- Email: [email protected]
290: Does fetal gender affect the labor curve?
Poster Session II Cesarean 38 wks vs. Later
aOR (95%CI)
22.8%
Birthwt >4kg
Diabetes, Labor, Ultrasound-Imaging
aOR (95%CI)
11.2%
Jaundice
aOR (95%CI)
17.3%
..........................................................................................................................................................................................
37.2%
2.1 (1.9-2.2)
17.1%
1.4 (1.4-1.7)
15.8%
0.9 (0.8-0.9)
..........................................................................................................................................................................................
39 wks vs. Later
23.1%
12.6%
15.2%
..........................................................................................................................................................................................
35.4%
1.9 (1.8-2.0)
18.3%
1.5 (1.4-1.6)
15.7%
1.0 (0.9-1.1)
..........................................................................................................................................................................................
40 wks vs. Later
24.1%
15.7%
15.7%
..........................................................................................................................................................................................
38.9%
1.6 (1.2-1.8)
19.2%
1.0 (0.9-1.1)
16.2%
1.2 (1.2-1.4)
..........................................................................................................................................................................................
41 wks vs. Later
30.1%
17.9%
14.8%
..........................................................................................................................................................................................
37.8%
1.5 (1.4-1.7)
19.5%
1.1 (0.9-1.3)
16.8%
1.3 (1.1-1.6)
..........................................................................................................................................................................................
288 Fetal growth in association with maternal and fetal insulin, proinsulin and IGF-1 levels in gestational diabetic and non-diabetic pregnancies Zhong-Cheng Luo1, Anne-Monique Nuyt1, Edgard Delvin1, Francois Audibert2, Isabelle Girard3, Roberta Shear3, Emile Levy1, Bryna Shatenstein2, Pierre Julien4, William Fraser1 University of Montreal, Montreal, QC, 2Universite de Montreal, Montreal, QC, 3McGill University, Montreal, QC, 4Laval University, Laval, QC
indication. Neonatal outcomes included; APGAR scores, NICU admission, ventilator use, RDS, TTN, TPN, phototherapy, and seizures. RESULTS: Of 13,851 infants delivered during this period, 405 were LBW (2.9%). Stillbirth complicated 19.8/1000 of LBW infants (vs. 1.0/1000 for BWT ⱖ2500 g, p⬍0.001). Only 83 of 405 LBWs (20.5%) were diagnosed FGR before delivery. FGR had an ultrasound closer to delivery than U-FGR (1.3 vs. 3.7 wks p⬍0.001). Mean delivery gestation was statistically but not clinically different between the two groups (38.0 vs. 38.2 wks, p⫽0.048). Intrapartum & neonatal outcomes are summarized in the Table. CONCLUSIONS: Fetuses with U-FGR at term area at markedly increased risk for stillbirth, and are commonly not diagnosed before birth. UFGR pregnancies are less likely induced, and surprisingly are at increased risk for cesarean delivery for “dystocia”. Strategies to better identify those at risk for FGR at term are needed. Table: Perinatal outcomes between FGR & U-FGR FGR (Nⴝ83) (%)
1
OBJECTIVE: Insulin and insulin-like growth factor (IGF)-1 are essen-
tial fetal growth factors. Whether maternal IGF-1 affects fetal growth remains uncertain. It is unknown whether maternal and fetal insulin and IGF-1 have a similar effect on fetal growth in gestational diabetic vs. non-diabetic pregnancies. We assessed the associations of fetal growth with maternal and fetal insulin and IGF-1 in gestational diabetic and non-diabetic pregnancies. STUDY DESIGN: In a prospective singleton pregnancy cohort study (n⫽307), we analyzed fetal growth (birth weight, length, ponderal index, placenta weight, head circumference) in relation to glucose, insulin, proinsulin and IGF-1 concentrations in maternal 50 grams oral glucose tolerance test (OGTT) blood at 24-28 weeks and in umbilical cord blood. RESULTS: Maternal OGTT and cord blood insulin, proinsulin and IGF-1 concentrations were significantly higher in gestational diabetic vs. non-diabetic pregnancies. Adjusting for infant sex, gestational age, maternal and paternal characteristics, for each standard deviation increase in plasma concentrations, maternal IGF-1 was associated with a greater increase in birth weight (196 vs. 55 g), fetal IGF-1 was associated with a smaller increase in birth weight (136 vs. 252 g) in gestational diabetic (n⫽27) vs. non-diabetic pregnancies, while maternal proinsulin was associated with a significant increase (1.1 kg/m^3) in ponderal index, and fetal insulin was associated with a significant increase (0.7 cm) in birth length in gestational diabetic pregnancies only. CONCLUSIONS: The positive impact on birth weight is strengthened for maternal IGF-1 and weakened for fetal IGF-1 in gestational diabetic vs. non-diabetic pregnancies. Maternal OGTT proinsulin is strongly associated with fetal adiposity, and fetal insulin is strongly associated with linear growth in gestational diabetic pregnancies.
