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322: Shoulder dystocia: What is the risk of recurrence?
SMFM Abstracts
www.AJOG.org 321
ADDITIONAL RECTAL MISOPROSTOL PLUS INTRAVENOUS OXYTOCIN VERSUS INTRAVENOUS OXYTOCIN FOR THE PREVENTION OF POSTPARTUM HEMORRHAGE AFTER CESAREAN SECTION SOON CHEOL HONG1, JI WON KIM2, HYUN TAE PARK2, HYUN-JOO SEOL3, HAI JOONG KIM4, SUN HAENG KIM5, KYU WAN LEE4, 1Korea University Medical Center, Seoul, South Korea, 2Korea University Medical Center, , Sudan, 3 Korea University Medical Center, Department of Obstetrics and Gynecology, Seoul, South Korea, 4Korea University Medical Center, Obstetrics and Gynecology, Seoul, South Korea, 5Korea University Medical Center, Obstetrics and Gynecolgy, Seoul, South Korea OBJECTIVE: To evaluate the value of additional rectal misoprostol in preventing the risk of postpartum hemorrhage after cesarean delivery STUDY DESIGN: Subjects were randomized to receive two, 200microgram misoprostol tablets rectally (study medication) plus 20 units oxytocin in Ringer fs lactate intravenously or two lactose talets rectally plus 20 units oxytocin in Ringer fs lactate intravenously (control medication). Our outcome measures were change in hemoglobin and hematocrit value from baseline to postpartum day 1, additional uterotonin, transfusion rate and side effects. RESULTS: There were no significant differences between two groups with regard to a drop in hemoglobin and hematocrit. The primary outcome measures were similar in the two groups CONCLUSION: Additional rectal misoprostol to intravenous oxytocin is not more effective than intravenous oxytocin for the prevention of postpartum hemorrhage after cesarean section
323
The value of additional rectal misoprostols in preventing postpartum hemorrhage after cesarean section
Age Parity Drop in hemoglobin level (g/dL) Drop in hematocrit level (%) Additional oxytocin (n) Intravenous ferric hydroxide sucrose complex Postpartum blood transfusion Fever (⬎38) (%) Shivering (%)
Misoprostol plus oxytocin (n⫽96)
Cotrol (oxytocin)(n⫽118) P-value†
32.0 ⫾ 4.1 0.57 ⫾ 0.72 1.6 ⫾ 4.1 3.8 ⫾ 5.1 28 (29.2) 31 (32.3)
32.4 ⫾ 4.4 0.74 ⫾ 0.74 1.0 ⫾ 2.4 3.0 ⫾ 6.1 31 (26.3) 32 (27.1)
0.5235 0.1049 0.1632 0.2856 0.6373‡ 0.4089‡
11 (11.7) 10 (10.4) 1 (1.1)
13 (12.0) 5 (4.2) 0 (0.0)
0.9415‡ 0.0782‡ 0.4460‡
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.338
324 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.336
322
SHOULDER DYSTOCIA: WHAT IS THE RISK OF RECURRENCE? ANWAR NASSAR1, FADI YAHYA1, IHAB USTA1, 1American University of Beirut Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon OBJECTIVE: To study the risk of recurrence of shoulder dystocia in patients who have had at least one shoulder dystocia in a previous pregnancy. STUDY DESIGN: A retrospective maternal and neonatal chart review of all vaginal deliveries complicated by shoulder dystocia between January 1990 and December 2005. Shoulder dystocia was defined as impaction of the fetal shoulder at the perineum, requiring extra maneuvers for delivery. Diagnosis was made by the delivering physician and documented in the chart. Charts with subsequent delivery beyond 24 weeks of gestation were identified and reviewed for parity, body mass index (BMI), gestational age (GA) at delivery, birthweight, operative vaginal delivery, Apgar scores, duration of labor, and birth injuries. Patients were divided into 2 groups, those with recurrent shoulder dystocia (group I) and those with normal subsequent delivery (group II). RESULTS: One hundred ninety-three cases of documented shoulder dystocia were identified. Of those, 48 women had a subsequent delivery at our hospital. After excluding 3 who had a cesarean delivery, 45 patients were analyzed. Ten of those patients had recurrence of shoulder dystocia (22.2%). The birth weight in the index pregnancy was smaller than the previous pregnancy in a significantly larger proportion of women in group I compared with group II (30.0% vs 71.4%, P⫽0.027). Otherwise, there were no differences in the maternal age, GA at delivery, parity, duration of labor, gender, history of macrosomia, birth injuries or interval between pregnancies in the two groups. CONCLUSION: The risk of recurrence of shoulder is dystocia is around 22%. This study did not demonstrate any predictors for the risk of recurrence of shoulder dystocia. When counseling patients about the risk of recurrence, a smaller birth weight than the previous pregnancy could be reassuring.
