- Email: [email protected]
317: Withdrawn
SMFM Abstracts 316
www.AJOG.org
THE RELATIONSHIP OF NUCHAL CORD AND TRUE KNOT WITH INTRAUTERINE FETAL DEMISE (IUFD) IN PREGNANCY > 24 WEEKS GESTATION KATHLEEN SMITH1, JAMES EGAN2, YU MING VICTOR FANG1, LISA DRIES3, MARY BETH JANICKI4, CAROLYN ZELOP4, 1 University of Connecticut, Farmington, Connecticut, 2University of Connecticut, Obstetrics and Gynecology, Farmington, Connecticut, 3St Francis Hospital, Hartford, Connecticut, 4St. Francis Hospital, Hartford, Connecticut OBJECTIVE: To evaluate the relationships between nuchal cord and true knot, with IUFD, in deliveries at 24 weeks gestation and beyond. STUDY DESIGN: The perinatal database at our institution was queried for all deliveries at least 24 weeks gestation occurring between 02/02 and 07/07. Data regarding nuchal cord, true knot, fetal gender, gestational and chronic hypertension (HTN), diabetes mellitus (DM), fetal anomalies, Group B Streptococcus (GBS) carrier status, and IUFD were collected from the perinatal database. Logistic regression analysis was used to estimate adjusted odds ratios (AOR) and test significance of relationships. RESULTS: A total of 16,948 deliveries had data available for analysis. Of these, 53 (0.3%) were IUFD. The mean gestational age was 38.8 weeks. The mean birth weight was 3280 g. For patients with IUFD the mean gestational age was 33.9 weeks. The mean birth weight was 2060 g. CONCLUSION: Nuchal cord is not associated with a higher rate of IUFD after 24 weeks gestation. True knot is associated with IUFD. This association persists after accounting for other factors, including HTN and DM, known to be associated with increased risk of IUFD.
Nuchal cord True knot HTN DM GBS carrier Fetal anomaly Gender, male
NO IUFD
IUFD
AOR
P-value
4623 (27.4%) 198 (1.2%) 794 (4.7%) 580 (3.4%) 3125 (18.4%) 58 (0.3%) 8659 (51.3%)
11 (20.8%) 4 (7.5%) 6 (11.53%) 0 (0%) 4 (9.4%) 4 (7.5%) 33 (62.3%)
0.67 7.35 2.93 — 0.43 27.8 1.55
NS ⬍0.001 0.014 NS NS ⬍0.001 NS
319
Mean resting and squeeze pressures over time
Mean resting pressure Mean squeeze pressure
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.331
317
WITHDRAWN
318
A NATIONAL PROFILE OF CESAREAN SECTION IN IRELAND USING THE ROBSON CLASSIFICATION SYSTEM IYAD AFANEH1, GERARD BURKE1, 1Mid-Western Regional Maternity Hospital, Limerick, Ireland OBJECTIVE: There are marked differences in cesarean section (CS) rates between maternity units in Ireland. We used the Robson Ten Group Classification System to analyze CS rates in six large maternity units. The System consists of ten mutually exclusive but totally inclusive, prospectively determined, clinically relevant and clearly defined groups of patients. It takes account of previous obstetric record, course of labor (spontaneous or induced), category (number of fetuses, presentation) and gestational age. Data analysis includes the number of patients in each group, the relative sizes of the groups, the CS rate in each group and the contribution of each group to the overall CS rate. STUDY DESIGN: Data were compiled for 2004 from the clinical reports of National Maternity Hospital, Coombe Women’s Hospital, the Rotunda Hospital (all Dublin), Our Lady of Lourdes Hospital, Drogheda, and University College Hospital, Galway and from a database at Mid-Western Regional Maternity Hospital, Limerick. RESULTS: There were 33,805 women delivered in the six units. The CS rate was 23.2% (range: 17.1-29.6). The CS rate in Group 1 (nulliparous, singleton term cephalic (SCT), in spontaneous labor) was 12.3 % (range: 6.9-16.5), while in Group 2 (nulliparous, SCT, induced or prelabor CS) it was 38.4% (range: 30.2-51.4). Group 5 (previous CS, SCT) contributed 7.1% of the total of 23.2%. The CS rate in this group was 63.4% (range: 51.2% - 76.7%). The relative size of this group varied from 8.5% to 13%. Differences between hospitals in Groups 6 to 10 were small. CONCLUSION: Groups 1, 2 and 5 account for almost two-thirds of cesareans in the six units, a proportion that is fairly consistent irrespective of the unit’s individual rate. The units with highest and the lowest CS rates tended to have high or low rates in all ten groups, indicating the difference is due to ‘culture’ rather than to the management of specific groups of patients. Overall, Group 5 is the biggest contributor to the CS rate but it is less important relatively in the unit with the highest proportion of nulliparous patients.