289 Fetal growth restriction at term: impact of antenatal diagnosis on intrapartum management & newborn outcomes Alicia Mandujano1, Stephen Myers1, Brian Mercer1 1 MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH
OBJECTIVE: To compare intrapartum management and newborn outcomes in term patients with an antenatal diagnosis of fetal growth restriction (FGR) versus those undiagnosed before delivery (U-FGR). STUDY DESIGN: This is a retrospective cohort study of singleton gestations delivered ⱖ37 weeks gestation and with birth weight (BWT) ⬍2500g (LBW), from 2005-2009. Those with fetal anomalies, aneuploidy, scheduled cesarean section, and non-vertex presentation at delivery were excluded. A diagnosis of FGR required a documented EFW ⬍10%ile before delivery. Intrapartum outcomes included; admission indication, induction, delivery mode, and operative delivery
S120
www.AJOG.org
Induction
66.3
U-FGR (Nⴝ322) (%) 27
p-value < 0.001
..........................................................................................................................................................................................
Primary CS or failed TOL 12 12.1 0.43 ................................................................................................................................................................................. FHR abnormality 12 6.5 0.09 ................................................................................................................................................................................. Dystocia
0
5.6
0.03
..........................................................................................................................................................................................
Operative vaginal delivery 2.4 4.7 0.37 .......................................................................................................................................................................................... Birth weight, grams (mean) 2209 2353 < 0.001 .......................................................................................................................................................................................... ⬍ 3% birth weight 80.7 64.9 0.008 .......................................................................................................................................................................................... 1m APGAR (median) 9 9 0.15 .......................................................................................................................................................................................... 5m APGAR (median) 9 9 0.64 .......................................................................................................................................................................................... NICU admit 10.8 10.9 0.58 .......................................................................................................................................................................................... RDS 2.4 2.5 0.66 .......................................................................................................................................................................................... Ventilator use 1.2 1.9 0.56 .......................................................................................................................................................................................... Seizure 0 0.6 0.63 .......................................................................................................................................................................................... Phototherapy 8.4 4.3 0.11 .......................................................................................................................................................................................... TTN 4.8 2.5 0.22 .......................................................................................................................................................................................... TPN 3.6 2.5 0.40 ..........................................................................................................................................................................................