CYCLOOXYGENASE-2 (COX-2) AND INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) GENE POLYMORPHISMS INFLUENCE THE TIME INTERVAL BETWEEN LABOR INDUCTION AND DELIVERY DANIEL SKUPSKI1, NEIL NORMAND2, GARY EGLINTON3, STEVEN S. WITKIN4, 1Cornell University, Flushing, New York, 2Cornell University Medical College, Obstetrics and Gynecology, New York, New York, 3New York Hospital Medical Center of Queens, Flushing, New York, 4Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: The time interval from induction to delivery differs and biochemical and genetic variables remain to be identified. Cervical ripening and labor involve activation of inflammation-inducing mediators. We hypothesized that functional polymorphisms in genes coding for IL-1ra and cox-2, two proteins that regulate the extent of inflammation, influence the time between labor induction and delivery in women who are undelivered by 42 weeks. STUDY DESIGN: Subjects were women participating in a randomized trial of sequential versus simultaneous dinoprostone and oxytocin for induction of labor with an unfavorable cervix at term (SMFM 2007 abstract #272) due to post dates (26), oligohydramnios (20), hypertension or preeclampsia (9), abnormal fetal heart rate (6), diabetes (5) or other reasons (4). Buccal DNA was tested for a G⬎C polymorphism at position -765 in the cox-2 gene promoter and a length polymorphism in intron 2 of the IL-1ra gene. Clinical data were collected only after completion of all laboratory testing. Women delivered by cesarean section for fetal indications during labor were excluded. RESULTS: Carriage of the cox-2 C allele was present in 15/32 (46.9%) women who delivered at ⱕ 20 hours after labor induction and in only 6/34 (17.6%) who delivered at ⬎20 hours (P⫽.01). Among post-dates inductions, 11/26 (42.3%) were cox-2 allele C positive as opposed to 12/44 (22.7%) induced for other indications. Carriage of the IL-1ra 2 allele was seen in 5/11 (45.5%) women with induction duration ⱕ10 hours, as compared to 15/58 (25.9%) with induction duration ⬎10 hours. IL-1ra 2 allele was present in 12/28 (42.9%) women with post dates induction as opposed to 8/44 (18.2%) women induced for other indications (P⫽.03). Genotype distributions were similar between study arms. CONCLUSION: Possession of cox-2 allele C, associated with reduced production of cox-2 protein, or IL-1ra allele 2, associated with increased pro-inflammatory activity, are two genetic factors that influence the time interval from labor induction to delivery in women with unripe cervices at term.
