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306: Prophylactic administration of 17 alpha-hydroxyprogesterone caproate (17P) in clinical practice: The impact on rates of preterm birth
SMFM Abstracts 305
SHOULD NORMALLY GROWN MONOCHORIONIC DIAMNIOTIC TWINS BE ROUTINELY DELIVERED EARLY? RHONA MAHONY1, CELIA MULCAHY2, MICHAEL FOLEY3, FIONNUALA MCAULIFFE4, COLM O’HERLIHY5, PETER MCPARLAND6, STEPHEN CARROLL7, 1 Department of Maternal Fetqal Medicine, Dublin, Ireland, 2Department of Maternal Fetal Medicine, Dublin, Ireland, Ireland, 3Department of Obstatrics, Dublin, Ireland, 4Department of Maternal Fetal Medicine, Dublin, Ireland, 5UCD School of Medicine and Science, Dublin 2, Ireland, 6National Maternity Hospital, Dublin 2, Ireland, 7National Maternity Hospital, Dublin, Ireland OBJECTIVE: The incidence of intrauterine fetal death (IUFD) is greater in monochorionic diamniotic (MCDA) compared with dichorionic diamniotic (DCDA) twin pregnancy and may be unpredictable, prompting various recommendations for routine delivery at ⱖ34 weeks gestation. We examined the incidence of IUFD in twin pregnancy according to chorionicity and fetal growth to further determine optimal timing of delivery. STUDY DESIGN: Ten year retrospective cohort analysis of all consecutive twin deliveries at a single tertiary care centre (1997-2006). Chorionicity was determined by placental examination. Intrauterine growth restriction (IUGR) was defined as birth weight below the 5th percentile for gestational age and significant inter-twin weight discordance as ⱖ20%. RESULTS: Of 276 MCDA (25.3%) and 818 DCDA twin pregnancies (74.7%) ⱖ24 weeks delivered, the incidence of IUFD in MCDA twins was three times that in DCDA twins [11/276 (3.9) % vs. 11/818 (1.3 %) p⬍0.001]. The majority of deaths in MCDA twins (8/11; 72.7%) were associated with twin twin transfusion (TTTS), all of which occurred before 34 weeks gestation. After 34 weeks, the prospective risk of IUFD was similar in MCDA and DCDA pregnancies [2/205 (0.97% vs. 6/708 (0.84%) p⫽1] with 2/2 IUFDS in MCDA and 4 /6 IUFDS in DCDA pregnancies associated with growth discordance or IUGR. In apparently normally grown twins, the incidence of IUFD was similar in MCDA and DCDA twins [1% vs 0.87%) p⫽1.0] with a prospective risk of IUFD of ⬍ 0.5% in both at ⱖ34 weeks. The risk of IUFD was greater in pregnancies complicated by growth discordance or IUGR (TTTS excluded) [MCDA 2/82 (2.4%) vs DCDA 5/243 (2.1%); p⫽1] with a prospective risk of IUFD at ⱖ34 weeks of 3.4 in MCDA and 1.8 in DCDA pregnancies rising to 4.3 and 2.0 at ⱖ36 weeks gestation. CONCLUSION: Preterm delivery should be considered in all twin pregnancy complicated by growth discordance or IUGR. The benefit of routine preterm delivery, even in MCDA, in normally grown twins is less clear.