EFFECT OF MULTIPLE SUBSEQUENT DELIVERIES ON THE PELVIC FLOOR FOLLOWING OBSTETRIC ANAL SPHINCTER INJURY. CLIONA MURPHY1, MYRA FITZPATRICK2, MARY CASSIDY3, COLM O’HERLIHY4, 1Society for Maternal-Fetal Medicine, Dublin, Ireland, 2 National Maternity Hospital, Obstetrics and Gynaecology, Dublin 2, Ireland, 3 University College Dublin, Obstetrics and Gynaecology, Dublin, Ireland, 4University College Dublin, Obstetrics and Gynaecology, Dublin 2, Ireland OBJECTIVE: Increased awareness of anal sphincter injury has prompted several reports of perineal outcome at next vaginal delivery. Because the effect of multiple subsequent births is uncertain, we have investigated a cohort of women with more than one delivery after third or fourth degree tear.(3DT) STUDY DESIGN: Since 1996, all women sustaining 3DT at delivery at the National Maternity Hospital have been reviewed for continence assessement postnatally at the Perineal Clinic, including continence questionnaire (Rockwood) and score Pescatori (PS), endoanal ultrasound and anal manometry. Women who had two or more deliveries following 3DT were identified and invited for reassessment. RESULTS: Of 37,805 deliveries from 1996 to 2003, 525 (1.4%) sustained obstetric anal sphincter injury (3DT). While 70 women who had two or more deliveries following 3DT were identified, only 34 reattended for this study,a mean of 90 months since 3DT and 32.3 months since most recent delivery; 79% delivered vaginally, 38/70 (54%) underwent antenatal perineal assessment in the next pregnancy. In 13/70(18%), last delivery had been by cesarean section.12/70 (17%) sustained a further 3DT. On reassessment,15/34 women had normal continence PS⫽0 while 8/34 (24%) had symptom scores of PS ⬎9/20. Antenatal anal manometry pressures prior to next delivery after 3DT correlated (r2 ⫽0.28,p⫽0.02) with longterm values, with normal manometry (resting pressure ⬎/ 40mmhg) predictive of future continence scores. CONCLUSION: Repeated vaginal deliveries following anal sphincter injury does not compromise long-term continence when anal manometry (RP⬎40) and continence are normal prior to next delivery. Antenatal continence assessment is valuable in determining optimal mode of delivery.
First assessment in next pregnancy
After third delivery
47.2mmhg 69.7mmhg
40.9mmhg 66.3mmhg
35..0mmhg 62.5mmhg
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.334
320
RISK FACTORS FOR SUBTYPES OF LACERATION AMONG PRIMIPAROUS WOMEN RAFAEL MIKOLAJCZYK1, JUN ZHANG1, LINDA CHAN2, JAMES TROENDLE1, 1National Institutes of Health (NIH), Bethesda, Maryland, 2Naval Medical Center San Diego, Obstetrics and Gynecology, , California OBJECTIVE: Lacerations are frequent side effects of vaginal delivery. 3rd and 4th degree perineal lacerations and their risk factors received much attention in the literature. Less is known about risk factors for other types of laceration. STUDY DESIGN: We analyzed a dataset including 1009 nulliparous women with singleton, vaginal deliveries in a tertiary level military hospital. Subjects had spontaneous onset of labor and the fetuses had vertex presentation and normal birth weight. We examined risk factors for 3rd and 4th degree perineal laceration, periurethral, vaginal and labial lacerations using multivariable multinomial logistic regression analysis. RESULTS: Older maternal age was a risk factor for 3rd and 4th degree perineal laceration. Large fetal size increased the risk of perineal and periurethral lacerations two to four-fold. Episiotomy had no impact on 3rd and 4th degree perineal laceration but had very strong protective effects on other lacerations (odds ratio: 0.1; 95% CI 0.0-0.1). Prolonged 2nd stage of labor increased the risk of 3rd and 4th degree perineal and vaginal lacerations while fast labor increased the risk for periurethral laceration. Although all instrumental deliveries were risk factors for 3rd and 4th degree perineal lacerations, delivery with low forceps was the most prominent with an odds ratio of 25 (95% confidence interval: 12.2-51.2) compared to spontaneous delivery. Use of low forceps also increased the risk of vaginal laceration seven-fold. CONCLUSION: Patterns of risk factors differ across the subtypes of laceration. Episiotomy does not protect against 3rd and 4th degree perineal lacerations, but decreases the risk for other subtypes. Periurethral and labial lacerations are more likely to occur in short 2nd stage of labor. Future studies of epidemiology and risk factors for laceration should consider the distinct subtypes. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.335