290 Does fetal gender affect the labor curve? Alison G. Cahill1, Kimberly A. Roehl1, Anthony O. Odibo1, George A. Macones1 1
Washington University in St. Louis, St. Louis, MO
OBJECTIVE: While established obstetric texts have acknowledged the par-
ticipation of the fetal endocrine access in the initiation and progression of labor, the mechanisms remain unknown. Given recent data supporting the relationship between fetal endocrine access and labor, the unknown role of fetal gender follows. We sought to estimate the association between fetal gender and labor curve of the active first stage at term. STUDY DESIGN: As a planned part of large patient cohort study of consecutive, singleton term labor patients who delivered in the second stage, we compared the active phase of first stage labor by fetal gender. The primary exposure was male fetal gender. The primary outcome was length of active stage 1, defined to start at ⱖ5cm dilation. Based on previously published methods for the evaluation of labor curves, interval-censored regression was used to estimate the affect of fetal gender on time in the active first stage (5-10cm), adjusting for relevant covariates. RESULTS: Of 2400 women, 2373 women had complete labor information and were available for this analysis. Male gender was associated with a statistically significantly longer active first stage of labor, which persisted after adjusting for regional anesthesia, birthweight ⱖ4000g, nulliparity, and prostaglandin exposure, as well as in stratified analyses by parity.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2011
Diabetes, Labor, Ultrasound-Imaging
www.AJOG.org
CONCLUSIONS: Male fetuses are associated with longer active phase of the first stage of labor. Fetal gender may play an important role in labor progression, and specifically may need to be considered in the setting of arrest diagnoses. Median (hrs)
Standard error (hrs)
p
..........................................................................................................................................................................................
4.5
0.2
0.001
..........................................................................................................................................................................................
Female 3.9 0.1 .......................................................................................................................................................................................... Nullips only ** .......................................................................................................................................................................................... Male
4.8
0.2
0.012
..........................................................................................................................................................................................
Female 4.1 0.2 .......................................................................................................................................................................................... * Adjusted for regional anesthesia, birthweight ⱖ4000g, nulliparity, prostaglandin exposure (PGE); ** Adjusted for regional anesthesia, birthweight ⱖ4000g, PGE.
291 Outcomes of term dichorionic twins are better with scheduled cesarean compared to planned vaginal delivery Amos Grunebaum1, Frank A. Chervenak1, Joachim W. Dudenhausen1 1
Weill Cornell Medical College, New York, NY
OBJECTIVE: The optimal mode of delivery for twins is unknown. The
objective of this study was to assess the outcomes and delivery modes of term dichorionic twin pregnancies with the first twin presenting by vertex. STUDY DESIGN: This is a cohort study done at one academic institution. A twin pair was eligible to be included in the study if the delivery was between 2000 and 2009, the gestational age was 37 weeks and beyond, twins were dichorionic, and the first twin presented by vertex. Twins were allocated to one of two groups: Patients with scheduled cesarean delivery (SCD) and those with planned vaginal delivery (PVD). RESULTS: Our study population included 308 pairs of dichorionic twins, with 88 SCD patients and 220 PVD patients. The cesarean delivery rate of twin A in the PVD group was 15.5% (34/220), and 19.5% (43/220) for twin B. In pregnancies where twin A was delivered vaginally there was a 4.8% (9/186) cesarean delivery rate for twin B. When compared to twin B after scheduled cesarean, twin B after planned vaginal birth was significantly more likely to have an acidocic arterial cord pH (p⬍0.02), to be admitted to the NICU (after excluding twins with congenital malformations), and more likely to have low Apgar scores. CONCLUSIONS: There is an increased risk to twin B after a planned vaginal birth. This should caution obstetricians about the increased risks of a planned vaginal birth in twin pregnancies. Our study results can aid physicians in counseling patients with term twin pregnancies when discussing options for delivery modes. Scheduled Cesarean
Planned Vaginal Twin A(220)
Twin A(88)
Twin B(88)
1-Min Apgar <7
3.4% (3)
6.8% (6)
1.4% (3)
Twin B(220) 14.5% (32)
5-Min Apgar <7
2.3% (2)
0
0.5% (1)
3.5% (8)
apH <7.1
0%
0%
0% (0)
6.4% (14)
p *B 0.06*(B)
..........................................................................................................................................................................................
0.07*(B)
..........................................................................................................................................................................................
⬍0.02*(B)
..........................................................................................................................................................................................