www.AJOG.org 307
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.335
308 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.333
306
PROPHYLACTIC ADMINISTRATION OF 17 ALPHA-HYDROXYPROGESTERONE CAPROATE (17P) IN CLINICAL PRACTICE: THE IMPACT ON RATES OF PRETERM BIRTH ANDREI REBARBER1, NATHAN S. FOX1, CHAD K. KLAUSER1, MANISHA GANDHI2, DEBBIE RHEA3, NIKI ISTWAN3, GARY STANZIANO3, DANIEL SALTZMAN1, 1Maternal Fetal Medicine Associates, New York, New York, 2Mount Sinai Medical Center, Obstetrics and Gynecology, New York, New York, 3Matria Healthcare, Clinical Research, Marietta, Georgia OBJECTIVE: Following the 2003 publication by Meis, et al in the NEJM, ACOG has advocated the use of 17P for prevention of recurrent preterm birth (PTB) in women with singleton gestations. Our purpose was to examine the impact of prophylactic 17P administration on rates of recurrent preterm birth (PTB) in clinical practice. STUDY DESIGN: An historical cohort of 1368 patients with prior PTB initiating outpatient 17P administration services between 16.0-20.9 weeks= gestation from 7/04 to 12/06 were identified from a database. Outpatient 17P services included patient education, weekly home nursing visits for assessment and 17P injection, 24/7 telephonic nurse and pharmacist availability for pregnancy or 17P related questions, home delivery of medication and supplies, and care-coordination. Multiple gestations, stillbirths and those receiving ⬍4 weeks of injections were excluded, yielding 1301 singleton gestations available for analysis. RESULTS: The population was 50.8% white, 25.8% non-white, and 23.4% undocumented race. 78.4% were between the ages of 18-35, and 72.3% were married. The median gestational age (GA) at 17P initiation was 17.3 weeks; the median GA at final injection was 35.0 weeks. 98.7% of injections were administered within protocol (every 5-10 days). Patients received a mean of 16.5 injections at a mean interval of 6.7 days. The median GA at delivery was 37.2 weeks. The median birth weight was 2948 gms with 9.5% being small-for-GA. 39.4% of infants were delivered via cesarean. In table, rates of recurrent PTB presented with those of the Meis NEJM 2003 study.
CONCLUSION: These data represent the largest cohort of patients using 17P therapy for prophylactic prevention of recurrent PTB outside the auspices of a clinical trial. These results support the ACOG recommendations for use of 17P in clinical practice to prevent recurrent spontaneous PTB. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.334
S96
SMALL FOR GESTATIONAL AGE FETUSES < 1500G: WHICH PERINATAL VARIABLES INFLUENCE LONG-TERM OUTCOME? FRANCESCA ORSENIGO1, NADIA RONCAGLIA1, ISABELLA CRIPPA1, IRENE CAMERONI1, ANNA LOCATELLI1, CESARINA BORRONI1, PATRIZIA STOPPA1, PATRIZIA VERGANI1, 1University of Milano-Bicocca, Monza, Italy, Italy OBJECTIVE: To identify perinatal predictors of adverse long-term outcome in a group of small for gestational age (SGA) fetuses with birth weight (BW) ⬍1500g. STUDY DESIGN: 108 cases of euploid non-malformed singleton SGA fetuses with a BW ⬍1500g diagnosed between 1/2001 and 12/2007 were considered for analysis. The perinatal variables considered were preeclampsia, abdominal circumference centile, umbilical artery and uterine arteries Doppler, gestational age at delivery (GA), BW at delivery, and adverse neonatal outcome. Adverse neonatal outcome was defined as neonatal death or admission to neonatal intensive care unit for indications other than low BW alone. Adverse outcome at 24 months follow up included: infants growth ⬍ 3° centile or neurological sequelae divided in major neurological dysfunctions, intermediate dysfunctions and minor impairment. RESULTS: The range of GA at delivery was 24.1-35.4 wks. The rate of adverse neonatal outcome was 53% (57/108) and neonatal mortality was 10% (11/108). Logistic regression analysis showed that GA at delivery was the only predictive variable of adverse neonatal outcome (p⫽0.05). Follow up at 24 months of 67/97 live born infants was recorded (11 cases lost at follow-up and 19 neonates born in 2007 not included in the analysis); 76% of infants had normal follow-up, 10% presented deficitary growth, 13% minor or intermediate neurological sequelae. None infant developed major neurological dysfunctions. At the logistic regression, none of the evaluated perinatal variables, included adverse neonatal outcome, predicted long-term outcome. CONCLUSION: SGA neonates with BW ⬍ 1500 g have a survival rate of 90%. Only GA at delivery is significantly associated with adverse neonatal outcome. Only 13% of infants present neurological sequelae and no perinatal variables can be related significantly with long-term outcome.
