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250 Repeated intracervical prostaglandin administration for cervical ripening
SPO Abstracts
Yolumc 164 Number 1, Part 2
248
PAIN RESPONSE TO AMNIOCENTESIS Kathleen Kennedy, M.D.', Steven L. Clark, M.D. University of Utah and IHC Perinatal Center, Salt Lake City, Utah 479 women were studied to assess determinants of subjective pain response to amniocentesis. All procedures were performed With a single needle insertion (22 gal Without local anesthesia. Pnor to the procedure patients were asked to fill out a questionnaire regardmg apprehension level. A questionnaire regardmg subjective pain response followed the procedure. All procedures were performed by the same operator. The abdomen was divided into 13 areas, and amniocentesIS was performed at a location determmed by fetaVplacental position. Pam was judged on a scale of 0 to 5; 0 bemg pamless, 5 being terrible pain. Pre.procedure apprehension was similarly judged on a scale of 0 to 5; 0 bemg not frightened at all, 5 bemg frightened to death. 63% of patients judged the pam of ammocentesis to be 2 or less. 11 % reported the procedure was pamless. Results: 1. Less pam is perceived if the procedure is performed toward the midline and lower on the abdomen than If It IS performed laterally or in the hypogastnc area (P < .05). 2. There was no correlation between apprehension level and perceived pain. 3. There was a significant correlation between apprehension level and prior ammocentesis, but no correlation Mean Pam Score by IDeation between actual pain rperception and prior ammocentesls. 'r-ConclUSions: AmniocenteSIs pam relates more closely r-to location of needle InsertIOn 'r-0 than to pre· procedure anxiety r-or prevIous amnIOcenteSIs .f--expenence.
249 EVALUATION OF OBSTETRICAL ULTRASOUND AT FIRST PRENATAL VISIT Jeffrey M. Barrett, MD, Jennifer Brinson, RNCx Watson Clinic: Lakeland, Florida A prospective study was performed on 1000 consecutive patients to assess the value of ultrasound at first prenatal visit. Significant ultrasound findings were noted in one third of the patients. A discrepancy between ultrasound and menstrual dating was the most frequently noted abnormality, occurring in 27%, of which 59% would not have been discovered on initial physical examination. Other frequently noted abnormalities included missed abortion (5.7%) and twins (1.6%). The frequency of abnormalities on the initial laboratory studies recommended by the American College of Obstetrics and Gynecology was evaluated and found to be significantly less than the frequency of clinically important ultrasound findings, ranging from 4.0% for positive urine cultures to 0.4% for positive serology. Unexpected findings on physical examination were even less frequent, occurring in 2.5% of the patients. It is concluded that the obstetrical ultrasound at the time of the first prenatal visit is highly valuable and should be considered for all patients.
315
250 REPEATED INTRACERVICAL PROSTAGLANDIN ADMINISTRATION
FOR CERVICAL RIPENING Kurt H. Stiver. M.D., Mary Jane Davis, M.D." and Alan M. Golichowsla, M.D., Indiana Umversity Medical Center, Indianapohs, IN Although It has been wen established that prostaglandin ~ m gel win improve the compliance of the unfavorable term cerviX prior' to labor induction, that intracervical admmistration is effective at lower doses than drug given intravaginally, and that repeated doses are more effective than smgle administration, the lowest effective intracervical dose has not been established. In this randomized, double·blmded study, primigravid patIents at ~ 37 weeks gestation with indications for dehvery and Bishop scores ~ 5 received either 0.2 mg (Group A; 15 patients) or 0.5 mg (Group B; 13 patients) prostaglandin E2 in 1.0 mL gel at intervals of 6 h until spontaneous rupture of membranes or labor occurred, dilatIon was ~ 4 cm, or 5 doses were given, at which time oxytocin induction or augmentation was begun. Bishop score was as· signed pnor to each administration of drug. Spontaneous labor occurred in only one patient during treatment. There was no significant difference between the two groups in the number of doses required to achieve 75% effacement (Group A mean 3 15. range 2-5; Group B mean 3.17, range 1-5) or to reach ~ 3 cm dilation (Group A mean 3.4, range 1-5; Group B mean 3.7, range 2-4), or in the cumulative percent of patients with a Bishop score of ~9 after each dose: Bishop Score ~ 9 (%) Dose Number 2 3 4 5 Group A (0.2 mg) o 27 47 60 60 Group B (0.5 mg) 8 39 46 69 69 Only one patient showed change in score with the fifth dose. Forty per-cent of Group A and 31% of Group B required c",sarean dehvery, but no patient underwent c",sarean section for failure of cervical change or distress during prostaglandin administration. We conclude that repeated intracervical admmistration of 0.2 mg of prostaglandm E2 IS as effecltve as repeated doses of 0.5 mg m changing cervical compliance, but that after 4 doses no further cervical improvement is seen.