NICU Admits
13.6% (12)
9.1% (8)
5.9% (13)
15.5% (34)
15.5% (34)
19.5% (43)
⬍0.14
..........................................................................................................................................................................................
Cesarean
100%
100%
292 Increase in rates of cesarean delivery (CD) among nulliparae with singleton term fetuses in cephalic presentation: which factors play a role? Marianna Andreani1, Elena Ciriello1, Maddalena Incerti1, Federica Accordino2, Alessandro Ghidini3, Anita Regalia1, Anna Locatelli2 1
All *
Male
Poster Session II
..........................................................................................................................................................................................
University of Milano Bicocca, Monza, 2University of Milano-Bicocca, Monza, 3Georgetown University Hospital, Washington, DC
OBJECTIVE: To evaluate the factors involved in the changes in CD rates among nulliparae at term with singleton fetuses in cephalic presentation at a University Hospital with overall low rates of CD, standardized and unchanged protocols of care in labor, and ongoing clinical audit. STUDY DESIGN: Retrospective analysis of all deliveries in 2 periods tenyear apart (1994-96 and 2004-06). Demographic and obstetrics characteristics were analyzed in relation to changes in rates of CD using the Robson classification, with particular focus on Robson’s groups 1 and 2 combined (term singleton cephalic in nullipara with spontaneous or induced labor). RESULTS: A total of 8237 consecutive deliveries occurred during the 1st period and 8420 in the 2nd period. The overall rate of CD increased from 12.5% to 17.9% (p⬍0.001). Term singleton cephalic in nulliparaecontributed to 49% of deliveries in the 1st period and to 42% in the 2nd period, as well as to 32% of all CDs in the 1st period vs 36% in the 2nd period. Factors associated with the changes in CD rate were BMI (21.5 ⫾ 3.2 vs 22⫾ 3.6, p⬍0.01) and maternal age (29.5⫾1.2 years vs 30.5 ⫾ 12, p⬍0.01). At multivariate analysis, BMI (OR 1.0; 95% CI 1.06-1.1) and maternal age (OR 1.6; 95% CI 1.05-1.08) were independently related to CD, as was the difference in CD rate between the 2 period (OR 1.7, 95% CI 1.5-2.0). CONCLUSIONS: BMI and maternal age are independent factors associated to the increasing rate of CD among nulliparae in spontaneous or induced labor with term fetus in cephalic presentation.
293 The safety of the Foley catheter for preinduction cervical ripening in a low risk population Anthony Sciscione1, Matthew Hoffman2, Casey Bedder3, Philip Shlossman3 1 Christiana Hospital, Newark, DE, 2Christiana Care Health System, Newark, DE, 3Christiana Hospital, Newark, DE
OBJECTIVE: The Foley Catheter (FC) has been shown to be an effective method for preinduction cervical ripening and a recent randomized trial has demonstrated that it is as efficacious in the outpatient as the inpatient setting for ripening. While the outpatient setting will likely result in a significant cost savings, before it can be recommended a large scale study assessing the safety of the FC in the preinduction cervical ripening time period must be performed. We sought to determine the safety of preinduction cervical ripening with the FC. STUDY DESIGN: A retrospective review of our obstetrical database was performed for all inductions of labor performed at our hospital from 1/1/2006 until 6/14/09. We included all term labor inductions of nonanomalous singleton gestations that used the FC for preinduction cervical ripening. All preinduction cervical ripening was performed in the inpatient setting with continuous fetal monitoring. We excluded pregnancies with hypertensive disorders, diabetes, growth restriction, multiple gestations, premature rupture of the membranes, non-reassuring fetal testing, or any condition that would preclude outpatient ripening. If any other pharmacologic or mechanical method was used in or before this time period they were excluded. We observed the rate of adverse outcomes in the period of preinduction cervical ripening (Foley placement until oxytocin initiation). Adverse outcomes were defined as cesarean delivery for any indication, placental abruption, chorioamnionitis, rupture of the membranes after insertion and cord prolapse.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S121
aOR (95%CI)
22.8%
Birthwt >4kg
Diabetes, Labor, Ultrasound-Imaging
aOR (95%CI)
11.2%
Jaundice
aOR (95%CI)
17.3%
..........................................................................................................................................................................................