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
FETAL OVINE CARDIAC LEFT VENTRICULAR DIASTOLIC AND SYSTOLIC FUNCTION MEASURED BY TISSUE DOPPLER DECREASED WITH CHRONIC ANEMIA BUT THE REMODELED HEART COULD RESPOND TO ACUTE AFTERLOAD CHALLENGE. LEAH BERNARD1, JASON HASHIMA1, ROGER HOHIMER1, DAVID SAHN1, LOWELL DAVIS1, JUHA RASANEN2, 1Oregon Health & Science University, Portland, Oregon, 2Oregon Health & Science University, Obstetrics & Gynecology, Portland, Oregon OBJECTIVE: To evaluate alterations in cardiac function measured by Tissue Doppler (TD) in the chronically anemic fetus at baseline and in response to increased afterload. STUDY DESIGN: Chronic catheters were placed in 7 twin gestations. After recovery, one twin was made anemic (A) over 8 days by isovolemic volume exchange, lowering O2 content to 2.5⫾0.2 ml/dL (8.2⫾0.5 for twin controls (C)). Cardiac ultrasound (GE Vivid 7) was performed with the ewe anesthetized at baseline and during increased afterload (⬃15mmHg) via angiotensin II (ATII) infusion. Right (RV) and left ventricular (LV) contractility were assessed by measuring longitudinal TD acceleration (ACC) and deceleration (DEC) at the level of the valve annuli respectively which are thought to be load independent parameters. RV and LV cardiac output (CO) were measured. RESULTS: See table. BASE⫽Baseline. ATII⫽Angiotensin. Means ⫾ SEM; * ⫽ A different than C for same study period (Pⱕ0.05); # ⫽ Baseline different than ATII in same animal (Pⱕ0.05); † ⫽ difference between A and C in % change from baseline to ATII CONCLUSION: Chronic anemia decreased LV contractility and relaxation at baseline but the ventricles still provided increased blood flow. Both the RV and LV in the remodeled anemic fetal heart were able to maintain contractility and CO in the face of ATII infusion. It is unclear whether the decrease in TD indices of contractility and relaxation at baseline in the anemic LV was adaptive or an early predictor of future failure. NIH HL45043 supported. Results
RV CO ml/min TD RV ACC m/sec2 TD RV DEC m/sec2 LV CO ml/min TD LV ACC m/sec2 TD LV DEC m/sec2
C BASE
C ATII
A BASE
A ATII
800⫾76 5.1⫾0.5
863⫾52 6.5⫾0.8
1176⫾68* 4.0⫾0.7
1228⫾57* 5.0⫾0.9
4.1⫾0.4
5.1⫾0.6
3.2⫾0.4
4.1⫾0.5
547⫾74 5.8⫾0.9
683⫾71 5.3⫾0.9
735⫾60 3.2⫾0.3*
826⫾58 4.9⫾0.7
4.8⫾0.5
4.9⫾0.4
2.9⫾0.4*
3.9⫾0.3#†
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.336
SHOULD NORMALLY GROWN MONOCHORIONIC DIAMNIOTIC TWINS BE ROUTINELY DELIVERED EARLY? RHONA MAHONY1, CELIA MULCAHY2, MICHAEL FOLEY3, FIONNUALA MCAULIFFE4, COLM O’HERLIHY5, PETER MCPARLAND6, STEPHEN CARROLL7, 1 Department of Maternal Fetqal Medicine, Dublin, Ireland, 2Department of Maternal Fetal Medicine, Dublin, Ireland, Ireland, 3Department of Obstatrics, Dublin, Ireland, 4Department of Maternal Fetal Medicine, Dublin, Ireland, 5UCD School of Medicine and Science, Dublin 2, Ireland, 6National Maternity Hospital, Dublin 2, Ireland, 7National Maternity Hospital, Dublin, Ireland OBJECTIVE: The incidence of intrauterine fetal death (IUFD) is greater in monochorionic diamniotic (MCDA) compared with dichorionic diamniotic (DCDA) twin pregnancy and may be unpredictable, prompting various recommendations for routine delivery at ⱖ34 weeks gestation. We examined the incidence of IUFD in twin pregnancy according to chorionicity and fetal growth to further determine optimal timing of delivery. STUDY DESIGN: Ten year retrospective cohort analysis of all consecutive twin deliveries at a single tertiary care centre (1997-2006). Chorionicity was determined by placental examination. Intrauterine growth restriction (IUGR) was defined as birth weight below the 5th percentile for gestational age and significant inter-twin weight discordance as ⱖ20%. RESULTS: Of 276 MCDA (25.3%) and 818 DCDA twin pregnancies (74.7%) ⱖ24 weeks delivered, the incidence of IUFD in MCDA twins was three times that in DCDA twins [11/276 (3.9) % vs. 11/818 (1.3 %) p⬍0.001]. The majority of deaths in MCDA twins (8/11; 72.7%) were associated with twin twin transfusion (TTTS), all of which occurred before 34 weeks gestation. After 34 weeks, the prospective risk of IUFD was similar in MCDA and DCDA pregnancies [2/205 (0.97% vs. 6/708 (0.84%) p⫽1] with 2/2 IUFDS in MCDA and 4 /6 IUFDS in DCDA pregnancies associated with growth discordance or IUGR. In apparently normally grown twins, the incidence of IUFD was similar in MCDA and DCDA twins [1% vs 0.87%) p⫽1.0] with a prospective risk of IUFD of ⬍ 0.5% in both at ⱖ34 weeks. The risk of IUFD was greater in pregnancies complicated by growth discordance or IUGR (TTTS excluded) [MCDA 2/82 (2.4%) vs DCDA 5/243 (2.1%); p⫽1] with a prospective risk of IUFD at ⱖ34 weeks of 3.4 in MCDA and 1.8 in DCDA pregnancies rising to 4.3 and 2.0 at ⱖ36 weeks gestation. CONCLUSION: Preterm delivery should be considered in all twin pregnancy complicated by growth discordance or IUGR. The benefit of routine preterm delivery, even in MCDA, in normally grown twins is less clear.