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.333
S98
Postnatal assessment after 3DT
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007
www.AJOG.org
THE RELATIONSHIP OF NUCHAL CORD AND TRUE KNOT WITH INTRAUTERINE FETAL DEMISE (IUFD) IN PREGNANCY > 24 WEEKS GESTATION KATHLEEN SMITH1, JAMES EGAN2, YU MING VICTOR FANG1, LISA DRIES3, MARY BETH JANICKI4, CAROLYN ZELOP4, 1 University of Connecticut, Farmington, Connecticut, 2University of Connecticut, Obstetrics and Gynecology, Farmington, Connecticut, 3St Francis Hospital, Hartford, Connecticut, 4St. Francis Hospital, Hartford, Connecticut OBJECTIVE: To evaluate the relationships between nuchal cord and true knot, with IUFD, in deliveries at 24 weeks gestation and beyond. STUDY DESIGN: The perinatal database at our institution was queried for all deliveries at least 24 weeks gestation occurring between 02/02 and 07/07. Data regarding nuchal cord, true knot, fetal gender, gestational and chronic hypertension (HTN), diabetes mellitus (DM), fetal anomalies, Group B Streptococcus (GBS) carrier status, and IUFD were collected from the perinatal database. Logistic regression analysis was used to estimate adjusted odds ratios (AOR) and test significance of relationships. RESULTS: A total of 16,948 deliveries had data available for analysis. Of these, 53 (0.3%) were IUFD. The mean gestational age was 38.8 weeks. The mean birth weight was 3280 g. For patients with IUFD the mean gestational age was 33.9 weeks. The mean birth weight was 2060 g. CONCLUSION: Nuchal cord is not associated with a higher rate of IUFD after 24 weeks gestation. True knot is associated with IUFD. This association persists after accounting for other factors, including HTN and DM, known to be associated with increased risk of IUFD.
Nuchal cord True knot HTN DM GBS carrier Fetal anomaly Gender, male
NO IUFD
IUFD
AOR
P-value
4623 (27.4%) 198 (1.2%) 794 (4.7%) 580 (3.4%) 3125 (18.4%) 58 (0.3%) 8659 (51.3%)
11 (20.8%) 4 (7.5%) 6 (11.53%) 0 (0%) 4 (9.4%) 4 (7.5%) 33 (62.3%)
0.67 7.35 2.93 — 0.43 27.8 1.55
NS ⬍0.001 0.014 NS NS ⬍0.001 NS
319
Mean resting and squeeze pressures over time
Mean resting pressure Mean squeeze pressure
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.331
317
WITHDRAWN
318
A NATIONAL PROFILE OF CESAREAN SECTION IN IRELAND USING THE ROBSON CLASSIFICATION SYSTEM IYAD AFANEH1, GERARD BURKE1, 1Mid-Western Regional Maternity Hospital, Limerick, Ireland OBJECTIVE: There are marked differences in cesarean section (CS) rates between maternity units in Ireland. We used the Robson Ten Group Classification System to analyze CS rates in six large maternity units. The System consists of ten mutually exclusive but totally inclusive, prospectively determined, clinically relevant and clearly defined groups of patients. It takes account of previous obstetric record, course of labor (spontaneous or induced), category (number of fetuses, presentation) and gestational age. Data analysis includes the number of patients in each group, the relative sizes of the groups, the CS rate in each group and the contribution of each group to the overall CS rate. STUDY DESIGN: Data were compiled for 2004 from the clinical reports of National Maternity Hospital, Coombe Women’s Hospital, the Rotunda Hospital (all Dublin), Our Lady of Lourdes Hospital, Drogheda, and University College Hospital, Galway and from a database at Mid-Western Regional Maternity Hospital, Limerick. RESULTS: There were 33,805 women delivered in the six units. The CS rate was 23.2% (range: 17.1-29.6). The CS rate in Group 1 (nulliparous, singleton term cephalic (SCT), in spontaneous labor) was 12.3 % (range: 6.9-16.5), while in Group 2 (nulliparous, SCT, induced or prelabor CS) it was 38.4% (range: 30.2-51.4). Group 5 (previous CS, SCT) contributed 7.1% of the total of 23.2%. The CS rate in this group was 63.4% (range: 51.2% - 76.7%). The relative size of this group varied from 8.5% to 13%. Differences between hospitals in Groups 6 to 10 were small. CONCLUSION: Groups 1, 2 and 5 account for almost two-thirds of cesareans in the six units, a proportion that is fairly consistent irrespective of the unit’s individual rate. The units with highest and the lowest CS rates tended to have high or low rates in all ten groups, indicating the difference is due to ‘culture’ rather than to the management of specific groups of patients. Overall, Group 5 is the biggest contributor to the CS rate but it is less important relatively in the unit with the highest proportion of nulliparous patients.