37.2%
2.1 (1.9-2.2)
17.1%
1.4 (1.4-1.7)
15.8%
0.9 (0.8-0.9)
..........................................................................................................................................................................................
39 wks vs. Later
23.1%
12.6%
15.2%
..........................................................................................................................................................................................
35.4%
1.9 (1.8-2.0)
18.3%
1.5 (1.4-1.6)
15.7%
1.0 (0.9-1.1)
..........................................................................................................................................................................................
40 wks vs. Later
24.1%
15.7%
15.7%
..........................................................................................................................................................................................
38.9%
1.6 (1.2-1.8)
19.2%
1.0 (0.9-1.1)
16.2%
1.2 (1.2-1.4)
..........................................................................................................................................................................................
41 wks vs. Later
30.1%
17.9%
14.8%
..........................................................................................................................................................................................
37.8%
1.5 (1.4-1.7)
19.5%
1.1 (0.9-1.3)
16.8%
1.3 (1.1-1.6)
..........................................................................................................................................................................................
288 Fetal growth in association with maternal and fetal insulin, proinsulin and IGF-1 levels in gestational diabetic and non-diabetic pregnancies Zhong-Cheng Luo1, Anne-Monique Nuyt1, Edgard Delvin1, Francois Audibert2, Isabelle Girard3, Roberta Shear3, Emile Levy1, Bryna Shatenstein2, Pierre Julien4, William Fraser1 University of Montreal, Montreal, QC, 2Universite de Montreal, Montreal, QC, 3McGill University, Montreal, QC, 4Laval University, Laval, QC
indication. Neonatal outcomes included; APGAR scores, NICU admission, ventilator use, RDS, TTN, TPN, phototherapy, and seizures. RESULTS: Of 13,851 infants delivered during this period, 405 were LBW (2.9%). Stillbirth complicated 19.8/1000 of LBW infants (vs. 1.0/1000 for BWT ⱖ2500 g, p⬍0.001). Only 83 of 405 LBWs (20.5%) were diagnosed FGR before delivery. FGR had an ultrasound closer to delivery than U-FGR (1.3 vs. 3.7 wks p⬍0.001). Mean delivery gestation was statistically but not clinically different between the two groups (38.0 vs. 38.2 wks, p⫽0.048). Intrapartum & neonatal outcomes are summarized in the Table. CONCLUSIONS: Fetuses with U-FGR at term area at markedly increased risk for stillbirth, and are commonly not diagnosed before birth. UFGR pregnancies are less likely induced, and surprisingly are at increased risk for cesarean delivery for “dystocia”. Strategies to better identify those at risk for FGR at term are needed. Table: Perinatal outcomes between FGR & U-FGR FGR (Nⴝ83) (%)
1
OBJECTIVE: Insulin and insulin-like growth factor (IGF)-1 are essen-
tial fetal growth factors. Whether maternal IGF-1 affects fetal growth remains uncertain. It is unknown whether maternal and fetal insulin and IGF-1 have a similar effect on fetal growth in gestational diabetic vs. non-diabetic pregnancies. We assessed the associations of fetal growth with maternal and fetal insulin and IGF-1 in gestational diabetic and non-diabetic pregnancies. STUDY DESIGN: In a prospective singleton pregnancy cohort study (n⫽307), we analyzed fetal growth (birth weight, length, ponderal index, placenta weight, head circumference) in relation to glucose, insulin, proinsulin and IGF-1 concentrations in maternal 50 grams oral glucose tolerance test (OGTT) blood at 24-28 weeks and in umbilical cord blood. RESULTS: Maternal OGTT and cord blood insulin, proinsulin and IGF-1 concentrations were significantly higher in gestational diabetic vs. non-diabetic pregnancies. Adjusting for infant sex, gestational age, maternal and paternal characteristics, for each standard deviation increase in plasma concentrations, maternal IGF-1 was associated with a greater increase in birth weight (196 vs. 55 g), fetal IGF-1 was associated with a smaller increase in birth weight (136 vs. 252 g) in gestational diabetic (n⫽27) vs. non-diabetic pregnancies, while maternal proinsulin was associated with a significant increase (1.1 kg/m^3) in ponderal index, and fetal insulin was associated with a significant increase (0.7 cm) in birth length in gestational diabetic pregnancies only. CONCLUSIONS: The positive impact on birth weight is strengthened for maternal IGF-1 and weakened for fetal IGF-1 in gestational diabetic vs. non-diabetic pregnancies. Maternal OGTT proinsulin is strongly associated with fetal adiposity, and fetal insulin is strongly associated with linear growth in gestational diabetic pregnancies.
