.69, 95% CI 1.29-2.23, p⫽0.0002), intake Bishop score ⱖ3 (OR 1.4, 95% CI 1.09-1.8, p⫽0.008), maternal age ⬍30 years (OR 1.31, 95% CI 1.0007-1.7, p⫽0.044), and birth weight ⬍3500 grams (OR 1.44, 95% CI 1.12-1.8, p⫽0.004) were significant for predicting successful induction of labor. Gestational age did not appear to correlate with the mode of delivery (95% CI 0.95-1.65, p⫽0.1004). A multivariate logistic regression was performed in order to evaluate each factor individually as an independent predictor. All variables, with the exception of gestational age, were significant independent predictors for successful induction of labor after adjusting for all other factors (see Table). CONCLUSION: Maternal characteristics (BMI, age and parity), birth weight and Bishop score can be used as independent factors in predicting a successful induction of labor.
www.AJOG.org 220
DOES BALLOON OCCLUSION OF UTERINE ARTERIES DECREASE THE RISK OF POSTPARTUM COMPLICATIONS? DANIEL BARRAEZ-MASROUA1, ANA HERNANDEZ2, GARY SISKIN3, CAMILLE KANAAN4, 1Albany Medical College, Obstetrics,Gynecology and Reproductive Sciences, Albany, New York, 2Albany Medical College, Obstetrics, Gynecology and Reproductive Sciences, albany, New York, 3Albany medical college, Department of Radiology, Albany, New York, 4Albany medical College, Albany, New York OBJECTIVE: To determine if balloon occlusion of uterine arteries (BOUA) decreases the risk of postpartum complications in patients(pts) with the diagnosis of placenta previa (PP). STUDY DESIGN: Pts delivered at AMC between June/03-Dec/07.Inclusion Criteria:Pts with diagnosis of PP by MFM U/S at AMC.Statistical analyses using StatsDirect 2.7.0.The analysis was conducted by using T-Test.A significant level P⬍ 0.05. RESULTS: Group1:38 pts were treated with BOUA and group2:38 pts without BOUA. There is no statistical difference in the mean of EBL.There is no statistical difference in units transfused (table 2). Hct levels were compared among pts who did not receive blood transfusion, we found no difference (table 3). The mean of hospitalization stay in group 1 was 3.6 days and group 2 was 3.2 ( 95% CI 0.08 to 0.54; SD 0.11) P:0.004 CONCLUSION: 1.BOUA did not reduce EBL.2.There is no statistical difference in units of RBC transfused.However, BOUA increases the risk of blood transfusion.OR 2.88 (95% CI 1.00-8.59) P:0.04.3.BOUA has equivalent drop in the levels of hct after delivery placenta comparing with group control.4.Group 2 spent shorter time at the hospital after C/D.5.There is no difference in the risk of Hysterectomy.OR 2.09 (95% CI 0.2- 24.6) P:0.337.6.Even though,there were no significant differences in the outcomes,it is possible that patients who underwent to BOUA were preselected due to high risk of hemorrhagic.A randomize study will be needed to address this selection bias. Table 1. Comparative outcome
EBL(ml) Hysterectomy Blood Transfusion
Group1
Group2
P
1548.68(SD1135.09) 4 1.13(SD1.94)
1169.73(SD850.63) 2 0.52(SD1.2)
0.09 0.33 0.10
Table 2. Mean of RBC 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.245
219
PARENTAL WISHES, RESUSCITATION DECISIONS, AND PROGNOSTIC ESTIMATES AT 22-24 WEEKS GESTATION MILDRED RAMIREZ1, ANN BERTLES1, NEHAL PARIKH1, SEAN BLACKWELL1, JON TYSON1, 1University of Texas Health Science Center at Houston, Houston, Texas OBJECTIVE: 1) To identify parental wishes and resuscitation decisions at 22 0/7-24 6/7 wks. 2) To relate these to the expected % survival rate with intensive care in the Neonatal Research Network as calculated on the NICHD website estimator (EST) (Tyson, Parikh, et al. New Eng J Med 2008:358;1672). STUDY DESIGN: Chart review was performed assessing neonatal outcome and parental assent for cesarean delivery (CD) and neonatal