EFFECT OF MULTIPLE SUBSEQUENT DELIVERIES ON THE PELVIC FLOOR FOLLOWING OBSTETRIC ANAL SPHINCTER INJURY. CLIONA MURPHY1, MYRA FITZPATRICK2, MARY CASSIDY3, COLM O’HERLIHY4, 1Society for Maternal-Fetal Medicine, Dublin, Ireland, 2 National Maternity Hospital, Obstetrics and Gynaecology, Dublin 2, Ireland, 3 University College Dublin, Obstetrics and Gynaecology, Dublin, Ireland, 4University College Dublin, Obstetrics and Gynaecology, Dublin 2, Ireland OBJECTIVE: Increased awareness of anal sphincter injury has prompted several reports of perineal outcome at next vaginal delivery. Because the effect of multiple subsequent births is uncertain, we have investigated a cohort of women with more than one delivery after third or fourth degree tear.(3DT) STUDY DESIGN: Since 1996, all women sustaining 3DT at delivery at the National Maternity Hospital have been reviewed for continence assessement postnatally at the Perineal Clinic, including continence questionnaire (Rockwood) and score Pescatori (PS), endoanal ultrasound and anal manometry. Women who had two or more deliveries following 3DT were identified and invited for reassessment. RESULTS: Of 37,805 deliveries from 1996 to 2003, 525 (1.4%) sustained obstetric anal sphincter injury (3DT). While 70 women who had two or more deliveries following 3DT were identified, only 34 reattended for this study,a mean of 90 months since 3DT and 32.3 months since most recent delivery; 79% delivered vaginally, 38/70 (54%) underwent antenatal perineal assessment in the next pregnancy. In 13/70(18%), last delivery had been by cesarean section.12/70 (17%) sustained a further 3DT. On reassessment,15/34 women had normal continence PS⫽0 while 8/34 (24%) had symptom scores of PS ⬎9/20. Antenatal anal manometry pressures prior to next delivery after 3DT correlated (r2 ⫽0.28,p⫽0.02) with longterm values, with normal manometry (resting pressure ⬎/ 40mmhg) predictive of future continence scores. CONCLUSION: Repeated vaginal deliveries following anal sphincter injury does not compromise long-term continence when anal manometry (RP⬎40) and continence are normal prior to next delivery. Antenatal continence assessment is valuable in determining optimal mode of delivery.
First assessment in next pregnancy
After third delivery
47.2mmhg 69.7mmhg
40.9mmhg 66.3mmhg
35..0mmhg 62.5mmhg
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.334
320
RISK FACTORS FOR SUBTYPES OF LACERATION AMONG PRIMIPAROUS WOMEN RAFAEL MIKOLAJCZYK1, JUN ZHANG1, LINDA CHAN2, JAMES TROENDLE1, 1National Institutes of Health (NIH), Bethesda, Maryland, 2Naval Medical Center San Diego, Obstetrics and Gynecology, , California OBJECTIVE: Lacerations are frequent side effects of vaginal delivery. 3rd and 4th degree perineal lacerations and their risk factors received much attention in the literature. Less is known about risk factors for other types of laceration. STUDY DESIGN: We analyzed a dataset including 1009 nulliparous women with singleton, vaginal deliveries in a tertiary level military hospital. Subjects had spontaneous onset of labor and the fetuses had vertex presentation and normal birth weight. We examined risk factors for 3rd and 4th degree perineal laceration, periurethral, vaginal and labial lacerations using multivariable multinomial logistic regression analysis. RESULTS: Older maternal age was a risk factor for 3rd and 4th degree perineal laceration. Large fetal size increased the risk of perineal and periurethral lacerations two to four-fold. Episiotomy had no impact on 3rd and 4th degree perineal laceration but had very strong protective effects on other lacerations (odds ratio: 0.1; 95% CI 0.0-0.1). Prolonged 2nd stage of labor increased the risk of 3rd and 4th degree perineal and vaginal lacerations while fast labor increased the risk for periurethral laceration. Although all instrumental deliveries were risk factors for 3rd and 4th degree perineal lacerations, delivery with low forceps was the most prominent with an odds ratio of 25 (95% confidence interval: 12.2-51.2) compared to spontaneous delivery. Use of low forceps also increased the risk of vaginal laceration seven-fold. CONCLUSION: Patterns of risk factors differ across the subtypes of laceration. Episiotomy does not protect against 3rd and 4th degree perineal lacerations, but decreases the risk for other subtypes. Periurethral and labial lacerations are more likely to occur in short 2nd stage of labor. Future studies of epidemiology and risk factors for laceration should consider the distinct subtypes. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.335
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.333
S98
Postnatal assessment after 3DT
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007