289 Fetal growth restriction at term: impact of antenatal diagnosis on intrapartum management & newborn outcomes Alicia Mandujano1, Stephen Myers1, Brian Mercer1 1 MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH
OBJECTIVE: To compare intrapartum management and newborn outcomes in term patients with an antenatal diagnosis of fetal growth restriction (FGR) versus those undiagnosed before delivery (U-FGR). STUDY DESIGN: This is a retrospective cohort study of singleton gestations delivered ⱖ37 weeks gestation and with birth weight (BWT) ⬍2500g (LBW), from 2005-2009. Those with fetal anomalies, aneuploidy, scheduled cesarean section, and non-vertex presentation at delivery were excluded. A diagnosis of FGR required a documented EFW ⬍10%ile before delivery. Intrapartum outcomes included; admission indication, induction, delivery mode, and operative delivery
S120
www.AJOG.org
Induction
66.3
U-FGR (Nⴝ322) (%) 27
p-value < 0.001
..........................................................................................................................................................................................
Primary CS or failed TOL 12 12.1 0.43 ................................................................................................................................................................................. FHR abnormality 12 6.5 0.09 ................................................................................................................................................................................. Dystocia
0
5.6
0.03
..........................................................................................................................................................................................
Operative vaginal delivery 2.4 4.7 0.37 .......................................................................................................................................................................................... Birth weight, grams (mean) 2209 2353 < 0.001 .......................................................................................................................................................................................... ⬍ 3% birth weight 80.7 64.9 0.008 .......................................................................................................................................................................................... 1m APGAR (median) 9 9 0.15 .......................................................................................................................................................................................... 5m APGAR (median) 9 9 0.64 .......................................................................................................................................................................................... NICU admit 10.8 10.9 0.58 .......................................................................................................................................................................................... RDS 2.4 2.5 0.66 .......................................................................................................................................................................................... Ventilator use 1.2 1.9 0.56 .......................................................................................................................................................................................... Seizure 0 0.6 0.63 .......................................................................................................................................................................................... Phototherapy 8.4 4.3 0.11 .......................................................................................................................................................................................... TTN 4.8 2.5 0.22 .......................................................................................................................................................................................... TPN 3.6 2.5 0.40 ..........................................................................................................................................................................................