251 CERVICAL DILATATION AND PARITY ARE THE BEST
PREDICTORS OF VAGINAL DELIVERY IN THE POSTTERM PATIENT. Arnold L. MedearistJM.D., Richard M. Fanner, M.D., PhD.*, Anna S. Leung, M.D. *,mversity of Southern CalIfornia LACA. In posttenn pregnancy most management protocols call for inductIOn when the patient has a "favorable cervix" (bishop score (BS» 6). The purpose of our study is to evaluate the componentsofthe BS (dilatation, effacement, station, consistency and cervical position (Obstet. Gynecol. 24:266 , 1964» in conjunction with gravidity, parity and gestational age to assess whIch variables are the SIgnificant contributors to vaginal delivery (NVD). 297 patients from 287 to 310 days gestation were seen in the postterm referral clinic. 165 cases with BS > 6 were admitted for induction oflabor. 108 cases with BS < 5 were induced for medical or obstetrical indications. Components were scored as in the original article with the exception of a modification of effacement to use assessment oflengtli. Patients mduced were managed by the staff in labor and delivery.with pitocm. Records were reviewed for the presence of NYD or cesarian section (22 in BS > 6, 30 in BS < 5). The previously listed variables were evaluated by' univariate and stepwise regression analysis using BMDPLR (BMDP Stattstical Software, Inc.). The results are presented below. Odds Ratio <5 >6 Bishop Score Dilatation 1A1 7:88 * Length 0.83 1.78 StatIon 0.70 1.22 Consistency 0.83 0.92 Position Cervix 1.00 1.10 Total Bishop 0.87 1.49 Gravida 1.91 * 1.07 Parity 4.76 * 1.04 Gestational ;\ge 1.08 1.02 Upper and lower confidence mtervals for * statistically significant (p < 0.001) variables are 1.01 . 61.5 for dilatation, 1.25 ·2.92 for gravity and 2.01 . 11.3 for parity. Stepwise regression of all: ., , ". . lected only parity (BS S. 5) ane " • to successful predIctIOn . 'I\portant variable when of NV considering induction in the postterm patient with an unfavorable cervix while dilatation IS associated with successful induction in the postterrn pregnancy with a BS ? 6.
Yolumc 164 Number 1, Part 2
248
PAIN RESPONSE TO AMNIOCENTESIS Kathleen Kennedy, M.D.', Steven L. Clark, M.D. University of Utah and IHC Perinatal Center, Salt Lake City, Utah 479 women were studied to assess determinants of subjective pain response to amniocentesis. All procedures were performed With a single needle insertion (22 gal Without local anesthesia. Pnor to the procedure patients were asked to fill out a questionnaire regardmg apprehension level. A questionnaire regardmg subjective pain response followed the procedure. All procedures were performed by the same operator. The abdomen was divided into 13 areas, and amniocentesIS was performed at a location determmed by fetaVplacental position. Pam was judged on a scale of 0 to 5; 0 bemg pamless, 5 being terrible pain. Pre.procedure apprehension was similarly judged on a scale of 0 to 5; 0 bemg not frightened at all, 5 bemg frightened to death. 63% of patients judged the pam of ammocentesis to be 2 or less. 11 % reported the procedure was pamless. Results: 1. Less pam is perceived if the procedure is performed toward the midline and lower on the abdomen than If It IS performed laterally or in the hypogastnc area (P < .05). 2. There was no correlation between apprehension level and perceived pain. 3. There was a significant correlation between apprehension level and prior ammocentesis, but no correlation Mean Pam Score by IDeation between actual pain rperception and prior ammocentesls. 'r-ConclUSions: AmniocenteSIs pam relates more closely r-to location of needle InsertIOn 'r-0 than to pre· procedure anxiety r-or prevIous amnIOcenteSIs .f--expenence.
249 EVALUATION OF OBSTETRICAL ULTRASOUND AT FIRST PRENATAL VISIT Jeffrey M. Barrett, MD, Jennifer Brinson, RNCx Watson Clinic: Lakeland, Florida A prospective study was performed on 1000 consecutive patients to assess the value of ultrasound at first prenatal visit. Significant ultrasound findings were noted in one third of the patients. A discrepancy between ultrasound and menstrual dating was the most frequently noted abnormality, occurring in 27%, of which 59% would not have been discovered on initial physical examination. Other frequently noted abnormalities included missed abortion (5.7%) and twins (1.6%). The frequency of abnormalities on the initial laboratory studies recommended by the American College of Obstetrics and Gynecology was evaluated and found to be significantly less than the frequency of clinically important ultrasound findings, ranging from 4.0% for positive urine cultures to 0.4% for positive serology. Unexpected findings on physical examination were even less frequent, occurring in 2.5% of the patients. It is concluded that the obstetrical ultrasound at the time of the first prenatal visit is highly valuable and should be considered for all patients.