www.AJOG.org 307
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.335
308 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.333
306
PROPHYLACTIC ADMINISTRATION OF 17 ALPHA-HYDROXYPROGESTERONE CAPROATE (17P) IN CLINICAL PRACTICE: THE IMPACT ON RATES OF PRETERM BIRTH ANDREI REBARBER1, NATHAN S. FOX1, CHAD K. KLAUSER1, MANISHA GANDHI2, DEBBIE RHEA3, NIKI ISTWAN3, GARY STANZIANO3, DANIEL SALTZMAN1, 1Maternal Fetal Medicine Associates, New York, New York, 2Mount Sinai Medical Center, Obstetrics and Gynecology, New York, New York, 3Matria Healthcare, Clinical Research, Marietta, Georgia OBJECTIVE: Following the 2003 publication by Meis, et al in the NEJM, ACOG has advocated the use of 17P for prevention of recurrent preterm birth (PTB) in women with singleton gestations. Our purpose was to examine the impact of prophylactic 17P administration on rates of recurrent preterm birth (PTB) in clinical practice. STUDY DESIGN: An historical cohort of 1368 patients with prior PTB initiating outpatient 17P administration services between 16.0-20.9 weeks= gestation from 7/04 to 12/06 were identified from a database. Outpatient 17P services included patient education, weekly home nursing visits for assessment and 17P injection, 24/7 telephonic nurse and pharmacist availability for pregnancy or 17P related questions, home delivery of medication and supplies, and care-coordination. Multiple gestations, stillbirths and those receiving ⬍4 weeks of injections were excluded, yielding 1301 singleton gestations available for analysis. RESULTS: The population was 50.8% white, 25.8% non-white, and 23.4% undocumented race. 78.4% were between the ages of 18-35, and 72.3% were married. The median gestational age (GA) at 17P initiation was 17.3 weeks; the median GA at final injection was 35.0 weeks. 98.7% of injections were administered within protocol (every 5-10 days). Patients received a mean of 16.5 injections at a mean interval of 6.7 days. The median GA at delivery was 37.2 weeks. The median birth weight was 2948 gms with 9.5% being small-for-GA. 39.4% of infants were delivered via cesarean. In table, rates of recurrent PTB presented with those of the Meis NEJM 2003 study.