290 Does fetal gender affect the labor curve? Alison G. Cahill1, Kimberly A. Roehl1, Anthony O. Odibo1, George A. Macones1 1
Washington University in St. Louis, St. Louis, MO
OBJECTIVE: While established obstetric texts have acknowledged the par-
ticipation of the fetal endocrine access in the initiation and progression of labor, the mechanisms remain unknown. Given recent data supporting the relationship between fetal endocrine access and labor, the unknown role of fetal gender follows. We sought to estimate the association between fetal gender and labor curve of the active first stage at term. STUDY DESIGN: As a planned part of large patient cohort study of consecutive, singleton term labor patients who delivered in the second stage, we compared the active phase of first stage labor by fetal gender. The primary exposure was male fetal gender. The primary outcome was length of active stage 1, defined to start at ⱖ5cm dilation. Based on previously published methods for the evaluation of labor curves, interval-censored regression was used to estimate the affect of fetal gender on time in the active first stage (5-10cm), adjusting for relevant covariates. RESULTS: Of 2400 women, 2373 women had complete labor information and were available for this analysis. Male gender was associated with a statistically significantly longer active first stage of labor, which persisted after adjusting for regional anesthesia, birthweight ⱖ4000g, nulliparity, and prostaglandin exposure, as well as in stratified analyses by parity.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2011
Diabetes, Labor, Ultrasound-Imaging
www.AJOG.org
CONCLUSIONS: Male fetuses are associated with longer active phase of the first stage of labor. Fetal gender may play an important role in labor progression, and specifically may need to be considered in the setting of arrest diagnoses. Median (hrs)
Standard error (hrs)
p
..........................................................................................................................................................................................
4.5
0.2
0.001
..........................................................................................................................................................................................
Female 3.9 0.1 .......................................................................................................................................................................................... Nullips only ** .......................................................................................................................................................................................... Male
4.8
0.2
0.012
..........................................................................................................................................................................................
Female 4.1 0.2 .......................................................................................................................................................................................... * Adjusted for regional anesthesia, birthweight ⱖ4000g, nulliparity, prostaglandin exposure (PGE); ** Adjusted for regional anesthesia, birthweight ⱖ4000g, PGE.
291 Outcomes of term dichorionic twins are better with scheduled cesarean compared to planned vaginal delivery Amos Grunebaum1, Frank A. Chervenak1, Joachim W. Dudenhausen1 1
Weill Cornell Medical College, New York, NY
OBJECTIVE: The optimal mode of delivery for twins is unknown. The
objective of this study was to assess the outcomes and delivery modes of term dichorionic twin pregnancies with the first twin presenting by vertex. STUDY DESIGN: This is a cohort study done at one academic institution. A twin pair was eligible to be included in the study if the delivery was between 2000 and 2009, the gestational age was 37 weeks and beyond, twins were dichorionic, and the first twin presented by vertex. Twins were allocated to one of two groups: Patients with scheduled cesarean delivery (SCD) and those with planned vaginal delivery (PVD). RESULTS: Our study population included 308 pairs of dichorionic twins, with 88 SCD patients and 220 PVD patients. The cesarean delivery rate of twin A in the PVD group was 15.5% (34/220), and 19.5% (43/220) for twin B. In pregnancies where twin A was delivered vaginally there was a 4.8% (9/186) cesarean delivery rate for twin B. When compared to twin B after scheduled cesarean, twin B after planned vaginal birth was significantly more likely to have an acidocic arterial cord pH (p⬍0.02), to be admitted to the NICU (after excluding twins with congenital malformations), and more likely to have low Apgar scores. CONCLUSIONS: There is an increased risk to twin B after a planned vaginal birth. This should caution obstetricians about the increased risks of a planned vaginal birth in twin pregnancies. Our study results can aid physicians in counseling patients with term twin pregnancies when discussing options for delivery modes. Scheduled Cesarean
Planned Vaginal Twin A(220)
Twin A(88)
Twin B(88)
1-Min Apgar <7
3.4% (3)
6.8% (6)
1.4% (3)
Twin B(220) 14.5% (32)
5-Min Apgar <7
2.3% (2)
0
0.5% (1)
3.5% (8)
apH <7.1
0%
0%
0% (0)
6.4% (14)
p *B 0.06*(B)
..........................................................................................................................................................................................
0.07*(B)
..........................................................................................................................................................................................
⬍0.02*(B)
..........................................................................................................................................................................................