315
250 REPEATED INTRACERVICAL PROSTAGLANDIN ADMINISTRATION
FOR CERVICAL RIPENING Kurt H. Stiver. M.D., Mary Jane Davis, M.D." and Alan M. Golichowsla, M.D., Indiana Umversity Medical Center, Indianapohs, IN Although It has been wen established that prostaglandin ~ m gel win improve the compliance of the unfavorable term cerviX prior' to labor induction, that intracervical admmistration is effective at lower doses than drug given intravaginally, and that repeated doses are more effective than smgle administration, the lowest effective intracervical dose has not been established. In this randomized, double·blmded study, primigravid patIents at ~ 37 weeks gestation with indications for dehvery and Bishop scores ~ 5 received either 0.2 mg (Group A; 15 patients) or 0.5 mg (Group B; 13 patients) prostaglandin E2 in 1.0 mL gel at intervals of 6 h until spontaneous rupture of membranes or labor occurred, dilatIon was ~ 4 cm, or 5 doses were given, at which time oxytocin induction or augmentation was begun. Bishop score was as· signed pnor to each administration of drug. Spontaneous labor occurred in only one patient during treatment. There was no significant difference between the two groups in the number of doses required to achieve 75% effacement (Group A mean 3 15. range 2-5; Group B mean 3.17, range 1-5) or to reach ~ 3 cm dilation (Group A mean 3.4, range 1-5; Group B mean 3.7, range 2-4), or in the cumulative percent of patients with a Bishop score of ~9 after each dose: Bishop Score ~ 9 (%) Dose Number 2 3 4 5 Group A (0.2 mg) o 27 47 60 60 Group B (0.5 mg) 8 39 46 69 69 Only one patient showed change in score with the fifth dose. Forty per-cent of Group A and 31% of Group B required c",sarean dehvery, but no patient underwent c",sarean section for failure of cervical change or distress during prostaglandin administration. We conclude that repeated intracervical admmistration of 0.2 mg of prostaglandm E2 IS as effecltve as repeated doses of 0.5 mg m changing cervical compliance, but that after 4 doses no further cervical improvement is seen.
251 CERVICAL DILATATION AND PARITY ARE THE BEST
PREDICTORS OF VAGINAL DELIVERY IN THE POSTTERM PATIENT. Arnold L. MedearistJM.D., Richard M. Fanner, M.D., PhD.*, Anna S. Leung, M.D. *,mversity of Southern CalIfornia LACA. In posttenn pregnancy most management protocols call for inductIOn when the patient has a "favorable cervix" (bishop score (BS» 6). The purpose of our study is to evaluate the componentsofthe BS (dilatation, effacement, station, consistency and cervical position (Obstet. Gynecol. 24:266 , 1964» in conjunction with gravidity, parity and gestational age to assess whIch variables are the SIgnificant contributors to vaginal delivery (NVD). 297 patients from 287 to 310 days gestation were seen in the postterm referral clinic. 165 cases with BS > 6 were admitted for induction oflabor. 108 cases with BS < 5 were induced for medical or obstetrical indications. Components were scored as in the original article with the exception of a modification of effacement to use assessment oflengtli. Patients mduced were managed by the staff in labor and delivery.with pitocm. Records were reviewed for the presence of NYD or cesarian section (22 in BS > 6, 30 in BS < 5). The previously listed variables were evaluated by' univariate and stepwise regression analysis using BMDPLR (BMDP Stattstical Software, Inc.). The results are presented below. Odds Ratio <5 >6 Bishop Score Dilatation 1A1 7:88 * Length 0.83 1.78 StatIon 0.70 1.22 Consistency 0.83 0.92 Position Cervix 1.00 1.10 Total Bishop 0.87 1.49 Gravida 1.91 * 1.07 Parity 4.76 * 1.04 Gestational ;\ge 1.08 1.02 Upper and lower confidence mtervals for * statistically significant (p < 0.001) variables are 1.01 . 61.5 for dilatation, 1.25 ·2.92 for gravity and 2.01 . 11.3 for parity. Stepwise regression of all: ., , ". . lected only parity (BS S. 5) ane " • to successful predIctIOn . 'I\portant variable when of NV considering induction in the postterm patient with an unfavorable cervix while dilatation IS associated with successful induction in the postterrn pregnancy with a BS ? 6.