resuscitation for all births at 22 0/7 - 24 6/7 wks from 1999-2007. Survival estimates were then determined from EST by entering GA, BW, sex, antenatal steroids, and multiple birth. RESULTS: A total of 182 pregnancies including 24 twins and 5 triplets occurred. Mean gestational age (GA) was 23.7 ⫾ 0.8 wks and mean birth weight (BW) was 594.3 ⫾118.3 g. Parents requested “do all” (CD for fetal indications and neonatal resuscitation) for 62 % of deliveries, no resuscitation for 26%, and resuscitation if born alive but no CD for 10%. In the “do all” group the estimated survival with intensive care was 47% (range ⬍5% ⫺91%), and neonatal resuscitation was initiated in 96%;. When parent(s) requested no intervention, the median expected survival was 14% (range ⬍5%- 48%), and resuscitation was initiated in 4%. In the no CD group, the median estimated survival was 24% (range 9-69%), and resuscitation was initiated 92% of neonates. Survival was 40% in the resuscitation group, 0% in the no resuscitation group, and 21% in the no CD group. CONCLUSION: At our tertiary university center there is high concordance between resuscitation decisions and parental requests as recorded in the chart. Prognostic estimates for resuscitated and non-resuscitated infants varied and overlapped considerably. Future studies are needed to assess how routine use of the EST to promote more evidence-based parental counseling affects parental requests, resuscitation decisions, and neonatal outcomes at the threshold of viability. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.246
S72
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
patients Units
Group1
Group2
P
15 2.86(SD2.16)
7 2.85(SD1.06)
0.49
Table 3. Mean of HCT
Patients HCT before C/D HCT after C/D Delta HCT
Group1
Group2
P
23 34.49(SD3.71) 29.95(SD2.46) 4.53
31 34.90(SD3.44) 28.94(SD4.03) 5.95
0.34 0.13 0.07
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.247
PREDICTING A SUCCESSFUL INDUCTION OF LABOR: A SECONDARY ANALYSIS OF MISOPROSTOL VAGINAL INSERT TRIAL LEO PEVZNER1, PAMELA RUMNEY2, RITA PETERSEN3, DEBORAH WING1, 1University of California, Irvine, Orange, California, 2 University of California, Irvine, Department of OBGYN, Orange, California, 3 University of California, Irvine, Department of Statistics, Irvine, California OBJECTIVE: To determine and analyze the maternal and pregnancy characteristics that predict a successful induction of labor. STUDY DESIGN: A secondary analysis was performed on the recently collected data from a multi-center, randomized controlled trial comparing the misoprostol vaginal insert (MVI) to Cervidil for induction of labor. RESULTS: 1275 patients had sufficient labor and delivery data for a comparative analysis. Nine hundred seventeen (72%) of the induced patients subsequently had a vaginal delivery. Multiparity (OR 4.64, 95% CI 3.4-6.3, p⬍0.0001), maternal BMI ⬍30 (OR 1.69, 95% CI 1.29-2.23, p⫽0.0002), intake Bishop score ⱖ3 (OR 1.4, 95% CI 1.09-1.8, p⫽0.008), maternal age ⬍30 years (OR 1.31, 95% CI 1.0007-1.7, p⫽0.044), and birth weight ⬍3500 grams (OR 1.44, 95% CI 1.12-1.8, p⫽0.004) were significant for predicting successful induction of labor. Gestational age did not appear to correlate with the mode of delivery (95% CI 0.95-1.65, p⫽0.1004). A multivariate logistic regression was performed in order to evaluate each factor individually as an independent predictor. All variables, with the exception of gestational age, were significant independent predictors for successful induction of labor after adjusting for all other factors (see Table). CONCLUSION: Maternal characteristics (BMI, age and parity), birth weight and Bishop score can be used as independent factors in predicting a successful induction of labor.
