- Email: [email protected]
313: Timing of delivery in pregnancies complicated by fetal growth restriction: a decision analytic model
Poster Session II
ajog.org
RESULTS: There was no significant difference between the cohorts in
baseline demographics (age, parity, BMI).Gestational age (GA) at the time of MMC repair was no different between ENDO vs. OPEN (24.7 +/- 1.2 vs. 24.3 +/- 1.2) but GA in ENDO was significantly higher than in MOMS (24.7 +/- 1.2 vs 23.6 +/- 1.4 weeks). Intraoperatively at the time of MMC repair, there were no significant differences in the rate (point prevalence) of bradycardia. There were no episodes of fetal heart rate decelerations or bradycardia during fetal CO2 exposure for up to 5.5 hours (207 +/- 82 minutes). Operative time for the fetal surgery component was longer for ENDO (136 +/- 68 vs. 28 +/- 8 minutes; p < 0.001). Maternal and fetal blood loss,as well as postop recovery time were similar. There was no significant difference in the rate of PPROM or preterm birth (PTB), NICU length of stay (LOS) or in the perinatal death rate (Table). There was an observed trend towards a maternal benefit given that 1/5 (20%) had a vaginal delivery in the ENDO group vs. 0/ 25 OPEN (p¼0.36) and 0/78 in the MOMS trial data (p¼0.06). Pertinent fetal and neonatal data are presented in the Table. CONCLUSION: Concerns about the effects of intra-uterine CO2 on fetal acid-base status, membrane integrity, efficacy of the repair, and postnatal outcomes have limited the acceptance of fetoscopic approaches to MMC repair. Our initial data suggest that endoscopic repair of fetal meningomyelocele appears to have a similar short term fetal and neonatal outcome profile to open fetal repair. ENDO also allows vaginal delivery and thus offers significant potential advantages from a long term obstetric perspective.
week, accounting for the risk of stillbirth, spontaneous delivery and progression of UAD indices during each successive week of gestation. Outcomes included respiratory distress syndrome (RDS) and neonatal death. All probability estimates and utilities were derived from the published literature. The baseline probability of progression of UAD indices was set at 10%; however, this was varied widely (0-50%) in sensitivity analysis to account for the limited available data on this estimate. RESULTS: Scheduled delivery at 37 weeks was the preferred strategy under baseline assumptions. Sensitivity analysis found that our model was robust as long as the probability of progression from normal to abnormal UAD indices remained between 3.9% and 30.3%. Below that range, expectant management until 38 weeks became the preferred strategy; whereas, scheduled delivery at 36 weeks was preferred above that range. (Figure) CONCLUSION: This study suggests that 37 weeks is the optimal gestational age for delivery in pregnancies complicated by FGR with normal UAD indices, balancing risks of stillbirth with neonatal morbidity and mortality. Risk of progression from normal to abnormal UAD indices, with its associated increase in stillbirth risk, plays a critical role in determining optimal delivery timing.
Fetal and Neonatal Outcomes Data are mean +/- standard deviation (unless otherwise stated)
Fetoscopic Repair (ENDO) N=8
Open Repair (OPEN) N = 25
MOMS Trial Data P value for ENDO Adzick et al. vs. OPEN NEJM 2011
P value for ENDO vs. MOMS
Maternal Age (years)
28 +/- 5
27 +/- 6
0.68
29 +/- 5
0.7
Gestational Age at Repair (weeks)
24.7 +/- 1.1
24.3 +/1.2
0.38
23.6 +/- 1.4
0.02
Bradycardia during procedure
0/8 (0%)
2/25 (8%)
0.41
8/78 10%)
0.37
Perinatal death
0/8 (0%)
1/25 (4%)
0.57
2/78 (3%)
0.65
Improved hindbrain herniation at 6 weeks post fetal surgery
5/8 (63%)
21/24 (84%)
0.12
Not Reported
-
Gestational Age at birth (weeks)
36.3+/-3.3
34.5 +/-3.6 0.29
34.1+/-3.1
0.2
Preterm birth (PTB) < 34 weeks
1/7 (14%) 1 patient still < 34 weeks
5/25 (20%) 0.73
36/78 (46%)
0.13
Preterm birth (PTB) < 30 weeks
0/7 (0%) 1 patient still < 30 weeks
4/25 (16%) 0.26
10/78 (10%)
0.31
Surgery-to-delivery interval (weeks)
11.6 +/- 2.6 (n = 5)
10.2 +/4.0
10.5
0.39
0.45
Vaginal Delivery
1/5 (20%)
0/25 (0%)
0.36
0/78 (0%)
0.06
Birth Weight (g)
2562 +/- 657 (n = 5)
2344+/640
0.36
2383+/-688
0.58
Dehiscence at MMC repair site
2/5 (40%)
3/25 (12%) 0.41
10/77 (13%)
0.1
Persistent hindbrain herniation after delivery
2/5 (40%)
6/24 (25%) 0.49
45/70 (64%)
0.36
Postnatal treatment for hydrocephalus
2/5 (40%)
4/25 (16%) 0.13
31/78 (40%)
0.99
314 Small for gestational age among low risk pregnancies Suneet P. Chauhan1, Jessica A. Lavery2, Cande V. Ananth2 1
UT Health- University of Texas Medical School at Houston, Houston, TX, Columbia University Medical Center, New York, NY
2
313 Timing of delivery in pregnancies complicated by fetal growth restriction: a decision analytic model Katherine R. Goetzinger1, Janine S. Rhoades1, Moeun Son2, William A. Grobman2, Alison G. Cahill1 1
Washington University in St. Louis, St. Louis, MO, 2Northwestern University Feinberg School of Medicine, Chicago, IL