FACTORS INFLUENCING OUTCOMES OF PREGNANCY TERMINATION WITH INTRAVAGINAL MISOPROSTOL FOR FETAL ANOMALY JAN DICKINSON1, 1University of Western Australia, Perth, Western Australia, Australia OBJECTIVE: To review the factors impacting upon the process of pregnancy termination with intravaginal misoprostol in the second trimester for fetal abnormality. STUDY DESIGN: All cases of medical pregnancy termination performed after 13 weeks gestation during the 10 year period from 6/1997 through 6/2007 were prospectively identified. Women who received intravaginal misoprostol 400 mcg 6-hourly were then extracted from the database and the maternal and procedural characteristics reviewed. RESULTS: 1001 women underwent pregnancy termination with misoprostol for fetal abnormality. Median maternal age was 31 yrs (26,36) with median parity 1 (range 0-6). 15.5% had at least 1 prior CS. Principal indications for termination were aneuploidy (38.7%), neural tube defect (15.4%), cardiac (9.7%) and cerebral anomalies (9.7%). Median gestation at termination was 19.5 wks (17.9,20.8) with a median abortion interval of 16.5 hrs (12.1,23.7). Univariate analysis showed 3 factors significantly impacting upon abortion duration: maternal age, parity and gestation. Lower maternal age (median 17.3 vs 13.5 hrs, age ⬍20 vs ⬎40 yrs, p⬍ 0.001), nulliparity (median 19.2 vs 14.5 hrs, nulliparous vs parous, p⬍0.001) and increasing gestation (median 13.2 vs 18.2 hrs, 13-17 vs 20-24 wks, p⬍ 0.001) were associated with abortion prolongation. Controlling for gestation and parity, the specific fetal anomaly prompting the abortion did not influence the duration. Placental retention was a frequent complication, occurring in 31.5%. Gestation was significantly lower (18.6 vs 19.7 wks, p⬍0.001) and blood loss higher (200 vs 10 mls, p⬍0.001) with placental retention, but parity had no influence. There was 1 case of uterine rupture with 2 prior CS, necessitating suture repair. CONCLUSION: Nulliparity, younger maternal age and increasing gestation were associated with prolongation of misoprostol abortion duration. The fetal anomaly prompting the abortion did not impact on duration when controlled for gestation and parity. Placental retention rates were high and predominantly influenced by gestation at abortion. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.339
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.337
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S99
www.AJOG.org 321
ADDITIONAL RECTAL MISOPROSTOL PLUS INTRAVENOUS OXYTOCIN VERSUS INTRAVENOUS OXYTOCIN FOR THE PREVENTION OF POSTPARTUM HEMORRHAGE AFTER CESAREAN SECTION SOON CHEOL HONG1, JI WON KIM2, HYUN TAE PARK2, HYUN-JOO SEOL3, HAI JOONG KIM4, SUN HAENG KIM5, KYU WAN LEE4, 1Korea University Medical Center, Seoul, South Korea, 2Korea University Medical Center, , Sudan, 3 Korea University Medical Center, Department of Obstetrics and Gynecology, Seoul, South Korea, 4Korea University Medical Center, Obstetrics and Gynecology, Seoul, South Korea, 5Korea University Medical Center, Obstetrics and Gynecolgy, Seoul, South Korea OBJECTIVE: To evaluate the value of additional rectal misoprostol in preventing the risk of postpartum hemorrhage after cesarean delivery STUDY DESIGN: Subjects were randomized to receive two, 200microgram misoprostol tablets rectally (study medication) plus 20 units oxytocin in Ringer fs lactate intravenously or two