www.AJOG.org 220
DOES BALLOON OCCLUSION OF UTERINE ARTERIES DECREASE THE RISK OF POSTPARTUM COMPLICATIONS? DANIEL BARRAEZ-MASROUA1, ANA HERNANDEZ2, GARY SISKIN3, CAMILLE KANAAN4, 1Albany Medical College, Obstetrics,Gynecology and Reproductive Sciences, Albany, New York, 2Albany Medical College, Obstetrics, Gynecology and Reproductive Sciences, albany, New York, 3Albany medical college, Department of Radiology, Albany, New York, 4Albany medical College, Albany, New York OBJECTIVE: To determine if balloon occlusion of uterine arteries (BOUA) decreases the risk of postpartum complications in patients(pts) with the diagnosis of placenta previa (PP). STUDY DESIGN: Pts delivered at AMC between June/03-Dec/07.Inclusion Criteria:Pts with diagnosis of PP by MFM U/S at AMC.Statistical analyses using StatsDirect 2.7.0.The analysis was conducted by using T-Test.A significant level P⬍ 0.05. RESULTS: Group1:38 pts were treated with BOUA and group2:38 pts without BOUA. There is no statistical difference in the mean of EBL.There is no statistical difference in units transfused (table 2). Hct levels were compared among pts who did not receive blood transfusion, we found no difference (table 3). The mean of hospitalization stay in group 1 was 3.6 days and group 2 was 3.2 ( 95% CI 0.08 to 0.54; SD 0.11) P:0.004 CONCLUSION: 1.BOUA did not reduce EBL.2.There is no statistical difference in units of RBC transfused.However, BOUA increases the risk of blood transfusion.OR 2.88 (95% CI 1.00-8.59) P:0.04.3.BOUA has equivalent drop in the levels of hct after delivery placenta comparing with group control.4.Group 2 spent shorter time at the hospital after C/D.5.There is no difference in the risk of Hysterectomy.OR 2.09 (95% CI 0.2- 24.6) P:0.337.6.Even though,there were no significant differences in the outcomes,it is possible that patients who underwent to BOUA were preselected due to high risk of hemorrhagic.A randomize study will be needed to address this selection bias. Table 1. Comparative outcome
EBL(ml) Hysterectomy Blood Transfusion
Group1
Group2
P
1548.68(SD1135.09) 4 1.13(SD1.94)
1169.73(SD850.63) 2 0.52(SD1.2)
0.09 0.33 0.10
Table 2. Mean of RBC 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.245
219
PARENTAL WISHES, RESUSCITATION DECISIONS, AND PROGNOSTIC ESTIMATES AT 22-24 WEEKS GESTATION MILDRED RAMIREZ1, ANN BERTLES1, NEHAL PARIKH1, SEAN BLACKWELL1, JON TYSON1, 1University of Texas Health Science Center at Houston, Houston, Texas OBJECTIVE: 1) To identify parental wishes and resuscitation decisions at 22 0/7-24 6/7 wks. 2) To relate these to the expected % survival rate with intensive care in the Neonatal Research Network as calculated on the NICHD website estimator (EST) (Tyson, Parikh, et al. New Eng J Med 2008:358;1672). STUDY DESIGN: Chart review was performed assessing neonatal outcome and parental assent for cesarean delivery (CD) and neonatal resuscitation for all births at 22 0/7 - 24 6/7 wks from 1999-2007. Survival estimates were then determined from EST by entering GA, BW, sex, antenatal steroids, and multiple birth. RESULTS: A total of 182 pregnancies including 24 twins and 5 triplets occurred. Mean gestational age (GA) was 23.7 ⫾ 0.8 wks and mean birth weight (BW) was 594.3 ⫾118.3 g. Parents requested “do all” (CD for fetal indications and neonatal resuscitation) for 62 % of deliveries, no resuscitation for 26%, and resuscitation if born alive but no CD for 10%. In the “do all” group the estimated survival with intensive care was 47% (range ⬍5% ⫺91%), and neonatal resuscitation was initiated in 96%;. When parent(s) requested no intervention, the median expected survival was 14% (range ⬍5%- 48%), and resuscitation was initiated in 4%. In the no CD group, the median estimated survival was 24% (range 9-69%), and resuscitation was initiated 92% of neonates. Survival was 40% in the resuscitation group, 0% in the no resuscitation group, and 21% in the no CD group. CONCLUSION: At our tertiary university center there is high concordance between resuscitation decisions and parental requests as recorded in the chart. Prognostic estimates for resuscitated and non-resuscitated infants varied and overlapped considerably. Future studies are needed to assess how routine use of the EST to promote more evidence-based parental counseling affects parental requests, resuscitation decisions, and neonatal outcomes at the threshold of viability. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.246
S72
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
patients Units
Group1
Group2
P
15 2.86(SD2.16)
7 2.85(SD1.06)
0.49
Table 3. Mean of HCT
Patients HCT before C/D HCT after C/D Delta HCT
Group1
Group2
P
23 34.49(SD3.71) 29.95(SD2.46) 4.53
31 34.90(SD3.44) 28.94(SD4.03) 5.95
0.34 0.13 0.07
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.247