NICU Admits
13.6% (12)
9.1% (8)
5.9% (13)
15.5% (34)
15.5% (34)
19.5% (43)
⬍0.14
..........................................................................................................................................................................................
Cesarean
100%
100%
292 Increase in rates of cesarean delivery (CD) among nulliparae with singleton term fetuses in cephalic presentation: which factors play a role? Marianna Andreani1, Elena Ciriello1, Maddalena Incerti1, Federica Accordino2, Alessandro Ghidini3, Anita Regalia1, Anna Locatelli2 1
All *
Male
Poster Session II
..........................................................................................................................................................................................
University of Milano Bicocca, Monza, 2University of Milano-Bicocca, Monza, 3Georgetown University Hospital, Washington, DC
OBJECTIVE: To evaluate the factors involved in the changes in CD rates among nulliparae at term with singleton fetuses in cephalic presentation at a University Hospital with overall low rates of CD, standardized and unchanged protocols of care in labor, and ongoing clinical audit. STUDY DESIGN: Retrospective analysis of all deliveries in 2 periods tenyear apart (1994-96 and 2004-06). Demographic and obstetrics characteristics were analyzed in relation to changes in rates of CD using the Robson classification, with particular focus on Robson’s groups 1 and 2 combined (term singleton cephalic in nullipara with spontaneous or induced labor). RESULTS: A total of 8237 consecutive deliveries occurred during the 1st period and 8420 in the 2nd period. The overall rate of CD increased from 12.5% to 17.9% (p⬍0.001). Term singleton cephalic in nulliparaecontributed to 49% of deliveries in the 1st period and to 42% in the 2nd period, as well as to 32% of all CDs in the 1st period vs 36% in the 2nd period. Factors associated with the changes in CD rate were BMI (21.5 ⫾ 3.2 vs 22⫾ 3.6, p⬍0.01) and maternal age (29.5⫾1.2 years vs 30.5 ⫾ 12, p⬍0.01). At multivariate analysis, BMI (OR 1.0; 95% CI 1.06-1.1) and maternal age (OR 1.6; 95% CI 1.05-1.08) were independently related to CD, as was the difference in CD rate between the 2 period (OR 1.7, 95% CI 1.5-2.0). CONCLUSIONS: BMI and maternal age are independent factors associated to the increasing rate of CD among nulliparae in spontaneous or induced labor with term fetus in cephalic presentation.
293 The safety of the Foley catheter for preinduction cervical ripening in a low risk population Anthony Sciscione1, Matthew Hoffman2, Casey Bedder3, Philip Shlossman3 1 Christiana Hospital, Newark, DE, 2Christiana Care Health System, Newark, DE, 3Christiana Hospital, Newark, DE
OBJECTIVE: The Foley Catheter (FC) has been shown to be an effective method for preinduction cervical ripening and a recent randomized trial has demonstrated that it is as efficacious in the outpatient as the inpatient setting for ripening. While the outpatient setting will likely result in a significant cost savings, before it can be recommended a large scale study assessing the safety of the FC in the preinduction cervical ripening time period must be performed. We sought to determine the safety of preinduction cervical ripening with the FC. STUDY DESIGN: A retrospective review of our obstetrical database was performed for all inductions of labor performed at our hospital from 1/1/2006 until 6/14/09. We included all term labor inductions of nonanomalous singleton gestations that used the FC for preinduction cervical ripening. All preinduction cervical ripening was performed in the inpatient setting with continuous fetal monitoring. We excluded pregnancies with hypertensive disorders, diabetes, growth restriction, multiple gestations, premature rupture of the membranes, non-reassuring fetal testing, or any condition that would preclude outpatient ripening. If any other pharmacologic or mechanical method was used in or before this time period they were excluded. We observed the rate of adverse outcomes in the period of preinduction cervical ripening (Foley placement until oxytocin initiation). Adverse outcomes were defined as cesarean delivery for any indication, placental abruption, chorioamnionitis, rupture of the membranes after insertion and cord prolapse.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S121