OBJECTIVE: Although fetal growth restriction (FGR) is a common
obstetrical dilemma, limited data exist to guide decision-making on optimal delivery timing in pregnancies with this complication. The objective of this study was to determine the optimal timing of delivery in pregnancies complicated by FGR with normal umbilical artery Doppler (UAD) indices in late preterm/early term gestation. STUDY DESIGN: Using TreeAge software, a decision-analytic model was designed comparing five strategies of delivery timing for pregnancies complicated by FGR with normal UAD indices that have reached 36 weeks gestation. Strategies included scheduled delivery at 36, 37, 38, 39 or 40 weeks versus expectant management at each
OBJECTIVE: The link between small for gestational age (SGA; birthweight [BW] <10% for GA) and neonatal morbidity and mortality is considered to be limited to preterm birth or high-risk term births. The purpose of this population-based study was to determine if compared to referent group, the morbidity and mortality among low risk pregnancies is different for newborns at < 10% and for those at 10-19%. STUDY DESIGN: We analyzed non-anomalous singleton live births at 2441 weeks delivered in the US between 2005 and 2013. Low-risk was defined as women without hypertension (chronic or gestational) or diabetes (pregestational or gestational), who delivered at 37 to 41 weeks. We categorized GA as 37-38, 39-40 and 41 weeks and the BW percentiles as <1%, 1-2%, 3-4%, 5-9%, 10-19% and 20-79% (referent). The composite neonatal mortality (CNM) included 5 min Apgar score <4, NICU admission, seizures, assisted ventilation, or birth trauma. Neonatal mortality (NM; 0-27 days), sub-categorized into early (ENM; 0-6 days) and late (LNM; 7-27 days) was compared. Risk ratios (RR) were adjusted for year, maternal age, gravida, ethnicity, education, marital status, prenatal care and smoking through log-linear regression
S178 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2016
ajog.org
RESULTS: There was no significant difference between the cohorts in
baseline demographics (age, parity, BMI).Gestational age (GA) at the time of MMC repair was no different between ENDO vs. OPEN (24.7 +/- 1.2 vs. 24.3 +/- 1.2) but GA in ENDO was significantly higher than in MOMS (24.7 +/- 1.2 vs 23.6 +/- 1.4 weeks). Intraoperatively at the time of MMC repair, there were no significant differences in the rate (point prevalence) of bradycardia. There were no episodes of fetal heart rate decelerations or bradycardia during fetal CO2 exposure for up to 5.5 hours (207 +/- 82 minutes). Operative time for the fetal surgery component was longer for ENDO (136 +/- 68 vs. 28 +/- 8 minutes; p < 0.001). Maternal and fetal blood loss,as well as postop recovery time were similar. There was no significant difference in the rate of PPROM or preterm birth (PTB), NICU length of stay (LOS) or in the perinatal death rate (Table). There was an observed trend towards a maternal benefit given that 1/5 (20%) had a vaginal delivery in the ENDO group vs. 0/ 25 OPEN (p¼0.36) and 0/78 in the MOMS trial data (p¼0.06). Pertinent fetal and neonatal data are presented in the Table. CONCLUSION: Concerns about the effects of intra-uterine CO2 on fetal acid-base status, membrane integrity, efficacy of the repair, and postnatal outcomes have limited the acceptance of fetoscopic approaches to MMC repair. Our initial data suggest that endoscopic repair of fetal meningomyelocele appears to have a similar short term fetal and neonatal outcome profile to open fetal repair. ENDO also allows vaginal delivery and thus offers significant potential advantages from a long term obstetric perspective.
week, accounting for the risk of stillbirth, spontaneous delivery and progression of UAD indices during each successive week of gestation. Outcomes included respiratory distress syndrome (RDS) and neonatal death. All probability estimates and utilities were derived from the published literature. The baseline probability of progression of UAD indices was set at 10%; however, this was varied widely (0-50%) in sensitivity analysis to account for the limited available data on this estimate. RESULTS: Scheduled delivery at 37 weeks was the preferred strategy under baseline assumptions. Sensitivity analysis found that our model was robust as long as the probability of progression from normal to abnormal UAD indices remained between 3.9% and 30.3%. Below that range, expectant management until 38 weeks became the preferred strategy; whereas, scheduled delivery at 36 weeks was preferred above that range. (Figure) CONCLUSION: This study suggests that 37 weeks is the optimal gestational age for delivery in pregnancies complicated by FGR with normal UAD indices, balancing risks of stillbirth with neonatal morbidity and mortality. Risk of progression from normal to abnormal UAD indices, with its associated increase in stillbirth risk, plays a critical role in determining optimal delivery timing.