lactose talets rectally plus 20 units oxytocin in Ringer fs lactate intravenously (control medication). Our outcome measures were change in hemoglobin and hematocrit value from baseline to postpartum day 1, additional uterotonin, transfusion rate and side effects. RESULTS: There were no significant differences between two groups with regard to a drop in hemoglobin and hematocrit. The primary outcome measures were similar in the two groups CONCLUSION: Additional rectal misoprostol to intravenous oxytocin is not more effective than intravenous oxytocin for the prevention of postpartum hemorrhage after cesarean section
323
The value of additional rectal misoprostols in preventing postpartum hemorrhage after cesarean section
Age Parity Drop in hemoglobin level (g/dL) Drop in hematocrit level (%) Additional oxytocin (n) Intravenous ferric hydroxide sucrose complex Postpartum blood transfusion Fever (⬎38) (%) Shivering (%)
Misoprostol plus oxytocin (n⫽96)
Cotrol (oxytocin)(n⫽118) P-value†
32.0 ⫾ 4.1 0.57 ⫾ 0.72 1.6 ⫾ 4.1 3.8 ⫾ 5.1 28 (29.2) 31 (32.3)
32.4 ⫾ 4.4 0.74 ⫾ 0.74 1.0 ⫾ 2.4 3.0 ⫾ 6.1 31 (26.3) 32 (27.1)
0.5235 0.1049 0.1632 0.2856 0.6373‡ 0.4089‡
11 (11.7) 10 (10.4) 1 (1.1)
13 (12.0) 5 (4.2) 0 (0.0)
0.9415‡ 0.0782‡ 0.4460‡
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.338
324 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.336
322
SHOULDER DYSTOCIA: WHAT IS THE RISK OF RECURRENCE? ANWAR NASSAR1, FADI YAHYA1, IHAB USTA1, 1American University of Beirut Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon OBJECTIVE: To study the risk of recurrence of shoulder dystocia in patients who have had at least one shoulder dystocia in a previous pregnancy. STUDY DESIGN: A retrospective maternal and neonatal chart review of all vaginal deliveries complicated by shoulder dystocia between January 1990 and December 2005. Shoulder dystocia was defined as impaction of the fetal shoulder at the perineum, requiring extra maneuvers for delivery. Diagnosis was made by the delivering physician and documented in the chart. Charts with subsequent delivery beyond 24 weeks of gestation were identified and reviewed for parity, body mass index (BMI), gestational age (GA) at delivery, birthweight, operative vaginal delivery, Apgar scores, duration of labor, and birth injuries. Patients were divided into 2 groups, those with recurrent shoulder dystocia (group I) and those with normal subsequent delivery (group II). RESULTS: One hundred ninety-three cases of documented shoulder dystocia were identified. Of those, 48 women had a subsequent delivery at our hospital. After excluding 3 who had a cesarean delivery, 45 patients were analyzed. Ten of those patients had recurrence of shoulder dystocia (22.2%). The birth weight in the index pregnancy was smaller than the previous pregnancy in a significantly larger proportion of women in group I compared with group II (30.0% vs 71.4%, P⫽0.027). Otherwise, there were no differences in the maternal age, GA at delivery, parity, duration of labor, gender, history of macrosomia, birth injuries or interval between pregnancies in the two groups. CONCLUSION: The risk of recurrence of shoulder is dystocia is around 22%. This study did not demonstrate any predictors for the risk of recurrence of shoulder dystocia. When counseling patients about the risk of recurrence, a smaller birth weight than the previous pregnancy could be reassuring.