CONCLUSION: These data represent the largest cohort of patients using 17P therapy for prophylactic prevention of recurrent PTB outside the auspices of a clinical trial. These results support the ACOG recommendations for use of 17P in clinical practice to prevent recurrent spontaneous PTB. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.334
S96
SMALL FOR GESTATIONAL AGE FETUSES < 1500G: WHICH PERINATAL VARIABLES INFLUENCE LONG-TERM OUTCOME? FRANCESCA ORSENIGO1, NADIA RONCAGLIA1, ISABELLA CRIPPA1, IRENE CAMERONI1, ANNA LOCATELLI1, CESARINA BORRONI1, PATRIZIA STOPPA1, PATRIZIA VERGANI1, 1University of Milano-Bicocca, Monza, Italy, Italy OBJECTIVE: To identify perinatal predictors of adverse long-term outcome in a group of small for gestational age (SGA) fetuses with birth weight (BW) ⬍1500g. STUDY DESIGN: 108 cases of euploid non-malformed singleton SGA fetuses with a BW ⬍1500g diagnosed between 1/2001 and 12/2007 were considered for analysis. The perinatal variables considered were preeclampsia, abdominal circumference centile, umbilical artery and uterine arteries Doppler, gestational age at delivery (GA), BW at delivery, and adverse neonatal outcome. Adverse neonatal outcome was defined as neonatal death or admission to neonatal intensive care unit for indications other than low BW alone. Adverse outcome at 24 months follow up included: infants growth ⬍ 3° centile or neurological sequelae divided in major neurological dysfunctions, intermediate dysfunctions and minor impairment. RESULTS: The range of GA at delivery was 24.1-35.4 wks. The rate of adverse neonatal outcome was 53% (57/108) and neonatal mortality was 10% (11/108). Logistic regression analysis showed that GA at delivery was the only predictive variable of adverse neonatal outcome (p⫽0.05). Follow up at 24 months of 67/97 live born infants was recorded (11 cases lost at follow-up and 19 neonates born in 2007 not included in the analysis); 76% of infants had normal follow-up, 10% presented deficitary growth, 13% minor or intermediate neurological sequelae. None infant developed major neurological dysfunctions. At the logistic regression, none of the evaluated perinatal variables, included adverse neonatal outcome, predicted long-term outcome. CONCLUSION: SGA neonates with BW ⬍ 1500 g have a survival rate of 90%. Only GA at delivery is significantly associated with adverse neonatal outcome. Only 13% of infants present neurological sequelae and no perinatal variables can be related significantly with long-term outcome.
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
FETAL OVINE CARDIAC LEFT VENTRICULAR DIASTOLIC AND SYSTOLIC FUNCTION MEASURED BY TISSUE DOPPLER DECREASED WITH CHRONIC ANEMIA BUT THE REMODELED HEART COULD RESPOND TO ACUTE AFTERLOAD CHALLENGE. LEAH BERNARD1, JASON HASHIMA1, ROGER HOHIMER1, DAVID SAHN1, LOWELL DAVIS1, JUHA RASANEN2, 1Oregon Health & Science University, Portland, Oregon, 2Oregon Health & Science University, Obstetrics & Gynecology, Portland, Oregon OBJECTIVE: To evaluate alterations in cardiac function measured by Tissue Doppler (TD) in the chronically anemic fetus at baseline and in response to increased afterload. STUDY DESIGN: Chronic catheters were placed in 7 twin gestations. After recovery, one twin was made anemic (A) over 8 days by isovolemic volume exchange, lowering O2 content to 2.5⫾0.2 ml/dL (8.2⫾0.5 for twin controls (C)). Cardiac ultrasound (GE Vivid 7) was performed with the ewe anesthetized at baseline and during increased afterload (⬃15mmHg) via angiotensin II (ATII) infusion. Right (RV) and left ventricular (LV) contractility were assessed by measuring longitudinal TD acceleration (ACC) and deceleration (DEC) at the level of the valve annuli respectively which are thought to be load independent parameters. RV and LV cardiac output (CO) were measured. RESULTS: See table. BASE⫽Baseline. ATII⫽Angiotensin. Means ⫾ SEM; * ⫽ A different than C for same study period (Pⱕ0.05); # ⫽ Baseline different than ATII in same animal (Pⱕ0.05); † ⫽ difference between A and C in % change from baseline to ATII CONCLUSION: Chronic anemia decreased LV contractility and relaxation at baseline but the ventricles still provided increased blood flow. Both the RV and LV in the remodeled anemic fetal heart were able to maintain contractility and CO in the face of ATII infusion. It is unclear whether the decrease in TD indices of contractility and relaxation at baseline in the anemic LV was adaptive or an early predictor of future failure. NIH HL45043 supported. Results
RV CO ml/min TD RV ACC m/sec2 TD RV DEC m/sec2 LV CO ml/min TD LV ACC m/sec2 TD LV DEC m/sec2
C BASE
C ATII
A BASE
A ATII
800⫾76 5.1⫾0.5
863⫾52 6.5⫾0.8
1176⫾68* 4.0⫾0.7
1228⫾57* 5.0⫾0.9
4.1⫾0.4
5.1⫾0.6
3.2⫾0.4
4.1⫾0.5
547⫾74 5.8⫾0.9
683⫾71 5.3⫾0.9
735⫾60 3.2⫾0.3*
826⫾58 4.9⫾0.7
4.8⫾0.5
4.9⫾0.4
2.9⫾0.4*
3.9⫾0.3#†
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.336