Fetal and Neonatal Outcomes Data are mean +/- standard deviation (unless otherwise stated)
Fetoscopic Repair (ENDO) N=8
Open Repair (OPEN) N = 25
MOMS Trial Data P value for ENDO Adzick et al. vs. OPEN NEJM 2011
P value for ENDO vs. MOMS
Maternal Age (years)
28 +/- 5
27 +/- 6
0.68
29 +/- 5
0.7
Gestational Age at Repair (weeks)
24.7 +/- 1.1
24.3 +/1.2
0.38
23.6 +/- 1.4
0.02
Bradycardia during procedure
0/8 (0%)
2/25 (8%)
0.41
8/78 10%)
0.37
Perinatal death
0/8 (0%)
1/25 (4%)
0.57
2/78 (3%)
0.65
Improved hindbrain herniation at 6 weeks post fetal surgery
5/8 (63%)
21/24 (84%)
0.12
Not Reported
-
Gestational Age at birth (weeks)
36.3+/-3.3
34.5 +/-3.6 0.29
34.1+/-3.1
0.2
Preterm birth (PTB) < 34 weeks
1/7 (14%) 1 patient still < 34 weeks
5/25 (20%) 0.73
36/78 (46%)
0.13
Preterm birth (PTB) < 30 weeks
0/7 (0%) 1 patient still < 30 weeks
4/25 (16%) 0.26
10/78 (10%)
0.31
Surgery-to-delivery interval (weeks)
11.6 +/- 2.6 (n = 5)
10.2 +/4.0
10.5
0.39
0.45
Vaginal Delivery
1/5 (20%)
0/25 (0%)
0.36
0/78 (0%)
0.06
Birth Weight (g)
2562 +/- 657 (n = 5)
2344+/640
0.36
2383+/-688
0.58
Dehiscence at MMC repair site
2/5 (40%)
3/25 (12%) 0.41
10/77 (13%)
0.1
Persistent hindbrain herniation after delivery
2/5 (40%)
6/24 (25%) 0.49
45/70 (64%)
0.36
Postnatal treatment for hydrocephalus
2/5 (40%)
4/25 (16%) 0.13
31/78 (40%)
0.99
314 Small for gestational age among low risk pregnancies Suneet P. Chauhan1, Jessica A. Lavery2, Cande V. Ananth2 1
UT Health- University of Texas Medical School at Houston, Houston, TX, Columbia University Medical Center, New York, NY
2
313 Timing of delivery in pregnancies complicated by fetal growth restriction: a decision analytic model Katherine R. Goetzinger1, Janine S. Rhoades1, Moeun Son2, William A. Grobman2, Alison G. Cahill1 1
Washington University in St. Louis, St. Louis, MO, 2Northwestern University Feinberg School of Medicine, Chicago, IL
OBJECTIVE: Although fetal growth restriction (FGR) is a common
obstetrical dilemma, limited data exist to guide decision-making on optimal delivery timing in pregnancies with this complication. The objective of this study was to determine the optimal timing of delivery in pregnancies complicated by FGR with normal umbilical artery Doppler (UAD) indices in late preterm/early term gestation. STUDY DESIGN: Using TreeAge software, a decision-analytic model was designed comparing five strategies of delivery timing for pregnancies complicated by FGR with normal UAD indices that have reached 36 weeks gestation. Strategies included scheduled delivery at 36, 37, 38, 39 or 40 weeks versus expectant management at each
OBJECTIVE: The link between small for gestational age (SGA; birthweight [BW] <10% for GA) and neonatal morbidity and mortality is considered to be limited to preterm birth or high-risk term births. The purpose of this population-based study was to determine if compared to referent group, the morbidity and mortality among low risk pregnancies is different for newborns at < 10% and for those at 10-19%. STUDY DESIGN: We analyzed non-anomalous singleton live births at 2441 weeks delivered in the US between 2005 and 2013. Low-risk was defined as women without hypertension (chronic or gestational) or diabetes (pregestational or gestational), who delivered at 37 to 41 weeks. We categorized GA as 37-38, 39-40 and 41 weeks and the BW percentiles as <1%, 1-2%, 3-4%, 5-9%, 10-19% and 20-79% (referent). The composite neonatal mortality (CNM) included 5 min Apgar score <4, NICU admission, seizures, assisted ventilation, or birth trauma. Neonatal mortality (NM; 0-27 days), sub-categorized into early (ENM; 0-6 days) and late (LNM; 7-27 days) was compared. Risk ratios (RR) were adjusted for year, maternal age, gravida, ethnicity, education, marital status, prenatal care and smoking through log-linear regression
S178 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2016