CYCLOOXYGENASE-2 (COX-2) AND INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) GENE POLYMORPHISMS INFLUENCE THE TIME INTERVAL BETWEEN LABOR INDUCTION AND DELIVERY DANIEL SKUPSKI1, NEIL NORMAND2, GARY EGLINTON3, STEVEN S. WITKIN4, 1Cornell University, Flushing, New York, 2Cornell University Medical College, Obstetrics and Gynecology, New York, New York, 3New York Hospital Medical Center of Queens, Flushing, New York, 4Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: The time interval from induction to delivery differs and biochemical and genetic variables remain to be identified. Cervical ripening and labor involve activation of inflammation-inducing mediators. We hypothesized that functional polymorphisms in genes coding for IL-1ra and cox-2, two proteins that regulate the extent of inflammation, influence the time between labor induction and delivery in women who are undelivered by 42 weeks. STUDY DESIGN: Subjects were women participating in a randomized trial of sequential versus simultaneous dinoprostone and oxytocin for induction of labor with an unfavorable cervix at term (SMFM 2007 abstract #272) due to post dates (26), oligohydramnios (20), hypertension or preeclampsia (9), abnormal fetal heart rate (6), diabetes (5) or other reasons (4). Buccal DNA was tested for a G⬎C polymorphism at position -765 in the cox-2 gene promoter and a length polymorphism in intron 2 of the IL-1ra gene. Clinical data were collected only after completion of all laboratory testing. Women delivered by cesarean section for fetal indications during labor were excluded. RESULTS: Carriage of the cox-2 C allele was present in 15/32 (46.9%) women who delivered at ⱕ 20 hours after labor induction and in only 6/34 (17.6%) who delivered at ⬎20 hours (P⫽.01). Among post-dates inductions, 11/26 (42.3%) were cox-2 allele C positive as opposed to 12/44 (22.7%) induced for other indications. Carriage of the IL-1ra 2 allele was seen in 5/11 (45.5%) women with induction duration ⱕ10 hours, as compared to 15/58 (25.9%) with induction duration ⬎10 hours. IL-1ra 2 allele was present in 12/28 (42.9%) women with post dates induction as opposed to 8/44 (18.2%) women induced for other indications (P⫽.03). Genotype distributions were similar between study arms. CONCLUSION: Possession of cox-2 allele C, associated with reduced production of cox-2 protein, or IL-1ra allele 2, associated with increased pro-inflammatory activity, are two genetic factors that influence the time interval from labor induction to delivery in women with unripe cervices at term.
FACTORS INFLUENCING OUTCOMES OF PREGNANCY TERMINATION WITH INTRAVAGINAL MISOPROSTOL FOR FETAL ANOMALY JAN DICKINSON1, 1University of Western Australia, Perth, Western Australia, Australia OBJECTIVE: To review the factors impacting upon the process of pregnancy termination with intravaginal misoprostol in the second trimester for fetal abnormality. STUDY DESIGN: All cases of medical pregnancy termination performed after 13 weeks gestation during the 10 year period from 6/1997 through 6/2007 were prospectively identified. Women who received intravaginal misoprostol 400 mcg 6-hourly were then extracted from the database and the maternal and procedural characteristics reviewed. RESULTS: 1001 women underwent pregnancy termination with misoprostol for fetal abnormality. Median maternal age was 31 yrs (26,36) with median parity 1 (range 0-6). 15.5% had at least 1 prior CS. Principal indications for termination were aneuploidy (38.7%), neural tube defect (15.4%), cardiac (9.7%) and cerebral anomalies (9.7%). Median gestation at termination was 19.5 wks (17.9,20.8) with a median abortion interval of 16.5 hrs (12.1,23.7). Univariate analysis showed 3 factors significantly impacting upon abortion duration: maternal age, parity and gestation. Lower maternal age (median 17.3 vs 13.5 hrs, age ⬍20 vs ⬎40 yrs, p⬍ 0.001), nulliparity (median 19.2 vs 14.5 hrs, nulliparous vs parous, p⬍0.001) and increasing gestation (median 13.2 vs 18.2 hrs, 13-17 vs 20-24 wks, p⬍ 0.001) were associated with abortion prolongation. Controlling for gestation and parity, the specific fetal anomaly prompting the abortion did not influence the duration. Placental retention was a frequent complication, occurring in 31.5%. Gestation was significantly lower (18.6 vs 19.7 wks, p⬍0.001) and blood loss higher (200 vs 10 mls, p⬍0.001) with placental retention, but parity had no influence. There was 1 case of uterine rupture with 2 prior CS, necessitating suture repair. CONCLUSION: Nulliparity, younger maternal age and increasing gestation were associated with prolongation of misoprostol abortion duration. The fetal anomaly prompting the abortion did not impact on duration when controlled for gestation and parity. Placental retention rates were high and predominantly influenced by gestation at abortion. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.339
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.337
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S99